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By: Daniel James George, MD

  • Professor of Medicine
  • Professor in Surgery
  • Member of the Duke Cancer Institute

https://medicine.duke.edu/faculty/daniel-james-george-md

There are also computers available in the patient lounge and family lounge(not for patients) muscle relaxant alcoholism order ponstel overnight. Computer games You may bring a Nintendo muscle relaxant vecuronium safe ponstel 500mg, Playstation spasms with spinal cord injury buy ponstel 500 mg fast delivery, X Box muscle relaxant drugs over the counter buy ponstel online pills, or Gameboy from home. We have an X Box in our recreation room and several Wii games and accessories that can be signed out through the recreational therapist. You may feel comfortable in your own clothes and do not have to wear a hospital gown. During your hospitalization, clothes may 26 Bone Marrow Transplant Program – Autologous Patient Guide get soiled or stained, so please bring only clothes that can be cleaned or replaced. Laundry soap is available for everyone’s use unless you’d prefer to bring your own. We suggest bringing: Comfortable Pajamas Preferably ones that open up in the front to accommodate the care of your catheter Bathrobe, Sweatpants, T-Shirts the looser and baggier, the better Scarves/turbans/hats Hats and turbans are helpful to keep your head warm Undergarments Cotton only Sneakers/tennis shoes For exercise Personal Hygiene Notes: Shower daily. Like the clothes described above, blankets will need to be washed, dried, and placed in a plastic bag during transport. You will have a small refrigerator in your room to store special drinks, individual servings of pudding, Jell-O, popsicles, etc. A Patient Nourishment Room is available where you or your caregiver can get a cup of coffee, hot chocolate or use the microwave. Visitor Guidelines the Bone Marrow Transplant Staff encourages your family and friends to visit. Children under 12 years of age may visit but your nurse or physician must be notified in advance. Children cannot have received any live virus vaccinations (such as the flu mist or chicken pox vaccine) within the previous eight (8) weeks. In addition, military personnel who visit cannot have received a small pox vaccine within the previous eight (8) weeks. Please report to the nurse any recent immunizations received by a visitor, or if they have recently traveled outside of the United States. The nursing staff will screen visitors for any contagious conditions such as a fever, cough, cold, sore throat, runny nose, skin rash or other respiratory symptoms. One adult (18 years or older) may stay overnight with you during your hospitalization. Your overnight visitor must sleep in a separate day bed and is not allowed to use your toilet (your nurse can direct your visitor to toilets in the Family Waiting Area). A shower may be taken by an overnight visitor but only after you have showered first. To ensure the health of each patient, the medical or nursing staff may revise the above visitor guidelines as needed. There are two sinks for the hand scrub in the Family Waiting Area and outside the patient room entrances once inside the unit. This will give your family the opportunity to be updated on your progress and to ask questions. Family members should leave a correct phone number on file at the nursing station for emergency use. It is best if one family member calls to get reports on your care and then shares the information with other family members. This helps the staff so that they can refer to your spokesperson with any questions or calls from friends and relatives who ask about your condition. Infection Control on the Bone Marrow Transplant Unit Hand Hygiene: Hand Hygiene or hand washing is the single most effective way patients (and caregivers/visitors) can stop the spread of germs and infection. As a patient you should clean your hands often, especially after using the bathroom and before eating. This test is performed by your nurse who will obtain a rectal swab to be sent to lab. It is important to note that gowns and gloves are discarded in the patient’s room. Sometimes this occurs during or after taking antibiotics because the antibiotics destroy many of the “good” bacteria normally present in the bowel and allow the C. Symptoms of infection can range from mild diarrhea to severe inflammation of the intestine. Upon leaving the room they will remove and discard the glove and gowns and discard before exiting the patient’s room. If you are found to have one these, your Health Care Provider will explain this to you. Please use the “nurse call button” on the side of the bed rail for any assistance you need. Visitors should not give medications to a patient without permission from the nurse. Therefore, visitors shouldn’t empty urinals or emesis basins before the nurse can record the amount of fluid. If you give the patient water to drink, it is important to record how much fluid the patient drank. The doctors and nurses will take care of you during your hospital stay; but you can also help yourself in your recovery. Preventing Infections Decreasing the risk of infection is very important during your treatment. Therefore, we need your help and that of your visitors to follow these guidelines: You must wear a mask ever time you leave your room. The Bone Marrow Transplant Unit has a special air handling system that will allow you to walk in the hallways with your mask on. Use the incentive spirometer or ‘blow bottle’ (to help your lungs) at least 3-4 times per day. Mouth Care Chemotherapy and radiation therapy very likely may cause breakdown of the mucous membranes that line your mouth. Frequent and complete mouth care will help to prevent infection, lessen discomfort and promote healing. Wash skin folds, armpits, genital area and rectal area carefully and dry thoroughly. Use lotion on a daily basis to prevent dry skin caused by radiation and chemotherapy. For those patients receiving radiation, no lotions will be allowed on your skin before treatment. The treatment affects all body hair; therefore, your hair loss may not just be on your head. Other areas of hair loss may include underarms, pubic area, legs, eyebrows, eyelashes and facial hair. Some patients choose to take control of their hair loss and may elect to cut their hair shorter or shave their head prior to admission. Hats, wigs, scarves, hair pieces or turbans may be a short term alternative and are available in the Cancer Resource Center in the lobby of the North Carolina Cancer Hospital. The Recreational Therapist will develop an exercise program for you and if more intensive therapy is needed, a Physical Therapist will be assigned. It is important to establish an exercise regimen as soon as you are admitted and stick to it on a daily basis. You may be asked to use an exercise bicycle or treadmill and may even be given small weights. Be sure to bring sneakers or tennis shoes with you while using the exercise equipment. Plan on bringing some projects or activities that help occupy your time, because there will be some days that you may feel bored. Our Recreational Therapist will meet you on admission and 34 Bone Marrow Transplant Program – Autologous Patient Guide help plan activities with you. Try and think of something you have always wanted to do but never had time for use this time to do something positive. A hospital school teacher will visit your child’s room and continue their studies based upon the information that has been discussed and received from your child’s school. Take Control Work with your nurse to make out a daily schedule that fits your needs. This will help you achieve your daily goals and give you more control on how you want to spend your day. It is very important that a child develops his/her walking, playing and self care skills on schedule so he/she will have a good chance at a normal, independent adult lifestyle.

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Although the above studies disclose insights into the behavior and maintenance of cycling Fig spasms quadriceps order ponstel online from canada. It will be Switch from multipotency to muscle relaxant reversals order ponstel 500mg with visa unipotency two long-lived daughters (26 spasms movie 1983 quality 500 mg ponstel, 30) muscle relaxant reversal agents purchase 250mg ponstel free shipping. Although it was recently pacity of the intestinal crypt led to the initial either absorptive or secretory. Plasticity of initially on Lgr5 expression and mathematical glandular epithelium during modeling (48, 49) and subsequently on a novel regeneration. In super a cellular bandage, which perhaps analogously multipotent progenitor remains to be deter mined (61). A series of recent studies reveals that the fate and differentiation potential of epi B Fate of Dll1 progenitor after ionizing radiation thelial cells can broaden during tissue regeneration after wounding. Thecellular Ionizing plasticity and reversibility observed in adult radiation epithelial tissues have not been associated with “transdifferentiation” into completely un x related fates but rather with contribution to the repairofthetissuefromwhichthecellsorig Dll1 inated. In this regard, the plasticity seems to arise tracing x through a process of dedifferentiation and/or redifferentiation. By contrast, when progen committed epithelial lineage cells may have noteworthy that cells located in the upper bulge itors form tissue de novo during embryonic de the capacity to acquire stemness. Although future studies will be nec Similarly, after culture in vitro, marked thymic (44), are both short-lived Lgr5-derived progeny essary to more closely examine the long-term epithelial cells can be mixed with embryonic committed to the secretory lineage. How directly or after cell culture, they exhibit greater with subsequent transplantations, illustrating Wnt signaling might influence the reversion multipotency in their new microenvironment. Whether these reserve cells are suffi cient to be functionally relevant in the context of tissue repair is still Trachea during homeostasis and regeneration unclear, as g-irradiation–induced intestinal epithelial regeneration Ciliated cells does not occur after Lgr5 ablation (Fig. Simons, Unravelling stem cell dynamics revealed that Sox2-expressing cells in the isth pathway. Spradling, Stem cells and niches: mechanisms that promote stem cell maintenance throughout mach lineages (88). Green, Serial cultivation of strains of of chase, which shows that these cells play only formation (96). Green, Permanent coverage of large burn wounds with fold after tissue damage in vivo, suggestive of functionally by their ability upon serial trans autologous cultured human epithelium. Nature 459, cell regeneration seems to involve self-duplication ble of interconversion have also been identified 262–265 (2009). Lavker, Label-retaining cells ic and severe hepatic injuries stimulate mature bility that upon transplantation, more committed reside in the bulge area of pilosebaceous unit: Implications for follicular stem cells, hair cycle, and skin carcinogenesis. In particular, this seems to happen increases the potential for cancer progression. McDermitt, must respond quickly and creatively to ensure extent to which extent cell plasticity influences T. Tumbar, Distinct self-renewal and differentiation phases in the niche of infrequently dividing hair follicle stem cells. Fuchs, Transit-amplifying cells orchestrate by a differentiation-specific promoter develop the self-preservation of epithelia to repair body stem cell activity and tissue regeneration. Greco, Spatial organization within esting variation to this theme, normally fate after injuries. Science327,1385–1389 erogeneous expression of both basal and lu become mobilized to participate in wound repair. Cell Stem Cell 13, 471–482 prostate cancer, where ablation of a tumor juries, the tissue can no longer cope with repair. Joyner, Nerve-derived sonic hedgehog defines a niche for hair follicle formation (57). Basal progenitors seem intrin cellular plasticity, fate conversion, and reacqui stem cells capable of becoming epidermal stem cells. Ponder, A clonal marker Morphogenesis and renewal of hair follicles from adult origin of basal cell carcinoma. Morgan, Lgr5+ stem cells are indispensable for radiation-induced intestinal stem cells. Fuchs, Hair follicle stem long-term maintenance and repair of lung airway, but not (2011). Williams, Demonstration of somatic mutation and cell population, at the termination of catagen. Nature 494, tumorigenic melanoma cells from patients that is reversible for works not cited because of space constraints. Regenerative medicine, an interdisciplinary field that applies engineering and life science principles to promote regeneration, can potentially restore diseased and injured tissues and whole organs. These therapies and other regenerative medicine approaches currently being studied in preclinical and clinical settings will be covered in this review. Specifically, developments in fabricating sophisticated grafts and tissue mimics and technologies for integrating grafts with host vasculature will be discussed. Enhancing the intrinsic regenerative capacity of the host by altering its environment, whether with cell injections or immune modulation, will be addressed, as well as methods for exploiting recently developed cell sources. Finally, we propose directions for current and future regenerative medicine therapies. Strategies for improving the struc wrinkles; Celution, a medical device that ex malize congenital defects. Promising preclin tural sophistication of implantable grafts and tracts cells from adipose tissue derived from ical and clinical data to date support the effectively using recently developed cell sources liposuction; Epicel, autologous keratinocytes possibility for treating both chronic diseases will also be discussed. Finally, potential future for severe burn wounds; and the harvest and acute insults, and for regenerative med directions in the field will be proposed. Due of cord blood to obtain hematopoietic pro icine to abet maladies occurring across a wide to the considerable overlap in how researchers genitor and stem cells. Autologous cells re array of organ systems and contexts, includ use the terms regenerative medicine and tis quire harvest of a patient’stissue,typically ing dermal wounds, cardiovascular diseases sue engineering, we group these activities to creating a new wound site, and their use of and traumas, treatments for certain types of gether in this review under the heading of ten necessitates a delay before treatment as cancer, and more (1–3). The cells used in these thera the place of missing tissue, effectively replac and function of new tissue, and locally present pies are either autologous or allogeneic and ing it both structurally and functionally, or to growth factors (11). For example, 3D polymer are typically differentiated cells that still contribute to tissue healing (5). This review will first discuss regenerative chondrocytes are harvested from articular the authors declare no conflict of interest. Email:mooneyd@ living cells, or growth factors either to replace OtherexamplesincludelaViv,whichinvolves seas. As such, acellular noted above, and have been used to repair used to promote wound healing (Dermapure, products may be preferable from a regulatory large muscle defects in a human patient (32). A material alone can ment in patients requiring kidney di sometimes provide cues for regeneration and Therapies at the Preclinical Stage and in alysis (33). Despite these successes, a number graft or implant integration, as in the case of Clinical Testing of challenges remain. Mechanical properties bioglass-based grafts that permit fusion with A broad range of strategies at both the pre of tissues and organs may be affected by the bone (15). Incorporation of growth factors clinical and clinical stages of investigation are decellularization process, the process may that promote healing or regeneration into currently being explored. However,complications ronment to induce therapeutic responses, stripped tissue before implantation are ac can arise with these strategies (Infuse, particularly through cell infusion and mod tively being optimized. Finally, methods Synthetic scaffolds may also be fabricated due to the poor control over factor release for exploiting recently identified and devel that possess at least some aspects of the ma kinetics with the currently used materials. Because tissue and organ architecture derived alginate, or from synthetic poly products (9). They provide benefit in terms is deeply connected with function, the ability mers, such as poly(lactide-coglycolide) and of healing and regeneration but are unable to recreate structure is typically believed to poly(ethylene glycol); hydrogels are composed to fully resolve injuries or diseases (19–21). Onestrategytocapture scaffolds due to their compositional similarity made difficult by the large time and mone organ structure and material composition in to tissue (37, 38). This approach has for treating congenital heart defects in both per drug (22, 23). In contrast, medical devices, been executed in conjunction with bio pediatric and adult patients (40) (Fig. For example, soft fibrin– collagen hydrogels have been explored as lymph node mimics (43) whereas more rap idly degrading alginate hydrogels improved regeneration of critical defects in bone (44). In some cases, the polymer’s mechanical properties alone are believed to produce a therapeutic effect. For example, injection of alginate hydrogels to the left ventricle reduced the progression of heart failure in models of dilated cardiomyopathy (45) and is currently undergoing clinical trials (Algisyl). Combining materials with different properties can en hance scaffold performance, as was the case of composite polyglycolide and collagen scaf folds that were seeded with cells and served as bladder replacements for human patients (46).

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Although similar human liver organoids have filled lumen that eventually forms the brain Although the final product of neural develop not yet been generated muscle relaxant agents generic ponstel 500 mg, a very different approach ventricles muscle relaxant starting with z cost of ponstel. Axes are established through the con ment is a highly complex interconnected brain muscle relaxant pills safe 250 mg ponstel, was recently established to muscle relaxer 86 67 generic 250 mg ponstel overnight delivery generate tissues re certed action of morphogen gradients, such as earlier reaggregation studies suggest that this miniscent of human liver buds (41). The implication mimics the early cell lineages of the developing jority of the human brain, including the neo of these classic experiments is that if neuroepi liver. Neu istic apical-basal polarity and do not recapitulate metabolites in the blood. Asanalter of mice subjected to liver injury increased when proliferative divisions. During neurogenesis, stem native approach, neurospheres (47) are aggre liver buds were transplanted into them. However, neurospheres Brain organoids cell types, including neurons and intermediate are likewise not well organized and, therefore, the vertebrate central nervous system derives progenitors (44). Thesemoredifferentiatedcells are limited in their capacity to model many as from the neural ectoderm (6). This tissue gives migrate outward to generate stratified structures pects of brain development. This method has further oids, that contain several different brain regions mediate progenitor types, as well as the timed been improved in a recent study (55)thatalso within individual organoids (28)(Fig. Instead, the method is influ modeling the overall organization of the devel ing endogenous patterning with growth factors. For example, Hedgehog signaling drives ven ly, by embedding the tissues in Matrigel. In addition, cere extracellular matrix provided by the Matrigel the potential to recapitulate brain tissue organ bellar identities can be generated by treatment promotes outgrowth of large buds of neuroepi ization have been used extensively for investiga with either Bmp4 and Wnt3a to generate gran thelium, which then expand and develop into tions in the past several years. In particular, work ule neurons (57) or Hedgehog inhibition to gen various brain regions. Cerebral organoids can from the lab of Yoshiki Sasai has focused on erate Purkinje neurons of the cerebellum (58). Beginning with tors, such as serum proteins, promotes hypo trient and oxygen exchange. Thus, by stimulating lows the formation of a variety of brain regions, can be generated from neuroectoderm. In vivo, the primitive streak more complex tissues arise in 3D with structures and hippocampus. The intermediate mesoderm is the retina is the light-receptive neural region of further subspecified through the action of Fgf Organoids from model organisms the eye and is derived from the neural ectoderm. Theseincludetheendoderm-derived this optic vesicle begins as a pseudostratified velop early renal tubules. How Like many of the tissues for which organoids can be produced by overexpression of two fac ever, concerted movements at two hinge re have so far been developed, evidence that kid tors important for thyroid specification, Nkx2. Thus, early in retinal development, comes from early reaggregation experiments of thyroid-stimulating hormone (70). Lung organoids two adjacent epithelial layers are established: chick embryonic kidney (9). The resultant tis can develop from cocultured adult bronchioal the outer retinal pigmented epithelium and the sues displayed various segments of the nephron, veolar stem cells and lung endothelial cells (71) inner neural retina. This trend of stratification including collecting duct, distal and proximal in Matrigel. And finally, pancreatic organoids continues and eventually leads to a fully lami tubules, and glomeruli formed by the interac can develop from simply plating pancreatic pro nated tissue containing layers of photoreceptors tion with allantoic vessels upon transplantation genitor cells in Matrigel (72). All three systems and supportive cell types, such as bipolar cells and on the chick allantoic membrane. Specifically, the retina in the early 1960s and demonstrated the nized tissues if grown in a permissive environment. Addi foundation rooted in developmental biology 2D to Bmp4 and Fgf2 to drive mesodermal iden tionally, sensory epithelia of the inner ear can (Fig. Such ure promoting conditions with subsequent treat of Matrigel is dissolved in the medium at an teric bud cells can be cocultured with dissociated ment with Bmp4 followed by Fgf2 to drive otic early stage to allow the formation of more rigid mouse embryonic kidney to self-organize within identity (74). The resulting otic vesicles generate neuroepithelial tissues, a prerequisite of retinal the mouse aggregate and populate 3D ureteric functional inner ear sensory epithelia with stereo pigmented epithelium formation. Sequential application of is currently in its infancy, but the field is rapidly retinal tissue identity. Fi ready been established in mouse or where a ers of neural retina and retinal pigmented epi nally, application of retinoic acid followed by Fgf9 principle of self-organization has already been thelium, they display retinal stratification with then stimulates the tissues to take on a metanephric demonstrated in reaggregation studies. By coculturing with spinal include skin (9), mammary gland (75), muscle morphological tissue shape changes that mimic cord tissue, a known nephric inducer, this tissue (76), and bone (77), to name a few. This is particularly true for the human retinal organoids are larger than mouse termediate mesoderm identity upon exposure biological principles that are specific to humans. Similarly, these specification events were initially per retinal organoids have been used to test differ Kidney organoids formed in 2D, the cells take on 3D morphol ences between human and rodent tissue morpho Thekidneyarisesfromanearlyembryonictissue ogies by either growing at low density to allow genesis and timing (65). Similarly, retinal organoids have approach could even cut down on the use of ani Furthermore, organoids hold the potential to the potential to model human genetic disorders mal testing, reserving it for studies requiring model adult homeostasis as well. Indeed, intes that lead to blindness, such as retinitis pigmen whole-organism readouts. Drugs can be removed at derived from adult progenitors, such as liver technologies. They could, in principle, toxic metabolites can be produced specifically in be used to model various neurodevelopmental humans but not in tested animals. Methods to Therapeutic potential disorders that have been difficult or impossible screen compounds in an in vitro human liver Disease modeling will likely be a primary focus to model in animals. Indeed, brain organoids model are therefore being investigated as an of future organoid studies (Fig. These can were the first organoids to make use of patient alternative in the drug discovery process (87). In the future, produce human-specific metabolites (41), which gut organoids are already being used to examine cerebral organoids may even have the potential suggests that liver organoids could represent an infectious diseases (81, 82); tumor biology (83, 84); to model disorders such as autism, schizophrenia, ideal system to perform these types of studies. Recently, Organoids also have the potential to be used for organ replacement strategies in the clinic (Fig. Although the method did not test model degenerative conditions—for example, liver organoids hold enormous therapeutic potential as for a phenotype, this will likely represent an im fibrosis or cystic kidney diseases—where one could this is the organ with the highest rate of end-stage failure leading to the highest organ demand for transplants. Additionally, retinal organoids could be used to treat certain types of retinal degeneration and blindness. Indeed, stem cell–therapy clinical trials are already under way to replace certain degen erating retinal cell types (88). Retinal organoids could provide an alternative approach that may better recapitulate development and, therefore, produce particular cell types of interest for trans plantation. Finally, intestinal organoids could pro vide a treatment option for replacement of damaged colon after injury or following removal of dis eased tissue. Remarkably, intestinal organoid trans plantation has already been performed in mice and can contribute to colon repair after injury (35, 89). Organoid approaches could even allow for gene correction in the case of genetic defects, using modern genome-editing technologies to replace damaged organ with repaired tissue. Although it is clear that there are many po tential uses for organoids, it is important to keep in mind their current limitations. In particular, all of the organoid systems so far established re main to be thoroughly characterized with regard to the extent of recapitulation of in vivo develop ment. For example, although retinal organoids Organ Drug nicely display typical laminar organization, outer replacement safety segments fail to form; for example, photorecep therapy testing torsfailtofullymaturetobecomelight-sensitive. Organoids can be used to model diseases (beige box), early events in brain development, but later fea for example modeling neurodevelopmental disorders with cerebral organoids. Drug compounds can be tested for toxicity and metabolic profile in liver organoids (gray box). Cell reserve stem cells to generate all lineages of the stomach producing Lgr5+ adult stem cells (33). Neuron 48, culture system: Generation of organoids having mature therapeutic purposes.

An attempt is made to muscle relaxant injection cheap 250mg ponstel amex listen attentively muscle relaxant oral ponstel 500mg amex, accurately observe and understand the psychological event or phenomenon so that the observer can spasms urethra generic ponstel 500mg without prescription, as far as possible muscle relaxant cyclobenzaprine buy ponstel 250 mg free shipping, know for himself what the patient’s experience must feel like. Descriptive psychopathology therefore includes subjec tive aspects (phenomenology) and objective aspects (description of behaviour). It is concerned with the rich variety of human experience, but it is deliberately limited in its scope to what is clinically relevant; for example it can say nothing about the religious validity of what James (1902) has called ‘saintliness’. Phenomenology demands a very precise description of exactly how she feels inside herself: ‘that horrible feeling of not really existing’ and ‘not being able to feel any emotion’. Some psychiatrists have held the method of phenomenology in derision as archaic, hair splitting or hare-chasing pedantry, but the diagnostic evaluation of symptoms is a task that the psychiatrist omits at his own, and his patient’s, peril. Studying phenomena whets diagnostic tools, sharpens clinical acumen and improves communication with the patient. If ‘the proper study of mankind is man’, the proper study of his mental illness starts with the description of how he thinks and feels inside – ‘chaos of thought and passion, all confused’ (Pope, 1688–1744). A cavalier neglect of abnormal phenomena can have serious repercussions for care of the patient. Eight mentally well researchers were sent separately to twelve admission units in American mental hospitals on the pretence of complaining of hearing these words said aloud: ‘empty’, ‘hollow’ and ‘thud’ (Rosenhan, 1973). They produced no further psychiatric symptoms after admission to hospital but acted as normally as they could, answering questions truthfully except to conceal their name and occupation. The ethics and good sense of the experiment can certainly be ques tioned, but what comes out clearly is not that psychiatrists should refrain from making a diagnosis but that their diagnosis should be made on a sound psychopathological basis. Neither Rosenhan, nor his colleagues, nor the admitting psychiatrists gave any information as to what symptoms could reasonably be required for making a diagnosis of schizophrenia; this requires a method based on psychopathology (Wing, 1978). With adequate use of phenomenological psychopathol ogy, this failure of diagnosis would not have occurred. Jaspers (1959) wrote, ‘Phenomenology, though one of the foundation stones of psychopathol ogy, is still very crude’. One of the great problems in using this method is the muddled nature of terminology. Almost identical ideas may be assigned different names by people from different theoretical backgrounds, for example the plethora of descriptions of how a person may concep tualize himself: self-image, cathexis, body awareness and so on. P1 refers to its commonest clinical usage as a mere synonym for ‘signs and symptoms’ (as in ‘phenomenological psychopathology’); this is a bastardized usage, and hence conceptually uninteresting. P2 refers to a pseudo-technical sense often used in dictionaries and which achieves spurious unity of meaning by simply cataloguing successive usages in chronological order; this approach is misleading in that it suggests false evolutionary lines and begs important questions relating to history of phenomenology. P3 refers to the idiosyncratic usage started by Karl Jaspers who dedicated his early clinical writings to the description of mental states in a manner which (according to him) was empathic and theoretically neutral. Finally, P4 refers to a complex philosophical system started by Edmund Husserl and continued by writers collectively named the ‘Phenomenological Movement’. Jaspers defnes phenomenology perhaps 30 to 40 times in his writings in subtly different ways but always implying the study of subjective experience. Walker (1995a, b) considers that Jaspers radically misconstrued Husserl’s phenomenol ogy. The implication for what follows in this chapter, and in the rest of the book, is that the concept of phenomenology used here comes directly from Jaspers and was probably infuenced by both Kant and Husserl. Phenomenology, the empathic method for the eliciting of symptoms, cannot be learned from a book. Patients are the best teachers, but it is necessary to know what one is looking for – the practical, clinical aspects in which the patient describes himself, his feelings and his world. The doctor tries to unravel the nature of the sufferer’s experience, to understand it well enough and to feel it so poignantly that the account of his fndings evokes recognition from the patient. The method of phenomenology in psychiatry is entirely subjugated to its single purpose of rendering the patient’s experience understandable (this is a technical word in phenomenology and is described in more detail on p. It is not the assimilation of abstruse facts or the accumulation of foreign eponyms that is most diffcult in phenomenology, although either of these may be hard: it is the comprehension of a method of investigation and the ability to use new concepts. In an attempt to avoid the obscure and obvious, in the rest of this chapter some of these concepts are discussed. This is a vast subject that has received discussion from philoso phers, theologians, administrators and lawyers as well as from physicians. Doctors who spend most of their working time dealing with disease rarely ask this question and even less frequently attempt to answer it. But, an even more pressing issue is whether it is possible for the mind to be diseased in the same way or manner that the liver or the kidneys can be diseased. These questions are outside of the scope of this book but it is important to be aware of the varied approaches that different authori ties take to this matter. The most compelling model of a disease is that which grounds a medical condition such as pulmonary tuberculosis on the basis of a distinctive morbid anatomy demonstrable on examina tion of the lungs and which is independent of any particular observer and is assumed to be value free. It is even better if there is an understanding of the detailed pathophysiology: how the causa tive agent, in tuberculosis for instance, results in the recognized, typical morbid anatomy of the lungs. It is obvious from the foregoing that in most psychiatric diseases no such typical morbid anatomy or pathophysiology has been described. On the basis of the absence of demonstrable physical lesions, Szasz (1960) argued that psy chiatric or mental diseases did not exist and that only behavioural deviance and moral or social judgements were at play in psychiatry. He also argued that ‘mental’ is an abstract concept and not an objective, physical thing and hence it could not be diseased. Brain diseases, in his view are real but mental diseases are a logical impossibility, and thus Szasz uses the term ‘myth’ to characterize mental diseases. Other writers including Scadding (1967), Kendell (1975), Boorse (1976) and Sedgwick (1973) have put forward arguments that stand in opposition to Szasz. Scadding and Kendell use the combination of statistical deviance and biological disadvantage defned as reduced fertility to determine what a disease is. Boorse adds that a disease is any condition that interferes with any function of an organism (and in this view mental functioning counts), which is necessary for its survival and reproduction. Finally Sedgwick makes the claim that all diseases start off as illnesses, because the symptoms are nega tively valued and hence become a focus of social and moral interest and that in this way the symptoms later attain disease status. In this account both the so-called physical illnesses and mental illnesses start off as negatively valued states afficting human beings and there is no sharp distinction to be drawn between them. It is clear that there is no widely accepted view about the status of the conditions that fall under the interest of psychiatrists. A simple dictum is to regard disease as what doctors treat and illness as what persons suffer from. Although this distinction between normality and disease, health and illness, is by no means trivial: A large part of medical ethics and much of the whole underpinning of current medical policy, private and public, are squarely based on the notion of disease and normality. Left to himself the physician (whether he realizes it or not) can do very well without a formal defnition of disease Unfortunately, the physician is not left alone to work his common sense. He is attacked from two angles: the predatory consumers and the pretentious advisers. Psychiatric diseases are distinct from mere neurological diseases in the sense that in neurology the disease process leaves the self, the personhood of an individual, intact. This means that we can speak of a person who suffers from multiple sclerosis or motor neuron disease. In psychiatry, the diseases affict the self; affect the person in a deep and not superfcial sense. Mood disorders and schizophrenia have a pervasive infuence on aspects of the self in a way that strikes at what it means to be human. The ability to experience and represent the world; the capacity to inhabit a social world including recognizing the rules and conventions that operate therein; the ability to form relation ships and to imagine the world of the Other; the ability to communicate, to use language and to understand symbols, that is to inhabit a world of meanings; the wherewithal to be an agent, the author of one’s own projects and the drive and will to act; the capacity to operate in a world of moral and aesthetic values; and, the possibility of having an attitude to time, an orientation to the future; these manifold aspects of the person and many more yet to be fully described are infuenced if not impaired by psychiatric diseases. Abnormalities and pathology in these domains are manifest in social behaviour and are without independent or objective markers. So, talk of norms, normality and abnormality are integral to any discussion of psychiatric phenomena, since in order to recognize impairments in these areas of function we need an understanding of what normal function entails, but more fundamentally what it means to talk about norms, normality and abnormality. The word normal is used correctly in at least four senses in the English language according to Mowbray et al. These are the value norm, the statistical norm, the individual norm and the typological norm. Thus the statement ‘It is normal to have perfect teeth’ is using normal in a value sense; in practice, most people have something wrong with their teeth. The statistical norm is, of course, the preferred use; the abnormal is considered to be that which falls outside the average range. If a normal Englishman is 5 feet 8 inches tall, to be either 6 feet 2 inches or 5 feet 2 inches tall is equally abnormal statistically. Following brain damage, a person may experience a decline in intelligence that is certainly a deterioration from his previous individual level but may not represent any statistical abnormality from that of the general population (for example a decline in intelligence quotient from 125 to 105).

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