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Collaborative planning allows all levels of government to plan together to synchronize their efforts cheap 150 mg pregabalin free shipping. This is why the Guide stresses the importance purchase generic pregabalin on-line, where practicable purchase pregabalin uk, of placing planning responsibility on the shoulders of those who will actually operate in an emergency purchase cheapest pregabalin and pregabalin. This planning approach focuses on available personnel and resources that can be applied to address significant incidents. Requirements and capabilities are derived from the 10/27/08 927 National Planning Scenarios, the National Homeland Security Plan, strategic planning, risk assessments, concepts of operations, and threat information. This capabilities-based planning approach and the National Preparedness Guidelines foster vertical and horizontal integration of Federal, State, local, and Tribal plans allowing State, local and Tribal capability assessments to inform Federal requirements and capabilities planning. A functional planning approach identifies a list of common tasks an organization must perform during an incident, an emergency, a specific event/activity or a directed requirement. A scenario-based plan is developed from a National Planning Scenario; there are currently 15 National Planning Scenarios. In addition, each capability contains both preparedness and performance tasks and measures that support the capability outcome and serve as a guide for preparedness planning. The preparedness tasks and measures describe major elements or issues that should be addressed in plans, procedures, and systems, as well as authorities, relationships, and agreements that need to be in place to prepare to use the capability. Crisis action planning provides the means to transition from normal circumstances to heightened threats, emergency response, and recovery. A plan is complete if it incorporates major actions, objectives, and tasks to be accomplished. The complete plan addresses the personnel and resources required and sound concepts for how those will be deployed, employed, sustained, and demobilized. Completeness of a plan can be greatly enhanced by including in the planning process all those who could be affected. Flexibility and adaptability are promoted by decentralized decisionmaking and by accommodating all hazards ranging from smaller-scale incidents to wider national contingencies. A plan is interoperable and collaborative if it identifies other plan holders with similar and complementary plans and objectives, and supports regular collaboration focused on integrating with those plans to optimize achievement of individual and collective goals and objectives in an incident. It follows logical steps from plan initiation to analysis of objectives, to development and comparison of ways to achieve the objectives, and to selection of the best solution. It provides a common framework to guide preparedness by establishing the desired end state and the tasks required to accomplish it. Capabilities provide the means to accomplish a mission and achieve desired outcomes by performing critical tasks, under specified conditions, to target levels of performance. Exercises provide opportunities to demonstrate and evaluate performance, while periodic assessments of plans identify lessons learned and provide the means to share best products and practices. The National Strategy for Homeland Security attaches special emphasis to planning for catastrophic events that embody the greatest risk of mass casualties, massive property loss and immense social disruption. Planning provides the opportunity for a jurisdiction or regional response structure to work through these very complex situations and their unique associated problems. Planning helps decision makers understand how their decisions might affect the ability of their and neighboring jurisdictions to achieve response goals. The causes of incidents across the spectrum of homeland security can vary greatly, but the effects do not. For example, floods, wildfires, and hazardous materials releases may lead a jurisdiction to issue an evacuation order. Differences in the speed of onset may influence when an evacuation order is given, but the process of issuing an evacuation order does not change. All-hazards planning ensures that planners identify common tasks and determine who is responsible for accomplishing those tasks. Many States publish their own standards and guidance for emergency planning, conduct workshops and training courses, and assign their planners to work with local planners. By reviewing existing emergency or contingency plans, planners can: o Identify applicable authorities and statutes, o Gain insight into community risk perceptions, o Identify organizational arrangements used in the past, o Identify mutual aid agreements with other jurisdictions, and o Learn how some planning issues were resolved in the past.

The duration of nocturnal sleep may be greatly prolonged order pregabalin, or cheap 150mg pregabalin amex, as in our patients referred to below pregabalin 75 mg amex, they may sleep for days on end buy 150mg pregabalin otc. Food intake during and around the period of hypersomnia may exceed three times the normal (bulimia) and occurs almost compulsively during brief periods of semiwakefulness; to a variable extent, there are other behavioral changes such as social withdrawal, negativism, slowness of thinking, incoherence, inattentiveness, and disturbances of memory. The condition usually disappears during adulthood, and there is limited pathologic material (see page 488). We have cared for a sibling pair who had the illness into young adulthood (Katz and Ropper). The hyperphagia has suggested a hypothalamic disorder, but anatomic verification is lacking. The case reported by Carpenter and coworkers, in which an acute and chronic inflammation in the medial thalamus but not the hypothalamus was found, must be questioned as representative of the idiopathic adolescent condition. Their patient was a man 39 years of age who had episodes of diurnal drowsiness, hyperphagia (intermittently relieved by methylphenidate), and hypersexuality over a period of months. In some patients with this disorder, schizophrenic and sociopathic symptoms have been recorded between attacks, raising doubt as to whether all the reported cases are of the same type. In most instances, the disease is self-limited and disappears by early adult life, as mentioned. We have seen variants of this syndrome manifesting themselves in drowsiness and extreme inactivity lasting for a few weeks, then with a complete return to normalcy. In two of our patients, the use of serotonergic antidepressants lengthened the interval between episodes. No consistent change in the level of hypocretin (orexin) has been found in the spinal fluid, as occurs in narcolepsy (see further on), and the two disorders are distinct. In one typical case there was pronounced hypoperfusion of the left medial temporal lobe both during and between attacks, but the intepretation of this finding is unclear (Portilla et al). Finally, it should be mentioned that sleep laboratories now recognize a form of idiopathic hypersomnia in which there are repeated episodes of drowsiness throughout the day. This condition is discussed further on, in relation to the diagnosis of narcolepsy, with which it is most often confused. Sleep Apnea and Excessive Daytime Sleepiness Excessive daytime sleepiness is a common complaint in general medical practice (Table 19-1). Medications (including many types of sedatives, tranquilizers, anticonvulsants, antihistaminics, antidepressants, betaadrenergic blockers, and atropinic drugs), L-dopa and dopaminergic agonists, abuse of alcohol and illicit drugs 2. Acute medical illness of the mononucleosis type, including mundane respiratory and gastrointestinal infections 3. Idiopathic hypersomnia the use of any one of the large variety of medications that are not prescribed primarily for their sedative effect. Most conditions associated with severe fatigue produce daytime sleepiness and a desire to nap. One notable medical cause is infectious mononucleosis, but many other viral infections have the same effect. Certain chronic neurologic conditions produce fatigue and sleepiness, multiple sclerosis being the outstanding example. Among general medical conditions, hypothyroidism and hypercapnia must always be considered when daytime sleepiness is a prominent feature. Also, one must not overlook the possibility that excessive daytime drowsiness is the result of repeated episodes of sleep apnea and the disruption of nocturnal sleep by disorders such as the restless legs syndrome. Such apneas and those occurring at the onset of sleep are not in themselves considered to be pathologic. In some individuals, however, sleep-induced apneic periods are particularly frequent and prolonged (greater than 10 s), and such a condition may be responsible for a variety of clinical disturbances in children and adults. This pathologic form of sleep apnea may be due to a reduction of respiratory drive (so-called central apnea), an obstruction of the upper airway, or a combination of these two mechanisms. This last term is now applied to many forms of total loss of automatic breathing, especially during sleep. In the few autopsied cases of congenital central hypoventilation, Liu and colleagues found the external arcuate nuclei of the medulla to be absent and the neuron population in the medullary respiratory areas to be depleted. Patients with primary hypoventilation syndromes are usually of normal body habitus. Awakenings during the night are frequent, usually after an apneic period, and insomnia is a common complaint.

Further study will determine the validity of this view and its contribution to our understanding of what will certainly prove to be a polygenic inheritance of intellectual traits buy pregabalin 75mg cheap. One would think that neurologic structure and function would correlate in some way with intelligence; but with the exception of the pathologically retarded (Chap order 150 mg pregabalin mastercard. One is the two-factor theory of Spearman order cheapest pregabalin, who noted that all the separate tests of cognitive abilities correlated with each other discount generic pregabalin uk, suggesting that a general factor ("g" factor) enters into all performance. Since none of the correlations between subtests approached unity, he postulated that each test measures not only this general ability (commonly identified with intelligence) but also a subsidiary factor or factors specific to the individual tests, which he designated the "s" factors. A second theory, the multifactorial theory of Thurstone, proposed that intelligence consists of a number of primary mental abilities such as memory, verbal facility, numerical ability, visuospatial perception, and capacity for problem solving, all of them more or less equivalent. These primary abilities, although correlated, are not subordinate to a more general ability. For Eysenck, intelligence exists in three forms: biologic (the genetic component), social (development of the genetic component in relation to personal relationships), and a number of specific abilities subject to measurement by psychometric tests. He recognizes six categories of high-order cerebral ability: the linguistic (encompassing all language functions); the musical (including composition and performance); the logical-mathematical (the ideas and works of mathematicians); the spatial (including artistic talent and the creation of visual impressions); the bodily-kinesthetic (including dance and athletic performance); and the personal (consciousness of self and others in social interactions). He refers to each of these as intelligence, defined as the ability to solve problems or resolve difficulties and to be creative within the particular field. Several lines of evidence are marshaled in support of this parceling of what are really separable skills and abilities: (1) each of these abilities may be developed to an exceptionally high level in certain individuals, constituting virtuosity or genius; (2) each can be destroyed or spared in isolation as a consequence of a lesion in a certain part of the nervous system; (3) in certain individuals, i. Each of these abstracted entities has a genetic basis, but the full development of each is influenced by environmental factors. There are only limited data regarding the highest levels of intelligence identified as genius. One of the leading theories has been that of Piaget, who proposed that this is accomplished in discrete stages related to age: sensorimotor, from 0 to 2 years; preconceptual thought, from 2 to 4 years; intuitive thought, from 4 to 7 years; concrete operations (conceptualization), from 7 to 11 years; and finally the period of "formal operations" (logical or abstract thought), from 11 years on. This scheme implies that the capacity for logical thought, developing as it does according to an orderly timetable, is coded in the genes. One would suppose that in neurology, where one is exposed to so many diseases affecting the cerebrum, it might be possible to verify one of these several theories of intelligence and to determine its anatomy. Presumably the g factor of intelligence would be maximally impaired by diffuse lesions, in proportion to the mass of brain involved (expressed by Lashley as the "mass-action principle"). Indeed, according to Chapman and Wolff, there is a correlation between the volume of tissue lost and a general deficit of cerebral function. Others have disagreed, claiming that no universal psychologic deficit has been linked to lesions affecting particular parts of the brain. According to Tomlinson and colleagues, who studied the effects of vascular lesions in the aging brain, lesions that involve more than 50 mL of tissue cause some general reduction in performance, especially in speed and capacity to solve problems. Piercy, on the other hand, found correlations only between specific intellectual deficits and lesions of particular parts of the left and right hemispheres. The authors conclude from personal experience and from evidence provided by neurologic studies that intelligence is a gestalt of multiple primary abilities, each of which seems to be inherited and each of which has a separate but as yet poorly delineated anatomy. Yet we would disagree with Thurstone and with Gardner that these special abilities are of equivalent rank with regard to what is generally considered as "intelligence. These last abilities are integral to ideation and problem solving and are largely absent in the mentally retarded and lost early in dementing diseases. Neurologic data certainly do not exclude the possibility of a g factor- one that is unavoidably measured in many different tests of cerebral functions. It is expressed in thinking and abstract reasoning and is operative only if the connections between the frontal lobes and other parts of the brain are intact. Attention, drive, and motivation are noncognitive psychologic attributes of fundamental importance, the precise anatomy and physiology of which remain to be identified. Also, we would insist that retentive memory and capacity to learn constitute a separate cognitive entity, with its own neuroanatomic localization. The relationships of some of these special abilities have been thoughtfully analyzed by Luria (see the section on frontal lobes in Chap. An even more complex problem arises in the neurologic analysis of the highest human achievement and the method of human advancement, namely creativity. Some insight is gained from the fact that intelligence and problem-solving ability are innately but only roughly tied to creativity and that there are congenital absences and deficiencies of appreciation of visual, artistic, or mathematical skills. As pointed out in the following chapter, traits such as creativity almost certainly do not reside in a particular lobe or structure of the brain but may depend on the overdevelopment of certain associative areas as well as on frontal lobe drive and, of course, are fully manifest only by educational exposure.

Syndromes

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Admittedly pregabalin 150mg visa, the line that separates normal emotional reactions and pathologic ones is not sharp buy pregabalin toronto. In this chapter we are concerned with nervousness cheapest pregabalin, irritability buy pregabalin overnight delivery, stress, anxiety, and depression as symptoms, together with currently accepted views of their origins and biologic significance. Anxiety Reactions and Panic Attacks There is no unanimity among psychiatrists as to whether symptoms of nervousness, irritability, anxiety, and fear comprise a single emotional reaction, varying only in its severity or duration, or a group of discrete reactions, each with distinctive clinical features. Anxious patients, when frightened under experimental conditions, state that the fear reaction differs in being more overwhelming. The exceedingly frightened person is "frozen," unable to act or to think clearly, and his responses are automatic and sometimes irrational. The fear reaction is characterized by overactivity of both the sympathetic and parasympathetic nervous systems, and the parasympathetic effects (bradycardia, sphincteric relaxation) may predominate- unlike anxiety, in which sympathetic effects are the more prominent. Long ago, Cicero distinguished between an acute and transient attack of fear provoked by a specific stimulus (angor) and a protracted state of fearfulness (anxietas). This distinction was elaborated by Freud, who regarded fear as an appropriate response to a sudden, unexpected external threat and anxiety as a neurotic maladjustment (see below). By this vague term the lay person usually refers to a state of restlessness, tension, uneasiness, apprehension, irritability, or hyperexcitability. Obviously, a careful inquiry as to what the patient means in complaining of nervousness is always a necessary first step in the analysis of this complaint. Most often nervousness represents no more than a transient psychic and behavioral state in which the person is maximally challenged or threatened by difficult personal problems. Some persons claim to have been nervous throughout life or to be nervous periodically for no apparent reason. In these instances the symptoms blend imperceptibly with those of anxiety or depression, described below. Auden referred to his era as "the age of anxiety," and little has changed since then. Medical historians have identified comparable periods of pervasive anxiety dating back to the time of Marcus Aurelius and Constantine, when societies were undergoing rapid and profound changes and individuals were assailed by an overwhelming sense of insecurity, personal insignificance, and fear of the future (Rosen). Like lassitude and fatigue, nervousness, irritability, and anxiety are among the most frequent symptoms encountered in office and hospital practice. A British survey found that more than 40 percent of the population, at one time or another, experienced symptoms of severe anxiety, and about 5 percent suffered from lifelong anxiety states (Lader). By topical content is meant the idea, person, or object about which the person is anxious. The vasomotor and visceral accompaniments are mediated through the autonomic nervous system, particularly its sympathetic part, and involve also the thyroid and adrenal glands. Panic Attacks the symptoms of anxiety may be manifest either in acute episodes, each lasting several minutes or up to an hour, or as a protracted state that may last for weeks, months, or years. In the panic attack, or panics, as they are called, the patient is suddenly overwhelmed by feelings of apprehension, or a fear that he may lose consciousness and die, have a heart attack or stroke, lose his reason or self-control, become insane, or commit some horrible crime. These experiences are accompanied by a series of physiologic reactions, mainly sympathoadrenal hyperactivity, resembling the "fight-or-flight" reaction. Breathlessness, a feeling of suffocation, dizziness, sweating, trembling, palpitation, and precordial or gastric distress are typical but not invariable physical accompaniments. As a persistent and less severe state, the patient experiences fluctuating degrees of nervousness, palpitation or excessive cardiac impulse, shortness of breath, light-headedness, faintness, easy fatigue, and intolerance of physical exertion. Attacks tend to occur during periods of relative calm and in nonthreatening circumstances. Usually, the apprehension and physical symptoms escalate over a period of minutes to an hour and then abate over 20 to 30 min, leaving the patient tired and weak. Often, discrete anxiety attacks and persistent states of anxiety merge with one another. The fear of further attacks leads many patients, particularly women, to become agoraphobic and homebound, fearing public places, especially if alone. Because panic is a common disorder, affecting 1 to 2 percent of the population at some time in their lives, and the symptoms mimic neurologic disease, the neurologist is often called upon to distinguish panic attacks from temporal lobe seizures or from vertiginous diseases. Except for the occasional inability of the patient to think or articulate clearly during a panic, the manifestations of epilepsy are quite different. If dizziness predominates in the attacks, there may be concern about vertebrobasilar ischemia or labyrinthine dysfunction (see Chap. Vertigo from any cause is accompanied by many of the autonomic symptoms displayed during a panic attack, but careful questioning in the latter will elicit the characteristic apprehension, breathlessness, and palpitations, and the absence of ataxia or other neurologic signs.