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By: Y. Garik, M.S., Ph.D.

Professor, Duke University School of Medicine

Natalie: So what does a typical exam for a patient presenting with depression look like when they come to your office? Schachter: In our practice erectile dysfunction acupuncture purchase viagra on line amex, we occasionally prescribe antidepressant medication erectile dysfunction (ed) - causes symptoms and treatment modalities order 50mg viagra visa, but generally as a last resort erectile dysfunction treatment nhs buy discount viagra 25mg line, rather than a first option. We usually will try various natural treatment first. If these are not sufficient, we will usually add an antidepressant to the program, using as low a dosage as possible to try to avoid adverse effects. Frequently, when using various non-drug adjuncts, the dosage of antidepressant can be much lower. Schachter: We recommend a thorough evaluation with a full medical and psychological history, including what medications have been taken recently, a dietary evaluation, a variety of tests that may include: various vitamin levels (like vitamin D and B12 and others), a search for mineral toxicity (such as mercury), and mineral deficiencies, a urine test to measure neurotransmitters (like serotonin and dopamine), a saliva test to measure various hormones (such as DHEA, cortisol, sex. However, we have some general rules about avoiding sugar, caffeine, alcohol and tobacco and do give each patient a list of things to avoid and other things that are desirable. Natalie: I noticed that you mentioned earlier that you do give patients antidepressants on occasion. Do you believe they are effective in treating depression and in what instances would you recommend a patient take them? Schachter: In our practice, we occasionally prescribe antidepressant medication, but generally as a last resort, rather than a first option. We usually will try various natural treatment first. If these are not sufficient, we will usually add an antidepressant to the program, using as low a dosage as possible to try to avoid adverse effects. Frequently, when using various non-drug adjuncts, the dosage of antidepressant can be much lower. Also, in some very serious depressions, we might start the medication right away along with other measures we might use. The symptoms often give clues as to what a person needs. For example, a person who is lethargic, has dry skin, has gained weight and is constipated, may be suffering from an essential fatty acid deficiency as well as a low functioning thyroid gland. One who is anxious and agitated as well as depressed (see: Relationships between Anxiety and Depression ), may have excessive neuroexcitatory neurotransmitters along with a deficiency of serotonin. These need to be corrected starting with trying to correct the excitatory symptoms first (see: Depression and Anxiety Treatment ). Natalie: One of the things you focus on in the book is eating the proper foods. Schachter: Proper eating is important to treat depression and any other chronic conditions. Within our body, we have trillions of cells and an almost infinite number of biochemical reactions occurring each minute. In order for these biochemical reactions to work properly, the building blocks must be present. For example, our neurotransmitters (the messages that are transmitted from one nerve cell to another) are made from certain amino acids (like tryptophan or tyrosine). If a person has insufficient protein in his diet, he may become depleted of serotonin or dopamine and thus become depressed. Other examples may include deficiencies of the essential fatty acids necessary to build the membranes of our nerve cells. A person that eats and drinks primarily a junk food diet will be deficient in vitamins, minerals and other important nutrients. The importance of a good diet cannot be overemphasized. Natalie: Will a poor diet eventually lead to depression or rather is it a symptom of depression? Schachter: A poor diet may certainly contribute to depression in many people.

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One depends on the existence and availability of the reflection to produce the emotion of self-love erectile dysfunction related to prostate discount 100 mg viagra visa. The absence of a "compass" erectile dysfunction treatment new drugs generic viagra 100mg mastercard, an "objective and realistic yardstick" impotence yahoo answers purchase viagra australia, by which to judge the authenticity of the reflection. In other words, it is impossible to tell whether the reflection is true to reality - and, if so, to what extent. The popular misconception is that narcissists love themselves. He who loves only impressions is incapable of loving people, himself included. But the narcissist does possess the in-bred desire to love and to be loved. If he cannot love himself - he must love his reflection. Thus, driven by the insatiable urge to love (which we all possess), the narcissist is preoccupied with projecting a loveable image, albeit compatible with his self-image (the way he "sees" himself). The narcissist maintains this projected image and invests resources and energy in it, sometimes depleting him to the point of rendering him vulnerable to external threats. To a narcissist, love is interchangeable with other emotions, such as awe, respect, admiration, attention, or even being feared (collectively known as Narcissistic Supply). Thus, to him, a projected image, which provokes these reactions in others, is both "loveable and loved". The more successful this projected image (or series of successive images) is in generating Narcissistic Supply (NS) - the more the narcissist becomes divorced from his True Self and married to the image. I am not saying that the narcissist does not have a central nucleus of a "self". All I am saying is that he prefers his image - with which he identifies unreservedly - to his True Self. The narcissist, therefore, is not selfish - because his True Self is paralysed and subordinate. The narcissist is not attuned exclusively to his needs. On the contrary: he ignores them because many of them conflict with his ostensible omnipotence and omniscience. He does not put himself first - he puts his self last. He caters to the needs and wishes of everyone around him - because he craves their love and admiration. It is through their reactions that he acquires a sense of distinct self. In many ways he annuls himself - only to re-invent himself through the look of others. He is the person most insensitive to his true needs. The narcissist drains himself of mental energy in this process. This fact, as well as his inability to love human beings in their many dimensions and facets, ultimately transform him into a recluse. His soul is fortified and in the solace of this fortification he guards its territory jealously and fiercely. He protects what he perceives to constitute his independence. His convoluted mind comes up with the most elaborate contraptions in lieu of answers. Why should people indulge the narcissist, divert time and energy, give him attention, love and adulation? He feels that he deserves whatever he succeeds to extract from others and much more. Actually, he feels betrayed, discriminated against and underprivileged because he believes that he is not being treated fairly, that he should get more than he does. There is a discrepancy between his infinite certainty that his is a special status which renders him worthy of recurrent praise and adoration, replete with special benefits and prerogatives - and the actual state of his affairs. To the narcissist, this status of uniqueness is bestowed upon him not by virtue of his achievements, but merely because he exists.

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A depression also may be considered hard to treat if depressive symptoms keep reoccurring impotence occurs when cheap viagra 75 mg overnight delivery. Note: hard to treat depression is not defined in the Diagnostic and Statistic Manual of Mental Disorders (DSM) erectile dysfunction treatment brisbane order 25 mg viagra amex. The rate of treatment response to first-line depression treatment with SSRIs is between 40% - 60% herbal erectile dysfunction pills nz discount viagra online master card, but the rate of complete remission from depression is only 30% - 45%. This indicates that most people do not achieve complete remission from their first SSRI medication. Moreover, 10% - 30% of patients do not respond adequately to antidepressant treatment in general. Special report on why people with major depression sometimes switch antidepressant medications, why you should never suddenly stop your antidepressant and how to change antidepressants safely. Amy* was 21 and a college student when she experienced her first major depression. When she felt so bad she had to drop out of the school and move home, she finally saw a doctor. It was the golden years for Prozac (fluoxetine), one of the first selective serotonin reuptake inhibitors (SSRIs) to hit the market. With its relatively low risk of side effects and an efficacy similar to those of the older antidepressants, Prozac was touted as a miracle drug for depression. She was part of a small percentage of people in whom Prozac triggered feelings of agitation, nervousness, and restlessness, a condition called "akathisia. She went through nearly all the SSRIs, including Zoloft (setraline) and Paxil (paroxetine), most of the tricyclic antidepressants, including Elavil (amitriptyline), Norpramine (desipramine) and Pamelor (nortriptyline), and the norepinephrine reuptake inhibitor Effexor (venlafaxine). Her doctor tried adding other medications to the antidepressants, including the anti-epilepsy drug Depakote (divalproex ), the stimulant Ritalin (methylphenidate), the antipsychotic Abilify (aripiprazole), and even lithium, a medication which may help with depression but is typically prescribed for bipolar disorder, which Amy did not have. One of the largest studies ever conducted of antidepressant treatment for depression, the STAR*D (Sequenced Treatment Alternatives to Relieve Depression) found that only a third of patients fully recover from their depression on the first antidepressant tried. Inside, a depressed person often experiences a lot of anxiety ??? even leading to panic attacks. Of course, having panic attacks can itself be a depressing thing. Any lack of control within our lives can contribute to depression. Anxiety and depression disorders are not the same although there are similar elements. Depression generates emotions such as hopelessness, despair and anger. Energy levels are usually very low, and depressed people often feel overwhelmed by the day-to-day tasks and personal relationships so essential to life. A person with anxiety disorder, however, experiences fear, panic or anxiety in situations where most people would not feel anxious or threatened. The sufferer may experience sudden panic or anxiety attacks without any recognized trigger, and often lives with a constant nagging worry or anxiousness. Both anxiety and depression treatment are similar, which may explain why the two disorders are so often confused. Antidepressant medication is often used for anxiety and depression and behavioral therapy frequently helps people overcome both conditions. Although no one knows exactly why, depression and anxiety often occur together. In one study, 85% of those with major depression were also diagnosed with generalized anxiety disorder and 35% had symptoms of panic disorder. Other anxiety disorders include obsessive-compulsive disorder and post-traumatic stress disorder (PTSD). Because they so often go hand in hand, anxiety and depression are considered the fraternal twins of mood disorders. Believed to be caused in part by a malfunction of brain chemistry, generalized anxiety is not the normal apprehension one feels before taking a test or awaiting the outcome of a biopsy. A person with an anxiety disorder suffers from what President Franklin Roosevelt called "fear itself. Being chronically anxious is like being stalked by an imaginary tiger.

Finally erectile dysfunction treatment high blood pressure discount viagra 100 mg with visa, THERE IS NO REQUIREMENT THAT DIFFERENT PERSONALITIES BE VISIBLY DIFFERENT TO AN OBSERVER medicare approved erectile dysfunction pump buy generic viagra 25mg line. It is only necessary that each alter fulfill the basic function of an alter personality-- that is erectile dysfunction gnc products discount viagra master card, to protect the host personality from the knowledge and experience of the trauma. This task is accomplished by means of dissociative barriers or walls of amnesia. Thus a multiple could conceivably have dozens of alters that look just the same, but who, nevertheless, serve the function of walling off trauma from the host (and dispersing it among many alters). The answers to the above questions can now be more easily understood in light of the basic task of an alter personality. It is not required that these new alters look different, nor is it necessary that they all be active at one time; it is only necessary that they do their job (of containing the trauma of the abuse). The typical alters that are found in a person with MPD include: a depressed, depleted host; a strong, angry protector; a scared, hurt child; a helper; and, an embittered internal persecutor who blames (or persecutes) one or more alters for the abuse that has been suffered. While there may be other types of alters in any given MPD individual, most of them will be variations on the theme of these 5 alters. Although the data is not all in, the best estimate of the prevalence of MPD is that it approximates that of about 1% of the population. This estimate would translate into at least 2,000,000 cases in the U. Because MPD is directly linked to the prevalence of child abuse. The range of impairment across different persons with MPD is best analogized to that of alcoholism. Impairment due to alcoholism a) ranges from skid row bums to high functioning senators, congressmen, and corporate executives; and, b) varies in any given alcoholic from one period of time to another as a function of binges, patterns of drinking, life stresses, etc. There are some multiples who are chronic state mental patients, others who undergo recurrent hospitalization due to self-destructive behavior, and many more who raise children, hold jobs, and may even be high-functioning lawyers, physicians, or psychotherapists. If you are a multiple alters have, for the most part, been your good friends. It allows them to protect themselves and remain sane in the face of severe abuse. It allows them to endure the bad times and to keep their heart and soul safe from their abusers. If you doubt yourself this way, you can become confused or uncertain. You can also feel ashamed, frightened, or want to spend time alone. This self-doubt and confusion can make you feel bad about yourself. A person who is "multiple" will REMAIN "multiple" until successfully treated. About 90% of "multiples" are totally unaware they are MPD. A person who is "multiple" may appear to be fine for years and then suddenly begin to have strong symptoms- usually due to flashbacks of past trauma. Look for MPD if there is a pattern of:History of depression or suicidal behaviorChildhood history of physical, sexual, emotional, or psychological abuse... Hyde"Family history of dissociationDaytime enuresis or encopresisHistory of psycho-physiological symptomsHistory of nightmare and sleep disordersHistory of sleepwalkingReports psychic experiencesHistory of shifting symptom picture (one day symptoms of day symptoms of that)Two positive items from among 1-15 mandates consideration of a diagnosis of a dissociative disorder (e. Four or more positive items (especially among 1-15) mandates serious consideration of a diagnosis of Multiple Personality Disorder now known as Dissociative Identity Disorder. F or many observers, MPD is a fascinating, exotic, and weird phenomenon. For the patient, it is confusing, unpleasant, sometimes terrifying, and always a source of the unexpected.