By W. Tippler. City University of Los Angeles.

Ischemic ophthal- toms start under certain circumstances [1]: mopathy is a specific actonel 35 mg without prescription, concomitant disorder of uncompensated generic actonel 35 mg without prescription, critically reduced perfusion pressure on standing up very quickly, even if postural due to internal carotid artery occlusive disease. Quite hypotension cannot be demonstrated in the clinic characteristic is the history of a gradual, progressive immediately after a heavy meal loss of visual acuity, occasionally with bouts of in very hot weather obscuration, leading to a slowly progressive, irrevers- with exercise, coughing or hyperventilation ible damage of the retinal neuronal layer. Further during Valsalva maneuver (but embolism is typical findings are neovascularization of the retina another possibility) and iris (rubeosis iris) [2]. The vertebral artery is usu- ated with severe large artery disease with exhausted ally compressed at the atlantoaxial C1–C2 level. Itis Tendinous insertions, osteophytes or degenerative characterized by 30–60 sec episodes of repetitive changes resulting from cervical spondylosis may be jerking movements of contralateral arm and/or leg the cause of compression. The symptoms usually point towards a seizure- with a mixed downbeat torsional and horizontal beat- like activity and are often misdiagnosed as focal ing nystagmus which may spontaneously reverse dir- seizures. The labyrinth is predominantly supplied shows no somatotopic spread of movement activity by the internal auditory artery, which is usually a (no Jacksonian march) and usually has a low branch of the anterior inferior cerebellar artery frequency (about 3 Hz). A 55-year- old woman with risk factors (metabolic syndrome, smoking) presented with a limb shaking of the left leg when standing. Brief episodes of rotational vertigo can also symptoms such as vertigo, diplopia or blurred vision be caused by compression of the vestibular nerve as (Figure 9. Drop attack and vertebrobasilar ischemia Subclavian steal syndrome and hemodynamic effects “Drop attacks” are episodes of sudden loss of postural of proximal vertebral artery disease tone which cause the subject to fall to the ground Most patients with subclavian artery stenosis or without apparent loss of consciousness, vertigo or occlusion are asymptomatic. Among 116 patients with unilat- immediately after the fall despite being uninjured. With vertebrobasilar ischemia, sudden able to significant subclavian or innominate artery Section 3: Diagnostics and syndromes Figure 9. An 82-year-old woman with insulin-dependent diabetes mellitus suffered from recurrent short episodes with nausea, vertigo (sensation of being turned around), sweating, blurred vision, weakness and sudden falling without losing consciousness. Symptoms which have been associated Hyperviscosity and low flow with decreased anterograde flow or retrograde flow Blood flow in the brain is determined by the size of in the vertebral artery are episodes with dizziness, blood vessels, blood pressure and hemorrheological diplopia, decreased vision or oszillopsia. Abnormal changes of blood plasma are brief and may be elicited by exercise of the arm. Waldenstrom’smacro- A difference in the wrist or the antecubital pulses and globulinemia or paraproteinemia), increase in cell a difference of blood pressure between the two arms counts (e. Causes of stenosis or occlusion of the verte- red cell deformability (sickle-cell anemia, spherocytosis, bral artery are: arteriosclerosis, Takayashu disease and hemoglobinopathies) lead to a hyperviscous state [9]. Symptoms Most patients with subclavian artery stenosis or are often unspecific, such as headache, dizziness or occlusion are asymptomatic. Low may include episodes with dizziness, diplopia, flow and/or increased coagulability may be the cause decreased vision or oszillopsia. Different ischemic patterns Severe stenosis or occlusion of the proximal verte- have been described, such as lacunar infarction, bral artery is more likely to be a cause of embolism boundary infarction, Binswanger’s disease or large than to have hemodynamic effects: among 407 artery (territorial) infarction. In sickle-cell anemia, patients in the New England Medical Center Posterior deformability of red cells is decreased. This may cause Circulation Registry 80 of 407 patients had severe damage in the microcirculation, particularly in the stenosis or occlusion of the proximal vertebral artery. In 45 of the 80 (56%) embolization was the most likely But large-artery occlusive disease, occasionally with cause of cerebral ischemia. Twelve of these 13 patients had with mucous membrane bleeding, blurred vision, 138 severe bilateral occlusive disease of the vertebral visual loss, lethargy, headache, dizziness, vertigo, tin- artery [8]. A 65-year-old with hypercholesterolemia was referred to the hospital because of a sudden weakness of left face, arm and leg. Symptoms disappeared after about 10 minutes but over the next 5 hours he had four further identical episodes lasting for several minutes. The next day he suffered a lacunar stroke in the internal capsule with persisting pure motor hemiparesis. It is assumed that the occlusion of a single perforating artery (lenticulostriate artery) was the cause of the lacunar infarct. In situ small- vessel disease (microatheroma or lipohyalinosis) is considered to be the most likely mechanism. The term “capsular stroke and has been explained by an occlusion of the warning syndrome” describes the phenomenon in “top of the basilar artery” at the origin of the posterior 139 which the infarct may be preceded by repetitive, cerebral arteries [11]. A 65-year-old patient with known Parkinson’s disease and vascular risk factors (diabetes mellitus, hypertension, obesity and smoking) suddenly lost muscle tone and consciousness. On admission he was awake, responded to verbal commands and was partially oriented. Although without conscious visual perception he was able to unconsciously prevent himself from bumping into objects when walking. When showing him different numbers of fingers he mentioned not seeing the fingers but his performance of rating the number of presented fingers was much above chance. Embol- Personal (autobiographical) memories depend on ism from the heart or the proximal vertebrobasilar the ability to encode, store and retrieve information artery is the cause of this sign [12]. The cognitive system representing this be: memory loss, usually involving both anterograde ability is termed episodic memory.

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Their distinctive molecular structure appears to render them resistant to proteolytic destruction generic actonel 35 mg overnight delivery. They appear to play an important role in mucosal integrity purchase actonel 35mg on line, repair of lesions and limiting epithelial cell proliferation, as well as in protecting the epithelium from a broad range of toxic chemicals and drugs. Trefoil proteins also appear to be central players in the restitution phase of epithelial damage repair, where epithelial cells flatten and migrate from the wound edge to cover denuded areas. Mice with targeted deletions in trefoil genes showed exaggerated responses to mild chemical injury and delayed mucosal healing. An important part of barrier function is to prevent transit of bacteria from the lumen through the epithelium. Paneth cells are epithelial granulocytes located in small intestinal crypts of many mammals. They synthesise and secrete several antimicrobial peptides, chief among them isoforms of alpha-defensins, also known as cryptdins (‘crypt defensin’). These peptides have antimicrobial activity against a number of potential pathogens, including several genera of bacteria, some yeasts and Giardia trophozoites. Their mechanism of action is likely similar to neutrophilic alpha-defensins, which permeabilise target cell membranes. Barrier function is also supported by the gastrointestinal immune system; much of the epithe- lium is bathed in immunoglobulin A (IgA), which is secreted from sub-epithelial plasma cells and transcytosed across the epithelium into the lumen. IgA provides an antigenic barrier by binding bacteria and other antigens, although this barrier function is specific for particular antigens and requires previous exposure for development of the response. Pancreatic secretions are secreted into the lumen of the acinus and accumulate in intralobular ducts that drain to the main pancreatic duct, then directly into the duodenum. Control of the exocrine function of the pancreas is via the hormones gastrin, cholecystokinin and secretin. Pancreatic secretions from ductal cells contain bicarbonate ions that neutralise the acidic chyme from the stomach and are important in protecting the pancreas from recurrent acute and chronic pancreatitis by quickly sweeping zymogens out of it. To remain viable, all cells of the body are required to maintain a low intracellular concen- tration of sodium. The sodium–potassium pump is a highly conserved integral membrane protein, expressed in virtually all animal cells. The transport of sodium creates both an electrical and a chemical gradient across the plasma membrane. In turn this provides: • a cell’s resting membrane potential, the gradient of which is the basis for excitability in nerve and muscle cells • export of sodium from the cell, providing the driving force for several facilitated transporters, which import glucose, amino acids and other nutrients into the cell • translocation of sodium from one side of an epithelium to the other, creating an osmotic gradient that drives absorption of water. A beta glycoprotein subunit appears critical in facilitating plasma membrane localisation and activation of the alpha subunit. There are 8–10 transmembrane domains; alpha and beta subunits exist in several isoforms. Different isoforms of the alpha subunit have different affinities for such glycosides. Binding of these widely-used drugs to sodium pumps specifically inhibits their activity. Inhibition of sodium pump activity in cardiac myocytes results in an increase in intracellular sodium concentration; in turn this leads to an increase in intracellular calcium concentration by sodium–calcium exchange, which appears to be the proximal mechanism for enhancing cardiac contractility. The major hormonal controls over pump activity can be summarised as follows: • Thyroid hormones appear to stimulate subunit gene transcription. Within minutes of elevated insulin secretion, pumps containing alpha-1 and 2 isoforms have increased affinity for sodium and increased turnover rate. In skeletal muscle, insulin may also recruit pumps stored in the cytoplasm or activate latent pumps already present in the membrane. Some molecules, water for instance, are transported by both routes, but the tight junctions are impermeable to large organic molecules from the diet (e. Such molecules are transported exclusively by the transcellular route, by absorptive enterocytes equipped with specific transporter molecules that facilitate their entry into and out of the cells. Within the intestine, there is a proximal-to-distal gradient in osmotic permeability. The observed differences in permeability to water across the epithelium are due almost entirely to differences in conductivity across the paracellular path; tight junctions vary considerably in ‘tightness’ along the length of the gut. In the case of secretion, two distinct processes establish an osmotic gradient that pulls water into the lumen of the intestine: • Increases in lumen osmotic pressure resulting from influx and digestion of foodstuffs. The chyme that passes into the intestine from the stomach typically is not hyperosmotic, but as its macromolecular components are digested, the osmolarity of that solution increases (e. Chloride ions enter the crypt epithelial cell by co-transport with sodium and potassium; sodium is pumped back out via sodium pumps and potassium is exported via a number of channels on the basolateral surface. Accumulation of negatively charged chloride anions in the crypt creates an electric potential that attracts sodium ions, pulled into the lumen apparently across tight junctions; the net result is secretion of NaCl. Secretion of NaCl into the crypt creates an osmotic gradient across the tight junction and water is drawn into the lumen by the paracellular route. It is one of the most common clinical signs of gastrointestinal disease, but can also reflect primary disorders outside of the digestive system. There are numerous causes of diarrhoea, but in almost all cases this disorder is a manifestation of one of the following four basic mechanisms: • Osmotic diarrhoea.

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Dead practicable bodies should only be disturbed to give access to live casualties buy cheap actonel 35 mg line. Finally buy actonel 35 mg amex, cordon keep control of your equipment to prevent it being lost to the police forensic team particularly if death is declared on scene. Assess the priority patients with blunt trauma, these tools may under-triage a number before treatment 2. Thecharacteristicphysiological response to blood loss of increasing tachycardia can be less marked Walking? In most situations the Rate level of threat to the rescuer will be low and the full spectrum 10-30/min of prehospital critical care intervention possible. In the event unconscious or over 120/min Write T1 of an unexpected escalation in threat level (e. Catastrophic haemorrhage control Triage Rapidly assess for exsanguinating limb haemorrhage and apply Mass shootings and bomb blasts often result in multiple casualties. The time of application should be Initial triage should be performed using a simple triage tool such noted. Trauma: Ballistic and Blast 107 tourniquet above the first particularly on proximal limb injuries own airway and drain secretions and blood. Patients presenting in traumatic cardiac arrest position should be maintained during transfer to a facility capable or in a peri-arrest state with critical hypovolaemia following sig- of fibreoptic intubation and/or surgical tracheostomy. Patients nificant limb trauma should have tourniquets applied even in should not be forced to lie supine. Obtunded or unconscious the absence of active bleeding as rebleeding is common with patients with significant facial bleeding and pooling of secretions resuscitation and/or movement during packaging. Where transfer distances are short and the patient’s injuries dressings and direct pressure. In cases where transfer time, persistent obstruction or other injuries dictate Airway management further airway intervention, the location and severity of injury will Penetrating injury or blast trauma to the face or neck may result in determine the type of intervention selected (Figure 20. Conscious patients will Cervical spine immobilization maintain themselves in the optimum position to maintain their Penetrating ballistic trauma to the neck involving the cervical spine is often fatal. For this reason routine cervical spine immobilization is not recommended for patients with penetrating head or neck trauma unless there is clear evidence of neurological deficit. In these cases head blocks only are recommended in order that the neck remains clear for vascular observation. Roll the casualty so that posterior wounds are not missed and remember to check the axilla and neck. Do not be falsely reassured by lack of wounds to the chest, as projectiles may still traverse the thoracic cavity from remote wound sites. Sucking chest wounds should be sealed off as soon as they are found using occlusive or valved dressings. Assess for and rapidly treat tension pneumothorax with needle decompression and/or finger thoracostomy if ventilated. Insertion of an intercostal drain may be indicated if transfer distance and time is prolonged or if the patient is spontaneously breathing. Management is supportive with supplementary oxygen, observation, judicious fluid resuscitation and ventilatory support if there are signs of respiratory failure. Prophylactic bilateral thoracostomy should be considered due to the increased risk of barotrauma. Circulation management Circulatory volume should be preserved at all costs through the aggressive application of haemorrhage control techniques, splinting of fractures and minimal handling. Even simple wounds to the legs, particularlytheupperthigh,canprovefatalasuncontrolledbleeding occurs into the large volume of the thigh. Fluid resuscitation may be initiated during transfer Exposure and should be targeted to a central pulse or verbal response in It is vital that the patient is kept warm throughout the resuscitative penetrating torso trauma. Care should be taken to avoid volume process with appropriate use of blankets and vehicle heaters. Common sites for missed wounds include the back, have a high incidence of associated pelvic injury and the early buttocks, perineum, axilla and scalp. If broad spectrum prehospital application of a pelvic binder is recommended in these cases. Limbs amputated by blast or high calibre munitions may also prove challenging - subclavian central venous access and are rarely suitable for reimplantation. They should however be sternal intraosseous access are useful points of access in these bagged up and accompany the patient to preserve forensics. Tranexamic acid should be given to all patients at risk specificinterventionisrequiredforsuspectedblastbowelorblastear of ongoing significant haemorrhage who are within 3 hours of in the prehospital environment other than standard resuscitation their injury. Disability Tips from the field Head injury is common following blast injury and may be the result of primary (concussion), secondary (penetrating fragmentation) • Never enter a ballistic scene before police arrival or tertiary (blunt trauma) blast mechanisms. Gunshot wounds to • For the shocked patient with a ballisticairway injury, secure the the head carry a high mortality, especially through-and-through airway early because airway bleeding may worsen with wounds and those passing close to the brainstem. The level of consciousness after resuscitation is the most – defibrillator pads stick better to clammy skin than electrode leads useful indicator of survival (Box 20. The team leaders come together at regular intervals to • Understand the concept of ‘reading the wreckage’ ensure the overall plan is progressing and that each part of the team • Know how to assess safety in casualty extrication scenarios is aware of the other’s constraints and progress.

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Key principles Trager • Mainly floor-based or fixed axis machine-based Additional discussion of Trager work is found in exercise effective 35mg actonel. Key principles Key principles • The technique consists of simple exercises called mentastics and deep purchase actonel 35mg with mastercard, non-intrusive, • The objective of Xi gong is to build qi (also hands-on work. This may be the Xi gong practitioner connecting with the • The result is a feeling of lightness, freedom Earth’s natural Schumann resonance – as and flexibility. Yoga Voice work Additional information on yoga research results is Underlying premise given in Chapter 10. The word ‘yoga’ comes from the Sanskrit word yuj, which Key principles means ‘to bind, join, attach, yoke’. These methods • Raja yoga – focuses on concentration and mind concentrate on the effort of opening up the control. Chapter 9 • Rehabilitation and Re-education (Movement) Approaches 403 Hatha yoga employ a hierarchical system incorporating all of the major forms of metabolic typing in a prioritized Hatha yoga, the physical practice, is a form of raja order. Current popular based on your unique biochemical heritage is a styles include (but are not limited to): pseudo-scientific, commonsense way of answering • Hatha yoga – a gentle style of yoga. Use of the the question ‘How can I achieve optimal health term ‘hatha’ is debatable, some believing the through nutrition? The answer is to look at how we got here – the single In Hatha yoga, the focus is on long stretches biggest experiment in history. How did they survive in a harsh, competitive (yogic breathing is known as ‘pranayama’). This can be very soothing for the mind – it is a In what environment and with what foodstuffs were parasympathetic-stimulating style of yoga. In • Power yoga, which is also known by the fact, most foods will irritate the digestive system if Sanskrit term Vinyasa yoga (a ‘vinyasa’ is a eaten in enough quantity as the food in question will series of rapid movements which warm up the always technically be ‘non-self’ and will eventually body all over). This is a very active form of spark an immune response resulting in stimulation of yoga, in which a person moves quickly ubiquitous mast cells, setting off a cascade of bio- through the poses (called ‘asanas’), not holding chemical events leading to inflammation of the diges- them as long as in other styles. Such inflammation, if sustained, will create intesti- nal permeability and sensitize the immune system further. Sensitization of the immune system will, in Nutritional considerations in rehabilitation itself, have a negative impact on the systemic response Although nutrition is technically outside of the remits to inflammatory and repair processes, thereby having of this chapter, there are two major and important a direct impact on rehabilitation. This, then, is a reflection of requisite for good digestion and will be discussed quantity of consumption – in tandem with the given separately below. The simple interpre- tation – and reality of the situation – is that the more Eating appropriate macronutrient ratios any one foodstuff is consumed, the more likely your Barry Sears popularized the idea of eating appropri- immune system is to respond to it, as described ately portioned macronutrient ratios in his highly above. However, Sears did not incorporate a model of biochemical individu- ality (see ‘Biomechanical universality’ above). Wolcott Viscerosomatic reflexes is considered by many as the forerunner in the field The net result of cumulative inflammation is repetitive of biochemical individuality or metabolic typing stimulation of the afferent nerves returning to the (Chaitow 2002, Wharton 2001). As Willard (1997, naturopathic book The Metabolic Typing Diet (Wolcott 2001, 2002) states, the B-afferent visceral nerves spe- & Fahey 2000) and his global network of advisers cifically are sensitive to repetitive stimuli. This means 404 Naturopathic Physical Medicine that they are able to set up a zone of sensitization in the convergence with other visceral and somatic nerves. This sensitization may travel up to five levels and general adaptive response, and when activated above and below the primary segment affected, though exhibit plasticity – in other words they may actually the stimulus will always be greatest at the segmental change and maintain a new firing rate or level of excit- level of the returning afferent nerve (see Box 9. Often this The various characteristics of the B-afferent system facilitation of the intrinsic spinal cord circuitry may mean it is ideally suited to respond to recurrent stimu- be maintained for several days after the irritation in lation from irritating foodstuffs, from dysbiotic condi- the gut has subsided. In nature, of undergraduate osteopathic students for motor control course, foods are cycled seasonally and geographi- of their lower abdominal wall using a pressure bio- cally – as we know the larger part of the development feedback unit. Measurements were taken over the 4 era that shaped Homo sapiens was nomadic (see weekly phases of one menstrual cycle. A post-hoc test revealed that success rate during menstruation was significantly Box 9. Small fiber system/unmyelinated and myelinated sured in percentage achieving successful control. Sensitive to repetitive stimuli The conclusion of the study was that, regardless of 3. Nociception and general adaptive response tive input from the uterus or uterine tubes, which 5. Activity-dependent plasticity share the same nerve roots as transversus abdominis, 6. Once initiated, intrinsic spinal cord circuitry may result in increased afferent drive and later the maintains facilitation. Secrete neuropeptides when activated: ‘reflex inhibition’ resulting in spinal instability. Higher preponderance than A-afferent fibers whose predominant function is stabilization of joints, have a low threshold to stimulus. In a state of dehydration the body will compensate by borrowing water from its stores – 66% from the intra- Why don’t patients’ transversus cellular reservoir, 26% from extracellular sources and about 8% from the blood volume (Batmanghelidj abdominis or multifidus muscles ‘spasm’? Quite aside from musculoskeletal dysfunction, The most likely explanation is that, in the early stages a decrease in cell volume correlates with catabolic of facilitation, it may well be that the lumbar multifi- states in a variety of diseases (Haussinger et al 1993).

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However actonel 35mg cheap, this is most commonly found in dementia with its more global manifestations actonel 35mg on-line. Rarely, a patient may look in the mirror and decide that the reflection represents an untrue version of the self (shades of Capgras, although the patient may simply be unsure of the facts). Shakespeare’s Caliban, an outcast in the Tempest, appears to have had this syndrome. The dominant hemisphere then views this activity as alien to the self because of a primary dissociation in the functioning of the two cerebral hemispheres in schizophrenia. Hallucinations may be seen as an expression of brain activity or as products of adaptive behaviour, as when seeking organisation in a chaotic array or motivated by dynamic imperatives. In particular, thought-disordered content could be superimposed on either primary or compensatory brain-based phenomena. During simultaneous occurrence of hallucinations and external stimuli, hallucinations were reported to lower N100 amplitudes and changed topography, suggesting competition between auditory stimuli and hallucinations for physiological resources in the primary auditory cortex; auditory hallucinations may therefore be a consequence of abnormal primary cortex activation. Interestingly, subvocalising during reading decreases reading speed but improves comprehension. Bick and Kinsbourne (1987) found that schizophrenic patients reported that the voices they heard went away when they kept their mouths open, so precluding subvocalisation, but not when they merely clenched their fists. Nevertheless, most patients with schizophrenia can make clear distinctions between auditory verbal hallucinations (‘voices’) 123 and their everyday thoughts. Definitions Lability of affect: variably defined as excessive emotional responsivity or unpredictable changes in affect, such as when the happy person suddenly becomes angry, only to sink into despair a short time later (e. Winston Churchill told his doctor on July 3, 1953 that ‘Since this (stroke) happened I have been very lachrymose. At parts of Phineas Finn I became very tearful, though it is not at all a moving story’. In schizophrenia, the emotional reaction may initially be congruous but then not change with altered circumstances, so-called stiffening of affect. The patient with abulia has no impulse to action, his mind is blank and empty, and volition is absent. However, it has also been described in association with damage to the 123 They do this by examining mainly thought content and sense of control, whereas loudness and clarity are of lesser use. Apathy with blunting or flattening of affect may also occur in schizophrenia; also common in dementia and after stroke. There is said to be sustained emotional indifference or diminution of emotional response, although a flat affect is quite compatible with subjective emotional arousal. Should only be diagnosed when subject has been observed in a variety of circumstances and when not sedated. Flattening of affect can accompany frontal lobe lesions as part of an apathetic-akinetic syndrome. Anxiety is characterised by apprehensiveness and tension, but the stimulus is ill defined and may be totally intrapsychic, e. It has been suggested by many authors that anxiety disorders properly belong with the affective disorders. Phobias (simple, social, agoraphobic): patient recognises their irrationality; they persist despite rational argument; and they lead to avoidance of what is feared. Derealisation: similar notions about the external environment (things are bigger or smaller, closer or further away, two- dimensional, flat). Both states are common in severe anxiety from any cause and do not of necessity indicate that the patient is ill – it is very difficult for someone to describe an unpleasant state of loss of normal emotional responsiveness; causes include normal emotional upset, tension or fatigue; a symptom of psychiatric or physical illness; and primary cases, the so-called ‘depersonalisation disorder’. Ambivalence: mixed feelings or opposing impulses experienced about something or someone experienced simultaneously. The patient who finds out that he has a month to live and who then goes around with a smile on his face and joins the local football team might be using the defence mechanism called reaction formation (doing the opposite to what one might expect like crying, feeling depressed, looking for a second opinion, preoccupied, etc). Obsessional thoughts consist of words, beliefs, ideas or images that the subject recognises as his own but that intrude forcibly into consciousness, are usually distasteful, and the subject tries to exclude them. Obsessional ruminations consist of an argument going on in the mind in which the pros and cons are gone over ad infinitum. In obsessional doubting the subject worries lest he has failed to complete some action, done harm, or told the priest all his sins in the confessional (scrupulosity). Obsessional impulses urge the patient to perform acts, often of a violent or socially embarrassing variety. Obsessional rituals are either repetitive, meaningless acts or some mental activity like repetitive counting e. It should be noted that obsessional rituals may raise or lower anxiety levels in different instances. Psychomotor retardation: slowing or sluggish thinking and movement; common in depression. Negativistic behaviour: associated with naughty children and schizophrenia; patient does the opposite of what is asked for no apparent reason, e. These two phenomena occur in schizophrenia, organic brain damage, and Tourtette disorder. Catatonic patients may reply to a question by echoing the content of the question but using different words, so-called echologia.

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