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By T. Zarkos. Brandeis University. 2019.

This chapter provides a brief overview of the history of The dramatic improvements in womens health dur- womens health and the array of factors that have played ing the 20th century should be noted at the onset order red viagra without prescription. First 200mg red viagra mastercard, it presents a background changes are described in detail in a document compiled describing gender-based disparities in health care order 200 mg red viagra free shipping. From 1900 to 1990 cost of red viagra, been perceived by society, their representation in the womens life expectancy increased by more than 30 health care workforce, and the development of the med- yearsfrom 48. These dramatic toward gaining equality with men in education, employ- changes occurred even before the introduction of antibi- ment, societal role, and political empowerment. Such patterns of atypical and/or nonspe- to advances in medicine and technology, many women cific symptomatology greatly contribute to an with disabling conditions are now able to survive and underestimation of the extent of the problem by the participate in various activities at a rate higher than ever. In fact, it has been found that women are ing with disabilities; 70% of those with nonsevere dis- referred for coronary artery bypass graft at a more abilities and 25% of those with severe disabilities were advanced stage of the disease than men. This is in part a result umented higher rates of such procedures in men than in of the failure to integrate womens health in general women. However, investigators have been unable to medical practice due to (1) a view of womens health as determine whether these findings indicated that these pro- encompassing only the reproductive system, consisting cedures were overused by men or underused in women. Because until recently medical research ing not only reproductive health, but general health as has almost exclusively included men, the symptoms, pro- well. Such a finding has led us to have been, and still are, based on what has been observed better understand changes in the likelihood of develop- in men and not in women. Similar have been incorporated in didactic courses taught in med- observations about disease presentation and treatment ical schools. Health care professionals who have received may be made about other clinical conditions as well. How locations are described as atypical in cardiology text- women were viewed by the society, and how the med- books, a term used to mean not like men. From a socioeconomic per- For centuries, women have been perceived as spective, the traditional role of women in attending to weak, sickly creatures. Assumptions have been made their families has been greatly responsible for the about the smaller size of their brains and their inferior reduced devotion of their mental and physical energy to intelligence, as well as their frailty. This position has the personal development of their mind and body; this shaped the beliefs and attitudes of the medical commu- focus has contributed to gender inequalities in educa- nity, leading to an almost a priori assumption that most tion, secure work, and income observed throughout health complaints presented by women may be psy- history and persisting until today. It is through the chosomatic in nature or have a psychological under- consideration of the complex and strongly linked set of pinning. To date, the example, Chinese sages considered menstrual blood the term hysteria is used in the medical lexicon to refer to essence of Mother Earth. There are several elementsor eventsin female It is worth noting the issues of quality of life that reproductive health that have shaped societys percep- are associated with menstruation. From a menstrual cups that had to be inserted in the vagina to biological perspective, the fact that menstruation and collect blood, to reusable pads, women have had to use childbirth are unique to women and that they are often a wide array of menstrual products. Menopause has led a clear understanding of the pres- This technology was later used to develop adult diapers ence of a biological clock in womens reproductive and special pads for adults with urinary incontinence. However, there were sev- ing menopause implied a sense of finality and worth- eral concerns with the use of tampons. Conversely, the sustained sexual functions in men and Fears about their safety were intensified in 1980, when their (apparently) sustained reproductive function in toxic shock syndrome in young women (813 cases and 5 History of Womens Health in the United States 38 deaths) was linked to a type of superabsorbent Female midwives, many of whom were educated tampons. More recently, false rumors spread through the and trained like surgeons, were primarily in charge of Internet also raised concerns that tampons may contain childbirth. Male midwives started appearing in the 17th century in birthing rooms, mostly in affluent homes. Female Sexuality Obstetrics was slow to be incorporated in the medical profession; it was rejected by the American Historically an interest in and enjoyment of sexual College of Physicians as an ungentlemanly profession. As an By the early 19th century, however, obstetrics became example, masturbation and sexual arousal were thought part of the medical curriculum. The suppression of sexual feelings uterus, its pathology, and details in measuring the could be achieved by removing the clitoris; clitoridec- pelvis to predict difficulties in childbirth became impor- tomies were performed in America until the late 1930s tant components of obstetrics. Ergotamine was intro- and continue to be performed to date in many regions duced in the early 1800s to control postpartum of Africa. A significantly higher rate of infections Female sexuality remains severely underre- was observed among women attended by physicians, searched. In 1953, a report published by Michael Kinsey compared to those who were attended by midwives. These findings challenged the techniques by physicians performing autopsies on widely held belief that womens role in lovemaking was women who had died as a result of postpartum fever, to satisfy the husband. The biological framework in and who later attended to women during delivery, which sexuality is studied, and the medicalization of it, resulting in the transmission of infectious agents. In the medical context, erec- women were meant to suffer in childbirth, pursuant to tile function is considered paramount in the study of the Biblical imposition of labor pain as a punishment for male sexuality, with numerous studies on impotence. However, the higher cost, although some historians believe women number of studies on female sexual dysfunction and its advocated for it. The use of diagnostic and interventional considered to be focal events in reproductive life. The treatment of infertility, which led to a health and its research in very important ways. The movement favoring natural childbirth and The human egg was not discovered until early 1800s, breast-feeding, which recognizes pregnancy and child- although it is much larger in size than the sperm. The profession of midwifery experienced a of abortions, as antiabortion laws encourage illegal rebound during this time. Later, birthing centers were and clandestine practice of abortions, most often per- developed and were designed to simulate a homelike formed in nonoptimal conditions, leading to adverse environment in a hospital setting. The legalization of heightened interest in home deliveries and doulas, or abortions has contributed to dramatic reductions in laypersons providing physical, emotional, and informa- maternal mortality. Contraception Efforts to prevent pregnancy can be traced to as far Abortion back as ancient Greece. Until a few decades ago, Abortions were not considered illegal until the 19th however, women relied on breast-feeding that serves as century when Britain and the United States passed their a fairly effective means of contraception, through the first antiabortion laws. Freeing themselves from the con- ers, vaginal douches with toxic solutions, or ingestion stant function of reproduction was perceived as the key of strong chemicals. The psychological stress was also considered information on birth control as obscene, significant. One had been well rooted in these societies, abortions con- Package, Margaret Sanger and the Federal Legislation tinued to be performed openly, and juries refused to on Birth Control were successful in arguing that convict abortionists. Supreme Court held that limiting a the Comstock Law that prohibited the dissemination womans right to terminate her pregnancy violated of information on contraceptives. In 1976, the Hyde of the last state laws prohibiting the use of contracep- Amendment banned the use of Medicaid funds for abor- tives by married couples. To date, many faiths and institutions, such federally funded program to serve low-income women. Early versions of the birth control female population is likely to serve lesbian women as pill contained high levels of estrogen; their use was well as women of other sexual orientations (heterosex- associated with elevated risks of blood clots, heart ual and bisexual) and the physician must be prepared disease, and stroke. As a result, increasing use was to provide an adequate environment for optimal care. For instance, it has been contributed to the decline in teen births in the United reported that only a few hours are devoted to the study States during the last decade. The use of insurance, because they may not be eligible to receive contraceptives requires careful planning; unfortunately, coverage under their partners policies. It has been access to contraceptives may be limited in some circum- reported that in 2000, only 99 (or 20%) of Fortune 500 stances. The use of some of the most effective forms of companies, and 8 state governments offered benefits to family planning methods requires consultation with a domestic partners. Even when those benefits were physician and a willingness to undergo a gynecologic available, many employees were reluctant to disclose exam. This poses a significant impediment to young their sexual orientation in the workplace for fear of women who may find the physical exam and the disclo- compromising their employment position. Some have attempted to bility of ensuring family planning is ideally shared by explain cessation of menstrual blood flow through sexual partners, the burden engendered by unprotected the presence of insufficient pumping force through sexual activity is typically borne by women. The boundaries between normal physiology Lesbian Health and pathology with regard to menopause were not delin- Lesbian health has been part of public debate only eated until recently. That menopause was a natural in recent years, and the Healthy People 2010 (the federal process and that symptoms were not fatal was first governments guidelines for health care in the next cen- explained in a 1904 publication by Pancoast and others, tury) has specifically called for the elimination of dis- entitled Beautiful Womanhood: Guide to Mental and parities in the health of gay and lesbian communities. Nail salons have been identified as ality, osteoporosis (or loss of bone mass), as well as a possible venue for the transmission of various infec- changes in mood and cognition.

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Fortunately order red viagra master card, the list of malonate-free foods is much longer than malonate-containing foods purchase red viagra overnight delivery. Malonate-Free Foods Here is the malonate-free food list; stick to it; do not eat foods that are not listed purchase genuine red viagra line. The fastest way to recover the health of your sick organ buy generic red viagra 200mg online, is to stop poisoning it with malonic acid. You may notice less sleepiness after eating and a higher body temperature after a few weeks, which brings with it a rosier complexion. Eat Only These Remember, that a food may be malonate-free and still not be good for you for other reasons. But milk from the su- permarket (not including goat milk) is an exception; it has traces. Yet, cows milk (based on 2 samples) directly from the cow did not have malonic acid, either. Your 21 Day Program does not allow any dairy foods, though, not even with treatment. Yet, it has never been suspected that we are eating it daily in significant amounts! Does the tumor attract it the way a rapidly divid- ing tissue attracts metal or carcinogens? Or does the metal al- ready piled up in the tumor cells attract the malonate because of its chelating nature? Perhaps malonate accumulates in tumor cells simply because it cannot be detoxified there. I believe there is a normal route for your body to metabolize malonic acid, because when malonic acid-containing foods are eaten, I observe the immediate appearance of malonyl- Coenzyme A (malonyl CoA). Malonyl CoA has been well studied by scientists and found to be the beginning of fat formation. So this alternate fat-making mechanism that uses up malonic acid seems to me like a favor evolution is trying to do for us. Its normal ability to metabolize malonic acid is lost, so it must try the next route, detoxification. Detoxifying Malonate A popular detoxification method used by the body is to pin a methyl group onto the offending molecule. That uses up the or- gans supply of vitamin B12 and folic acid, but at least the malo- nic acid is gone. Of course we must still get rid of the methyl malonate, which is toxic, but thats another story. Another drawback of pinning a methyl group is that it uses up your methyl supply, which means methionine, choline and betaine. The organ under siege is becoming vitamin deficient and malnourished, and so is the rest of your body that is trying to support it by sending more supplies to it. If it has a tough, thick wall around it, these supplements cannot enter, so we must wait for the second week of the 21 Day Program. There are three more steps: malonic acid methyl malonate maleic acid D-malic acid maleic anhydride Fig. Tumor cells have lost the ability to do the detoxifying chemistry on their own, but if you supply the ingredients, they can still carry out the detoxification routine. Couldnt we simply stay on these supplements and not be deprived of the malonate-containing foods? Unfortunately, we would have to stay drenched in supplements, even taking them in the night. Other Malonic Acid Sources Once I identified malonic acid as a common denominator in all tumors I searched everywhere for it. Then most recently I learned that acrylic acid that we eat with heated oils gets changed into malonic acid by our metabolism. You have killed tapeworms, removed dental plastic, and are in the process of excluding it from your diet. Some Expected Benefits The most surprising benefit from the malonate-free diet and malonate-free mouth is stopping the production of effusates. Effusates are caused by seepage of body fluid into places where it does not belong. The lung is a favorite tissue for water ac- cumulation of this type, but the abdomen is another common site. The actual culprit is maleic anhydride a substance that is formed from malonic acid in your body. Maleic anhydride as a cause of tissue edema has been 67 known a very long time, but only when inhaled. It was never guessed that cancer sufferers with effusions actually had this chemical in them. And the pressure of this fluid against heart and lungs, against liver and intestine, or against lymph nodes in the groin can produce se- vere pain and breathlessness. Another surprising benefit of removing all malonate from your body is improved kidney function. Stopping use of malonic acid foods and getting every vestige of plastic out of your mouth can start your 67 The Merck Index, 10th Ed. But eating the tiniest bit of an ordinary malonate- containing dairy product (not allowed in this program) can ruin your progress in days! No amount of the detoxifiers, vitamins B12, C and folic acid could stop effusates from occurring or creatinine levels from rising when malonates were still arriving in the body from any source. We were forced to conclude that detoxifying malonic acid after consuming it did not prevent the damage done by it. The supplements needed to detoxify all the malonates in your body are included in the 21 Day Program. In a few days, with your new malonate-free diet and rein- forcing supplements, your tumor cells will no longer have to put up with Krebs cycle blockage. And a daily dose of thyroid will help your mitochondria to divide so fresh young mitochondria are born to handle the improved Krebs cycle activity. Damaging Dyes Your anti-tumor (tumor-shrinking) diet should also be free of carcinogenic dyes. Of course, we have believed that our diet is free of cancer-causing dyes, since laws were passed outlawing them decades ago. Cheese, butter, cream, which state that an- natto seed or riboflavin (natural dyes) have been added, also have traces of these dyes! Not only these, but a host of azo dyes, a finding as unbelievable as it is revealing. Azo dyes have a special chemical structure that involves two nitrogen atoms ( N=N). Is it the result of an error in identifying it to the manufacturer using other food dyes? A manufacturer using unsafe dye for some legitimate purpose and safe food dye nearby cannot keep them totally apart? One cannot expect the work force in a fac- tory to understand the issuesthe terrible seriousness of keep- ing them apartthe system must be made fool proof. With over 20,000,000 people (mostly women) dying their hair in the United States alone, should it not be made safe? Could there be simple negligence, in spite of safeguards such as required testing of each batch of synthetic dye to be used? This would proba- bly uncover the mysterious transmissible factor that pollutes nearly all (over 90%) of the processed food in the U. It was a cruel hoax to perpetrate on young war heroes and their families, but incredibly, researchers 71 are still experimenting with its use! It is not easily detoxified by your body and therefore, cannot be quickly eliminated. The left hand portion of the molecule is respon- sible for the carcinogenic action. It produces mainly tumors of the liver, gallbladder, lung, and urinary blad- der (particularly papillomas here). Most azo dyes were taken out of the food market because of their carcinogenicity but now are present everywhere in trace amounts, detected by the Syncrometer. At one time it was allowed as a butter colorant, hence its popular name Butter Yellow. It has three azo portions in the molecule, making it the most difficult of dyes to detoxify, too.

She developed pain in her left upper arm generic 200 mg red viagra fast delivery, and a medical specialist made the diagnosis of left-sided biceps tendinitis buy red viagra online. The packing worker for 10 years had high- repetitive work with many high and strenuous purchase generic red viagra on-line, rather heavy lifts buy cheap red viagra, which were awkward and stressful for the left upper arm. When cutting front ends, he had to take down and hang up the front ends on Christmas tree hooks. Both deboning, cutting and taking down and hanging up on Christmas tree hooks involved frequent movements of the right shoulder joint, the upper arm often being either taken forward or outward, as well as repeated lifts of the right arm to 60 degrees or more. He developed complaints consistent with his right shoulder and a medical specialist made the diagnosis of right-sided impingement syndrome. The slaughterhouse worker developed a right-sided impingement syndrome after having for several months performed repetitive movements of the shoulder joint with simultaneous strenuous work and repeated lifts of his right upper arm to at least 60 degrees. There furthermore were awkward working postures, including work with the arm in exterior positions, and short cycle times with little restitution of the right arm. The work was very stressful for the right shoulder, and there is furthermore good time correlation between the exposure and the onset of the symptoms. Example 6: Recognition of rotator cuff syndrome (industrial operator for 3 years) A 38-year-old woman had worked for 3 years as an industrial operator. For two thirds of the working day her work consisted in removing ready-made plates from a plant. She first grabbed hold of the remotest edge with her right hand while holding the lower edge with her left hand. Then the plate was lifted onto one of the three pallets and stapled from hip height to shoulder height. The last third of the working day she serviced other employees by picking up empty pallets and driving away the full pallets. The pallets ran on rails in the floor, and this work did not involve repeated movements of the shoulder joint, strenuousness or repeated lifts of the arm. She developed complaints in her right shoulder, and a medical specialist made the diagnosis of right-sided rotator cuff syndrome. The industrial operators first work function was relevantly shoulder-straining as the work involved repetitive movements of the shoulder joint with strenuousness, with the arm extended in exterior positions and with repeated lifts of the right upper arm to more than 60 degrees. The other work function (servicing of colleagues) cannot be characterised as shoulder-straining work as they did not involve repeated movements of the shoulder joint with strenuous exposure of the shoulder or stressful lifts of the upper arm. The first function, however, did take more than half of the working day and was relevantly stressful for the development of rotator cuff syndrome of the right shoulder. The units weighed from a few kilos up to 30 kilos and had to be lifted manually into the machine and fastened between four claws. He lifted the units up to the correct position, and then the unit was fastened by means of a T-key. Once the unit was fastened, he made it extra tight with the T-key by pulling with his right hand and pushing with his left hand. Each unit required up to several fastening movements, which were performed with strenuousness. The key was positioned in such a way that it was not necessary to reach upward, but there was a long reaching distance forward. In the course of a working day he fastened up to 100 units with several fastening movements for each unit. The injured person developed pain in his right shoulder and a medical specialist diagnosed him with right-sided impingement syndrome. The injured person performed work that involved repeated movements of the shoulder joint in combination with great exertion, his right arm being held in exterior positions. There is furthermore good time correlation between the load and the onset of the symptoms. Example 8: Recognition of impingement syndrome (slaughterhouse worker for 4 years) A 44-year-old man worked as a slaughterhouse worker for well over 4 years. For approximately 60 per cent of the working day he was cutting front ends weighing 10-12 kilos. The front ends were hanging on hooks, from where they had to be lifted manually at varying lifting height, from knee level to head height, onto the cutting table. During the cutting work he performed movements with his right arm that led to inward and outward turning of the shoulder joint. This happened by lifting the shoulder blade with a knife, gripping hold of it and pulling it out with a strenuous pulling movement. The last approximately 40 per cent of he working day the injured person was a service man. This happened by pulling Christmas tree hooks out of the lorry with his right hand. The work as a service man did not involve any particular loads on the shoulder joint, only moderate movements of the shoulder joint and moderate strenuousness. After 4 years work he developed pain and restricted motion of his right shoulder, and a medical specialist made the diagnosis of right-sided impingement syndrome. The slaughterhouse worker performed relevant, shoulder-joint straining work for 4 years and developed a right-sided impingement syndrome. The first work function involved repetitive movements of the shoulder joint with strenuous work and repeated lifts of the upper arm of up to more than 60 degrees, the arm at the same time being held in exterior positions, and the movements were performed with a short cycle time. The other work function consisted in pushing and pulling and did not involve a relevant load on the right shoulder. The first work function was, however, very shoulder-straining for more than half of the working day and for several years, and there is good time correlation between the load and the onset of the disease. He spent two thirds of the working day doing shovelling work in the period from April to, and including, November (8 months) and well over one third of the working day the rest of the year (4 months). The remaining part of the working day he maintained the banks of rivers and streams, i. In the examination made by a medical specialist it was not possible to establish a rotator cuff syndrome, but the medical specialist made the diagnosis of degeneration of the right biceps tendons (biceps tendinitis). When shovelling bottom crops from streams, the gardener performed work with repetitive movements of his right shoulder joint and upper arm with strenuousness and repeated lifts up to or above 60 degrees. He furthermore had relevantly stressful work in connection with periodical cutting of edge crops with a scythe. The work function of cutting grass with a motorised grass cutting machine cannot be characterised as a strain on the right upper arm. The overall, relevantly stressful work functions did, however, constitute more than half of the working day for the major part of the year and for a considerable number of years. Furthermore there is good time correlation between the work and the onset of the symptoms. Example 10: Recognition of bilateral rotator cuff syndrome (packer for 8 years) A 36-year-old woman worked for 8 years as a packer in a business manufacturing disposable plastic service. Via a belt, the mugs came from the machine and landed on the packing table, where they were packed in plastic bags. The plastic bag was packed around the mugs, and as the bag was narrow, the work required precision and slight to moderate strenuousness, with movements from head height to table height. Once the plastic bag was on, the package was pressed against a tape machine at table height with little exertion. The packer was able to complete a couple of thousand packages a day, and each package required several movements in the shoulder joints. After eight 8 years she developed symptoms from both shoulders, and a medical specialist made the diagnosis of bilateral rotator cuff syndrome. The woman developed bilateral rotator cuff syndrome after packaging the whole working day for 8 years. The work involved frequently repeated movements in both shoulder joints, with repeated lifts of the upper arms to 60 degrees or more, and in addition slight strenuousness, the arms occasionally being held in exterior positions. The work was furthermore characterised by a short cycle time with little restitution of the arms. There is furthermore good time correlation between work and the onset of the symptoms. Example 11: Recognition of degeneration in the long biceps tendon (carpenter for 6 months) A 28-year-old man worked for 6 months as a carpenter for a large contractor. For the major part of the day the work consisted in fitting ceilings of gypsum board or other materials, typically in big, newly- built office buildings. When fitting the ceilings he grabbed a gypsum board, with his left hand or both hands, from a tall trolley next to the ladder on which he was standing.

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Many people are on their way This may explain some of the morbidity and mortality to recovery by 6 months order cheap red viagra online, although others continue to associated with bereavement buy discount red viagra 200 mg on-line. There have been numer- have symptoms through the first year and even into the ous studies on mortality following the death of someone second year buy cheapest red viagra. Men under the age of 75 (the young-old) have disturbed on holidays order red viagra 200mg without a prescription, anniversaries, the birthday of the an increased mortality in the first 6 months after a loss. For postbereavement entrenched, whereas the weight loss usually ends after depression, open-label studies of antidepressants have the second month. From the third month on there is demonstrated remission rates at or above 50% in the first more likely to be weight gain. By one year, the most 23 months of treatment; low relapse rates occurred prominent symptoms are sleep disturbance and loneli- following medication discontinuation. The third stage, recovery, is acceptance of the definitive study involving placebo controls. A study of normal in part by weight loss, and reduction in psychological bereavement. Depression through the first year positive reinforcement of healthy eating, stimulus con- after the death of a spouse. American Journal of Psychiatry, 148, trol by limiting exposure to unhealthy foods, and devel- 13461352. A variation to this approach is following a very low calo- rie diet with liquid nutritional supplements, but partial relapse during refeeding frequently occurs. The specific focus behaviors such as vomiting or excessive use of diuretics is on examination of thoughts and feelings related to and laxatives. Currently, it falls under the category of body image and in promotion of self-acceptance. Interpersonal control over his or her eating, rapidly consuming large therapy seeks to identify the problems between indi- quantities of food over an extremely short period of viduals that contribute to maintenance of this maladap- time. A substantial reduction in binge eating may continue to eat until they are uncomfortably full. They initially occur but by 1 year, some symptoms often may eat alone out of embarrassment and disgust, return. The frequency of binge eating is at least twice group behavioral weight loss treatment and subsequent a week, for 6 months or more. All socioeconomic classes of group behavioral weight control program and close and ethnic groups are affected. A 6-week focus on improved physical and psychological placebo-controlled trial of fluoxetine (2080 mg/day) health could lead to behavioral changes and improved in 60 outpatients reported a significant reduction in self-acceptance. The goals of treatment include cessa- frequency of binge eating, body mass index, and sever- tion of binge eating, improved physical health mediated ity of illness. Bipolar disorder is characterized by Brown Obsessive Compulsive Scale (modified for binge the presence of mania, or a manic episode, defined as eating). One small study suggests that the opiate antag- a period of abnormal, persistently elevated, expansive, onist naltrexone may also reduce binge eating and or irritable mood. A therapeutic plan tailored to the individual in the context of mania include grandiosity or patients needs is advisable. More information is available inappropriately elevated self-esteem, excessive or for the public at www. Although individuals with a manic episode frequently lack insight into illness (understanding and awareness of Suggested Reading their illness), and will deny acknowledgment of their Arnold, L. A placebo controlled, condition if confronted by it, manic symptoms are randomized trial of fluoxetine in the treatment of binge-eating associated with severe impairments in functioning. In Synopsis of mania become psychotic or paranoid, and may require psychiatry (8th ed. Philadelphia: Lippincott, hospitalization for protection of themselves and others. Venlafaxine treatment of binge- ence depressive episodes characterized by depressed eating disorder associated with obesity. Topiramate in the treatment sleeping, significant weight change, decreased energy, of binge eating disorder associated with obesity. American feelings of worthlessness or inappropriate guilt, dimin- Journal of Psychiatry, 160(2), 255262. A guide for Gender appears to be related to the order and the primary care physician. Women are more likely to have the first mood episode in the form of depression, and may be more likely to experience depressive episodes compared to men. Additionally, women with bipolar disorder are particularly vulnerable to episode recurrence after Biofeedback see Psychotherapy childbirth, in the postpartum period. Postpartum psy- chosis may occur, with some women experiencing their first episode shortly after childbirth. This rate of occurrence is consistent across children and adolescents as well as may occur for the groups of diverse ethnicity and culture. Bipolar disorder is bipolar disorder is a long-term illness with an episodic generally a chronic illness, with multiple occurrences of and variable course. More than 90% of individuals who have 104 Bipolar Disorder a single manic episode go on to have future episodes. The specific biological average of 4 episodes will occur over a 10-year period, factors that cause bipolar illness have not been clearly and individuals with untreated bipolar disorder may have identified; however, most theories regarding possible more than 10 episodes of abnormal mood states (highs biological origins of bipolar disorder involve dysregula- or lows) during their lifetime. The duration of episodes tion/dysfunction in neurotransmitter systems including and duration of between-episode periods frequently the serotonergic, noradrenergic, dopaminergic, cholin- stabilize after the fourth or fifth episode. In many cases, an individual will experience several In addition to the often-serious effects of acute bouts of depression before the occurrence of a first manic symptoms of bipolar illness, individuals with bipolar episode. For this reason, a diagnosis of bipolar disorder disorder frequently have substantial psychosocial diffi- may be overlooked, particularly in the early phases of ill- culties as a result of the disorder. It is not uncommon to see individuals who eventu- are frequently affected including marriage relationships, ally are proven to have bipolar disorder being mistakenly child-rearing, and occupational status. Divorce rates are diagnosed with depressive disorder, schizophrenia, or generally higher among individuals with bipolar illness, even some types of personality disorders. The occupational especially in cases where patients may not be knowl- status of individuals with bipolar illness is twice as edgeable about bipolar disorder and its symptoms. This likely to be impaired as compared to individuals with- may lead to a nonreporting/underreporting of manic out bipolar illness. It is critical that the diagnosing clinician be Suicide is also a significant risk in bipolar disorder, aware of such issues as individual history of mania or with up to 19% of individuals with bipolar illness even- hypomania, family history of mood disorder or family tually committing suicide. The risk of suicide appears to history of manic episodes, substance abuse history, and be greatest when individuals have depressive symptoms any history of previous treatment. Consultation with and during the first few years after the onset of bipolar family members or significant others is often extremely illness. Bipolar disorder may be differentiated from more likely to make suicide attempts compared to indi- major depressive disorder by the occurrence of viduals with bipolar disorder who do not abuse alcohol. Individuals with Additionally, stressful life events may precede suicide or schizophrenia primarily experience psychotic symp- suicide attempts among individuals with bipolar illness. Close observation of of other psychiatric syndromes in addition to the prin- symptoms over a longer time period will assist in dif- cipal psychiatric diagnosis. The rate of comor- disorder experience four or more episodes within a bidity between bipolar disorder and substance-related 12-month period. This variant of bipolar disorder is clas- disorder is particularly high, and among all Axis I psy- sified as rapid-cycling type and is more common in chiatric conditions, bipolar disorder appears to have the women. Other factors that favor the occurrence of the highest prevalence of comorbid substance abuse. Bipolar disorder has both genetic and biological Although substance abuse is generally seen more often underpinnings. Choice of mood-stabilizing medication should generally be based upon an individuals history and The goal of treatment in bipolar disorder is com- clinical status. Both lithium and valproate have plete remission of symptoms with a return to baseline proven efficacy as first-line agents. Unfortunately, at this a good history of medication response to a particular time, there is no cure for bipolar disorder, but it is compound are very likely to have a repeat good entirely possible for individuals with bipolar illness to response with treatment with this same compound.

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