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In INTERSTROKE, we explored the association of anger or emotional upset and heavy physical exertion with acute stroke, to determine the importance of triggers in a large, international population.INTERSTROKE was a case-control study of first stroke in 32 countries. Using 13 462 cases of acute stroke we adopted a case-crossover approach to determine whether a trigger within 1 hour of symptom onset (case period), vs. the same time on the previous day (control period), was associated with acute stroke. A total of 9.2% (n = 1233) were angry or emotional upset and 5.3% (n = 708) engaged in heavy physical exertion during the case period. Anger or emotional upset in the case period was associated with increased odds of all stroke [odds ratio (OR) 1.37, 99% confidence interval (CI), 1.15-1.64], ischaemic stroke (OR 1.22, 99% CI, 1.00-1.49), and intracerebral haemorrhage (ICH) (OR 2.05, 99% CI 1.40-2.99). Heavy physical exertion in the case period was associated with increased odds of ICH (OR 1.62, 99% CI 1.03-2.55) but not with all stroke or ischaemic stroke. There was no modifying effect by region, prior cardiovascular disease, risk factors, cardiovascular medications, time, or day of symptom onset. Compared with exposure to neither trigger during the control period, the odds of stroke associated with exposure to both triggers were not additive.Acute anger or emotional upset was associated with the onset of all stroke, ischaemic stroke, and ICH, while acute heavy physical exertion was associated with ICH only.

Ventricular free wall rupture (FWR) is a catastrophic complication of that occurs after acute myocardial infarction (AMI), and at present, its clinical characteristics are unclear. We analyzed a total of 6,712 consecutive patients who presented with ST-segment elevation myocardial infarction (STEMI), and 78 patients with FWR after STEMI were enrolled in the study. Patients' demographic data, clinical manifestation, laboratory test results, and angiographic features were then collected and analyzed. FWR occurred in 78 cases (1.16%), and the inhospital mortality of FWR was up to 92.3%. Among the 78 FWR patients, 72 obtained accurate rupture time. FWR typically occurred within the first week after the infarct. Compared to late-phase FWR (more than 48 hours after STEMI) patients, early-phase FWR (during 48 hours after STEMI) patients showed significantly higher random glucose and higher percentage of anterior myocardial infarction. Besides, dual antiplatelet therapy (DAPT), β-blockers, and angiotensin-converting enzyme inhibitors/angiotensin receptor blocker (ACEI/ARB) were used less frequently in early-phase FWR patients. Moreover, we first reported the precipitating factors of FWR. Defecating, transporting, acute emotional upset, diets, and invasive treatment turned out to be the main triggers for FWR. Furthermore, we found that patients who survived from FWR were younger, had higher β-blocker coverage in the inhospital treatment, and had a higher frequency of primary PCI. FWR remains an infrequent but devastating complication of STEMI. We have found several factors related to the occurrence and prognosis of FWR. This study provides evidence for a better understanding of FWR.

Background. Vitiligo is not a well-studied disease in Ethiopia. Therefore, this study assessed its clinico-epidemiological profile and treatment patterns. Methods. An institutional-based cross-sectional study was conducted in conveniently selected dermatologic clinics of Mekelle city, Ethiopia. A two-phased study was conducted, in which the first was to determine prevalence of vitiligo while the second phase was to describe the clinico-epidemiological profile and treatment pattern of vitiligo. Four-hundred three randomly selected dermatological patients were included in the first phase study. The second phase study included vitiligo cases from the first phase study and additional vitiligo cases found in a two months period prospective study. Results. Of the 403 randomly selected dermatological patients who presented in the year 2017 to 2019, the prevalence of vitiligo was 13.15%. Of the 79 cases with vitiligo, nearly two-thirds (50, 63.3%) were males with five years as the median age at onset of the disease. Positive family history of vitiligo was recorded in about one-third (25, 31.6%) of the cases. Limbs (48, 44.5%) followed by the head and neck (26, 24%) were the most commonly affected parts of the body at the onset of the disease. The most prevalent clinical form of vitiligo was vulgaris (39.2%) followed by the focal type (26.6%). Emotional upset (24, 33.8%) and physical traumas (23, 32.4%) were the frequently reported triggering factors of vitiligo. Three-fourths (75.5%) of the cases had prescriptions of topical corticosteroids, and 24.5% of them had prescriptions of sun screen lotion. Conclusion. The prevalence of vitiligo was found to be high. The clinico-epidemiological profile of vitiligo in Ethiopia was similar with that found globally. However, treatment options of vitiligo were very limited in Ethiopia.

Whether or not the source of aortic pathology is Marfan syndrome (MFS) or other processes leading to development of abdominal aorta aneurysms (AAA), the awareness of pathology may lead to an emotional upset and low assessment of satisfaction with life.To assess, in regard to MFS patients with aortic pathology and to abdominal aortic aneurysm patients: 1) whether or not self-efficacy (SE) and health locus of control (HLoC) affect the patients' satisfaction with life; 2) whether the two groups of patients differ in terms of mental dispositions.The study population consisted of 16 MFS patients with aortic pathology and 16 AAA patients, 9 men and 7 women in each group. The mean age of the MFS patients was 28.5 ±8.214, and of the AAA patients 64.25 ±7.019. The following scales were applied: Generalized Self-Efficacy Scale, Satisfaction With Life Scale, Multidimensional Health Locus of Control Scale.Abdominal aorta aneurysms patients compared to MFS patients gave a higher rating for SE (In patients with aortic diseases, special attention must be paid to the state of personal resources (PR). Interactions made by medical professionals should focus on enhancing PR supporting the patients' self-knowledge on their SE. This will help to improve their satisfaction with life and form a positive attitude to the illness.Niezależnie od tego, czy źródłem choroby aorty jest zespół Marfana (MFS) lub inne procesy prowadzące do rozwoju tętniaków aorty brzusznej (AAA), świadomość choroby może prowadzić do zaburzeń emocjonalnych oraz niskiej oceny satysfakcji z życia.Ocena pacjentów z MFS z patologią aorty oraz pacjentów z tętniakiem aorty brzusznej: 1) czy skuteczność własna (SE) i umiejscowienie kontroli zdrowia (HLBadaniem objęto 16 chorych z MFS z patologią aortalną oraz 16 pacjentów z AAA. W każdej grupie było 9 mężczyzn i 7 kobiet. Średni wiek pacjentów z MFS wynosił 28,5 ±8,214 roku, a pacjentów z AAA – 64,25 ±7,019. Zastosowano następujące skale: Skalę uogólnionej własnej skuteczności, Wielowymiarową skalę umiejscowienia kontroli zdrowia oraz Skalę satysfakcji z życia.Pacjenci z AAA oceniali swoją SE wyżej niż pacjenci z MFS (U pacjentów z chorobami aorty należy zwrócić szczególną uwagę na stan zasobów osobistych (PR). Działania prowadzone przez pracowników ochrony zdrowia powinny skupiać się na edukacji i wspieraniu pacjentów. Pomoże to zwiększyć satysfakcję pacjentów z życia oraz poprawi ich podejście do choroby.

We thank Culic for his comments on our recent publication,1 but we wish to make 2 comments. First, we would like to clarify the assessment methods of physical exertion. Participants were asked about physical exertion in 2 ways: as a potential triggering event in the hour before acute myocardial infarction (AMI) and in the same hour on the previous day, and the usual level of physical activity. Therefore, we must clarify that we do not know whether mild to mderate physicial activity preceded AMI; instead we know that 24.6% of …

In their intriguing analysis of triggering events for acute myocardial infarction within the INTERHEART study population, Smyth et al1 found a relatively high percentage of physical activity and anger or emotional upset (13.6% and 14.4%, respectively) as an immediate precedent. Certainly, it is important to acknowledge the limitation that the INTERHEART …

A recent analysis of data from the INTERHEART study1 confirmed that physical exertion and anger or emotional upset can trigger acute myocardial infarction (AMI) and that those triggers have an additive effect when they come together. At the same time, the results confute some previous observations on effect modification by individual characteristics or cardiovascular prevention medication.1 However, 2 issues seem to be worth noting. In the INTERHEART study, physical exertion was reported by 13.6% of participants during the case period.1 The estimated population attributable risk (ie, number of AMIs that could have been avoided if there has been no …

This study was conducted with adolescent children from a probabilistic sample with national representation from both rural and urban areas, in Mexican households eligible for services from the federal social program known as Oportunidades and characterized by conditions of extreme poverty. Participating were 1,093 youth of whom 61 % live in urban localities and 56 % are males, with an average age of 14.92 (±1.29) years and an average number of completed years of schooling of 8.33 (±1.71). The results indicated that the subjective well-being of these adolescents was dependent on a positive self-concept (self-esteem and strength), positive interactions with their parents (respectful, understanding and close) and with their friends (supportive), with importance placed on their studies, and the absence of emotional upset (stress or depression). Among the population studied, males and those younger, as well as those who only study, reported greater subjective well-being.

As identified by quantitative electroencephalography, statistically abnormal brain wave patterns were observed when a person thought about a trauma when compared with thinking about a neutral (baseline) event. Reassessment of brain wave patterns (to the traumatic memory) immediately after thought field therapy diagnosis and treatment revealed that the previous abnormal pattern was altered and was no longer statistically abnormal. An 18-month follow-up indicated that the patient continued to be free of all emotional upset regarding the treated trauma. This case study supports the concept that trauma-based negative emotions do have a correlated and measurable abnormal energetic effect. In addition, this study objectively identified an immediate energetic change after thought field therapy in the direction of normalcy and health, which has persisted.

Urticaria is a common dermatosis characterized by spontaneous recurrent bouts of hives. A common belief is that the tedious search for an underlying cause of spontaneous urticaria is fruitless, and even when successful an appropri- ately dealt with, is not necessarily followed by complete resolution of symptoms. In contrast, urticaria has a great impact on patients' quality of life. These patients suffer considerable loss of energy, sleep disturbance, and emotional upset. Urti- caria remains a big problem in term of etiology, pathogenetic mechanism, and pharmacologic treatment. Whereas text- books and reviews on the topic of urticaria devote limited space to investigations and optional trial therapies for the entity, this article is devoted to the subject. A three-step template for the treatment of urticaria is offered which may prove help- ful for you and your patients.

It has long since been suggested that people can suffer a ‘broken heart’ as a result of severe emotional upset. However, the phenomenon of ‘broken heart’ has only recently been subjected to rigorous scientific enquiry where it now formally recognized as acute stress cardiomyopathy. Acute stress cardiomyopathy, a distinct form of acute dilated cardiomyopathy, results in abrupt left ventricular dysfunction which can be acutely damaging and potentially fatal. However, the old adage ‘time mends a broken heart’ rings true with this condition as prognosis is very favorable with a period of time and appropriate nursing and medical care.

Aim. This paper reports a study to assess the interrelationships between physiological measures of children's heart rates and blood pressure, subjective measures of children's level of anxiety, and direct behavioural observations in children's emotional responses to surgery. Background. Psychological upset has been described as a multidimensional phenomenon which includes behavioural, subjective, and physiological components. However, a majority of previous studies have employed only one or two measures of psychological upset. Most importantly, the interrelationships among these three components of psychological upset have seldom been explored. Methods. A cross-sectional design was employed, and 106 Chinese children admitted for day surgery during the summer of 2004 were invited to participate in the study. They were asked to respond to the Chinese version of the State Anxiety Scale for Children. Their mean arterial blood pressure and heart rates were recorded in the operating theatre after being transferred to the operating table but before anaesthesia induction. A research nurse used the Children's Emotional Manifestation Scale to document the children's emotional behaviours during anaesthesia induction. The data were collected in 2004. Results. Children with high preoperative anxiety levels manifested more negative emotional behaviour during anaesthesia induction. Those with more negative emotional behaviour or high levels of state anxiety also had faster heart rates and higher mean arterial blood pressure. Conclusion. A child's response to stressful medical procedures can be varied. The emotional responses of children to surgery need to be understood as a multidimensional phenomenon. To gain a more comprehensive understanding of the effects of surgery on children, it is recommended that assessment strategies used should reflect the multidimensional phenomenon of the emotional upset.

鼠径ヘルニア根治術を受ける３～７歳の子どもと保護者を対象に，家庭でのVTR視聴をメインとしたプレパレーションの有効性をランダム化比較試験により検証した。入院前の時点で，２群への無作為割り付けを行い，対照群（n=31）には従来のケアすなわち「外来での術前オリエンテーションビデオ（以下，VTR）の１回のみの集団視聴」を行い，介入群（n=28）には従来のケアに加え「各家庭におけるVTRの反復視聴」を小冊子に沿って子どもに行うよう保護者に依頼した。経時的な子どもの心理的混乱を主要アウトカムとし，介入前１回，周手術期２回，退院時１回，退院後３回（退院後１ヶ月の時点まで）の計７回，測定した。周手術期のバイタルサインや，親の不安も評価した。 結果，「子どもの心理的混乱（代理評価）（p=0.01）」，「麻酔導入時の協力行動（p=0.04）」，「周手術期の体温（p=0.003）および心拍数（p=0.02）」において介入効果が得られた。 一方で，介入の有無に関わらず，退院後の子どもの退行行動は問題を呈したことから，医療者は，術前のみならず術後においても，子どもと保護者の精神面のアセスメントとフォローを行う必要性が示唆された。 今回，VTRの反復視聴をメインとする家庭でのプレパレーションによって，子どもの周手術期の心理的混乱や生理反応が緩和された一方で，子どもの退行行動および母親の不安に関しては介入の有効性が明らかにはならなかった。

BACKGROUND: Despite large numbers of blood donors being notified of abnormal infectious disease screening results, there has been little scientific study of the effects of this process. STUDY DESIGN AND METHODS: With a 28-item questionnaire, an anonymous mail survey was conducted of 4141 blood donors notified of 15 distinct categories of abnormal infectious disease screening and confirmatory test results. RESULTS: The survey had a 42 percent response rate, and 10 percent of the respondents did not recall being notified of their results. Of the 1556 respondents who recalled being notified, 27 percent contacted the blood center for further information, 60 percent discussed their results with a health care provider, and 73 percent of permanently or indefinitely deferred donors correctly understood their deferral status. Confusion and emotional upset were reported in 81 and 75 percent of notified donors, respectively. CONCLUSIONS: The notification process appears to achieve most of its aims in the majority of donors. Nevertheless, some donors did not understand that they were ineligible for future donation, and many donors were confused and upset. These data indicate that the adverse impact of notifying donors about abnormal test results needs to be considered when new blood donor screening tests and confirmatory algorithms are being licensed and implemented. Further studies of the effectiveness of newer revised donor notification materials are needed.

One hundred fourteen headache sufferers recorded their headaches, stressful events, appraisal processes, and coping responses over a 28 day period. Stressful events were found to precede headache attacks more often than periods of headache freedom. Primary appraisals (how much the event mattered), levels of affective regulation coping and ratings of emotional upset were all higher for stressful events that were not associated with subsequent headache. Stressful events occurring during headache were followed by increases in the intensity of the attack. In such instances, avoidance coping was associated with higher ratings of headache intensity following the event and direct coping with lower post-event ratings. It was concluded that stressful events may be causally related to headache and that the ways in which headache sufferers respond to these events may also have implications for the onset and intensity of attacks.

Cyanotic breath-holding spells are generally benign and resolve spontaneously by 4 to 5 years of age. Treatment with iron and other drugs has been employed in selected cases with very frequent and severe episodes. We describe a 10-year-old boy with recent-onset cyanotic breath-holding spells that were activity limiting. He was unable to participate in physical activities with his peers as any argument or emotional upset provoked these spells. Treatment with oral iron and piracetam was ineffective. However, treatment with oral theophylline produced dramatic amelioration of symptoms, and he was once again able to participate in play activities with his peers. We believe that general central nervous system stimulant and respirogenic effects of theophylline were instrumental in control of symptoms in our child.

Cumulative risk assessment posits that multiple agents work together to induce disease and that multiple stressors therefore must be considered in order to gain a true understanding of why adverse health effects occur.1 Now a small but growing number of scientists are pushing the envelope by investigating whether chronic psychological stress might be one of those factors, enhancing a child’s vulnerability to certain chemical exposures and contributing to effects that later show up as asthma, neurodevelopmental disorders, cardiovascular disease, obesity, cancer, and other problems. These researchers are also starting to identify biomarkers that may shed light on the mechanisms by which psychological stress acts on a child’s developing immune system and brain to modify or enhance the response to certain pollution exposures such as traffic-related air pollutants and lead. “We really don’t know how broadly such interactions may occur across chemicals. They are much more likely to occur when the chemical itself acts directly upon stress systems,” says Deborah Cory-Slechta, a professor of environmental medicine at the University of Rochester School of Medicine & Dentistry. “We know some chemicals that interact with stress, such as lead exposure, but we don’t know which others do.” Observations of links between stress and disease date back to at least the twelfth century, when the philosopher Maimonides cited emotional upset as a factor in asthma.2 But proving such links poses a significant challenge, says Malcolm P. Cutchin, a professor at the School of Medicine of the University of North Carolina at Chapel Hill. “Much has been hypothesized about the linkages, but we are just now beginning to tease out relationships and understand the processes,” Cutchin says. As researchers have learned more about techniques that can identify chemical and stress exposures in the human body, they have begun to apply techniques to estimate how people respond to stress and how that response, if it goes awry, can facilitate the development of diseases.

James Spence deserves great credit for his work with mothers and babies and his contributions to our understanding of “the purpose of the family”,1 but he was not the first to recognise the need for mothers to nurse their own infants. Perhaps the most remarkable of his predecessors never seems to have received credit for his vision and common sense. James H Nicoll, Surgeon of the Western Infirmary and the Royal Hospital for Sick Children, Glasgow, gave a paper to the Section of Surgery of the 77th Annual Meeting of the British Medical Association in July 1909.2 Drawing on his experience of some 9000 operations on children, he advocated that whenever possible children under 2 years of age should be treated as outpatients. After operation without a mother, he said a child was “all over the bed” and “if splinted his crying and struggling put fresh strain on his sutures”. He concluded that the small child would “do best in their mother’s arms, and nest there more quietly on the whole, than anywhere else”. Perhaps more surprising to the contemporary reader, however, is Nicoll’s statement: > “for seven years I have had a small house, near the Glasgow Children’s Hospital, for the accommodation of young infants and their mothers. The mothers are catered for, and themselves nurse their infants. My experience of the cases so treated has been such as to make me confident in the opinion that no children’s hospital can be considered complete which has not, in the hospital or hard by, accommodation for a certain number of nursing mothers whose infants require operation”. During World War I at the instigation of Miss Geeta Rowell, recently returned to Newcastle from Italy, an anonymous donor purchased a house on West Parade in Newcastle and gave £500 to equip …

The purpose of this study was to determine whether patient reporting of a relationship between seizure exacerbation and menses helps distinguish premenopausal women with epileptic seizures from those with nonepileptic seizures (NES). We reviewed the responses to the question "What tends to bring on your seizures?", administered during the initial evaluation of women ages 18–45 years with epileptic seizures ( n = 27) and NES ( n = 38) at our outpatient clinic. Only one out of 38 women with NES versus 13 of 27 women with epilepsy reported a relationship of seizures with the menstrual cycle ( p = .0001). Other precipitants identified for seizure exacerbation such as stress, or emotional upset, did not distinguish these two groups. Patient reporting of a relationship between seizure exacerbation and menses can help distinguish epileptic from NES in premenopausal women.

Ventricular arrhythmia exhibits considerable within-subject variability that cannot be attributed to clinical status alone. This investigation examined the extent to which cardiac arrhythmia was associated with psychological and physical factors assessed during the hour preceding arrhythmic or nonarrhythmic activity. Approximately twice hourly, 46 patients randomly completed a diary assessing mood and physical symptoms during 24-hr electrocardiographic monitoring. Greater negative emotion was associated with increased arrhythmia. Additionally, greater negative emotion was significantly associated with increased arrhythmia among participants in a low left ventricular ejection fraction group (LVEF). However, this relationship between negative emotion and arrhythmia was not observed among higher LVEF participants. These findings contribute to a larger body of evidence suggesting that negative moods may exacerbate cardiac conditions.

Hereditary trembling chin is an autosomal dominant condition characterized by recurrent bouts of tremor involving the chin. These episodes are precipitated by emotional upset. There has been considerable debate about the gravity of this condition. This may be a benign movement disorder; however, the rhythmic trembling of mentalis at rest or during times of stress in these patients is often misinterpreted as betraying an incipient emotional upset. For this reason, some patients with this condition may find it socially disabling. We have recently successfully treated one such family with regular botulinum toxin injections to the mentalis muscle. ( J Child Neurol 1992;7:154-156).

The aim of this article is to present a selective review of the research on children’s psychological responses to hospitalisation. Children vary in their capacities to cope with the stress of hospitalisation. A significant proportion of them, however, suffer from some degree of emotional disturbance due to the experience. Prolonged and repeated hospitalisation increases the chance of later problems. The separation of the child from familiar figures during admission may be the cause of some of the emotional upset. Younger children, especially those between the ages of 6 months and 4 years are most vulnerable. Individual factors such as the children’s temperament and intelligence contribute to their style of coping and thus may influence both the short term and long term effects of hospitalisation. Children who take an active coping role are more cooperative with hospital staff and show less disturbance after discharge. The preparation of children for the experience of hospitalisation has proven to be very effective in reducing their emotional distress during admission.

Myocardial infarction has been shown to have a circadian pattern of occurrence, with a significantly increased incidence in the early morning hours. 1 Recognition that onset of acute coronary syndromes may not occur as a random event has led investigators to search for triggers of myocardial infarction. 2 Both psychological and physical stresses have been implicated as possible triggers. However, thus far only excessive physical exertion has been temporally linked to onset of pathologically documented acute myocardial infarction. 3 We report the first case of an acute myocardial infarction associated with extreme emotional upset, which resulted in cardiogenic shock and was successfully reversed by rapid treatment with thrombolytic therapy.

Myocardial infarction (MI) usually results from thrombotic coronary artery occlusion at the site of a ruptured atherosclerotic plaque. The factors responsible for triggering MI are not known but conditions that increase serum catecholamines may be involved. Accordingly, the authors prospectively evaluated the presence of factors that may increase catecholamines immediately prior to MI in 186 patients. Myocardial infarction was documented by a rise in serum CK-MB. There were 149 men and 37 women, aged 57 +/- 12 (mean +/- SD) years. All patients were interviewed within 72 hours of admission concerning strenuous physical activity, emotional stress, and assumption of the upright posture immediately prior to the onset of symptoms. Seventy-five (40%) patients had one or more of these factors immediately prior to the onset of MI chest pain. Fourteen (8%) experienced acute emotional upset; 28 (15%) were involved in strenuous physical activity; and 39 (21%) had suddenly changed position. In the latter group, 18 changed from being supine for more than 1 hour to standing; three rose from supine to sitting; and 18 changed from prolonged sitting (greater than 60 minutes) to standing. The conclusion is that a potential triggering factor is present in many patients immediately prior to the onset of MI. A sudden change in position is the most frequent potential trigger, typically occurring the morning after awakening from sleep.

Erectile dysfunction is much more common than generally supposed, with an estimated prevalence of 10% in men of all ages and 1.9% in men $40 years of age (1). It is nearly always constitutional or psychogenic in origin. The onset may be gradual or, in the case of a precipitating emotional upset, it may be sudden. Often, a vicious cycle is quickly established: the more the man fails, the more likely he is to fail. Treatment consists of a psychodynamic and behavioral approach combined with medical management (2).

In the early part my medical career I was full of the enthusiasm and overwhelming confidence about my clinical skill that one generally finds in a novice. A 19 year old college student was admitted with complaints of not talking and giddiness. The history included an emotional upset, as she had quarrelled with her mother before the onset of the symptoms. When I examined her, she was conscious but kept her eyes tightly …

Stress-induced cardiomyopathy is described as an acute cardiomyopathy that occurs under the influence of an excessive level of catecholamine related to intense emotional stress. A 64-year-old woman presented with symptoms of acute myocardial infarction after emotional upset, but her coronary angiographic findings were revealed to be normal. Diffuse T wave inversions were observed in her electrocardiograms with akinetic wall motions sparing the basal segments in her left ventriculography. After four months, her electrocardiogram and echocardiogram findings had completely returned to normal. The precise diagnosis of this acute cardiomyopathy must be emphasized because it can initially be misdiagnosed as acute coronary syndromes. However in complete contrast to acute myocardial infarction, it has a rapid and favorable recovery with hardly any sequelae after a few months.

A group of detained Scottish Young Offenders were assessed shortly after being placed on Strict Suicidal Observation. Suicidal intent and medical lethality were, in most cases, particularly low. Methods of parasuicide varied, the majority of inmates verbally threatening suicide or exhibiting minor wrist laceration while a small number adopted cell arson, swallowed objects or used the unpredictable and dangerous method offeigned hanging. A voidance of expected inmate confrontation, manipulative intent and emotional upset were the prime motivators for parasuicidal behaviour-psychiatric disturbance playing a minor role. Our findings are discussed in relation to penal setting and parasuicide in the general population.

The General Health Questionnaire has had some popularity as an index of minor psychiatric morbidity and was used in the present study to ascertain the emotional state of newcomers to a practice in a new town. High scorers on the GHQ had more episodes of illness, had more severe ratings of psychological problems, and were more likely to receive a formal psychiatric diagnosis than were low scorers. A second survey one year later confirmed the variability of response to the GHQ, inherent in a ‘present state’ inventory. Doubts are expressed as to the psychiatric nature of the emotional upset measured by the GHQ.

Evaluating a method of treatment depends on the ability to define outcome. While this is easy if the outcome measures are concrete, such as survival, recurrence of disease or return to work, it is very difficult when outcome depends on assessment of the quality of a patient's life. This is particularly relevant in cardiac rehabilitation. Regression analysis has been used to predict physical, psychological and social outcome in 72 patients one year after a myocardial infarction using information available while the patients were in hospital recovering from the acute illness. Some aspects of outcome were successfully predicted: employment prospects, continuing emotional upset and the patient's attitude to and complaints about residual problems and difficulties. The study has shown the value of using multiple regression techniques which allow all putative predictors to be considered together, thus facilitating the elimination of relatively unimportant measures.

Out-patient surgery for infants and children offers the advantages of minimal emotional upset, less risk of infection, and fiscal economy. Many different operations can be done in the out-patient department and most children can be accepted for general anaesthesia for these operations. Preparation of the child is similar to that required for in-patient surgery. Premedication is unnecessary and contraindicated. A variety of techniques may be selected for induction of anaesthesia without unduly prolonging recovery. General inhalation anaesthesia with halothane is preferred for maintenance. Careful tracheal intubation should be utilized whenever indicated. Regional analgesia has many advantages over narcotic analgesics in the treatment of post-operative pain. A follow-up service should be provided.

From a telephone survey of 1,673 Montreal women, all consenting psychotrope users and randomly selected controls (N = 179) then were interviewed in their homes as to psychotropic drug and alcohol use. The results presented are based on these in-depth interviews. In the first phase of the analysis, the respondents were grouped according to whether they abstained from both alcohol and psychotropes, used alcohol alone, psychotropes alone, or both. The variables that distinguished these groups were determined by use of one-way analysis of variance. Some of these factors included age, level of education, anxiety, nervous tension, depression, subjective ratings of health, and responses to emotional upset. The second series of results involved correlation procedures to determine the covariates of alcohol and psychotrope use. Most significant of these findings were that psychotrope use was associated with anxiety, depression, and nervous tension, while alcohol use was not. Further, unlike alcohol use, psychotrope use was associated with a variety of coping techniques for dealing with emotional upset. The findings were interpreted to mean that there are two distinct populations.

The purpose of this paper is to indicate that many psychoneuroses are essentially upsets of the autonomic nervous system, that in many cases we are not dealing with an emotional upset, but with the secondary autonomic disorder caused by that upset, and that this autonomic disorder is to the patient the essential part of his or her illness and the suffering from which he or she desires relief. Accordingly in such cases therapy should be pharmacological by drugs specific for the type of upset present. Such therapy gives excellent results, especially in early cases. Toxic or psychological factors which are still operating must, of course, be dealt with by appropriate measures, but even in such cases pharmacological therapy proves a useful auxiliary. If, after elimination of those causal factors the resultant autonomic upset persists. pharmacological therapy is essential to bring about a complete cure. This has been proved to us by observation of the failure of persistence in psychotherapy in such cases with subsequent relief by pharmacological therapy.

We report below the occurrence of congenital intermittent vertical nystagmus in a father and son who were in all other respects normal. So far as we can determine, such a case has never been previously reported. Report of Case Case 1. —A 28-year-old male graduate student at the University of California had suffered from attacks of vertical nystagmus since the age of 7 months. These attacks which were usually precipitated by fatigue or emotional upset, occurred at least once a day, were sudden in onset, lasted 20 to 30 minutes, and subsided spontaneously. No aura preceded these spells, but the patient recognized their onset by experiencing blurred vision and rapid vertical oscillation of the environment (oscillopsia). During an attack he could minimize the blurring by looking down and tilting his head back. He had never experienced any alteration in consciousness before, during, or after these attacks. No nausea, vomiting, tongue-biting

We report a 10-year-old boy with mild developmental delay and epilepsy with new events of right back tickling and emotional upset. These initially appeared behavioral, causing postulation of habit behaviors or psychogenic nonepileptic seizures. Several ictal and interictal EEGs were unrevealing. Continuous EEG revealed only poorly localized frontal ictal activity. Given that his clinical symptoms suggested a parietal localization, double-density EEG electrodes were placed to better localize the epileptogenic and symptomatogenic zones. These revealed evolution of left greater than right frontoparietal discharges consistent with seizures at the time of the attacks. Medical management has significantly reduced the patient's seizures.

A study of 151 new outpatients attending a dermatology clinic in Bristol, England, has been performed to determine what patients with skin disease believe and are told about their condition. The factor most commonly blamed as a causative agent by the patients was worry or emotional upset. Forty-one percent of the patients had used self-medication before going to their general practitioner (GP). Forty-five percent of patients had attended their GP on 4 or more occasions before their referral to hospital. Forty-one percent felt the GP's treatment had either done no good or made things worse, and 13% had experienced some side-effects from treatment. Forty-two percent of patients had been given a diagnosis by their GP but only 16% had been told whether the condition was contagious. Eighteen patients believed they had a contagious disease, but this was subsequently confirmed by the hospital doctor in only 6 cases. Six patients had a skin cancer, but none of them appeared to suspect this diagnosis.

A person in crisis is at a turning point. He faces a problem that he cannot readily solve by using the coping mechanisms that have worked for him before. As a result, his tension and anxiety increase, and he becomes less able to find a solution. A person in this situation feels helpless—he is caught in a state of great emotional upset and feels unable to take action on his own to solve his problem.

Summary Emotional disturbances in children often develop in the setting of physicalillness. An understanding of the meaning of the illness to the child is helpful in the prevention of lasting emotional upset. To many children illness comes as punishment. A common psychologic reaction is a regression to an immature level of social and emotional adaptation. While many children react to illness in a constructive way, others may respond with persistent dependency patterns, rebellion, or chronic invalid reactions. Attention to the psychologic needs of the child during the convalescent period is also important in the over-all care of the sick child.

Within the framework of Hebb's dissonance theory (Hebb, 1949) marked discrepancies between expected and observed perceptual experience result in an unpleasant affective state. This emotional upset is characterized by disorganization and stereotyping of thinking and/or behavior patterns and the organism is motivated to reduce the state. Rats have been shown reliably to display more defecation and less ambulation when exposed to a strange environment and both of these responses may be considered indices of emotional upset in the animal (Hall, 1934, 1936; Broadhurst, 1957). Recent research (Grumpelt, et al., 1969) suggested that intense inter-sense perceprual dissonance was one of the factors responsible for the emotional upset usually contingent upon a new experience with a particular kind of motion. In an attempt to replicate these findings and further explore their implications, 180 female rats (Holtzman strain), approximately 130 days old, were randomly assigned to 12 groups of 15 rats each in a 3 by 4 design. Drug type was one variable (10 mg/kg diazepam, 0.4 mg/kg meclizine hydrochloride or mammalian saline solution, all orally administered 90 min. prior to testing) and motion-dissonance condition was the second. A previously described (Grumpelt, et al., 1969) acetate test cage and surrounding display, which could be rotated independently, allowed design of the following groups: motion-dissonance, M-D, motion alone, M, dissonance alone, D, and no-motion-no-dissonance control, C. It was hypothesized that diazepam, a tranquilizer, might reduce emotional upset effects on D groups while meclizine hydrochloride, an anti-motion sickness agent, might reduce these effects on M groups. Diazepam was chosen because it has no demonstrated peripheral autonomic blocking action or extrapyramidal side effects (Randall, et dl., 1961) while meclizine has no known effects except on the vestibular nuclei. The specific meclizine dosage Level was established after pilot work but it appeared that an appropriate dosage level of diazepam could be estimated from the literature. Measures of ambulation and defecation were used (cf. Grumpelt, et al., 1969) to assess emotional upset. A factorial analysis of variance on ambulation scores yielded a significant main effect of motion-dissonance treatment (P = 6.71, df = 3/168, p < ,005); however, the drug treatment (P = 2.21, df = 21168) and the interaction (F = 0.91, df = 6/168) were nonsignificant. A similar analysis of defecation scores also indicated that motion-disso

I N a previous report’ I discussed the subject of emotional disturbance as a cause of an acute cardiac insult. I presented some of the possible physiologic and pathologic changes responsible for such an insult under emotional strain. The following case, which was sent to me for review by a physician from Los Angeles, further illustrates the causal relationship between a severe emotional upset and an acute myocardial infarction. The case is of interest because the condition occurred in an apparently perfectly healthy person, forty-two years of age, an airplane pilot who usually is not easily disturbed by danger or by an exciting event. It also illustrates the intermittency of subjective manifestations as the pathologic process progressed for about two days before the diagnosis was established. During this interval there were periods when he felt quite well, and even piloted his plane over a stretch from the West Coast to Hawaii without discomfort. It is hoped that more cases illustrating the effect of emotion and strain upon the heart will be brought to our attention.

Surgical operations, although necessary for the patient's life and health, are frightening and upsetting. The adult recovers from this emotional upset in a reasonably short time and does not necessarily show in his later emotional reactions the effects of the operation. This is not so true of the child. His emotional development, that is, his capacity to handle his emotional reactions, is still incomplete. His ego has not acquired a very stable ability to test reality. His knowledge of his own physiology and anatomy is meager and is confused with weird speculations about the inside of his body, and he is reticent about discussing these weird ideas with adults lest he be laughed at, as has happened so often. When he has to have an operation, he is seldom told what is going to happen to him and may even not be told that there is to be an operation