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COPING WITH EPILEPSY: WHEN COUNSELING DIDN’T HELP”You’ve only told us about your successes. Tell us about your failures. Everybody with epilepsy doesn’t end up happy, having outgrown epilepsy and off in college, do they?”"No. One of the distressing facts you have to face as a counselor is that you can’t save the world. There are some pathetic people out there. Yes, there are some sad kids, and some miserable parents, as well. There are some who enjoy being unhappy. There are some who derive their pleasures from saying ‘poor me.’ There are those who just don’t have any motivation, and some who don’t have enough motivation to change at the time you see them. You have to try to keep communications open, so if their motivation develops later, they can come back and get help.”The successes I’ve been talking about are primarily among the 80 percent of children whose seizures can be brought under control and who don’t have other handicaps. In this group it is easier to give them hope. You can easily and honestly say to them, ‘Look, most people like you will have their seizures completely controlled. You will probably outgrow your epilepsy’ I can give them some positives to look forward to.*231\208\8*

ROUTINE MATTERS: CLEANLINESS COUNTSThe bare essentials of at-home skin care.CLEANLINESS COUNTSToday’s cleansers are a sophisticated bunch, as they not only remove the day’s grime but can also provide tangible and long-lasting benefits. Someone with acne-prone skin, for example, might do well with an exfoliating cleanser containing glycolic or salicylic acid. Even though a cleanser remains in contact with the skin for barely a minute, in that short time it will have prepped the skin to receive an exfoliating cream. Better penetration of the cream will be achieved simply because of the cleanser. Similarly, botanicals such as green tea are extremely soothing, and a cleanser that is chock-full of such ingredients is beneficial for those with sensitive skin types.As a general rule, those with dry skin should opt for a creamy cleanser that has very little foaming action; oily skin does well with gel cleansers, and those lucky enough to have normal skin can use pretty much anything. Cleansing twice a day is ideal but if you must absolutely whittle it down to just once daily, I recommend that it be done at night. It’s been said a million times, but going to sleep with a face full of make-up is an open invitation to spots and dull skin.*31\82\8*

RHEUMATOID ARTHRITIS AND PRACTICAL MATTERS  There’s no getting around the fact that rheumatoid arthritis (RA) can interfere with a person’s ability to work. Stiffness, pain, decreased mobility, and fatigue present problems for someone whose employment involves an eight-hour workday. We have already mentioned that people with RA often find it helpful to talk with their employers about arranging for increased flexibility in work hours and creating an arthritis-friendly workplace. These modifications can help a person with RA avoid having minor flare-ups interfere with work. Another possibility is a job-sharing program, in which two people each work halftime to fulfill the duties of one full-time job.We stress the fact that persons with RA are differently abled and that with creative planning, flexibility, and understanding a person with RA often can continue in his or her job. This is what many people would prefer to do; but sometimes, despite a person’s best creative efforts, it is not possible to continue being employed as before. This is particularly true for people with a physically demanding job that requires repeated use of inflamed joints.A person with RA who is having problems at work would be well advised to discuss the situation with his or her doctor and social service worker. If the best decision seems to be to make a change, the person might consider pursuing another form of employment, making arrangements with his or her employer to change jobs within the same company (or to change the description and duties of the present job), or applying for disability benefits. This decision, of course, is highly personal. The choice you make depends on your work experience, education, age, financial responsibilities, degree of arthritis involvement, and the advice of your health care team.*116/209/5*

HIV: PRACTICAL MATTERS-PUTTING YOUR AFFAIRS IN ORDER: STIPULATING WHAT HAPPENS TO YOUR PROPERTY AND PROVIDING FOR HOSPICE CAREMost people stipulate what happens to their property by making a will. No one requires that you do so. If you die without a will (called dying intestate), your property goes automatically first to your spouse and then to your nearest living relatives. Your property will not go to friends or to unmarried partners. To assign property to friends or unmarried partners, you must make a will.     Wills apply mostly to property—money, house, car, furniture, clothes. Wills do not necessarily legislate any of your other wishes. Life insurance benefits will go to the beneficiary, even if the will states otherwise. In principle, a will may specify what your funeral arrangements are and whether you’d like to be buried or cremated, but in practice, wills are often not read until after the funeral.     Over a certain value, property left in a will is taxable. You can minimize the taxes your beneficiaries will pay by setting up trusts or by giving to them a certain amount of money per year while you are still alive. Neither trusts nor gifts under a certain dollar amount are taxable.     Trusts and annual gifts also ensure that you will have property to leave. Some people, rather than use their property to finance their own medical care, decide to put it into trusts or give it to the people they love.     Once they are impoverished, their medical bills will be paid by public assistance programs. Leaving your property in trust or as a gift must be done years before you need extensive medical care: Medicaid/Medicare will check to see if money or property has been given away in recent years. To find out how and when to leave your property, see a lawyer or a financial planner.     A lawyer is the best source of information regarding what happens to your property. Lawyers also often draw up wills. State laws set the forms for wills, however, and if you know the form, you can draw up your own will.     Providing for Hospice Care-Some people want to decide where they will die. Some choose to die at home; some would rather leave their homes as a place for the living, so choose to die elsewhere. In either case, they may choose hospice care.     A hospice can be either a place or a concept, that is, either a building or a program dedicated to care of the dying. Hospice programs can be run through hospitals, nursing homes, or private organizations. Nursing agencies, like the Visiting Nurse Association, often also provide hospice care.     Both private insurance policies and medical assistance provide some level of reimbursement for hospice care, providing the requirements of the hospice are met. To find a hospice or hospice program, ask your doctor or nursing agency or hospital social worker. Your doctor can advise you on when to consider hospice services.*219\191\2*

EPILEPSY AS A PSYCHO-SOCIAL DISEASE: WHERE COUNSELING HELPS”Karen is one of the best examples of the importance of counseling. Karen had her first seizure when she was about ten. It was a tonic-clonic seizure, and then she had a few complex partial seizures later. Medication controlled these for about two years, but when she was about twelve she again began having seizures and first came to Hopkins. The doctor wanted to change Karen’s medicine but was also very concerned about the fact that things were going poorly for her in school and thought the cause might be a problem with the school’s acceptance of her seizures. The doctor asked me to see Karen and find out what was going on.”Karen was a very shy young lady, and during our first visit all she did was cry. I couldn’t get her to talk at all. So I asked her to keep a journal, to go home and write down her thoughts about everything she felt, so that when she came back we could talk about them. What we discovered was that the problems weren’t in school, they were at home. The major problem was a father who blamed Karen for all of the family strife, arguing, and financial problems.Eventually we asked her family to come in to talk. Her father never would participate. He was a very domineering type, her mother a rather meek lady. The counseling, which went on weekly for over a year, helped Karen gain control and do better in school. This may have had less to do with understanding epilepsy than with the fact that the family situation changed. Her mother, who ostensibly came to counseling to understand more about epilepsy, gained insight into her own problems. She ultimately decided to divorce Karen’s father. This led to an additional need for family counseling as they readjusted to a single-parent family.”It took a long time for Karen to realize that the problems were really not due to her but to the dynamics of her family. She finally realized that she was not responsible for having epilepsy. She learned that her medical bills were not the cause of the family’s financial problems. She eventually saw that her father was just using the epilepsy as an excuse and that she was suffering from his blame and her own feelings of guilt.”"So what you’re saying is that the epilepsy wasn’t Karen’s problem, is that right?”"Well, not exactly. Karen’s seizures were not a major problem, but she had no education about epilepsy. She was surrounded by all of these family arguments and strife, and she said to herself, ‘Hey, I’m the only one who is sick. I’m the only one who is different. Therefore, all of this must be my fault.’ This also led to her doing poorly in school, which made her think that she was dumb, which she attributed to her epilepsy. All of these things contributed to a terrible self-image. So we had to work on these issues. We also had to work with her brother and sister, who were jealous that she was getting a disproportionate share of attention. They needed to see that Karen was the victim not the cause of parental discord.*221\208\8*

PICK YOUR PROTEINS: THE WAY FORWARD-CHILLI WITHOUT CAMESpanish onions, roughly chopped     green and red peppers, roughly chopped     tomatoes, roughly chopped, or canned tomatoes     garlic, minced or sliced     olive oil     tomato paste     cayenne pepper, paprika, cumin, oregano, pepper, or other     spices     vegetable stock or water      Soya mince (TVP, textured vegetable protein)      kidney beans, cooked from dried or canned, drained and rinsed      fresh chilli pepper, deseeded and finely chopped, or dried     Cook the fresh vegetables and даг1к in olive oil until softened, then add the spices, tomato paste, stock or water and heat up. Add the soya mince and kidney beans. Simmer for at least 30) minutes, longer if possible. Add more stock or water if the mixture shows signs of drying out.     Serve with baked potato, tortillas or brown rice. Add toppings: sliced mild onions or spring onions, sliced tomato, sliced avocado, plain yoghurt.     The way forward-A diet that maintains sufficient protein levels to nurture the individual is essential. However, it is preferable to reduce the amount of animal protein from the levels typical of a Western diet and, at least partially, replace it with vegetarian sources of protein. Dishes based on legumes (beans, chick-peas, lentils), grains, soya products (tofu, TVP-textured vegetable protein), quinoa and Quorn mycoprotein are all excellent sources of vegetable protein. Plant sources of protein have the added advantage of offering protection by offering other cancer fighters such as fibre, antioxidants and plant hormones.     Animal proteins should ideally be kept to fish sources, which offer the potent breast cancer-fighting omega-3 fats, and meats that are lowest in saturated fats and chemicals, such as skinless organic chicken and game. The importance of non-contaminated sources of meat cannot be over-emphasized in view of possible contamination by oestrogenic compounds which can be found in intensively farmed meat. Ideally, animal sources of protein – meat, fish, fowl, game, eggs and dairy produce – should be used as a condiment to flavour and enhance dishes, rather than as the main ingredient. Instead of a large slab of meat on a plate with a few vegetables, meals which reflect the cuisine of Eastern or Third World countries are best. This means, for example, bean stews, with a little meat for flavour, or stir-fries with a little seafood as one of several ingredients.     Fermented milk products, such as yoghurt and cottage cheese, should be preferred over other dairy sources such as milk and hard cheese as they are more easily digested, the milk proteins having been partially pre-digested by bacteria. Eggs in moderation – about three or four a week – are fine. Eggs, along with cottage cheese, are a valuable source of sulphur containing amino acids, which aid the liver’s detoxification process.     If you are already a vegetarian, or are planning to switch over, it is important not to become a ‘bread and cheese’ vegetarian. A high intake of cheese, milk and eggs with insufficient vegetables, fruits and pulses to redress the balance, is not much better, from the point of view of breast cancer, than being a fully fledged meat-eater.     It is probably not necessary to become vegetarian if it does not suit you, as the main protective benefits that come from a vegetarian diet are derived from the increased intake of vegetables, fruit, grains and pulses. Increasing these in the diet is more important than cutting out all sources of animal protein, though reducing the amount of animal protein, typical of a Western diet, is advisable.*75\240\2*

CORTICOSTEROIDS FOR TREATMENT OF RHEUMATOID ARTHRITIS (RA): CORTICOSTEROID INJECTIONSIn RA it is common for one joint to become more swollen than others or to lag behind the others in improvement. An injection of corticosteroids directly into the joint will decrease the pain, warmth, and swelling in the joint that is giving the person the most trouble. The beneficial effects generally last four to six weeks.This is a frequently performed and effective procedure that is generally safe and well tolerated. Before the injection is administered, the skin is generally numbed with a local anesthetic. (Be certain to warn your doctor if you have ever had a reaction to local anesthetics such as Novocain or Xylocaine.) A needle is then introduced through the skin and into the joint, into which the corticosteroid is injected.The side effects of the small amount of corticosteroid injected into the joint are minimal. If a given joint is injected no more frequently than every four months, adverse effects from the corticosteroid itself are unlikely.Corticosteroid injection into the same joint more frequently than every four months, however, may cause joint damage. In fewer than 5 percent of patients the injected corticosteroid can actually increase inflammation for a short period. This is known as a post-infection flare. Although uncomfortable, the inflammation will decrease within two to three days. It is impossible to tell in advance of the injection whether a particular individual will suffer this side effect.Occasionally, a dimple in the skin or a mild change in skin color will be noticed at the site of injection. These skin changes will almost always disappear with time.As with any procedure, complications related to the procedure itself can arise. Care must be taken to avoid injuring surrounding tendons or other structures. Sterile technique is required to prevent the possibility of introducing bacteria and infection into the joint. Experienced physicians, generally rheumatologists or orthopedic surgeons, take exceptional care to avoid these complications.*106/209/5*

STOP SMOKINGMore than 95 percent of former smokers quit on their own, usually at the recommendation of their physician. People who follow this popular strategy outlined by the American Lung Association have had good results:Set a future date when you will stop smoking, a d sign a contract with yourself to that effect.Make a list of:
All the reasons you continue to smoke (“It’s a crutch,” “It feels good”).All your bonds with smoking (coffee, alcohol, etc.).All your reasons for not quitting.All the reasons you should quit smoking.All the rewards for becoming a nonsmoker.Every cigarette you smoke for the two weeks before your quit date.All situations you think will be difficult without a cigarette.
Find substitutes for cigarettes, like chewing gum.Save your butts for two weeks before quitting day. Put them in a jar and then fill the jar up with water and keep it in a visible place. Every time you feel the urge to smoke, open the jar and take a whiff.Be prepared for withdrawal symptoms—cough, constipation, tiredness, headache, sore throat, trouble sleeping. There last only a week at most.Begin a daily exercise program (walking, etc.) and eat the proper foods.Tell all the people you know that you are going to quit and tell your friends how they can help.Use coping techniques to break your smoking pattern:
“I have the strength to do it.”Doodle, stretch, touch your toes.Put a rubber band on your wrist and snap it every time you have the urge.Take a deep breath and hold it for several seconds and then exhale. Repeat this several times until the urge disappears.Avoid smoking situations and places; avoid people who smoke.Move around, take a shower, go get a drink, etc.Remember: “A craving for a cigarette will go away whether or not I smoke.”Don’t dwell on your desire for a cigarette. Simply decide youhave smoked your last cigarette.Don’t have in mind an estimated time by which the discomfort should end. Change your routine to distract yourself.Sign a final nonsmoker contract with yourself.A common mistake a “quitter” makes is to think it is all right to have one or two cigarettes every once in a while. If you could have done that before, you would have.Smokers who have existing heart disease can reduce their risk of future heart attacks and death if they quit smoking. Prospective findings in a study that involved over 7,000 people who are 65 years old or older indicate that smokers who continue to smoke will have a higher rate of mortality, but those who quit will have an improved life expectancy. So it’s never too late to quit.Many people say that they do not want to stop smoking because they fear gaining weight Weight gain may occur in those who stop smoking, but it is likely to occur only in a small percentage of them. This study and others never considered the fact that people who were quitting took no measures to control their weight.Many studies indicate that if a person quits smoking for at least ten years, his risk of developing coronary heart disease is the same as a nonsmoker of the same age. On the other hand, a person must quit smoking for fifteen years before his risk of developing cancer will equal that of a nonsmoker.Federally sponsored programs support tobacco prices, benefiting allotment holders (a unique monopoly situation) and tobacco growers. In addition, other federally sponsored programs benefit the tobacco industry. The programs and their cost to the taxpayer—both smoker and nonsmoker—are the following: tobacco inspection and grading, $6.1 million; market news service, $10.5 million; research, $7.4 million; short-term credit, $69.2 million (1979). Total cost to the taxpayer: over $157 million in 1979.On the other hand, federal funds are spent to discourage smoking, to research the health effects of smoking, and to provide a great portion of the cost of medical care for people who are suffering from and dying of smoking-related diseases. Patients with self-induced smoking-related diseases and families of these patients receive Social Security benefits.The United States has adopted uncompromisingly restrictive measures concerning food additives, but only a verbal statement of caution is required on every package of cigarettes. The Delaney Clause legislation prohibits the sale of any product to the American people that has been shown to be carcinogenic to humans and animals, and thus applies to situations in which the human hazard may be minimal. Tobacco is a major risk factor for cancer, cardiovascular diseases, lung diseases, and other illnesses. If you smoke, you should stop. If you have not started, don’t! Seek professional help if you must, but stop smoking.*73\360\2*

IMMUNOSUPPRESSANTS FOR TREATMENT OF RA (RHEUMATOID ARTHRITIS): METHOTREXATERheumatrexTablet size: 2.5 mgUsual dose: two to six pills all on one day per week or in one weekly injection Effective within: three to eight weeksMethotrexate was used initially in the 1940s to treat people with leukemia and is still frequently taken in very high doses as an anticancer drug. It later became widely used as treatment for severe psoriasis and a form of arthritis associated with this skin condition. Since the early 1980s its use in the treatment of RA has skyrocketed.The marked increase in this drug’s popularity for RA treatment has many explanations. First, it becomes effective more rapidly than the other DMARDs: improvement is sometimes noted within two weeks of the first use. Second, it is possibly the most effective medication available. It is as effective as injectable gold or penicillamine, previously believed to be the most effective pharmaceutical treatment for RA. Third, it is very convenient in that it can be taken once a week if tolerated.*96/209/5*

PSYCHIATRIC DIMENSIONS OF MEDICAL PRACTICE: COMPETENCE TO REFUSE MEDICAL ADVICE-WHEN THE EXAMINER IS UNCERTAIN: INVOLVING FAMILY MEMBERSIt is not uncommon for physicians to evaluate the competence of patients they have never met before. As in the case described above, family members can be helpful when the outcome of the evaluation is equivocal. Based on his sister’s report, Mr. B.’s reluctance to follow medical advice did not spring from a delusional belief that God would heal him. The patient’s decision-making capacity was intact, though he was understandably apprehensive about a lung biopsy and responded with characteristic irritability and obstinacy when repeatedly urged to have one.     Family members are almost always willing to compare a patient’s current way of thinking with what they have observed in the past. They cannot be asked to decide whether or not the patient is competent, but they can be asked to decide whether or not he is himself.*73\172\2*