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L. Josh. Antioch University Santa Barbara.

Discuss the subject as you would any other topic of concern with a friend cheap 180mg cardizem mastercard. Whenever you think that someone you know is in danger of suicide buy cardizem 120 mg without a prescription, get help discount 180mg cardizem free shipping. Suggest that he or she call a suicide prevention center, crisis intervention center or whatever similar organization serves your area. Or suggest that they talk with a sympathetic teacher, counselor, clergyman, doctor or other adult you respect. If your friend refuses, take it upon yourself to talk with one of these people for advice on handling the situation. In some cases you may find yourself in the position of having to get direct help for someone who is suicidal and refuses to go for counseling. With time, most suicidal people can be restored to full and happy living. But when they are feeling hopeless, their judgment is impaired. In that case, it is up to you to use your judgment to see that they get the help they need. What at the time may appear to be an act of disloyalty or the breaking of a confidence could turn out to be the favor of a lifetime. Your courage and willingness to act could save a life. If a friend is talking about suicide or displaying other warning signs, you can start by listening to and reassuring him. This means sharing your concerns with an adult you trust as soon as possible. If necessary, you can also call a local emergency number or the toll-free number of a suicide crisis line. The important thing is that you notify a responsible adult. Perhaps you yourself have sometimes felt like ending your life. If you like, you can call one of the agencies mentioned above and talk about the way you feel without telling them who you are. Sudden changes in behavior (withdrawal, apathy, moodiness) Depression (crying, sleeplessness, loss of appetite, hopelessness) Final arrangements (such as giving away personal possessions)Discuss it openly and franklyShow interest and supportPrepared by the Suicide Prevention and Crisis Center of San Mateo County, California, in cooperation with the American Association of Suicidology. Recent losses: This may include the death of a relative, a family divorce, or a breakup with a girlfriend. Social isolation: The individual does not have social alternatives or skills to find alternatives to suicide. Drug abuse or alcohol abuse: Drugs decrease impulse control making impulsive suicide more likely. Additionally, some individuals try to self-medicate their depression with drugs or alcohol. Exposure to violence in the home or the social environment: The individual sees violent behavior as a viable solution to life problems. Some research suggests that there are two general types of suicidal youth. The first group is chronically or severely depressed or has Anorexia Nervosa. Their suicidal behavior is often planned and thought out. The second type is the individual who shows impulsive suicidal behavior. He or she often has behavior consistent with conduct disorder and may or may not be severely depressed. This second type of individual often also engages in impulsive aggression directed toward others. Adolescents often will try to support a suicidal friend by themselves. They may feel bound to secrecy, or feel that adults are not to be trusted. If the student does commit suicide, the friends will feel a tremendous burden of guilt and failure. It is important to make students understand that one must report suicidal statements to a responsible adult. Ideally, a teenage friend should listen to the suicidal youth in an empathic way, but then insist on getting the youth immediate adult help. What causes a person to consider taking their own life? Risk factors for teens thinking about suicide or self-harm and how to help. Teen suicide is becoming more common every year in the United States. In fact, only car accidents and homicides (murders) kill more people between the ages of 15 and 24, making suicide the third leading cause of death in teens and overall in youths ages 10 to 19 years old. Read on to learn more about this serious issue - including what causes a person to consider taking their own life, what puts a teen at risk for suicide or self-harm, and warning signs that someone might be considering suicide and how they can get help to find other solutions. They may begin to consider spiritual or philosophical questions such as what happens after people die. To some, death, and even suicide, may seem poetic (consider Romeo and Juliet, for example). To others, death may seem frightening or be a source of worry. For many, death is mysterious and beyond our human experience and understanding. Thinking about suicide goes beyond normal ideas teens may have about death and life. Beyond thoughts of suicide, actually making a plan or carrying out a suicide attempt is even more serious. What makes some teens begin to think about suicide - and even worse, to plan or do something with the intention of ending their own lives? Suicide attempts are usually made when a person is seriously depressed or upset. A teen who is feeling suicidal may see no other way out of problems, no other escape from emotional pain, or no other way to communicate their desperate unhappiness.

Vaknin: It depends whether the narcissistic bully represents the corporate culture of the workplace - or is an isolated case attributable to a quirky nature or a personality disorder safe 180mg cardizem. Bullies rarely dare to express their tendencies in isolation and in defiance of the prevailing ethos discount cardizem 120mg fast delivery. Or buy 180 mg cardizem visa, if they do run against the grain of their place of employment, they lose their jobs. Typically, narcissists join already narcissistic firms and mesh well with a toxic workplace, a poisonous atmosphere, and an abusive management. If one is not willing to succumb to the mores and (lack of) ethics of the workplace, there is little one can do. Surprisingly few countries (Sweden, the United Kingdom, to some extent) outlaw workplace abuse specifically. Whistleblowers and "troublemakers" are frowned upon and are not protected by any institutions. The victim would do well to simply resign and move on, sad as this may be. As awareness of the phenomenon increases and laws take effect, hopefully this will change and bullied and abused workers will find effective ways to cope with mistreatment. TimeToFly: What typically happens to a narcissist when they lose their position of authority or their job. But since then he has been on a rampage to destroy me. It was right after the loss of his previous job that he left me and our children 4 years ago. He had been the manager of engineering and was first demoted, and then finally left the company. He has just remarried, but his new life somehow has not distracted him from his obsession with destroying mine. The entire edifice of the Narcissistic Personality Disorder is an elaborate and multi-layered reaction to past narcissistic injuries. A gap opens between the way the narcissistic imagines himself to be (grandiosity) and reality (unemployed, humiliated, discarded, unneeded). The narcissist strives to bridge the grandiosity gap but sometimes it is simply to abysmal to deny or ignore. So, some narcissists go through decompensation - their defense mechanisms crumble. The narcissists redouble their efforts to obtain narcissistic supply by any means - sex, exercise, attention-seeking behaviors. Yet others withdraw altogether to "lick their wounds" (schizoid posture). What is common to all these narcissists is the ominous feeling that they are losing control (and maybe even losing it). In a desparate effort to re-exert control, the narcissist becomes abusive. Others seek "easy targets" - lonely women to "conquer" or simple tasks to accomplish, or no-brainers, or to compete against weak opponents with a guaranteed result. The accepted wisdom is that NPD is tan adaptative reaction to early childhood or early adolescence trauma and abuse. The more familiar ones - verbal, emotional, psychological, physical, sexual - of course yield psychopathologies. But are far more subtle and more insidious forms of mistreatment. Doting, smothering, ignoring personal boundaries, treating someone as an extension or a wish-fulfillment machine, spoiling, emotional blackmail, an ambience of paranoia or intimidation ("gaslighting") - have as long lasting effects as the "classic" varieties of abuse. Mental health disorders - and especially personality disorders - are not divorced from the twin contexts of culture and society. Disparate scholars and thinkers - Christopher Lasch on the one hand and Theodore Millon on the other hand - have concluded as much. Narcissistic behaviors - now labeled "misconduct" - have long been nornmative. The basically narcissistic traits of individualism competitiveness, unbridled ambition - are the founding stones of certain versions of capitalism. Thus, certain forms of abuse and bullying actually constitute an integral part of the folklore of corporateAmerica. As long as this is the case, workplace abuse would be hard to overcome. Vaknin, for being our guest this evening and for sharing this information with us. And to those in the audience, thank you for coming and participating. We have a very large and active community here at HealthyPlace. You will always find people interacting with various sites. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment. As a Family Physician, I have a different perspective on mental health than those that deal only with mental health issues. I have treated thousands of patients for the disorders involving "Biological Unhappiness. In my regular practice, I see patients with BPD (borderline personality disorder) from all over the world. My first book was " Life at the Border - Understanding and Recovering from the Borderline Personality Disorder. I hope you enjoy your visit and get a positive experience from my site. These definitions - which are criteria based - are the results of consensus building from hundreds of psychiatrists of many different perspectives and belief systems from all over the world, not just the U. Definitions are regularly being revised as research and other information becomes available. The DSM IV is the latest edition, being published in 1994. Like other diagnoses, diabetes is established by specific criteria such as fasting sugar greater than 126 on two separate occasions. Physicians do have the right to explain and treat disorders according to their knowledge, training expertise - but not to establish their own criteria. If a physician disagrees with the established criteria, he/she needs to explain the reasoning in the chart. There are many common misconceptions about the BPD diagnosis:that the diagnosis is based on why it may have happened - NOT TRUE!

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Nervous System: Frequent: agitation purchase 120 mg cardizem otc, extrapyramidal syndrome generic cardizem 180 mg with amex, tremor cardizem 60 mg mastercard, dystonia, hypertonia, dyskinesia, hostility, twitching, paresthesia, confusion, vertigo, hypokinesia, hyperkinesia, abnormal gait, oculogyric crisis, hypesthesia, ataxia, amnesia, cogwheel rigidity, delirium, hypotonia, akinesia, dysarthria, withdrawal syndrome, buccoglossal syndrome, choreoathetosis, diplopia, incoordination, neuropathy; Infrequent: paralysis; Rare: myoclonus, nystagmus, torticollis, circumoral paresthesia, opisthotonos, reflexes increased, trismus. Respiratory System: Frequent: dyspnea; Infrequent: pneumonia, epistaxis; Rare: hemoptysis, laryngismus. Skin and Appendages: Infrequent: maculopapular rash, urticaria, alopecia, eczema, exfoliative dermatitis, contact dermatitis, vesiculobullous rash. Special Senses: Frequent: fungal dermatitis; Infrequent: conjunctivitis, dry eyes, tinnitus, blepharitis, cataract, photophobia; Rare: eye hemorrhage, visual field defect, keratitis, keratoconjunctivitis. Urogenital System: Infrequent: impotence, abnormal ejaculation, amenorrhea, hematuria, menorrhagia, female lactation, polyuria, urinary retention, metrorrhagia, male sexual dysfunction, anorgasmia, glycosuria; Rare: gynecomastia, vaginal hemorrhage, nocturia, oliguria, female sexual dysfunction, uterine hemorrhage. Adverse Findings Observed in Trials of Intramuscular ZiprasidoneAdverse Events Occurring at an Incidence of 1% or More Among Ziprasidone-Treated Patients in Short-Term Trials of Intramuscular Ziprasidone Table 5 enumerates the incidence, rounded to the nearest percent, of treatment-emergent adverse events that occurred during acute therapy with intramuscular ziprasidone in 1% or more of patients. In these studies, the most commonly observed adverse events associated with the use of intramuscular ziprasidone (incidence of 5% or greater) and observed at a rate on intramuscular ziprasidone (in the higher dose groups) at least twice that of the lowest intramuscular ziprasidone group were headache (13%), nausea (12%), and somnolence (20%). Treatment-Emergent Adverse Event Incidence In Short-Term Fixed-Dose Intramuscular TrialsPercentage of Patients Reporting EventExtrapyramidal SyndromeOther Events Observed During Post-marketing Use Adverse event reports not listed above that have been received since market introduction include rare occurrences of the following (no causal relationship with ziprasidone has been established): Cardiac Disorders: Tachycardia, Torsade de Pointes (in the presence of multiple confounding factors - see WARNINGS ); Reproductive System and Breast Disorders: galactorrhea; Nervous System Disorders: Neuroleptic malignant syndrome; Psychiatric Disorders: Insomnia; Skin and subcutaneous Tissue Disorders: Allergic reaction, rash; Vascular Disorders: Postural hypotension. Controlled Substance Class - Ziprasidone is not a controlled substance. Physical and Psychological Dependence - Ziprasidone has not been systematically studied, in animals or humans, for its potential for abuse, tolerance, or physical dependence. While the clinical trials did not reveal any tendency for drug-seeking behavior, these observations were not systematic and it is not possible to predict on the basis of this limited experience the extent to which ziprasidone will be misused, diverted, and/or abused once marketed. Consequently, patients should be evaluated carefully for a history of drug abuse, and such patients should be observed closely for signs of ziprasidone misuse or abuse (e. Human Experience - In premarketing trials involving more than 5400 patients and/or normal subjects, accidental or intentional overdosage of oral ziprasidone was documented in 10 patients. In the patient taking the largest confirmed amount, 3240 mg, the only symptoms reported were minimal sedation, slurring of speech, and transitory hypertension (200/95). In post-marketing use, adverse events reported in association with ziprasidone overdose generally included extrapyramidal symptoms, somnolence, tremor, and anxiety. The largest confirmed postmarketing single ingestion was 12,800 mg; extrapyramidal symptoms and a QTc interval of 446 msec were reported with no cardiac sequelae. Management of Overdosage - In case of acute overdosage, establish and maintain an airway and ensure adequate oxygenation and ventilation. Intravenous access should be established and gastric lavage (after intubation, if patient is unconscious) and administration of activated charcoal together with a laxative should be considered. The possibility of obtundation, seizure, or dystonic reaction of the head and neck following overdose may create a risk of aspiration with induced emesis. Cardiovascular monitoring should commence immediately and should include continuous electrocardiographic monitoring to detect possible arrhythmias. If antiarrhythmic therapy is administered, disopyramide, procainamide, and quinidine carry a theoretical hazard of additive QTprolonging effects that might be additive to those of ziprasidone. Hypotension and circulatory collapse should be treated with appropriate measures such as intravenous fluids. If sympathomimetic agents are used for vascular support, epinephrine and dopamine should not be used, since beta stimulation combined with ~a1 antagonism associated with ziprasidone may worsen hypotension. Similarly, it is reasonable to expect that the alpha-adrenergic-blocking properties of bretylium might be additive to those of ziprasidone, resulting in problematic hypotension. In cases of severe extrapyramidal symptoms, anticholinergic medication should be administered. There is no specific antidote to ziprasidone, and it is not dialyzable. The possibility of multiple drug involvement should be considered. Close medical supervision and monitoring should continue until the patient recovers. GEODON^ Capsules should be administered at an initial daily dose of 20 mg BID with food. In some patients, daily dosage may subsequently be adjusted on the basis of individual clinical status up to 80 mg BID. Dosage adjustments, if indicated, should generally occur at intervals of not less than 2 days, as steady-state is achieved within 1 to 3 days. In order to ensure use of the lowest effective dose, ordinarily patients should be observed for improvement for several weeks before upward dosage adjustment. Efficacy in schizophrenia was demonstrated in a dose range of 20 to 100 mg BID in short-term, placebo-controlled clinical trials. There were trends toward dose response within the range of 20 to 80 mg BID, but results were not consistent. An increase to a dose greater than 80 mg BID is not generally recommended. The safety of doses above 100 mg BID has not been systematically evaluated in clinical trials. Maintenance Treatment While there is no body of evidence available to answer the question of how long a patient treated with ziprasidone should remain on it, systematic evaluation of ziprasidone has shown that its efficacy in schizophrenia is maintained for periods of up to 52 weeks at a dose of 20 to 80 mg BID (see CLINICAL PHARMACOLOGY ). No additional benefit was demonstrated for doses above 20 mg BID. Patients should be periodically reassessed to determine the need for maintenance treatment. Oral ziprasidone should be administered at an initial daily dose of 40 mg BID with food. The dose should then be increased to 60 mg or 80 mg BID on the second day of treatment and subsequently adjusted on the basis of toleration and efficacy within the range 40-80 mg BID. In the flexible-dose clinical trials, the mean daily dose administered was approximately 120 mg (see CLINICAL PHARMACOLOGY ). There is no body of evidence available from controlled trials to guide a clinician in the longer-term management of a patient who improves during treatment of mania with ziprasidone. While it is generally agreed that pharmacological treatment beyond an acute response in mania is desirable, both for maintenance of the initial response and for prevention of new manic episodes, there are no systematically obtained data to support the use of ziprasidone in such longer-term treatment (i. Intramuscular Administration for Acute Agitation in Schizophrenia The recommended dose is 10 to 20 mg administered as required up to a maximum dose of 40 mg per day. Doses of 10 mg may be administered every two hours; doses of 20 mg may be administered every four hours up to a maximum of 40 mg/day. Intramuscular administration of ziprasidone for more than three consecutive days has not been studied. If long-term therapy is indicated, oral ziprasidone hydrochloride capsules should replace the intramuscular administration as soon as possible. Since there is no experience regarding the safety of administering ziprasidone intramuscular to schizophrenic patients already taking oral ziprasidone, the practice of co-administration is not recommended. Oral: Dosage adjustments are generally not required on the basis of age, gender, race, or renal or hepatic impairment.

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Chronic administration of NUVIGIL at 250 mg reduced the systemic exposure to midazolam by 32% and 17% after single oral (5 mg) and intravenous (2 mg) doses cheap 180 mg cardizem with amex, respectively purchase cardizem 180 mg on line, suggesting that administration of NUVIGIL moderately induces CYP3A activity cheap cardizem 120 mg online. Drugs that are substrates for CYP3A4/5, such as cyclosporine, may require dosage adjustment. Chronic administration of NUVIGIL at 250 mg did not affect the pharmacokinetics of caffeine (200 mg), a probe substrate for CYP1A2 activity. Coadministration of a single 400-mg dose of NUVIGIL with omeprazole (40 mg) increased systemic exposure to omeprazole by approximately 40%, indicating that armodafinil moderately inhibits CYP2C19 activity. Drugs that are substrates for CYP2C19 may require dosage reduction. Population pharmacokinetic analysis suggests no gender effect on the pharmacokinetics of armodafinil. Data specific to armodafinil in special populations are not available. Age Effect: A slight decrease (~20%) in the oral clearance (CL/F) of modafinil was observed in a single dose study at 200 mg in 12 subjects with a mean age of 63 years (range 53 - 72 years), but the change was considered not likely to be clinically significant. In a multiple dose study (300 mg/day) in 12 patients with a mean age of 82 years (range 67 - 87 years), the mean levels of modafinil in plasma were approximately two times those historically obtained in matched younger subjects. Due to potential effects from the multiple concomitant medications with which most of the patients were being treated, the apparent difference in modafinil pharmacokinetics may not be attributable solely to the effects of aging. However, the results suggest that the clearance of modafinil may be reduced in the elderly (See Dosage and Administration ). Race Effect: The influence of race on the pharmacokinetics of modafinil has not been studied. Renal Impairment: In a single dose 200 mg modafinil study, severe chronic renal failure (creatinine clearance ?-T20 mL/min) did not significantly influence the pharmacokinetics of modafinil, but exposure to modafinil acid was increased 9-fold (See Precautions ). Hepatic Impairment: The pharmacokinetics and metabolism of modafinil were examined in patients with cirrhosis of the liver (6 men and 3 women). Three patients had stage B or B+ cirrhosis and 6 patients had stage C or C+ cirrhosis (per the Child-Pugh score criteria). Clinically 8 of 9 patients were icteric and all had ascites. In these patients, the oral clearance of modafinil was decreased by about 60% and the steady state concentration was doubled compared to normal patients. The dose of NUVIGIL should be reduced in patients with severe hepatic impairment (See Precautions and Dosage and Administration ). The effectiveness of NUVIGIL in improving wakefulness has been established in the following sleep disorders: obstructive sleep apnea/hypopnea syndrome (OSAHS), narcolepsy and shift work sleep disorder (SWSD). The effectiveness of NUVIGIL in improving wakefulness in patients with excessive sleepiness associated with OSAHS was established in two 12-week, multi-center, placebo-controlled, parallel-group, double-blind studies of outpatients who met the International Classification of Sleep Disorders (ICSD) criteria for OSAHS (which are also consistent with the American Psychiatric Association DSM-IV criteria). These criteria include either, 1) excessive sleepiness or insomnia, plus frequent episodes of impaired breathing during sleep, and associated features such as loud snoring, morning headaches or dry mouth upon awakening; or 2) excessive sleepiness or insomnia; and polysomnography demonstrating one of the following: more than five obstructive apneas, each greater than 10 seconds in duration, per hour of sleep; and one or more of the following: frequent arousals from sleep associated with the apneas, bradytachycardia, or arterial oxygen desaturation in association with the apneas. In addition, for entry into these studies, all patients were required to have excessive sleepiness as demonstrated by a score ?-U10 on the Epworth Sleepiness Scale, despite treatment with continuous positive airway pressure (CPAP). Evidence that CPAP was effective in reducing episodes of apnea/hypopnea was required along with documentation of CPAP use. Patients were required to be compliant with CPAP, defined as CPAP use ?-U4 hours/night on ?-U70% of nights. For a successful trial both measures had to show statistically significant improvement. The MWT measures latency (in minutes) to sleep onset. An extended MWT was performed with test sessions at 2 hour intervals between 9AM and 7PM. The primary analysis was the average of the sleep latencies from the first four test sessions (9AM to 3PM). For each test session, the subject was asked to attempt to remain awake without using extraordinary measures. Each test session was terminated after 30 minutes if no sleep occurred or immediately after sleep onset. The CGI-C is a 7-point scale, centered at No Change, and ranging from Very Much Worse to Very Much Improved. Evaluators were not given any specific guidance about the criteria they were to apply when rating patients. In the first study, a total of 395 patients with OSAHS were randomized to receive NUVIGIL 150 mg/ day, NUVIGIL 250 mg/day or matching placebo. Patients treated with NUVIGIL showed a statistically significant improvement in the ability to remain awake compared to placebo-treated patients as measured by the MWT at final visit. A statistically significant greater number of patients treated with NUVIGIL showed improvement in overall clinical condition as rated by the CGI-C scale at final visit. The average sleep latencies (in minutes) in the MWT at baseline for the trials are shown in Table 1 below, along with the average change from baseline on the MWT at final visit. The percentages of patients who showed any degree of improvement on the CGI-C in the clinical trials are shown in Table 2 below. The two doses of NUVIGIL produced statistically significant effects of similar magnitudes on the MWT, and also on the CGI-C. In the second study, 263 patients with OSAHS were randomized to either NUVIGIL 150 mg/day or placebo. Patients treated with NUVIGIL showed a statistically significant improvement in the ability to remain awake compared to placebo-treated patients as measured by the MWT [Table 1]. A statistically significant greater number of patients treated with NUVIGIL showed improvement in overall clinical condition as rated by the CGI-C scale [Table 2]. Nighttime sleep measured with polysomnography was not affected by the use of NUVIGIL in either study. The effectiveness of NUVIGIL in improving wakefulness in patients with excessive sleepiness (ES) associated with narcolepsy was established in one 12-week, multi-center, placebo-controlled, parallel-group, double-blind study of outpatients who met the ICSD criteria for narcolepsy. A total of 196 patients were randomized to receive NUVIGIL 150 or 250 mg/day, or matching placebo. The ICSD criteria for narcolepsy include either 1) recurrent daytime naps or lapses into sleep that occur almost daily for at least three months, plus sudden bilateral loss of postural muscle tone in association with intense emotion (cataplexy), or 2) a complaint of excessive sleepiness or sudden muscle weakness with associated features: sleep paralysis, hypnagogic hallucinations, automatic behaviors, disrupted major sleep episode; and polysomnography demonstrating one of the following: sleep latency less than 10 minutes or rapid eye movement (REM) sleep latency less than 20 minutes and a Multiple Sleep Latency Test (MSLT) that demonstrates a mean sleep latency of less than 5 minutes and two or more sleep onset REM periods and no medical or mental disorder accounts for the symptoms. For entry into these studies, all patients were required to have objectively documented excessive daytime sleepiness, via MSLT with a sleep latency of 6 minutes or less and the absence of any other clinically significant active medical or psychiatric disorder. For each test session, the subject was told to lie quietly and attempt to sleep. Each test session was terminated after 20 minutes if no sleep occurred or immediately after sleep onset. Each MWT test session was terminated after 20 minutes if no sleep occurred or immediately after sleep onset in this study. Patients treated with NUVIGIL showed a statistically significantly enhanced ability to remain awake on the MWT at each dose compared to placebo at final visit [Table 1]. A statistically significant greater number of patients treated with NUVIGIL at each dose showed improvement in overall clinical condition as rated by the CGI-C scale at final visit [Table 2]. The two doses of NUVIGIL produced statistically significant effects of similar magnitudes on the CGI-C.