Which enzymes are present in pancreatic and intestinal juice?

Pancreatic juice is an alkaline secretion of the pancreas, a large gland which sits somewhat behind the stomach from where it empties its secretions into the upper part of the intestine called the duodenum. This is regarded as the exocrine function of the pancreas. In addition to pancreatic juice, the pancreas secrets hormones, mainly insulin and glucagon, a role which is regarded as the endocrine function of the pancreas.

The pancreas plays a very significant role in food digestion because the enzymes contained in the pancreatic juice partially or completely break down the carbohydrates, proteins and fat we eat.

An enzyme called the pancreatic amylase is the enzyme contained in pancreatic juice which is responsible for completing the digestion of carbohydrates. Trypsin and chymotrypsin are the enzymes contained in pancreatic juice which complete the digestion of proteins and another enzyme called lipase is the enzyme responsible for the breakdown of fat.

A digestive juice called bile originates from the liver and it is transported in the common bile duct which joins the pancreatic duct carrying pancreatic juice  to form the ampulla of vater. It is through the ampulla of vater that both contents are discharged into the first part of the intestine called the duodenum. 

What is the difference between plasmolysis and de-plasmolysis?

Although both plasmolysis and de-plasmolysis occur in plant cells based on the amount of water inside their cell walls, they produce opposite reactions.

Plasmolysis occurs when a plant does not receive enough water, causing outward osmosis, or the movement of water out of the cell. Within the cell walls, the cytoplasm and plasma membrane shrink due the lack of water in the vacuole, causing them to pull away from the wall. Ultimately, this process causes the plant to shrink and wilt.

De-plasmolysis is the opposite of plasmolysis. When a plant takes on water, which is held in the vacuole, the cytoplasm and plasma swell within the cell wall. The pressure, which is caused by the influx of water, is called turgor pressure. As the pressure within the cell walls rises, the plant returns to its upright state.

Explain how cellular respiration provides energy for the cell by breaking down sugar molecules.

In the process of cellular respiration, the glucose molecules are consumed and a number of products are generated, along with the energy molecules (ATP). The balanced chemical reaction for the process is:

`C_6H_12O_6 + 6O_2 -> 6 CO_2 + 6H_2O + ATP`

In this process, 1 mole of glucose and 6 moles of oxygen are used to produce 6 moles of carbon dioxide, 6 moles of water and ATP (adenosine triphosphate) molecules. The ATP molecules are the energy currency of the cell. 

The process of cellular respiration can take place both aerobically as well as anaerobically. It has been observed that aerobic process is much more efficient, as compared to anaerobic respiration, in terms of ATP molecules generated per molecule of glucose. Aerobic respiration produces about 36 molecules of ATP per molecule of glucose consumed, whereas anaerobic respiration produces only 2 molecules of ATP.

Interestingly, cellular respiration and photosynthesis are complementary processes and each uses the products of the other. 

Hope this helps. 

What are conduct disorders?

Background

Conduct disorder (CD) is characterized by pervasive dishonesty, aggression, and callous disregard for others and for rules. These behaviors are more intense and longer-lasting than the occasional rule-breaking behavior associated with young people, for example. Also, CD is two to three times more common in boys than in girls.

The disorder exists in a continuum with two closely related disorders, one of which—oppositional defiant disorder (ODD)—tends to appear in younger children and the other of which—antisocial personality disorder—is not strictly diagnosable until adulthood. It is believed that some children with ODD “grow into” CD in their teenage years; later, some teens with CD demonstrate an antisocial personality when they become adults.

In practical terms, some children with high levels of irritability, developmentally inappropriate tantrum-like behaviors, and defiance of adults may demonstrate (as they age) a continuing lack of empathy, increasing callousness, and difficulty in restraining from cruel impulses. If these tendencies manifest in three or more different types of serious misbehavior that are repeated multiple times for more than one year, clinicians may consider a diagnosis of CD. Even in this case, the behaviors must be substantially worse than occasional acts of petty cruelty or vandalism and the behaviors cannot be caused by underlying mood problems, attention deficit hyperactivity disorder, or post-traumatic stress disorder. Usually, the earlier the problem behaviors appear, the more severe the disorder is likely to be.

Causes

Most mental illnesses emerge from the interaction of internal and external causes. Traditionally, some of the internal causes for aggressive behavior are believed to be low self-esteem, aberrant moral judgment, low frustration tolerance, low IQ, and concomitant low school achievement. CD is highly heritable. A person with a sibling or parent with conduct, hyperactivity, or substance abuse problems is more likely to have a CD.

Other studies have pointed to neurological dysfunctions as important in CD. One study of extremely violent men has offered evidence that the neural pathways associated with recognizing and interpreting facial cues are not particularly effective in these men. Although the data are arguable, it is possible that persons with CD may be similarly unable to correctly interpret facial cues and are therefore more likely to believe that neutral persons are hostile.

Other neurologic studies suggest that the brains of antisocial persons experience difficulty with regulating stress and maintaining appropriate levels of certain neurotransmitters, including serotonin and norepinephrine. Low levels of these brain chemicals have been associated with depression. Persons who experience increased levels of serotonin and norepinephrine after engaging in risky behaviors may increasingly seek out those behaviors to avoid low moods. Other studies have examined problems in neural pathways linking those parts of the brain responsible for overall decision making with other parts of the brain associated with rewards and with learning.

Even someone prone to aggression or dishonesty may not demonstrate significant behavioral problems without environmental stress. Among the more commonly accepted environmental contributors to CD are poor parenting, especially ineffective monitoring or inappropriate discipline; family problems, including conflict between parents or other disruptions in family life; economic problems like family poverty and poor and crime-ridden neighborhoods; and school problems, including schools that are plagued with high rates of criminal or deviant behavior among students. Not all who experience these environmental issues demonstrate conduct problems, however.

Typically a diagnosis of CD will be based on extensive problems with aggression, property destruction, dishonesty, and rule-breaking behaviors. These problems are discussed here.

Types

Aggression Toward People and Animals. The first group of behaviors associated with CD has to do with repetitive viciousness toward people and animals. These behaviors indicate deep unconcern with the basic rights of others to be safe from physical harm. Hence, persons with CD may enjoy bullying or threatening. Beyond just threats, however, many will start fights and may use whatever weapons are available to wound or kill others. Other vicious behaviors in this group include the perpetration of other serious criminal acts in the course of physically harming or threatening others. Armed robbery, rape, and extortion are some examples.

Destruction of Property. Those with little regard for others’ physical well-being frequently demonstrate even less respect for others’ property. This second group of behaviors associated with CD involves arson, vandalism, and other forms of property destruction. However, this group does not include vandalism that is better explained as thrill-seeking behavior; instead, it includes vandalism for the purpose of destruction and to deprive others.

Dishonesty and Stealing. When confronted with their behavior, many with CD either minimize the severity of their actions or project the blame onto the victim. This basic dishonesty characterizes the third group of behaviors used to diagnose CD. These behaviors include house breaking, lying, forgery, writing worthless checks, and stealing when victims are not present.

Rule-Breaking Behaviors. As the previous sets of behaviors demonstrate, someone diagnosed with CD may often perceive others as unimportant, so, rules developed in society to protect others will be likewise unimportant. However, this fourth group of diagnostically significant behaviors involves the transgression of rules designed to maintain the safety of the young person with CD him- or herself. These behaviors include eloping from school or from home multiple times, especially overnight and often before age thirteen years.

There are other deviant or dangerous behaviors associated with CD that are not diagnostically definitive but nonetheless important. Persons with CD are more likely to engage in several risky behaviors, including risky sexual behaviors, substance abuse, and other criminal behaviors.

Treatment

Persons with CD do not appear to respond well to medications. At its most basic level, no medication can help someone who refuses to take it, and with persons who have problems with honesty, compliance can be difficult to determine. Moreover, although they may help with mood lability or poor impulse control, medications are unlikely to help a person unlearn aberrant behavior patterns.

The more effective forms of treatment for children or adolescents with CD involve the entire family. Parents or other caregivers are taught to set appropriate limits, to encourage and reward good choices, and to use sensible and consistent discipline. Sometimes caregivers are taught the importance of spending more time with their children with CD, involving them in socially appropriate activities to lessen the amount of time they can spend with bad influences. Other therapies emphasize the importance for the person with CD of learning impulse control and stress management skills.

Bibliography


Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Arlington, VA: American Psychiatric Association, 2000.

Finger, E. C., et al. “Disrupted Reinforcement Signaling in the Orbitofrontal Cortex and Caudate in Youths with Conduct Disorder or Oppositional Defiant Disorder and a High Level of Psychopathic Traits.” American Journal of Psychiatry 168.2 (2011): 152–62. Print.

Murray, Joseph, and David P. Farrington. “Risk Factors for Conduct Disorder and Delinquency: Key Findings from Longitudinal Studies.” Canadian Journal of Psychology 55.10 (2010): 633–42. Print.

“Options for Managing Conduct Disorder.” Harvard Mental Health Letter 27.9 (2011): 1–3. Print.

Scheepers, Floortje E., Jan K. Buitelaar, and Walter Matthys. “Conduct Disorder and the Specifier Callous and Unemotional Traits in the DSM-5.” European Child and Adolescent Psychiatry 20.2 (2011): 89–93. Print.

Van Goozen, Stephanie, et al. “The Evidence for a Neurobiological Model of Childhood Antisocial Behavior.” Psychological Bulletin 133.1 (2007): 149–82. Print.

What is addiction relapse?

What Is Relapse?

There has been a major shift in how relapse is conceptualized by addiction researchers. Before the 1980s, the term relapse was used to signify any return to substance use following a period of abstinence, much as a disease state recurs following a period of remission. However, largely as a result of work by G. Alan Marlatt and colleagues, relapse is now viewed as a dynamic process through which a person gives in to the urge to resume drinking, smoking, or taking drugs following a period of sobriety or abstinence. An important feature of the dynamic process approach is that relapse is distinguished from slips or lapses that are one-time (slip) or brief occurrences (lapses) of substance use during the recovery process.

Despite wide variations in relapse criteria (from a single drink, cigarette, or drug use episode to a return to pretreatment substance use levels), studies have shown that recovery from substance abuse is typically characterized by repeated episodes of relapse, with the first episode most often occurring within one year of treatment. For alcohol-dependent persons who have undergone treatment, relapse is the most common outcome, with less than 25 percent remaining abstinent after one year. Approximately one-half of recovering cocaine addicts are reported to relapse within one year of detoxification. However, relapse rates for addictive behaviors are not significantly different from those of other chronic conditions such as asthma, diabetes, and hypertension.

Risk Factors

The use of electronic devices, such as ecological momentary assessment (EMA), for real-time monitoring has provided valuable information about external events, thoughts, and mood states that precede a slip, lapse, or relapse. Among the most common triggers reported for abstinence cessation are exposure to substance-related cues, negative mood states or stress, social interactions, and substance use even in small quantities.

In a 1996 analysis, negative mood states and interpersonal conflict were identified as triggers for more than 50 percent of all relapse episodes involving alcohol and smoking and for more than 40 percent for those involving heroin. However, these triggers do not inevitably precipitate a relapse. Researchers are paying more attention to individual differences in relapse risk and in the potential for predisposing factors, such as severity of dependence, genetics, and beliefs about drug effects and coping skills to moderate or interact with precipitating factors that increase the risk for relapse.

In studies of alcohol dependency, Marlatt and his colleagues described an emotional reaction to a lapse that can influence progression to a relapse. Persons who blame themselves for lapsing subsequently experience guilt and negative emotions and are then more likely to continue drinking than persons who perceive the lapse as an occasion to improve their coping skills. Studies using retrospective reports of the lapse suggest that the magnitude of this reaction is related to relapse; however, EMA studies have not observed this relationship.

Brain imaging studies have shown that specific regions of the corticostriatal limbic circuitry involved in stress-induced and drug-cue-induced craving states are associated with drug relapse outcomes. Moreover, some persons have less effective orbitofrontal cortex circuitry, making it more challenging to manage their urge to seek drugs and more difficult to make good decisions. These studies are important for developing new medications for use in relapse prevention.

Genetic differences have been shown to influence susceptibility to relapse through their interaction with medications. In a 2003 study using naltrexone to reduce craving in alcohol-dependent patients, the relapse rate was significantly higher (47.9 percent) in patients with the Asn40 variant in an opioid receptor gene compared with patients with the Asp40 variant (26.1 percent).

Theories of Relapse

A number of models have been constructed to explain the phenomenon of relapse. One of the most influential models is Marlatt’s cognitive-behavioral approach to relapse prevention. This model bases relapse risk on self-efficacy, outcome expectancies, attributions of causality, and decision-making processes. An abstinent person who encounters a high-risk situation (trigger) and engages in a successful coping response will heighten self-efficacy (confidence in ability to remain abstinent).

In contrast, an abstinent person with poor coping skills will be unable to manage the craving elicited by the trigger, leading to a reduction in self-efficacy, an increase in the expectation of a positive outcome, and an increased risk of lapsing. Lapses that are attributed to personal failure generate guilt and negative emotions and a further reduction in self-efficacy, thereby heightening the risk of relapse.

Conditioning models also have contributed prominently to the understanding of relapse. Cues associated with substance use are thought to be Pavlovian conditioned stimuli that come to elicit various conditioned responses, including drug craving. Human cue-reactivity studies have confirmed this account of craving. Several studies also have tested the prediction that exposure to such cues in the absence of substance use (cue exposure therapy, or CET) should be an effective extinction procedure for eliminating craving and guarding against relapse. Results have been mixed.

Researchers Peter Monti, Damaris Rohsenow, and colleagues showed that cue exposure combined with coping-skills training may result in increased use of skills, increases in days abstinent, and decreases in drinking. Other studies of alcohol dependency, however, have found little impact of CET in eliminating craving and reducing relapse.

Laboratory studies of extinction in animals may provide some insight in clinical studies about the apparent fragility of CET for relapse prevention. The phenomena of reinstatement, renewal, retraining, and spontaneous recovery collectively illustrate that extinction does not remove original learning. In a 2002 review paper, researcher Mark Bouton discussed how each of these phenomena may underlie relapse. For example, his research on renewal has shown that extinction is context specific, such that when an extinguished CS is presented in its original conditioning context, responses to the CS are renewed.

Future Directions

Addiction researchers are in general agreement that a multivariate, biopsychosocial approach to relapse is essential. In a 2006 commentary on relapse in the addictive behaviors, researchers Stephen Maisto and Gerard Connors recommended that more attention be paid to the operational definition of relapse, theory development and its systematic testing, modeling of the relapse process, and the role of moderating variables on relapse outcome.

Bibliography

Bouton, Mark E. “Context, Ambiguity, and Unlearning: Sources of Relapse after Behavioral Extinction.” Biological Psychiatry 52 (2002): 976–86. Print.

Brandon, Thomas H., Jennifer Irvin Vidrine, and Erika B. Litvin. “Relapse and Relapse Prevention.” Annual Review of Clinical Psychology 3 (2007): 257–84. Print.

Conklin, C. A., and S. T. Tiffany. “Applying Extinction Research and Theory to Cue-Exposure Addiction Treatments.” Addiction 97 (2002): 155–67. Print.

Daley, Dennis C., and Antoine Douaihy. Relapse Prevention Counseling: Clinical Strategies to Guide Addiction Recovery and Reduce Relapse. Eau Claire: PESI, 2015. Print.

Granfield, Robert, and Craig Reinarman. Expanding Addiction: Critical Essays. New York: Routledge, 2015. Print.

Maisto, Stephen A., and Gerard J. Connors. “Relapse in the Addictive Behaviors: Integration and Future Directions.” Clinical Psychology Review 26 (2006): 229–31. Print.

Marlatt, G. Alan, and Dennis M. Donovan. Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. New York: Guilford, 2005. Print.

Pool, Eva, Tobias Brosch, Sylvain Delplanque, and David Sander. "Stress Increases Cue-Triggered 'Wanting' for Sweet Reward in Humans." Journal of Experimental Psychology 41.2 (2015): 128–36. Print.

Shiffman, Saul. “Ecological Momentary Assessment (EMA) in Studies of Substance Use.” Psychological Assessment 21.4 (2009): 486–97. Print.

Siegel, Shepard. “Drug Tolerance, Drug Addiction, and Drug Anticipation.” Current Directions in Psychological Science 14 (2005): 296–300. Print.

Sinha, Rajita, and Chiang-Shan R. Li. “Imaging Stress- and Cue-Induced Drug and Alcohol Craving: Association with Relapse and Clinical Implications.” Drug and Alcohol Review 26 (2007): 25–31. Print.

Would Trifles have the same impact if the characters were reversed--that is, the main characters were males?

The impact of the play depends on an understanding of the patriarchal culture that Mrs. Hale, Mrs. Peters, and Mrs. Wright functioned in, so a play in which a man murders his wife and his male neighbors withhold evidence would not have anywhere near the same impact as the play Trifles has. The fact that Mrs. Wright is a woman has everything to do with why she was treated the way she was and why she responded the way she did.

Mr. Wright, as the man of the house, made the decisions and had all the power in their relationship. Mrs. Wright was little more than a servant, trapped in their isolated home, without the ability to pursue her own interests. When she did attempt to express her wants by purchasing a canary, John Wright evidently broke the cage and killed the bird. This act of violence toward a defenseless creature suggests Mr. Wright was similarly abusive toward his wife. Mrs. Wright had no support system to help her escape from the trap she was in. If, for example, she had gone to Mr. Peters, the sheriff, and explained that she was afraid for her safety or her life because her husband had killed her bird, chances are she would have been ignored or even mocked. Mr. Peters and the attorney display condescension toward Mrs. Hale and Mrs. Peters, hinting at how any such complaint Mrs. Wright might have made about her husband would have been treated. 

Mrs. Wright's murder of her husband was an act of desperation that grew from the power disparity in her relationship with her husband and in her society. It is hard to imagine any comparable situation where the tables could be turned and a man would be so controlled by his wife. Although there certainly are controlling women, a husband in John Wright's time would still have enjoyed many options in his society simply by virtue of being a man--such as mobility and the support of the legal system and male-dominated social structure. Since the issues of abuse and power are central to the plot and conflict, and these are wrapped up in gender roles, the play could not have the same impact if the main characters were male rather than female.

In Animal Farm, how did Napoleon succeed in becoming the animals' leader?

Napoleon became the leader of Animal Farm by employing sly tactics and using other animals to do his evil. From the outset, he is described as a character who wanted his own way and who seemed to be plotting something, waiting his turn. At the beginning of chapter two, he is described as follows:

Napoleon was a large, rather fierce-looking Berkshire boar, the only Berkshire on the farm, not much of a talker, but with a reputation for getting his own way. 

Napoleon's primary opponent for leadership was Snowball who is described as not having the 'same depth of character' as his adversary. In effect, this suggests that Napoleon seemed to be always planning and plotting but did not expose much of what he was thinking. This deviousness is illustrated at numerous moments in the novel, such as when he took Jesse and Bluebell's puppies soon after they were weaned. His actions are described in chapter three, not long after the animals had taken over the farm:

It happened that Jessie and Bluebell had both whelped soon after the hay harvest, giving birth between them to nine sturdy puppies. As soon as they were weaned, Napoleon took them away from their mothers, saying that he would make himself responsible for their education. He took them up into a loft which could only be reached by a ladder from the harness-room, and there kept them in such seclusion that the rest of the farm soon forgot their existence.

Napoleon was obviously up to something and the extent of his plotting would soon become clear when the puppies made their first appearance as fierce dogs, slavishly obedient to Napoleon's command. Before this particular incident, though, he had also manipulated the sheep into disrupting Snowball's speeches when they loudly bleated whilst he was talking. We read about this in Chapter 5:

At the Meetings Snowball often won over the majority by his brilliant speeches, but Napoleon was better at canvassing support for himself in between times. He was especially successful with the sheep. Of late the sheep had taken to bleating "Four legs good, two legs bad" both in and out of season, and they often interrupted the Meeting with this. It was noticed that they were especially liable to break into "Four legs good, two legs bad" at crucial moments in Snowball's speeches. 

Napoleon realised that he would never be able to beat Snowball at rhetoric and the creation of new ideas which would benefit the farm. He was single-minded in his purpose. He wanted power and had no interest in taking care of the general good of all the animals. His actions spoke of one who was plotting something. This much became pertinently evident when Snowball delivered a most inspiring speech about the benefits of building a windmill. It was apparent that Snowball had won the animals' support and Napoleon would, for all intents and purposes, have lost the authority he so much desired. 

We read about Napoleon's response in chapter five:

By the time he had finished speaking, there was no doubt as to which way the vote would go. But just at this moment Napoleon stood up and, casting a peculiar sidelong look at Snowball, uttered a high-pitched whimper of a kind no one had ever heard him utter before.

At this there was a terrible baying sound outside, and nine enormous dogs wearing brass-studded collars came bounding into the barn. They dashed straight for Snowball, who only sprang from his place just in time to escape their snapping jaws...

...Then he put on an extra spurt and, with a few inches to spare, slipped through a hole in the hedge and was seen no more.

This was what Napoleon had been planning all along. He had gotten rid of his fiercest opponent and could then, claim sole leadership. The animals who had been traumatised by the brutal nature of Snowball's expulsion were informed soon after, that:

...from now on the Sunday-morning Meetings would come to an end. They were unnecessary, he said, and wasted time. In future all questions relating to the working of the farm would be settled by a special committee of pigs, presided over by himself. These would meet in private and afterwards communicate their decisions to the others. The animals would still assemble on Sunday mornings to salute the flag, sing 'Beasts of England', and receive their orders for the week; but there would be no more debates.

And so, Napoleon's tyrannical reign began. He would, with the help of especially Squealer and his dogs, brutalise, deceive, manipulate, threaten and abuse the general animal populace, with the exception of the pigs, and become much the same as Mr Jones had been. 

What are clinical interviewing, testing, and observation in psychology?

Introduction

The purpose of clinical interviewing, testing, and observation is to obtain a clear, comprehensive, balanced view of the patient, which is termed a clinical formulation, and to develop a rational treatment plan to address the patient’s difficulties. Clinical interviewing, in combination with observation, is the backbone of all mental health professions, a creative and dynamic process that represents a somewhat elusive set of complex skills, including integrating a large amount of information about a person into a clinically useful formulation, developing a diagnosis, and making recommendations for treatment based on the clinical assessment. Today the clinician is required to perform many types of interviews suited to the clinical task at hand, including assessments in settings as diverse as an inpatient psychiatric unit, an inpatient medical unit, a psychotherapy practice that includes either a consultation and/or a liaison setting, and an emergency room. Psychological testing may also be needed to gain additional information and to validate a diagnosis developed during the clinical interview and observations.

Clinical Interviewing and Observation

The clinical interview can be structured, semistructured, or unstructured. In the structured interview, the clinician covers the topics in a consistent way, using one of several published guidelines. In the semistructured interview, only part of the interview uses a published interview schedule. Most clinicians use a free-flowing, unstructured exchange between the clinician and patient. No matter what format is used, the clinician will work to develop rapport with the patient so that the essential information needed to help the patient can be obtained. Observation of the patient’s verbal and nonverbal behavior is also noted during the interview.

Whether the interview is structured, semistructured, or unstructured, the clinician must produce a written record of the interview. This report is focused on the referral question, which is the reason the assessment was requested. Most clinicians begin by presenting identifying information such as the patient’s name, age, marital status, sex, occupation, race or ethnicity, place of residence and circumstances of living, and referral information. The chief complaint or the problem for which the patient seeks professional help is usually described next, stated in the patient’s own words. The intensity and the duration of the problem are noted, including any possible precipitating events, such as the loss of a loved one. Symptoms associated with the chief complaint are assessed and noted in the report.

Current and past health history, for both physical and psychological problems, is important to review. There are physical illnesses that may affect the patient’s psychological state and vice versa. Prior episodes of emotional and mental disturbances should be described. The clinician needs to inquire about and report prescribed medication and alcohol and drug use.

Personal history may include information about the patient’s parents and other family members and any family history of psychological or physical problems. The account of the patient’s own childhood and noteworthy experiences can be very detailed. Educational and occupational history are outlined, along with social, military, legal, and marital experiences. The mental status exam is also part of the clinical interview and written report.

The Mental Status Exam

The mental status exam is simply the clinician’s evaluation of the patient’s current mental functioning. It is a staple of the initial mental health examination. The mental status exam may be viewed as consisting of two major parts: the behavioral observation aspects and the cognitive aspects.

The behavioral observation aspects include noting general appearance and behavior, mood, and flow of thought of the patient. General appearance and behavior are assessed by noting such things as the patient’s apparent age in relation to stated age(for instance, does the patient look younger or older than he or she actually is?), body posture, degree of alertness, hygiene, motor activity, facial expressions, and voice quality. Anything that seems outside the general norm would be noted (for instance, agitation). The clinician should also note any physical difficulties such as the need to wear glasses. The basic quality of mood is closely monitored and noted during the interview. The basic moods can be boiled down to anger, anxiety, contentment, disgust, fear, guilt, irritation, joy, sadness, shame, and surprise. Finally, the flow of the patient’s thoughts must be described if it is unusual in any way.

It is important to clearly delineate any noteworthy aspects of the person’s appearance, behavior, mood, or thought content rather than just providing a summary statement. For example, the clinician may write in the report that the person had a sad face and appeared to be about to cry, yet claimed to be happy. Another patient may have jumped from topic to topic and seemed unaware that there appeared to be no connection between topics. Attitude toward the clinician is also important. For example, some patients might be openly hostile while others are very cooperative. All the findings made in this first portion of the mental status exam are generally discovered by observation alone.

The second part of the mental status exam, the cognitive aspect, is determined by asking the patient certain types of questions. Some clinicians fail to assess the cognitive aspects of the mental status exam, despite the critical importance of this information to the overall evaluation of the patient. These clinicians may believe that it may be insulting to ask obvious questions of a patient who appears unimpaired. The clinician can prepare the patient for such questions by explaining that these questions are just a routine part of the clinical interview. The initial questions assess the person’s orientation to person, place, and time. That is, does the patient know who he or she is, where he or she is (city, state, facility), and what the date is? Then the patient is asked to memorize three common objects. Serial sevens are conducted, a task in which the patient is asked to subtract seven from one hundred, and then subtract seven from the result and so on toward zero. After that task is completed, the patient is asked to name the three objects memorized earlier. Other tasks may include naming objects the clinician points to, such as a pencil, following three-stage commands, and copying simple designs. These tasks assess attention, concentration, language, and short-term memory. Abstract thinking ability can be assessed by asking the patient to interpret proverbs (for instance, “What does it mean when someone says that people who live in glass houses shouldn’t throw stones?”) or explain likenesses and differences (such as, “How are an orange and an apple alike?”).

In this part of the mental status exam, the patient’s content of thought is noted, particularly bizarre ideas. A delusion
is a fixed, false belief that cannot be explained by the patient’s culture and education. Types of delusions include delusions of grandeur (such as believing that one is a musical virtuoso when one actually has little musical ability), body change (such as believing that one’s insides are rotting), reference (such as believing that others are always talking about one), and thought broadcasting (such as believing that one’s thoughts can be transmitted across the world). Hallucinations are false sensory perceptions that occur in the absence of a related sensory stimulus. Any of the five senses can be involved in hallucinations, but it is the auditory or visual modalities that are typically involved. For example, a patient may see someone who is not there. A phobia
is an unreasonable and intense fear associated with some object (such as spiders) or some situation (such as closed spaces). Finally, the presence of obsessions
and compulsions
needs to be assessed. An obsession is a belief, idea, or thought that dominates the patient’s thought content, while a compulsion is an impulse to perform an act repeatedly in a way that the patient realizes is neither appropriate nor useful.

Interviewing Informants

While most patients will tell clinicians all they need to know, it is often useful to obtain information about the patient’s present difficulties from other sources such as relatives, friends, and other mental health professionals. In some instances, verifying data or seeking additional information is essential. For example, information gained from children, adolescents, and adults who are psychotic or have limited cognitive ability may need to be verified and supplemented. Having a personality disorder may not particularly bother the patient, but family and friends suffer and can offer specific examples of problems involving the patient. Informants can also give information about cultural norms, childhood health history, and other relevant facts. Therefore, valuable information can be gained from people who know the patient well.

Interviewing informants will provide the opportunity to gain additional insight into the patient’s interpersonal relationships. The extent and quality of emotional and tangible support available to the patient may also be determined. Emotional support is having someone to talk to about problems, everyday occurrences, and triumphs. Types of tangible support include financial assistance, a place to live, and transportation to work and doctor appointments.

Psychological Testing

Testing may be requested by the mental health professional to clarify issues that came up in the clinical interview and to validate a diagnostic impression. Psychological testing is essentially assessing a sample of behavior using an objective and standardized measure. Although all mental health professionals are trained to conduct clinical interviews, typically, applied psychologists conduct and interpret the testing required. Applied psychologists include school, clinical, and counseling psychologists. The type of testing requested depends on what information is needed to answer the referral question or questions. For example, if there were some question about the patient’s level of intelligence, cognitive testing would be needed. The types of testing requested may include personality assessment, cognitive assessment, and assessment of specific abilities or interests. Personality assessment is the measurement of affective aspects of a person’s behavior such as emotional states, motivation, attitudes, interests, and interpersonal relations using standardized instruments. Cognitive assessment includes intelligence, achievement, and neuropsychological testing. Neuropsychological testing is used to assess brain dysfunction. The measurements of specific abilities or interests include assessing multiple aptitudes such as the potential to do well in a certain type of job (such as mechanical skills) and the measurement of values and interests. Information gathered from the clinical interview, observations, and the results of the tests are integrated into a formal report usually written by a psychologist.

Although some instruments can be administered by those trained by a psychologist, others require rather extensive training. For example, most pencil and paper instruments such as the well-known Minnesota Multiphasic Personality Inventory II (MMPI-2), a comprehensive personality assessment instrument, require little training to administer. Others, such as individual intelligence tests and most projective instruments (such as the Rorschach inkblot test), require extensive advanced training to administer. Interpretation of psychological tests needs to be done by doctoral-level applied psychologists.

Behavioral observations are also done during the testing process. How does the patient approach the task? For example, one patient may approach a task in a careful, systemic way, while another patient may use a trial-and-error approach. Verbalizations during testing are noted and may reveal a pattern of behavior. Some patients, for example, may consistently make excuses for what they perceive as poor performance on tests. Signs of anxiety, restlessness, boredom, anger, or other noteworthy reactions are important data.

Information gleaned from various psychological tests, the clinical interview, and behavioral observations are formed into a comprehensive and useful report with a diagnosis and specific recommendations for treatment. Writing this type of psychological report is a highly developed skill formed in graduate-level coursework and during extensive supervised experience.

The DSM

The results of the clinical interview, observations, and any psychological testing are used to develop a clinical formulation and to decide on a diagnosis. The American Psychiatric Association’s (APA)
Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), which was released in 2013, is the primary diagnostic system used by all mental health professionals. Whereas the previous edition of the DSM (DSM-IV-TR. Rev. 4th ed., 2000) summarized information according to five axes that organized, discussed, and evaluated syndromes, disorders, codes, assessments, and diagnoses, the DSM-5 utilizes a nonaxial documentation of diagnosis (formerly Axes I–III in the DSM-IV) with separate notations for significant psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V). Psychosocial and contextual factors covered in the DSM-5 are provided in an expanded set of V codes, which allow clinicians to note other conditions affecting diagnosis, prognosis, or the course of treatment of a primary disorder. The GAF (Global Assessment of Functioning) and C-GAS (Children's Global Assessment Scale for children ages four through sixteen), which were covered under Axis V in the DSM-IV and provided a scoring system to help clinicians assess and diagnose the severity of a psychiatric illness, were also changed in the DSM-5: separate measures of the severity of symptoms and disability are now listed for individual disorders. The DSM-5 also provides what it calls a "crosswalk," which serves to help clinicians match DSM-5 diagnosis codes with the codes used by insurance companies for billing purposes. Insurance companies only accept ICD-9 codes (International Classification of Diseases, ninth revision) when submitting invoices, and the ICD-9 codes do not always match the codes provided in the DSM. One of the APA's goals in revising the DSM-5 was to bring it more in-line with approaches and terminology consistent with the World Health Organization (WHO) and the Centers for Disease Control and Prevention's (CDC) International Classification of Diseases.

Bibliography

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington: American Psychiatric Association, 2013. Print.

Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. Rev. 4th ed. Washington, DC: American Psychiatric Association, 2000. Print.

Barlow, David H. The Oxford Handbook of Clinical Psychology. New York: Oxford UP, 2011. Print.

Gladding, Samuel T. Counseling: A Comprehensive Profession. 4th ed. Upper Saddle River, N.J.: Prentice Hall, 2008. Print.

Goldstein, Gerald, and Michel Hersen. Handbook of Psychological Assessment. 3d ed. New York: Pergamon, 2000. Print.

McConaughy, Stephanie H. Clinical Interviews for Children and Adolescents. 2nd ed. New York: Guilford, 2013. Print.

Morrison, James. The First Interview. 3d ed. New York: Guilford, 2008. Print.

Reik, Theodore. Listening with the Third Ear. 1948. Reprint. New York: Farrar, Straus and Giroux, 1983. Print.

Silverstein, Marshall L. Personality Assessment in Depth: A Casebook. New York: Routledge, 2013. Print.

Sommers-Flanagan, John, and Rita Sommers-Flanagan. Clinical Interviewing. 5th ed. Hoboken: John Wiley, 2014. Print.

What are two scavengers and their levels in the food chain?

When teaching ecology and trophic relationships, I always make a point of distinguishing between scavengers and decomposers because a cursory definition such as "eating dead material" doesn't sufficiently explain the differences between them.

Decomposers have an ecological role specifically filled by bacteria and fungi. They are capable of eating, or at least breaking down, dead material that cannot be eaten by anything else. They speed up the natural process of decomposition simply by splitting up dead organisms into smaller pieces, thereby increasing the surface area of the dead material and making it easier for natural forces to act upon it. 

Scavenging is just a particular lifestyle for consumers; all scavengers are consumers, just as all decomposers are consumers. All decomposers are scavengers, but not all scavengers are decomposers. For example, vultures are scavengers because they eat carcasses that have already died of natural causes or been killed by another animal; they behave exactly as a predator would, except they don't do the killing themselves. They are not decomposers, though. Another way of looking at it is that decomposers are generally much smaller, consume less overall energy, are incapable of directly killing their food, and exist on the periphery of the food web, whereas scavengers are the opposite. There are, of course, exceptions.

Two good examples of scavengers are hyenas and jackals. Both animals are actually omnivores, and scavenging may simply be an opportunistic way for them to consume, allowing greater access and flexibility in a variety of ecological environments. Since they are omnivores, they have multiple positions in the food chain, including primary, secondary and perhaps even tertiary consumer positions, although omnivores are often just categorized as secondary consumers to make things simpler.

What was in the two letters Claudia mailed when she and Jamie got off the train?

One letter is to their parents telling them they have run away and the other is to mail in Box Tops.

Claudia and Jamie run away from home and go live in a museum. That is pretty unusual, but Claudia is unusual. She is leaving because she is the oldest and feels unappreciated. She brings her little brother Jamie because he is quiet and has saved his money.

Claudia is twelve and Jamie is nine, so they are going to be missed. They are going to the museum by train, and Claudia stops to mail a letter. She is hoping to buy them some time. Jamie asks her what was in the two letters. She tells him,

"One was a note to Mom and Dad to tell them that we are leaving home and not to call the FBI. They'll get it tomorrow or the day after." 

"And the other?" 

"The other was two box tops from corn flakes. They send you twenty-five cents if you mail them two box tops with stars on the tops. For milk money, it said" (Chapter 2).

The two children are looking for independence and adventure. While Claudia is smart, her two letters show she has sort of strange priorities and is incredibly naive, even for a twelve-year-old. There is no way the FBI will not look for them, and expecting her parents no to take action for the two days until the letter arrives shows Claudia doesn't understand how her parents will react to losing two of their children. In addition, twenty-five cents is not enough to fund a runaway, and where would they send it to? (Jamie points out the folly of the Box Tops.)

Claudia chose the Metropolitan Museum of Art because it is quiet, orderly, and has plenty of interesting stuff to look at. She desired "a large place, a comfortable place, an indoor place, and preferably a beautiful place." The museum fit the bill.

Explore the fear of science in Frankenstein. How is the novel a foreshadowing of things to come?

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What are links between Shakespeare's Macbeth and the events at the time Shakespeare was writing the play?

Shakespeare wrote Macbeth during the reign of James I of England after the failed assassination attempt of the king with the 1605 Gunpowder Plot.  In Act II, scene 3, the porter at the gate of Macbeth's castle at Inverness drunkenly delivers a soliloquy that serves the practical purpose of allowing time for the actor playing Macbeth to wash off Duncan's blood while the porter delivers a farcical invocation of the perpetrators of the failed assassination, a group of English provincial Catholics.  The audience would have immediately recognized his allusions and been amused by them, breaking the dramatic tension created with the events and emotions surrounding Duncan's murder.

James I assumed the throne of England in 1603 after having been the king of Scotland since 1567, roughly a year after his birth.  Shakespeare chose the history of Scotland's kings to underpin the play, though he did depart from the facts to suit his dramatic purposes, to please his patron, the king.  James I believed his family to be descended from the historical Banquo; this is likely the reason that Fleance survives when he and his father are attacked and Banquo is fatally wounded.  

James I was interested in the supernatural and considered himself a witchcraft expert, hence the inclusion of the Weird Sisters.  Moreover, during his reign he worked on the clarification of his theory of the divine right of kings to rule--the integral plot point that drives Macbeth.

Can prayer be a useful tool in cancer support?

History and origin: The idea of healing through faith is not new. Within most formal religions—Hinduism, Buddhism, Judaism, Christianity, and Islam—some form of prayer has evolved as a means of communicating with a deity or spiritual being whom the faithful believe has the power to heal and provide physical and mental solace during challenging times. Spirituality, or a strong belief in a higher power, can also exist outside the boundaries of formal religion, and in this case, prayer is often a communication with a higher force or energy that has powers beyond those of humans. An illness such as cancer is a powerful life event that often makes people face mortality and question the purpose and meaning of life. In many instances, this questioning leads them to prayer, spiritual growth, and a positive outlook, which helps them cope. This increased ability to cope as a result of prayer can be very helpful for patients dealing with cancer and its debilitating effects, even though it cannot cure the disease.

Scientific evidence for the mind-body connection: A growing body of research indicates that the mind exerts a powerful influence on the way a body responds to trauma and stress. Cancer creates a substantial amount of stress in the body, which in turn can be detrimental to the recovery process. Analysis of data from an online support group of breast cancer patients revealed that those who prayed or meditated had a more positive mental outlook and seemed to be more in control of their situation. Doctors have found that patients with advanced cancer who believe in and practice prayer and meditation cope well with the trauma from the disease and are often able to find meaning in their experience.

Scientific evidence for the use of prayer alone in cancer therapy is not conclusive; however, many positive outcomes have been observed when it is used as an adjunct to conventional medical treatment. Studies on the positive correlation between prayer and recovery of patients with a strong faith in prayer have suggested that it may help speed up the recovery process. About one-third of advanced-stage cancer patients use prayer and spiritual healing to improve symptoms, survival, or likelihood of cure and also seek other complementary and alternative medicine approaches, according to a 2011 study in Psychooncology. A 2010 study in the Journal of Clinical Oncology reported that when advanced-stage cancer patients' medical teams addressed their spiritual needs, patients were more likely to use hospice and those who were highly religious requested less aggressive end-of-life treatments. Therefore, for patients with a strong faith, the integration of spiritual practices into their medical care can be overall very beneficial to them.

Integrating prayer in medical care: For many years the medical community believed that there was no correlation whatsoever between spirituality and medicine. However, some physicians are beginning to acknowledge the existence of the mind-body connection in recovery, and a number of medical schools in the United States include a spirituality and prayer component in their medical curriculum as part of a complementary, adjunct strategy. Some hospitals include a spiritual representative as part of the patient’s cancer care team. Prayer and spirituality are an integral part of the lives of many cancer patients, and they also play an important role in dealing with issues of dying and death. Many medical institutions and physicians respect their patients’ religious beliefs and help them incorporate them into their treatment regimen.

Mechanics of integrating prayer: Prayer can be practiced in many different ways—alone or in a group, spoken silently or aloud or with the accompaniment of music, with or without affiliation with any religion. Many cancer support groups use standard forms of prayer composed by religious leaders to pray for cancer patients. In addition, many hospitals have prayer rooms and contracts with clergy from various religious organizations to cater and minister to their patients’ spiritual needs.

If faith plays a very important role in the life of a cancer patient and is not acknowledged by the care team while making decisions for treatment, conflicts can arise and channels of communication can be closed, resulting in a stressful situation that could be detrimental to the patient’s health. When physicians inquire about and acknowledge a patient’s spiritual beliefs in a nonjudgmental, sensitive manner, they set the stage for open communication and better decision making.

However, prayer should never be forced on patients, and spiritual practices should be incorporated into the treatment regimen only with their consent. On occasions when patients want to use prayer alone for their recovery and refuse or want to delay conventional medical treatment, it is the responsibility of the medical staff to explain the risks and serious health consequences involved in delaying or refusing treatment while simultaneously acknowledging the patient’s religious beliefs respectfully.

Dwyer, J. W., L. L. Clarke, and M. K. Miller. “The Effect of Religious Concentration and Affiliation on County Cancer Mortality Rates.” Journal of Health and Social Behavior 31 (1990): 185–202. Print.

Mytko, J. J., and S. J. Knight. “Body, Mind, and Spirit: Towards the Integration of Religiosity and Spirituality in Cancer Quality of Life Research.” Psycho-oncology 8 (1999): 439–50. Print.

Ott, Mary Jane. “Mind-Body Therapies for the Pediatric Oncology Patient: Matching the Right Therapy with the Right Patient.” Journal of Pediatric Oncology Nursing 23.5 (2006): 254–57. Print.

"Spirituality and Prayer." Cancer.org. Amer. Cancer Soc., 7 Dec. 2012. Web. 29 Oct. 2014.

"Spirituality in Cancer Care." Cancer.gov. Natl. Cancer Inst., Natl. Inst. of Health, 3 July 2014. Web. 29 Oct. 2014.

What is addiction?

The Costs of Addiction

According to the National Institute on Drug Abuse, the societal cost of drug and alcohol addiction, in terms of lost productivity, crime, and health-care associated costs, is more than $600 billion per year. Perhaps an even greater cost, but one that is far more difficult to calculate, is the harm of addiction to those addicted and the “collateral damage” that often occurs to the loved ones of the addicted individual.

Most people can think of someone in their lives—a friend, partner, parent, or child—who is affected by addiction. Addiction is far too common, and its effects can be devastating. Researchers are making considerable progress in understanding the illness, and with greater understanding should come better treatment and more reason for hope.

Diagnostic Categories Related to Addiction

Substance use disorder involves a set of maladaptive set of behaviors associated with the taking of substances, including drugs and alcohol, that lead to significant impairment or distress. Maladaptive behaviors include the failure to fulfill one’s responsibilities at work, school, or home; engaging in risky or dangerous situations while using substances (such as driving while intoxicated or operating machinery while under the influence of drugs); or continuing to use substances despite recurrent negative consequences (such as losing one's job or arguments or physical altercations with others).

Tolerance of a substance is also an diagnostic criteria of addiction and substance use disorder. Tolerance is the need for increased amounts of a substance to achieve the desired effect or to reach intoxication. Tolerance is also marked by noticeably diminished effects despite continued use of the same amount of the substance. Other criteria include withdrawal (unpleasant symptoms associated with drug removal). Additional criteria for substance dependence include the tendency to escalate drug use; taking the drug more frequently, in greater doses, or for longer periods of time; loss of control over drug use; and an inability to limit one’s use.

The term "addiction" has been expanded in the DSM-5 to include excessive, compulsive, or destructive habits that have nothing to do with drugs or alcohol, such as gambling disorder. Although several societal addictions have not been formally recognized in the DSM-5, two terms, workaholics and shopaholics are commonly used by individuals to reflect society’s belief that a person can be addicted to working or to shopping. The concept of addiction also is commonly applied to cigarette smoking, Internet use, overeating, and sexual behavior, though not formally recognized in the DSM-5.

General Features of Addiction

Addictions occur with behavioral rewards. Behavioral rewards include experiences that a person wants, experiences for which a person is willing to behave in a particular way. In short, the objects of addictions always feel good, at least in the beginning. While certain potentially addicting drugs and behaviors may indeed be harmful in all circumstances, this is not true across the board. There is nothing inherently unhealthy in things that feel good, or in the tendency to engage in certain behaviors to obtain those things. These behaviors have evolved, and they are tendencies that have served well for human survival.

The problem with addiction is that the effect of the behavioral reward changes in particular ways. With time and repeated exposure, a person’s reaction to the behavioral reward changes in three observable ways. First, the person may develop a tolerance and then experience withdrawal. More and more of the behavioral reward will be needed to get the same amount of pleasure (tolerance), and the behavior may need to continue to keep feeling pleasure (withdrawal).

The presence of tolerance and withdrawal has been used as the primary indicator of addiction in years past. However, a person can vary in the extent to which he or she experiences tolerance and, especially, withdrawal, in his or her addiction, even with drugs such as alcohol, which produce symptoms of physical dependence.

In addition, other changes in a person’s reaction to behavioral rewards also typically accompany the development of addictions. For example, the value of the addictive behavior, relative to other possible behaviors, changes. The person’s behavioral repertoire shifts from one in which variable behaviors and responses occur to a far narrower focus, in which behaviors associated with the addiction come to predominate. Finally, the person seems to lose control of the addiction. Once he or she gets started with the behavior in question, they “overdo it” in ways that they did not intend and that they frequently regret. Efforts to permanently curtail or eliminate the addiction are extraordinarily difficult. Relapse, or returning to the behavior after successfully staying away from it for a time, is a common problem.

Models of Addiction

Many different models, from widely diverse theoretical orientations within the field of psychology and medicine, have been proposed to account for addiction. Advances in brain imaging, however, have allowed scientists and researcher to see inside the brain of addicted individuals and study the areas of the brain that are affected by drugs and alcohol. Research has found that addiction is a brain disease because alcohol and drugs change the structure and function of the brain itself. Although many outside the scientific and research communities still consider addiction to be learned behavior, research is proving otherwise.

Other experts have sought to explain addiction in terms of personality variables, emphasizing the role of inner conflict or inadequate psychological coping mechanisms. Finally, numerous biological models search for the root of addictive behaviors in genetics and neurochemistry. It seems likely that a complete understanding of addiction may ultimately require a synthesis of several, if not all, of these approaches.

Bibliography

DiClemente, Carlo C. Addiction and Change: How Addictions Develop and Addicted People Recover. New York: Guilford, 2006. Print.

Granfield, Robert, and Craig Reinarman, eds. Expanding Addiction: Critical Essays. New York: Routledge, 2015. Print.

Hart, Carl L., and Charles Ksir. Drugs, Society, and Human Behavior. 16th ed. New York: McGraw-Hill, 2014. Print.

Julien, Robert M., Claire D. Advokat, and Joseph E. Comaty. A Primer of Drug Action. 13th ed. New York: Worth, 2014. Print.

Koob, George F., Michael A. ARends, and Michel le Moal. Drugs, Addiction, and the Brain. Boston: Academic, 2014. Print.

Miller, Peter M. Biological Research on Addiction. Amsterdam: Elsevier, 2013. Print.

Nutt, David J., and Liam J. Nestor. Addiction. Oxford: Oxford UP, 2013. Print.

Rosenberg, Kenneth Paul, and Laura Curtiss Feder. Behavioral Addictions: Criteria, Evidence, and Treatment. Boston: Academic, 2014. Print.

Rosner, Richard. Clinical Handbook of Adolescent Addiction. Chichester: Wiley-Blackwell, 2013. Print.

Sheff, David, Clean: Overcoming Addiction and Ending America's Greatest Tragedy. Boston: Houghton Mifflin Harcourt, 2013. Print.

Volkow, Nora. "Teacher's Guide: The Essence of Drug Addiction." The Brain: Understanding Neurobiology Through the Study of Addiction. Natl Inst of Health, 2010. Web. 8 Sept. 2014.

How does Gatsby act when the visiting trio comes to visit?

When the trio of Tom Buchanan, Mr. Sloane, and Mrs. Sloane drop by Gatsby's house, Gatsby's behavior is a little manic.  At first, he is anxious to offer them something to drink, and he is "uneasy," knowing somehow that they've only come for such a reason.  When Gatsby turns to Tom, he speaks a little "aggressively," asserting that he knows Tom's wife.  Gatsby is welcoming to Mr. and Mrs. Sloane, claiming that he'd love to have them all at his next party, and he eventually gets "control of himself" and urges them to stay for dinner.  When the woman invites him and Nick to supper, Tom can tell that Gatsby does not understand that Mr. Sloane doesn't really want them to come.  Nick sees it, Tom sees it, but Gatsby does not.  He sort of betrays himself as someone who cannot read the social cues of the old money.  Thus, his behavior is varied: at one moment anxious, the next aggressive, and later, self-assured when he shouldn't be. 

How can teachers deal with having limited options in their classrooms?

It is going to be a bit difficult to give a really specific answer to this question, because it doesn't specify what the limited options are.  Are options limited because of the school budget?  Is it limited because of a lack of technology?  Are options limited because new ideas and teaching methods are "frowned upon?"  All of the above?  

The best, all encompassing, answer that I can give a teacher with limited options or resources is be creative.  

Let me give you an example of something that I have had to do before.  I teach 8th grade science, and labs can be expensive to do, so making them cheap and easy requires some creative thinking.  At one point in the year, to reinforce the use of the scientific method and the concepts of balanced and unbalanced forces, I make students build bridges across the table gaps.  Their building supply? Straws.  Straws are cheap.  But getting enough straws for each group can become expensive.  I do two things to offset the cost.  First, I offer extra credit to any student that brings in a "fistful" of straws.  That's usually about 25 straws and for sure covers one group's supplies.  With a classroom full of kids, that's a lot of students straw hunting on the weekend.  I guarantee that on any given weekend, there are numerous students that eat at a fast food restaurant and can grab a few more straws than normal.  The other thing that I do is drive to three to four fast food restaurants.  I ask to see the manager and explain who I am and what I want to do in class.  I then ask if the restaurant is willing to donate a bunch of straws.  One year I had Wendy's and Jack in the Box donate 1000 straws . . . each.  

If the limiting option is classroom technology, then be creative with what students are likely bringing with them in the first place.  Leverage the cell phones that kids have.  It's basically a bring your own device option.  Let's say that you are teaching Romeo and Juliet.  Groups of students work together to pose each act and scene.  The pose needs to make it clear which act and scene is being referenced.  A group member would take a picture of the posed scene with a cell phone.  Then the students put those pictures all together in a slide show with a caption that uses real lines of text from the play. There are tons of free apps that do this kind of thing.  The finished product is a slideshow that has students posing out each important part of the entire play.  They get really into it, because they are the stars, and they are always shocked that a teacher will actually let them use their phones in class.  

What are goldenseal's therapeutic uses?

Overview

Although goldenseal root is one of the most popular herbs sold, it is taken almost entirely for the wrong reasons. Originally, it was used by Native Americans both as a dye and as a treatment for skin disorders, digestive problems, liver disease, diarrhea, and eye irritations. European settlers learned of the herb from the Iroquois and other tribes and quickly adopted goldenseal as a part of early colonial medical care.

In the early nineteenth century, herbalist Samuel Thompson created a wildly popular system of medicine that swept the country. Thompson spoke of goldenseal as a nearly magical cure for many conditions. His evangelism led to a dramatic upsurge in demand, followed by overcollection and decimation of the wild plant. Prices skyrocketed but then collapsed when Thompsonianism faded away.

Goldenseal has passed through several more booms and busts. Again in great demand, it is under intentional cultivation.

Therapeutic Dosages

When goldenseal is used as a topical treatment for minor skin wounds, a sufficient quantity of goldenseal cream, ointment, or powder should be applied to cover the wound. It is important to be sure to clean the wound at least once a day to prevent goldenseal particles from becoming trapped in the healing tissues.

For mouth sores and sore throats, goldenseal tincture is swished or gargled. Goldenseal may also be used as strong tea for this purpose, made by boiling 0.5 to 1 gram in a cup of water. The herb has a bitter taste. Goldenseal tea is also used as a douche for vaginal yeast infections.

Therapeutic Uses

Goldenseal contains a substance called berberine that has been found to inhibit
or kill many microorganisms, including fungi, protozoa, and bacteria. On this
basis, contemporary herbalists often use goldenseal as a topical antibiotic for
skin wounds, as well as to treat viral mouth sores and superficial fungal
infections, such as athlete’s foot. However, there is no
direct scientific evidence that goldenseal is effective for any of these
purposes.

Goldenseal is not likely to work as an oral antibiotic, because the blood levels of berberine that can be achieved by taking goldenseal orally are far too low to matter. However, goldenseal could theoretically be beneficial in treating sore throats and diseases of the digestive tract (such as infectious diarrhea) because it can contact the affected area directly. Since berberine is concentrated in the bladder, goldenseal could be useful for bladder infections. Nonetheless, there is no direct evidence that goldenseal is effective for these uses.

Extremely weak evidence (far too weak to rely upon) suggests that goldenseal or berberine may be helpful for various heart-related conditions, including arrhythmias, congestive heart failure, high cholesterol, diabetes, and high blood pressure. Similarly, infinitesimal evidence hints that goldenseal could be helpful for conditions in which spasms of smooth muscle play a role, such as dyspepsia (nonspecific stomach distress) and irritable bowel syndrome, as well as various forms of pain caused by inflammation.

Ironically, goldenseal’s most common uses are entirely inappropriate.
Goldenseal is frequently combined with the herb echinacea to
be taken as a “traditional immune booster” and “antibiotic” for the prevention and
treatment of colds. However, as the noted herbalist Paul Bergner has pointed out,
there are three things wrong with this packaging. First, there is no credible
evidence that goldenseal increases immunity. Only one study weakly hints at an
immune-strengthening effect. Second, colds are caused by viruses and do not
respond to antibiotics, even if goldenseal were an effective systemic
(whole-body) antibiotic, which it almost certainly is not. Third, goldenseal was
never used traditionally for the common cold.

The other myth that has helped drive the sales of goldenseal is the widespread belief that it can block a positive drug screen. The origin of this false idea dates back to a work of fiction published in 1900 by a pharmacist and author named John Uri Lloyd. In Stringtown on the Pike, a dead man is found to have traces of goldenseal in his stomach. In fact, he had taken goldenseal regularly as a digestive aid, but a toxicology expert mistakes the goldenseal for strychnine and deduces intentional murder.

This work of fiction sufficed to create a folkloric connection between goldenseal and drug testing. Although the goldenseal in the story actually made a drug test come out falsely positive, this has been turned around to become a belief that goldenseal can make urine drug screens come out negative. A word to the wise: It does not work.

Safety Issues

Although there are no reports of severe adverse effects attributed to use of goldenseal, this herb has not undergone much safety testing. One study suggests that topical use of goldenseal could cause photosensitivity (an increased tendency to react to sun exposure).

Goldenseal should not be used by pregnant women because the herb has been
reported to cause uterine contractions. In addition, berberine may increase levels
of bilirubin and cause genetic damage. The last of these
effects indicates that individuals with elevated bilirubin levels
(jaundice) also should avoid use of goldenseal. Safety in
young children, nursing women, or those with severe liver or kidney disease is
also not established.

Just as there are incorrect rumors regarding the benefits of goldenseal, there are popular but incorrect beliefs regarding its health risks. For example, it is often said that goldenseal can disrupt the normal bacteria of the intestines. However, there is no scientific evidence that this occurs. Another fallacy is that small overdoses of goldenseal are toxic, causing ulcerations of the stomach and other mucous membranes. This idea is based on a misunderstanding of old literature.

Some evidence suggests that goldenseal might interact with various medications
by altering the way they are metabolized in the liver. One study found that
berberine impairs metabolism of the drug cyclosporine,
thereby raising its levels. This could potentially cause toxicity. It is
important, therefore, to speak with a physician before taking goldenseal with
other medications.

Bibliography

Hubbard, M. A., et al. “Clinical Assessment of Cyp2d6-Mediated Herb-Drug Interactions in Humans: Effects of Milk Thistle, Black Cohosh, Goldenseal, Kava Kava, St. John’s Wort, and Echinacea.” Molecular Nutrition and Food Research 52, no. 7 (2008): 755-763.

Inbaraj, J. J., et al. “Photochemistry and Photocytotoxicity of Alkaloids from Goldenseal (Hydrastis canadensis L.).” Chemical Research in Toxicology 14 (2001): 1529-1534.

Scazzocchio, F., et al. “Antibacterial Activity of Hydrastis canadensis Extract and Its Major Isolated Alkaloids.” Planta Medica 67 (2001): 561-564.

Wu, X., et al. “Effects of Berberine on the Blood Concentration of Cyclosporin A in Renal-Transplanted Recipients: Clinical and Pharmacokinetic Study.” European Journal of Clinical Pharmacology 61, no. 8 (2005): 567-572.

Zhang, Y., et al. “Treatment of Type 2 Diabetes and Dyslipidemia with the Natural Plant Alkaloid Berberine.” Journal of Clinical Endocrinology and Metabolism 93, no. 7 (2008): 2559-2565.

When Lady Capulet asks Juliet how she feels about marriage, what is Juliet’s answer?

In Act I, Scene III of William Shakespeare's Romeo and Juliet, we find Juliet, Nurse, and Lady Capulet together. Nurse and Lady Capulet are discussing how Juliet is coming of age, when Nurse mentions how she hopes to live to see the day Juliet is married. Lady Capulet quickly turns this on her daughter to ask how she feels about the prospect of marriage. To this, Juliet replies, "It is an honor I that I dream not of." In our modern tongue, she might equally have said, "I haven't thought about it." 

Referencing marriage as an honor implies that Juliet understands the social significance of marriage and has probably thought a little bit about her own. However, she does not dream of it. She does not want to be married and to think on it might even be unpleasant for her. After all, she is only fourteen!

This particular exchange between Lady Capulet, Juliet, and Nurse is an important one for really understanding how intensely changed Juliet is after meeting Romeo. Here, she tells her mother and caretaker that she has no aspirations of marriage, yet just a few days later, she will be married to Romeo in secret.

What attributes of Brutus' character made the outcome of the play inevitable in Julius Caesar?

As a recap, Shakespeare's Julius Caesar ends with Cassio and Brutus, the two main assassins of Julius Caesar, meeting defeat and death on the battlefield against Octavius and Mark Antony. In many ways, Brutus' defeat is inevitable because the character's honorable moral code prevents him from succeeding in the corrupt and calculating world of Roman politics. For instance, Brutus alone works for the good of the Roman populace, striving to protect the individual political freedoms of Roman citizens. Since he is so noble, Brutus also assumes that his political companions will be accordingly honorable. Thus, Brutus' strong moral compass leaves him vulnerable to Mark Antony's manipulative rhetoric, which turns Roman opinion against Brutus, forces him into exile, and ultimately results in his death on the battlefield. Brutus could have avoided this fate by being more manipulative himself, but that wouldn't fit with his selfless character; Brutus wouldn't be Brutus without his innate nobility. As such, Brutus' admirable (and ultimately tragic) sense of honor makes his defeat and death at the end of the play inevitable. 

What did you think of the solution to the mystery in "The Red-Headed League"?

The solution is entirely satisfactory because Sherlock Holmes not only deduces that John Clay and his accomplice are going to loot the City and Suburban Bank, but he is there on the spot with a detective from Scotland Yard at almost the exact moment that Clay breaks through the flooring of the underground strongroom. The author sees to it that Holmes himself, and not the Scotland Yard man, makes the arrest.

Sherlock Holmes had sprung out and seized the intruder by the collar. The other dived down the hole, and I heard the sound of rending cloth as Jones clutched at his skirts. The light flashed upon the barrel of a revolver, but Holmes' hunting crop came down on the man's wrist, and the pistol clinked upon the stone floor.

As is typical of many of the Sherlock Holmes stories, a man or woman comes to Baker Street to solicit the detective's help. After listening to the prospective client's story, Holmes goes out to make a personal inspection and investigation. This can sometimes take him into the country, as in "The Adventure of the Speckled Band," or to some interesting part of London, as in "The Adventure of the Blue Carbuncle" and "The Red-Headed League." The titles of the Sherlock Holmes stories frequently contain the word "Adventure." The adventure takes place when the detective and his friend Watson are out making their investigation. Holmes then solves the case and typically explains his thinking to his friend Dr. Watson at the end of the story. For example, at the end of "The Red-Headed League" Holmes explains a great deal to Watson which his friend did not understand at the time, even though he accompanied Holmes through all the action in the story.

“You see, Watson,” he explained in the early hours of the morning as we sat over a glass of whisky and soda in Baker Street, “it was perfectly obvious from the first that the only possible object of this rather fantastic business of the advertisement of the League, and the copying of the Encyclopaedia, must be to get this not over-bright pawnbroker out of the way for a number of hours every day."

Because of what Jabez Wilson had already told him about his new assistant always diving into the cellar to "develop photographs," Holmes deduced that the assistant had to be digging a tunnel. When Holmes knocks at the door of Wilson's pawn shop and asks the assistant for directions to the Strand, he sees proof of his deduction.

"I hardly looked at his face. His knees were what I wished to see. You must yourself have remarked how worn, wrinkled, and stained they were. They spoke of those hours of burrowing." 

To forestall the reader's question as to why the pawn broker never went down into his own cellar out of curiosity, the author, Sir Arthur Conan Doyle, loads Wilson with handicaps which would prevent him from even daring to venture down the steep wooden steps into the dark cellar. Wilson is fat, he is old, and his "florid face" suggests that he has high blood pressure. Doyle also makes his character Jabez Wilson a heavy user of snuff, a finely ground tobacco which would affect his breathing. Nevertheless, Wilson is obviously in the way, and his presence in the shop prevents John Clay from bringing in his accomplice, who calls himself Duncan Ross, to help him dig. That explains the invention of the Red-Headed League. Though highly unusual, the story is entirely credible and the ending conclusive and satisfactory.

What horrible realization did Elie come to concerning Rabbi Eliahu and his son? How did Elie respond to this?

Toward the end of the novel, Rabbi Eliahu enters the shed where the narrator and his father are staying. The rabbi is a kind, respected man who radiates peace, and he's searching earnestly for his son, who was separated from him in a crowd. Eliezer mentally acknowledges that the rabbi's situation is devastating, since the two of them had managed to stick together for three years through the suffering and the herding from place to place. The rabbi was feeling weak and was falling behind his son in the crowd, and the son didn't notice. At least, that's what the rabbi reported.

Eliezer's horrible realization, which he didn't share with the poor rabbi, is that he did see the rabbi's son in the crowd--and the son did notice that his father was falling behind...and the son just let it happen.

Eliezer muses sadly:

"What if he had wanted to be rid of his father? He had felt his father growing weaker and, believing that the end was near, had thought by this separation to free himself of a burden that could diminish his own chance for survival."

How does Eliezer respond to all this?

First, he's grateful that such a horrible remembrance had easily slipped from his mind. He's glad that he's forgotten--and presumably, eager to forget again after having pondered the situation for a few moments.

Second, he's glad that the rabbi doesn't know the truth. He probably thinks it's better that the rabbi is protected from the sad knowledge that his son left him behind on purpose. Searching for his son will give the rabbi hope, Eliezer probably believes.

Finally, despite no longer believing in God, Eliezer prays anyway. He asks for the strength to never abandon his own father.

What is Percival's reaction/feelings towards the beast in Lord of the Flies?

In Chapter 5, Ralph holds an assembly meeting where the boys discuss the identity and nature of the "beast." Ralph, Jack, and Piggy all agree that the "beast" doesn't exist, despite the littluns' belief. One particular littlun named Percival Wemys Madison is pushed toward the center of the circle of boys to discuss the nature of "beast." When Percival is given the opportunity to speak, he begins to cry hysterically as he thinks about the "beast." Percival cannot control his emotions and begins to weep louder than the sound of the conch being blown, which triggers the other littluns' sorrows. When Jack asks where the "beast" lives, Percival mumbles to him that the "beast" comes out of the sea. Percival then passes out in the grass in the middle of the assembly. Percival is an innocent littlun who is overcome with fear at the thought of the "beast." He misses his home and cannot cope with the situation at hand. His imaginary fears are so intense that he loses consciousness when he is asked about the "beast." 

At a high school Algebra 2 level how do you solve x^2+4x +3 step by step?

We are asked to "solve" x^2+4x+3:

In the typical Algebra assignment you are asked to either evaluate an expression, simplify and expression, or solve an equation. Each of these, while related, involve a different approach.

We could evaluate x^2+4x+3 for a given value of x; say if x=3 then the expression has the value 3^2+4(3)+3=24.

If we are asked to simplify an expression, we strive to remove grouping symbols (parantheses, brackets, etc...) and then add/subtract like terms.

Here we are asked to "solve" x^2+4x+3. It is implied that we are to solve the general equation x^2+4x+3=0.

(a) You can factor the polynomial:

(x+3)(x+1)=0  

** One method is to rewrite the linear term as the sum of two terms where the product of the coefficients is the constant term: x^2+3x+1x+3; then factor by grouping: x(x+3)+1(x+3); use the distributive property to rewrite as (x+3)(x+1)=0 **

Now use the zero product property (if ab=0 then a=0, b=0, or a=b=0) to get:

x+3=0 ==> x=-3   x+1=0 ==> x=-1

So the solutions are x=-1 or -3

(b) You could complete the square:

x^2+4x=-3
x^2+4x+4=-3+4
(x+2)^2=1

x+2=1 or x+2=-1 

x=-1 or x=-3

(c) You could use the quadratic formula

-------------------------------------------------------------------

The solutions are x=-1 or x=-3

What are two odd things we learn about Sandy in Chapter 25 of The Westing Game?

Sandy had a bruise even though Turtle never kicked him.  Sandy apparently played chess with Theo when he supposedly could not play.  

When Sandy is supposedly dead, the others discuss his death.  Crow is accused of having filled the flask that killed him.  When Turtle says that Sandy was her friend, Denton says that if he was her friend she should not have kicked him.  Turtle is upset by the suggestion that she kicked Sandy. 

“That’s a lie, that’s a disgusting lie,” Turtle shouted. “The only person I kicked today was Barney Northrup and he deserved it. I didn’t even see Sandy until tonight at the Westing house. Right, Baba?” (Ch. 25) 

The fact that Turtle kicked Barney Northrup and Sandy McSouthers had a bruise is evidence that they are the same person.  At this point, no one has any idea of this, or that both of those are disguises of Sam Westing.  Turtle is really sad because she was close to Sandy. 

Theo talks about playing chess with Sandy, but Turtle says thinks Sandy didn’t know how to play chess.  Theo tells the judge that Doug watched the table to see who was moving the pieces.  This is further evidence that Sandy was actually Sam Westing.  Judge Ford knows how Westing plays chess because Westing taught her chess. 

It is the chess game that finally convinces the judge that Sandy was really Sam Westing.  Theo says that he was winning because he had Sandy’s queen.

The queen’s sacrifice! The famous Westing trap. Judge Ford was certain now, but there were still too many unanswered questions. “I’m afraid greed got the best of you, Theo. By taking white’s queen you were tricked into opening your defense. I know, I’ve lost a few games that way myself.” (Ch. 25) 

Turtle thinks back and remembers Sandy winking and saying that the game is not over.  She and the judge are both pondering the situation.  This is how Turtle, who actually has less information than Judge Ford, realizes that Sam Westing is still alive and pretending to be Julian R. Eastman.  She regrets kicking him.

In "The Secret Life of Walter Mitty" by James Thurber, what are the interactions Walter Mitty has with the other characters?

Walter Mitty's interactions with other people are not emotionally restorative.  

Walter's interactions with people in "The Secret Life of Walter Mitty" are distant.  He does not experience any meaningful emotional connection.  The opening interaction with his wife shows this disconnect.  When she reprimands his driving, Walter sees her as "grossly unfamiliar, like a strange woman who had yelled at him in a crowd."  The interactions between Walter and his wife show how she does not validate his experience. She condescendingly speaks to him, suggesting he needs to see a doctor or get his temperature taken when he disagrees with her.  At the end of the story, she stops at a store and orders Walter to wait outside because she "won't be a minute." Thurber writes, "She was more than a minute."  This capstones interactions between husband and wife that lack a healthy emotional connection.

A lack of social connection reflects the same distance that Walter experiences with his wife.  For example, the police officer and the parking lot attendant bark at him in imperative sentences.  They speak to him with commands such as, "Pick it up" and "Back it up."  Such orders focus on a task as opposed to a human being.  These interactions show how others easily subdue Walter into submission.  When Walter comes out of one of his dreams saying "Puppy biscuits," he passes a woman on the street who ridicules him to the friend with whom she is walking: "A woman who was passing laughed. 'He said 'Puppy biscuit,' she said to her companion. 'That man said 'Puppy biscuit' to himself."  In his interactions with the outside world, Walter is the source of derision and is easily bullied.

The emotionally distant level of Walter's interactions justifies his retreat into daydreams.  In this world, respect and importance dominate his interactions. They show an authentication of voice, something not taking place in Walter's daily life.

What are some tensions between men and women in Shakespeare's Julius Caesar?

Julius Caesar is a largely male-driven play. Calpurnia and Portia are the two main female characters, and they are both wives of major characters. Calpurnia is Julius Caesar’s wife. She makes public appearances with him, but there may be some awkwardness between them because of her inability to have children. He publicly tells Antony to touch Calpurnia to cure her of barrenness when he runs the Lupercal, a “holy race” and fertility festival.

Calpurnia has nightmares about Caesar’s death. She claims that she is not naturally superstitious, but these dreams, as well as other supernatural signs, frighten her. The macho Caesar is concerned but reluctant to show vulnerability. He eventually agrees to stay home for her sake. However, Decius Brutus arrives and convinces Caesar to go to the senate. He appeals to Caesar’s ego and pride. Caesar dismisses his wife: “How foolish do your fears seem now, Calpurnia! / I am ashamed I did yield to them.” In an apparent desire to assert his masculinity, Caesar ignores his wife’s premonitions, goes to the Capitol, and is assassinated by his friends.

Portia seems to have a more equal relationship with her husband Brutus. She is surprised that he is hiding something from her. She knows him well and observes that he has “some sick offence within [his] mind.” Portia demands that he tell her the truth, invoking his love for her and her position as his wife. She asserts her stoicism by revealing wounds she made in her leg. Brutus says he will relate his plans to her, but the audience is not certain whether he does. Either way, she fears for her husband’s life and eventually commits suicide.

Calpurnia is an example of a character who is helpless to change her husband’s mind due to her position as a woman and wife, and Portia is a powerful, brave woman who is also excluded from the circle of male politicians who decide the country’s fate.

What are natural treatments for osteoporosis?

Introduction

Many factors are known or suspected to accelerate the rate of bone loss. These
factors include smoking, alcohol, low calcium intake, lack of exercise, various
medications, and several illnesses. Excessive consumption of vitamin A may also
increase the risk of osteoporosis, and rapid weight loss may
increase the risk in postmenopausal women. Raw-food vegetarians are also likely to
have significant bone thinning.

In general, women are far more prone to osteoporosis than men. For this reason,
the following discussion focuses almost entirely on women.

Hormone
replacement therapy prevents or reverses osteoporosis in
women. However, long-term use of hormone replacement therapy has been found to be
unsafe, so conventional medical treatment for osteoporosis in women centers mainly
on drugs in the bisphosphonate family, including Fosamax (taken with calcium and
vitamin D).

Exercise, especially weight-bearing exercise, almost certainly helps strengthen
bone (although the evidence for this is weaker than one might expect). Minimal
evidence suggests that the Chinese exercise Tai Chi may
also provide some benefit.

Principal Proposed Natural Treatments

There is good evidence that people with osteoporosis, or who are at risk for it,
should take calcium and vitamin D supplements regardless of what other treatments
they may be using. Substances called isoflavones found in soy and other plants may
be helpful for osteoporosis (and for general menopausal symptoms). Vitamin K and a
newer supplement called strontium ranelate have also shown promise. A
semisynthetic isoflavone called ipriflavone has shown considerable promise for
osteoporosis, but safety concerns have decreased its popularity.

Calcium and vitamin D. Calcium is necessary to build and maintain
bone. Humans need vitamin D too, as the body cannot absorb calcium without it.
Many people do not get enough calcium in their daily diet. Although the body can
manufacture vitamin D when exposed to the sun, supplemental vitamin D may be
necessary because of the common use of sunscreen.

According to most studies, calcium supplements (especially as
calcium citrate, and taken with vitamin D) appear to be modestly
helpful in slowing bone loss in postmenopausal women. Contrary to some reports,
milk does appear to be a useful source of calcium for this purpose. Any
improvements in bone density rapidly disappear once the supplements are stopped.
People who ensure that they continue calcium use may do better than those who
forget from time to time. Vitamin D without calcium, however, does not appear to
offer more than minimal bone-protective benefits for the elderly.

The effect of calcium and vitamin D supplementation in any form is relatively minor and may not be strong enough to reduce the rate of osteoporotic fractures. A large study of more than three thousand postmenopausal women age sixty-five to seventy-one years found that three years of daily supplementation with calcium and vitamin D was not associated with a significant reduction in the incidence of fractures. The use of calcium supplements early in life might prevent problems later, especially when children also engage in physical exercise; however, study results are somewhat contradictory.

One study found benefits for elderly men using a calcium- and vitamin D-fortified milk product. However, there are some concerns that excessive calcium intake could raise the risk of prostate cancer in men.

Vitamin D and calcium taken together may also have a modestly protective effect against the severe bone loss caused by corticosteroid drugs such as prednisone. Certain other supplements may enhance the effects of calcium and vitamin D. One study found that adding various trace minerals (zinc at 15 milligrams [mg], copper at 2.5 mg, and manganese at 5 mg) produced further improvement. However, copper by itself may not be helpful.

There is some evidence that essential fatty acids may also enhance the effectiveness of calcium. In one study, sixty-five postmenopausal women were given calcium with either placebo or a combination of omega-6 fatty acids (from evening primrose oil) and omega-3 fatty acids (from fish oil) for eighteen months. At the end of the study period, the group receiving essential fatty acids had higher bone density and fewer fractures than the placebo group. In contrast to this, however, a similar twelve-month double-blind trial of forty-two postmenopausal women found no benefit from essential fatty acids. The explanation for the discrepancy may lie in the differences among the women studied. The first study involved women living in nursing homes, while the second studied healthier women living on their own. The second group of women may have been better nourished and already receiving sufficient essential fatty acids in their diet. Vitamin K may also enhance the effect of calcium.

Vitamin D may offer another benefit for osteoporosis in the elderly: Most, though not all, studies have found that vitamin D supplementation improves balance in the elderly (especially women) and reduces the risk of falling. Because the most common adverse consequence of osteoporosis is a fracture caused by a fall, this could offer a meaningful benefit. Also, there is weak, preliminary evidence that calcium supplementation in healthy, postmenopausal women may slightly increase the risk of cardiovascular events, such as myocardial infarction.

Genistein and other isoflavones. Soy contains substances called
isoflavones that produce effects in the body somewhat
similar to the effects of estrogen. (For this reason, they are called
phytoestrogens.) Although study results are not entirely
consistent, growing evidence suggests that genistein and
other isoflavones can (like estrogen) help prevent bone loss.

For example, in a one-year, double-blind, placebo-controlled study, ninety women age forty-seven to fifty-seven were given genistein at a dose of 54 mg per day or standard hormone replacement therapy (HRT) or placebo. The results showed that genistein prevented bone loss in the back and hip to approximately the same extent as HRT. No adverse effects on the uterus or breast were seen. A subsequent two-year double-blind study of 389 postmenopausal women with mild bone loss found that 54 mg of genistein plus calcium and vitamin D improved bone density to a greater extent than did calcium and vitamin D alone. However, a fairly high percentage of participants given genistein experienced substantial digestive distress.

In a one-year, double-blind, placebo-controlled study of 203 postmenopausal Chinese women, the use of soy isoflavones at a dose of 80 mg daily had mildly positive protective effects on bone mass in the hip. This supplement contained 46.4 percent daidzein, 38.8 percent glycetein, and 14.7 percent genistein.

Another study evaluated an isoflavone supplement made from red clover (containing 6 mg biochanin A, 16 mg formononetin, 1 mg genistein, and 0.5 mg daidzein daily). In this one-year, double-blind, placebo-controlled study of 205 people, the use of red clover isoflavones significantly reduced loss of bone in the lumbar spine. Benefits were also seen in a one-year, double-blind, placebo-controlled study using an extract made from the soy product tofu.

However, it is not clear that the consumption of foods rich in isoflavones offers the same benefits. For example, in placebo-controlled study involving 237 healthy women in the early stages of menopause, the consumption of isoflavone-enriched foods (providing an average of 110 mg isoflavone daily) for one year had no effect on bone density or metabolism.

The effect of isoflavones on bone may be more complex than that of
estrogen. Bone is always undergoing two opposite processes
at once: bone breakdown and bone formation. Estrogen acts on the first of these
processes by inhibiting bone breakdown. Isoflavones may affect both sides of the
equation at once: inhibiting bone breakdown, while at the same time enhancing new
bone formation.

In about one of three people, intestinal bacteria convert some soy isoflavones into a substance called equol. Isoflavones may have a greater bone-protecting effect in such equol producers.

Strontium. Growing evidence indicates that the mineral
strontium (as strontium ranelate) is effective as an aid in
the treatment of osteoporosis. The best and largest study on strontium was a
double-blind, placebo-controlled study of 1,649 postmenopausal women with
osteoporosis. In this three-year study, a dose of strontium ranelate at 2 grams
(g) daily significantly increased bone density in the spine and hip and
significantly decreased the rate of vertebral fractures.

While some treatments for osteoporosis act to increase bone formation and others act to decrease bone breakdown, some evidence suggests that strontium ranelate has a dual effect, providing both these benefits at once. There is one major caveat, however. All major controlled clinical trials of strontium ranelate have involved some of the same researchers. Entirely independent confirmation is needed. It is not clear to what extent the “ranelate” portion of strontium ranelate is necessary for this benefit, or whether other strontium salts would work too. (The strontium used in these studies is not the same as the radioactive strontium that was such a concern during the decades of above-ground atomic testing in the mid-twentieth century.)

Vitamin K. Increasing, but inconsistent, evidence indicates that
vitamin
K may help prevent osteoporosis. It may work by reducing bone
breakdown, rather than by enhancing bone formation.

Perhaps the best evidence for a beneficial effect comes from a three-year, double-blind, placebo-controlled trial of 181 women. Participants, all postmenopausal women between the ages of fifty and sixty years, were divided into three groups: placebo, calcium plus vitamin D plus magnesium, or calcium plus vitamin D plus magnesium plus vitamin K (at a dose of 1 g daily). Researchers monitored bone loss by using a standard dual-energy X-ray absorptiometry bone density scan. The results showed that the study participants using vitamin K with the other nutrients did not lose as much bone as those in the other two groups. However, another placebo-controlled trial involving 452 older men and women with normal levels of calcium and vitamin D failed to demonstrate any beneficial effects of 500 micrograms per day of vitamin K supplementation on bone health over a three-year period.

Ipriflavone. Ipriflavone is a semisynthetic
variation of soy isoflavones. Ipriflavone appears to help prevent osteoporosis by
interfering with bone breakdown. Estrogen works in much the same way, but
ipriflavonedoes not appear to produce estrogenic effects anywhere else in the body
other than in bone. For this reason, it probably does not increase the risk of
breast or uterine cancer. However, it also does not reduce the hot flashes, night
sweats, mood changes, or vaginal dryness of menopause. In addition, it may cause
health risks of its own.

Numerous double-blind, placebo-controlled studies involving more than seventeen hundred participants have examined the effects of ipriflavone on various forms of osteoporosis. Overall, it appears that ipriflavone can stop the progression of osteoporosis and perhaps reverse it to some extent. For example, a two-year double-blind study followed 198 postmenopausal women who had evidence of bone loss. At the end of the study, there was a gain in bone density of 1 percent in the ipriflavone group compared to a loss of 0.7 percent in the placebo group.

Conversely, the largest and longest study of ipriflavone found no benefit. In this three-year trial of 474 postmenopausal women, no differences in extent of osteoporosis were seen between ipriflavone and placebo groups. However, for reasons that are not clear, the researchers in this study gave women only 500 mg of calcium daily. All other major studies of ipriflavone gave participants 1,000 mg of calcium daily. It is possible that ipriflavone requires the higher dose of calcium to work properly.

Ipriflavone may also be helpful for preventing osteoporosis in women who are
taking Lupron or corticosteroids, medications that accelerate bone loss.
(However, the combined use of ipriflavone and drugs that suppress the immune
system, such as corticosteroids, presents risks.)

There is some evidence that combining ipriflavone with estrogen may improve benefits against osteoporosis. However, it is not known whether such combinations increase or decrease the other benefits and adverse effects of estrogen-replacement therapy. Finally, for reasons that are not clear, ipriflavone appears to be able to reduce pain in osteoporosis-related fractures.

Other Proposed Natural Treatments

It is often said that magnesium supplements are helpful for strong bones, but there is only minimal evidence to support this claim. It has been suggested (though with little meaningful supporting evidence) that the typical American diet causes the body to become acidic, and that this in turn leads to bone loss. One study tested potassium citrate as a treatment for bone loss, in the belief that this supplement would counteract this hypothesized diet-related acidity. The results in this one-year study of 161 postmenopausal women indicated that potassium citrate reduced bone loss to a greater extent than did the placebo (potassium chloride). This study had numerous problems in design, analysis, and reporting, so it does not necessarily show anything about dietary “acidity.” It may, however, indicate that the citrate part of potassium citrate has some bone-protective effects. If this is true, it could in turn explain why calcium citrate has, in some studies, proven more effective for treating or preventing osteoporosis than other forms of calcium.

Observational studies hint that higher levels of homocysteine might increase the
risk of osteoporosis. Vitamins B12, B6, and folate are known
to reduce homocysteine levels. On this basis, supplementation with these vitamins
has been proposed for preventing or mitigating the effects of osteoporosis. One
double-blind study found weak evidence that supplemental folate and
vitamin B12 (known to reduce homocysteine) might reduce risk of
osteoporotic fractures in people who had had a stroke. However, two other studies
failed to find that the use of mixed B-vitamins had any positive effect on bone
density or chemical markers of bone turnover.

Some evidence suggests that the hormone dehydroepiandrosterone (DHEA) may be helpful for preventing or treating osteoporosis, especially in postmenopausal women older than age seventy years. Also, one study found weak evidence that DHEA might be helpful for preventing the osteoporosis that sometimes develops in women with anorexia nervosa.

Chinese studies suggest that the herb Epimedium brevicornum has phytoestrogenic effects and, on this basis, may be helpful for preventing bone loss. (E. brevicornum is related, but not identical, to E. sagittatum, otherwise known as horny goat weed.)

Preliminary evidence suggests that black tea may help protect against
osteoporosis. Similarly weak evidence hints that the herb black cohosh
might help prevent osteoporosis. Although it has long been stated that high
phosphorus intake from the consumption of soft drinks might lead to osteoporosis,
there is no solid evidence for this claim. Elevated intake of phosphorus may help
prevent osteoporosis. The reason is that bone contains both calcium and
phosphate.

According to one preliminary study, but not another, boron may be helpful for
preventing osteoporosis. However, there are some concerns that boron
supplements may raise levels of the body’s own estrogen, especially in women on
estrogen-replacement therapy, and therefore might present an increased risk of
cancer. To increase boron intake, one should eat more fruits and vegetables.

One study widely advertised as showing that silicon is helpful for osteoporosis actually failed to show much of anything. Extremely weak evidence hints at possible benefit for osteoporosis through the use of royal jelly.

Although it has long been believed that consuming too much protein (especially animal-based protein) increases the risk of osteoporosis, the balance of available evidence suggests the reverse: If anything, high intake of protein appears to help strengthen bone. One study found that calcium supplements may do a better job of strengthening bones in people with relatively high protein intake than in those with lower intake.

It has been suggested both that water fluoridation helps prevent osteoporosis
and also that it causes the condition; on balance, however, the evidence suggests
that it does neither. Another study failed to find arginine supplements helpful
for enhancing bone density.

Progesterone. Many books promote the idea that natural
progesterone prevents or even reduces osteoporosis. In this
case, the term “natural” means the same progesterone found in the body. It is
still made synthetically, but it is called natural progesterone to distinguish it
from its chemical cousins known as progestins. Generally, prescription
“progesterone” is actually a progestin.

The progesterone-osteoporosis story began with test-tube and other preliminary studies suggesting that progesterone or progestins can stimulate the activity of cells that build bone. Subsequently, a poorly designed and uncontrolled study (actually, a series of case histories from one physician’s practice) purportedly demonstrated that progesterone cream can slow or even reverse osteoporosis.

However, a one-year double-blind trial of 102 women using either progesterone cream (providing 20 mg progesterone daily) or placebo cream, along with calcium and multivitamins, found no evidence of any improvements in bone density attributable to progesterone. Furthermore, in a three-year study of 875 women, combination treatment with estrogen and oral progesterone was no more effective for osteoporosis than estrogen alone.

Estriol. Some alternative medicine practitioners have popularized
the use of a special form of estrogen called estriol,
claiming that, unlike standard estrogen, it does not increase the risk of cancer.
However, this claim is unfounded.

Controlled trials performed in Japan have found that estriol helps prevent bone loss in menopausal women, although one small study found no benefit. However, like other forms of estrogen, oral estriol stimulates the growth of uterine tissue. This leads to a risk of uterine cancer.

In a placebo-controlled study of 1,110 women, greater uterine tissue stimulation was seen among women given estriol orally (1 to 2 mg daily) than among those given placebo. Another large study found that oral estriol increased the risk of uterine cancer. In another study of 48 women given estriol at a dose of 1 mg twice daily, uterine tissue stimulation was seen in the majority of cases.

In contrast, a twelve-month double-blind trial of oral estriol (2 mg daily) in sixty-eight Japanese women found no effect on the uterus. It may be that the high levels of soy in the Japanese diet altered the results. Additionally, test-tube studies suggest that estriol is just as likely to cause breast cancer as any other form of estrogen. Women who use estriol should consider it like any other form of estrogen.

Herbs and Supplements to Use with Caution

While the evidence is not yet strong, some research suggests that excessive intake of vitamin A may increase the risk of osteoporosis. Also, herbs and supplements may interact adversely with drugs used to treat osteoporosis, so persons should be cautious when considering the use of herbs and supplements.

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