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#morbid diathesis
bl6ckmirror · 3 years
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"Tim. For you, my heart...ripped from my chest. Eviscerated, I am. And if I could, I would plunge my fingers through my chest and rip out my heart and give it to you. A pulpy mass of morbid diathesis.
In addition to my heart, there are some small organs that I want to give you: glands... sweetbreads... variety meats. I'm offering these gifts. Rare gifts. I know that they don't amount to much in the face of what you've given me.
I've heard these organs can't survive outside the body for more than a few hours. But I'll try to get there as soon as I can. Whatever happens, it will be on me. On my heart."
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graduallythensudden · 2 years
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For you, my heart...ripped from my chest. Eviscerated, I am. And if I could, I would plunge my fingers through my chest and rip out my heart and give it to you. A pulpy mass of morbid diathesis. In addition to my heart, there are some small organs that want to give you: glands... sweetbreads... variety meats. I'm offering these gifts. Rare gifts. I know that they don't amount to much in the face of what you've given me. I've heard these organs can't survive outside the body for more than a few hours. But I'll try to get there as soon as I can. Whatever happens, it will be on me. On my heart
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kimjo · 4 years
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About Psychosis: Symptoms, Causes, & Role as a Psychic Self-Care System | On Hallucinations & Delusions in C-PTSD, Schizotypy, etc. [CC]
Covers topics such as:
- Symptoms of psychosis like Hallucinations, Delusions, & Cognitive issues, & early signs of psychosis
- Co-morbidity with other disorders, & risk factors for developing psychosis
- Development of psychosis & the diathesis-stress model (genetic predisposition plus environmental trigger)
- Explanation of psychosis as a psychic self-care system: fragmentation of Ego, to protect the ego from awareness of experiences
- Understanding & accepting psychosis
If you or a loved one experiences psychosis, I hope you may find this information helpful. Know that hope and recovery is possible.
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juniper-twig · 5 years
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For you, my heart...ripped from my chest. Eviscerated, I am. And if I could, I would plunge my fingers through my chest and rip out my heart and give it to you. A pulpy mass of morbid diathesis. In addition to my heart, there are some small organs that I want to give you: glands... sweetbreads... variety meats.
jenny schecter, the L word
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Iris Publishers_ Annals of Urology & Nephrology (AUN)
Role of Retrograde Intrarenal Surgery in Management of Renal Stones: 3 Years Experience
Authored by:  Yadav Rajinder
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Abstract
Introduction and Objective: Retrograde Intrarenal Surgery (RIRS)is considered as a minimally invasive procedure for management of renal stones with minimal morbidity. Our objective is to demonstrate its effectiveness in management of not just small, but even large, multiple and staghorn stones.
Methods: A prospective study was done of 274 patients who presented to us with renal and upper ureteric stones and were managed with RIRS. Preoperatively, stone size and laterality were assessed on NCCT KUB and X-ray KUB. Intraoperative parameters assessed were operative time, need for ureteric dilatation and intraoperative complications. Post operatively, check X-ray KUB/USG KUB was done before stent removal. Patients were followed up in outpatient department and telephonically.
Results: Out of 274 patients, 185 patients were males and 89 were females. 83 patients had single stone and 191 patients had multiple stones. 25 patients were pre stented in view of septicemia or renal impairment. 47 patients had renal impairment at the time of presentation, which improved in all patients and returned to normal value in 36 patients. 85 patients underwent bilateral RIRS and 189 underwent unilateral RIRS. 68 patients had stone size <1 cm., 99 patients had 1-2 cm. and 107 patients had more than 2 cm sized stones. 6 patients had residual stones out of which, 3 patients underwent URS, 2 patients underwent RIRS and 1 patient underwent ESWL.
Conclusion:RIRS is feasible in large stone burden like partial and complete staghorn stones with minimal morbidity. Our study demonstrates its effectiveness in large stone burden(size>2cm.), with additional procedure required in < 3% patients.
Introduction
The incidence of urinary stone disease is increasing all over the world due to environmental conditions in association with improving health services and diagnostic modalities [1,2]. The management of renal stones has evolved due to technological advancements in last few decades from open to percutaneous to very minimally invasive procedures. The success of these minimally invasive modalities has made open surgery for renal stone disease rare. PCNL (percutaneous nephrolithotomy) became the procedure of choice after its first description in 1976 for management of large burden renal stones and as a treatment option for small renal calculi [3]. Although PCNL had a good stone clearance rate, it is associated with a potential morbidity of bleeding which may need angioembolisation (0.6-1.4%) Michel MS, et al. [4] and so has limitations in patients with bleeding diathesis. Also, PCNL is technically more demanding and is a morbid procedure associated with longer hospitalization, postoperative pain, longer bed rest, and longer time to return to work etc. With rapid advances in technology, miniaturization of endoscopes, improvement in fiberoptic technology, availability of holmium: YAG laser and other ancilliary instruments have rendered RIRS (Retrograde Intrarenal Surgery) a better opportunity for management of renal and ureteric stones. Also, RIRS is associated with low complication rate, minimal morbidity and early return to work
We started flexible ureteroscopy in 2003 with the availability of 30 Watts Holmium laser. Initially we used to do diagnostic ureteroscopy and used to remove small stones left over after fragmentation by ESWL and PCNL and broken stents. With the availability of first flexible ureteroscope we could perform only 30 cases successfully. It was not possible to buy another flexible ureteroscope as it was costly. We borrowed the flexible laryngoscope and performed another 25 cases of removal of small stones from ureter and kidney. Both the scopes were from stortz. With the availability of baskets and flexible ureteroscope we performed RIRS in another 100 cases of upper ureteric and renal stones of up to 2 cm. size. More than 2 cm. size renal stones were treated by PCNL till 2013. With rapid advances in technology, miniaturization of endoscope and video endoscope and improvement in fiber-optic technology, availability of Holmium: YAG laser and other ancillary instruments has rendered RIRS (Retrograde intrarenal surgery) a better opportunity for management of renal and ureteric stones. Also, RIRS is associated with low complication rate, minimal morbidity and early return to work. At present RIRS is limited to patients where PCNL/ESWL are contraindicated because of presence of bleeding diathesis, patients with morbid obesity, malrotated kidney, malpositioned kidney and stone size up to 2 cm [5]. We have evaluated the feasibility and efficacy of RIRS for management of stones including those of stone size > 2cm (including partial and complete staghorn). Staged RIRS is performed for patients with large stone burden (partial and complete staghorn stones) as an alternative to PCNL [6].
Materials and Methods
A prospective study was done from August 2013 to June 2016. 274 patients with renal and upper ureteric stones including stone size > 2 cm to multiple, bilateral including even partial and staghorn stones underwent RIRS at our institution. RIRS was considered the first choice for management of renal stones coming to our hospital irrespective of stone size. Patients were pre-informed about staged procedure if they had bilateral large renal stones. Preoperatively, Stone size and laterality were assessed on NCCT KUB, X-ray KUB films or CT urography. All the patients were investigated for comorbidity. All the patients had urine culture and sensitivity done before the procedure and RIRS was carried out only after urine culture was sterile. Most of the patients were admitted on the same day in the morning and those who were suspected to have infection or obstructed system were pre-stented and treated for a week with appropriate antibiotics to clear the infection and improve renal function in those cases where renal functions were deranged. Almost all patients were operated under general anesthesia except for few cases who were not fit for GA, were done under spinal anesthesia. We did not routinely pre stent the patient. Cystoscopy was performed in all patients to rule out any urethral obstruction or bladder abnormality and to assess the compliance of ureteric orifices. We used video-endoscopes and flexible ureteroscope from Storz and Olympus with double deflection.
All the patients were ureteroscoped by semi-rigid ureteroscope of size 7/8.5 Fr. and guidewire was inserted into the kidney and the ureteroscope was passed up to the renal pelvis. There was no need to dilate ureteric orifice in patients in whom ureteroscope could be passed till renal pelvis and 14/12 Fr. was easily negotiated up to PUJ without any difficulty. We used new ureteroscopic sheath in all patients except in pre-stented patients, where old sheaths were reused. Those patients in whom ureteroscope could not be negotiated, dilatation of orifice was done with balloon dilator. Few of the patients had stricture in ureter, which did not allow urteroscopic dilatation and underwent balloon dilatation. During these procedures, if the patient had pyonephrosis or turbid infected urine, we did not proceed further, and patient was left with the stent and RIRS was done at a second stage. Double guide wire was rarely used. All these procedures were carried out under C-arm guidance.
RGP was not done in most of the cases except in few where the calyces were in awkward position, just to guide the ureteroscope into a particular calyx. Sometimes to access a stone in a difficult calyx, the table was tilted towards right or left depending on the side of the stone or by placing a sandbag under the renal angle. In 9 cases where access sheath could not be negotiated, flexible ureteroscope was guided over flexible biwire into the renal pelvis. We did not reposition the stones from calyces in most cases (except in 4 cases). If calyx was not negotiable, we divided the infundibulum, diverticular or calyceal neck with laser wherever needed, particularly in lower calyx to fragment the stones. We used 200-micron laser fiber in lower calyces and middle calyx stone and 365 microns in upper calyx and pelvic stones. Our energy setting was 0.2 Joules and 10 Hertz. We used painting and popcorn effect in all patients to fragment the stones. We did not used drilling technique. By painting technique, we powdered the stone by keeping the laser fiber 1-2 mm. away from the stone. In most of the cases painting was started from one of the margins and continued on the margins only. At the end of fragmentation, the stone was fragmented by popcorn effect where laser beam was focused in the center of the calyx and fragments flew like popcorns coming in contact with laser and get hit by laser fiber to become tiny fragments. Fragments were not removed except for taking few pieces for chemical analysis.
The stones were observed under C-arm and larger fragments were fragmented if visible. The fragments were basketed by tipless basket or by engage basket for chemical analysis. All the patients were stented after passing a guidewire through the sheath and the sheath was withdrawn under ureteroscopic guidance to see any injury to ureter. The stents were inserted over the guidewire into the collecting system without Ureteroscope and cystoscope by pusher under C-arm guidance. Patient was catheterized for next 24 hours. Most of the patients were discharged after 24 hours and allowed to resume normal work after 2-3 days. All the patients were advised to come for follow-up after 1 week to see the progress. They were advised to get X-ray KUB done after 3 weeks prior to stent removal. If any fragments of stone were found in kidney or ureter, they were relooked and removed during stent removal.
Results
Our case series has the largest study populations in adults published in literature until now. We had in total 274 patients, 185 patients being males and 89 females. 83 patients had single stone, 96patients had multiple stones, 54 patients had partial staghorn stone and 16 patients had staghorn stone. According to stone size 68 patients had < 1cm stone size, 99 patients had stone size 1-2 cm and 107 patients had > 2 cm stone size. 87 patients had unilateral renal stones, 85 patients had bilateral renal stones, 77 patients had renal with ureteric stones and 25 patients had upper ureteric stones (FIgure 1&2).
85 patients underwent B/L RIRS and 189 underwent U/L RIRS. 25 patients were pre stented in view of septicemia or renal impairment out of 274 patients. All 35 patients (who were prestented) underwent RIRS after 1 week of stenting when their general condition was stabilized. 47 patients had renal impairment at the time of presentation, which improved in all patients and returned to normal value in 36 patients. Operative time for RIRS in our patients ranged from 35 minutes – 160 minutes and average time was 85 minutes. 234 patients required no dilatation i.e. after passing ureteroscope access sheath passed easily over the guide wire. 25 patients had narrowing at VUJ (Vesicoureteric junction) and 15 patients had narrowing at multiple sites in ureter which required balloon dilatation. 4 patients were stented in view of failed dilatation and procedure was staged.
Post operatively 14 patients had urinary tract infection and 7 patients had hematuria which were managed conservatively. One patient had ureteric perforation intraoperatively (during dilatation). RIRS was completed in same sitting in this patient after passing access sheath over guidewire and retrograde double J stent was placed at the end of the procedure. None of our patient had ureteric stricture even on long term follow up. Hospital stay ranges from 12 hrs – 2 days and average stay was 28 hrs. Post operatively patients had mild pain which were managed with analgesics. All patients returned to work within 3 days of RIRS. 38 (appr. 14%) out of 274 patients had stent related symptoms (dysuria, flank pain during micturition etc.) which were settled with medications. All patients were evaluated with X-ray KUB (for radiopaque stones) and Ultrasound KUB (for radiolucent stones) before double J stent removal. Out of 274 patients, 268 patients (96%) had complete clearance of stones in first sitting, 6 patients had residual stones out of which, 3 patients underwent URS, 2 patients underwent RIRS and 1 patient underwent ESWL. All the 6 patients were stone free after ancillary procedure.
Discussion
Before the development of modern flexible scopes, PCNL was the only option to treat large upper ureteric and renal stones, although it had its own limitations being better for low volume disease, was associated with more complications mainly connected to longer procedure time, radiation exposure and hospital stay. In 1983, Huffman and associates first reported the use of ureteroscopy to treat renal pelvic stone [7].
Various studies have been done in the past where efficacy of RIRS has been found to be comparable to PCNL for stone size up to 2 cm [8-11]. Very few studies have been done where RIRS was done for stone size 2-4 cm and no study has been done to the best of our knowledge where RIRS has been employed in stag horn and multiple stones [12-13]. Prabhakar M, et al. [12], have recently done RIRS for stone size 1.6 to 3.5 cm (average size 2.5 cm) on 30 patients and achieved a stone free rate of 86.6% in first sitting and 100% in second sitting. In a study by Haffron J, et al. [14], 14 patients were treated with combined RIRS and SWL (Shock wave lithotripsy) where they were either unfit for PCNL or refused PCNL. The calculated stone surface area was 847 mm2 (58mm2 – 1850mm2). Only 14% of patients were stone free after first sitting, whereas overall stone free rate was 77%. Ricchiuti DJ, et al. [15] carried out a retrospective analysis of 23 patients treated with RIRS, found an overall stone free rate of 74%. They found that lower pole stones had a better stone free rate (83%) as compared to stones located at other sites (74%).
Sabnis RB, et al. [16] compared microperc versus RIRS for management of small renal calculi. There were 35 patients in each group. They concluded that although microperc was a safe and effective alternative to RIRS but was associated with higher requirement of DJ stenting. Ho CC, et al. [17] did a retrospective study and reviewed the data of 46 patients who underwent RIRS for lower pole to calyceal stones of < 2cm. They found stone free rates was significantly better in the group that underwent primary RIRS as compared to the group undergoing RIRS after failure of SWL. In our study RIRS was done as a procedure of choice for all kind of stones except in cases where stone was associated with hydronephrosis and poor renal function, or PCNL was the preferred option by the patient which was rare. Almost 98% of patients came to our center for RIRS inspite of being advised for PCNL for large stones, staghorn stones and multiple stones at other centers, although we offered them all modalities including PCNL.
Stone free rate in our study was 96% in first sitting and 99.8% in second sitting. In one patient ESWL was done to clear the stone and another patient had three sittings. Most of the time second sitting was done during stent removal, removing fragments visible on X-ray KUB. We have been incising infundibular and narrow calyceal neck with laser in difficult situation to achieve better access to stone free rate. Only in one case we could not reach the stone in the lower calyx inspite of incision where ESWL was done. It is always advisable to paint the stone of any size rather than fragmenting, as fragments go to different calyces and it becomes tedious to break the stone in each calyx. We also take the anesthetist’s help in minimizing the movement of the kidney by decreasing the tidal volume. By combining above mentioned techniques we have been able to achieve a better stone free rate with lesser complications as compared to other studies.
RIRS is replacing ESWL and PCNL in management of renal stones as first choice. RIRS is safe, efficacious, reproducible with minimal morbidity and faster recovery. RIRS is feasible in large stone burden like partial and complete staghorn with minimal morbidity. Our study demonstrates its effectiveness in large stone burden(size>2cm.), with additional procedures required in < 3% patients.
Conclusion
A stone free rate of 96% was achieved in our study in first sitting for patients of renal stones treated by RIRS. Based on our encouraging results and as per reports in literature RIRS may be considered as a safe and effective procedure in all kinds of renal stones (small, big, bilateral and staghorn) with higher stone free rates, low morbidity and less auxiliary and re-treatment rates. Patients have to be informed about the possibility of staged procedure when RIRS is considered as treatment option to attain a higher stone free rate. At our center RIRS has already replaced other procedures of stone removal for all kinds of single, multiple and bilateral and staghorn stones with comparable stone free rate to PCNL with added advantage of lesser complications, shorter hospital stays and quicker resumption of work post-operatively.
For More Open Access Journals in Iris Publishers Please Click on: https://irispublishers.com/
For More Information: https://irispublishers.com/aun/fulltext/role-of-retrograde-intrarenal-surgery-in-management-of-renal-stones-3-years-experience.ID.000514.php
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homeoship · 3 years
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What is Diathesis in Homeopathy?
What is Diathesis in Homeopathy?
Today, we are going to explain about, very small yet interesting topic i.e DIATHESIS. Let’s start with a Definition The constitutional state of the person that predisposes him to a particular disease or a group of diseases because of some structural or metabolic anomalies can be called the Diathesis. The Greek word “diatithenai” means “to arrange”. So, the morbid disposition arising from the…
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cecinestpasuncitron · 3 years
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"Tim. For you, my heart... ripped from my chest. Eviscerated, I am. And if I could, I would plunge my fingers through my chest and rip out my heart and give it to you. A pulpy mass of morbid diathesis. In addition to my heart, there are some small organs that I want to give you: glands... sweetbreads... variety meats. I'm offering these gifts. Rare gifts. I know that they don't amount to much in the face of what you've given me. I've heard these organs can't survive outside the body for more than a few hours. But I'll try to get there as soon as I can. Whatever happens, it will be on me. On my heart."
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Lupine Publishers | Impact of Insomnia on Optimism-A Predictor Factor Among Young Adults in Indian Context
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Lupine Publishers | Journal of Otolaryngology
Abstract
Recent research studies have revealed that inadequate quantity of sleep cycle and deprived sleep quality, are one of the most common emerging issues which are affecting the personality and attitude traits of an individual. There are significant research studies conducted which indicates optimism and self-esteem are the core salient features for maintaining a good health.
Aim of the study: There is a dearth of knowledge regarding the possible determinants of positive optimism characteristics among young adults. Therefore, the present study was conducted to examine the relationship of optimism with insomnia symptoms among young adults.
Method: Sleep parameters and optimism were assessed by administering standardized questionnaire(s) among a sample of 92 young adults aged between 17 and 26 years studying in University.
Results: Statistical analysis shows significant correlation between optimism scale and sleep cycle, the participants exhibiting higher score of insomnia tend to show lower score on optimism scale.
Conclusion: The result provides preliminary input on risk factors for insomnia and effect on optimism, as adequate amount of sleep has a strong relationship with optimism leading to a more confident and improved quality of life.
Keywords: Insomnia Symptoms; Sleep Duration; Optimism
Introduction
Emerging research supports the findings that nocturnal sleep is one of the most important aspect of our life for maintaining a sound physical and mental health. This area is one of the emerging areas in the field of psychology which has been immensely studied. Various research studies indicate that sleeping less than 7 hours as well as sleeping more than 8 hours is closely linked to an increased susceptibility to a broad range of physical and psychological health problems, such as ranging from poor vigilance and memory to reduced mental and physical reaction times, reduced motivation, depression, insomnia, metabolic abnormalities, obesity, immune impairment, and even a greater risk of coronary heart disease and even cancer [1,2]. Longitudinal evidence suggests that, insomnia is most common co-morbid condition seen with mood, anxiety and predates the onset of low optimistic attitude within an individual [3]. Numerous research studies also reveal significant results which indicates that sleep deprivation among young adults tends to interfere with the mechanism, which is responsible for regulating personality characteristics including optimism, with increased risk for anxiety, negative mood, impulsivity, and inability to cope up with social stresses [4-8].
Neurobiology of Sleep
The circadian rhythm i.e. the sleep-wake cycle is controlled by the suprachiasmatic nucleus of hypothalamus [9]. The inhibitory projections of ventrolateral preoptic nucleus (VLPO) of the hypothalamus to the tuberomammillary nucleus (TMN), the dorsal and median raphe nucleus and the locus coeruleus, the cholinergic basal forebrain, the pedunculopontine thalamic nucleus (PPT) and lateral dorsal thalamic nucleus (LDT) functions as a switch promoting sleep [10]. The orexinergic neurons of lateral hypothalamic area (LHA) promote wakefulness and the inhibitory effect of VLPO promotes sleep [10].
Models of Insomnia
There are various models which define the foundation of insomnia explaining the various factors that are responsible for related sleep disturbances. One such model is The Diathesis Stress Model or the 3-P model (predisposing, precipitating and perpetuating) factors given by Spielman and colleagues (2011) mentioned the role of the three P’s in development and maintenance of insomnia. The insomnia symptoms worsen in an attempt to relieve it hence the model focuses on behavioral pattern [11]. For example, an attempt to compensate for reduced sleep by spending increased time in bed, may worsen insomnia unintentionally. The classical conditioning principles proposed by Bootzin (1972) is the basis of the stimulus control model which states that the person with insomnia becomes conditioned to sleep and bed environment as a stimulus for wakefulness instead of sleep. The therapy attempts to decondition to this stimulus by limiting activities like lying awake, watching TV in bed and ensuring bed is used for sleep only [12]. According to Cognitive Model of insomnia thoughts, (worry about poor sleep and its daytime effects) and associated feeling interferes with the sleep [13]. Study has suggested that scanning of the internal and environment threat signals, and the safety behaviours to increase sleep and minimize the outcome of insomnia ,worsens insomnia [13] whereas, the role of selective attention to sleep-related indicators in the development and maintenance of insomnia is as per the basis of the Psychobiological Inhibition Model [14]. As per Diagnostic Guidelines of Insomnia (ICD-10, 2004) the following are essential clinical features for a definite diagnosis [15].
a) The complaint is either of difficulty falling asleep or maintaining sleep or of poor quality of sleep.<
b) The sleep disturbance has occurred at least three times per week for at least 1 month.
c) There is preoccupation with the sleeplessness and excessive concern over its consequences at night and during the day.
d) The unsatisfactory quantity and/or quality of sleep either causes marked distress or interferes with ordinary activities in daily living.
e) The unsatisfactory quantity and /or quality of sleep is the patients only complain.
Compared to the research studies conducted on consequences of poor sleep, there is inadequate evidence regarding the association between sleep duration with positive individual characteristics. According to the data published by National Sleep Foundation (2002) revealed that individuals who had an average sleeping duration of 7 – 8 hours reported to have better mental satisfaction with life compared to the other group of individuals who had a sleeping duration of less than 6 hours a night [16]. Fredriksen (1994) conducted another similar kind of study in which the results obtained were evident indicating that longer the sleep duration higher is the self-esteem in adolescents [17]. Various other studies revealed a strong association between ample sleep duration and short sleep onset latency resulting in higher optimism in children [3]. Another experimental study was administered to examine the effect of insomnia and the results indicated that sleep deprivation leads to gradual degradation of self-reported optimism and poor social interaction in young adults, which suggested that sleep duration is a determinant factor for the initiation of positive personality characteristics in an individual [18]. Most of the research studies say that lack of sleep may lead to co-morbid condition which could be anxiety and depressive symptoms and also lack of optimism. In the present study, we therefore tested associations of sleep parameters with optimism among university students aged 17 to 26 years. In particular, the study was conducted to examine the relation between symptoms of insomnia and optimism. Simultaneously, also aimed to evaluate whether individuals with an average sleep duration (between 7 and 8 hours/day) are more optimistic compared to individuals who sleep less than 7 hours or, conversely, more than 8 hours per day [19].
Method
Participants
A total of 92 subjects were selected using purposive sampling based on their encouragement to participate in the present study from the university. The participants were divided into
a) Group 0: 63 (aged 17-21 years)
b) Group 1: 29 (aged 22-26 years)
Individuals who fulfilled the criteria of insomnia with the minimum age of 18 years were included in the study. On the other hand, individuals who were suffering from other psychiatric illness or co morbid conditions were excluded from the study. All the subjects were explained in detail regarding the purpose of the study. Primarily, the mother tongue of all the participants was Hindi simultaneously had a good knowledge of English. Informed consent and personal information were taken from the participant.
Materials Used
Two questionnaires were administered:
a) Pittsburgh Sleep quality Index (PSQI) which consisted of 19 individual items, creating 7 components. Higher the score on Pittsburgh quality index, the lower is the sleep quality and vice versa [19].
b) Optimism sleeping Index (OSI) to measure the five facets of Optimism. There are 60 items in the test which are in 5-point Likert system. All the questions were closed set task with 3-point rating scale i.e., yes or no and not sure [20].
The data collected was analyzed using SPSS (version 17, IBM Corporation, Bengaluru, India), along with percentages of the study subjects, with respect to a particular response. The percentages and proportions of different categories of questionnaires were used to analyze the data.
Results and Discussion
The aim of the study was to find out the relationship between insomnia and five facets of Optimism among University students. On statistical analysis, the correlation (Table 1) between Pittsburgh Sleep Quality Index and Optimism Index was found to be: (r = -.342, P < .01). Therefore, the findings reveal that there is a negative correlation between Sleeping Difficulties and Optimism which means higher level of optimism is related to better Sleep Quality and more sleeping difficulties relate to lower level of optimism. Further, the data analysed on optimism five facets Positive Emotions (P_E), Engagement (E_M), Meaningfulness(M_F), Relationships(R_S) and Accomplishment(A_C) also provides negative correlation is found again between Sleep Difficulties using PSIQ and each Optimism Facet using OSI (Table 1). Extensive research study on optimism; which is an major aspect of positive personality is important as it is considered one of core platform for the development subjective well-being and health [21].A prospective review study was conducted over a 9 year follow-up period which showed a protective effect of dispositional optimism against various cardiovascular mortality in old age controlling the initial health status [22].Considering the literature current study also revealed similar result findings among the university students. The detailed description are as follows:
Table 1: MRI of the parotid gland showing homogeneous mass on the superficial lobe of the left parotid gland on hyper signal T1 and T2 and a weak signal on fat suppressed sequences. The lesion is hypointense to parotid and uniformly non-enhancing.
a) Positive Emotions and PSIQ: On statistical analysis, the correlation between Positive Emotions and Pittsburgh Sleep Quality Index was found to be: (r = -.304, P < .01) as shown in (Figure 1). This indicates that there is a negative correlation between Sleeping Difficulties & Positive Emotions. This implies the inference that good quality sleep is related to higher value of positive emotions and vice versa.
Figure 1: Graph representing relationship between Sleep Quality Index and Positive Emotions.
Figure 2: Graph representing relationship between Sleep Quality Index and Engagement.
b) Engagement and PSIQ: The relationship between Engagement and Pittsburgh sleep quality index is (r = -.241, P < .05) which implies a negative correlation between Sleeping Difficulties and Engagement also (Figure 2). A higher value of engagement is seen in students with lower Pittsburgh sleep quality index score as compared to those with higher Pittsburgh score. This implies the same inference as with above facet i.e. good quality sleep relates to good engagement score and Sleeping Difficulties relate to low engagement score/bad engagement skills.
c) Relationship and PSIQ: The correlation value between Relationship and sleep quality Index: (r = -.289, P < .01). A negative correlation value also indicates that this facet of optimism also relates to a higher value corresponding to lower values on Pittsburgh Sleep Quality Index (Figure 3). This again confirms our inference that more Sleeping Difficulties are related to lower inter-personal Relationship skills. A good quality sleep is related to a higher level of Relationship values in students. There are similar supporting studies which shows that people with lower social network and relationships tend to exhibit poor sleep. Researchers pointed out the importance of relationship support on health which indicated that higher level of non-reciprocity in social interaction, the higher level of sleep problems, depression and lower level of physical and mental health [23].
Figure 3: Graph representing relationship between Sleep Quality Index and Relationship.
d) Meaningfulness and PSIQ: The fourth facet of optimism is meaningfulness which correlates as: (r = -.258, P < .05) with the Pittsburgh score. This value also suggests that a good meaningfulness score is seen in students with good quality sleep as compared to those with sleep difficulties (Figure 4). Haack And Mullington [24] demonstrated that sleep deprivation resulted in a gradual reduction of self-reported optimism and sociability in young adults, which suggests a causal relation between sleep and positive personality characteristics. There are rich literature studies conducted which shows the relationship between insomnia and physical health [25] wherein optimism on one side has a sleep-enhancing effect; whereas poor sleep constitutes pessimism on the other side [24,25]. Similarly, it’s interesting to study that depressive mood fully moderates the first pathway, from optimism to sleep quality, the effects of sleep on optimism are only partially explained by depressive mood [26].
Figure 4: Graph representing relationship between Sleep Quality Index and Meaningfulness.
e) Accomplishment and PSIQ: The last facet which is accomplishment has a correlation value: (r = -.289, P < .01) with the Pittsburgh score. This facet is also related to Pittsburgh Sleep Quality Index similarly. Sleeping Difficulties relate to a lower value of accomplishment and good quality sleep relates to a higher value of accomplishment (Figure 5). Robert et al. [27] stated that chronic insomnia is one of the leading causes that can result in poor performances in various aspects, including the interpersonal, somatic and psychological functioning of an individual [27].
Figure 5: Graph representing relationship between Sleep Quality Index and Accomplishment.
Further, analysis was done to compare the variation in Optimism Index and Pittsburgh Score of participants with variation across the age Group (Table 2). The mean Optimism Index for Age Group 0 & Age Group 1 (Table 2) were found to be M(SD) = 222.06(18.562) & M(SD) = 226.59(27.514). These mean optimism index scores of the students of the two age groups was compared and the variation was found to be just 2.04%, the mean Optimism Index increased by just 2.04% when moving from lower age group(Group 0) to higher age group(Group 1), which was considered as a marginal difference. This implies in turn reveals that Optimism level was comparatively better in Group 1: “22-26” age group. Thus, this present study also suggests age doesn’t have a significant impact on the optimism level of university students. Comparison was also done between the mean Pittsburgh scores of the two age groups. The Mean Pittsburgh Sleep Quality Index Scores for Age Group 0 and Age Group 1 found to be M(SD) = 6.05(3.333) & M(SD) = 5.86(3.710) which was suggestive marginal/negligible difference. However, there are longitudinal studies conducted on adolescence which revealed that sleep duration decreased with age. Longer sleep duration was concurrently associated with better subjective psychological wellbeing [28] whereas, there was contraindicatory findings which showed that both the age groups had a variation of just 3.14% in Mean Pittsburgh Index Scores. The Mean Pittsburgh Sleep Quality Index shows a decrease by 3.14% from lower age group (Group 0) to higher age group (Group1). This finding suggest that Sleep Quality was found marginally better in Group 1 i.e. “22-26” age group which indicates that age group variation among university students doesn’t significantly affect their sleep quality which can be related to limited sample size. A similar study was conducted on effect of Optimism and Self-Esteem related to sleep in a large community-Based Sample and results indicated that individuals with insomnia symptoms scored lower on optimism and selfesteem which was largely independent of age and sex, controlling for symptoms of depression and short duration. Thus, the current findings confirm the previous knowledge gained by studies that people with better sleep quality have higher optimism and people with poor sleep quality have lower optimism. Also, that high level of optimism also directly or indirectly results in better sleep quality
Table 2: Sociodemographic details and Clinical Characteristics of participants(N=92).
Despite the success to find out the impact of insomnia on the five facets of optimism among young adults, there were certain limitations in the current study, which are as follows:
a) As the data collected was disproportionate in terms of sample size, gender therefore, standard generalization of the result is limited.
b) The optimism index scale questionnaire used in the study is under construction hence, superficial information regarding the facets of optimism was obtained which can be a factor that may affect the result analysis.
To overcome these shortcomings, further studies should be conducted so that a causal linkage between the variables can be drawn. Also, in order to give some more accurate result, different other aspects of the variable (e.g., stress and five facets of optimism; depression and optimism) should also be measured. Moreover, standardized objective instruments should be used to measure the variables, so that the reliability can be measured, and generalized results can be increased.
Conclusion and Implication
In summary, current study extends the knowledge towards the facets of optimism, elaborating that a better sleep quality is also related to higher level of positive facets viz. Positive Emotions, Engagement, Relationship, Meaningfulness & Accomplishment. It also the expands the knowledge towards expansion of the facets of optimism, elaborating that a better sleep quality is related to five positive facets of optimism index scale viz. Positive Emotions, Engagement, Relationship, Meaningfulness & Accomplishment. Future studies can make a greater effort in verifying the relationship among optimism, stress, depression, social support and how they interact with each other in order to predict insomnia or any sleep deprivation.
In a university setting, finding can be implemented to nurture optimism and guide sleep hygiene promotion and intervention among college students.
Acknowledgement
The authors would like to acknowledge all the participants of this study and also acknowledge all the participants who willingly participated in the study. Authors would also like to extend the gratitude toward Chancellor and Pro-vice chancellor of Amity University Haryana for their valuable support, motivation, and help during data collection and preparation of the manuscript.
For more Otolaryngology Journals please click on below link https://lupinepublishers.com/otolaryngology-journal/
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For you my heart, ripped from my chest.  Eviscerated I am,  and if I could,  I would plunge my fingers,  through my chest,  and rip out my heart,  and give it to you.  A pulpy mass of morbid diathesis. In addition to my heart,  there are small organs I want to give you,  glands,  sweetbreads,  variety meats.
Jenny’s letter from The L Word
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sillybeaver · 7 years
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20 followers i would like to get to know better
20 followers i would like to get to know better
#Rules: Tag 20 amazing followers you want to get know better!
Tagged by: @friedsweetplantains
Name/Nickname: Marina/ Má
Gender: Female (she/her)
Star Sign: Sun and moon in Aquarius, Capricorn rising but the aspect I like the most is Venus in Pisces.
Height: 1,62 m
Sexual Orientation: Bissexual
Hogwarts House: Hufflepuff (which has the closest home room to the kitchen yay)
Favourite Color: Indigo blue and golden.
Favourite Animal: Dogs, cats, humming birds and rabbits.
Average Hours of sleep: It depends if I have something to do in the morning - if so, I get only 4 hrs usually; if not, i get around 10hrs +.
Cat or dog person: Both
Favourite Fictional Characters: Any female character from Studio Ghibli, but the most relatable one is Shizuku from Whisper of the Heart; other favourites are Lindsay Weir from Freaks and Geeks, Momo from Peach Girl and Kira from Mars. Number of blankets I sleep with: During summer only one bed sheet, during winter two blankets (and then i wake up sweating because winter pretty much doesn't exist in Brasil even though i like to pretend it does).
Favourite Singer/Band: CocoRosie, although i also like to listen to almost anything else that is pop but isn't Taylor Swift/Miley Cyrus/Iggy Azalea.
Dream Trip: travel all over South America by land or river.
Dream Job: deep down what I really wanted to do was to be a Globe Trekker presenter, but illustrator or calligrapher would be pretty neat as well.
When was this blog created: ??
Current number of followers: 325
When did your blog reach its peak?: i have no idea?? What made you decide to make this Tumblr?: I got started by noticing my sister using tumblr and then I thought it could be fun to get an account. Since then I've been just reblogging whatever floats my boat. Tags: @eternafebre ; @lifewith-out-shame; @tourdetour1977; @beeac; @awkwardangie; @the-joys-of-writing; @toadmom; @annafridacharlotte; @morbid-diathesis; @hooligan-choir; @cloud-pleaser; @avocado--avocado; @sssuperstylin; @fairytalesinred; @joeyswarehouse; @verklighetsflykten; @coytes; @perfectframes; @kiyomaro; @saradah
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emanuelmaca-blog · 4 years
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anemia
Maternal anemia has been reported as the most
common hematologic problem in pregnant women. This
disorder occurs frequently as a result of insuffucient
intake of iron and folic acid during pregnancy (1-4). It is
reported that iron deficiency anemia occurs in 85-100%
pregnant women with insufficient supplementation of
iron during pregnancy (5,6). The rate and severity of
maternal anemia has some variabilities in the different
geographic and economical distribution (5). While many
women in developed countries start pregnancy with low
iron stores, this is much more serious in developing
countries. Maternal anemia in the gestational period
may also be related to obstetric complications such as
postpartum hemorrhage, operative delivery and placental
abnormalities (5,6). Maternal anemia might cause serious fetal and maternal
complications during pregnancy (7). The effects of this
disorder on the placenta and child weight have been reported
in the several studies (8-11). Anemia with hemoglobin levels
between 6-10 g/dL might cause placental hypertrophy during
the pregnancy. A retrospective study from Oxford, England
showed a correlation between maternal iron deficiency
anemia and increased placental weight and placental/
birth weight ratio (12). Some correlation between maternal
anemia and low economic environment conditions and
high morbidity of the newborn has been reported (13-17).
Maternal anemia may also be associated with prematurity,
low birth weight, miscarriages and even fetal death, even at
moderate hemoglobin (Hb) levels of 8-11 g/dL (18,19).
The aim of this cross-sectional clinical study was to
investigate the possible effects of maternal anemia in
primiparous and multiparous pregnant woman with respect
to placental weight and child weight in the west part of
Turkey.
Materials and Methods
The study retrospectively included 68 pregnant women
who were admitted to the 2nd İzmir Atatürk Training and
Research Hospital, Clinic of Obstetrics and Gynecology.
Exclusion criteria was hereditary blood disease, systemic
disease, hemorrhagic diathesis, non-gastrointestinal system
disease that could lead to continuous blood loss, third
trimester hemorrhage, premature rupture of membranes,
hemolytic anemia and laboratory tests without Rh
incompatibility.
A venous blood sample was taken from the pregnant
women in the first stage of labor and Hb levels were
measured. Gestational anemia was defined as a hemoglobin
value of less than 10 g/dL. Weights of babies and placentas
were measured in the delivery room by the same researcher
(NT) after delivery.
Due to the commencement of labor, pregnant women
were admitted to the clinic and the following parameters
were recorded in order to compile the information in
the patient files of all pregnant women: 1) Vital signs
(body temperature, pulse, blood pressure, body weights
and heights), 2) age, education level, socio-economic status,
smoking and use of substances poor for the health, 3)
complaints and anamnesis of application (systemic diseases
such as diabetes, hypertension, heart failure, kidney disease,
familial hematological diseases, presence of bleeding
diathesis and previous operations), 4) obstetric anamnesis
(gravid, parity, evacuation curettage, spontaneous abortion
and number of living children), 5) presence of conditions
that may make pregnancy risky in previous pregnancies,
infant mortality, 3rd trimester and/or postpartum
hemorrhage, how previous pregnancies ended, drug use, use
of vitamins and especially iron preparations, diseases during
pregnancy, trauma, surgery, 6) blood groups, 7) general
systemic and obstetric examination (gestational week, fetal
size, presentation, whether the presenting part is engaged,
uterine tone during contraction and resting phase, etc.), 8)
vaginal examination (cervical opening, wiping, coming part,
height of the coming part, bone and soft tissue parts of birth
canal) in patients with no bleeding that may be dangerous
by examining whether there is bleeding in antenatal period
in the current pregnancy.
The study was approved by Ethical Committee of Atatürk
Training and Research Hospital (approval number: 47, date:
03.08.1999).
Statistical Analysis
In the statistical analysis, correlation between all
biochemical and demographic parameters with Spearman
Correlation Analysis test was investigated.
Results
Demographic Characteristics: The study included 36
(52%) multiparous and 32 (48%) primiparous women. The
mean age of the pregnant women in the study cohort was
27.40 years [standard deviation (SD)+7.23 age range: 17-yearold
primigravid and 45-year-old multigravida]. The mean
gestational week of the newborns was 39.8 weeks of age
(SD: 0.97).
Maternal Anemia, Placenta Weight and Child Weight:
The maternal anemia was defined in 18 of 68 pregnant
woman (27%). Multiparous pregnant women (31.7%) had
four times higher rates of anemia compared to the rate of
primiparous pregnant women (8.3%).
We compared the Hb levels and placenta weight of the
pregnant woman and child weight at the delivery according
the gravida number of the pregnant woman in the two
groups (group 1: Primiparous versus, group 2: Multiparous).
There were no statistically significant differences between
two groups for the Hb levels, placenta weight and child
weight respectively (p=0.31, p=0.75, p=0.65, p>0.05) in
Table I.
The Correlation Between Maternal Anemia, Placenta
Weight and Child Weight: A possible correlation was
studied between the studied parameters (Hb, placental
weight and child weight). There was no positive or negative correlation between maternal Hb values and child weight
(R: 0.26, t value: 0.41). However, there was a weak negative
correlation between placental weight and Hb values in the
whole group. (R: -0.23, t value: 0.02, R square: 0.56) (Figure
1). A positive correlation was found between placental
weight and child weight. (R: 0.657, t value: 0.00) (Figure 2).
However, there was no statiscally significant correlation
(positive or negative) between maternal Hb values and child
weight. (R: 0.26, t value: 0.41, R square: 0.00) (Figure 3).
Discussion
According to World Health Organization reports,
maternal anemia has been reported as the most common
form of anemia in pregnancy, which occurs as a result of
insuffucient intake of iron and folic acid during pregnancy
(20). In this study, the rate of maternal anemia was defined
as 27% in the total cohort of primiparous and multiparous
pregnant women. Multiparous pregnant women (31.7%)
had four times higher rates of anemia compared the rate for
primiparous pregnant women (8.3%).
The rate of anemia in pregnant women was compatible
with the rates of reported in the previous studies (between
25% to 58%) (17-19). In their study, Prual et al. (21) reported the
rate of gestational anemia at 25% of pregnant women in Chad.
Lijestrand et al. (22) reported anemia in 58% of the pregnant
women with Hb levels below 11.0 gr/dL in 58% of pregnant
women. Our study and previous studies identified higher
rates of gestational anemia in multiparous pregnant women
compared with the rate of gestational anemia in primiparous
women. These results indicate that the multiparous pregnant
woman should be more carefully followed and supported with
iron and folic acid supplementation.
In the present study we also studied the correlation
between the parameters (Hb, placental weight and child
weight). A positive correlation was found between placental
weight and child weight. However, there was a weak negative correlation between placental weight and Hb values in the
whole group. Wheeler et al. (23) reported that placental
growth was determined by maternal factors prevailing
before conception. They stated that maternal anemia is
one of the environmental factors associated with increased
placental weight at birth and thought that these factors
modified angiogenesis in trophoblastic villi.
Previously, a few clinics studies reported that increased
placental weight and hypertrophy are associated with
maternal anemia. (4,24,25). The placenta weight to
newborn weight ratio was found to increase in patients
with anemia (26).
However, there was no statistically significant correlation
(positive or negative) between maternal Hb values and child
weight. However, although there is a contradiction in this
issue in the literature, it has been found in some studies
that placental weight increases with maternal anemia. In a
prospective cohort study conducted by Williams et al. (27)
in 1997 among 2507 pregnant women in Australia, placental
weight was found to increase with maternal anemia. In the
same study, gestational age was also positively correlated
with an increase in placental weight. However, it was added
that the ratio of placental weight to birth weight is not an
accurate indicator for fetal growth. In a study conducted in
1991, it was reported that the higher the placental weight,
the lower the Hb level and the mean maternal erythrocyte
volume. The ratio of placental weight to birth weight was
highest in the most anemic mothers. In addition, mother’s
smoking reduces placenta weight (28).
Study Limitations
There are several limitation of this cross-sectional study.
First, the small number of patients in the present study is a
major limitation of the study. This scarity did not allow us
to conduct a etiologic subgroup categorization of maternal
anemia (iron deficiency, folic acid deficiency Vitamin B12
deficiency, obstetric complications such as postpartum
hemorrhage, operative delivery and placental abnormalities)
as well as the the severity of gestational anemia. A second
limitation is the lack of the histopathologic evaluation of
maternal placenta. Thirdly, we did not conduct a follow-up
measurement of the newborns at the 21st day of life to access
the newborn weight without the maternal edema effects.
Conclusion
The placenta and fetal organ systems are able to
compensate for maternal anemia without any major
complications, that is, the child is somehow protected from
anemia.
Ethics
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bluewatsons · 5 years
Text
Marie-Pier Larrivée, Borderline personality disorder in adolescents: the He-who-must-not-be-named of psychiatry, 15 Dialogues Clin Neurosci. 171 (2013)
Abstract
This article reviews the possibility and pertinence of diagnosing borderline personality disorder in adolescents. The etiology and clinical manifestations of this disorder in adolescents are discussed, and its management is addressed in terms of psychotherapy, pharmacology, hospitalization issues, and family involvement considerations.
Introduction
It is largely assumed that adolescence is a period of change and turmoil. This might be the reason that it is confusing for clinicians to consider diagnosing a personality disorder during a time of identity questioning and consolidation. This review aims to clarify the question in order to work more efficiently with those patients in whom the affective instability and the identity disturbance surpass normal adolescent levels, and might lead to increased morbidity and mortality if not treated or treated inadequately.
Does borderline personality disorder exist in adolescents?
Many studies suggest that we can reliably diagnose borderline personality disorder (BPD) in adolescents1 and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) agrees with this; it states that:
Personality disorder categories may be applied to children or adolescents in those relatively unusual instances in which the individual's particular maladaptive personality traits appear to be pervasive, persistent and unlikely to be limited to a particular developmental stage or an episode of an Axis I disorder... To diagnose a personality disorder in an individual under 18 years of age, the features must have been present for at least one year.2
Hence, according to DSM-IV-TR, when personality traits are inflexible, maladaptive, and chronic, and cause significant functional impairment or subjective distress, they constitute a personality disorder, regardless of age.1 The DSM also mentions that the onset is often traced to adolescence, which is corroborated by the literature.2-5 The same criteria as for adults are used. It is being more and more demonstrated that the diagnostic criteria for BPD are as reliable, valid, and stable in adolescence as they are in adulthood.6-9 BPD is estimated to affect between 0.9% and 3% of teenagers in the community,6 which is equivalent to the prevalence in adults.10
Miller et al point out that studies indicate that, while there is a legitimate subgroup of severely affected adolescents for whom the diagnosis remains stable over time, there appears to be a less severe subgroup that moves in and out of the diagnosis.1
The literature suggests that individual symptom presentation is likely to vary over time, but that one can make an accurate diagnosis by considering core dysfunctional areas of BPD (identity disturbance, affective instability, relationship difficulties, impulsivity).1 In the same vein, Chanen et al demonstrated that the stability of the categorical BPD diagnosis was rather low, but that its stability measured dimensionally was considerably higher.9 Indeed, we can understand that a dichotomous diagnosis might make it easy for an adolescent to switch from being just above the threshold to a subclinical level of symptoms, while a dimensional approach allows variations in the level of symptoms. Miller et al also mention that a dimensional approach may better account for the developmental variability and heterogeneity found in adolescents.1
Clinicians tend to be reluctant to diagnose BPD in adolescents, saying that adolescence is a period of transition that can be marked by turmoil, and that this should not be called a personality disorder. Also, as these disorders are chronic, clinicians prefer to wait before making such a conclusion. It is true that moodiness and some degree of impulsive behavior and risk-taking are common in adolescents, but most of them are not seriously troubled. Some clinicians also fear that labeling the teenager could be prejudicial.
Though we should avoid pathologizing a normal behavior, diagnosing BPD in adolescents when clinically appropriate has important advantages. Less emphasis could be put on psychopharmacology, and the use of psychotherapy could be enhanced, as there is stronger evidence for its efficacy.11 Making the diagnosis earlier also suggests an early intervention and thus prevention of crystallization of behaviors that can have severe consequences on functioning. As BPD traits are malleable and flexible in young people,12 it means this is a good period to try an intervention. Indeed, the evidence supports the use of early intervention programs for BPD in youth.6
Also, although BPD traits in adolescents tend to attenuate over time, this does not mean they recover. According to the CIC Study,13 high symptom levels of any personality disorder in adolescence have negative repercussions on functioning over the subsequent 10 to 20 years, and these repercussions are often more serious or pervasive than those associated with Axis I disorders. The same study also found that symptoms of BPD were the strongest predictors of later PD. Data from the CIC study were used to investigate the relationship between early BPD symptoms and subsequent psychosocial functioning. They demonstrated an association of early BPD symptoms and less productive adult role functioning, a lower educational attainment and occupational status in middle adulthood; an adverse effect on relationship quality, and a lower adult life satisfaction.14 Elevated BPD symptoms in adolescence have been shown to be an independent risk factor for substance-use disorders during early adulthood.15 These are all further arguments to advocate for the development of accessible intervention programs for youth with BPD symptoms. Besides, the symptoms have been shown to peak around ages 14 to 17, making it a critical risk period and a good point in time to intervene and modify the trajectory of the disorder towards a better functioning.16
Appropriate management of BPD symptoms in the right settings would also alleviate the burden on the health system. Patients with BPD symptoms and no treatment plan may consult at the ER repeatedly, at every crisis. In the absence of a treatment team to be directed to, they might also be hospitalized, with all the possible iatrogenic effects that could be envisioned, and a deleterious effect on functioning caused by suicidal threat or acting-out behaviors.
Etiology
Having an idea of the origin of BPD aids in considering it when an adolescent consults with suggestive symptoms. It is believed that BPD results from the interaction between temperament and parenting failures. Fonagy and Bateman postulated17 that constitutional vulnerabilities coupled with parental underinvolvement or neglect result in deficits in the child's ability to regulate emotions through mentalization. The invalidating environment described by Linehan18 may also interfere with attachment and the learning of emotion regulation strategies. The temperamental factors might be emotional reactivity or difficulty being soothed, which are challenging for any parent, and especially for those who share these genetic predispositions.
Studies investigating the type of attachment of BPD patients largely conclude that there is a strong association between BPD and insecure (mainly preoccupied) attachment.19,20 Preoccupation is characterized by affective instability and unsteady representations of attachment figures. As a result, patients expect that they can not trust others to be available to support them.
Factors identified as predictors or risk factors for BPD in adolescents include history of disrupted attachment, maternal neglect, maternal rejection, grossly inappropriate parental behavior, number of mother and father surrogates, physical abuse, sexual abuse, and parental loss.21,22 These are all supportive of an insecure attachment etiological model. In their review, Chanen and Kaess add low socioeconomic status to childhood abuse and neglect, and problematic family environment, as significant risk factors for personality pathology, especially BPD.22
The results of a large prospective study in UK suggest that inherited and environmental risk factors make independent and interactive contributions to borderline etiology, supporting the current models of diathesis-stress theories, pointing to an interaction between genetic vulnerability and harsh treatment in the family.23 Borderline characteristics at age f 2 were more frequent in children who had exhibited poor cognitive function, impulsivity, and more behavioral and emotional problems at age 5 years, but also in those who were exposed to harsh treatment. These all become higher risk factors in the presence of each other and also when there is a family history of psychiatric illness.23
Clinical manifestations
The disorder's first manifestations typically arise during adolescence or young adulthood.13
As noted earlier, the DSM-IV-TR criteria2 are the same as for adults. It is a “pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts.” It is indicated by five (or more) of the criteria. The first criterion describes frantic efforts to avoid real or imagined abandonment. As they tend to have insecure attachment—mainly unresolved, preoccupied, or fearful19—patients with BPD expect other people cannot be trusted and will not be available for support. In a study about diagnostic efficiency of BPD criteria in adolescents compared with adults, the abandonment fears were found to be the best inclusion criteria for adolescents.24 In this study, patients had an 85% chance of meeting the full diagnostic criteria when they endorsed the abandonment fears. On a regular basis, we hear these patients tell us that the worst thing that could happen to them would be to be left alone. At its extreme, this symptom can lead young girls to do such things as undressing in front of a Web cam, or agreeing to prostitution in order not to lose their boyfriends. On the other hand, their fear of being abandoned is so great that in some circumstances, they break bonds or ruin their relationships in anticipation that they might be rejected.
The second criterion describes the intense and unstable relationships characterized by alternating between extremes of idealization and devaluation. Anyone likely to take care of an adolescent with BPD—like a teacher, schoolmate, or a therapist—is very soon of great importance and he or she is being idealized for his or her virtues and capacities. However when the patient unfortunately becomes disappointed, which happens at some point given the great expectations and the extreme sensitivity to feeling of rejection, there is a rapid shift to a devalued position.
The third criterion introduces the identity disturbance, a markedly and persistently unstable self-image or sense of self. Their perceptions of themselves, their values, their friends, and even their sexual identity can change dramatically. Questioning about one's identity is of course normal in adolescence, but it is the marked and persistent character of the instability that distinguishes normal from pathological. In BPD, confusion and changes are out of proportion. Westen et al assessed the potential manifestations of identity disturbance in adolescence, and they concluded that the items most distinctively associated with BPD describe feelings of emptiness, fluctuations in self-perception, and dependency on specific relationships to maintain a sense of identity.25
Criterion 4 concerns self -damaging impulsivity in at least two areas. We can often see these youngsters either abuse drugs, drive recklessly, engage in dangerous sexual practices, or have bulimic episodes, for example, but beyond the level of normal experimentation in adolescence.
These patients recurrently demonstrate suicidal behavior, gestures, or threats, or self-mutilating behavior (criterion 5). This is often what first brings them to clinical attention, as they are taken to the emergency department for these threats or gestures. Miller26 mentions studies stating that interpersonal conflicts and separations are the most common precipitants of adolescent suicide. He points out examples derived from different studies: breakups of romantic relationships, disciplinary crisis or legal problems, humiliation and arguments, which are stressors identified in attempted and completed suicides of youth.
Self-mutilation must be distinguished from suicidal attempts, as there is no intent to die in the former. Indeed, in the literature, it is widely called “non-suicidal self-injury” (NSSI). It generally begins in early adolescence.27 Zanarini et al reported that 32.8% of BPD self-injurers began before age 12, as 30.2% began as adolescents and 37% began as adults.28 Jacobson et al29 point out that the explanations of NSSI remain mostly theoretical, including psychodynamic, behavioral, and emotion-regulation models. They state that the emotion-regulation model has received the most empirical support. Indeed, the patients do feel relieved after the act. They might say it distracts them from their suffering, it allows them to vent their anger, it stops derealization, it makes them regain a sense of control, or it is self -punishment. The precipitant is most often abandonment, real or perceived, or a separation.
When assessing for NSSI with an adolescent, one needs to inquire about what is going on in the peer group, as cutting is susceptible to social contagion. It can be learned from friends (or social networks and other media) and it can be normalized or even valued among them; the teen becomes part of a “community of suffering.”
While being different from a suicide attempt, self-injury is still a risk factor for suicide, as are substance use; childhood sexual and physical abuse, neglect, losses (particularly interpersonal), psychiatric comorbidity, struggling with sexual orientation issues, and parental mental disorders.30,31 Adolescents being susceptible to suggestion and contagion, media coverage of suicides or a suicide in their community also increases the risk, specifically for adolescents.
Criterion 6 describes affective instability due to a marked reactivity of mood (eg, intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). We are normally able to find the precipitant, which can appear minor from an external point of view but is experienced intensely. Indeed, the family or friends will often not share the patient's perception of the circumstances. The shifts seem exaggerated and unpredictable.
We find in criterion 7 chronic feelings of emptiness. The study by Becker et al24 did not support the observation by Pinto et al32 that emptiness or boredom was among the best discriminators of BPD in adolescents.
The inappropriate, intense, and hard-to-control anger of criterion 8 is regularly expressed when the patient feels neglected or abandoned; hence the therapist might be targeted at some point, or at least witness it. In the study by Becker et al24 anger was found to be the best exclusion criterion for BPD in adolescents.
The transient paranoia or dissociative symptoms of criterion 9 arise in highly stressful situations. The patient might describe feeling detached from his or her body or “like in a dream” (depersonalization, derealization). In the extreme, this can take the form of brief psychotic-like episodes.
Even if absent from diagnostic criteria, splitting deserves to be mentioned, as it is widely used by BPD patients, especially teenagers, who tend not to tolerate ambiguity or grey zones. They-or their parents-often note that they think and act in “all black or all white” way.
Many patients (and their parents) also describe themselves as moody and sensitive children.33
A study demonstrated that the antecedents of adolescent personality disorder could be traced to 10 years earlier in the form of childhood emotional and behavioral problems. Conduct problems were predictive of all three clusters, as depressive symptoms were associated with cluster B.34 The early temperament differences and early-onset mental state or behavioral problems are confirmed in a later review.22Oppositional defiant disorder and attention deficit-hyperactivity disorder are also pointed out as possible predictive factors of BPD in adolescents.35
Management of BPD in adolescents
First, one should establish the aims of the intervention, to avoid wearing it down with unrealistic expectations. An important goal should be to improve the psychosocial functioning, and decrease the BPD symptoms, suicide and self-harm being primary targets. Discussing the management of BPD in adolescents implies addressing psychotherapies, pharmacology, hospitalization, and family implication.
Psychotherapy
Dialectical behavior therapy (DBT)
DBT18,36,37 is an adaptation of cognitive behavioral therapy by Marsha Linehan, who uses the dialectical philosophy in her therapeutic interventions, by flexibly balancing and synthesizing acceptance and change. It refers to the fact that opposite constructs can both be true at the same time; “you are doing the best you can at the moment and you need to do better.” The core dialectic in DBT is accepting patients where they are in the moment and working to help them change.
The therapy, as initially used with adults, includes weekly individual sessions, skills-training group sessions, phone consultation available at all times with the therapist, and team consultation meetings. The skills taught are mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance. There is an important hierarchy of the treatment targets, with life-threatening behaviors being addressed in priority. They are followed by therapy-interfering behaviors and quality-of-life interfering behaviors. This constitutes the first stage of treatment; subsequent stages are described but have not yet been the focus of studies.
Miller and colleagues first adapted DBT for use with suicidal adolescents. The treatment length was decreased from 12 months to 16 weeks to increase the likelihood of commitment and also assuming that teens might not need the same length of therapy as adults. The number of skills taught was reduced to make learning easier given the new length of treatment. Family members were included in the weekly skills sessions and were offered intersession skills coaching to enhance generalization of skills. Family sessions can also be added to address specific family issues. The terminology of the handouts was adapted to teenagers. Finally, a fifth skills module was added; walking the middle path, to help patients and families with polarized ways of thinking, feeling, and interacting.
Clinical research suggests that DBT may be an effective treatment for adolescents with BPD features, as it has been associated with reductions in suicidal and non-suicidal self-injury, psychiatric hospitalizations, and other problems associated with BPD.
Mentalization-based treatment
Mentalization-based treatment (MBT) was the second psychotherapy technique developed specifically for BPD. Mentalization is the imaginative mental capacity to perceive and interpret human behavior in terms of intentional mental states (feelings, needs, desires, beliefs, and goals.38 It is believed that this understanding of others in terms of their thoughts and feelings is a developmental achievement dependant on the quality of attachment relationships (particularly early ones).38 The capacity to mentalize varies in relation to emotional and interpersonal context. According to Fonagy, the failure of mentalizing, in combination with profound disorganization of self-structure, may account for the core features of BPD.38 In fact, adolescents with BPD features were found to hypermentalize,39 defined as “over-interpretative mental state reasoning.”40 MBT aims to improve the patient's ability to understand his own and other's mental states (mentalizing) in the context of attachment relationships, which is demonstrated as helpful in both affective and behavioral aspects of BPD. Concretely, this is done using weekly individual sessions and group sessions. MBT has proven more effective than usual treatment in reducing self-harm and depression in adolescents. It reflected improvement in emergent BPD symptoms and traits.41
The HYPE clinic: an early intervention service for BPD
HYPE42 stands for “helping young people early.” The clinic is based in Melbourne and uses a team-based intervention model comprising time-limited cognitive analytic therapy (CAT) by Ryle, case management, and general psychiatric care. The goal is to offer treatment as early as possible in the course of BPD (in contrast to services working only with individuals with a severe disorder) with an intervention appropriate to the phase of the disorder and the developmental stage of the patient and his or her family. Meeting three DSM-IV-TR BPD criteria is enough to be included. CAT is the core of the therapeutic model, and has been demonstrated to be effective in reducing externalizing psychopathology in teenagers with subsyndromal or full-syndrome BPD.43 It integrates elements of psychoanalytic object relations theory and cognitive psychology by focusing on understanding the individual's problematic relationships patterns and the resulting thoughts, feelings, and behavioral responses. Routinely, 24 CAT sessions are offered with four post-therapy follow-ups. The patient also benefits from general psychiatric care for assessment and treatment of comorbidity and use of eventual pharmacotherapy, plus crisis team and occasional brief and goal-directed inpatient care. The HYPE program also engages families with psychoeducation and up to four sessions of family intervention. The HYPE intervention is supported by effectiveness data and can be adapted to existing services in other settings.42
Pharmacotherapy
There is very little empirical evidence supporting the use of pharmacotherapy with adolescents struggling with BPD. This discussion will be derived from what is suggested in adults and from our clinical experience with adolescents (the reader may refer to the article by Luis H. Ripoll [p 213] in this issue for a review of the pharmacologic treatment of BPD). In BPD, medication should only be used as an adjunct to a multidimensional psychosocial approach and its limitations should be made clear for the patient. If two different persons are involved as the psychotherapist and the prescribing doctor, communication is very important. The pharmacological treatment will be symptom-oriented and will address impulsivity, affective instability, suicidal behaviors, and non-suicidal self-injury. No medication has received an official indication in the treatment of BPD, and long-term use of pharmacotherapy has not been studied in BPD. A good strategy could be to maintain a medication that works until psychotherapy has led to the development of new strategies.
Selective serotonin reuptake inhibitors
In BPD, most studies suggest that selective serotonin reuptake inhibitors (SSRIs) are most effective in reducing anger and impulsive symptoms; a reduction in mood swings is also mentioned.44,45 Other antidepressants are also studied (tricyclics and MAO inhibitors) but SSRIs are preferred, since they are better tolerated in regard to side effects and also they appear safer in case of overdose, which is a particular concern with BPD patients. Bulimia nervosa, a form of behavioral dyscontrol that usually develops in adolescents, is frequently associated with BPD and tends to respond to SSRIs.46 Regarding antidepressants, which are widely prescribed to patients with BPD, one has to keep in mind that they do not treat the disorder and do not produce remission.44
Antipsychotics
The literature concerning antipsychotics in BPD is sparse and the samples are small.44,45Cognitive-perceptual symptoms (reference and paranoid ideas, illusions and hallucinations, derealization) arise mainly in periods of intense emotional stress. Because they have a rapid effect, antipsychotics can be used on a short-term basis for crisis periods. We tend to prefer atypical neuroleptics over typical ones because of their side-effect profile; however, even if they produce much fewer extrapyramidal symptoms, we still have to consider their potential to induce a metabolic syndrome and weight gain. Longer-term low-dose antipsychotics can be used as an adjunct to anger management, but only if an alternative with a better side-effect profile, like an antidepressant, has failed.
Mood stabilizers
Adult meta-analyses have shown that mood stabilizers as a class reduce anger and impulsivity somewhat, and may have some effect on affective instability and depression.47 However, evidence for individual medications comes from only one or two studies each47and the risk of overdose may be great.
Hospitalization
A 2004 article stated:
Hospitalization is of unproven value for suicide prevention and can often produce negative effects. Day treatment is an evidence-based alternative to full admission. Chronic suicidality can best be managed in an outpatient setting.48
Specialists criticized the American Psychiatric Association guidelines49,50 when they were published, as they recommended hospitalization whenever patients were suicidal. When facing self-destructive behaviors, clinicians can be tempted to use hospitalization but it may prove useless, and even damaging. First, the behavior will very likely have relieved the crisis and the message given to the patient that he or she is not able to get through this crisis without the hospital would be invalidating. Paris states that “hospitalizations make the therapy almost impossible as you cannot help people learn to cope with life or get a life if they are living on a psychiatric ward.“50 Repeated hospitalizations seriously hinder the adolescent's normal functioning. Things go quickly in young patients' lives, and being away can rapidly degrade their social network, just as not attending school will likely delay them academically, which may increase pressure and stress. Being in hospital will prevent dealing with interpersonal conflicts or misunderstandings, which are often the trigger of the gesture, and then create an overrating of the problem by the youngster. Hospitalization may also reinforce pathological behaviors and make the patient worse.
There are exceptions we can make to this rule of not hospitalizing. We should consider it for very brief periods of intense distress that could lead to a suicidal gesture. Paris also points that micropsychotic episodes might be treated with medications in a hospital setting, and near-lethal suicide attempts can be briefly admitted in order to re-evaluate the treatment plan.50
Not hospitalizing does not mean that we should ignore suicidal behaviors—which tend to provoke a ”boy who cried wolf“ scenario in families and doctors—as suicide rate is estimated at 10% in BPD,49,51 and suicidal ideas are a sign of distress. The therapist can acknowledge the patient's suffering and his or her need for relief of dysphoria by working with him or her to develop alternative strategies to self-harm.
Family involvement
BPD symptoms in an adolescent have a tremendous impact on his or her family; the greatest effect is suggested to be on their emotional health.52 The same study also found that a majority of parents reported physical health problems and marital difficulties. In the same study of 233 female offspring meeting strict criteria for BPD, symptoms correlated with intensity of parental burden were acting-out behavior, property destruction, delusional symptoms, and hallucinatory symptoms.52 This suffering of the family has to be validated. Parents need to be told that their anger, guilt, or anxiety are normal and can be controlled to avoid an exacerbation of their child's pathological behaviors. The therapist has to build on their strengths and avoid blaming them.
Not only is the family a valued ally as a source of information and the primary support of the adolescent, it is essential in the management of a teenager with a BPD.
Indeed, an interview with the family enlightens the therapist on the relational mode of the patient and allows targeted interventions.
Family work is important because the home environment often plays a major role in the adolescent's behavior.53 Parents can help their child to use the skills learned in therapy and even use the same skills themselves. They may also learn to modify the way they respond to the patient's pathological behaviors.53Miller suggests they be partners rather than targets in treatment.53 Also, assuming that the environment influences the genetic vulnerability in the expression of the disorder, an intervention at the family level might be protective.16
Psychoeducation is the basis of the necessary intervention with the family. They need information about BPD; its symptoms, what we know about its etiology, recommended treatments. Parents shall be taught about effective communication, behavior management, and problem-resolution strategies. While being validated regarding how much the situation is worrisome and frustrating, they can also be told that they can remain optimistic since something can be done.
The therapist also has to be clear from the beginning with the patient and his or her family about confidentiality issues. Confidentiality shall be broken if the patient's safety is at stake, if there is a suicidal plan with an intent to act it out, a plan to seriously hurt oneself or someone else, or if there is a situation of physical or sexual abuse or neglect. Regarding self-mutilation, the DBT model proposes that we validate the parents' worry while telling them that we won't disclose every gesture unless it threatens life, or there is an uncontrollable escalation of the behavior. This will allow the adolescent to feel more comfortable to discuss his or her behaviors. When it becomes necessary to break confidentiality, the patient should be involved as much as possible in the process.
Conclusion
In the Harry Potter novels, Professor Dumbledore told Harry Potter that he could call the evil Voldemort by his real name instead of “He-who-must-not-be-named,” because not calling things by their real name just makes us more afraid of them. Avoiding stating that an adolescent has features of BPD when it is the case is burying one's head in the sand, and this can result in being inefficient in addressing the problem. It can result in the patient receiving inappropriate treatment, or no treatment, with the imaginable consequences on his or her functioning, even on his or her life, and also on the health system. By contributing to detecting BPD and becoming skilled in addressing it properly, we, as clinicians, can contribute to the improvement of these patients' quality of life and both short and long-term prognosis.
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thebowlercapfairy · 6 years
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Plate XXI: Psoriasis. Cornua cutanea (with degenerative (from uric-acid diathesis) changes in right hand and left foot). #books #book #bookstagram #reader #bookworm #literature #reading #creepy #morbid #medical #antique #vintage #illustration #medicalillustration #disturbing #19thcentury
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cryofthenightingale · 13 years
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"for you my heart ripped from my chest eviscerated i am, and if i could i would plunge my fingers through my chest and rip out my heart and give it to you; a balmy mass of morbid diathesis. 
what's diathesis?
umm..it's like a susceptibility to disease. it's like all those parts of me that are susceptible to invasion. 
wow. morbid diathesis. morbid diathesis. morbid diatheisis. morbid diathesis. but that would mean it would be putrid."
- The L Word
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