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By: William A. Weiss, MD, PhD

  • Professor, Neurology UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA

The first muscle 60 caps brahmi mastercard symptoms 7 days before period, the sphincter muscle discount brahmi 60caps amex medicine woman dr quinn, is innervated by the parasympathetic nerv ous system discount brahmi 60caps fast delivery sewage treatment, and its activation results in pupillary constriction or myosis discount 60 caps brahmi mastercard medicine review. The second muscle, the dilator muscle, is innervated by the sympathetic nervous system, and its activation results in pupillary dilation otherwise known as mydriasis. The cell bodies for the parasympathetic preganglionic neurons are located in the Edinger-Westphal nucleus of the upper midbrain. These axons join with the ipsilateral oculomotor nuclei motor fibers and form the third cranial nerve. Throughout the course of the oculomotor nerve the parasympathetic fibers are situated immediately internal to the epineurium (superficially) and are suscep tible to compressive injury. The ciliary ganglion houses the cell bodies of the post ganglionic neurons, which emerge to form the short ciliary nerves. Sympathetic innervation starts in the ipsilateral posterolateral hypothalamus and terminates in the ciliospinal center of Budge-Waller (intermediolateral gray matter of cord segments C8–T2). These preganglionic neurons (second-order) ascend in the sympathetic chain and synapse in the superior cervical ganglion. An abnormally small pupil is a sign of a lesion in the sympathetic nervous sys tem whereas a large pupil suggests a lesion affecting the parasympathetic nervous system. Parasympathetic dysfunction can occur from one of four possibilities: the first being injury to the third nerve, the second one being damage to the iris itself, the third occurring from pharmacologic effects (atropine, scopolamine, etc. Lesions to the third nerve or injury to Edinger-Westphal nucleus cause pupillary Ciliary ganglion Internal carotid artery Trigeminal ganglion Superior cervical ganglion Figure 32–1. Compression of the third nerve by the uncus of the temporal lobe or by a posterior communicating artery aneurysm presents with unilateral dilation and unresponsiveness. Dysfunction of the ciliary ganglion or the short ciliary nerves gives rise to a tonic pupil. This is characterized by absent reaction of the pupil to light but a slow constriction to prolonged near effort focusing (light-near dissociation). On slit lamp examination seg mental palsy of the iris sphincter can be seen as evident by segmental vermiform movements of the iris borders. These movements represent physiologic pupillary unrest that becomes noticeable in areas where the sphincter muscle still reacts. This reaction is most likely from collateral sprouting to the sphincter after dam age to the ciliary ganglion or short ciliary nerves. Cholinergic supersensitivity of the innervated iris sphincter may be demonstrated with agents such as 1% pilo carpine. Autonomic peripheral neuropathy can cause damage to the ciliary gan glion or short ciliary nerves. A syndrome known as Holmes-Adie syndrome consists of a unilat eral or in some cases bilateral tonic pupils (unresponsive pupils), impaired corneal sensation, and absent or depressed deep tendon reflexes in the legs. It is idiopathic with a female predilection and tends to occur in young adults (20–40 years of age). This syndrome can present with sudden blurring of vision, photo phobia, or without symptoms as an incidental finding. There are other rare causes of tonic pupils including orbital injuries, orbital tumors, retinal cryotherapy, herpes zoster, amyloidosis, and other autonomic neuropathies. Treatment for Holmes-Adie syndrome is often only reassurance that it is a benign condition. If treatment is necessary because of blurred vision the use of a contact lens with an artificial pupil may be of help. Associated symptoms such as weakness of the extraocular muscles support a third nerve palsy B. Light responses are absent in both conditions; however, in a third nerve palsy normal accommodation is present C. Light responses are normal in Holmes-Adie pupil but absent in the third nerve palsy D. Deep tendon reflexes are absent in a third nerve palsy but present in Holmes-Adie pupil. The history including associated symptoms is critical in determin ing severity C. Additional clinical findings are useful in differentiating the various causes of unresponsive pupils D. Light responses are abnormal in both a third nerve palsy and in Holmes-Adie pupil; however, constriction of the pupil on accommo dation is seen with the latter only. Disability after severe head injury, observa tions on the use of the Glasgow Outcome Scale. Her headaches are described as an aching type sensation encompassing the entire head. The severity of the headache has been such that she has been able to do all activities of daily living until today when the headache acutely worsened to the point she could not function. She has not experienced nausea, vom iting, or other symptoms besides visual impairment. Over the past 2 weeks, she has experienced transient graying-out of her vision most noticeably when she gets up from a chair. As the emergency room physician you notice the follow ing on examination: temperature (T), 37.

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A personality trait is a tendency to buy 60 caps brahmi with mastercard medications ending in pam feel brahmi 60caps medications restless leg syndrome, perceive generic 60 caps brahmi mastercard medications pregnancy, behave order brahmi 60caps with visa medicine overdose, and think in relatively consistent ways across time and across situations in which the trait may manifest. For example, individuals with a high level of the personality trait of anxiousness would tend to feel anxious readily, including in circumstances in which most people would be calm and relaxed. Individuals high in trait anxiousness also would perceive sit­ uations to be anxiety-provoking more frequently than would individuals with lower lev­ els of this trait, and those high in the trait would tend to behave so as to avoid situations that they think would make them anxious. They would thereby tend to think about the world as more anxiety provoking than other people. Importantly, individuals high in trait anxiousness would not necessarily be anxious at all times and in all situations. All individuals can be located on the spectrum of trait dimensions; that is, personality traits apply to everyone in different degrees rather than being present versus absent. For ex­ ample, the opposite of the trait of callousness is the tendency to be empathie and kind hearted, even in circumstances in w^hich most persons would not feel that way. More­ over, its opposite pole can be recognized and may not be adaptive in all circumstances. Broad trait dimensions are called domains, and specific trait dimensions are calledfacets. Personality trait domains comprise a spectrum of more specific personalityfacets that tend to occur together. For ex­ ample, withdrawal and anhedonia are specific traitfacets in the trait domain of Detachment. Despite some cross-cultural variation in personality trait facets, the broad domains they collectively comprise are relatively consistent across cultures. The specific 25 facets represent a list of personality facets chosen for their clinical relevance. Although the Trait Model focuses on personality traits associated with psychopathol­ ogy, there are healthy, adaptive, and resilient personality traits identified as the polar opposites of these traits, as noted in the parentheses above. Emotional Stability, Ex­ traversion, Agreeableness, Conscientiousness, and Lucidity). Their presence can greatly mitigate the effects of mental disorders and facilitate coping and recovery from traumatic injuries and other medical illness. Distinguishing Traits, Symptoms, and Specific Behaviors Although traits are by no means immutable and do change throughout the life span, they show relative consistency compared with symptoms and specific behaviors. For example, a person may behave impulsively at a specific time for a specific reason. Nevertheless, it is important to recognize, for example, that even people who are impulsive are not acting impulsively all of the time. A trait is a tendency or disposition toward specific behaviors; a specific behav­ ior is an instance or manifestation of a trait. Similarly, traits are distinguished from most symptoms because symptoms tend to wax and wane, whereas traits are relatively more stable. For example, individuals with higher levels of depressivity have a greater likelihood of experiencing discrete episodes of a depressive disorder and of showing the symptoms of these disorders, such difficulty con­ centrating. However, even patients who have a trait propensity to depressivity typically cy­ cle through distinguishable episodes of mood disturbance, and specific symptoms such as difficulty concentrating tend to wax and wane in concert with specific episodes, so they do not form part of the trait definition. Importantly, however, symptoms and traits are both amenable to intervention, and many interventions targeted at symptoms can affect the longer term patterns of personality functioning that are captured by personality traits. The clinical approach to personality is similar to the well-known review of systems in clinical medicine. This systematic review is facilitated by the use of formal psychometric instruments designed to measure specific facets and do­ mains of personality. A detailed clinical assessment would involve collection of both patient and in­ formant-report data on all 25 facets of the personality trait model. However, if this is not possible, due to time or other constraints, assessment focused at the five-domain level is an acceptable clinical option when only a general (vs. Clinical U tility of the M ultidim ensional Personality Functioning and T rait Model Disorder and trait constructs each add value to the other in predicting important anteced­ ent. Therefore, assessment of personality functioning and pathological personality traits may be relevant whether an individual has a personality disorder or not. Emotional lability Instability of emotional experiences and mood; emotions that are easily aroused, intense, and/or out of proportion to events and cir­ cumstances. Anxiousness Feelings of nervousness, tenseness, or panic in reaction to diverse situa­ tions; frequent worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful and apprehensive about uncertainty; expecting the worst to happen. Hostility Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults; mean, nasty, or vengeful behavior. Perseveration Persistence at tasks or in a particular way of doing things long after the behavior has ceased to be functional or effective; continuance of the same behavior despite repeated failures or clear reasons for stopping. Restricted affectivity the lack o/this facet characterizes low levels of Negative Affectivity. Extraversion) from interpersonal interactions (ranging from casual, daily interac­ tions to friendships to intimate relationships) and restricted affective experience and expression, particularly limited hedonic capacity. Withdrawal Preference for being alone to being with others; reticence in social sit­ uations; avoidance of social contacts and activity; lack of initiation of social contact. Intimacy avoidance Avoidance of close or romantic relationships, interpersonal attach­ ments, and intimate sexual relationships. Depressivity Feelings of being down, nuserable, and/or hopeless; difficulty recov­ ering from such moods; pessimism about the future; pervasive shame and/or guilt; feelings of inferior self-worth; thoughts of sui­ cide and suicidal behavior. Restricted affectivity Little reaction to emotionally arousing situations; constricted emo­ tional experience and expression; indifference and aloofness in nor­ matively engaging situations. Suspiciousness Expectations of—and sensitivity to—signs of inte ersonal ill intent or harm; doubts about loyalty and fidelity of others; feelings of being mistreated, used, and/or persecuted by others. Deceitfulness Dishonesty and fraudulence; misrepresentation of self; embellish­ ment or fabrication when relating events.

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Children with autistic spectrum disorder will only rarely have a history of social neglect purchase 60 caps brahmi with visa sewage treatment. The restricted interests and repetitive behaviors characteristic of autism spectrum disorder are not a feature of reactive attachment disorder brahmi 60 caps discount treatment 3rd degree burns. These clinical features manifest as excessive adherence to order 60 caps brahmi free shipping medications vs medicine rituals and routines; restricted generic brahmi 60 caps on-line treatment alternatives, fixated interests; and unusual sensory reactions. However, it is important to note that children with either con­ dition can exhibit stereotypic behaviors such as rocking or flapping. Children with either disorder also may exhibit a range of intellectual functioning, but only children with autis tic spectrum disorder exhibit selective impairments in social communicative behaviors, such as intentional communication. Children with reac­ tive attachment disorder show social communicative functioning comparable to their overall level of intellectual functioning. Finally, children with autistic spectrum disorder regularly show attachment behavior typical for their developmental level. In contrast, children with reactive attachment disorder do so only rarely or inconsistently, if at all. Developmental delays of­ ten accompany reactive attachment disorder, but they should not be confused with the disorder. Children with intellectual disability should exhibit social and emotional skills comparable to their cognitive skills and do not demonstrate the profound reduction in positive affect and emotion regulation difficulties evident in children with reactive attach­ ment disorder. In addition, developmentally delayed children who have reached a cogni­ tive age of 7-9 months should demonstrate selective attachments regardless of their chronological age. In contrast, children with reactive attachment disorder show lack of preferred attachment despite having attained a developmental age of at least 9 months. Depression in young children is also associated with reductions in positive affect. There is limited evidence, however, to suggest that children with depres­ sive disorders have impairments in attachment. That is, young children who have been di­ agnosed with depressive disorders still should seek and respond to comforting efforts by caregivers. Comorbidity Conditions associated with neglect, including cognitive delays, language delays, and ste­ reotypies, often co-occur with reactive attachment disorder. Medical conditions, such as severe malnutrition, may accompany signs of the disorder. A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least two of the following: 1. Reduced or absent reticence in approaching and interacting with unfamiliar adults. Overly familiar verbal or physical behavior (that is not consistent with culturally sanctioned and with age-appropriate social boundaries). Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings. The behaviors in Criterion A are not limited to impulsivity (as in attention-deficit/hyper activity disorder) but include socially disinhiblted behavior. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults. Specify current severity: Disinhibited social engagement disorder is specified as severe when the child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels. Diagnostic Features the essential feature of disinhibited social engagement disorder is a pattern of behavior that involves culturally inappropriate, overly familiar behavior with relative strangers (Criterion A). A diagnosis of disinhibited social engagement disorder should not be made before children are developmentally able to form selective attachments. Associated Features Supporting Diagnosis Because of the shared etiological association with social neglect, disinhibited social en­ gagement disorder may co-occur with developmental delays, especially cognitive and lan­ guage delays, stereotypies, and other signs of severe neglect, such as malnutrition or poor care. However, signs of the disorder often persist even after these other signs of neglect are no longer present. Therefore, it is not uncommon for children with the disorder to present with no current signs of neglect. Moreover, the condition can present in children who show no signs of disordered attachment. Thus, disinhibited social engagement disorder may be seen in children with a history of neglect who lack attachments or whose attach­ ments to their caregivers range from disturbed to secure. Nevertheless, the disorder appears to be rare, occurring in a minority of children, even those who have been severely neglected and subsequently placed in foster care or raised in institutions. In such high-risk populations, the condition occurs in only about 20% of children. Deveiopment and Course Conditions of social neglect are often present in the first months of life in children diag­ nosed with disinhibited social engagement disorder, even before the disorder is diag­ nosed. However, there is no evidence that neglect beginning after age 2 years is associated with manifestations of the disorder. If neglect occurs early and signs of the disorder appear, clinical features of the disorder are moderately stable over time, particularly if conditions of neglect persist. Indiscriminate social behavior and lack of reticence with un­ familiar adults in toddlerhood are accompanied by attention-seeking behaviors in pre­ schoolers. When the disorder persists into middle childhood, clinical features manifest as verbal and physical overfamiliarity as well as inauthentic expression of emotions. Peer relationships are most affected in adolescence, with both indiscriminate behavior and conflicts appar­ ent.

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This friend is sweating profusely and describes a terrifying dream where he was stabbed by a surgeon who pimped him extensively 2 weeks ago buy cheap brahmi 60caps treatment 4s syndrome. The med student questions his friend the next morning who flatly denies any sort of screaming episode order brahmi 60 caps otc medicine hunter. He has been caught snoring multiple times by the supervising resident and attending discount brahmi 60 caps without a prescription treatment cervical cancer. He has been making mistakes on the job and no longer enjoys activities he previously enjoyed-Shift Work Sleep Disorder generic brahmi 60 caps without prescription medications narcolepsy. A 27 yo F is given a warning letter for the 4th episode of lateness since beginning a new job 4 days ago. This friend is sweating profusely and describes a terrifying dream where he was stabbed by a surgeon who pimped him extensively 2 weeks ago-Nightmare disorder. The med student questions his friend the next morning who flatly denies any sort of screaming episode-this is sleep terror disorder (patient does not remember, occurs during stages N3/4 of sleep which are associated with delta waves. Other meds here include Ramelteon (melatonin receptor agonist) and Suvorexant (orexin receptor antagonist). You should find Lewy bodies (alpha synuclein only in the substantia nigra, contrast with Lewy Body Dementia where Lewy bodies are in the cortex and substantia nigra). It is an antihistamine that also has powerful serotonin receptor blocking activity. Treatment options include desmopressin (caution with hyponatremic seizures) and imipramine. Swear words are well suited to express emotion as their pri mary meanings are connotative. The emotional impact of swearing depends on one’s experience with a culture and its language conventions. A cognitive psychological framework is used to account for swearing in a variety of contexts and provide a link to impoliteness research. In support of this framework, native and non-native English-speaking college students rated the offensiveness and likelihood of hypothetical scenarios involving taboo words. The ratings demonstrated that appropriateness of swearing is highly contextually variable, dependent on speaker-listener relationship, social physical context, and particular word used. Additionally, offensiveness rat ings were shown to depend on gender (for native speakers) and English experience (for non-native speakers). Collectively these data support the idea that it takes time for speakers to learn where, when, and with whom swearing is appropriate. Keywords: swearing, rudeness, taboo words, profanity, verbal aggression, impoliteness 1. The pragmatics of swearing1 the aim of this research is to develop a cognitive psychological frame work to explain how swearing varies as a function of communication context. The goal of cognitive psychology is to examine our higher men tal processes such as memory, language, problem solving, attention, deci sion making, and reasoning in order to explain how we think and behave in a variety of situations. Swearing is a topic that is most amenable to study in natural settings, but laboratory studies offer more control over variables of interest. The focus of the present research is to examine how people attend to contextual variables such as speaker-listener relationship and social physical setting in the process of swearing. We believe that people learn to judge when, where, and with whom it is appropriate to swear, or where swearing would be offensive. Offensiveness judgments provide the basis for determining the extent to which speech is rude or impolite. Our work is also informed by research on linguistic impoliteness, particularly as we describe native-non-native speaker disparity in the perception of the offensiveness and likelihood of swearing. In this paper, we describe factors that influence the likelihood and offensiveness of swearing, as well as the relationship between swearing and politeness research. We believe that swearing is not necessarily impo lite, inasmuch as offensive language is often used within the boundaries of what is considered situationally appropriate in discourse; further, some instances of swearing are neither polite nor impolite. Furthermore, we consider that one’s experience with a language influences likelihood and offensiveness judgments about swearing. We present data that sup port the context-dependence of one’s perception of the inappropriateness of swearing, both in terms of situational variables. We believe that language experience influences likelihood and offensiveness judgments about swearing. Fluent speakers, relative to those who are less familiar with a language, should have a broader and more flexible knowledge of the ways in which swearing can be construed as polite or impolite. Swearing and (im)politeness Swearing is the use of taboo language with the purpose of expressing the speaker’s emotional state and communicating that information to listen ers (see Jay 1992, 2000). In contrast to most other speech, swearing is primarily meant to convey connotative or emotional meaning; the mean ings of the words themselves are primarily construed as connotative (Jay and Danks 1977). As constructed in popular news media, swearing is superficially understood, masking its deeper and more complex com municative function. Field studies of swearing (Jay 1992, 2000; Jay and Janschewitz 2006) have demonstrated that swearing in public is not an infrequent act, and most instances of swearing are conversational; they are not highly emotional, confrontational, rude, or aggressive. Through thousands of incidents of recorded swearing, we have never witnessed the pragmatics of swearing 269 any form of physical aggression as a consequence of swearing. From what we have observed, we argue that swearing can be polite, impolite, or neither and it may be used with any emotional state. A common problem for impoliteness, rudeness, and swearing research is that all three phenomena are impossible to define universally because all are culturally and personally determined. Classic approaches to po liteness (Brown and Levinson 1987 [1978]) frame interpersonal com munication as situations in which a speaker’s motivation is to promote social harmony and to avoid threatening the face (Goffman 1967) of a listener through behaviors such as swearing. These approaches do not necessitate an exploration of the vicissitudes of swearing. However, more recent approaches to politeness that encompass impoliteness and rude ness (Thomas 1983; Arndt and Janney 1985; Lakoff 1989; Kasper 1990; Beebe 1995; Culpeper 1996; Culpeper et al.

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