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book report ruberic As a bonus, site members have access to a banner-ad-free version of the site, with print-friendly pages. Book Report Graphic Organizers. Writing a Book Report (plus a Rubric) Book Report Graphic Organizers Printouts. First, read the book. As you're reading, take notes on key information, such as the essay service, names of the main characters, personality quirks of these characters, the setting, key plot twists, important events, and any other things that seem important and research database, that you think you might want to include in your book report. Critique! The Structure of Your Report : Start your report with an introductory paragraph that states the book's title, the author, and redemption essay questions, the type of book it is critique, (mystery, fairy tale, science fiction, western, etc.). Help Paper! Then write at critique service least four to five paragraphs that clearly describe the kite redemption questions, book. Each paragraph should cover one topic (for example, you should have at least one paragraph that describes the main character). End the essay, report with a closing paragraph that summarizes what you learned from the book and if you liked or disliked the book (and why).
Check that your grammar, spelling, and punctuation are correct. Make sure to use complete sentences and write neatly! Define any technical terms that you use. Help Paper Writing! Proofread your report for errors before you hand it in -- do not hand in a rough draft. Topics to Include in Your Report : When you write your report, try to cover as many of the following topics as you can: Setting : Describe the essay, setting or settings of the book. Note where the action takes place and when. Have you ever been to a place like that?
Did you like it or not? Would you like to be in a place and time like that described in the book? Main Character : Write about the main character, including what they are like, what they look like, what they like to do, and so on. Help! Does the character change, learn, or grow in the story? If so, describe how and why this happens.
Would you like to be friends with this character? Other Characters : List the other characters in the books and give some characteristics for each. Which characters did you like/dislike? : State why you liked/disliked certain characters. Did any of the characters do things that you think are wrong, noble, risky, etc? What happened at the beginning of the essay critique, story? : How does the writing, story start? Usually this is where the characters are introduced to us and the problem is stated. What happened in the middle of the story? : This is usually where we find out a lot about the characters and the story becomes more exciting. What happened at essay the end of the writing, story? : This is usually where the main problem in the book is resolved.
What was the problem in the story and how was it solved? : What was the essay service, big problem in the story, how was it solved, who solved it. and runner questions, why? What did you learn from this story? : The best books leave the reader with a lot to think about and learn. Critique Service! Theme/Main Idea : What was the main idea or theme of the book? Some stories have a moral (like Aesop's fables), while others try to teach a life lesson. Essay Gilded Lily! Do you like this story? : Tell if you liked or disliked this story and why you did or didn't like it. Essay Service! Citing Your References : When you write your bibliography, list all of your references. Formats for each type of publication follows (there are different formats for different media): Book: Author(s). Title of book . Critical! Edition. Location of publisher: Name of Publisher, year of publication. Web Site: Author(s) if appropriate.
Title of Site or web page . URL of site, date of publication (the earliest copyright year listed). Essay Critique! Author(s) are listed last name first, first name or initials (as cited in the publication). Essay! Another format for Internet sources is as follows: Last name, First name of author. Title of Page. Name of the publisher (EnchantedLearning.com in our case). Date the page was created (at Enchanted Learning, this is the earliest date on essay the copyright notice located at the bottom of each page), Date of gilded lily, revision (at Enchanted Learning, we do not keep track of essay service, page revisions). Some teachers also request that you include the date of access; this is the date (or dates) that you went to the web page (or pages). The Following is a Rubric For Assessing each Part of Your Book Report : Book Reports and Movie Reviews: Movie Review: Write a simple movie review, describing the characters, the story, and what you like the most and the least about the movie.
A one-page printable worksheet. Men 5 Essay! Write ten things about a book you've read (plus one thing you would like to change). A one-page printable worksheet. Write ten things about a movie (plus one thing you would like to change). Book Impressions: Triple Draw and Write. Draw three of the major characters, scenes, or ideas from a book you have read, and write about each picture.
Or go to a pdf of the essay critique service, worksheet. Lily! Story Characters: Draw and Write 3 Things. Draw three of your favorite characters in books or stories and write about each of them.. Or go to a pdf of the worksheet. Service! TV Characters: Draw and Write 3 Things.
Draw three of your favorite characters in in the movies or on TV and write about each of them.. Or go to a pdf of the worksheet. Books: Draw and Write 3 Things. Draw a scene or character from three of help with paper, your favorite books and critique service, write about each of them. Or go to a pdf of the kite redemption essay, worksheet. Movies: Draw and Write 3 Things. Draw a scene or character from three of your favorite movies and write about each of essay, them. Or go to a pdf of the worksheet. Report Graphic Organizers for Book Reports and Movie Reviews: This story map prompts the student to summarize the beginning, middle, and end of 12 angry, a story. Essay Critique Service! This story map prompts the student to gilded summarize the beginning, middle, and essay, end of a story, with two extra cells for each (to list extra details).
This story map prompts the student to summarize the place, time, characters, problem, and solution of a story. This story map prompts the kite redemption questions, student to summarize the essay, title, place, time, characters, problem, solution and gilded lily, moral of a story. This story map chart prompts the student to summarize describe the settting, the characters, the problem, two major events, and the solution. This story map chart prompts the essay, student to 12 angry men 5 essay summarize describe the settting, the characters, the problem, three major events, and the solution. This story map diagram prompts the student to summarize describe the settting, the characters, the problem, two major events, and the solution. This story map diagram prompts the student to critique service summarize describe the settting, the characters, the problem, three major events, and the solution. This graphic organizer prompts the student to redemption essay questions write about the characters, setting, and events of a story. This graphic organizer prompts the student to review a book, summarizing the book and writing their opinion about the text. This graphic organizer prompts the student to review a book, summarizing the book and writing their opinion about the essay, text. Make a book report wheel using this 2-page print-out; it consists of a base page together with a wheel that spins around.
The student fills out the parts of the book report, including: Genre, Year Published, Setting, Main Character(s), Plot - Beginning, Middle, End, Problem or Conflict, and Message or Moral of Story. When you spin the wheel, the essay gilded, the parts of the book report appear, one at essay service a time. The student then answers the questions, Did you like this book? Would you recommend this book to a friend? Explain why. Make a reading log wheel for earthquake statement, 8 books using this 2-page print-out; it consists of a base page together with a wheel that spins around.
After putting the wheel together, the student follows the instructions on the front wheel and fills out the essay critique, reading log for each given genre (type of book), including: Biography, History, Science, Animals, Science Fiction/Fantasy, Fables/Myths, Any Fiction, Any Non-Fiction. For each of the 8 books, the student writes: Title, Author, Number of Pages, Your Rating of the Book, Date Completed. The student then answers the papers database, questions, Which book was your favorite book (and why)? Would you recommend this book to a friend? and Which book was your least favorite book (and why)? Print 4 different bookmarks. Essay Critique! Each bookmark is a graphic organizer on which the student can write information about the book that is being read. Print 3 different bookmarks.
Each long bookmark is a graphic organizer on which the student can write information about the book that is being read. This storyboard matrix gives the student cells in which they can illustrate the major events in the obscure essays, a story in chronological order - 6 cells. This storyboard matrix gives the student cells in critique, which they can illustrate the major events in a story in chronological order - 9 cells. Help Paper! This storyboard matrix gives the student cells in which they can illustrate the major events in a story in chronological order - 12 cells. Story clock with three divisions. Story clock with four divisions. Story clock with five divisions. Story clock with six divisions. A story star is a type of essay critique service, star diagram that can be used to describe the key points of a story or event, noting the 5 W's of the kite questions, story: who, when, where, what, and why.
5 labeled petals around a main oval. A chart with 2 columns and 5 rows, labeled: Who, When, Where, What, and Why. 5 labeled options around a central oval. 5 labeled circles around a main oval. Book Impressions: Triple Draw and Write. Draw three of the major characters, scenes, or ideas from a book you have read, and write about each picture. Service! Or go to a pdf of the worksheet.
Books: Draw and Write 3 Things. Draw a scene or character from three of your favorite books and write about each of them. Or go to a pdf of the earthquake thesis, worksheet. Diagrams for writing paragraphs with a topic sentence, support details, and a conclusion sentence. Use this form to write a book report, noting the book's name, author, main characters, setting, and plot summary.
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panic attack essay A Comprehensive Overview. This essay summarizes current information about varieties of panic disorder and their treatment. It is service based almost entirely on publicly available information gathered during the years 1998 through 2000 from sources (not specifically cited) that include published research papers (most available through MedScape or MedLine), published textbooks and trade books authored by qualified mental health professionals, articles in WebMD and men 5, the New York Times, the opinions of clinicians specialized or experienced in the treatment of panic disorders, and the experiences of some hundreds of individuals (patients, health care professionals, and peer counselors) who have shown up in various Internet-based support communities focused on critique service, panic disorders or other anxiety disorders. Earthquake Thesis. The intent is to introduce the reader to the wide body of knowledge that exists today and to integrate and disseminate a variety of emerging insights often omitted from the narrow classical view of essay critique these disorders.
This essay should not take the place of medical and psychological treatment. Individuals who believe they may have panic disorder should be evaluated by a physician familiar with the complexities of panic disorders and the conditions that mimic or accompany them (some of which are discussed herein) and earthquake, should receive an appropriate combination of pharmaceutical and essay critique service, psychological treatment from qualified caregivers specialized in this family of conditions. For further background and a more detailed disclaimer, please refer to the end of this document. The online source for this essay resides at http://www.panic411.org/ This essay may be linked to or printed for limited noncommercial distribution by individuals.
Any other form of runner essay dissemination or republication must be authorized in writing. Panic Disorder is a broad-brush label currently applied to a variety of conditions having clearly distinct etiologies, prognoses, and essay critique, appropriate treatment strategies. Reasonably distinct causes of panic disorder include: Phobic sensitization to symptoms of panic or anxiety #150; fear of the fear Prolonged stress Anxious or obsessive patterns of thinking Poor breathing habits, whether rooted in runner essay anxiety or other causes Emotional or existential turmoil (whether conscious or unconscious), often deriving from conflicting expectations, needs, desires, or external requirements and resulting in critique a subjective perception of helplessnes or paralysis. These first causes are the kite, best known and, together with one or two concepts such as false suffocation alarm and separation anxiety, are considered the classic causes. However, they may in fact explain a minority of cases.
Other causes include: A hereditary defect in the metabolism of critique service cholecystokinins (CCK), endocrine substances involved with regulating both digestion and jude the obscure, stress endorphins. Service. People with this form of panic disorder have likely exhibited escalating gastrointestinal symptomatology, often Gastro-Esophageal Reflux Disease or Irritable Bowel Syndrome, for years or decades before the emergence of panic attacks. Norepinephrine and secondarily epinephrine GABA Serotonin. Each of the causes of panic disorder listed above is supported by a body of jude essays published research, except as noted in essay the last point, where the relevance to panic disorder is more speculative and is not suggested by the researchers but is suggested by the well-documented statistical association of panic disorder with schizophrenic families. With Paper. Ongoing advancement in essay critique service the scientific understanding of panic disorder may reveal etiological overlap among these factors beyond the overlap already suggested or it may lead to further differentiation. In addition, there are a number of critical distinct medical conditions, some commonly recognized and others not, that mimic panic disorder or exacerbate sub-acute cases into an acute phase. Beyond the critique, universally recognized but very rare pheochromocytoma, some of the more commonly encountered conditions are: Hypothyroidism. Thesis Statement. Screening for service, TSH levels is essay gilded widely regarded among first-line clinicians as sufficient screening for thyroid abnormalities; however, such limited screening consistently fails to identify a number of hypothyroid conditions that lead to panic attacks and other serious and critique service, sometimes life-threatening pathology. Once the runner redemption essay questions, condition has advanced to the stage of panic disorder, correcting the essay critique, underlying imbalance may not be sufficient to bring about remission, as damage to the nervous system can already have occurred at essays, this point. Strictly speaking, it can be argued that panic disorder is a misdiagnosis when it is essay critique service secondary to papers database any of these conditions. In the real world, however, medicine most often fails to essay critique diagnose the underlying condition if the kite runner questions, presenting symptoms have an critique anxious presentation to them.
As a result, the panic disorder population #150; on which all research is thesis statement conducted, from which the essay, understanding of panic disorder derives, on 12 angry, which treatments are tested, and to which the resulting diagnostic and therapeutic protocols are applied #150; is exactly this mixed bag of patients and causes. A diagnosis of panic disorder carries with it a substantial likelihood that one (or more than one) of these factors is present. Studies over long periods have established that thought patterns once thought to be causative in panic disorder, such as hypervigilance, catastrophic thinking or catastrophic interpretation of sensations, among others, emerge in many patients as a result of the condition and critique, cannot in fact be considered preexisting causative factors in those patients #150; that, for kite redemption questions, instance, the tendency toward catastrophic interpretation of relatively normal physical sensations typically emerges (if at essay, all) as a gradual consequence of the normal interpretation of gilded lily catastrophic physical sensations lying outside non-afflicted individuals' realm of essay experience. It is also critical to understand that individuals with panic disorder do not necessarily worry more, feel more stressed, or internalize or somatize more than non-afflicted individuals. They can certainly develop such traits as a result of the condition (or possess them from birth), but the distinguishing factor is that the neurochemistry of an kite runner redemption questions individual with panic disorder reacts differently from that of a non-afflicted individual even to low or normal levels of stress #150; or to essay critique other, idiopathic factors not necessarily related to situational stress or worry.
This difference manifests itself in gilded lily a variety of ways, some of which are well understood and critique service, some of which are not. Absolute elimination of panic attacks should be one goal of treatment, because of their kindling effect. Research Normalization. With each panic attack, the nervous system becomes more prone to service experience the next one. This is not only a psychological process, but a neurological one as well. Absolute elimination of panic attacks is not a sufficient goal of treatment, much as elimination of sugar from the urine of a diabetic is not a sufficient goal of treatment for diabetes. The insufficiencies, imbalances, and processes leading up to the panic attacks, both neurological and psychological, are far from benign. Because of the research, variety of causes and processes at work in panic disorder, there are few generalizations one can make that would apply to critique as much as 75% of the panic population. However, subgroups and regularities do clearly exist, so there are many generalizations one can make that apply to various groups of as much as 30-40% of the kite runner redemption essay questions, population.
The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV™) describes a panic attack as follows: The essential feature of a Panic Attack is a discrete period of intense fear or discomfort that is accompanied by at least 4 of 13 somatic or cognitive symptoms. The attack has a sudden onset and builds to essay critique service a peak rapidly (usually in 10 minutes or less) and is often accompanied by a sense of imminent danger or impending doom and an urge to escape. The 13 somatic or cognitive symptoms are palpitations, sweating, trembling or shaking, discomfort, nausea or abdominal distress, dizziness or lightheadedness, derealization or depersonalization, fear of losing control or going crazy, fear of dying, paresthesias, and kite essay questions, chills or hot flashes. Attacks that meet all other criteria but that have fewer than 4 somatic or cognitive symptoms are referred to as limited-symptom attacks. This is probably as good a rudimentary operational description as any, although it is critique only a committee consensus not based on any consideration of essential underlying mechanisms. (The idea of peaking within 10 minutes is kite essay now generally agreed in the panic disorder community to apply to a minority of cases. Essay Critique Service. Full status panicus can persist for hours or even days. Presence of the 10-minute observation in papers database normalization DSM-IV is probably a legacy from the time when panic disorder was thought to be synonymous with hyperventilation syndrome.) It is important to note that anxiety or fear, although typical, is essay critique not a requirement.
Intense discomfort, whether existential or physiological, is equally a qualifying factor. In fact, the terms panic disorder and jude, panic attack may do as much to obscure the true face of the disorder from clinicians and patients as they do to make it understandable to the general public. Much additional insight can be gained from one of the critique, pioneers in treating panic disorder before there was much medical understanding of the condition, Dr. Claire Weekes. She wrote of a panic attack as consisting of a first fear and a second fear. The first fear is some cluster of sensations, often untriggered, of jude which the patient suddenly becomes aware. These would be sensations like those broadly categorized in the DSM-IV definition (and treated in somewhat more detail under later headings in this essay). We know today that the critique service, term arousal or dysautonomia is more appropriate than fear to men 5 essay many patients and clusters of sensations, but Dr. Weekes' early insight is still remarkable for her time, crucial to understanding the anatomy of a panic attack, and therapeutically useful today.
The second fear is a reaction to essay the appearance and sensations of the first fear. Competing descriptions have emerged for why this second fear comes about #150; premonition of death, fear of suffocation, resonance with primal separation trauma, catastrophic thinking, etc. Runner Redemption Essay. #150; but basically, Weekes' premise is that the second fear is fear of the first fear. It is a rapidly escalating, possibly eruptive panic reaction that feeds back into the manifestations of the essay service, first fear or triggers new manifestations. It is Weekes' second fear that is addressed by most attempts to treat panic disorder. Patients are taught not to fear the primary sensations of the essay, episode. This is an extremely useful concept in Cognitive-Behavioral Therapy for panic attacks. Critique. In the days before any such phenomena were recognized, patients either learned to do this on their own or medicated themselves with alcohol or with medications prescribed for nerves. Redemption Questions. (Or in essay service the worst cases, they were committed to psychiatric hospitals.) The aim of such CBT is to learn and help with, internalize the idea that the primary manifestations are benign and to learn not to compound them with a panic reaction. Antidepressant medications also primarily treat this second fear, even as some of them may exacerbate the primary manifestations of panic disorder. Nonetheless, the fact remains that the primary manifestations of a panic attack, the first fear, can be intensely unpleasant. Even without any second fear, the primary manifestations of a panic attack can have a distinctly paroxysmal quality of essay service their own, akin to vomiting or a slow-motion sneeze or a slow-motion shudder or an orgasm.
They have differing causes in different cases. Various theories compete to provide an essay explanation. Essay Service. Some neurologists hypothesize neuroelectrical chaos. Some make an analogy to papers database a sort of epilepsy outside the brain, while others dispute the appropriateness or desirability of such an analogy. Essay Service. Others find deficiencies of parasympathethic neurotransmitters.
In some patients, blood oxygen saturation drops by jude the obscure critical essays, 25% or more, sometimes in response to circulatory disturbances and other times in response to underbreathing. It is essay likely that a relatively large number of paper transitory endocrinological and neurological manifestations exist but are difficult to observe in progress. And then there are patients in whom the primary manifestations are non-paroxysmal. Such patients may simply shake randomly and uncontrollably, or feel intense generalized abdominal distress, or experience a variety of alien internal sensations. These sensations can be frustratingly difficult to describe, since they often lie outside of essay shared experience, the redemption essay questions, language lacks any directly descriptive terms for critique service, them, and database, the non-afflicted can only try to interpret such descriptions in terms of personal experience. Essay. A further complication is that even medical doctors versed in with paper writing panic disorder do not always know what is essay critique service happening biologically or how to observe or measure it in other than superficial terms. The experience usually looks like fear and it most often, though not always, feels like fear as well, albeit sometimes a strange fear. These manifestations may continue for hours or even days in the absence of medical intervention (despite the DSM-IV's specification of 10 minutes as a norm), and not all patients experiencing these symptoms experience the help paper, escalating or eruptive second fear to which Weekes refers. It is possible to learn not to compound one's reaction when blood oxygen saturation falls substantially, or when a drop in essay service the availability of the neurotransmitter acetylcholine below a certain threshold causes muscles to go into random spasms, or when any of a host of other manifestations appear, but absence of a compounding second fear by 12 angry men 5 paragraph essay, no means implies that one is well or feels well. One might well say of some cases #150; and such cases are not rare #150; that over time the panic disappears but the disorder remains. Critique Service. On one level, that is a facetious statement, but on another level, it captures an important truth.
So while practicing psychologists and psychiatrists largely focus (wittingly or unwittingly) on treating Weekes' second fear and associated complications (primarily inter-attack anticipatory anxiety, agoraphobia, or phobic avoidance), researchers and neurologists work at expanding our understanding of the first fear, or the primary manifestations of panic attacks. The belief that most panic disorder patients are simply overreacting to normal sensations that others ignore is rapidly being relegated to papers database history. The primary manifestations of panic attacks are often anything other than normal sensations. Researchers in whom such sensations have been induced artificially have described them as harrowing. One described them as comparable in essay critique degree of trauma to with paper wartime experiences. Hyperarousal and the Mind-Body Duality. The conditions commonly called anxiety disorders #150; Generalized Anxiety Disorder, Panic Disorder, Social Anxiety Disorder, Obsessive-Compulsive Disorder, and other less commonly diagnosed conditions #150; are all essentially disorders of hyperarousal.
In the case of panic disorder, particularly of the familial variety, the hyperarousal tends to be essential (having no single, clearly identifiable cause, much like essential high blood pressure) and, at least in the early years, autonomic (expressing itself primarily or initially in physical symptoms not under conscious control). There has been a tendency in the conceptualization of these disorders (at least the first three) to think in terms of hyperarousal specifically of the fear, alarm, and essay critique, watchfulness circuits of the brain, but in truth the hyperarousal tends to jude critical essays be more generalized in nature. It may even lack an intuitively anxious presentation. Because typically anxious arousal is more likely to be noticed, clinicians' unawareness of the generalized nature of the hyperarousal involved can lead to underdiagnosis of hyperarousal disorders or to too narrow a focus on treatment of specific symptoms. Mental arousal comprises thoughts and feelings, both conscious and essay, unconscious. It may express itself in many ways, some of them subjectively negative (such as worry or non-specific agitation), some of 12 angry men 5 paragraph them subjectively positive (such as anticipation), some of them constructive (such as productive focus on essay, a project), some of them destructive (such as constant worry about improbable what-if scenarios). Mental arousal resides in the higher levels of the brain, those responsible for conscious and unconscious thoughts and feelings. Autonomic arousal consists of many bodily functions that are not under volitional control, such as heartbeat, sweating, digestion, and others; and some bodily functions that are partially under volitional control, such as breathing and 12 angry men 5 essay, excretion, so that they self-regulate in normal circumstances but are subject to conscious or unconscious intervention from higher levels of the brain.
Autonomic arousal resides nearly everywhere in the body outside the higher levels of the brain, including the nervous, endocrinological, and essay critique, immune systems and the most primitive parts of the brain that regulate autonomic function. It is an axiom of psychosomatic medicine that where the kite redemption essay, mind goes, the body will follow. Essay. There is, however, an equally true but often neglected corollary to that maxim, namely that where the body goes, the mind will follow. Each type of arousal disorder and each individual case has its characteristic mixture of mental and autonomic arousal and its own characteristic relationship between the two. It turns out to make little difference in panic disorder whether arousal is subjectively perceived as negative or positive, as anxiety or as pleasurable excitement. Help With Paper Writing. It is the essay service, fact of arousal in itself that primes the body to thesis statement experience panic attacks and then triggers the attacks. Critique. This is true whether the arousal stems from external stimulation or from internal factors, whether from primarily mental influences or primarily autonomic ones such as reactions to medication, food, heat, or panicogenic inhalants (including certain common air pollutants). The classical view of anxiety disorders is that mental hyperarousal is the help with paper, impetus behind autonomic hyperarousal. This is an understandable oversimplification, because it describes what is true much of the time in normally functional individuals. It ignores the key point, however, that these are precisely disorders of arousal, and that there are various forms of these disorders. An arousal disorder may be driven by essay critique service, intrinsic hyperarousal of the mind, by intrinsic hyperarousal of the autonomic nervous system, or by an aberration in the way either one influences the other.
And whatever the primary impetus of the disorder, secondary effects nearly always emerge to essays complicate the condition and confuse its characterization #150; effects seen in the mental and autonomic domains and in essay critique the way that the the obscure critical essays, two domains influence each other. Yes, the mind can arouse the body and it can calm the body. It can even make the body ill, as one sees in the traditional view of stress and psychosomatic medicine; and essay critique, it can heal the body, as one sees in the response of such conditions as cancer to the influence of psychotherapy #150; although thankfully, one does not see anyone advocating treatment of the mind as the primary care for kite runner redemption, cancer patients. (One hopes that the average treatment of panic disorder will some day be so enlightened…) However, the reverse is essay critique service equally true: the body can arouse the jude essays, mind and it can calm the mind; and critique service, it can even make the mind ill or heal the mind. One sees one obvious example in the relaxing (or in some cases invigorating) effects of massage #150; indeed the ability of massage therapy to influence the course of mental and with paper, even physical illness. Another example is found in the mental illnesses #150; depression, obsession, anxiety #150; that frequently develop as secondary consequences of essay critique service chronic organic illness.
Food reactions distinct to paragraph essay certain genetic groups constitute another example, as do arousal reactions to certain antibiotics and anticholinergic medications that do not act directly on higher levels of the brain. The spectrum connecting mental and autonomic arousal could be compared to a pushme-pullyou, the fictional creature from Dr. Dolittle with two front ends and two brains. The beast is essay critique particularly unpredictable in individuals with anxiety/arousal disorders. The mind can be driving the disorder with the essay, body mostly along for the ride. Or the body can be driving the disorder, with the mind doing its best to resist. Treatment of the mind can accomplish surprising effects on biology, but this is essay service compensation, and it does have its limits. If this were not so, then psychotherapy would be the earthquake, primary treatment against for instance epilepsy, a condition with certain similarities to some forms of panic disorder and critique service, a condition that is sometimes partially responsive to jude psychotherapy. So a good understanding of the mind-body connection in panic disorder generally and in any specific patient is essential to intelligent diagnosis and essay, effective treatment. Normalization. Notwithstanding the mind-body overlap, the essence of critique each case is usually to statement be found in some intrinsic factor on one side or the other. The reader should know that the essay service, medical community currently applies the term dysautonomia to an abnormality in the self-regulation of autonomic arousal and applies the term anxiety to research papers normalization an abnormality in the level of mental arousal, including any manifestations of autonomic arousal presumed correctly or incorrectly to derive from conscious or unconscious thoughts or feelings.
This conceptual bias tends to hobble treatment, but it is important for the reader to understand the doctor's likely perspective at the outset of the relationship. Most of the clinical progress currently taking place in the medical treatment of panic disorder occurs through the process of patients exposing their doctors to service the body of research relevant to their own variant of redemption essay panic disorder. Dysautonomia and its Paroxysms. The panic attacks in panic disorders are usually just the tip of the iceberg. Just as significant as panic attacks per se is the essay critique service, chronic dysautonomia present in panic disorder. A number of expressions of dysautonomia are often present for extended periods in panic disorder patients, even in the absence of research frank panic attacks. Indeed panic attacks could in most cases be called dysautonomic paroxysms, and the disorder could reasonably be called paroxysmal dysautonomia. The following is a reasonably comprehensive but certainly not exhaustive list of mostly dysautonomic symptoms associated with panic disorder. (Not all of these are strictly speaking dysautonomic, though most are, but this is a convenient place to gather symptoms frequently associated with panic disorder.) Any given person is essay critique service likely to experience only a handful of these symptoms, though they may be frequent and intense. The point of such an extensive list is to help with writing provide reassurance to someone diagnosed with panic disorder who is essay critique service experiencing any of these very diverse symptoms that they can indeed be merely symptomatic of panic disorder and paragraph, not necessarily a sign that some other medical or biological condition is present.
Heart-and circulation-related: Rapid, irregular, or forceful, loud heartbeat. Sensation of skipped heartbeats. Chest pain. Low or high blood pressure, often with remarkably wide swings. Panic disorder patients are sometimes diagnosed with atypical mitral valve prolapse or mitral valve prolapse syndrome.
It is characteristic of panic disorder that symptoms from several of the service, groups above occur together. (panic disorder is a polysystemic condition, which is one factor leading to poor recognition, diagnosis, and treatment.) It is also normal for some varying level of with writing these symptoms to be present much or most of the time for uncontrolled patients, but for the symptoms periodically to escalate to the point of paroxysm followed by relief of varying duration. It is common for critique service, panic attacks to jude critical occur during sleep, especially in patients with the gene for cholecystokinin-related bile reflux panic disorder. In many respects, these dysautonomic symptoms ought to be of more concern to clinicians than the panic attacks themselves, except that patients experiencing panic attacks are at a strikingly elevated risk of suicide. Normal research subjects who have had panic attacks induced by the administration of GABA antagonists have described the experience as completely unbearable and the worst experience of their lives. (It is conceptually interesting that although synthetic panic attacks can be created with some degree of service success under laboratory conditions using serotonin depleters, serotonin reuptake inhibitors, cholecystokinin, sodium lactate, and norepinephrine, no class of substances but perhaps cholecystokinin comes anywhere close to earthquake thesis statement the panicogenic effect of a GABA antagonist. This suggests that the old GABA-based conceptualization of panic disorder in the wild was more correct than newer serotonin-based conceptualizations.) In a significant number of patients, dysautonomic symptoms and panic attacks emerge not during periods of long-term or short-term stress, but after the cessation of such stress or during its period of essay critique abatement. This is probably true in particular of the patients with cholecystokinin abnormalities.
In a significant number of patients, mental/emotional anxiety waxes and wanes, and the dysautonomia waxes and wanes, but there is no identifiable pattern of correlation. It is in these patients that the neurological dimension of the disorder is the most obvious. There is an interesting minority of patients who experience severe dysautonomia, even to the point of physical incapacitation, without experiencing what they themselves would call a panic attack. This is not too difficult for many sufferers of panic disorder to understand, particularly after therapy or years of paper writing experience with the condition have desensitized (to varying degrees) the fear response that can be aroused by the dysautonomia. Critique Service. One experiences all of the escalating dysautonomic arousal without the paroxysmal culmination that provides temporary relief. People who have not experienced a panic attack can perhaps understand this distinction by thinking of sexual arousal and orgasm as an with paper writing analogy. It is service possible to be highly aroused without experiencing orgasm. Similarly, these non-paroxysmal dysautonomic states can be very intense #150; indeed they can be more intense than the thesis statement, states that would induce paroxysmal panic in other panic disorder patients or in normal individuals. Current thinking distinguishes between Generalized Anxiety Disorder (GAD) and critique service, panic disorder largely (though not entirely) on the basis of absence or presence of panic attacks.
But in some respects, these conditions appear much of the time to be differing degrees of the same biological disorder, and the obscure essays, if it is useful to distinguish at essay service, all, it might be more diagnostically and therapeutically useful to apply a distinction at jude essays, right angles to critique service the current one, recognizing one disorder that is primarily somatic/dysautonomic and another that is primarily cognitive/emotional. Granted there is papers database overlap, but there does appear often to be an etiological distinction in reality. It is common practice to consider panic disorder controlled when panic attacks are eliminated. However, the goals of treatment should actually include elimination of most or all of the associated dysautonomia, as the dysautonomia is symptomatic of uncontrolled underlying pathology and in some cases exacerbates the underlying pathology (just as uncontrolled panic attacks escalate through neurological as well as psychological mechanisms). Panic disorder of biological genesis is service chronic and mildly progressive. Kite Redemption Questions. Although some clinicians claim encouraging cure rates, usually in carefully selected groups, studies have shown that when one looks at patients over critique service, periods of time four years or longer, a preponderance of men 5 paragraph essay patients experience relapse in the absence of ongoing pharmaceutical treatment. This is essay critique not always evident to research papers treating clinicians (who have been known to claim cure rates as high as a thoroughly suspicious 100%), because patients frequently change doctors if they perceive that their treatment was unsympathetic or ineffective; and relapse is readily perceived as a sign that treatment was ineffective if the essay critique, treating physician has created unrealistic expectations of a permanent cure or has exerted subtle pressure to recover or to tough out minor episodes. It is often stated that panic attacks do not lead to heart attacks. Papers. This is true as far as it goes; however, sufferers of uncontrolled panic disorder are at critique service, a quadrupled risk for eventually experiencing a serious cardiac event. For instance, QT prolongation (a type of subtle heart arrhythmia) is present in a disproportionate number of undertreated panic disorder patients.
In fact, a variety of 12 angry paragraph arrhythmias are observed with disproportionate frequency in panic disorder patients, though many of them are only observable during an episode or during the lead-in to an episode. The paroxysm of the attack itself may serve to correct the arrhythmia. One of the greatest health risks for sufferers of panic disorder as they grow older is unrecognized serious illness that would be diagnosed earlier in other patients. If it is true that a certain proportion of panic disorder patients tend toward hypervigilance and hypochondria, particularly in essay service the years just prior to and following correct diagnosis with panic disorder, yet it is also documented that primary care physicians and with writing, many specialists tend to dismiss the complaints of patients bearing a diagnosis of critique service panic disorder (or generalized anxiety disorder) without sufficient foundation for doing so. Panic disorder patients get organic illness just as often as other patients. They just don't get it diagnosed as often. In fact, it has been clearly shown that patients with anxiety disorders go longer before diagnosis of serious conditions than do patients without these stigmatizing diagnoses, and kite runner essay questions, physicians have cause to be more concerned with the potential for medical error and liability. Particularly problematic is the practice in some emergency rooms of shunting panic disorder or GAD patients presenting with chest pain or other possible cardiac symptomatology into psychiatric observation without sufficient examination. There are documented instances of fatalities resulting from such systematized negligence. On the critique service, other side of the 12 angry essay, same coin, emergency rooms also represent frequently missed opportunities to identify potential cases of essay critique panic disorder.
Many ER doctors are poorly trained to recognize panic disorder, particularly in its pre-emergent guise of essay gilded lily non-paroxysmal dysautonomia. This is not surprising given the diagnostic criteria in use today. Pre-emergent panic disorder often does not look much like GAD, as it is essay service is likely to essay gilded lily be primarily somatic until the first string of panic attacks initiates the cycle of fear or worry and cognitive-emotional-behavioral disturbance. Unfortunately, even when ER doctors do recognize panic disorder, they are still as likely as not to dismiss it as neurosis unworthy of serious attention and counseling or referral. Patients are still likely to be told to breathe into a paper bag next time, although this is in fact more likely to essay critique trigger than to stave off a panic attack for a sufferer of biologically rooted panic disorder. In fact, panic disorder patients are often told (not asked) that they are claustrophobic, or anxious travelers, when in fact their bodies are reacting in predictable and well-understood ways to the elevated levels of CO2 present in redemption essay questions poorly ventilated spaces full of breathing bodies. Critique. This ties in with the false suffocation alarm interpretation of panic disorder, although this theory has become less prominent in the field as other mechanisms have become better documented.
This is papers normalization not to essay critique say that the interpretation will prove to be wrong, merely that it is not universal. Help Writing. And in point of fact, it has not as yet been proven to be anything; hypotheses and assertions relating to panic disorder must be subjected to essay the same standard of proof as other, non-psychology-related, statements of medical doctrine. One finds that clinicians who demonstrate admirable scientific rigor in making non-psychiatric diagnoses are given to the obscure comically whimsical leaps of critique service faith in attributing patients' symptoms to psychosomatic processes. (Hence the derisive terms psycho-so-magic and psycho-so-magical that one sometimes encounters in patient discussions.) Note: There is ample research around the gilded lily, false suffocation alarm to essay service indicate that elevated CO2 levels do in essay gilded fact provoke hyperarousal and panic attacks in a subset of the panic disorder population. At issue is the histrionic labeling of this reaction on the assumption that all individuals ought to experience identical toxic reactions to CO2 at critique, identical concentrations. One might just as easily label hypoglycemic states as false starvation alarm reactions. It is not the alarm per se that is false, it is merely its characterization as one of jude the obscure life-threatening suffocation or starvation that is false #150; and that is essay service not the patient's error of interpretation, as the term implies, but the diagnostician's. (And when this model was extended to essay a population with anxiety from pulmonary disease, the alarm sadly turned out not to be so false.) There are a number of conditions frequently associated with panic disorder. Some of them may be cause or effect of the disorder, while others are merely associated. It is important for physicians to recognize the associations, because sometimes it is essay service difficult to treat the associated condition if the underlying or associated panic disorder is left untreated.
GERD, IBS. Probably the conditions most universally present in panic disorder are Gastro-Esophageal Reflux Disease and Irritable Bowel Syndrome. 12 Angry Men 5. In approximately 40% of essay critique service panic disorder patients, both are caused primarily though not entirely by thesis, the excessive and irregular secretion of bile so characteristic of hereditary panic disorder. In some patients the effects are mostly upward in the GI tract, resulting in excessive stomach acid secreted to neutralize the bile and leading to service GERD #150; sometimes with associated asthma or sinusitis that is not recognized as related to panic disorder or GERD. Redemption. (Gastric swelling and consequent pressure on the diaphragm or a nerve center has been proposed as one possible cause of abnormal breathing in panic disorder; such a suggestion is supported by the fact that subjective difficulty in breathing related to panic disorder can be alleviated in critique service some individuals by pressing fingertips downward into the abdomen not far below the sternum.) Often patients will have had GERD or IBS for years or decades, frequently even since childhood, before the emergence of panic disorder diagnosable by current DSM-IV criteria. Even panic disorder patients who do not show overt symptoms of GERD or IBS often exhibit the men 5 paragraph, characteristic abnormalities of essay service bile secretion. The combination of paragraph Xanax and Carafate has been found to be remarkably effective in essay treating these conditions in panic disorder patients; indeed therapeutic response of GERD or IBS to this combination can almost be regarded as a diagnostic criterion. (It is not known why Carafate is often so much more effective in kite questions the panic disorder population than newer drugs like acid blockers and proton pump inhibitors, but the phenomenon is distinct.) As one follows any group of panic disorder patients over critique service, a period of years, half or more do apparently keep the diagnosis of essential panic disorder. However, every year a certain percentage are found to 12 angry men 5 have an organic condition the diagnosis and treatment of which resolves the panic disorder. Obviously the organic condition, or at least a tendency to it, was present years before it became overt enough to trigger normal diagnostic flags. A panic disorder patient should be prepared to believe and to accept the benign diagnosis of panic disorder for essay service, the rest of their life. But clinicians and patients alike should be alert to changes and should recognize that for instance normal ranges on laboratory tests apply to a statistical abstraction and not necessarily to every individual.
Often individuals experience well-being only within a narrower range of 12 angry paragraph essay values than the service, stated range (which varies from lab to lab in any case), and on some types of tests, even the optimal center point may be different for different individuals. Panic disorders, the comorbid conditions mentioned above, and the possible reasons for comorbidity offer much fertile and largely unturned ground for research in the coming years. There are quite a few chicken-and-egg questions raised by just the associations discussed above, not to mention associations that will emerge with more research. One thing that is with clear even now, though, is that with or without statistical documentation, most of the associations discussed above are widely recognized in critique service the panic disorder community. On Medicine As Biology. Those of us without a medical education tend to think of our doctor as a kind of master detective biologist. It's a natural assumption but it reflects an important misunderstanding of medicine as art or science. A doctor is only a master biologist in the loose sense that an architect or a structural engineer would be a master physicist. The Obscure Critical Essays. After a few notoriously rigorous courses in certain traditional elements of human biology, a medical education branches rather quickly into the study of established medical protocols for diagnosis and treatment of well-recognized conditions. When a doctor examines and diagnoses us, he is not, as we might easily imagine, unraveling the mysteries of our biological individuality. Rather he is comparing our presentation to a multitude of checklists that would match us to one of the standard diagnoses and treatments he has (in the best case) mastered.
American medicine in particular prides itself in being based on statistical models of essay critique disease. The European medical tradition recognizes the statistical perspective and and the case-based or anecdotal perspective as complementary halves of a complete picture, halves that are roughly analogous to macroeconomics and microeconomics. But the case-based perspective interests American medicine only insofar as cases reflect what is 12 angry men 5 paragraph essay typical of the statistical perspective on a patient's illness. Doctors are explicitly trained to gloss over and filter out the critique, idiosyncrasies that conflict with the accepted model of the condition. Thus many will persist with a favored class of medication despite a patient's obvious adverse effects or lack of response. It is revealing that the doctor's impatience will be with the patient, not with the papers, medication. They will ignore patients' reports of unusual symptoms as irrelevant when in fact they could be highly relevant to unraveling the individual mystery and finding a treatment that is effective for the individual patient. In such cases, the doctor is not treating the patient, he is treating the statistical model of the patient's diagnosis (a diagnosis which may or may not be correct) . Nowhere does this approach to medicine fail more spectacularly than in a condition like panic disorder, where it is so difficult to define what is typical. But it fails in other contexts as well.
The author of this document himself was evaluated by 14 doctors over a span of more than 10 years before aldosteronism was finally noticed, proven, and identified as the root cause of all the symptoms that had received such a variety of diagnoses and service, misdiagnoses (including panic disorder) over that time. Mumblings about kite, anxious patient and essay, panic attacks were always somewhere in the background. In the end, he himself had to 12 angry men 5 paragraph suggest the diagnosis that proved to be correct and argue vigorously for the definitive test that clinched the diagnosis. Unfortunately, the author's experience is not at all unusual. Such outcomes are commonplace in panic disorder support groups.
They may even be more the essay, rule than the exception. The overlooked diagnoses vary, but the experience is the same. Runner Redemption Essay Questions. Patients go years and even decades getting hurried, substandard and frequently condescending care from doctors (often at premier practices or medical facilities) who jump to hasty conclusions and rush to try out the latest psychotrophic medication. Often the final and essay critique, correct diagnosis is a condition thought to be rare, such as celiac disease, aldosteronism, or thyroid dysfunction, but which appears to be strikingly common in jude the panic disorder population. Sometimes these failures of essay critique diagnosis occur because a doctor who might recognize a single unmistakable result on a routine test or some other unmistakable clinical indicator is not good at recognizing a constellation of paper writing borderline results or suggestive indicators that must be considered in combination before they add up, as in the author's case, to essay a clear picture. More often such failures of diagnosis reflect a simple failure to be meticulous. Essay Gilded Lily. So patients suffer years of adverse medication reactions, stigma, and essay critique, other woes that often include lost jobs, lost mobility, lost careers, lost marriages, and lost financial security.
Then a single meticulous doctor provides a correct diagnosis and correct treatment, and essay, the neurotic symptoms magically evaporate. One truth is abundantly clear in all of this: the extent to which our presentation is atypical is almost precisely the extent to which our doctors will fail to correctly diagnose and treat us. They are trained to ignore the essay critique, atypical, not to seek an explanation or accommodation for essay gilded lily, it. And there are virtually no typical cases in panic disorder or the conditions that mimic it. Service. There are only typical treatments. There have been studies showing that doctors almost universally overstate their treatment successes and understate their patients' adverse reactions. Some studies have even explored psychological reasons for papers database, the disconnect from reality. But it is also easy to explain by natural selection. There are many doctors who treat panic disorder ineffectively and who fail to diagnose medical conditions masquerading as panic disorder.
There are only a few who routinely do well at it. Essay Service. It is well documented that most panic patients see multiple doctors (averaging ten or more) before finally receiving effective treatment or correct diagnosis. Almost every one of men 5 paragraph essay those earlier doctors assumes that treatment has been successful, or at critique, the very least fails to receive any feedback on the negative outcome or misdiagnosis. Thus there will inevitably be a large majority of doctors who think they are doing much better than they actually are. One could well object, in cases of delayed diagnosis, that then it's not panic disorder. But if all the patients who have had this experience or will have it in the future could omnisciently be removed from the population that forms the core of the panic disorder industry, it's not clear that there would be many left. Certainly much that the medical community now thinks it knows about the condition would no longer be valid in such an runner essay omnisciently sifted patient population, because most of the current knowledge (such as it is) has been derived from this heterogeneous population.
Unfortunately, all of this talk about undiagnosed and misdiagnosed conditions feeds into critique service the worst and normalization, most common fear in the panic disorder community, namely that some terrible condition has gone unnoticed, one that will kill us before it is discovered. The bad news is that undiagnosed medical conditions are very common in the panic disorder population. But the critique service, good news it that they are almost never fatal conditions. The fatal conditions do get diagnosed quickly. In fact, finding things that will kill you is the database, one thing that modern American medicine does better than anything else. By the time a panic disorder patient has undergone EKGs, MRIs, and all of the other routine technological marvels requiring little initiative or detective work from a doctor, the patient can be confident there is essay critique no undetected brain tumor, no undetected adrenal tumor, no potentially fatal heart arrhythmia, and 12 angry paragraph, no other killer lurking unseen in the background. The conditions that commonly mimic panic disorder are almost never fatal. But it is inarguably difficult to get adequate testing.
Out of essay critique every 30-60 Americans with celiac disease (a common mimic of panic disorder), only one will be diagnosed during his or her lifetime. Countless celiac patients have written in online panic support groups about the long battle for testing that they had to wage before getting the critical, definitive tests and a correct diagnosis. For aldosteronism, the figure would be around one out of about 10-30 who ever receives the correct diagnosis. For autoimmune hypothyroidism, the prospect of diagnosis is presumably brighter, but many people write of waging long battles before the diagnosis was made. Panic disorder or the syndrome of its symptoms, even when caused by essay critique, some other condition makes it hard for the patient to practice acceptance. Yet it is vital to do so. We should recognize and accept that if we had a fatal condition, it would be noticed. We should recognize and accept that there may very well be some non-fatal condition causing our symptoms that has not yet been noticed #150; and that is not a catastrophe . We should recognize and research papers normalization, accept that in the doctor corps, as in every other walk of life, there is a small percentage (maybe 5%?) of people who do their work really well, a somewhat larger minority who are adequate for garden-variety patients (which we are not), and essay critique service, a full 50% who are below average (not to mention inadequate). We must be our own detectives and advocates, but we should do so methodically, patiently, and without rancor. We should ignore the condescension and hostility of doctors threatened by our persistence or our discontent.
People can only be as good as they are, and it is futile to earthquake hold anyone's mediocrity against them. Essay Critique. We should never remain locked in conflict with an unresponsive doctor, but should undramatically find another. We should remember that statistically, it will probably be the tenth or eleventh doctor who turns out to earthquake statement understand our condition and its treatment. Every new doctor is a step toward the right one. We should not be ashamed of looking for the right doctor, not be intimidated by charges of doctor shopping. If there is a treatable and unnoticed medical condition underlying our case, it will be our own initiative and nobody else's that leads to essay a doctor who can diagnose it. But in many cases, maybe half or more, no such underlying medical condition will ever be found, and we should accept that probability as well. The fact that panic is jude essays so hereditary (and genetically linked to a variety of other conditions) makes it clear that biology is a strong factor, but not every biological problem has found its way into the protocols of medicine. We should accept that as well. It is critique very possible to live a good life with panic disorder if only we find a doctor who can practice appropriate and individualized treatment. We should seek a therapist as well, one who can teach us to use the mind to compensate for failings of the research database normalization, body.
The first resolution must be to live as well as possible within the parameters of the condition. Often correct medication and competent therapy can lead to virtual normality. The search for explanations should never become more important than making the most of the function and possibilities we have. The search for another explanation is like prospecting for gold: it is a long-term quest, one in which we must pace ourselves wisely and one in which there may never be a payoff. On Treatment Options. The most commonly used treatments for panic disorder, in no particular order, are Cognitive-Behavioral Therapy (or a special variant known as Panic Control Therapy), various meditation or progressive relaxation practices, medication with tricyclic antidepressants, medication with SSRIs (selective serotonin reuptake inhibitors, another class of antidepressant agent), medication with benzodiazepines (a form of minor tranquilizer), medication with anti-epileptic agents other than benzodiazepines, and occasionally hypnosis or medication with one or another class of monoamine oxidase inhibitors (MAOIs or RIMAs) or antipsychotic agents. Hypnosis is relatively uncommon because it is seldom effective for critique service, non-phobic panic and can easily worsen the situation. Attempts to paragraph unearth and treat the underlying trauma are usually misguided because if the critique, initial diagnosis of essay panic disorder has been rigorous, it appears that there is seldom an essay critique service underlying trauma to unearth. Medication with MAOIs is relatively uncommon because of the dietary restrictions involved and the danger of hypertensive crisis.
Some clinicians are working with reversible monoamine oxidase inhibitors, but so far there appears to be little data on success. In listening to patients, it becomes apparent that there are patients who respond well to kite redemption each of the therapies in common use, either alone or in combination. It appears somewhat common and highly advisable, for example, to supplement medication with CBT or PCT, but one also sees combinations of medications. Reactions to medications appear to be highly variable in panic disorder #150; less consistent, for instance, than reactions to anti-hypertensive medications in the treatment of hypertension. One sees that some patients respond negatively to several medications or classes of medications, only to respond well to another. Some patients report that SSRI medications foster a return to spontaneity and exuberance, but others report a range of negative outcomes ranging from essay critique service, a dulling out of emotions or even physical sensations (resulting in thesis serious accidental burns or cuts) at one extreme to unbearable agitation at the other. Similarly, some patients report a normalizing effect from benzodiazepines, but others experience negative outcomes ranging from stupefaction or emotional dulling at one extreme to critique awkward or even dangerous disinhibition at men 5, the other. It seems quite clear in critique service talking to patients that reactions are highly individual, and kite essay, it seems probable that this is due to differences in respective patients' underlying biochemical disturbances. (A number of studies have pointed out that generally speaking, antidepressants seem to work well when the primary manifestations are of a psychological character, while benzodiazepines seem to essay service work better when the primary manifestations are of a somatic character. Here again we see evidence that there are separate etiologies underlying such a systematic difference in efficacy #150; that indeed distinct conditions are probably involved: a sort of GAD plus panic attacks and a dysautonomia with paroxysms and sometimes secondary worry.) It appears that few psychiatrists are aware of the distinct varieties of panic disorder outlined in the beginning of this essay, although the research documenting them is readily available in research journals and correct identification of the variety of panic disorder is critical to the correct choice of treatment.
Moreover, it appears that few cases of panic disorder are even referred for psychiatric evaluation in the first place. Instead, primary care physicians tend to feel competent to diagnose and treat the condition. Men 5 Paragraph Essay. A typical PCP is even less aware of the complexities of panic disorder than a psychiatrist, and will almost certainly regard the condition as invariably a serotonin deficiency (which term is itself a considerable oversimplification of one of several serotonin-related pathologies sometimes present in depression, panic disorder, anxiety disorders generally, and some other conditions not relevant to this discussion). So while it is quite apparent that reactions to panic disorder medications and the correct choice of medication vary by individual and by service, subtype of panic disorder, it also becomes apparent in listening to patients that many if not most physicians prescribe not according to what should or does work for individual patients, but according to what works for the individual doctor. One doctor treats virtually all cases of panic disorder with SSRI medications; another treats virtually all cases with tricyclic antidepressants; another treats virtually all cases with benzodiazepines. Patients who respond poorly to that class of medication typically suffer through several trials of four to six weeks each before changing doctors. It is not uncommon for a panic disorder patient to have gone through a number of physicians (with considerable personal suffering and sometimes loss of employment) before responding well to treatment. Oddly, it is the patient rather than the physician who is labeled non-responsive when one size does not fit all.
(Patients also tend to be unaware of the large proportion of doctors who have conflicts of interest in the form of subtle and sometimes not-so-subtle financial incentives to prescribe particular medications. Research Papers Database Normalization. In this respect, the ethical canons in critique medicine appear, at least based on actual practice, to be remarkably lax in comparison to those of other licensed professions.) It is unfortunate that individual response is typically ignored in prescribing for panic disorder, because the more one examines the evidence, the more it becomes apparent that any given individual is likely to respond really well to a benzodiazepine or to an antidepressant, but not interchangeably. Response to one of research these classes of service drugs is likely to be optimal, while response to the other will be marginal at database, best. A small minority of essay critique service patients seem to statement need both, but it can also happen that the essay critique, two types of meds antagonize each other instead of complementing each other. Kite Redemption Questions. This is contrary to the prevailing treatment practice, but at present, practice appears to be based more on agenda (or sometimes on tradition, lore, or peer pressure) than on objective evidence. Indeed most non-specialists appear to be wholly unfamiliar with the actual evidence, which is often at critique, odds with the claims of the salespeople (most of whose education is in paper writing sales,marketing, or communication) on whose counsel they rely.
The first rule of essay treatment in panic disorder should be: If it's currently working, don't even think about changing it! It is men 5 paragraph utterly appalling to see the numbers of patients who have been controlled and highly functional with one strategy of essay critique service management over the course of years, only to move to a new state or change employer (and thus change insurance company) or have their doctor retire, and then have complete havoc wrought in their medical condition, their emotional state, their marriage, and even their employment and financial status, all because an inept and overly self-assured doctor sought to adhere to research papers one or another of the continually emerging vogues in prescribing. One need only search MedLine to see the course of these successive vogues over essay, the last two decades, and it is clear that what is in today will be out a few years from now. There are choices to make in treating any newly emergent case of research papers normalization panic disorder, and humane, flexible, patient-responsive experimentation may be necessary. But experimentation with patients who are functional and satisfied is unconscionable, should be regarded as malpractice, and has indeed been grounds for successful malpractice litigation. Critique Service. Undermedication of chronic anxiety or dysautonomia is just as irresponsible and just as ripe for judicial redress as undermedication of chronic pain. On Cognitive-Behavioral Therapy.
(and Panic Control Therapy) A large proportion of patients undergoing CBT or PCT report that they have experienced significant benefits from such therapy, particularly in the area of essay coping with their symptoms, reducing the severity of their panic attacks, and improving their overall well-being. Critique. However, very few report that CBT or PCT alone is sufficient to eliminate or even necessarily to earthquake reduce the number of their panic attacks. Although there have been reports in critique service the past of redemption essay questions very high success rates with CBT alone, a recent study revisited some of the essay, results and essay lily, came to quite different conclusions. David Barlow, Ph.D., one of the leading figures in psychological treatment of essay critique anxiety, commented on this study with the laudable observation that The one thing that we've learned . now that more data are in, is that we're not really as good as we thought we were. This was refreshing candor and integrity in a field where professional pride has often taken priority over a dispassionate and earthquake, monetarily disinterested look at the relative merits of service various approaches to research papers treatment. One would expect the best results of CBT or PCT to be achieved when the condition is rooted in anxious or obsessive patterns of thought. However, it is critique service not always easy to research distinguish such cases. Certainly it seems incumbent to treat such thinking whenever it is present, whether it is a preexisting causative factor or merely a result of the service, disorder. Further investigation is needed into the effects of CBT and PCT on essay questions, the dysautonomia associated with panic disorder.
Although a patient is essay service likely to be very grateful (and at a sharply reduced risk for suicide) after learning to statement experience less severe panic attacks in essay service the face of prolonged dysautonomia or dysautonomic paroxysm, little has been gained from essay lily, a medical perspective if the patient nonetheless experiences prolonged and frequent dysautonomic episodes. Critique Service. There is a certain value in teaching patients to cope with the symptoms of medically uncontrolled essential dysautonomia (especially if such treatment may reduce actual symptoms), just as there is value in thesis statement teaching patients to cope with the symptoms of other chronic medical conditions. Critique Service. Nonetheless, such therapy should not be substituted in whole for treatment of the medical condition itself. Meditation and progressive relaxation techniques are helpful for some people. Meditation techniques need to be undertaken with the understanding that dissociative states like those it may promote are not always desirable in panic disorder patients #150; that indeed they can trigger panic attacks in themselves or simply be more difficult to terminate for jude the obscure critical, individuals with anxiety disorders. (There is a fair amount of controversy around meditation in panic disorder, with strong opinions for and against.) And individuals undertaking either meditation or progressive relaxation need to understand that even when the practices are beneficial, a panic attack is most likely to occur during the transition from a state of essay high arousal to one of lower arousal.
This appears to be true of all or most panic disorder patients, but it is especially noticeable among those who have the essay lily, aberrant CCK gene. Obviously it is essay service desirable to make the transition from paragraph, high to essay low arousal, but most people would prefer to do so without triggering panic attacks in the process. Learning effective relaxation may thus be more complicated for kite redemption essay questions, the panic disorder patient than for other individuals. On Tricyclic Treatment. A growing number of clinicians now treat panic disorder using tricyclic medications, often after having used SSRI treatment for a number of years and then reverted to the use of tricyclics based on the number of adverse patient experiences. Tricyclics seem to work well for essay service, a minority of research papers normalization panic disorder patients. Statistically, some tricyclics are the most successful type of antidepressant for treating panic disorder, and those statistics were compiled in an era of less brazen manipulation of clinical trial data than we see today.
However, due to critique service the parasympathetic insufficiency so frequently present in the disorder, a certain subset of panic disorder patients seem particularly prone to excessive cardiac stimulation from this class of medications, which increase the papers, availability of service norepinephrine. Tricyclics are also inherently less safe than most modern antidepressants, with substantially lower margins for dosage error or deliberate misuse. Tricyclic medications also reduce the availability of acetylcholine, and research database normalization, reduced availability of acetylcholine is believed to essay service be implicated in the mechanism of panic disorder. Their overall effect is to increase autonomic arousal, so like the SSRIs, they seem to work best where the panic disorder is research database normalization of psychological origin or has highly prounounced psychological manifestations. On SSRI Treatment. Among clinicians new to essay service treating panic disorder or new to thesis statement using SSRI-type medications, these medications are often regarded as the treatment of choice or even a panacea. This point of view appears to be in service retreat among more experienced clinicians, although it is jude the obscure critical still heavily promoted by pharmaceutical companies, whose representatives still grossly understate the side effect and withdrawal profiles while greatly overstating the success rates of these medications in treating panic disorders. However, the side effect profile for SSRI medications is much worse than initially published studies revealed, the essay critique, effectiveness is highly unpredictable in treating panic disorder, and there is high risk for precipitating iatrogenic crisis when using this class of medications to help with writing treat panic disorder (especially during the beginning of treatment). An alarming percentage of critique patients in the Internet support communities for panic disorder had never experienced or even heard of a panic attack before they were treated for depression with an SSRI, but experienced panic attacks leading to an ultimate diagnosis of panic disorder within their first week or even the first day of 12 angry men 5 essay treatment and have not been able to rid themselves of the disorder after discontinuation of the SSRI.
Now they have depression and panic disorder, or sometimes panic disorder that persists beyond recovery from depression. Primary care physicians on the whole, and a sizable minority of service psychiatrists, are unfamiliar with the true side effect profiles of various SSRI medications, are unaware of the tolerance that develops to these medications when they are used to treat panic disorder, and are unaware of the withdrawal syndromes, despite the fact that all of these have been well documented in such sources as the British Medical Journal and the Journal of Clinical Psychiatry, among others. (And yes, it is called withdrawal and not discontinuation or discontinuation syndrome everywhere except in the United States.) A disturbing number of patients are not informed of the potential long-term risks of their medications, including the significant weight gain and sexual dysfunction, both of which can persist long after discontinuation of SSRI medications. When patients report some of the side effects of kite runner redemption questions usage or discontinuation that are typical in panic disorder, such as visual lag and critique, sensations of random electric shock, their physicians incorrectly state that these are not recognized as attributable to SSRI medications, even though they are well documented in the psychiatric literature. Additionally, almost every recent, independent study that has looked at help with paper writing, suicidality with SSRIs has concluded that although these medications are indeed safer in overdose than tricyclic antidepressants, a significantly greater proportion of SSRI users than tricyclic users actually attempt suicide. These people are not uninformed, either #150; they know that their SSRI is essay service not lethal, so they tend to use acetaminophen, gunshot, or hanging instead. Both anecdotal reports and systematic surveys of clinical practice reveal that a majority of physicians prescribing SSRIs do not know how to kite runner redemption essay questions correctly taper the essay, beginning and end of treatment with these medications, nor what reduced dosages to use in treating panic disorder, nor what protocol to jude the obscure critical essays follow in switching from essay, one SSRI to another #150; usually a direct switch is advisable, but some physicians prescribe a washout period that is both uncomfortable (if not debilitating) and writing, dangerous to service the patient #150; nor how to switch between an SSRI and another class of gilded antidepressant. One does see a large minority of panic disorder patients whose condition responds well to SSRI medications, even though these patients are no more exempt from the usual side effects than other patients. Essay. (Some find that the addition of essay gilded lily Serzone [now banned], or less often Wellbutrin, can restore sexual function lost to the primary SSRI and/or reverse the perversely treatment-resistant weight gain experienced by a majority of long-term SSRI users; however, neither of these medications appears to be useful alone in the treatment of panic disorder.) Not all of the essay critique service, patients who respond to SSRI treatment are the ones in whom the condition seems attributable to anxious or obsessive thought patterns, so it appears likely that there is some set of patients for whom these medications correctly target some underlying abnormality or imbalance.
However, many physicians seem unaware that a significant number of panic disorder patients react very badly and sometimes very suddenly to the anticholinergic effects of SSRI medications, a reaction that should not be surprising given the parasympathetic insufficiency posited to be so often present or even causative in panic disorder. Most long-term panic disorder patients who show up in the Internet support communities have been on a progression of different SSRI medications, often with a progression of different doctors, before being stabilized long-term on a regimen of research papers Xanax, Ativan, or Klonopin. Essay. A small number end up on research papers normalization, Valium, Tranxene or other benzodiazepines. [Update: A study presented in essay critique Atlanta at the 2001 annual conference of the Anxiety Disorders Association of America made a similar observation regarding the panic disorder population as a whole.] A significant number of other panic disorder patients who show up in runner redemption the Internet support communities began treatment on both an essay SSRI and a benzodiazepine, but were forced to discontinue the SSRI due to unacceptable side effects, and then found that they were well controlled on the benzodiazepine alone. One of the disturbing characteristics of SSRI medications is that once a particular SSRI has ceased to be effective in controlling panic disorder, it usually cannot be used effectively again in the future, not even years later #150; the earthquake, cessation of effect is persistent and perhaps permanent. This raises some troubling questions about the mechanisms behind the well-known poop out phenomenon distinctive to essay service SSRIs and other reuptake-inhibiting medications.
Current research hypotheses with some degree of experimental foundation include depletion of dopamine (though it is unclear why that would be so persistent), an excess of the otherwise therapeutic effect of desensitizing serotonin receptors (but why so persistent?), and physiological damage to men 5 paragraph essay or destruction of serotonin receptors (in which case it is doubtful but unproven whether they can be regenerated). SSRI medications reduce the service, availability of statement nitric oxide, and reduced availability of nitric oxide is suspected as a factor in the mechanism of panic disorder. They also increase production of prolactin, which may be a factor in the high incidence of sexual dysfunction, and essay critique service, alter the function of the hypothalamus, which is one of the mechanisms being studied as a possible factor in the strangely treatment-resistant weight gain associated with SSRI usage. (It is a shame that the dramatic differences in thesis reactions to SSRI treatment are so often minimized, trivialized, or dismissed outright instead of essay critique service being acknowledged and studied more closely. 12 Angry Paragraph. It is a shame because the differences probably provide, in their sheer starkness, some of the best clues currently available to the varieties of biochemical mechanisms underlying panic disorders #150; and to the various mechanisms underlying depression and critique, obsessive-compulsive disorder too, for that matter. Groups of people with similar reactions to one class of earthquake statement drugs, particularly drugs as selective and powerful as SSRIs, probably represent de facto classifications of people with similar variants of essay panic disorder or depression. It is possible that failure to follow up such an obvious line of jude the obscure investigation is due to essay critique commercial agendas. Kite Runner Redemption. But it is also possible that it is simply easier, with current research technology, to plan and study interactions between drugs and neurons in the laboratory than it is to look inside a living human being and observe the individual's true neurochemical processes or status at a given moment #150; that our ability to create drugs that act at the neuronal level has far outpaced our ability to observe in thorough and objective ways their actual effects on living creatures' neurochemistry. And so we rely on a priori speculation, we rely on subjective reporting of sensations and feelings far removed from the biochemical processes that cause them, and essay service, we conjecture as to their meaning.
Typically this takes place in trials where the protocol assures minimization or even outright dismissal of reactions that are not universal or at least common to a large proportion of subjects. So when something goes wrong for gilded lily, a minority of essay critique service patients, we conjecture around variations on the presumed and jude critical, intended workings of the drug at the biochemical level; but we do not know, and essay service, we have few tools to uncover, the subtleties that explain the full range of unintended effects.) There is an old saw that antidepressants cure panic disorder, whereas tranquilizers merely control it. Never mind that such a belief erroneously regards panic disorder as a single monolithic disorder. Even overlooking that point, when one looks beyond the short-term perspective of typical clinical trials, it becomes apparent that antidepressants do not cure panic disorder, other than in rare cases #150; the condition is chronic and often mildly progressive.
Follow-up studies show similar relapse rates in the long term, and it is dishonest and irresponsible to paper tell patients anything else. With CBT or PCT, one can sometimes reduce the incidence of outright attacks by reducing sensitivity to triggers, but the underlying dysautonomia persists #150; and it is the dysautonomia, not its paroxysms, that represents the most insidious threat to health and longevity. In any case, the cure/control distinction is at best misleading because very few pharmaceutical treatments cure anything. Control of essay service symptoms is an admirable ambition and one that is deemed fully sufficient in many other medical contexts. The Obscure Critical Essays. There is critique service no call to discriminate against the panic disorder population with a specious and condescending distinction between cure and bandaid. The fixation on SSRIs as the lily, one-size-fits-all treatment of choice for panic disorders is largely attributable to a marketing campaign targeting primary care physicians and their patients that was conducted for SmithKline Beecham (as the makers of Paxil were known at the time) by the Ruder Finn agency.
As Ruder Finn trumpeted until recently on a World-Wide Web site intended for advertising industry insiders, the critique, Paxil for Panic Disorder program was one of the most spectacular successes of pharmaceutical blitzmarketing in the history of the industry. To quote from the Web site: The Paxil for 12 angry men 5 paragraph, Panic Disorder program leveraged a new indication of an existing antidepressant for a relatively obscure anxiety disorder to generate unprecedented product sales growth. Seven months after the panic disorder launch, The Wall Street Journal referred to critique panic attacks as the hot new malady that is quickly replacing depression as the mental illness du jour.. The objectives of the Paxil for Panic Disorder campaign are: Increase sales and statement, overall market noise [sic] about Paxil by generating widespread awareness of FDA clearance of the medication's new indication as a treatment for panic disorder. Urge undiagnosed sufferers to see their physicians for a diagnosis and ask for Paxil.
Take advantage of seasonal and other opportunities. Essay Service. The launch phase of the men 5 paragraph, program was also supported with a Morning Drive-Time Radio Tour in 18 cities across the country. Critique. A satellite media tour was considered [but dropped]. Tie in to the stressful nature of the holiday season. Sales growth of Paxil since May, which SmithKline Beecham describes as unprecedented, has been attributed by the company to the sales and public relations launch of the panic disorder indication. SmithKline Beecham saw its share of the runner, total SSRI market share grow by 8.7% and its share of essay critique service new prescriptions grow 7.7% between April and November.
Note that by Ruder Finn's published report, SKB itself attributed the success of Paxil not to scientific or medical documentation but to essay gilded its savvy sales and public relations launch. The clinical trials submitted as the basis of the essay, FDA approval and ensuing media blitz were three, and in them the drug was successful in eliminating or reducing panic attacks in 25% (misstated as 76%*), in gilded 51%, and in 33% of trial subjects on service, Paxil, versus 44%, 32%, and 14% of subjects on placebo. To specialists in the treatment of panic disorder, these numbers are anything but impressive #150; indeed if the drug had been promoted on numbers like these rather than the sweeping generalizations primary care physicians hear from pharmaceutical salespeople, it is unlikely that much enthusiasm would ever have developed in the first place. Additionally, grave questions have since been raised about the integrity of the kite runner redemption questions, research itself. * The company did not cite a figure for all subjects in the first study, but instead counted only the one-third of subjects who responded best #150; and who were on service, a dosage intolerable to many patients. Thus the 76% for best-responders actually represents 25% for the study as a whole. (3/4 x 1/3 = 1/4) This little white lie is among the least of the irregularities that have emerged in court cases involving the kite redemption, clinical trials of Paxil. The Ruder Finn campaign aimed to broadcast the cleaner side effect profile of Paxil, although the sad truth is that clinicians are largely in agreement today, about service, three years later, that of all the earthquake statement, commonly prescribed SSRIs, Paxil seems to have the dirtiest long-term side effect profile and the most problematic withdrawal. (The World Health Organization's statistics on complaints about withdrawal put Paxil in a very clear #1 position.) Based on the difficult-to-ignore evidence of their own clinical experiences, primary care physicians are spontaneously moving away from essay critique, Paxil in favor of research database milder or supposedly cleaner SSRIs. The plaintiffs in critique service a California class-action lawsuit against the makers of Paxil (seeking changes to labeling, release of gilded embargoed data, and only modest monetary damages) intend to critique service introduce documentary and testimonial evidence: that Paxil performed significantly, indeed markedly, worse than placebo in statement its early trials, before statistical spin doctors were brought in to fix the problem; that when dozens of essay trials did not yield positive results, statisticians manipulated the numbers to produce hypothetical trials in which one single patient who endured or thrived on Paxil for 365 days would completely offset 365 patients who could not endure the medication for paper, more than one day; that the makers changed numerous reports (adding up to tens of percents) complaining explicitly of withdrawal, as distinct from relapse, to instances of relapse instead; that the critique service, company suppressed evidence of a 0.77% incidence of jude the obscure suicidality (considered quite high for such a serious side effect, and later demonstrated to essay critique be even higher); that a certain identified FDA official illegally coached the makers of Paxil in clandestine conversations on how to avoid scrutiny on the suicidality issue; that the company suppressed information on a 20-25% dropout rate in early trials; that the company deliberately claimed on jude the obscure critical, the record in essay service an FDA hearing that it had studied withdrawal issues and found none, when in fact it had not studied withdrawal issues but had inadvertently become aware of frequent and severe withdrawal experiences; and critical, that the company has systematically promoted the impression that the only people who become dependent on Paxil are multi-drug abusers, even though the company has abundant evidence (which it suppresses) that dependence and a pronounced neurological withdrawal syndrome are common. As internal company documents have come to light in other civil and criminal trials regarding Paxil in the United States and essay critique, other countries, it has become clear that the earthquake thesis, drug's makers possessed far more documentation of the essay, drug's potential for adverse effects than they ever disclosed to the FDA, to the public, or to the scientific community.
There is database obviously a place for the discriminating use of SSRI medications in the treatment of panic disorder. They are irreplaceable, indeed life-saving for many people. Essay Service. However, they have been prescribed indiscriminately and with, even recklessly in critique recent years. The appropriateness of their use has been greatly exaggerated and the long-term risks and essay lily, sometimes severe dependence and withdrawal effects (which bear no resemblance at all to the condition being treated) have been swept under the carpet for as long as humanly possible. The question is not whether there is a place for SSRIs in essay service the treatment of panic disorder. The question is what is the proper role of an advertising agency in shaping medical opinion and practice in the treatment of neuropsychiatric disorders. On Benzodiazepine Treatment. By far the largest group of functional, well-controlled panic disorder patients who show up in the Internet support communities are those on a regimen of long-acting or short-acting benzodiazepines (or both). Kite Runner Essay Questions. This parallels the conclusions of recent long-term reports following up on earlier studies and in some cases coming to new conclusions.
The most common regimen among such patients is a long-acting benzodiazepine taken on a regular schedule, with a short-acting benzodiazepine to critique service be taken for breakthrough symptoms. However, significant numbers do well on a regimen of short-acting or long-acting benzodiazepines alone. A substantial proportion of these patients take only enough medication to manage their autonomic arousal, thus breaking the autonomic link in the arousal-anxiety-arousal-panic cycle, and normally rely on techniques learned in Cognitive-Behavioral Therapy to manage the cognitive-emotional aspects of the condition. Many clinicians are reluctant to help with writing prescribe benzodiazepines long-term for panic disorder, despite abundant evidence that panic disorder patients respond better to this class of critique medication than any other group of patients and that panic disorder patients are the least likely to abuse these or any other medications. The typical pattern is that panic disorder patients require some adjustment of dosage in the beginning of 12 angry paragraph their treatment #150; either up or down #150; and then remain at or below that dosage for essay critique, years. Thesis Statement. When considering research on benzodiazepines, there is every reason to look at research specifically into their use in panic disorder, because the patterns that emerge are quite different from those that emerge when this class of medication is used to treat GAD or situational conditions. It is common for essay, panic disorder patients spontaneously to reduce their medication after six months to a year, and to remain satisfactorily controlled at the lower maintenance dosage.
It is common for panic disorder patients to with writing try to service eliminate their medication after a considerable period free of symptoms, only to find that they must go back on their original level of gilded lily medication. There may be a medication-free period of success lasting months or occasionally years, but the essay critique service, condition eventually returns #150; sometimes with an intensity requiring more medication than before. Panic disorder, at least in its biologically-rooted forms, is a chronic condition. Where normal individuals report a dulling of sensation from benzodiazepine treatment, panic disorder patients typically report that they feel normal again for the first time in jude critical years. This subjective assessment is often supported by an increased level of performance at work or in school. Such an assessment might even be regarded as a useful diagnostic factor. Essay. The baseline levels of kite essay autonomic arousal and essay critique, of parasympathetic nervous system activity tend to be different in earthquake statement panic disorder patients from those found in essay critique normal individuals, and that helps explain why benzodiazepine treatment can be not merely therapeutic but normalizing in the panic disorder patient, with a lower incidence of side effects than those experienced by the general population and an incidence of abuse so low as to be almost nil. Optimal cognitive and motor function require the nervous sytem to be within a certain functional range of arousal. If you have just woken up from a deep sleep or you have just hopped off a treadmill after ten minutes of running your fastest, your cognitive ability in particular but also your motor ability to deal with demanding tasks are both going to be well below adequate.
Your nervous system is outside its functional range of arousal. States of depression and states of autonomic anxiety like those seen in panic disorder are analogous. Both may fall outside the optimal range of autonomic arousal, or even outside the men 5 essay, functional range. This explains why people with panic disorder often demonstrate improved cognitive or motor function when taking benzodiazepines. Learning is a particularly demanding task, and the brain is biochemically inhibited from learning well when there are high levels of arousal-inducing hormones or neurotransmitters. Thus patients with panic disorder or a condition that mimics it may be unable to learn in an academic setting and unable to benefit from Cognitive-Behavioral Therapy (which teaches the brain new patterns of thought and essay critique, new reflexive behaviors) until an the obscure appropriate dose of a benzodiazepine is taken. The dose must be large enough to lower nervous arousal into the optimal range without being so large as to push it from over-arousal to a state of under-arousal.
Much of the early research on the use of benzodiazepines in essay critique service anxiety and the obscure, panic was conducted with dosages that today appear stunningly high. It is strange indeed to read of studies using 6-10 mg of Xanax for essay service, panic disorder when today we know that the earthquake statement, great majority of critique patients function optimally on kite runner questions, 1-4 mg spread across 24 hours. Some patients require as much as 6 mg per day, but that is so rare that even the most benzodiazepine-friendly physician would almost certainly question the diagnosis or consider a different type of medication. At present Xanax is the best-known benzodiazepine used against panic disorder (and the one that is FDA-approved for the condition), but perusal of early research into the use of Klonopin and other benzodiazepines against panic disorder shows the same thing: the dosages tested tended to be far higher #150; 2x, 3x, or even 4x #150; than the dosages commonly used and critique service, known to be effective today. It is of course important to taper the papers database normalization, cessation of benzodiazepines carefully. Papers on essay critique service, this subject report that a three-month taper is a reasonable standard, but that six months or a year is not unreasonable for high dosages or long-term use.
In the case of panic disorder, there should not be undue pressure to jude the obscure essays get off of any class of medication, and during cessation it is often difficult to distinguish withdrawal symptoms from symptoms of the critique, underlying panic disorder (except in the case of essay gilded discontinuing SSRIs, where the most dramatic withdrawal symptoms are clearly neurological and bear no resemblance to panic disorder or depression). A number of papers report that panic disorder patients are frequently withdrawn successfully from their medication only to have to go back on it at the same or a higher level half a year or a year or two later. These papers suggest that it is probably healthier to maintain panic disorder patients at a constant level of medication, if no problems emerge, than to essay service subject them to this cycle of cessation and recommencement of medication #150; regardless of the class of medication in question. There are occasional patients who taper cessation of benzodiazepines over two weeks or less without difficulty. This is definitely the exception, however, and should not represent an kite questions expectation. Such a rapid taper can be dangerous and critique, even life-threatening. One sees a small number of panic disorder patients who do not tolerate benzodiazepines well.
It is widely regarded as canonical that benzodiazepines cannot be used in the treatment of jude critical patients with a history of alcohol abuse. However, with proper supervision, this is not necessarily true. In fact, it turns out that benzodiazepine treatment for panic disorder can be a key to preventing alcoholic relapse. Essay Service. Abusers of alcohol who experience panic attacks may have been self-medicating for their panic disorder, and some even lose the desire to drink at essay gilded, all once the underlying state of arousal is controlled. This seems particularly true in the case of essay service measured drinkers, those who drink regular amounts at regular times of gilded lily day. Both anecdotal reports and published research emphasize that the essay service, definition and manifestations of papers database tolerance, dependence, and addiction are commonly misunderstood among physicians and even among a surprising number of essay critique psychiatrists. Experts in the use of benzodiazepines report that tolerance normally develops to their sedative, cognitive, emotional, and motor effects, but not to essay gilded lily the autonomically anxiolytic effects, i.e. Essay Critique Service. not to their ability to interrupt the neurological panic circuit. Thus a patient may report drowsiness in the early days of treatment, but the drowsiness wears off. Once an effective dosage is found in kite runner redemption the first weeks of treatment, this dosage (or, after a while, a lower one) will eliminate panic attacks and most dysautonomia for service, years and decades. Patients on such a maintenance dosage should be regarded as medically dependent, just as many patients are dependent on glucophage or insulin or anti-hypertensive medications that exhibit a rebound effect on cessation #150; or on Paxil, for that matter #150; but should not be regarded as addicted in 12 angry essay the absence of all the other criteria that characterize addiction. The matter of dependence is also put into a new light by the appearance of more and more studies (particularly, it would seem, in Britain) stressing the point of view that antidepressants also promote physical dependence in anxiety disorders.
A World Health Organization report goes so far as to state plainly that SSRI withdrawal is a more difficult problem today than Valium withdrawal was in essay service its time. 12 Angry Essay. Reports such as these call into critique service question whether it is jude critical well-advised after all to critique service promote antidepressants over benzodiazepines in the belief that ADs do not cause dependence. It is after all widely recognized that benzodiazepines are often more effective and work more quickly. It is the help, consensus within the panic disorder community that every medication that is actually effective in treating panic disorder has the potential to create dependence. Dr. Robert DuPont, a former director of the [United States] National Institute On Drug Abuse, has stated that the concept of critique using the lowest possible dose of a benzodiazepine for the shortest period of 12 angry time is inconsistent with sound clinical practice. This concept needs to critique include the important qualification that our goal is to maximize the patient's ability to function well and to enjoy life. Benzodiazepines are among the safest and most effective treatments in all of medicine , including their role in the treatment of panic disorder. Jude The Obscure Critical Essays. He is joined in his opinion by many experts of critique comparable stature and by a World Health Organization report entitled Rational Use of Benzodiazepines , WHO/PSA/96.11. (This consensus document from the WHO is distinct from the 1994 document Guidelines For The Rational Use Of Benzodiazepines authored by jude essays, Dr.
Heather Ashton.) These medications are not a panacea and they are not without their potential drawbacks. However, they have been the subject of such a fierce backlash from their extravagant misuse and overprescription in the 1970s (similar to but exceeded by the SSRI bonanza of today), and critique, have been the target of such unscrupulous propaganda from the promoters of other drugs which still, unlike most benzodiazepines, enjoy the profitability of patent protection, that most doctors are unfamiliar with the actual evidence that should govern their prescribing. The evidence clearly shows that at present there is no other class of medication that works nearly as well, in nearly as large a proportion of the panic disorder population, as benzodiazepines; it shows that dependence is real but is not unique to benzodiazepines and jude the obscure, thus not a major differentiating factor; and it shows that there is no other population less prone to critique addiction or abuse of jude the obscure critical benzodiazepines prescribed as part of a comprehensive management strategy. No discussion of benzodiazepine treatment would be complete without a brief mention of at least two quasi-cult-like self-help networks of individuals who claim that use of even very low doses of benzodiazepines for brief periods caused them permanent neurological damage and years or decades of anxiety and panic attacks a thousand times worse than anything they experienced before. (One wonders what they were experiencing before that could stand 1000-fold amplification.) With a vehemence and personally directed vitriol strongly suggestive of critique service fanaticism, they reject any suggestion that they might instead be suffering from untreated anxiety or panic disorders, since the questions, symptoms they describe when one pins them down to specifics sound very much like the essay critique service, symptoms of uncontrolled, advanced panic disorder. If this were all there were to the story, it would not be worth dignifying with mention here. However, this group cruises the Internet panic disorder support communities looking for newcomers and then bombards them with email offering self-help cures for prices that begin in the thousands of dollars and gradually decline, and terrorizing these vulnerable individuals with dreadful anecdotes that sound perfectly outlandish to pharmacologists and clinicians alike. Identifiable individuals who speak up against this group are deluged with organized hate mail, some of it threatening in nature. In this age when many patients research their conditions using the Internet (as well they should), physicians should know something about this bizarre phenomenon so that they can offer knowledgeable and convincing support to patients who fall prey to these groups' terroristic tactics. On Treatment With Other Classes of jude the obscure critical Drugs.
Other classes of drugs are sometimes used in treatment of panic disorder but do not represent first-line choices. Other drugs used clinically or in research include anti-psychotics, beta blockers, CCK antagonists, alpha2-adrenergic agonists, and anti-epileptics. Although the author lacks statistical data, there are a notable number of reports from essay service, patients experiencing good results with Effexor XR (which seems for unknown reasons to earthquake statement behave very differently from essay critique service, its non-extended-release version Effexor), often after having bad results with SSRIs or simply having run the gamut of the major SSRIs, only to have each one in turn poop out research database (if the reader will excuse the scientific jargon) after a period that typically begins at a number of years but tends to shorten with each successive replacement drug. Some patients are also reporting good results with the RIMA moclobemide, and essay critique service, a few are reporting doing well with beta blockers. Reports of success with alpha2-adrenergic agonists are not common but do occur. This class of medication can be helpful in conjunction with other treatments. Kite Runner Redemption. The same observations apply to beta blockers.
There is a small but growing trend to treat panic disorder with anti-epileptic medications. Success is mixed, but these medications are successful for an indeterminate proportion of panic disorder patients. There has been a puzzling surge of critique service reports over the last year of doctors resorting to antipsychotic medications in the treatment of jude the obscure critical panic disorder, often before even trying all of the mainstay classes of medications, and often with unfortunate consequences. However, there are a few patients who do respond better to these medications and need to use them despite their extensive side effects. A small number of essay patients have reported success with the opiate blocker naltrexone, which at least theoretically could be of help to people whose symptoms are caused by stimulation from the database, opioid peptides in critique service gluten or casein.. By patient accounts, the least effective drugs commonly misprescribed for the treatment of panic disorder (although there are always exceptions), are BuSpar, Wellbutrin, and Serzone. Serzone has the earthquake, particular complication, of which an alarming number of prescribing physicians seem unaware, of substantially inhibiting the metabolism of other psychotropic drugs, thus making it difficult to calibrate effective dosages. This is not to say that there are no panic disorder patients who benefit from these drugs, but they are a small percentage. There is a trend toward polypharmacy in the treatment of essay panic disorder, with drugs added to treat the side effects of drugs added to 12 angry men 5 paragraph treat other side effects. Often drugs are piled on essay service, in an jude critical attempt to avoid or make acceptable the obvious but in some circles politically incorrect choice of benzodiazepines, or in blind adherence to the doctrine that SSRI medications simply must work for all.
The author has not encountered much anecdotal or published evidence that a polypharmaceutical approach works better than (or even as well as) the service, mainstay treatments, except for rare complex cases; and complex cases should absolutely be referred to a specialist in panic disorder. Complications of panic disorder can occasionally be severe and even life-threatening. Pharmaceutical industry insiders report that the with writing, next big push in anxiolytics will be the CCK antagonists. Already marketed successfully outside the United States for this purpose (as well as for essay, treatment of GERD and 12 angry paragraph essay, IBS), these are reportedly intended for an aggressive push into the American market when a favorable point is reached in the product life cycle of the SSRI medications. (It is possible that this CCK-antagonist generation of anti-anxiety medications may yet be leapfrogged by a newer class of medications under development to target GABA receptors even more finely than existing drugs do, but new patent filings for CCK antagonists quietly continue to accumulate.) For the time being, the SSRIs are still among the most profitable of pharmaceutical products in the United States and critique service, are among the least vulnerable to jude essays competition. Their makers aggressively seek new areas of application for essay critique, these flagship profit-makers.
But factors already at work to shift the market equilibrium include recently published major studies identifying the chromosomal locus and runner questions, the importance in panic disorder, GERD, and IBS of essay service defects in help paper writing CCK metabolism, increasingly general awareness of essay service SSRI complications, and the proliferation of lawsuits alleging improprieties in the conduct of clinical trials for SSRIs and the withholding of unfavorable research data. It is simply a matter of time before we see the next shift in focus. On Reported Effectiveness and 12 angry men 5 essay, Side Effects. It is evident to essay critique the author that at least in the case of newer psychotropic drugs, one should trust postmarketing research and the reports of experienced clinicians over the published results of kite redemption essay Food and Drug Administration -supervised clinical trials for approval of new drugs. For instance, in the case of essay critique service one popular medication, approval trials reported an incidence of sexual dysfunction well under 5%. Kite Redemption. Yet today experienced clinicians are in agreement that over the same length of time covered by the original trials, the true incidence of sexual dysfunction is at least 60%. Some claim up to an 85% incidence in their practices. And such numbers have been substantiated in postmarketing research. How does one explain such discrepancies in the light of FDA oversight? Looking at clinical trials generally, without examining specifics of this particular medication, sources of such misrepresentation can lie along a spectrum ranging from poor research protocol to outright fraud.
In the area of protocol, test subjects for the medication above were not asked about essay service, sexual dysfunction and felt reluctant to bring it up, especially given the relatively short duration of the essay gilded, trial. And while randomization may have been scrupulous within the trial, it has come to essay service light that all candidates for the study, whether they ended up on placebo or the experimental drug, were carefully hand-picked for previously demonstrated tolerance of that drug's side effects. (As an aside, it is lily interesting to note that physicians participating in clinical trials state that the concept of essay service double-blind placebo control is earthquake statement little more than a convenient fiction in essay critique the testing of psychotropic medications, and a somewhat ridiculous fiction at that. Gilded. They say that in most cases, the high incidence of dramatic side effects with psychotropics makes it perfectly obvious to the health care personnel, if not indeed to essay the patients, who is taking the medication and who is taking the placebo. For this reason, drug-against-drug trials are often more useful.)
Looking again at writing, the general case, there is critique also the question of fraud. Can this actually be a significant factor in American pharmaceutical testing? Doesn't the FDA ensure the validity and integrity of such testing? The General Accounting Office seems to think otherwise. The New York Times, in a 1999 series of articles on fraud in drug approval trials, cited a GAO report criticizing the jude the obscure essays, FDA for repeatedly failing to investigate whistle-blower reports of fraud and for colluding in some cases to cover up evidence of its commission. According to the NYT, this GAO report concluded that the FDA was oriented toward overseeing methodological correctness and toward screening for scientific error, but was essentially helpless and disinclined to take action in the face of service deliberate deception. Earthquake. As the NYT series documented, there are clinics that make a cottage industry out of essay critique manufacturing patients, complete with interview results and bogus specimens to kite redemption essay questions go along. Whistle-blowers have faced disbelief, systematic discrediting, and retribution comparable to any found in defense industries.
Far from ferreting out and essay service, assuring prosecution of such fraud, certain FDA employees and their supervisors seem to have facilitated its commission and cover-up, according to essay gilded lily the GAO. This may be one reason that American pharmaceutical testing is viewed with skepticism in for instance Germany and Finland, two of the essay service, thirty-odd countries consistently recognized by the World Health Organization (and other international observers) as practicing higher standards of health care and essay gilded lily, governmental oversight than the United States. The FDA is just another government agency. Critique Service. While it is thesis statement held in peculiar veneration by the medical community, there is no reason to essay critique expect it to be any more competent or any more scrupulous in its regulatory and inspection/examination activities than other agencies such as the Internal Revenue Service, the research papers, Department of Energy, or the Department of Agriculture. (Nor is there reason to expect it to be worse, although that is faint reassurance.) All of these agencies have many competent, dedicated, high-minded people trying to accomplish good things, but there is only so much that individuals can do in the face of service entrenched bureaucratic culture. Jude The Obscure. All of these agencies, including the FDA, experience periodic scandals around competence and integrity.
The FDA comes under blistering criticism from European medical authorities (not to mention domestic sources) for its pattern of approving medications for which pre-approval research demonstrated serious problems, only to end up withdrawing approval under pressure from essay, consumer organizations after unacceptable levels of fatality or injury appear. Essay Gilded. It is naive to exaggerate the competence or integrity of the United States' drug approval and essay, oversight compared to taxpayer service, oversight of the nuclear energy and weapons industries, or inspection of meat and agricultural products. Many who work in subordinate roles in pharmaceutical testing claim that data and conclusions are routinely and unethically manipulated under the very noses of the FDA. Diet and help paper writing, Supplementation. The mainstream view in the panic disorder community is essay critique service that neither diet nor dietary supplementation is essay lily sufficient for the management of panic disorder, but that both can make substantial contributions.
There is a sizable minority, though, who find that it is possible to manage their own panic disorder primarily or entirely with diet and supplementation. The four most dramatic examples of dietary management are elimination of caffeine-like stimulants, adoption of essay critique service a gluten-free/casein-free diet, supplementation with the amino acid taurine, and adoption of a ketogenic diet. Each of these measures is helpful only to a subset of the panic-disorder population, a subset consisting of help paper writing people with unusual sensitivities. Elimination of caffeine-like stimulants. Some people are exceptionally sensitive to the stimulants known collectively as xanthines, principally caffeine, theophylline, and theobromine, found in various combinations in coffee, most colas, tea (even green tea), and chocolate. The panic disorder population appears to include a greater proportion of critique these people than the general population. People who are not caffeine-sensitive have a hard time appreciating the extent to statement which the essay service, substance affects sensitive individuals. For some people, a single 12-ounce diet cola per day, the equivalent of about half a cup of American-brewed coffee, is enough to keep symptoms of panic disorder active. Quite a few people have reported that a single cup of lily decaffeinated green tea daily was the difference between experiencing heart palpitations and essay critique, not experiencing them. Caffeine must be discontinued carefully. Kite Essay. People seem to have the best success by tapering gradually #150; ounce by ounce at the end, if necessary #150; before completely quitting.
Many people take an NSAID like ibuprofen or aspirin for a few days starting the day before complete elimination in order to avoid the ferocious caffeine-withdrawal headaches that can otherwise result. It takes 3-8 weeks for a caffeine-sensitive individual to essay return to true baseline functionality and paragraph essay, sensation after completely quitting caffeine-like stimulants. Prominent symptoms during the withdrawal phase are likely to include headache, depression, loss of energy and initiative, muscular stiffness, constipation, temporary changes in vision, reduction in coordination, minor edema, sleeping several hours longer than usual, and markedly reduced athletic, physical, and essay critique service, mental performance. Because of the way caffeine affects biochemical production of energy to power muscle cells and brain cells, one is quite literally not as strong and help with paper writing, not as smart during caffeine withdrawal, but full function does return after withdrawal is essay critique complete. At some point there may be a day or two of unaccustomed heart palpitations as the body moves minerals around, establishing a new balance of electrolytes. But when the withdrawal phase is over, there is normally improvement over pre-withdrawal function in most of these areas. Many caffeine-sensitive people who complete withdrawal find that they are able to paper reduce or in some cases even eliminate their psychotropic medication. But this should not be an critique service expectation; the reason to jude critical essays try caffeine-elimination and persist until withdrawal symptoms disappear is simply to feel better, function better, and quite likely lessen some of the dysautonomia. Gluten-free casein-free (GF-CF) diet. It has been known for years that some patients' panic disorder (or GAD) improves with elimination of gluten sources and milk products. Only recently has a strong theoretical foundation for such observations emerged from research abroad and at a few major American medical centers.
It also turns out critique that truly aggressive dietary restriction, using the gilded, same vigilance a celiac patient must practice in avoiding even minimal, hidden amounts of gluten, benefits more people than was previously apparent with avoidance of only obvious, major sources. Unfortunately there is no quantification available yet, but it is an inviting area for research. Patients who suspect gluten intolerance should have an inexpensive screening for IgG anti-gliadin antibodies before commencing the GF diet. Critique. With strict avoidance, the paper, antibodies disappear in 3-12 months. However, one is still intolerant to gluten. It may be important to know one's status in that respect, since gluten intolerance is such a strong predictor or risk factor for other serious conditions including various forms of gastrointestinal cancer and a variety of autoimmune conditions. If celiac disease (one particular autoimmune consequence of gluten intolerance) is essay suspected, additional screening should be undertaken before commencing the GF-CF diet. A large proportion of paper writing people with very high levels of anti-gliadin antibodies also have very high levels of essay service antibodies to casein. Even without such high antibody levels, the gluten-intolerant patient is likely to experience psychotropic effects from help paper writing, casein, although the top American experts in critique celiac disease note that some patients recover the ability to tolerate milk products as their digestive tract regenerates itself. The amino acid glutamine is particularly helpful to patients with celiac disease, non-celiac gluten intolerance, or other GI problems that respond favorably to gilded lily dietary elimination. The digestive tract is one of the fastest-rebuilding parts of the human body and one of its principal building blocks is glutamine.
Even though glutamine sounds a little like gluten, it does not contain gluten. Essay Critique Service. When pure it is a safe nutrient and actually an kite runner redemption essay questions important nutrient for critique service, gluten-intolerant individuals. Taurine supplementation. Taurine was first tried in the treatment of panic disorder because it was known to 12 angry paragraph essay be effective in the treatment of essay critique service epilepsy. There are patients who control their panic disorder with nothing more than aggressive taurine supplementation. A number of other panic disorder patients find that they can reduce their medication with the jude the obscure essays, help of taurine supplementation. Ketogenic diet. The overall healthfulness of a ketogenic diet is certainly debatable. However, it is essay critique clear that some panic disorder patients are able to control their panic disorder without medication by following a ketogenic diet, or more often a diet that is research papers borderline ketogenic.
The reasons for the benefit of critique service this diet are not known, although it is well established that a ketogenic diet can also reduce or eliminate the research papers, incidence of seizure in epileptic patients. Many panic disorder patients report doing better on reduced-carbohydrate diets that do not, however, go as far in this regard as many of the critique service, currently popular low-carbohydrate or high-protein weight-loss diets. There is considerable research to suggest that this might be due to the fact that the jude critical, insulin-glucagon axis influences a host of critique service other hormonal and enzymatic systems. However, there has been little direct study of carbohydrate restriction in the treatment of with writing panic disorder, and the only service connection that seems obvious and likely to be uncontroversial is the adrenaline response that can be provoked by falling blood sugar levels. Further study will probably show this to runner redemption questions be a highly simplistic interpretation. Magnesium supplementation. Some people find that supplementation with a small amount of magnesium reduces their symptoms, particular symptoms like heart sensations, muscle tics, and critique service, annoying nerve sensations. Too much magnesium will cause diarrhea and exacerbate the writing, body's imbalance of minerals, but just enough can noticeably improve nervous function in people who have a deficiency of magnesium in nerve cells. (The relationship between magnesium in blood serum and magnesium in nerve cells is a bit complicated and should be interpreted by a physician who can consider the full picture, including medications that may influence where your body stores the magnesium it has available.) Fat restriction, supplementation with essential fatty acids.
In cases of defective cholecystokinin metabolism, fat restriction is an important but insufficient measure for essay, the prevention of panic attacks. On the other hand, in cases of panic disorder in families where schizophrenia is present, it seems prudent to essay gilded lily follow a diet that is sufficient in fat. Essay Critique. There are anecdotal reports of panic disorder apparently being precipitated in such families, even relatively late in life, by adherence to the obscure the ultra-low-fat diets so recently popular, and there is solid evidence that schizophrenics do better on high-fat diets than on fat-restricted diets. While the author has uncovered no proof that a diet relevant to the care of service schizophrenia is also relevant to the care of panic disorder in gilded families where schizophrenia is present, it seems prudent, at this point in the understanding of such panic disorder and of schizophrenia, for panic disorder patients from schizophrenic families to follow the dietary measures that should be followed in schizophrenia. Essay Critique. These include strict avoidance of casein (a milk protein) and gluten and gliadin (a family of proteins found in wheat, oats, barley, rye, and some exotic grains), and the inclusion of sufficient amounts of fat, perhaps above-average amounts of writing fat. Essay. This has obvious implications for weight control but is documented as beneficial to schizophrenics. Some mainstream medical sources also warn against supplementation of the schizophrenic diet with sources rich in the fatty acid GLA (gamma linolenic acid), principally evening primrose oil and borage oil. However, where the author has observed such warnings, they have occurred in contexts attempting to debunk the kite runner redemption essay, purported benefits of these supplements, and therefore the standard of proof was probably lower than if the essay service, authorities in statement question had been asserting a benefit rather than a danger. (In other words, there is in medicine, as opposed to the body of science proper, one standard of proof applied to a claim like substance X may cause hair to grow back on your balding scalp, but quite a lower standard of proof applied to a scare-claim like not only will substance X not cause hair to grow back on service, a balding scalp, but furthermore, substance X may cause the hair you still have to fall out, and maybe your teeth, too .) Nonetheless, prudence should prevail. Writing. There is solid evidence that GLA is essay critique service contraindicated in patients with seizure disorders, and it may be wise for the panic disorder patient from a schizophrenic family (or an epileptic one) to avoid GLA-rich supplements. Other dietary measures.
It is the obscure essays beyond the scope of this document to treat the full complement of dietary supplements being used in the treatment of panic disorder or investigated for such use. There are simply too many to discuss, and the results are too individual to each patient. Essay Critique. It is essays clear, however, that while different individuals respond to different supplements, there are beneficial effects that go beyond what can responsibly or scientifically be attributed to a placebo effect. The supplements that prove effective are not the obvious choices #150; for instance, only a very small number of people report significant benefits from the well-known anti-anxiety supplements like Kava kava or Passionflower. Critique Service. Of those supplements, patients typically report no effect whatsoever or a reduction in anxiety without a corresponding reduction in men 5 dysautonomia. This poses an interesting conundrum for researchers who consider the dysautonomia of panic disorder to be caused by anxiety, and supports those patients (and some clinicians) who claim that it seems the anxiety is actually caused by the dysautonomia. Nor does the critique, antidepressant supplement St. John's Wort have very wide support among those who favor dietary supplementation.
One more often hears complaints of exacerbation of anxiety and dysautonomia, or complaints of sleep disturbance with no effect on anxiety or dysautonomia. These are similar to, but much milder than, the complaints one hears from many (by no means all) panic disorder patients treated with antidepressants. Valerian fares somewhat better, but when used in doses sufficient to thesis exert a beneficial effect, it is reported to cause more drowsiness than its pharmacological cousins the benzodiazepines. The currently popular 5-HTP has been variously described as either useful in the control of panic disorder or directly panicogenic. (Of course the same observation applies to 5-HTP's very distant cousins, the SSRI medications.) 5-HTP administered without restriction of vitamin B6 has been linked to heart fibrosis. Very recent double-blind, placebo-controlled research suggests that Gotu Kola is critique service somewhat effective against the variant of panic disorder arising from the genetic aberration in the obscure critical essays cholecystokinin metabolism. Essay. This fits theoretical predictions, because Gotu Kola and a small number of other far eastern herbs have been demonstrated to compete with cholecystokinin at CCK receptors in the body.
So far there is little experience or consensus in the panic disorder community. Supplements more commonly reported to be mildly beneficial are those that support parasympathetic nervous system function (B-vitamins, alpha-lipoic acid, precursors or cofactors for the synthesis of acetylcholine and nitric oxide), supplements promoting cardiac stability (Q10, carnitine), supplements soothing the digestive tract (chamomile, bismuth, glutamine, MSM, occasionally peppermint - although the last can also be counterproductive)… It is simply not possible to earthquake statement do more than scratch the surface lightly in this discussion. There is no clear consensus and there are almost no formal studies of the effects of special diets or supplementation on essay, panic disorder. 12 Angry Men 5 Essay. However, clinicians and patients alike report that certain measures have an obvious effect for certain individuals. One might suppose that panic disorder patients would be more susceptible than most to a placebo effect; but in critique service fact, panic disorder is so difficult to research papers database normalization control without medication, and essay, panic disorder patients are so reluctant to resign themselves to a lifetime of medication, that they often try many dietary supplements in a systematic fashion, generally rejecting the preponderance of them as ineffective.
For a panic disorder patient to report that a supplement is beneficial, even if it is not sufficient to fully control the condition, is an exceptional event that should usually be taken seriously #150; especially if it makes possible a lighter use of thesis statement medication. One cannot easily feign control of essay service panic disorder or delude oneself about doing so, and there is paper little incentive to try. Panic disorders are a family of disorders the understanding of service which is still in its infancy. Much of what we thought we knew only jude the obscure critical a few years ago has been proven false. (In some cases the earlier understanding directly confused cause and effect.) There is far more that is not known about service, panic disorder than there is that is known; however, a nascent body of research in several new directions is revealing some of the secrets. Panic disorder is earthquake thesis not a monolithic condition. Few generalities apply to a majority of the panic population, but many generalities apply to sizable minorities within the population. Some cases of essay critique service panic disorder fit the classical (since 1981, that is) psychiatric interpretation. Another set, quite possibly larger, does not, although this set has distinct subtypes for which it would be possible to develop a widely applicable diagnostic protocol. Nonetheless, by the time these disorders are diagnosed, they have almost invariably progressed to psychiatric dimensions. The disorders are polysystemic and usually require multi-modal diagnosis and treatment. Parasympathetic insufficiency, often hereditary, is emerging as a new and promising direction of investigation and treatment.
Problems in CCK metabolism have been linked to research normalization panic disorder by multiple independent researchers for some time now, but 1999 saw publication of a major study that claims to have identified the genetic defect in question. The biological basis of panic disorder and essay service, the long prelude of non-paroxysmal dysautonomia that typically precedes it are only beginning to receive the help with writing, attention they require. It will be a tremendous step forward when there is essay service general recognition that treatment of panic disorder must aim not only at total elimination of panic attacks (or dysautonomic paroxysms) but at elimination of the associated chronic dysautonomia as well. Runner Redemption Essay Questions. Beyond this, the goal should be much earlier recognition of chronic dysautonomia so that it can be treated well before it reaches a paroxysmal stage and the psychiatric complications that ensue. It is possible that focusing on the condition as chronic dysautonomia and its advanced stages as paroxysmal dysautonomia might facilitate such recognition and a shift in perception and attitude. It seems inevitable that subtypes of panic disorder will eventually receive individual recognition, naming, and treatment protocols.
Primarily for commercial reasons, funding for essay, panic disorder research has lately been focused far too narrowly on the role and the promise of SSRI medications in thesis statement treating panic disorder. Service. This shift in focus to follow the availability of research funding interrupted a number of other fruitful areas of earlier research. Help With Writing. Nonetheless, the biological understanding of essay critique this set of disorders has reached a stage where researchers have claimed for earthquake thesis, some time now that this reigning emperor in the pharmaceutical realm is at best scantily clad. Apparently the emperor's successor, in the form of CCK antagonists, has already been designated and is awaiting coronation, but only time and experience will tell whether the next panacea is more universally effective than the essay critique, current one. The author is extremely doubtful that any panacea will ever be found for gilded lily, what we know today as panic disorder #150; it is too clear that distinct and distinguishable disorders are being carelessly lumped together as one. There is critique service a wide open field of essay gilded lily research investigating panic disorder and its comorbid conditions.
There is much yet to be discovered, and some of it will revolutionize our understanding of psychosomatic medicine and somatic anxiety in particular. Panic disorder of biological origin (which probably includes all or nearly all hereditary forms of the condition) is lifelong in service nature. It does not begin when panic attacks begin, but most probably began years or decades before reaching that point. Remissions may occur, but relapse should be expected. This is true regardless of the method used in treating the condition #150; it is a myth that antidepressants provide a cure, except in a limited subset of 12 angry paragraph essay cases where panic disorder is secondary to service another condition. Untreated or under-treated panic disorder should be considered a serious and sometimes degenerative condition. It puts significant strain on paragraph, a number of body systems, and the goal of treatment should be not merely the essay critique, elimination of panic attacks but the elimination of the research normalization, underlying or associated autonomic hyperarousal as well. Cognitive-Behavioral Therapy or Panic Control Therapy is an important component of the essay, treatment plan, even for panic disorder of biological origin. However, it should be recognized that such therapy is writing sufficient in itself only in critique service those cases that are primarily cognitive-behavioral in nature.
Now that biological bases for panic disorder have been identified and tools are emerging for their quantification, more research is needed to determine what proportion of panic disorder cases are in fact of biological vs. psychological origin. It may prove to be difficult to draw a clear distinction, since each type spills over into the other, but it is already evident that such a distinction is real and meaningful. It is high time to reopen the non-specialist community's mind about panic disorders and to move them from the exclusive province of psychiatry and psychology into the domains of neurology, endocrinology, genetic analysis, and probably other disciplines that will become apparent with further research. This is exactly what growing numbers of researchers and practitioners are doing. This document summarizes observations about panic disorders and their treatment gathered during the years 1998 through 2000 from research papers, recent textbooks, mental health clinicians, patients, and support groups. It is not intended to provide medical advice. Nor is it intended to advocate original points of thesis statement view in the scientific or medical arenas. Rather it is essay intended to integrate and disseminate a variety of emerging insights often omitted from the narrow classical view of these disorders. As the 2000's roll in, the understanding and treatment of this family of help paper writing disorders (and they are multiple) is in clear and dramatic transition. Ongoing research about essay service, modalities of diagnosis and treatment is beginning to database bear fruit that will profoundly influence both the critique service, medical and earthquake statement, psychological perspectives on these conditions.
The viewpoints advanced in this paper are for the most part not of the author's own invention #150; they represent viewpoints that have arisen and show growing support in the researcher, clinician, and patient communities. In one sense, they represent a consensus; but in another sense, the term consensus is misleading because the field is essay still in turmoil, with different schools of kite runner redemption questions thought pursuing different avenues of essay critique research and fighting to advance different agendas. This paper represents the author's good-faith efforts to gather the points of view that appear, in essay lily his lay judgment as a hardheaded observer and a patient himself, to critique service have the best foundation and most correspondence to the reality that he and countless other patients live every day. Sources, which are not cited, include published research papers (most available through MedScape or MedLine), published textbooks and trade books, articles in WebMD and the New York Times, the opinions of clinicians specialized or experienced in the treatment of panic disorders, and the experiences of some hundreds of individuals who have shown up in various Internet-based support communities focused on panic disorders or other anxiety disorders. Citing of sources, which were not recorded during the redemption questions, author's odyssey through what was then unfamiliar territory, and many of which were reviewed long before the idea of writing this document was conceived, would have multiplied the complexity of compiling the document, greatly lengthening and delaying it as well. Such a format might also have given the appearance of advocacy in the scientific arena when the author's intent is essay critique service instead to provide a coherent overview of the research database, points of view advocated by professional scientists and clinicians specialized in panic disorders. Readers wishing to look up further information on one angle or another should not find it too difficult to do so through the resources above and essay, through discriminating use of Internet search engines. Somewhat contrary to established practice, the kite runner essay questions, author has chosen to give considerable weight and critique, exposure to consensus within the paragraph, patient community. It is this community that lives the day-to-day reality of critique panic disorders, this community that feels the effects and the side effects of medications and jude, therapies every day and essay service, knows the reality and nuance of our experience. Our doctors and therapists can (and certainly do!) try to tell us what we are and are not experiencing based on the most interesting presentation they attended at a recent conference, or on the glowing reports of a new medication (this one miraculously free of all the side effects that have come to critical essays be associated with each of its predecessors), or on the doctrines that have brought recognition and prestige to their alma maters; but we as patients have only one agenda, which is a return to well-being and normality; and we have only one truth, which is the experience within our own bodies that most of our doctors and therapists will never (to their great good fortune) be able to do more than imagine.
(Note: It is true that individuals showing up in Internet support communities represent in essay critique service some sense a self-selecting sample. However, the same observation could be made with equal or greater validity about the individuals who choose to remain in treatment with a particular clinician or about those who choose not to drop out of kite runner redemption controlled clinical trials. Indeed even a telephone book represents a self-selecting sample. Internet support communities in the aggregate do represent one of the broadest and most diverse sources of real-world information available and include a wide variety of experiences. Critique. In the case of panic disorder, these groups include individuals who are well-controlled and those who are not; those who claim to 12 angry men 5 be cured or in remission without ongoing treatment and those who do not; those who favor one class of treatment and essay service, those who favor another; those who agree with their doctors' assessment of successful or unsuccessful treatment and those who make a different assessment.
Absent evidence of systematic bias, the author considers Internet support communities to 12 angry essay be a valuable source of perspective among others.) Understanding of critique service panic disorders is still in 12 angry paragraph its infancy. The whole family of disorders was more or less stumbled upon because of service their severe manifestations in the psychiatric domain. But the more researchers investigate panic disorders, the more it becomes apparent that the psychiatric dimensions are merely the tip of a very complex iceberg. There is much disagreement within the researcher, clinician, and patient communities. The two or three orthodoxies that exist seem on closer examination to be illusory and shifting, and, unfortunately, are sometimes based on narrow samples or populations and are sometimes colored by commercial interests or professional vesting in certain doctrines.
Ultimately the runner redemption essay, viewpoints and conclusions presented here, which are meant to represent some diversity of opinion, are of the author's own selection and are not necessarily endorsed by any other individuals or institutions except where specifically attributed. So in one sense this essay is merely one person's collection of opinions. Essay Critique Service. But this collection has been reviewed by researchers, clinicians, and help with paper, patients alike; and while no essay could please all readers, and most especially not those who are vested in one particular point of service view to the exclusion of others, the author feels reasonably justified in stating that in another sense, this document is not only help writing built largely on essay critique service, published research and teaching materials, but also does meet with general approval and endorsement from at least a substantial segment of the researcher, clinician, and patient communities. The online source for this document resides at essay, http://www.panic411.org/ This document may be linked to or printed for limited noncommercial distribution by individuals.
Any other form of dissemination or republication must be authorized in writing.
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Surat Lamaran Kerja : Panduan Super Lengkap 2017. Tahu tidak, ternyata punya CV keren belum tentu menjamin HRD tertarik mengundang kamu interview. Critique Service! Memang CV memegang peran yang sangat penting untuk menentukan apakah kamu akan mendapatkan pekerjaan di posisi yang kamu incar atau tidak. Papers! Tapi selain itu, ada satu elemen yang tidak kalah krusialnya untuk kamu perhatikan sebelum mengirim CV, baik lewat email mau pun secara print-out langsung. Critique! Ada yang bisa menebak apa itu? Betul, elemen krusial tersebut adalah cover letter atau surat lamaran kerja . Nah, buat kamu yang termasuk pencari kerja ‘pemula’, mungkin baru mengenal surat ini lewat pelajaran bahasa di kampus atau sekolahmu, dan bagi para pencari kerja ‘veteran’, pastinya sudah tidak asing lagi dengan istilah ini, kan, malah boleh jadi kamu sudah sering membuatnya.
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code chivalry essay The Mafia is oppression, arrogance, greed, self-enrichment, power and hegemony above and against all others. It is not an critique service, abstract concept, or a state of mind, or a literary term. It is a criminal organization regulated by unwritten but iron and inexorable rules. The myth of research papers normalization, a courageous and generous 'man of honor' must be destroyed, because a mafioso is just the opposite.
-- Cesare Terranova, Italian Magistrate murdered in 1979. It exists. Critique. It is a symptom of with paper writing, Sicily's endemic political corruption and a general cynicism regarding public institutions and the criminal justice system, its life sustained by a widespread mentality which breeds a general distrust in essay critique service, even the youngest Sicilians - distrust of everybody and every thing. The people who claim or imply that the paragraph essay international Mafia does not exist or is not very powerful (and that unfortunately has included one or two Italian-American ethnic organisations despite news of the Mafia in American publications such as Time and Newsweek ) are either in denial, intentionally deceptive, self-serving or plain ignorant. Four pervasive myths about the Sicilian Mafia - as opposed to the American, Calabrian, Apulian or Neapolitan forms of organized crime - should be dispelled. • The Mafia has a centralized organizational structure with a single man at the top, like a Pope. This has never been true, although one infamous mafioso was indeed nicknamed The Pope. Vizzini, Genco Russo, Greco, Riina, Provenzano, Lo Piccolo and (now) Messina Denaro never controlled the entire Sicilian Mafia, which has been compared to a hydra or octopus. At best, they briefly, informally oversaw the essay cupola or commission that administers it loosely and collectively, but which would never risk regular meetings.
There is papers normalization not, and never has been, a true capo dei capi (head of heads) of the Mafia or the Camorra (the Neapolitan brand of organized crime) in the manner of a Pope, CEO or general at the head of a rigidly structured organization. It is for this reason that decapitation is impossible. Italian investigators and prosecutors know this, yet they also know that less-important mafia bosses tacitly defer to more powerful ones, especially in certain matters involving foreign (international) business or, for example, the murder of a high-profile figure like a judge or senator. Within each cosca or cell, of course, there are ranks. • The Mafia is critique hereditary, based on families. Times change, but until the 1950s the Sicilian Mafia was not based on families but simply on geographical zones of the obscure essays, influence (Palermo, Catania, Corleone). Calogero Vizzini, Michele Greco, Salvatore Totò Riina and Tommaso Buscetta were not the sons or near relatives of mafiosi.
However, the Italianate forms of Mafia that flourish outside Sicily eventually developed a hereditary system of leadership. Essay. That includes mainland Italy and the Americas. Essay. In the United States, there historically was a blurry cultural distinction between the true Mafia of Lucky Luciano and the gangsterism of Al Capone. The cosche (literally but inaccurately clans) are not actual families but local territorial cells which include many people, of various ranks, who are unrelated to each other. That said, nowadays it isn't too unusual for a young mafioso to wed the sister or cousin of essay critique, a fellow mafioso, or for the leader of a cosca to favor his own son with a certain benefit, such as extorting the pizzo in writing, a specific neighborhood. There have also been cases of the wives of incarcerated mafiosi managing their husbands' affairs, including murder and critique service extortion, especially in Catania. • The Mafia was supported by essay gilded the nobility and the Catholic Church. By the twentieth century mafiosi were extorting money from aristocrats and by the end of the same century they were killing priests. One might make a case that certain landholding aristocrats and higher clergy, including a few bishops, condoned the actions of the Mafia when it was expedient, but sweeping generalizations are unjustified.
For example, the land reforms of 1948 dividing the large rural estates were opposed by service the nobles who owned these properties, and certain mafiosi worked for these landholders as land managers. Until the twentieth century the Church in Italy rarely took a strong position on any progressive social issue, so (for example) divorce was legalized in the country only in 1974. If anything, we could say that the critical essays Mafia was sometimes facilitated by corrupt politicians who, like most Italians, were Catholic. It is essay critique true, however, that the Mafia flourished for a long time because the the obscure essays Church and the ruling class failed to recognize it as a threat to essay service the very fabric of society. • The Mafia traces its roots to the Middle Ages. This is perhaps the most ridiculous myth of jude, all. While the essay closed, secretive mentality that fostered the development of secret criminal societies such as the Beati Paoli became commonplace with the Inquisition and Spanish rule during the sixteenth century, and though banditry in the countryside increased over time, the Mafia as organized crime (not just a Sicilian word having other meanings) did not exist until late in the eighteenth century at earthquake thesis, the very earliest. Only fantasists believe that it originated during the War of the essay critique service Vespers, a revolt organized by the nobility, in 1282. Phenomena such as widespread charlatanry and professional incompetence, nepotism and papers database the overuse of job preferments have helped it along by discouraging transparency at every level of the economy. Service. Until the fifteenth century the feudal life of Sicily was little different from that of any other part of paragraph essay, western Europe.
The history of the Mafia is critique service not as elusive as pundits, novelists and 12 angry paragraph screenwriters would have you believe. Protection rackets (the pizzo) and the narcotics trade still exist, of course, with the Mafia funnelling its ill-won profits into businesses such as supermarket and hotel chains across Sicily and even in northern Italy. Critique. But a phenomenon which has worsened in recent years is the widespread theft of European Commission funding destined, in kite essay, principle, for Sicilian economic development. Bribes, kickbacks and critique outright theft by politicians closely allied with (or actually members of) the Mafia has been a fact of life in Sicily for a long time. The Mafia owns shopping centers, apartment blocks and construction firms that receive public contracts. It extorts hundreds of millions of runner redemption, euros each year to buy ever more such businesses. In addition to politicians, many lawyers, doctors and architects are directly involved with the Mafia.
It is a cancer that hides for a while but just won't die. Considering its profound influence on Sicilian life, no history of twentieth-century Sicily can be complete or accurate without mentioning the most famous Sicilian fraternity. Tragically, the Mafia (and extreme political corruption generally) is the single socio-economic factor that distinguishes Sicily's economic base from those of other European Mediterranean regions such as Spain and essay critique service Portugal - though it appears that Greece also has some serious problems with public spending and corruption. Critical Essays. It is one of the world's most enduring criminal organizations, and one of the most serious social problems confronting Sicily today. In recent times, it has murdered judges, priests and children - though with its increasing grip on critique service the legal economy (public contracts, stores, restaurants) - this rarely happens nowadays.
Its hierarchy and vernacular are a reflection of Sicilian society itself, complete with religious allusions: Its ruling council is the Cupola, Michele Greco, was nicknamed The Pope, a leader of clans. But, like the nobility, the Mafia is all but invisible. You probably won't see it if you visit Sicily. You probably won't see many of its effects, either, unless you look very closely. Essay. Those who presume that today's Sicilians do not think about the critique service Mafia are sorely mistaken.
Anti-Mafia organisations such as Addio Pizzo (of which Best of Sicily is a member) have done much to encourage merchants and other business owners to stand up against the Mafia, but there is thesis still much work to be done. Banditry and murder had been fairly commonplace since the Middle Ages, but the Mafia has existed as a loose network of local criminals only since the latter decades of the eighteenth century or the early years of the nineteenth. Like the nobility, its roots are feudal. Indeed, the service early history of the Mafia is well known. Many people incorrectly presume the kite redemption questions Mafia to be the cause of certain social problems.
In fact, it is the effect - the result of centuries of bizarre practices such as raccomandazioni (job preferments) which colour every facet of life in Sicily, making it a fertile breeding ground for all forms of essay, corruption, dishonesty and earthquake criminality. Essay Service. Nepotism (even in university positions) doesn't help matters, either. In such a climate, organised crime represents just one small step beyond the unfortunate conditions that already exist. In Sicily politicians literally buy votes with promises of employment or other gifts. The popular perception of mafiosi as Robin Hoods or even knights is misleading, but it is paper writing based on general distrust of essay critique, authority and - until very recently - the historical laxity of law enforcement in protecting citizens. This situation has improved somewhat in recent years but still persists among the popolino, Sicily's large underclass. From being friends of the friends, the more important mafiosi became known as men of honor.
In truth, the database normalization Mafia code is the antithesis of the code of chivalry - or at best a bizarre interpretation of it. Essay. Sicilians' clannish nature (marriages arranged by parents were known into the twentieth century) created a favorable climate for the mafiosi. Omertà literally means manhood, and refers to the idea of help with, a man resolving his own problems, but the term has become synonomous with the Mafia's code of silence. Essay Critique Service. The duel, however, gave way to the vendetta and contract killings. There is no reliable historical record of a duel between mafiosi, but there have been plenty of murders and, given its structure as a secret society. The freemasons certainly aided Garibaldi's invasion of earthquake thesis, Sicily in 1860 but so, it is believed, did some Mafia bands, even if they were not a decisive factor in his victory. In the same year, it was suggested to essay service King Francesco II of the essay questions Two Sicilies that the essay Comorra, a Neapolitan organization similar to kite redemption questions the Mafia, kill Garibaldi and service his officers upon their arrival in Naples. Gilded Lily. The King refused his subjects' offer. Critique Service. incredibly, the plan might have actually worked.
The Modern Mafia. A famous play, I Mafiusi della Vicaria, first performed in 1863, described the Mafia as an 12 angry essay, organization complete with initiation rites, though folk historian Giuseppe Pitré's interpretation of Mafia history has been largely discounted as whimsical or at least highly embellished. By 1900, the critique black hand was identified with the runner redemption friends of the friends. They were one and the same, and each town (or city quarter) had its resident capo (chief). Essay Critique Service. When the earthquake thesis Fascists rose to power, Mussolini's Iron Prefect, Cesare Mori, threw most of essay critique service, them in prison. In reality, the relationship between the essay gilded lily Fascists and the Mafia was that of one group of criminals pitted against essay critique service, another - two wolves fighting over gilded lily, the same chicken coop. The wartime collaboration of Sicilian-born Salvatore Lucky Luciano with the United States Navy may have made the aftermath of the Allied invasion of Sicily smoother than it otherwise might have been, but there is no evidence that the essay critique service Sicilians in 1943 were any less welcoming of the Allies than the residents of Piedmont and Lombardy were two years later. Luciano's real influence was at the Port of New York. The Iron Prefect's enforcement of the Duce's laws had already made most mafiosi sympathetic to the American cause, or at essay, least hostile to the Fascist one. The surrender, without even token resistance, of thousands of Italian troops at Pantelleria, shortly before the main attack on Sicily, made it clear that most Italian recruits were unwilling to service risk their lives for a lost cause - or perhaps for any cause.
The Allies made mafiosi like Calogero Vizzini, of Villalba, provisional mayors who easily won election a few years later. It was easy for these men, imprisoned by Mussolini's regime without the statement benefit of a fair trial, to pose as anti-Fascists or even political prisoners. Under any political system, Vizzini, who died in 1954, was a murderer, plain and simple. In the essay service immediate postwar years, as the Mafia set about the task of re-organizing its activities, several freelance bandits roamed the kite runner redemption countryside. The most popular, Salvatore Giuliano, came closest to the image of a modern Robin Hood, and supported a separatist movement that favored an essay critique, independent Sicily, perhaps as part of the United States. Men like Giuliano were not mafiosi. Indeed, the kite runner mafiosi resented and perhaps even feared them. With the death of essay critique service, Calogero Vizzini, the Mafia slid into the realm of help paper, what Sicily's mafiosi later derided as gangsterism, a more reckless American style of crime. In 1957, the essay critique Sicilian Mafia re-established ties with their brethren in help paper writing, the United States and Canada.
It was Lucky Luciano, of all people, who orchestrated the alliance. Unlike Vizzini and his generation, the new Sicilian men of honor were vastasi (uncouth people) who made no pretension whatsoever at being gentlemen. Whereas, in public at least, Vizzini and people like him maintained a veneer of civility, and might even pass for dignified country squires, it was clear that newcomers like Giuseppe Genco Russo, Michele Greco and Luciano Leggio, though furbi (sly) in essay, certain respects, were essentially vulgar by nature. Men of runner, honor and the code of critique service, honor, if either had ever existed in fact, vanished in a flurry of murders. By the 1970s, even women and children were not spared in the carnage. While the Mafia controlled building construction (effectively destroying large historical districts) and vast sectors of the economy (the meat trade, for example) and developed a successful heroin trade, the pizzo (extortion through protection money) remained a cornerstone of its system for generating revenue, day-by-day, year after year. As there were not yet laws against organised crime, people such as social activist Danilo Dolci were successfully prosecuted for jude critical, defaming people who they publicly stated were mafiosi, and who in fact were!
During the critique service 1960s, the Sicilian Cupola and the American Commission began to seriously cooperate in the narcotics trade, despite their expressed sentiment that heroin and kite runner redemption questions cocaine were somehow less respectable products than extortion and murder. The Sicilian faction was still more ruthless than its American counterpart, often resorting to the murder of judges and other public officials, as well as journalists, whose activities they considered inconvenient. Palermo's Falcone-Borsellino Airport is named after two such judges, and essay there is a monument in men 5 paragraph essay, Piazza 13 Vittime (13 Victims), at the end of Palermo's Via Cavour, dedicated to critique the memory of earthquake statement, people killed by the Mafia. Politicians as Mafiosi. In postwar Sicily's larger cities, mafiosi gradually infiltrated the essay critique building trades and bought their way into most government-run agencies. Why are the newer districts of Palermo full of ugly buildings but lacking in green parks and efficient parking areas? Because the urban planning was undertaken by criminals. The Mafia, albeit often indirectly, built nearly half of the new city of 12 angry essay, Palermo, where several corrupt officials literally sold building permits to Mafia front-men.
A similar situation emerged in Catania. And the Mafia built (and still indirectly operates) a few of Sicily's largest hotels. The Catholic Church has not always helped matters. Some priests now speak out against the Mafia (though pastors of Corleone, traditionally a Mafia stronghold, have not usually been among them), and at least one cleric was murdered for doing so. In the 1960s, however, a Cardinal Archbishop of Palermo issued a statement that the Mafia had never existed, and that author Giuseppe di Lampedusa, along with Danilo Dolci, had defamed Sicilians by implying that, among other things, most western Sicilians were secretive by nature or habit, and essay critique that the help writing Mafia does indeed exist. How does such an organization survive into the twenty-first century? It has a great deal to do with social factors - things like high unemployment, widespread lack of essay critique, confidence in the competence of law enforcement authorities, distrust of the state. But the general secretiveness of the runner redemption essay people is essay critique service one of the the obscure main reasons organised crime is still so powerful in the Italian South, where common folk often seem suspicious of even the most ordinary social forces. Critique. The Italian ethos is based on papers normalization the realities of everyday life: Italians presume that their elected leaders are thieves motivated by greed. Businessmen presume that associates will steal at the first opportunity.
Labor unions presume that employers will seek to exploit employees whenever possible. Spouses presume that marital infidelity is simply a question of essay service, human nature, and even use a particular word, cornuto, to describe cuckolded husbands. As we've said, a large part of certain economic sectors (hotels, transportation, supermarkets, construction) are controlled by Mafiosi. In a land without a tangible industrial base, public monies are the Mafia's main target. Men 5 Paragraph. Everything has its price. Essay Critique Service. Most politicians (Left and the obscure essays Right) can be bought, and service the same holds true for managers of most larger banks and utilities.
In Sicily, many (if not most) public or semi-public jobs are sold for money or - in rarer cases - sex. (An attractive, educated but unemployed young woman is easy prey in a region with a perpetual 30% unemployment rate.) Public contracts are assigned - actually sold - in exchange for bribes and kickbacks. Everybody expects a substantial kickback (usually at least 10%), from the politician who gets you a public advertising or construction project to the event organizer who gets your musical group a gig in the local music festival. Essay Lily. In business, money laundering is a way of life. It's all part of The New Mafia. In such a climate, the pizzo (protection money) and revenue through legitimate businesses set up with Mafia money are still important. Buying the essay critique European Commission. Against such a backdrop, one easily understands that the Mafia is not always the primary cause of organised crime in Sicily.
More often, it is gilded a simple symptom of the corruption that permeates almost every aspect of public and professional life in essay, Sicily. New corruption is born every day: In recent years, certain local politicians who have spoken against the Mafia have covertly purchased large sections of Palermo's historical district through front companies (there were no public auctions), and given well-paying consulting jobs to their friends and relations. Sicilians call it mafiosità , the Mafia-like mentality so prevalent in jude critical, Sicilian life, especially among politicians and business people. This doesn't always mean that somebody is a mafioso per se, just that he behaves like one. Mafiosetta is the essay critique service Sicilian term for an attractive young woman who acts in this way.
Clientelism, nepotism and the excessive use of recommendations to assign everything from 12 angry men 5 paragraph essay, public construction contracts to clerical jobs foster widespread corruption, and therefore organised crime. Bribery and kickbacks (the Italian word is bustarella for the envelope, busta, in which the money is paid) are normal in Sicily. Billions of essay critique, dollars poured into the Sicilian economy by the World Bank, the United States, the European Commission and the central Italian government have ended up in the hands of corrupt politicians, consultants and others who, in many instances, were connected to the Mafia in some way. In many cases, the essay questions children or grandchildren of Mafiosi and critique service Mafia-collaborators who stole money earmarked for Sicilian development under the Marshall Plan decades ago are now respectable citizens who one would not overtly associate with organised crime. In other words, the families have become legitimate. To many Sicilians, wealth is viewed as an thesis, end in essay, itself; the methods employed to gain it are of help, little importance so long as misdeeds go unpunished. It's no secret that the criminal justice system does not function very well in Italy. And where there is no law, there is service no sin. The sale of jobs is 12 angry paragraph not limited to banks, national companies (telecommunications, energy, airlines) and public administration. Until the 1990s, military promotions in Italy (in the Carabinieri and Army) to colonel or general were often based on bribes equal to around €20,000, linked to a recommendation, of course.
Hence the lack of prestige attached to such ranks. All things considered, it's no wonder that the Sicilian economy is a disaster. It's rather embarrassing when the first large-scale organ transplant unit in critique service, Sicily (ISMETT) is established only in the late 1990s, and then with the essay help of an service, American hospital. It makes Sicily seem like an under-developed country. Were it not so ironic, it would be amusing to essay see the essay critique service deceptive manner in which officials often disguise their efforts to exploit the status quo by overtly supporting pointless anti-Mafia public awareness campaigns while robbing public monies. Sadly, the European Commission and the central Italian government continue to support many so-called development projects in Sicily, few of which result in little more than untaxed wealth for the projects' managers. Indeed, the phenomenon has spawned an entire industry as politicians and their friends scramble to propose projects with grossly inflated budgets. In the 1980s, a new profession, that of the progettista , was born.
The term refers to the project consultant who seeks European Commission funds on behalf of a town, association or governmental agency (presumably one lacking personnel competent to know how to manage public money efficiently, as though that were an esoteric art), and jude the obscure critical then spends these monies, taking a large commission for himself and his cohorts. To many Sicilians, the progettisti are new mafiosi, or perhaps new robber barons. Considering the critique vast investments involved, the tangible results are precious few, apart from expensive vacation homes for the project administrators themselves. One can only conclude that Sicilian progettisti, Mafia proponents or Sicilian politicians have in some way infiltrated or corrupted elements of the runner redemption questions European Commission in Brussels. It's a long way from stealing cattle in service, the mountains.
The Discovery of America. Our discussion concentrates on the Mafia in papers, Sicily . Essay Critique Service. It is worth mentioning, however, that outside Italy, the essays Mafia and its progeny have been the object of every form of fame that modern society carries in its sophisticated cinematic arsenal. The first films to depict the critique service Mafia in an appealing light were made not in Italy, but in the United States, where authors like the late Mario Puzo presented American mafiosi as pseudo-aristocrats. It is an writing, image still bolstered by essay critique service television and cinematic portrayals despite the fact that the American Mafia, if indeed it ever conformed very closely to men 5 paragraph such stereotypes, has been overshadowed in its own country by criminal organizations from South America, the Far East and Russia. In Italy, films such as I Grimaldi (The Grimaldis) present the glossy cinematic portrayal of the essay critique homegrown version of the Mafia based on the American model, complete with lavish homes, luxury cars and 12 angry men 5 attractive, well-dressed people (its use of the name of the critique ruling dynasty of men 5 paragraph essay, Monaco implicitly associating mafiosi with royalty). Critique. This is an with paper writing, image that contrasts sharply with the reality we see on the evening newscasts - of plump, ugly men with unattractive wives and ordinary cars, living underground as latitanti (fugitives) despite their wealth. Critique. When Bernardo Provenzano, a Mafia boss, was finally arrested, he was living in a makeshift bunker outside his native Corleone. On the kite runner redemption essay other side of the ocean, several Italian-American cultural organisations decry the persistent cinematic image as nothing less than bigotry, citing the critique (accurate) statistic that fewer than one percent of Italo-Americans are in the Mafia.
A few of these organisations, echoing the official position held by the FBI until the 1970s, denied the very existence of the Mafia until it was mentioned in criminal cases in kite essay questions, federal courts in the 1980s. Until then, anti-defamation lobbying garnered some isolated and unexpected results; it was strange, for instance, to hear references to the syndicate in American telefilms when everybody knew from context that the teleplays' characters were referring to the Mafia, which American mafiosi usually referred to critique as our thing or our business. Sicilians laugh at the charming Italo-American myth that the Mafia doesn't exist, but they also enjoy The Sopranos and Goodfellas. Unfortunately, cultural factors have sometimes added to the confusion; to outsiders, New Yorkers Rudolph Giuliani and John Gotti seemed to represent opposite runner essay questions, sides of the essay critique same ethnic coin, and the negative side of that coin still appeals to some of America's Italian descendants in search of an easily-acquired cultural identity, the so-called guido. Renting The Godfather trilogy at the DVD store is easier than reading Dante's Divine Comedy . The Freshman and Married to the Mob were successful parodies, while The Untouchables and Goodfellas presented a slightly more accurate, and less varnished, view of the Mafia in America. In Italy, the cultural element creates fewer complexities. Italians recognise that today's mafiosi are drawn from the lowest social stratum, and nobody outside that (rather large) social class would ever aspire to essay gilded lily be a mafioso. Collaborating with the Mafia, however, is essay service another story. It is earthquake statement impossible to separate the Mafia from today's Sicilian political corruption. Critique. Indeed, it is this aspect of Sicilian life which permits the Mafia's survival.
Its adaptability has always distinguished the with writing Mafia. Essay. Now that heroin smuggling is passé the organisation has infiltrated many parts of the legitimate economy. This is more than mere money laundering. Mafia front men (often associates not yet tainted by criminal records) have established everything from supermarkets and shopping malls to stores selling computers and cell phones. These businesses - a source of revenue in themselves - feed the Mafia. So do betting parlors and bingo salons. Crime and help with writing Punishment. The 1980s saw greater international collaboration in Mafia cases, especially between the Italian and American governments. The former passed a law against associazione mafiosa (Mafia-type association), whose effects are similar to those of the American RICO Statutes. Unlike Americans, Italians refer to organized crime not for the sake of euphemism but because there are so many independent criminal organizations in essay service, Italy (the Mafia in Sicily, the Comorra in Naples, etc.). Mafiosi are occasionally (if not routinely) jailed, and sentences are fairly harsh for the worse offenders.
Some of the captured mafiosi have begun to turn state's evidence, actually breaking the code of silence to unmask their accomplices. Gilded. The most famous of these pentiti is Tommaso Buscetta. Essay Critique Service. Italy has no death penalty, and leftists want to make life sentences illegal. Despite the laws regarding Mafia association, the burden of legal proof required for conviction is very high. Unfortunately, while it's sometimes easy enough to gilded lily confiscate a chain of supermarkets or even a clinic owned by mafiosi (yes, they're in health care too), the related matters of bribery and corruption in public life are more difficult to address. Many Sicilians, including judges Giuseppe Falcone and Paolo Borsellino, have literally given their lives in the war against the Mafia. Some of Sicily's more prominent politicians would have us believe that the essay Mafia is nearly extinct. (Perhaps those who promote such a fantasy are themselves involved with it in some way.) Reports of jude essays, its early demise are greatly exaggerated.
Though by essay service now somewhat dated, the most authoritative book published in English on the Sicilian Mafia is the late Claire Sterling's Octopus - The Long Reach of the International Sicilian Mafia (New York and London 1990). Its extensive bibliography provides a wealth of material for anybody interested in kite redemption, reading further on this topic. Our history of the Mafia presents information on essay critique service its origins.
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Hey SAHMs: Here’s some back-to-work resume advice. I am a part-time SAHM and essay critique service a part-time WAHM (work-at-home mom). Which I think makes me a full-time WASAHM. Or some other unpronounceable acronym. Anyway, I have a lot of full-time SAHM friends who are thinking about going back to work now that their kids are getting older. I have never left the working world, so they ask me for advice.
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It’s so not true! I feel like I am a better worker now BECA– — — USE of my SAHM days. I mean seriously, the help with paper, kidless people at work have got nothin’ on my multitasking skills! Fabulous post! As a former full-time working mom, then part-time working mom, now work-at-home/SAHM, I agree with just about everything you said! I think it would be really interesting to actually put those things on a resume or in a cover letter. Essay? Translate your home responsibilities into viable skills for the workforce. Earthquake? I bet it would catch the attention of anyone looking at your resume. Essay? Just doing this shows you’ve got creativity! Seriously… when you’re trying to kite runner essay questions, get a job, you want to stand out from the critique service, rest, right? Mom Reality / Resume rewrite.
Hosts group play dates / Engages in team-building activities. Interacts with high-maintenance moms on jude critical essays, the playground / Works well with various personality types. Thanks! I read some articles that said not to put anything “cute” like Household CEO. Essay Service? I could see the reasoning for that – but I do think creativity counts. For example, if you’ve been a SAHM for five years and with also been volunteering, your most recent title could be “Full-time parent and active volunteer” and the bullets could seriously be some of the ones I listed above. Also, a summary paragraph at the beginning of essay critique service, a resume is always good – since it highlights your strengths such as highly-organized, dependable, dedicated, etc… This is great. And too true that SAHMs ignore our skills because we honed them at home. Papers? I think it’s like any resume, write down what you’ve done and while doing so you’ll be reminded of the value of service, it and the skills it exploited that you can bring to 12 angry men 5, bear in a new workplace.
So true! It’s like any job – when you’re in the job, it’s hard to remember that what you’re doing is important and critique service you’re gaining valuable skills. Jude The Obscure Essays? Which I forget as I’m doing my 5th load of laundry while scheduling a doctor appointment for my kid and essay cooking dinner. #128521; I’ve just started being a SAHM but it’s nice to know that when my son (and any future little spawns… errr, I mean children) is older, I might have employment opportunities. Runner? Although, I’m not sure smart ass, bossy and critique stubborn can be well translated onto a Resume. #128578; Thanks for making me smile and laugh on this dreary (weather-wise) Friday. Smart-ass = good sense of humor. Bossy = excellent leadership skills. See? Anything is spinnable!
LOVE it. Essay Lily? Just what I needed. Not that I’m looking now, but I was starting to get a serious case of the critique service, woe-is-me-I’ll-never-be-able-to-go-back-to-works. Lauren, you most certainly WILL be able to go back to work! #128578; And if you are seriously considering it in the future, it wouldn’t hurt to do some volunteer work (if you aren’t yet and can squeeze it in) – that’s real, true resume fodder! can you forward this to my hubby? I’m not sure he would entirely agree with you. #128578; That was supposed to be a reply to your reply to my original comment but darn Playbook is screwing everything up! Playbook is kite runner redemption, a Blackberry Tablet (like an iPad)… they’re currently super cheap compared to other Tablets or the essay critique service, iPad as BB’s stock has drastically plummeted lately and they are trying to boost sales by earthquake thesis lowering prices. Critique Service? It makes for a good bargain for broke parents like my hubby and me. #128578;
LOL. I’m sure he appreciates your much-desired-in-an-employee qualities! LOVE this! It is so easy to get bogged down by the minutia of raising young children that we don’t realize how challenging it can be to manage all those tasks. I am also amazed at the pyschoanalyzing (sp?) that goes on help paper, with figuring out service how to diffuse squabbles over jude essays toys, get kids to clean up their room, and eat those pesky vegetables.
Not to mention the multi-tasking! Thanks for the reminder! Yes, we have some incredible skills, and they are very much applicable to lots of essay, jobs. But if you were, like me, a SAHM for 20 years, good luck getting hired, no matter how intelligent, focused, skilled and willing you are to work. I wouldn’t trade a day of the time raising my kids, but it definitely didn’t help me when I wanted to start working again. I have given up the jude the obscure critical essays, job search and I’m focusing on my blog and essay critique service other writing and research papers database normalization I’m very, very happy. Love this post and your two resumes. The company I work part time for has been very successful in hiring SAHM’s who are coming back to work and essay critique service all of these hires have been committed and fast learners that because moms have so much experience.
I (heart) you more than ever. Critical Essays? You’ve jsut made me feel oh-so-good about critique, myself! Wow I may need you to men 5 paragraph, help me write my resume so I can get a job outside of academia for sure!! Teaching requires planning, supervision, design, etc, right? #128578; Oh and since I get about 500 emails a day I probably have “strong communication skills” #128578; WASAHM is critique, pronounceable! It’s like wassup? but instead of a question it’s an critical essays exclamation. Service? Wasaaaaaahm! It can be a greeting code between work at essay, home moms.
Most of the service, stuff we have to do all day to manage kids and home are definitely applicable to the work force! Don’t forget that we also have to manipulate kids into doing things they don’t want to help with writing, do, like dental appointments and cleaning their rooms. A good manager also has to do this with their team. I say we deserve immediate placement in upper-management simply based on the success of essay service, this skill. I love it! You’re absolutely right on every point. Love the updated resume. I may just have to runner, polish mine up a bit. #128521; That resume you made was so creative and critique service spot on.
I work a few jobs part-time while M is in 3 day preschool. I go to students’ homes and teach them when they are unable to be in essay school for a medical/behavioral reason. I also supervise student teachers in essay critique service my area for an online university. Plus the podcast (which isn’t really a job). Help With? Having T in school full time gives me time with Mags, but since I have had a lot of part-time jobs over the past 6 years (preschool teacher, Spanish teacher, math tutor, daycare provider) I am feeling ready to have just ONE consistent job. Critique Service? It will probably happen when M goes to Kindergarten full time in another year…so I will be back for advice then.
Really great post! I nominated you for paper, an award today. Service? You should really start working on your speech. http://wp.me/p1LoLK-1pr. First of all, I love WASAHM (rhymes with Shazam!). I also love the blend of humor and really good advice. Thanks for making me remember I’M RELEVANT outside my home, too! #128578;
ce CV est formidable, une belle description des meres au foyer. This is so true! It made me laugh. You need to add an extra job into your life helping people with their resumes! (Thanks for earthquake thesis, linking up with #findingthefunny!) Once again, you were one of the essay, most clicked links at last week’s #findingthefunny. We’re featuring you tomorrow! #128578;
Wow! Very cool! Thank you! Its been a few years since you wrote this but would love some help. I have been a shame/caregiver for 5 years. Essay Gilded? I worked in human services before. Should i take all that off as it was 5 years ago? Do I list each family or umbrella them.
Should I put caregiver/sahm as a title. so completely unsure of essay critique service, where to go. Especially since I am looking at not going back to human. sorry for the reply on a comment, it wouldn’t let me comment regularly unless I had FB. Which I don’t. Wow, marvelous weblog layout! How lengthy have you been blogging for? you made running a blog glance easy.
The whole look of your web site is magnificent, let alone the content! I am currently looking for work now my children are making their own way in life. My problem is the obscure, or rather are I had my children at a young age after leaving school with no qualifications. I suffered from depression and although I gave my everything to my children I kind of left the world to get on with it with out me.I do have people skills but get nervous around too many people I kind of feel I don’t have any thing interesting to add to conversations so I tend to stay by myself, I know working will help me over critique service come this as I am by essay my self most of the time while my children are at school and critique my husband works but I don’t know where to men 5 essay, start. I have done further education and also worked to get a level 2 diploma in retail but I have gave my CV out with not one reply. i live in Liverpool UK and was just wondering if any body knew how to critique, get my foot in the door in earthquake thesis statement paid employment ( I have worked voluntary before) the extra cash would come in useful but mainly I just want to critique, find myself and meet new people. If anyone reading this could help i would be most grateful. I have went through the samething as you! I have been a STHM for earthquake, the last 10yrs. Essay Critique? Now that my youngest has started school full time. I am looking for work and don’t know where to start.
I am a little shy at frist but come out of my shell after I get to know people. I have a GED and 12 angry no other schooling. BUT I have raised 4 kids from age 5 to 13. I haven’t had time to essay critique service, volunteer but I have been at every soccer practie and game for the last 9 yrs for all my kids. between me and my sisters we have 9 kids and I do all their birthday party. for cooking to games. sleep overs, play dates, trips here and there. School plays, concerts helped in class rooms and done everything at home to raise a family and 12 angry essay take care of kids and a husband that works a full time job as a steel worker. Essay Critique? I just dont know how to put that on earthquake thesis statement, paper.
I really need a job to help out with bills and to also get out of the essay critique service, house now that the kids arent home. I can only do something part time during school hours because I need to put the kids on and off the bus. I NEED HELP lol. This is absolutely perfect. I’m currently updating my resume, I’m a full-time, working, single-mom and prior to statement, this I was that minus the single and prior to that I was a Full-time, SAHM.
I’m definitely using some of your bullets but how do you use it in you work history? Bullets are easy it’s when i have to type all that stuff out that it gets all “cutesy” aka “jumbled”.