Stockholm syndrome - Part 2 - Diagnosis and management

Causes & symptoms

Stockholm syndrome does not affect all hostages (or persons in comparable situations); in fact, a Federal Bureau of Investigation (FBI) study of over 1200 hostage-taking incidents found that 92% of the hostages did not develop Stockholm syndrome. FBI researchers then interviewed flight attendants who had been taken hostage during airplane hijackings, and concluded that three factors are necessary for the syndrome to develop:

• The crisis situation lasts for several days or longer.
• The hostage takers remain in contact with the hostages; that is, the hostages are not placed in a separate room.
• The hostage takers show some kindness toward the hostages or at least refrain from harming them. Hostages abused by captors typically feel anger toward them and do not usually develop the syndrome.

In addition, people who often feel helpless in other stressful life situations or are willing to do anything in order to survive seem to be more susceptible to developing Stockholm syndrome if they are taken hostage.

People with Stockholm syndrome report the same symptoms as those diagnosed with posttraumatic stress disorder (PTSD): insomnia, nightmares, general irritability, difficulty concentrating, being easily startled, feelings of unreality or confusion, inability to enjoy previously pleasurable experiences, increased distrust of others, and flashbacks.

Diagnosis

Stockholm syndrome is a descriptive term for a pattern of coping with a traumatic situation rather than a diagnostic category. Most psychiatrists would use the diagnostic criteria foracute stress disorder or posttraumatic stress disorder when evaluating a person with Stockholm syndrome.

Treatment

Treatment of Stockholm syndrome is the same as for PTSD, most commonly a combination of medications for short-term sleep disturbances and psychotherapy for the longer-term symptoms.

Prognosis

The prognosis for recovery from Stockholm syndrome is generally good, but the length of treatment needed depends on several variables. These include the nature of the hostage situation; the length of time the crisis lasted, and the individual patient's general coping style and previous experience(s) of trauma.

Prevention

Prevention of Stockholm syndrome at the level of the larger society includes further development of crisis intervention skills on the part of law enforcement as well as strategies to prevent kidnapping or hostage-taking incidents in the first place. 

Prevention at the individual level is difficult as of the early 2000s because researchers have not been able to identify all the factors that may place some persons at greater risk than others; in addition, they disagree on the specific psychological mechanisms involved in Stockholm syndrome. 

Some regard the syndrome as a form of regression (return to childish patterns of thought or action) while others explain it in terms of emotional paralysis ("frozen fright") or identification with the aggressor.

Stockholm Syndrome and the story behind!

In psychology, Stockholm Syndrome is an apparently paradoxical psychological phenomenon in which hostages express empathy and have positive feelings towards their captors, sometimes to the point of defending them. These feelings are generally considered irrational in light of the danger or risk endured by the victims, who essentially mistake a lack of abuse from their captors for an act of kindness. 

The FBI’s Hostage Barricade Database System shows that roughly 27% of victims show evidence of Stockholm Syndrome.

The Syndrome is named after the Norrmalmstorg robbery of Kreditbanken at Norrmalmstorg in Stockholm, Sweden in which bank employees were held hostage from August 23 to August 28, 1973. In this case, victims became emotionally attached to their captors, and even defended them after they were freed from their six-day ordeal. The term "Stockholm Syndrome" was coined by the criminologist and psychiatrist Nils Bejerot, who assisted the police during the robbery, and referred to the Syndrome in a news broadcast. It was originally defined by psychiatrist Frank Ochberg to aid the management of hostage situations.

Stockholm Syndrome can be seen as a form of traumatic bonding, which does not necessarily require a hostage scenario, but which describes "strong emotional ties that develop between two persons where one person intermittently harasses, beats, threatens, abuses, or intimidates the other."

We will see causes, symptoms and treatment tomorrow!

Astigmatism

Astigmatism is an optical defect in which vision is blurred due to the inability of the optics of the eye to focus a point object into a sharp focused image on the retina. This may be due to an irregular or toric curvature of the cornea or lens. 

The two types of astigmatism are regular and irregular.

 Irregular astigmatism is often caused by a corneal scar or scattering in the crystalline lens, and cannot be corrected by standard spectacle lenses, but can be corrected by contact lenses. 

Regular astigmatism arising from either the cornea or crystalline lens can be corrected by a toric lens. 

A toric surface resembles a section of the surface of an American football or a doughnut where there are two regular radii, one smaller than the other one. This optical shape gives rise to regular astigmatism in the eye.

The refractive error of the astigmatic eye stems from a difference in degree of curvature refraction of the two different meridians (i.e., the eye has different focal points in different planes.) 

For example, the image may be clearly focused on the retina in the horizontal (sagittal) plane, but not in the vertical (tangential) plane. Astigmatism causes difficulties in seeing fine detail, and in some cases vertical lines (e.g., walls) may appear to the patient to be tilted. 

The astigmatic optics of the human eye can often be corrected by spectacles, hard contact lenses or contact lenses that have a compensating optic, cylindrical lens (i.e. a lens that has different radii of curvature in different planes), or refractive surgery.

Although mild astigmatism may be asymptomatic, higher degrees of astigmatism may cause symptoms such as blurry vision, squinting, asthenopia, fatigue, or headaches. Some research has pointed to the link between astigmatism and higher prevalence of migraine headaches

Astigmatism exists when the cornea of the eye is shaped more like a football than a basketball.  Light is focused in multiple points on the retina, which causes distorted vision

Image from:

http://www.capecoraleyecenter.com/

What is Gluten?

Gluten (from Latin gluten, "glue") is a protein composite found in foods processed from wheat and related grain species, including barley and rye. It gives elasticity to dough, helping it torise and to keep its shape, and often giving the final product a chewy texture.

Gluten is the composite of a gliadin and a glutelin, which is conjoined with starch in the endosperm of various grass-related grains. The prolamin and glutelin from wheat (gliadin, which is alcohol-soluble, and glutenin, which is only soluble in dilute acids or alkalis) constitute about 80% of the protein contained in wheat seed. Being insoluble in water, they can be purified by washing away the associated starch. Worldwide, gluten is a source of protein, both in foods prepared directly from sources containing it, and as an additive to foods otherwise low in protein.

The seeds of most flowering plants have endosperms with stored protein to nourish embryonic plants during germination. True gluten, with gliadin and glutenin, is limited to certain members of the grass family.

Sources of gluten. Top: High-gluten wheat flour. Right: European spelt. Bottom: Barley. Left: Rolled rye flakes.

  The stored proteins of maize and rice are sometimes called glutens, but their proteins differ from gluten.

Wheat allergy and celiac disease are different disorders

How did Grandma take care of a baby who cries?

New study, researchers tested the so-called "5 S's" approach -- a method of soothing a fussy baby popularized by pediatrician Dr. Harvey Karp in the book "The Happiest Baby on the Block."

The "S's" stand for swaddling, side/stomach position, shushing, swinging and sucking.

As soon as the vaccine is given, the baby is wrapped snuggly in a blanket, then placed on her side or stomach and gently "shushed" and rocked a bit. If that doesn't do the trick, she's given a pacifier.

Different infants will respond to different methods of comfort, whether it's swaddling, a pacifier or being rocked, Harrington said. "If you do all of (the 5 S's), you're likely to hit upon the one that will help a child soothe himself."

The study, published in the journal Pediatrics, included 234 two- and four-month-old infants having routine vaccinations.

The researchers divided the babies into four groups. In the "control" group, infants were given a tiny bit of water right before their shots, and after the jab they were passed to their parents for comforting. A second group got sugar water instead of plain water.

The other two groups received either water or sugar water before their shots, and then the 5 S's afterward.

Overall, the researchers found, the 5-S groups showed fewer signs of pain -- less grimacing and frowning. And their crying faded sooner.

Only a few were still crying one minute after vaccination, versus about half of the babies in the control group and 30 percent of infants given sugar water only.

By offering physical comfort and a soothing voice, "I think we're just tapping into kids' natural ways of comforting themselves," Harrington said.

Source: http://pediatrics.aappublications.org/content/early/2012/04/11/peds.2011-1607.abstract

Peas - 3/4 cup has more protein than a whole egg!

Peas

Serving size 1/2 cup cooked (80g) Amounts Per Serving % Daily Value Calories 70 Calories from Fat 0 Total Fat 0g 0% Sodium 0mg 0% Total Carbohydrate 13g 4%   Dietary Fiber 4g 14%   Sugars 5g Protein 4g Vitamin A 15% Vitamin C 20% Calcium 2% Iron 6% * Percent Daily Values are based on a 2,000 calorie diet.

Peas have been used in the dry form since ancient times, and archaeologists found them in Egyptian tombs. 

It was not until the sixteenth century that more tender varieties were developed and eaten fresh. 

Today only about 5 % of all peas grown are sold fresh. More than half of all peas sold are canned and most of the rest are frozen.

Green peas are actually a member of the legume family. 

This family includes plants that bear pods enclosing fleshy seeds. Green peas do not require the long cooking times that are required by dried legumes such as split peas and pinto beans. 

Peas are a good low calorie source of protein. A 100-calorie serving of peas (about ¾ cup) contains more protein than a whole egg or a tablespoon of peanut butter and has less than one gram of fat and no cholesterol.

Tomorrow we will talk about how to cook and store!

What about some PEAS for all of us!

Storage

It is best to serve all types of fresh peas the day they are purchased. If they must be stored, place them in a perforated plastic bag in the refrigerator. Do not wash them before they are stored. Shell green peas right before you cook them.

Preparation

Rinse peas before shelling them. To shell peas, pinch the stem off with your fingernails and pull the string down the length of the pod. The pod will pop open and the peas can be pushed out of the pod with your thumb. When finished, wash all peas.

Rinse snow peas and sugar snap peas before use. To trim snow peas, cut the tips from both ends of the pod. This can be done with kitchen shears. Sugar snap peas need to have the strings removed before eaten cooked or raw. The string runs around both sides of the sugar snap pod. It is easiest to start from the bottom tip and pull the string up the front, and then snap the stem off and pull the string down the back of the pod.

Varieties

Green peas are nestled within large, bulging, grass green pods that are typically round and sweet. The green pea pods are tough, do not have good flavor, and therefore, are not eaten.

Snow peas (Chinese pea pods) and sugar snap peas are more often found fresh, but many companies are now selling them frozen. These peas are eaten raw or cooked with the pod intact

Recipes

Vegetarian PaellaMakes 4 servings.

Ingredients

1½ Tbsp olive oil
1 large onion, chopped
½ tsp paprika
1 ½ cups long grain brown rice
3 ¾ cups stock or vegetable broth
¾ cups dry white wine
14 oz can tomatoes, chopped with juice
1 Tbsp tomato paste
½ tsp tarragon
1 tsp dried basil
1 tsp oregano
1 red pepper, roughly chopped
1 green pepper, roughly chopped
3 stalks celery, finely chopped
3 cups mushrooms, washed and sliced
½ cup snow pea pods
2/3 cup frozen peas, trimmed
1/3 cup cashew nut pieces
Salt and pepper to taste

Heat oil; sauté onions and garlic until soft. Add paprika and rice and continue to cook for 4 -5 minutes or until rice is transparent. Stir occasionally. Add stock, wine, tomatoes, tomato paste, and herbs and simmer for 10 - 15 minutes. Add peppers, celery, mushrooms, and pea pods and continue to cook for another 30 minutes or until rice is cooked. Add peas, cashews, salt and pepper to taste. Heat through and place on a large heated serving dish.

Nutrition information per serving: Calories 454, Fat, 12g, Saturated Fat 2g, Carbohydrates 71g, Cholesterol 0mg, Dietary Fiber 10g, Sodium 295mg, Protein 12g.

The Valsalva maneuve - Do you know what this is?

The Valsalva maneuver or Valsalva manoeuvre is performed by moderately forceful attempted exhalation against a closed airway, usually done by closing one's mouth, pinching one's nose shut while pressing out as if blowing up a balloon.

 Variations of the maneuver can be used either in medical examination as a test of cardiac function and autonomic nervous control of the heart, or to "clear" the ears and sinuses (that is, to equalize pressure between them) when ambient pressure changes, as in diving, hyperbaric oxygen therapy, or aviation.

The technique is named after Antonio Maria Valsalva, a 17th-century physician and anatomist. He described the Eustachian tube and the maneuver to test its patency (openness). He also described the use of this maneuver to expel pus from the middle ear.

The purpose of a Valsalva maneuver is to increase air pressure in the lungs, in order to help a person exert physical effort or force things out of the body.

This is how it works: Your abdominal muscles tighten up, squeezing the intestines and organs in the abdominal cavity, so that they press upward against the diaphragm - the dome-shaped muscle that separates the abdominal cavity from the chest cavity. This causes the diaphragm to bulge upward, compressing the chest cavity. Certain chest muscles also tighten to bring the rib cage down, which compresses the chest cavity even more.

Meanwhile, the larynx is neurologically programmed to close tightly around the upper airway to keep the air in the lungs from escaping. The more the abdominal muscles squeeze, the greater the air pressure becomes in the lungs, and the tighter the larynx closes. The larynx is doing one of the basic tasks for which it is designed. It is calledeffort closure.

We are all familiar with the other function of the larynx, which is phonation. That occurs when the vocal folds in the larynx are brought gently together across the airway to make the sound of our voice. But when the larynx performs effort closure during a Valsalva maneuver, it behaves very differently. The entire inside of the larynx closes tightly, like a fist, to block the air completely. As we saw in our exercise, the lips and tongue can also do this job. If for some reason your lips or tongue are blocking the airway when you start a Valsalva maneuver, they will be recruited to continue the closure. They will automatically press harder and harder to keep the air from escaping.

Lazy bug or proper sleep - How many hours of sleep do you need.

The optimal amount of sleep is not a meaningful concept unless the timing of that sleep is seen in relation to an individual's circadian rhythms. A person's major sleep episode is relatively inefficient and inadequate when it occurs at the "wrong" time of day; one should be asleep at least six hours before the lowest body temperature. 

The timing is correct when the following two circadian markers occur after the middle of the sleep episode and before awakening:

• maximum concentration of the hormone melatonin, and

• minimum core body temperature.

Hours by age

Age and condition	Sleep Needs
Newborns (0–2 months)	12 to 18 hours
Infants (3–11 months)	14 to 15 hours
Toddlers (1–3 years)	12 to 14 hours
Preschoolers (3–5 years)	11 to 13 hours
School-age children (5–10 years)	10 to 11 hours
Adolescents (10–17 years)	8.5 to 9.25 hours
Adults, including elderly	7 to 9 hours
Pregnant women	8(+) hour

Children need more sleep per day in order to develop and function properly: up to 18 hours for newborn babies, with a declining rate as a child ages. A newborn baby spends almost 9 hours a day in REM sleep. By the age of five or so, only slightly over two hours is spent in REM. Studies say that school age children need about 10 to 11 hours of sleep.

Sleep debt is the effect of not getting enough sleep; a large debt causes mental, emotional and physical fatigue.

Sleep debt results in diminished abilities to perform high-level cognitive functions.

Going bananas!

Nutrition and research

Bananas are an excellent source of vitamin B₆, soluble fiber, and contain moderate amounts of vitamin C, manganese and potassium.

Along with other fruits and vegetables, consumption of bananas may be associated with a reduced risk of colorectal cancer and in women, breast cancer andrenal cell carcinoma

Banana ingestion may affect dopamine production in people deficient in the amino acid tyrosine, a dopamine precursor present in bananas.

In India, juice is extracted from the corm and used as a home remedy for jaundice, sometimes with the addition of honey, and for kidney stones.

Individuals with a latex allergy may experience a reaction to bananas.

Flower

Banana hearts are used as a vegetable in South Asian and Southeast Asian cuisine, either raw or steamed with dips or cooked in soups, curries and fried foods. The flavor resembles that ofartichoke. As with artichokes, both the fleshy part of the bracts and the heart are edible.

The maroon colored vegetables are the Banana hearts (flowers)

Leaves

Banana leaves are large, flexible, and waterproof. They are often used as ecologically friendly disposable food containers or as "plates" in South Asia and several Southeast Asian countries. Especially in the South Indian states of Tamil Nadu, Karnataka, Andhra Pradesh and Kerala in every occasion the food must be served in a banana leaf and as a part of the food a banana is served. Steamed with dishes they impart a subtle sweet flavor. They often serve as a wrapping for grilling food. The leaves contain the juices, protect food from burning and add a subtle flavor

You can see some "claims" on the medical values of banana @ banana.com

Banana, raw, edible parts

Nutritional value per 100 g (3.5 oz)
Energy	371 kJ (89 kcal)
Carbohydrates	22.84 g
- Sugars	12.23 g
- Dietary fiber	2.6 g
Fat	0.33 g
Protein	1.09 g
Vitamin A equiv.	3 μg (0%)
Thiamine (vit. B1)	0.031 mg (3%)
Riboflavin (vit. B2)	0.073 mg (6%)
Niacin (vit. B3)	0.665 mg (4%)
Pantothenic acid (B5)	0.334 mg (7%)
Vitamin B6	0.4 mg (31%)
Folate (vit. B9)	20 μg (5%)
Choline	9.8 mg (2%)
Vitamin C	8.7 mg (10%)
Calcium	5 mg (1%)
Iron	0.26 mg (2%)
Magnesium	27 mg (8%)
Manganese	0.3 mg (14%)
Phosphorus	22 mg (3%)
Potassium	358 mg (8%)
Zinc	0.15 mg (2%)
Percentages are relative to US recommendations for adults. Source: USDA Nutrient Database

Second most common cause of missed work

Irritable bowel syndrome (IBS) is a chronic disorder of the gastrointestinal system that affects up to one in seven Americans. It is the second most common cause of missed work (the first being the common cold). Many people are undiagnosed, often due to being unaware that their symptoms are abnormal. Some people are also reluctant to see a doctor.

The symptoms of IBS include:
1. abdominal pain or discomfort AND
2. diarrhea OR
3. constipation OR
4. alternating diarrhea and constipation

Other symptoms may include bloating and abdominal distension. Symptoms may not be present all of the time, and many patients experience periods when they feel normal. 

IBS is complex condition and the cause is unknown. Potential contributors include increased sensitivity of the bowel, prior gastrointestinal infection, genetic predisposition, stressful life events, food intolerances and changes of intestinal bacteria.There is an increasing body of evidence that suggests a strong connection between the brain and intestines (the so called gut-brain axis). This interaction between brain and gut may explain why periods of stress, anxiety and even depression may worsen symptoms of IBS.

IBS symptoms like bloating, abdominal pain, diarrhea and constipation can occur in more serious conditions like ulcerative colitis, celiac disease or even colon cancer. Because of these similar symptoms, it is important for patients with these symptoms to seek the care of a physician. 

There is no single test for IBS. Diagnosis is only confidently made after other conditions are ruled out with a thorough history, physical examination, and possibly other tests including blood tests, X-rays or even a colonoscopy. 

Because the cause of IBS is not the same for all patients, there is no single effective treatment. However, many treatments are available which include education, dietary changes, psychosocial therapies, anti-spasm medications and other medications to help with pain.  A recent study has shown that antibiotics and probiotics may also be beneficial. Finally, new treatments are in development and clinical trials with new medications are ongoing. 

If you think you may have IBS or were previously diagnosed with IBS and suffer from uncontrolled symptoms, it is important to see a physician. Talk to your doctor about any gastrointestinal symptoms that concern you.  

This was written by:Dr. Logan is a board-certified gastroenterologist who is fellowship trained in gastroenterology and hepatology. He is affiliated with Sutter Medical Group and sees patients at 2068 John Jones Road in Davis.

Picture courtesy:http://www.puristat.com/conditions/ibsimage.aspx

Interesting story of TYLENOL (paracetamol)

Read about Tylenol: Annual sales in 2004 were $2.1 billion

Acetanilide was the first aniline derivative serendipitously found to possess analgesic as well as antipyretic properties, and was quickly introduced into medical practice under the name of Antifebrinby A. Cahn and P. Hepp in 1886. But its unacceptable toxic effects, the most alarming being cyanosis due to methemoglobinemia, prompted the search for less toxic aniline derivatives.

Axelrod an US biochemist (picture) along with Brodie discovered that acetanilide, the main ingredient of these pain-killers, was to blame. They found that one of the metabolites also was an analgesic. They recommended that this metabolite, acetaminophen (paracetamol), better known as Tylenol, be used instead.

Harmon Northrop Morse had already synthesized paracetamol at Johns Hopkins University via the reduction of p-nitrophenol with tin in glacial acetic acid in 1877, but it was not until 1887 that clinical pharmacologist Joseph von Mering tried paracetamol on patients.

 In 1893, von Mering published a paper reporting on the clinical results of paracetamol with phenacetin, another aniline derivative. Von Mering claimed that, unlike phenacetin, paracetamol had a slight tendency to produce methemoglobinemia. Paracetamol was then quickly discarded in favor of phenacetin. The sales of phenacetin established Bayer as a leading pharmaceutical company. Overshadowed in part by aspirin, introduced into medicine by Heinrich Dreser in 1899, phenacetin was popular for many decades, particularly in widely advertised over-the-counter "headache mixtures", usually containing phenacetin, an aminopyrine derivative of aspirin, caffeine, and sometimes a barbiturate.

Von Mering's claims remained essentially unchallenged for half a century, until two teams of researchers from the United States analyzed the metabolism of acetanilide and paracetamol. In 1947, David Lester and Leon Greenberg found strong evidence that paracetamol was a major metabolite of acetanilide in human blood, and in a subsequent study they reported that large doses of paracetamol given to albino rats did not cause methemoglobinemia.

A followup paper by Brodie and Axelrod in 1949 established that phenacetin was also metabolized to paracetamol. This led to a "rediscovery" of paracetamol. It has been suggested that contamination of paracetamol with 4-aminophenol, the substance von Mering synthesized it from, may be the cause for his spurious findings.

Paracetamol was first marketed in the United States in 1953 by Sterling-Winthrop Co., which promoted it as preferable to aspirin since it was safe to take for children and people with ulcers. The best known brand today for paracetamol in the United States, Tylenol, was established in 1955 when McNeil Laboratories started selling paracetamol as a pain and fever reliever for children, under the brand name Tylenol Children's Elixir—the word "tylenol" was a contraction of para-acetylaminophenol. 

In 1956, 500 mg tablets of paracetamol went on sale in the United Kingdom under the trade name Panadol, produced by Frederick Stearns & Co, a subsidiary of Sterling DrugInc. Panadol was originally available only by prescription, for the relief of pain and fever, and was advertised as being "gentle to the stomach," since other analgesic agents of the time contained aspirin, a known stomach irritant.