By R. Barrack. College of Saint Benedict. 2017.

N evertheless buy 5mg buspirone, it had taken him 40 years to accum ulate his expertise and the largest m edical textbook of all – the collection of cases which were outside his personal experience – was forever closed to him. Anecdote (storytelling) has an im portant place in professional learning20 but the dangers of decision m aking by anecdote are well illustrated by considering the risk–benefit ratio of drugs and m edicines. In m y first pregnancy, I developed severe vom iting and was given the anti-sickness drug prochlorperazine (Stem etil). W ithin m inutes, I went into an uncontrollable and very distressing neurological spasm. Two days later, I had recovered fully from this idiosyncratic reaction but I have never prescribed the drug since, even though the estim ated prevalence of neurological reactions to prochlorperazine is only one in several thousand cases. Conversely, it is tem pting to dism iss the possibility of rare but potentially serious adverse effects from fam iliar drugs – such as throm bosis on the contraceptive pill – when one has never encountered such problem s in oneself or one’s patients. Chapter 5 of this book (Statistics for the non- statistician) describes som e m ore objective m ethods, such as the num ber needed to treat (N N T) for deciding whether a particular drug (or other intervention) is likely to do a patient significant good or harm. Decision making by press cutting For the first 10 years after I qualified, I kept an expanding file of papers which I had ripped out of m y m edical weeklies before binning the less interesting parts. If an article or editorial seem ed to have som ething new to say, I consciously altered m y clinical practice in line with its conclusions. All children with suspected urinary tract infections should be sent for scans of the kidneys to exclude congenital abnorm alities, said one article, so I began referring anyone under the age of 16 with urinary sym ptom s for specialist investigations. The advice was in print and it was recent, so it m ust surely replace traditional practice – in this case, referring only children below the age of 10 who had had two well docum ented infections. H ow m any doctors do you know who justify their approach to a particular clinical problem by citing the results section of a single published study, even though they could not tell you anything at all about the m ethods used to obtain those results?

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As long as the person’s attention remains focused on the pain syndrome buspirone 5 mg visa, there is no danger that the emotions will be revealed. It has been a recurrent observation of mine that the more painful the repressed emotion, the more severe the pain of TMS has been. The patient who is found to be harboring enormous anger as a result of childhood abuses, for example, usually has severe, disabling pain, and the pain disappears only when that person has an opportunity to express the terrible, festering rage that has occupied his or her unconscious for years—another example of the potential of anger to initiate the pain of TMS. EQUIVALENTS OF TMS As has been suggested, other physical disorders may serve the same purpose as TMS. Here is a list of some of the most common ones: Pre-ulcer states Tension headache Peptic ulcer Migraine headache Hiatus hernia Eczema Spastic colon Psoriasis Irritable bowel syndrome Acne, hives Hay fever Dizziness Asthma Ringing in the ears Prostatitis Frequent urination All of these disorders should be treated by one’s regular physician. Though they may be serving a psychological purpose they must be investigated and treated medically. The more that practitioners identify them as “purely physical” the more they assist in the defense mechanism, which means the continuation of the pain, ulcer, headache or whatever is going on. Physical (as opposed to psychological) defenses against repressed emotions are undoubtedly the most common because they are so successful. For example, excellent drugs have been found to reverse the pathology of peptic ulcer. One man in his midforties told me that ten years before he had started to have trouble with his low back; after many years it was relieved by surgery. A few months after the operation he began to have stomach ulcer problems, and that went on for almost two years. Finally it stopped and shortly thereafter the patient began to have neck and shoulder pain; it had been going on for almost two years and so he had come to see me. The back surgery and ulcer treatment didn’t alleviate his basic problem; they merely acted as placebos and mandated a shift in the location of his physical symptoms. There has been a decline in the incidence of peptic ulcer in the United States and Canada over the past twenty to thirty years, due in part to the effective drugs that have been developed. For a better explanation, however, I am indebted to columnist Russell Baker, who asked in one of his Sunday columns in the New York Times Magazine (August 16, 1981), “Where Have All The Psychology of TMS 51 the Ulcers Gone?

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