What is the largest blood vessel in the human body?

The largest blood vessel is called the aorta. It is an artery which contains muscular walls capable of pumping blood containing oxygen away from the heart and directs its flow toward various tissues. The smooth muscle of the arteries pushes the blood through the circulatory system and is the pulse that can be measured at various pulse points in the body.

The left ventricle of the heart pumps out oxygenated blood which flows through the aortic valve into the aorta and this blood vessel provides the necessary force to pump the blood to all parts of the body. The aorta has branches that bring blood to the brain as well as to all organs and tissues of the body. 

As the aorta branches off, it forms smaller arteries, then arterioles, then finally capillaries. These are capable of allowing diffusion between body cells and the circulating blood. Nutrients, oxygen and water can cross from the blood into the cells and wastes like carbon dioxide can pass from the cells back to the circulating blood to be transported to organs of excretion.

I have included a link with a diagram of the blood flowing through the heart and into the aorta, and another of the aorta in detail.

What is Candy's dog a symbol of in John Steinbeck's Of Mice and Men?

The old dog and Candy himself are symbolic of what happens when someone outlives his usefulness. The dog has lived a long life as Candy's companion but no longer serves any purpose. He smells bad, is blind and has a bad coat. Carlson, a static character whose main purpose in the novel is to kill the dog, complains:

“Well, I can’t stand him in here,” said Carlson. “That stink hangs around even after he’s gone.” He walked over with his heavy-legged stride and looked down at the dog. “Got no teeth,” he said. “He’s all stiff with rheumatism. He ain’t no good to you, Candy. An’ he ain’t no good to himself. Why’n’t you shoot him, Candy?” 

Candy can't bring himself to put the dog down, but Carlson volunteers, and Slim, whose "opinions were law," thinks it's the best thing to do. Slim reiterates Carlson's claim that the dog is no longer useful:

“Carl’s right, Candy. That dog ain’t no good to himself. I wisht somebody’d shoot me if I get old an’ a cripple.” 

Symbolically, the dog is similar to Candy. The old swamper, who lost his hand in a ranch accident, has also outlived his purpose. He fears that he will soon be fired from the ranch since he can no longer work as hard as the other men. He expresses this fear after he offers to contribute his money for the farm that George wants to buy. He says,

Maybe if I give you guys my money, you’ll let me hoe in the garden even after I ain’t no good at it. An’ I’ll wash dishes an’ little chicken stuff like that. But I’ll be on our own place, an’ I’ll be let to work on our own place.” He said miserably, “You seen what they done to my dog tonight? They says he wasn’t no good to himself nor nobody else. When they can me here I wisht somebody’d shoot me. But they won’t do nothing like that. I won’t have no place to go, an’ I can’t get no more jobs. 

Unfortunately for Candy, the dream of the farm is shattered after Lennie accidentally kills Curley's wife. In Chapter Five, George is no longer interested in buying the farm because he knows he will have to kill Lennie. Lennie, too, has outlived his purpose. He can no longer live in society because of his actions. The dog, Candy and Lennie become castaways in a society which cannot be burdened by the old, the crippled or the mentally challenged. 

What are drug therapies?

Introduction

Before 1950, no truly effective drug therapies existed for mental illness. Physicians treated mentally ill patients with a combination of physical restraints, bloodletting, sedation, starvation, electric shock, and other minimally effective therapies. They used some drugs for treatment, including alcohol and opium, primarily to calm agitated patients. Interest in drug therapy in the early twentieth century was high, based on the rapidly increasing body of chemical knowledge developed during the late nineteenth century. Researchers in the first half of the twentieth century experimented with insulin, marijuana, antihistamines, and lithium, with varying success. The term
psychopharmacology
, the study of drugs for the treatment of mental illness, dates to 1920.

In 1951, a French scientist, Paul Charpentier, synthesized chlorpromazine (Thorazine) for use in reducing surgical patients’ anxiety and preventing shock during surgery. Physicians noted its calming effect and began to use it in psychiatry. Previously agitated patients with schizophrenia become calmer, their thoughts became less chaotic, and they became less irritable. Chlorpromazine was truly the first effective psychotropic drug (that is, a drug exerting an effect on the mind) and is still used.

The discovery of chlorpromazine ushered in a new era in the treatment of psychiatric illness. Pharmaceutical companies have developed and introduced dozens of new psychotropic drugs. Many long-term psychiatric treatment facilities have closed, and psychiatrists have released the vast majority of their patients into community-based mental health care. Patients with mental health problems are treated on an outpatient basis, with brief hospitalizations for stabilization in some cases. Treatment goals are no longer simply to sedate patients or to protect them and others from harm but rather to provide them with significant relief from their symptoms and to help them function productively in society. As scientific knowledge about the brain and its function increases, researchers are able to create drugs targeting increasingly specific areas of the brain, leading to fewer adverse side effects.

This psychotherapeutic drug revolution has had some negative consequences, however. Drug side effects range from annoying to life threatening. Community mental health treatment centers have not grown in number or received funding sufficient to meet the needs of all the patients released from long-term care facilities. Many mentally ill patients have fallen through the cracks of community-based care and live on the streets or in shelters for the homeless. In addition, some physicians and patients have come to expect a “pill for every ill” and fail to use other, equally or more effective treatment methodologies. The majority of prescriptions for psychotropic drugs are written by generalist physicians rather than by psychiatrists, raising concerns about excessive or inappropriate prescribing. Some people abuse these drugs, either by taking their medications in excess of the amount prescribed for them or by obtaining them illicitly. Studies have shown that prescription drug abuse causes more injuries and deaths than abuse of all illicit drugs combined. Feminist scholars have pointed out that physicians tend to prescribe psychotropic drugs more readily for women than for men.

Despite the negative effects, psychotropic drugs are extremely important in the provision of health care, not only for those people traditionally thought of as mentally ill but also for people with chronic pain, serious medical illness, and loss and grief, and those who have experienced traumatic events.

How Psychotropic Drugs Work

To understand how these mind-affecting drugs work, it is necessary to understand a little of how the brain works. The brain is made up primarily of neurons (nerve cells) that form circuits controlling thoughts, emotions, physical activities, and basic life functions. These nerve cells do not actually touch one another but are separated by a gap called a synapse. An electrical impulse moves along the neuron. When it reaches the end, it stimulates the release of chemicals called neurotransmitters into the synapse. These chemicals then fit into receptors on the next neuron and affect its electrical impulse. The neurotransmitters act by either causing the release of the electric impulse or inhibiting it so the neuron does not fire. Any neurotransmitter left in the synapse is then reabsorbed into the original neuron. This process is called reuptake.

Problems can arise in one of two ways: either too much or too little neurotransmission. Too much transmission may occur when the neuron fires in the absence of a stimulus or when too many neurotransmitters attach to the receptors on the far side of the synapse (the postsynaptic receptors). Too little transmission can occur when too few neurotransmitters attach to these postsynaptic receptors. The primary neurotransmitters involved in mental illnesses and their treatment are dopamine, serotonin (5-HT), norepinephrine, and gamma-aminobutyric acid (GABA).

Antidepressant Drugs

Some scientists believe that depression
is caused by insufficient norepinephrine, serotonin, or dopamine in the synapse. Others theorize that depression has to do with the number and sensitivity of postsynaptic receptors involved in the neuron’s response. Drugs for the treatment of depression fall into four major classes: the monoamine oxidase inhibitors (MAOIs), the tricyclic antidepressants, the selective serotonin reuptake inhibitors (SSRIs), and atypical antidepressants. None of these drugs is addictive, although patients need to be weaned from them slowly to avoid rebound depression or other adverse effects.

MAOIs were the first modern antidepressants. Monoamine oxidase is an enzyme that breaks down serotonin, norepinephrine, and dopamine. Inhibiting the enzyme increases the supply of these neurotransmitters. MAOI drugs available in the United States include phenelzine (Nardil) and tranylcypromine (Parnate). These drugs are not used as commonly as are the other antidepressants, mostly because of their side effects. However, they are used when other treatments for depression fail. In addition, they may be used to treat narcolepsy, phobias, anxiety, and Parkinson’s disease. Common side effects include drowsiness, fatigue, dry mouth, and dizziness. They may also cause orthostatic hypotension (a drop in blood pressure when arising) and sexual dysfunction. Most important, the MAOIs interact with tyramine-containing foods, such as hard cheese, red wine, and smoked or pickled fish. Consuming these foods along with an MAOI can cause a hypertensive crisis in which the patient’s blood pressure rises to potentially deadly levels. Patients taking MAOIs must also avoid other drugs that stimulate the nervous system to avoid blood pressure emergencies.

The tricyclic antidepressants were introduced in 1958. They all inhibit the reuptake of neurotransmitters but differ in which one is involved. Some affect primarily serotonin, some norepinephrine, and some work equally on both. Tricyclics available in the United States include amitriptyline (Elavil), imipramine (Tofranil), doxepin (Sinequan, Adapin), desipramine (Norpramin), nortriptyline (Pamelor, Aventyl), amoxapine (Asendin), protriptyline (Vivactil), and clomipramine (Anafranil). Primarily used for depression, these drugs may also be helpful in the treatment of bed-wetting, agoraphobia (fear of being out in the open) with panic attacks, obsessive-compulsive disorder, chronic pain, nerve pain, and migraine headaches. An important treatment issue is that it takes two to three weeks of drug therapy before the depressed patient feels much improvement in mood and energy. During this time, the side effects tend to be the most bothersome, leading patients to abandon the treatment before it becomes effective. Another important treatment issue is that tricyclic antidepressants are highly lethal in overdose. Common side effects include dry mouth, blurred vision, constipation, urinary retention, orthostatic hypotension, weight gain, sexual dysfunction, cardiac problems, and jaundice. Some of the tricyclics are highly sedating and so may be useful in patients who are having difficulty sleeping. On the other hand, a patient who is already feeling sluggish and sleepy may benefit from a tricyclic that is less sedating. Any antidepressant may precipitate mania or hypomania in a patient with a predisposition to bipolar disorder. Elderly patients may be at increased risk for falls or confusion and memory impairment when taking tricyclics and should be started on very low doses if a tricyclic is indicated.

The newer selective SSRIs have several advantages over the tricyclics: They are much less lethal in overdose, are far safer in the elderly, and do not cause weight gain. They work, as the name implies, by decreasing serotonin reuptake, thereby increasing the amount of neurotransmitter available at the synapse. Like the tricyclics, SSRIs may need to be taken for several weeks before a patient notices significant improvement in mood and energy level. SSRIs available in the United States include fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine (Luvox), paroxetine (Paxil), trazodone (Desyrel), nafazodone (Serzone), and venlafaxine (Effexor). In addition to depression, the SSRIs are used for treatment of bulimia nervosa and obsessive-compulsive disorder. Possible side effects include nausea, diarrhea, nervousness, insomnia, anxiety, and sexual dysfunction.

Other drugs used in the treatment of depression, known collectively as atypical antidepressants, include mianserin (Tolvon), maprotiline (Ludiomil), and bupropion (Wellbutrin). The mechanisms by which these drugs work are not clear, but they may be useful in patients for whom the other antidepressants do not work or are contraindicated.

Mood Stabilizers

Some patients who have depression also have episodes of elevated mood and erratic, uncontrolled behavior. These patients are diagnosed with bipolar disorder, formerly known as manic-depression. The underlying cause for this disorder is unknown, but there is a strong genetic predisposition. Evidence suggests it is due to overactivity of the neurotransmitters. Treatment for bipolar disorder consists of mood-stabilizing drugs. These drugs control not only the “highs” but also the episodes of depression.

Lithium is a naturally occurring mineral that was observed to calm agitated behavior as long ago as in ancient Egypt. Its usefulness as a mood stabilizer was first scientifically established in the 1940s, and it was approved in 1970 for use in the United States. It is effective not only in stabilizing the mood during a manic episode but also in the prevention of future episodes. A significant problem with the use of lithium is that the dose at which it becomes effective is quite close to the dose that produces toxicity, characterized by drowsiness, blurred vision, staggering, confusion, irregular heartbeat, seizures, and coma. Patients taking lithium must therefore have blood drawn on a regular basis to determine drug levels. Patients who have poor kidney function should not take lithium because it is excreted primarily through the urine. Lithium’s side effects include nausea, diarrhea, tremor of the hands, dry mouth, and frequent urination.

Drugs usually used for the treatment of seizures may also help stabilize mood in bipolar patients, usually at lower doses than would be used for seizure control. These include carbamazepine (Tegretol), divalproex sodium (Depakote), gabapentin (Neurontin), lamotrigine (Lamictal), and topiramate (Topamax). It is believed that these drugs increase the amount of GABA at the synapse. GABA has a calming or inhibitory effect on the neurons. Side effects of these medications include dizziness, nausea, headaches, and visual changes.

Psychostimulants

Attention-deficit hyperactivity disorder (ADHD)
is found in both children and adults. Children with ADHD have difficulties at school because of impulsivity and inattention. The underlying cause of ADHD is extremely complex, and the ways in which drugs used to treat it work are equally complex. The most successful treatments are with psychostimulants, drugs that stimulate the central nervous system. Drug therapy is most effective when combined with behavioral treatments. The most commonly used psychostimulant is methylphenidate (marketed in varying formulations as Concerta, Daytrana, Metadate, Methylin, and Ritalin), but amphetamines are sometimes used as well. Formerly, depressed patients were treated with amphetamines and similar compounds; occasionally this use is still found. These stimulant drugs do improve school performance; however, they may cause growth retardation in both height and weight. They may also cause insomnia and nervousness. These drugs may be abused, leading ultimately to addiction, paranoia, and severe depression during withdrawal.

Antianxiety Drugs

Antianxiety drugs
or anxiolytics are central nervous system depressants. Many of these drugs, in higher doses, are also used as sedative-hypnotics, or calming and sleep-inducing drugs. They seem to act by enhancing the effect of GABA in the brain. The earliest of these depressant drugs included chloroform, chloral hydrate, and paraldehyde, and they were used for anesthesia and for sedation.

Barbiturates were introduced in Germany in 1862 and were widely used for treatment of anxiety and sleep problems until the 1960s. Barbiturates are still available today, including pentobarbital (Nembutal), secobarbital (Seconal), amobarbital (Amytal Sodium), and phenobarbital (Solfoton, Luminal). Their major adverse effect is respiratory depression, particularly when used in combination with alcohol, another central nervous system depressant. With the advent of the safer benzodiazepines, use of the barbiturates has declined steadily.

Benzodiazepines are used for two major problems: anxiety and insomnia. Anxiety disorders appropriate for this kind of treatment include generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, phobic disorder, and dissociative disorder. The benzodiazepines commonly used for anxiety include alprazolam (Xanax), chlordiazepoxide (Librium), clonazepam (Klonopin), clorazepate (Tranxene), diazepam (Valium), lorazepam (Ativan), and oxazepam (Serax). For most of these disorders, however, behavioral, cognitive, group, and social therapy, or one of these therapies plus medication, are more effective than medication alone. Benzodiazepines used for insomnia include estazolam (Prosom), flurazepam (Dalmane), midazolam (Versed), quazepam (Doral), temazepam (Restoril), and triazolam (Halcion). Benzodiazepines may also be used to prevent the development of delirium tremens during alcohol withdrawal. Patients become tolerant to the effects of these drugs, meaning they have the potential for physical dependency and addiction. In addition, benzodiazepines interact with many other drugs, including alcohol. Their use should be limited to brief periods of time, particularly in the treatment of insomnia. Long-term treatment for anxiety should be monitored carefully by the health care provider. Elderly people are more likely to suffer adverse effects (such as confusion or falls) from benzodiazepine use.

Another drug developed for treatment of anxiety is buspirone (Buspar). Propranolol (Inderal) and atenolol (Tenormin), usually used to treat high blood pressure, are useful in treating stage fright or performance anxiety, and clonidine (Catapres), another blood pressure medication, is successfully used in treatment of anxiety. Nonbenzodiazepine sleep agents include zolpidem (Ambien) and zaleplon (Sonata).

Antipsychotic Drugs

Formerly known as major tranquilizers or neuroleptics, the antipsychotic drugs
have revolutionized the treatment of schizophrenia and other psychoses. The underlying cause of psychosis is not known, but it is thought to be related to the neurotransmitter dopamine. Most of the antipsychotics block the dopamine receptors in the brain. The older antipsychotic drugs, some of which are no longer on the market, include chlorpromazine (Thorazine), thioridazine (Mellaril), perphenazine (Trilafon), trifluoperazine (Stelazine), fluphenazine (Prolixin), thiothixene (Navane), and haloperidol (Haldol). These older drugs treat the so-called positive symptoms of schizophrenia—hallucinations and delusions—but they have little effect on the negative symptoms, which include withdrawal, poor interpersonal relationships, and slowing of the body’s movement. They also have multiple serious side effects, including severe muscle spasm, tremor, rigidity, shuffling gait, stupor, fever, difficulty speaking, blood pressure changes, restlessness, and involuntary movements of the face, trunk, arms, and legs. Some of these are treatable using other drugs, but some are neither treatable nor reversible. In an effort to overcome these problems, newer antipsychotics have been developed. The first of these was clozapine (Clozaril), which was successful in treating about one-third of the patients who did not respond to other antipsychotic drugs. Although it has fewer of the serious side effects listed above, a small percentage of patients experience a severe drop in the white blood cells, which puts them at risk for serious infection. For this reason, patients on clozapine must participate in frequent blood tests. Other newer antipsychotics include risperidone (Risperdal), olanzapine (Zyprexa), and quetiapine (Seroquel). In addition to fewer of the serious side effects, the newer antipsychotics seem to have some effect on the negative symptoms.

Bibliography

Breggin, Peter R., and David Cohen. Your Drug May Be Your Problem: How and Why to Stop Taking Psychiatric Drugs. Rev. ed. Philadelphia: DaCapo, 2007. Print.

Drummond, Edward H. The Complete Guide to Psychiatric Drugs: Straight Talk for Best Results. Rev. ed. Hoboken: Wiley, 2006. Print.

Gorman, Jack M. Essential Guide to Psychiatric Drugs. 4th ed. New York: St. Martin’s, 2007. Print.

Herzberg, David. Happy Pills in America: From Miltown to Prozac. Baltimore: Johns Hopkins UP, 2008. Print.

Kramer, Peter D. Listening to Prozac: A Psychiatrist Explores Antidepressant Drugs and the Remaking of the Self. New York: Penguin, 1997. Print.

Labbate, Lawrence A., et al. Handbook of Psychiatric Drug Therapy. 6th ed. Philadelphia: Lippincott, 2012. Print.

Ritter, Lois A., and Shirley Manly Lampkin. Community Mental Health. Sudbury: Jones, 2012. Print.

Shiloh, Roni, et al. Atlas of Psychiatric Pharmacotherapy. 2nd ed. Boca Raton: Taylor, 2013. Print.

Stahl, Stephen M. Stahl’s Essential Psychopharmacology: Neuroscientific Basis and Practical Applications. 3d ed. New York: Cambridge UP, 2008. Print.

Why do people develop "crushes" and how long do they last?

"Crush" is a colloquial or slang term for having affectionate, romantic, or desirous feelings for someone. The term is often used when talking about the affection young people feel for another person. Unfortunately, crushes may be unrequited-- that is, only one person has feelings for the other. 

People develop crushes for a variety of reasons, but all crushes have a human need in common. Humans are social creatures and we thrive in relationships. These relationships may be parental/familial, work relationships, or even friendships. As we age and our bodies develop, our hormones start signalling that it might be time to find a mate. Most humans desire a long-term, romantic relationship with a partner. While our evolutionary drive for partnership is to mate, the best matches are between people who find people emotionally and mentally attractive in addition to any physical attraction. When puberty begins and hormonal changes start signalling and interest in mating, we often begin to feel this emotional and mental attraction to other people. Of course, crushes may involve physical attraction, but this isn't always necessary.

In short, we develop crushes because our bodies and brains have evolved to want a romantic partner in life.

Crushes develop from and are sustained by positive events. For example, if there's someone you have a crush on, think about what things happened to make you like them. Are they physically attractive? Do you have a lot in common? Are they funny, or kind, or responsible? The crush may last as long as you know and spend time around this person. If you stopped spending time together, the feelings you have might fade. Alternately, the crush might fade away if you see this person doing something you don't find attractive.

Having a crush on someone can be pretty frustrating, especially if you don't know how the other person feels. You could have a friend speak to this person for you and find out if they have a crush on you, too. If your parents are okay with it and willing to accompany you, you might ask this person to go see a movie or have lunch. If you really just want this crush to be over with, try throwing yourself into your hobbies as a distraction.

The 'black box' used in "The Lottery" is a symbol to represent a bigger idea or concept behind this event. What does the black box symbolize?

The black box represents tradition and the people's unwillingness to break or change that tradition. It is noted that some have suggested using a new box. The barbaric ritual would continue, but simply with a newer looking box. But the consensus is that they wouldn't dare change anything about their traditions. So, the notion of a new box is squashed before it can even be debated. Tradition is more important: 

Mr. Summers spoke frequently to the villagers about making a new box, but no one liked to upset even as much tradition as was represented by the black box. There was a story that the present box had been made with some pieces of the box that had preceded it, the one that had been constructed when the first people settled down to make a village here. 

The black box has deteriorated over the years. This symbolizes the deterioration of the ritual. That ritual is a remnant of the past. It had been initiated as some type of sacred ritual to appease God and/or be a sacrifice to promote a good crop. But note that other towns talk of getting rid of the ritual. This suggests that other places are becoming more logical, ethical, and scientific. The ritual always was useless and barbaric, but within the context of a more modern society, the ritual seems even more absurd and out of touch. It's tattered appearance symbolizes how it is a vestige of a less enlightened society. 

The black box represents traditional ways of thinking and people's fear of changing. Note that the villagers don't even know what the ritual is. The only things that they do remember are the stones: 

Although the villagers had forgotten the ritual and lost the original black box, they still remembered to use stones. 

This shows a thoughtless acceptance of tradition, traditional thinking, past ideologies and belief systems. The black box represents tradition and this notion of mindlessly accepting tradition, no matter what the case is. 

How can I write a three– to four–page annotated bibliography, with eight sources, that supports what I have written on Shakespeare's Macbeth?

An annotated bibliography usually functions as a way for you as a writer to compile the various sources that pertain to your specific research topic. The format consists of a citation, then an evaluation and analysis of each source in paragraph form.

The above process will inform any topic on which one researches. For Shakespeare's Macbeth, I would urge you to narrow down your focus before you start looking for sources because of the wealth of scholarship produced. However, if you are unsure of your focus, you may also use an annotated bibliography to set the stage for what your research question might be. Typically, one prepares an annotated bibliography before writing a research paper (or any other paper, for that matter) to show the types of sources one might incorporate in an upcoming paper.

If, on the other hand, you already have the eight sources you mentioned, skim these sources and evaluate their main argument(s) and relevance, as well provide a brief analysis. This process will easily fill three (if not four) pages. In this process of evaluation, you might discover that the sources you have compiled are not relevant or interesting, so conducting further research may be necessary.

Also, since it is unclear as to what topic you have chosen with respect to the play, I would urge you to prepare an annotated bibliography to help in narrowing down the scope of your research.

Please see the reference link below for a few examples.

What happens in the Underworld in The Odyssey?

In Homer's epic poem The Odyssey, the protagonist Odysseus and his crew visit the Underworld. Their journey is guided by directions from Circe, the sea witch, who instructs them to make a sacrifice at the entrance to the world of the dead. Upon this sacrifice, ghosts visit the men. Odysseus is visited by three ghosts in particular.

Elpenor, a crew member, asks Odysseus to perform traditional burial rites for him. Odysseus acquiesces, reinforcing his characterization as a good leader and empathetic man. 

Anticleia, Odysseus' mother, next approaches. This is upsetting to Odysseus, who was unaware that his mother had died. At first, he does not let her drink the blood. When he does, she explains that she had died of grief and longing for Odysseus. She also reveals the dire nature of Penelope and Telemachus' situation. 

Odysseus also speaks with Tiresias, who offers further guidance and warnings for their trip home. In particular, he helps Odysseus to negotiate his relationships with the various gods who he has interacted or will interact with. 

What are factitious disorders?

Causes and Symptoms

Although factitious disorders cover a wide array of physical symptoms and are believed to be closely related to a subset of psychophysiological disorders (somatoform disorders), they are unique in all of medicine for two reasons. The first distinguishing factor is that whatever the physical disease for which treatment is sought and regardless of how serious, the patients who seek its treatment have deliberately and intentionally produced the condition. They may have done so in one of three ways, or in any combination of these three ways. First, patients fabricate, invent, lie about, and make up symptoms that they do not have; for example, they claim to have fever and night sweats or severe back pain that they actually do not have. Second, patients have the actual symptoms that they describe, but they intentionally caused them; for example, they might inject human saliva into their own skin to produce an abscess or ingest a known allergic food to cause the predictable reaction. Third, someone with a known condition such as pancreatitis has a pain episode but exaggerates its severity, or someone else with a history of migraines claims his or
her headache to be yet another migraine when it is not. Factitious disorders may manifest as complaints about psychological problems, physical problems, or both.

The second element that makes these disorders unique (and at the same time both fascinating to study and frustrating to treat) is that the sole motivation for causing or claiming the symptoms is for these patients to become and remain patients, to assume the sick role wherein little can be expected from them. These patients are not malingerers, individuals who consciously use actual or feigned symptoms for some other gain (such as claiming a fever so one does not have to go to work or school, or insisting that one’s post-traumatic stress is worse than it is to enhance the judgment in a lawsuit). In fact, it is the absence of any discernible external benefit that makes these disorders so intriguing.

Technically, psychiatrists and psychologists understand factitious disorders as having three subtypes. In the first, patients claim to have predominantly psychological symptoms such as memory loss, depression, contemplation of suicide, the hearing of voices, or false memory of childhood molestation. Characteristically, the symptoms worsen whenever the patients know themselves to be under observation. In the second, patients have predominantly physical symptoms that at least superficially suggest some general medical condition. In a more extreme form called Münchausen syndrome, individuals will have spent much of their lives getting admitted to medical facilities and, once there, remain as long as possible. While common complaints include vomiting, dizziness, blacking out, generalized rashes, and bleeding, the symptoms can involve any organ and seem limited only to the individuals’ medical knowledge and experience with the medical system. The third subtype combines both psychological and physical complaints in such a way that neither predominates.

Regardless of the subtype, factitious disorders are difficult to diagnose. Usually, the diagnosis is considered when the course of treating either a medical or a mental illness becomes atypical and protracted. Often, the person with a factitious disorder will present in a way that seems odd to the experienced clinician. The person may have an unusually extensive history of traveling, much familiarity with medical procedures and terminology, a complex medical and surgical history, few visitors during the hospitalization, behavioral disruptions and disturbances while hospitalized, exacerbation of symptoms while under observation, and/or fluctuating illness with new symptoms and complications arising as the workup proceeds. When present, these traits along with others make suspicion of factitious disorders reasonable.

No one knows how many people suffer with factitious disorders, but the condition is generally regarded as uncommon. It is certainly rarely reported, but this in part may be attributable to the difficulties in determining the diagnosis. While brief episodes of the condition occur, most people who claim a factitious disorder have it chronically, and they usually move on to another physician or facility when they are confronted with the true nature of their illness. It is therefore likely that some individuals are reported more than once by different hospitals and providers.

There is little certainty about what causes factitious disorders. This is true in large measure because those who know the most about the subject—patients with the disorder—are notoriously unreliable in providing information about their psychological state and often seem only dimly aware of what they are doing to themselves. It may be that they are generally incapable of putting their feelings into words. They are unaware of having inner feelings and may not know, for example, that they are sad or angry. It is possible that they experience emotions more physically, behaviorally, and concretely than do most others.

Another view suggests that people learn to distinguish their primitive emotional states through the responsivity of their primary caretaker. A normal, healthy, average mother responds appropriately to her infant’s differing affective states, thereby helping the infant, as he or she develops, to distinguish, define, and eventually name what he or she is feeling. When a primary caretaker is, for any of several reasons, incapable of responding in consistently appropriate ways, the infant’s emotional awareness remains undifferentiated and the child experiences confusion and emotional chaos.

It is possible, too, that factitious disorder patients are motivated to assume what sociology defines as a sick role wherein people are required to acknowledge that they are ill and are required to relinquish adult responsibilities as they place themselves in the hands of designated caretakers.

Treatment and Therapy

Understanding how to identify individuals with factitious disorders early in their treatment process is crucial to public health for three important reasons. First, early identification will help the individual obtain a more appropriate referral. Second, it will conserve valuable health care resources, so that clients who have pressing medical needs get the treatment that they deserve. Third, the earlier in the process these individuals can be identified, the sooner valuable health care dollars can be saved, lowering the cost of health care as a whole.

Internists, family practitioners, and surgeons are the specialists most likely to encounter patients with factitious disorders, although psychiatrists and psychologists are often consulted in the management of these patients. These patients pose a special challenge because, in a real sense, they do not wish to become well even as they present themselves for treatment. They are not ill in the usual sense, and their indirect communication and manipulation often make them frustrating to treat using standard goals and expectations.

Sometimes mental and medical specialists’ joint, supportive confrontation of these patients results in a disappearance of the troubling and troublesome behavior. During these confrontations, the health professionals are acknowledging that such extreme behavior evidences extreme distress in these patients, and as such is its own reason for psychotherapeutic intervention. These patients are not psychologically minded, however; they also have trouble forming relationships that foster genuine self-disclosure, and they rarely accept the recommendation for psychotherapeutic treatment. Because they believe that their problems are physical, not psychological, they often become irate at the suggestion that their problems are not what they believe them to be. Taken from the patient’s perspective, this anger makes some sense. For them, they have endured significant time in evaluation and often also a good bit of money, and if they are lacking insight into their condition, such a confrontation may leave them feeling helpless and misunderstood. As such, even in these circumstances, empathy remains an important element in successful intervention.

Bibliography:

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. Arlington, Va.: Author, 2013.

Feldman, Marc D. Playing Sick? Untangling the Web of Munchausen Syndrome, Munchausen by Proxy, Malingering, and Factitious Disorder. New York: Brunner-Routledge, 2004.

Mayo Clinic Staff. "Munchausen Syndrome." Mayo Clinic, May 13, 2011.

McCoy, Krisha, Rebecca Stahl, and Brian Randall. "Factitious Disorder." Health Library, Mar. 15, 2013.

New, Michelle. "Munchausen by Proxy Syndrome." KidsHealth. Nemours Foundation, Mar. 2012.

Phillips, Katherine A., ed. Somatoform and Factitious Disorders. Washington, D.C.: American Psychiatric Association, 2001.

What themes do Mr. Hooper's last words and the final images in "The Minister's Black Veil" suggest? Quote and paraphrase the text in your response.

At the end of this short story, Mr. Hooper is on his deathbed, speaking to another minister and the people who have come to be with him as he passes on.  Reverend Mr. Clark has told Mr. Hooper that it is time to remove the black veil from his face, and Mr. Hooper has vowed that it will never come off while he's alive.  The final paragraph sets the scene: Mr. Hooper in bed in the midst of a "circle of pale spectators."  He admonishes them for fearing the sight of him when they do not fear the sight of one another, and he finds it remarkable that he should have been avoided for his whole life, all because of the veil he wears.  He says,

"When the friend shows his inmost heart to his friend; the lover to his best beloved; when man does not vainly shrink from the eye of his Creator, loathsomely treasuring up the secret of his sin; then deem me a monster, for the symbol beneath which I have lived, and die!  I look around me, and, lo! on every visage a Black Veil!"

In other words, he claims that everyone wears such a veil, figuratively.  Mr. Hooper wears a literal black veil in order to symbolize this "secret sin" that each of us has.  We are all sinners, but none of us are willing to share this reality with our fellows.  Only Mr. Hooper has been honest enough to acknowledge this fact (of our sinfulness and our desire to hide it), and, for that honesty, he is been hypocritically ostracized. 

Thus, the story's final paragraph helps to convey the ideas that we are all sinners, and yet we all attempt to conceal this fact from the world.  Further, that we care more about the appearance of sinlessness than actually being sinless, and the order of our priorities renders us hypocrites.

What is bacterial endocarditis?

Definition

The endocardium is a thin membrane that covers the inner surface of the heart. Bacterial endocarditis is an infection of this membrane. Infection occurs when bacteria attach to the membrane and grow.

The infection is most common when the heart or heart valves have already been damaged. It can be life-threatening, and it can permanently impair the heart valves. This can lead to serious health problems, such as congestive heart failure.

The infection can also cause growths on the valves or other areas of the heart. Pieces of these growths can break off and travel to other parts of the body. This can cause serious complications.

Causes

Bacteria can travel to the heart through the blood. They can enter the blood
from an infection elsewhere in the body. They can also enter through breaks in the
skin or mucous membranes caused by dental work, surgery, or IV (intravenous) drug
use. Only certain bacteria cause this infection, the most common of which are
streptococci, staphylococci, and enterococci.

The bacteria may then be able to attach to the endocardium. Some heart conditions can increase the chance of infections. These conditions may cause blood flow to be obstructed or to pool, providing a place for the bacteria to build up.

Risk Factors

The following conditions place a person at greater risk for bacterial endocarditis during certain procedures: heart valve scarring from rheumatic fever or other conditions; artificial heart valve; congenital heart defect; cardiomyopathy; prior episode of endocarditis; and mitral valve prolapse, with significant regurgitation (abnormal backflow of blood).

The foregoing conditions increase the risk of the infection with certain activities, including IV drug use (risk is extremely high when needles are shared); any dental procedure, even cleanings; removal of tonsils or adenoids, and other procedures involving the ears, nose, and throat; bronchoscopy (viewing the airways through a thin, lighted tube); and surgery on the gastrointestinal or urinary tracks, including the gallbladder and prostate.

Symptoms

Symptoms of bacterial endocarditis vary from mild to severe, depending on the bacteria causing the infection, the amount of bacteria in the bloodstream, the extent of structural heart defects, the body’s ability to fight infection, and overall health. The symptoms, which can begin within two weeks of the bacteria entering the bloodstream, include fever, chills, fatigue, weakness, malaise, unexplained weight loss, poor appetite, muscle aches, joint pain, coughing, shortness of breath, bumps on the fingers and toes, and little red dots on the skin, inside the mouth, or under the nails. The first symptom may be caused by a piece of the infected heart growth breaking off.

Screening and Diagnosis

A doctor will ask about symptoms and medical history and will perform a
physical exam, which includes listening to the patient’s heart for a murmur. Tests
may include blood cultures to check for the presence of bacteria; blood tests to
look for signs of infections and complications related to endocarditis; a
computed
tomography (CT) scan (a detailed X-ray picture that
identifies abnormalities of fine tissue structure); an electrocardiogram (ECG or
EKG), which is a test that records the heart’s activity by
measuring electrical currents through the heart muscle; an echocardiogram, which is a test that uses high-frequency
sound waves (ultrasound) to examine the size, shape, and motion of the heart; and
a transesophageal echocardiogram, in which ultrasound is passed through the
patient’s mouth and then into the esophagus to better visualize the heart
valves.

Treatment and Therapy

Treatment, including medications and possible surgery, focuses on getting rid
of the infection from the blood and heart. Antibiotics
are given through an IV into a vein. The patient must be admitted to the hospital
for this treatment, which could take four to six weeks to complete. If the
antibiotics fail to remove the bacteria, or if the infection returns, surgery may
be needed. Surgery may also be necessary if the infection has damaged the heart or
valves.

Prevention and Outcomes

The best way to prevent endocarditis is to avoid the use of illegal IV drugs.
Certain heart conditions may increase the risk, too. To find out if the patient is
at increased risk for this condition, the doctor should be consulted.

The American Heart Association (AHA) recommends that people with high and moderate risk should take antibiotics before and after certain dental and nondental medical procedures. In addition, the AHA recommends taking an antibiotic just before and after any procedure that may put a person at risk.

The patient should tell his or her dentist and other health professionals about the heart condition. Other preventive measures include maintaining good oral hygiene, brushing teeth twice daily, flossing daily, visiting a dentist for a cleaning at least every six months, and seeing a dentist if dentures cause discomfort. Finally, people should seek medical care immediately for symptoms of an infection.

Bibliography

Bonow, R. O., et al. “ACC/AHA 2006 Guidelines for the Management of Patients with Valvular Heart Disease.” Journal of the American College of Cardiology 48 (2006).

Durack, David T., and Michael H. Crawford, eds. Infective Endocarditis. Philadelphia: W. B. Saunders, 2003.

Fauci, Anthony, et al., eds. Harrison’s Principles of InternalMedicine. 17th ed. New York: McGraw-Hill, 2008.

Giessel, Barton E., Clint J. Koenig, and Robert L. Blake, Jr. “Information from Your Family Doctor: Bacterial Endocarditis, a Heart at Risk.” American Family Physician 61, no. 6 (March 15, 2000): 1705.

Hoen, B. “Epidemiology and Antibiotic Treatment of Infective Endocarditis: An Update.” Heart 92 (2006): 1694-1700.

Rakel, Robert E., Edward T. Bope, and Rick D. Kellerman, eds. Conn’s Current Therapy 2011. Philadelphia: Saunders/Elsevier, 2010.

Zipes, Douglas P., et al., eds. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Philadelphia: Saunders/Elsevier, 2008.

How did Wilfred Owen's personal life affect his poetry?

Wilfred Owen once wrote, "The poetry is in the pity," and he spent much of his life feeling sympathy for the oppressed. This sympathy is certainly evinced in his poetry.

When he was near the age of ten, his devoted mother took Wilfred on holiday to Broxton by the Hill, which is near Wales and has a lovely countryside. Owen declared in a poem it was there that his "poethood" was born. While he did go forward in his schooling, Owen was forced because of financial difficulties to leave the University of London and be a pupil and a lay assistant to the Vicar of Dunsden, Oxfordshire. It was thought, then, that Wilfred should take orders, but although he felt great sympathy for the suffering of others, he was not sufficiently convinced of the powers of faith and Christianity to relieve this suffering.

Owen left the religious life and went to teach at the Berlitz school in Bordeaux. The incipience of war made Owen impatient with his life, so he returned to England and enlisted. Owen was later sent to the western front in 1917; then, because it was so cold and the fighting was fierce, Owen became ill and was sent to a hospital where he met the poet Siegfried Sassoon. Sassoon encouraged Owen in his poetic efforts, and he assured Owen that his experiences at the front when he returned would help his poetry. Sadly, Owen returned to the front and died a week before the armistice.

Wilfred Owen once wrote to his mother that his life was composed of "bouts": bouts of religion, bouts of horrifying danger, and bouts of poetry. Always, however, Owen felt affection for his mother and sympathy for the oppressed. 

Indeed, there is a poignancy in the Romantic images of the poetry of Wilfred Owen. In his "Dulce et Decorum Est," Owen expresses his sympathy for the suffering of humanity as well as his bitterness at the senseless harm done to men for the selfish purposes of those in power. Likewise, in "Anthem for Doomed Youth," he expresses his anger and pity for the soldiers whose deaths are marked by no choirs or bells, but only "shrill, demented choirs of wailing shells." Other poems, such as "Disabled"--

To-night he noticed how the women's eyes
Passed from him to the strong men that were whole
How cold and late it is! Why don't they come
And put him into bed? Why don't they come?--

and "Mental Cases," a haunting poem, comment with deep pathos upon the ruined lives of soldiers that he, unfortunately, viewed first-hand. Without doubt, his war experiences probably had the greatest influence upon Wilfred Owen's verse.                                                      

What could increase the rate of diffusion across a cell membrane?

Several things could increase the rate of diffusion across a cell membrane.

Diffusion is one of the transport processes that doesn't require energy, because it's driven by environmental conditions rather than a specific cell component. Diffusion can also be defined in terms of entropy; organized systems tend to decay without an influx of energy to maintain their organization. Diffusion is the motion of particles from a region of high concentration to low concentration, so all we need to do to affect this motion is alter either or both of the concentrations, or change the particle being diffused. 

If, for example, we choose to talk about the concentrations of ions, specifically sodium, then we can look at how pumps and gated channels would affect diffusion. Assuming that the cell membrane is impermeable to these ions, then the only way to let them into the cell is to create channels that allow them to flow in until they reach equilibrium with the outside of the cell; after that point, we have to spend energy using pumps to increase the concentration, and we also need gated channels to prevent them from flowing out until we want them to. So, if the cell has gated channels and pumps, this can control the rate of diffusion and increase it. It can also be further increased by adding additional pumps (to increase the high concentration) or additional gates (to allow particles to move through the membrane faster). 

The particles themselves could be changed as well; typically smaller particles will be able to diffuse faster simply by being less difficult to fit through the channels and pumps. You could also change the charge or polarity of the particle, although this would need to be evaluated on a case-by-case basis as the charge might be integral to the function of the gates and pumps.

Describe the lecture that Mrs. Amos gives Bud in the novel Bud, Not Buddy.

The lecture that Mrs. Amos gives Bud in Bud, Not Buddy is as self-righteous, insulting, and dishonest as her character proves to be.  Bud has awoken in his foster home to Todd Amos, his foster brother, shoving a pencil up Bud’s nose.  Bud slaps Todd in a knee-jerk reaction, but Todd retaliates by kicking Bud again and again.  This is when Mrs. Amos enters the scene and gives the lecture.  Bud realizes immediately that it does not matter what Bud says.  Mrs. Amos was only going to hear what Todd had to say.  Mrs. Amos’ lecture follows.

Mrs. Amos begins her lecture by calling Bud “boy,” an insult with racial overtones.  Mrs. Amos peppers her lecture with more insults to Bud when she refers to the “ingratitude” and “foolishness” of “vermin” such as Bud. The self-righteousness in Mrs. Amos’ speech is telling:

I do not have time to put up with the foolishness of those members of our race who do not want to be uplifted. … I do hope your conscience plagues you because you may have ruined things for many others.  I do not know if I shall ever be able to help another child in need.

These statements prove that the character of Mrs. Amos believes her character (and her family) to be far above all others, and especially above Bud.  Mrs. Amos also uses the incident as an excuse not to help orphans anymore.  In this way, she judges all orphans through her erroneous thoughts about the conduct of one orphan.  Further, Mrs. Amos' lecture shows Bud that escape from this foster family situation is now necessary.

How does the setting bring about changes in the conflict between Ulrich and Georg in "The Interlopers" by Saki?

When the lightning during the storm strikes in the contested forest, the huge birch tree that is struck by lightning pins Ulrich von Gradwitz and Georg Znaeym beneath its fallen branches. Held captive in this manner, the two enemies begin to reconsider their attitudes about each other.

Having been locked in conflict for generations, the two enemies who are now pinioned down near each other utter both "thank offerings and sharp curses." At first, the two men threaten that their entourages will reach them before the other's. Georg promises his men will free him, and in so doing, the mass of the trunk of the big tree will roll over the top of Ulrich. "For form's sake I shall send my condolences to your family," he says to his enemy. Ulrich claims his men will arrive first, and when they are able to release him from the branches, he will remember Georg's threat.

Only as you will have met your death poaching on my lands, I don't think I can decently send any message of condolence to your family.

As time passes and no men appear, Ulrich manages to bring his partially free arm around to his outer pocket and draw out his wine flask. After some time he manages to pour some of the warming liquid down his throat. Looking over at his enemy, Ulrich feels some pity and offers his suffering enemy some of his wine. Georg declines, telling him there is so much blood in his eyes that he can barely see; besides, he adds, he will not drink with an enemy.
Ulrich is quiet for a time, but "in the pain and languor that Ulrich himself was feeling," his hatred seems to die. Now, he calls Georg his neighbor, and he declares that if his men arrive first, he will have them help Georg first.

Lying here tonight, thinking, I've come to think we've been rather fools; there are better things in life than getting the better of a boundary dispute. Neighbor, if you will help me to bury the old quarrel, I—I will ask you to be my friend.

Georg Znaeym is silent for a long time—so long, in fact, Ulrich thinks that Georg may have fainted. At last, George answers haltingly:

How the whole region would stare and gabble if we rode into the market square together. No one living can remember seeing a Znaeym and a von Gradwitz talking to one another in friendship. And what peace there would be among the forester folk if we ended our feud tonight...I never thought to have wanted to do other than hate you all my life, but I think I have changed my mind about things...Ulrich von Gradwitz, I will be your friend.

They lie silently, imagining how things will be after this reconciliation. When no men appear after all this time, Ulrich suggests they shout for help. The two men raise their voices in a hunting call. In a short while, they hear sounds, but the sounds belong to neither company of men. Tragically, the men's conflict will soon end, but the end will come from their mutual deaths, not their reconciliation. For, the "rescue" company that runs toward them are not men, but wolves.

In Bud, Not Buddy, what does rule number 118 mean?

Rule number 118 is a long rule.  There's actually a couple of parts to it.  I'll start with the very last part.  

They Won’t Take Everything Because If They Did They Wouldn’t Have Anything Left To Hold Over Your Head To Hurt You With Later.

What Bud has become intimately familiar with by age ten is that adults like to punish children by taking things away from children.  I'm not going to lie, I use that tactic with my own children.  The last part of rule 118 explains that an adult won't take everything away from a child, because then the adult can't use the threat of taking something away anymore.  It would be like threatening to shoot somebody with your thumb and index finger held up in the shape of a gun.  There's no real threat there. 

The first part of the rule really shows Bud's understanding of the "adult taking stuff away" tactic.  

You Have To Give The Adults Something That They Think They Can Use To Hurt You By Taking It Away. That Way They Might Not Take Something Away That You Really Do Want

Bud explains that he knows that he has to make adults think that they are taking something away from him that he cares about.  That way the adult feels like the punishment is working, but if the item is really taken away, it's no big deal.  That's why Bud begs Mrs. Amos to not send him back to the orphanage.  Mrs. Amos is now likely to do that, because she feels like it will hurt Bud.  But going back to the home is exactly what Bud wants in the first place.  

"Please don't call the Home, please don't send me back." Shucks, going back to the Home was just what I wanted to do, but I was being just like Brer Rabbit in one of the books Momma used to read to me at night when he yelled out, "Please, Brer Fox, don't throw me into the pricker patch, please, please!"

What is F. Scott Fitzgerald's view of the American Dream?

This question is essential to F. Scott Fitzgerald's The Great Gatsby, as one of the novel's overarching preoccupations is a critique of the American Dream. Consider, for instance, Gatsby and Daisy's storyline: Gatsby begins as a poor young man in love with a young woman (Daisy) who chooses to marry a man (Tom) with vast riches at his disposal. Gatsby believes that, if he just works hard enough, he can earn enough money to become an important person worthy of Daisy's love. In the end, after wasting his life acquiring a vast, but ultimately meaningless, store of wealth and possessions, Gatsby fails to win Daisy's love and dies alone.

It's possible to read this storyline as a critique of the American Dream. In general, the classic American Dream asserts that anyone can acquire all that his or her heart desires, as long as he or she works hard enough. Gatsby's story suggests that this ideal is not realistic. Though Gatsby works hard and claws his way out of poverty, he is not happy in the end, and he fails to gain that which he most desires (Daisy's affection). As such, Fitzgerald is clearly questioning a fundamental American value that informs much of the country's cultural trends, and his ultimate evaluation seems to end in the pessimistic rejection of the American Dream. 

What are some racist quotes that are found throughout the novel Monster by Walter Dean Myers?

In the scene where James, Steve, Johnny, and Peaches are sitting on some steps discussing who they could rob and not get caught, Johnny makes a racist comment. After Peaches suggests that they rob a bank, Johnny says that banks are too serious. He says,

"You need to find a getover where nobody don’t care—you know what I mean. You cop from somebody with a green don’t even report it" (Myers 56).

Johnny's comment would be considered racist because he believes that the authorities would not care about an immigrant. He views immigrants as easy targets and believes that there would be no repercussions for stealing from them.

Another scene that depicts racism takes place when Steve asks O'Brien how she thinks the trial is going. She mentions that nothing speaks to Steve's innocence and says,

"Half of those jurors, no matter what they said when we questioned them when we picked the jury, believed you were guilty the moment they laid eyes on you. You're young, you're Black, and you're on trial" (Myers 83).

O'Brien's comments display the prejudice of each jury member who judges Steve by the color of his skin. The jurors believe that Steve is guilty for the simple fact that he is a young black male on trial.

What is a parathyroidectomy?

Indications and Procedures

The parathyroid glands are four structures attached to the rear of the thyroid gland, which is found in the neck. Their main function is the secretion of parathyroid hormone (PTH), a protein that regulates the concentration of blood calcium. Abnormalities in proper calcium concentration can lead to bone demineralization, neuromuscular problems, or renal (kidney) damage.

Parathyroidectomy is occasionally warranted under conditions of hyperparathyroidism: the excess secretion of PTH. Hyperparathyroidism most commonly results in excess resorption of bone calcium, causing skeletal pain or loss of height. The demineralization may also lead to fractures of the spine or long bones, which may be accompanied by extreme muscle weakness and frequent urination. Since the patient may be asymptomatic, diagnosis is most commonly made on the determination of excess serum and urine calcium. X-rays may also indicate bone abnormalities resulting from the resorption of calcium. The condition itself may be caused by hyperplastic (overactive or enlarged) glands, or in less common circumstances (2 percent of cases), hyperparathyroidism may result from a parathyroid adenoma (a benign tumor on a gland).

Asymptomatic patients, or patients with only mildly elevated blood calcium, may not need treatment. Should symptoms become more severe, surgical procedures may be necessary, generally involving the removal of excess parathyroid tissue. If the hyperplasia involves all four parathyroid glands, three of the glands are usually removed, with resection of the fourth. If the cause of the PTH elevation is an adenoma, it is necessary to remove the tumor surgically.

Uses and Complications

Since the primary symptom of hyperparathyroidism is excess blood calcium, the removal of excess tissue may suddenly reduce calcium levels to normal. The rapid fall of calcium may cause a transient tetany (involuntary muscle contractions), but otherwise recovery from such surgery parallels any other surgical procedure. PTH and calcium levels must continue to be monitored postoperatively. If parathyroidectomy results in excessively low PTH levels, it may be necessary to provide lifelong diet supplements of calcium and vitamin D. Surgical complications include injury to the thyroid gland and/or to the vocal cords.

Bibliography

Braverman, Lewis E., ed. Diseases of the Thyroid. 2d ed. Totowa, N.J.: Humana Press, 2003.

Gardner, David G., and Dolores Shoback, eds. Greenspan’s Basic and Clinical Endocrinology. 9th ed. New York: McGraw-Hill, 2011.

Melmed, Schlomo, et al., eds. Williams Textbook of Endocrinology. 12th ed. Philadelphia: Saunders/Elsevier, 2011.

Montemayor-Quellenberg, Marjorie. "Parathyroidectomy—Conventional." Health Library, June 13, 2013.

Montemayor-Quellenberg, Marjorie. "Parathyroidectomy—Minimally Invasive." Health Library, June 13, 2013.

Neal, J. Matthew. Basic Endocrinology: An Interactive Approach. Malden, Mass.: Blackwell Science, 2000.

"Parathyroid Gland Removal." MedlinePlus, December 10, 2012.

Rosenthal, M. Sara. The Thyroid Sourcebook. 5th ed. New York: McGraw-Hill, 2009.

Ruggieri, Paul, and Scott Isaacs. A Simple Guide to Thyroid Disorders: From Diagnosis to Treatment. Omaha, Nebr.: Addicus Books, 2004.

What is the significance of Romeo asking Balthasar whether he has "letters from the Friar"?

Romeo is looking for any important news about Juliet while he serves his exile in Mantua. It would probably be correct to assume the Friar would act as a surrogate in the delivery of letters between Romeo and Juliet. The Friar also promised he would eventually attempt to reconcile the situation by announcing the marriage and begging the Prince for a pardon. Of course, it's way too soon for that to happen, but the ever-impatient Romeo is looking for any bit of news from Verona. In Act V, Scene 1, Romeo has just had a dream where he received good news. He says,

If I may trust the flattering truth of sleep,
My dreams presage some joyful news at hand.
My bosom’s lord sits lightly in his throne,
And all this day an unaccustomed spirit
Lifts me above the ground with cheerful thoughts.

He also foreshadows his death in this short speech as he says Juliet found him dead and tried to kiss him back to life:

I dreamt my lady came and found me dead
(Strange dream that gives a dead man leave to
think!)
And breathed such life with kisses in my lips
That I revived and was an emperor.

This event does happen in Scene 3 but, unfortunately, Romeo has already taken a deadly poison when Juliet kisses him.

Balthasar's news is not from the Friar. Instead, he tells Romeo that Juliet is dead and that he has seen her taken to the Capulets' tomb. Rather than send his letter about the plot to fake Juliet's death with Balthasar, Friar Laurence sends Friar John with the letter, but he is delayed by a plague threat. The all-important news does not reach Romeo, as Balthasar arrives first with the "ill news" of Juliet's supposed death.

What is a cesarean section?

Indications and Procedures

Cesarean section was initially intended to be performed when it is impossible or dangerous to deliver
a baby vaginally. For example, the operation is necessary if the fetus is unable to fit through the mother’s pelvis or if it shows signs of fetal distress. Fetal distress is detected by abnormal changes in the fetal heart rate, which may indicate that the fetus is not receiving adequate oxygen from the placenta. Other reasons for the procedure include a placenta that is lying over the cervix, which blocks the opening to the birth canal (placenta previa); scarring of the uterus from other surgical procedures (or previous cesarean section), which reduces the ability of the uterus to contract; unsuccessful induction of labor with oxytocin (Pitocin); breech
presentation, in which any part other than the head presents first; and postmaturity, in which gestation and fetal development indicate that labor should have begun yet is delayed.

These medically necessary indications for a cesarean section have been largely overshadowed by a tremendous increase in cesareans because of patient choice and/or by an overuse of the practice by physicians for a variety of reasons, including over-medicalization of birth, support of often misinformed patient choice, or convenience. In 2010, more than 32 percent of live births were delivered by cesarean. One major reason for this increase is that after a woman has a cesarean, vaginal delivery in subsequent births becomes less likely.

A cesarean section allows the delivery of a baby through a horizontal or vertical incision through the mother’s abdominal and uterine walls. Prior to surgery, an anesthesiologist gives the mother an epidural or spinal anesthetic so that she can remain conscious but free of pain during the procedure. Occasionally, under certain emergency conditions such as severe fetal distress, a general anesthetic is given. The use of epidural anesthesia

, however, is preferred in the majority of deliveries. The anesthesiologist administers epidural anesthesia by injecting a locally acting anesthetic into the space that surrounds the spinal cord. This space is known as the epidural space, and when it is filled with anesthetic agents, the nerves to the abdominal and pelvic cavities are blocked.

A catheter is inserted into the urinary bladder to empty it prior to making an incision into the abdomen. Typically, a horizontal incision is made just above the pubic bone, as this type of cut heals more readily and is more cosmetically acceptable. Once the pregnant uterus is exposed, a second transverse incision is made in the lower region of the uterus. The amniotic fluid is drained off by suction, and the baby is delivered. Once the infant’s head is exposed, its mouth and nose are cleared of any fluid that may hinder respiration. After completely removing the baby from the uterine cavity, the physician clamps the umbilical cord, cuts and ties it, and hands the baby to the parents or a member of the surgical team. Vertical incisions are more likely to be made in emergency situations, since they allow for quicker delivery; however, they result in poorer healing of the uterine muscle. After the placenta is delivered, the physician sutures the uterine and abdominal walls and provides postoperative care to the patient. A
drug known as ergonovine can be used after delivery of the infant to stimulate uterine contractions and to aid in preventing postpartum bleeding. A patient in pain or discomfort may be given analgesics such as meperidine or morphine as needed. The medical staff closely monitors the patient’s vital signs, such as her heart rate, blood pressure, and urine flow, as well as the status of the uterus, including abnormal bleeding.

Uses and Complications

The major adverse effects to women undergoing cesarean section have been complications caused by anesthesia, infection, hemorrhaging, and blood-clotting disorders, such as thromboembolic episodes in which a blood clot breaks loose from a vessel and causes a stroke, heart attack, or pulmonary
embolism. One of the most frequent complications from cesarean section is postoperative fever. Physicians can reduce the incidence of fever, however, by administering antibiotics prophylactically. Some women also experience damage to internal organs during the surgery, especially the bowel and bladder. Risks to the fetus include entrapment of a fetal head or limb in the uterine incision, which may result in injury to the head or spine and in limb fractures, and wounding of the fetus when the incision is made in the uterine wall.

Patients and their health care providers must weigh these potential adverse effects against the benefits of cesarean sections. Cesarean section is often performed when a normal vaginal delivery is possible, and women may not be fully aware of the risks involved. For most patients who are failing to progress in labor or whose baby is in the breech position or in distress, a cesarean is indicated. It is not always necessary, however, for a cesarean to be performed on a patient who has had a previous cesarean. Research supports the use of attempted vaginal births after cesarean (VBACs) for women who are appropriately selected, counseled, and managed.

Perspective and Prospects

Cesarean section was first performed in ancient Rome when the law required physicians to examine the fetus in the event of a mother’s death. Some medical historians have proposed that Julius Caesar was delivered in this way; the term for the procedure is derived from his name. Whether this story is truth or legend, however, is still a matter of debate. In the eighteenth century, many women attempted to perform the procedure as a method of abortion. These self-surgeries usually resulted in the mother’s death.

The rate for delivery by cesarean section has increased in the United States since the 1960s. In 1965, 4.5 percent of babies were born via cesarean. By 2010, more than 32 percent of all children born in the United States were delivered by cesarean. The cesarean delivery rate declined during the late 1980s through the mid-1990s but has been on the rise since 1996. Because fetal monitoring during labor is much more sophisticated than it was in the past, problems with the fetus are more easily detected, leading to an increased number of cesareans; still, far too many cesareans are being performed for reasons other than medical necessity. There is a great deal of controversy currently about the practice of cesarean delivery on maternal request (CDMR), and about whether women are adequately informed of the risks of the procedure.

Bibliography

Crombleholme, William R. “Obstetrics.” In Current Medical Diagnosis and Treatment 2006, edited by Lawrence M. Tierney, Jr., Stephen J. McPhee, and Maxine A. Papadakis. New York: McGraw-Hill Medical, 2006.

"Cesarean Birth." acog.org, June 18, 2013.

Cesarean Section: Understanding and Celebrating Your Baby’s Birth. Baltimore: Johns Hopkins University Press, 2003.

Cunningham, F. Gary, et al., eds. Williams Obstetrics. 23d ed. New York: McGraw-Hill, 2010.

Greene, R. A., C. Fitzpatrick, and M. J. Turner. “What Are the Maternal Implications of a Classical Caesarian Section?” Journal of Obstetrics and Gynaecology 18, no. 4 (July, 1998): 345–347.

Menacker, F., E. Declercq, and M. F. Macdorman. “Cesarean Delivery: Background, Trends, and Epidemiology.” Seminars in Perinatology 30, no. 5 (2006): 235–241.

Menaker, F. "Neonatal Mortality Risk for Repeat Cesarean Compared to Vaginal Birth afterCesarean (VBAC) Deliveries in the United States, 1998–2002 Birth Cohorts." Maternal & Child Health Journal. 14,2. (March 2000): 147–154.

Murphy, Magnus. Choosing Cesarean: A Natural Birth Plan. Amherst, New York: Prometheus Books, 2012.

Tower, Clare L., B. K. Strachan, and P. N. Baker. “Long-Term Implications of Caesarean Section.” Journal of Obstetrics and Gynaecology 20, no. 4 (July, 2000): 365.

What are some examples of figurative language in chapter 5 of Lord of the Flies?

William Golding was a master at weaving figurative language into his stories as a way of creatively describing important concepts that readers should take note of. Basically, figurative language departs from the literal meaning, using comparisons or connotative meanings to convey ideas in a unique manner. The most common types of figurative language are similes and metaphors, but there are many others, as well.  In chapter 5 of Lord of the Flies, Golding uses a nice mix to exemplify the tension Ralph and the other boys are experiencing.  Here are a few, in chronological order:

Oxymoron & epithet: As Ralph walks toward the platform to call a meeting, he faces the “concealing splendors of the sunlight.” Sunlight is generally revealing, making this a contradictory phrase.  It is also an unusual adjective to describe sunlight, making it an epithet.

Metaphor: Worrying over how to handle this meeting, Ralph “lost himself in a maze of thoughts that were rendered vague by his lack of words to express them.” Although his mind is not literally a maze, this analogy works well, since Ralph often loses his train of thought, due to the stress he is under.

Simile: Ralph gets distracted when he suddenly realizes how dirty he is. “[H]e noticed --in this new mood of comprehension--how the folds [of his shirt] were stiff like cardboard.”  This direct comparison helps readers almost feel the thick layer of grime that coats Ralph’s shirt.  Kind of makes you want to take a shower, right?

Simile: Ralph looks at the gathered boys with the reflection of the water coming up from below the platform, “and their faces were lit upside down--like, thought Ralph, when you hold an electric torch in your hands.”  Our modern comparison would be holding a flashlight under your face.  It’s an eerie image, which shows that Ralph is a bit intimidated to face the boys, knowing that they won’t like what he has to say.

Symbolism: "Ralph felt a kind of affectionate reverence for the conch...He flourished the conch" which causes the boys to fall silent, waiting for him to begin. Later, when Ralph asks Piggy how he was brave enough to argue with Jack, Piggy replies with simple logic: “I had the conch. I had a right to speak.” Ralph could not run the meetings without the shell, around which they have formed rules of civilized behavior for meetings, using it kind of like a gavel. For Ralph and Piggy especially, it symbolizes order and civilized society, which is why they cling to it.

Simile & symbolism:  “One had to sit, attracting all eyes to the conch, and drop words like heavy round stones among the little groups.” This comparison shows that Ralph knows his words must be carefully chosen to have an impact on the boys.  It also furthers the symbolism of stones as a destructive force in their loss of innocence.

Metaphor: When the littlun Percival recites his full name and address, it brings his buried memories of home crashing down on him. ¨As if this information was rooted far down in the springs of sorrow, the littlun wept....A spring had been tapped, far beyond the reach of authority.¨ Likening the child’s memories to water buried deep in the earth is a fitting comparison, since the boy’s next reaction is to cry uncontrollably.

Personification: Golding frequently gives the ocean human-like qualities, which is fitting, considering that it is an antagonist, keeping the boys from their homes, families and normal childhoods.  As it gets dark and the meeting turns to talk of beasts and ghosts in the forest, the boys ¨heard silently the sough and whisper from the reef.¨ Shortly later, a¨flurry of wind made the palms talk...Two gray trunks rubbed each other with an evil squeaking.¨ At night, the whole island seems to turn evil and come to life. Ralph realizes that this distracts the boys and admits to them that this is a bad time for a meeting.

Allusion: By the end of the chapter, when Jack has rejected Ralph’s authority and drawn the boys away with wild screams and laughter, Ralph feels hopeless.  He suggests that he should give up being chief.  Although Piggy and Simon stick by his side, he laments,  "'Fat lot of good we are.  Three blind mice.  I´ll give up.'" The reference to the popular children’s song reminds us that these boys are supposed to be just kids.  Instead, they feel small, helpless, and blind as they try to determine the answers to their increasingly hopeless situation.

In the book Fahrenheit 451, besides Montag, who or what else could be the hero(es) of the novel and why?

Arguably, Granger is another hero of Fahrenheit 451. Montag meets Granger in Part Three after he has fled the city. He is the leader of an underground group, composed mainly of former college professors, who have memorised books to prevent the total loss of knowledge. Granger tasks Montag with memorising the Book of Ecclesiastes and thus gives him a sense of purpose in the resistance movement.

For Granger, society is like the Phoenix: a "silly damn bird" which burned itself in a funeral pyre ever few hundred years. Society has made some great mistakes, notably in permitting the destruction of books, and Granger envisions a society in which this mistake is rectified:

Someday we'll stop making the goddamn funeral pyres and jumping into the middle of them.

His ability to stay hopeful in this climate of fear and censorship makes Granger the most optimistic and heroic of all the characters in Fahrenheit 451. He knows that this task is not easy and that society cannot be rebuilt overnight:

We pick up a few more people that remember, every generation…Someday the load we're carrying with us may help someone.

His determination, however, is rewarded with the closing of the book. The city is destroyed, leaving Granger and his men to oversee its rebuilding and to pass on the stories they have memorised.

How does Shakespeare present Macbeth's state of mind in Act V, Scene 3?

On the one hand, Macbeth is still very confident (overly so) in the prophecies of the witches. When his terrified servant comes to him with the news that an English force of over ten thousand men is massed outside Dunsinane, Macbeth curses the man for his fear, and reiterates that he is not himself afraid. He contemptuously dismisses the thanes who are fleeing his banners to those of the English, and he threatens to hang any man who shows fear. He is also aware, somehow, that his days are numbered, as he reveals in a poignant soliloquy:

I have lived long enough. My way of life
Is fall'n into the sear, the yellow leaf,
And that which should accompany old age,
As honor, love, obedience, troops of friends,
I must not look to have; but, in their stead,
Curses, not loud but deep, mouth-honor, breath,
Which the poor heart would fain deny and dare not.

Macbeth is resolved, as he says, to "fight. . . 'til from my bones the flesh be hack'd." He also launches into a tirade when the Doctor reveals that he is unable to treat Lady Macbeth for the mental collapse she has experienced. Macbeth is clearly very agitated. He claims to be without fear, and shows open scorn for those who are afraid before the battle. His behavior reveals a man who seems to recognize that his world is falling apart around him.

Describe the policeman on the beat in "After Twenty Years."

O. Henry does a remarkable job of introducing a major character without actually revealing who he is. The reader is deliberately misled into taking the cop for just one of many uniformed cops patrolling a beat in New York City. The cop (who we later realize is Jimmy Wells) also deceives Bob, who mistakes him for the cop assigned to this particular beat and thinks he is only stopping to talk to him because he looks as little suspicious standing in a darkened doorway. Bob doesn't give Jimmy a chance to identify himself but starts in doing all the talking.

“It's all right, officer,” he said, reassuringly. “I'm just waiting for a friend. It's an appointment made twenty years ago...."

Bob seems to be trying to show that he is completely innocent and at ease. He lights his cigar, both as a way of showing he feels at ease and of demonstrating that he is standing in a doorway because he can't very well light a cigar or smoke it out in the rain. When he lights the cigar he reveals that he is the man wanted by the Chicago police. So Jimmy refrains from introducing himself to his old pal and lets him do most of the talking.

O. Henry makes Jimmy seem like just another uniformed beat cop simply by describing an ordinary beat cop.

Trying doors as he went, twirling his club with many intricate and artful movements, turning now and then to cast his watchful eye adown the pacific thoroughfare, the officer, with his stalwart form and slight swagger, made a fine picture of a guardian of the peace. 

The ironic thing is that Jimmy really is patrolling his own beat--which just happens to be where he plans to meet Bob at 10 p.m. He is a bit early, so he does what he always does, which is mainly trying shop doors to make sure they are securely locked. Bob pulls out his ornate pocket watch.

“Three minutes to ten,” he announced. “It was exactly ten o'clock when we parted here at the restaurant door.”

This dialogue is to inform the reader that Jimmy is early, which explains why he was trying doors along the way and taking his time about getting to the rendezvous. It also informs the reader that the appointment is for ten o'clock. If Bob says he will wait a half-hour longer than that for his friend to arrive, then Jimmy knows he has until ten-thirty to get someone to make the arrest which he doesn't care to make himself.

Incidentally, the "handsome watch" with the lids set in small diamonds is one of the things by which Jimmy identifies Bob as the man wanted by the Chicago police. They sent a "wire," a telegram, in which they provided as much of a description of 'Silky' Bob as possible. Photos or even sketches could not be sent by wire. They also included two other things Jimmy saw when Bob lit his cigar.

The light showed a pale, square-jawed face with keen eyes, and a little white scar near his right eyebrow. His scarf pin was a large diamond, oddly set.

The setting for the large diamond would have been described in more detail in the telegram. Since Bob never gives his name, O. Henry would have to provide other means by which Jimmy could be sure the man in the doorway was really his old pal and really the man wanted in Chicago. Bob doesn't introduce himself by name because that would have pretty much forced the cop to do the same. And if the cop didn't introduce himself, that might have made Bob suspicious--in which case he might not have been standing there when the tall plainclothes detective showed up at around twenty minutes past ten.

What are Romeo's passions?

Romeo is a son of the Montague family, and in the beginning of the play we find him lamenting his unrequited love for a girl named Rosaline. Romeo is very idealistic and dreamy, and this makes him rather prone to being dramatic. The first we hear of Romeo is that he's been spending a lot of time by himself, thinking and wandering, caught up in the longing he feels for Rosaline. We do not know much about Rosaline other than Romeo's affections for her, but we can assume based on the intensity of Romeo's actions and feelings later in the play that he has built up their potential relationship into something that does not really exist. 

Romeo seems to be in love with love and the ideal of what it is like to be in love. One could argue that his greatest passion in life is love, seeing as he is willing to die for it. In addition to romantic love, Romeo feels he has a duty to honor his family. It is his contradicting passions to uphold his family name and his newfound love for Juliet that create the conflict of the play.

In Sophocles' play Antigone, why does Creon choose live entombment for the execution of Antigone?

Creon’s original decree prohibiting the burial of the bodies of any of those who had fought against Thebes set the punishment at death by stoning. However, when he is faced with the reality that it was his niece, Antigone, who defied the decree and buried her brother, Polynices, Creon seeks to find an alternative to such a direct and public execution by the state.

After his initial anger at Antigone subsides, Creon offers his niece a chance to save her life by renouncing what she has done. Antigone not only refuses to renounce her actions in burying her brother’s body, but adamantly proclaims that she would do the same again and that Creon’s law is an affront to divine law, and thus not to be followed. Creon, conversely, argues that the laws of the state are more important than the laws of the gods, and that he, as king, must follow the laws of the state as they are his own laws.

However, Creon is not unmindful that a public stoning of his niece, Oedipus’s daughter, would be problematic, especially given that she is also the betrothed of his son. Thus, Creon orders that Antigone be sealed in a cave with a measure of food. This action is not a direct execution by the state, but it is a sentence of death. And although everyone understands that it is a sentence of death, Creon states that it will not leave a stain on Thebes as it is Antigone’s choice whether she lives or dies, even though her food is limited and the eventuality is that she will die entombed in the cave. Thus, he ensures the enforcement of the law he had proclaimed while also insulating Thebes, and himself, from the stain of directly and publically executing Antigone.

Name two parts of a chemical reaction.

A chemical reaction is said to take place when chemical changes take place. Chemical changes refer to a change in the chemical composition of the reacting species. In other words, chemical reactions produce (at least one) chemically different compound than those which participated in the reaction. A chemical can be written as:

A -> B

in this reaction A is the species which reacts and is called the reactant, while B is the species which is formed as a result of this reaction and is called the product. Thus, each chemical reaction has 2 sides: a reactant side and a product side. The reactant side is typically shown on the left, while the product side is typically written on the right side of the equation. There can be single or multiple reactants and/or products. We can also show the phase of the various reactants and products in a chemical reaction, such as solid, liquid, gas, and aqueous.

Hope this helps. 

`int tan^5(x) sec^3(x) dx` Evaluate the integral

`inttan^5(x)sec^3(x)dx`

Rewrite the integrand as,

`=inttan^4(x)tanx(x)sec^3(x)dx`

Now use the identity: `tan^2(x)=sec^2(x)-1`

`=int(sec^2(x)-1)^2sec^3(x)tan(x)dx`

Now apply the integral substitution,

Let `u=sec(x)`

`du=sec(x)tan(x)dx`

`=int(u^2-1)^2u^2du`

`=int(u^4-2u^2+1)u^2u`

`=int(u^6-2u^4+u^2)du`

`=intu^6du-2intu^4du+intu^2du`

`=u^7/7-2(u^5/5)+u^3/3`

Substitute back `u=sec(x)`

`=1/7sec^7(x)-2/5sec^5(x)+1/3sec^3(x)`

Add a constant C to the solution,

`=1/7sec^7(x)-2/5sec^5(x)+1/3sec^3(x)+C`

What are cutting and self-mutilation?

Risk Factors and Related Conditions

Although self-injury can occur at any age, it usually begins in adolescence. It was originally thought that women were more likely than men to engage in self-injury, but later research indicates that the incidence is equal among women and men. Statistically, women are more likely to cut, while men are more likely to engage in other forms of self-harm, such as burning or hitting. According to the US National Library of Medicine, every one in one hundred people inflicts self-injury.

Persons who self-injure commonly have a history of abuse, including sexual, physical, or emotional abuse. Self-injury is often associated with other mental health problems, such as eating disorders, substance abuse, obsessive-compulsive disorders, schizophrenia, depression, bipolar disorder, borderline personality disorder, anxiety disorders, post-traumatic stress disorder, dissociative disorders, panic disorder, and phobias.

Persons who engage in self-injury often come from homes where expressing anger and other emotions is (or was) forbidden. They frequently have low self-esteem and exhibit perfectionism. Also, they are likely to be impulsive and to have poor problem-solving skills. However, self-injury does not indicate the severity of mental illness or the ability of the person to function and lead a relatively normal life.

Why Persons Self-Injure

There are many reasons for self-injury. One is using the behavior to provide a way to deal with overwhelming feelings, such as anger, extreme sadness, anxiety, depression, stress, sense of failure, self-hatred, or the helplessness of a trauma. Persons who self-injure have difficulty coping with severe emotional pain.

Self-injury can serve as a distraction from emotional pain, a way to express feelings that the person is unable to describe, or a way to feel a sense of control over something that is uncontrollable. Persons who self-injure often describe a feeling of calmness and relief of their intense feelings after they have injured themselves. Other self-injurers describe feeling emotionally numb and empty. For these persons, the self-injury allows them to feel something. Some are communicating their distress and expressing a need for help through self-injury. Others are punishing themselves for some imagined wrong.

Other persons use self-injury to prevent something worse from happening to them. A person may justify his or her behavior through the belief that if something bad is happening to him or her now, nothing else bad can happen. Others use self-injury to separate themselves from their feelings, which fade in the face of the physical pain. Though research has not conclusively proven it, a prevalent theory is that self-injury leads to the release of endorphins in the brain. Endorphins are chemicals found in the body that act as natural pain relievers and tranquilizers. Endorphin release produces a natural high that can temporarily mask emotional or physical pain.

It is thought that some persons self-injure to seek attention and to manipulate others. This is unlikely because most self-injurers are ashamed of the injuries that they cause, and they will hide their self-inflicted injuries. It is common for self-injurers to wear shirts with long sleeves and full-length pants in all types of weather to hide their injuries. The exceptions to this are persons who are developmentally or otherwise mentally disabled, such as those with autism. They are likely to engage in self-injury without also trying to hide the injury or the behavior. In this context, self-harm is called self-injurious behavior (SIB) and can have a number of causes. Someone with autism, for example, may exhibit SIB as a result of biochemical imbalances, sensory issues, to distract from other sources of physical pain, or in response to social or environmental triggers.

Symptoms and Treatment

No single therapy exists to treat persons who self-injure, and there is no consensus as to the most effective treatment. Typically, treatment must be developed based on the needs and other mental health conditions of the self-injurer. Possible helpful medications include antidepressants, antipsychotic drugs, and minor tranquilizers.

Often-used psychotherapeutic approaches include cognitive-behavioral therapy, dialectical-behavior therapy, and psychodynamic psychotherapy. The type of psychotherapy also depends on the other psychological illnesses of the client. In severe cases of self-injury, the person may be hospitalized to exert some control over the behavior.

Psychotherapy usually begins with an exploration of why the person self-injures. The therapist will teach alternative behaviors to use when the person feels like self-injuring. These alternatives include physical activities, journaling, and talking with friends or family members. Alternative actions also may be taught, such as snapping an elastic band that is wrapped around the self-injurer’s wrist. While this action does cause some pain, it does not cause injury. Biofeedback may be used to help the person identify the feelings that lead to the urge to self-injure.

It is important that the person understands that treatment, especially self-treatment, takes time, hard work, and motivation. If the self-injurer is an adolescent or child, family therapy may be necessary to identify what triggers the self-injuring behavior. Group therapy also may be used to provide the person with supportive relationships with others who are dealing with similar issues. Self-injurers who are developmentally disabled can be taught how to accomplish goals without using self-harming behaviors.

Bibliography

Hollander, Michael. Helping Teens Who Cut: Understanding and Ending Self-Injury. New York: Guilford, 2008.

Peterson, John, et. al. "Nonsuicidal Self Injury in Adolescents." Psychiatry 5.11 (2008): 20–26. Print.

Smith, Melinda, and Jeanne Segal. “Cutting and Self-Harm.” Jan. 2012. Web. 17 Apr. 2012. http://www.helpguide.org/mental/self_injury.htm.

Strong, Marilee. A Bright Red Scream: Self-Mutilation and the Language of Pain. New York: Virago, 2005.

Sutton, Jan. Healing the Hurt Within: Understanding Self-Injury and Self-Harm, and Heal the Emotional Wounds. 3rd ed. Oxford, England: How to Books, 2007.