Geriforte

By V. Sancho. University of Tennessee Health Science Center.

In his response the CEO wrote generic 100 mg geriforte fast delivery, “…I am a very moral and ethical person and feel incredible shame that this happened…I admit freely the lies I told…” It may be difficult to obtain a complete understanding of events from newspaper reports cheap geriforte 100mg. Here, the reader finds it difficult to comprehend how a person in a position of responsibility could admit to telling “lies”, but at the same time maintain that, “I am a very moral and ethical person”. One explanation would be that the individual is narcissistic and thinks well of himself, in spite of evidence to of immoral actions. Cluster C – Individuals appear anxious or fearful Avoidant Pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. There must be at least 4 of the following:  Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection  Is unwilling to get involved with people unless certain of being liked  Shows restraint within intimate relationships because of the fear of being shamed or ridiculed  Is preoccupied with being criticized or rejected in social situations  Is inhibited in new interpersonal situations because of feelings of inadequacy  Views self as socially inept, personally unappealing, or inferior to others  Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing Prevalence of 0. There must be at least 5 of the following:  Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others  Needs others to assume responsibility for most major areas of his/her life  Has difficulty expressing disagreement with others because of fear of loss of support or approval  Lack of initiative  Goes to excessive lengths to obtain nurturance and support form others  Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for him/her self  Urgently seeks another relationship as a source of care and support when a close relationship ends  Unrealistically preoccupied with fears of being left to take care of him/herself May be the most common personality disorder. Obsessive-compulsive Pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency. There must be at least 4 of the following:  Preoccupation with details, rules, lists, order, organization or schedules to the extent that the major point of the activity is lost  Perfectionism that interferes with task completion  Over conscientiousness, scrupulousness, and inflexible about matters of morality, ethics, or values. There is an increased risk of major depressive disorder and anxiety disorder, but for evidence for increased risk of OCD has not been established. Alternative DSM-5 Model for Personality Disorders The DSM-5 authors are in favour of moving to a dimensional approach. They present the categorical model (and diagnoses) which are well established, but also introduce The Alternative DSM-5 Model for Personality Disorder, with the aim of addressing some shortcomings of the categorical approach, and with the suggestion that this may be the way of the future. This model contends that personality disorders are characterized by impairments in personality functioning and personality traits. Identity: Experience of oneself as unique, with clear boundaries between self and others, stability of self-esteem and accuracy of self- appraisal; capacity for and ability to regulate, a range of emotional experiences. Self-direction: Pursuit of coherent and meaningful short-term and life goals; utilization of constructive and prosocial internal standards of behaviour; ability to self-reflect productively. Intimacy: Depth and duration of connection with others; desire and capacity for closeness; mutuality of regard reflected in interpersonal behaviour. Five Pathological Personality traits have also been listed in DSM-5 1. Psychoticism And each of these can exist at five levels. Neuroimaging in personality disorder Neuroimaging in personality disorders is a relatively new field. It would not be surprizing if the brains of people who thought and behaved differently to the average person had somewhat different brain operations. It needs to be said that personality and personality disorder is subtle stuff – and modern neuroimaging techniques generate vast amounts of information, and neuroimaging teams do not follow a standard protocol. Accordingly, it is most unlikely that neuroimaging will produce anything of clinical significance in the foreseeable future – the following details are provided to give a sense of the activity in this research area. Structural studies have reported decreased prefrontal grey matter, decreased posterior hippocampal volume and increased callosal white matter, but to this point, these studies have not been confirmed. Functional studies suggest reduced perfusion and metabolism in the frontal and temporal lobes. Two studies are of interest - Kiehl et al (2001) used fMRI and reported that when criminal psychopaths were dealing with emotional material (words), there was increased activity in the frontotemporal cortex. This was taken as evidence that psychopaths needed to exert additional effort to deal with emotional material. The same group (Kiehl et al, 2004) then reported that criminals failed to show a difference in activation of the right anterior temporal gyrus when processing abstract and concrete words. This was consistent with the proposition that psychopathy is associated with dysfunction of the right hemisphere during the processing of abstract material. The authors speculated that complex social emotions such as love, empathy and guilt may call for abstract functioning, and that abstract processing deficits based in the right temporal lobe, may be a fundamental abnormality in psychopathy. Blair (2003), however, argues that the neural basis of psychopathy is malfunction of the amygdala and connections to the orbitofrontal cortex. Borderline personality disorder Imaging studies demonstrate differences between people with BPD and healthy controls. Kuhlmann et al (2012) found, in women with BPD, reduced grey matter in the hippocampus and increased grey matter in the hypothalamus. Functional abnormalities have been detailed (Krause-Utz et al, 2014). Magnetic Resonance Spectroscopy (MRS) reveals N-acetyl-aspartate (NAA) concentrations are reduced in the dorsolateral prefrontal cortex, suggesting a lower density of neurons and disturbed neuronal metabolism. These anatomical studies are consistent with functional imaging findings.

The statement “The Multi-Colour White/ Throws out Light” does not explain the scientific principles well generic 100mg geriforte amex. Under the heading of clanging geriforte 100 mg with amex, Andreasen (1979) has drawn attention to punning. Here the sound of the word “sense” (cents) brings in a new topic (money), which is the essence of punning. With mood elevation the punning of flight of ideas can be frequent, amusing and apparently clever. Debates about the diagnosis in particular cases have sometimes centred on whether utterances were derailment or flight of ideas. The old view was that there is something different in the quality of the connections which justifies the use of separate categories. However, when flight of ideas and derailment are transcribed onto paper, that is, when they are stripped of the manner in which they were vocalized, it is often impossible (unless there is much clanging and punning, which is rare) to tell them apart. Andreasen (1979) states that in the absence of pressure of speech the term derailment be applied, and in the presence of pressure of speech, the term flight of ideas be applied. The characteristics of pressure of speech are 1) increased in speed of talk, 2) increased volume, and 3) the patient is difficult to interrupt. Flight of ideas most often occurs in mania, however it also occurs in schizophrenia and intoxication with stimulants. The patient suffering infarction of the cerebellum may be loud, disinhibited and verbalize what could pass as flight of ideas. Poverty of content of thought (Poverty of content) Poverty of content is not to be confused with “Poverty of thought” (see below). In poverty of content there are plenty of thoughts, but because of the severity of FTD, the listener does not get a clear message. It can be conceptualized as a midpoint on a spectrum of severity, with derailment (minor) problems at one end and incoherence (severe) at the other. He starts out with concerns about the diagnosis of schizophrenia, then mentions insomnia, a poem and ankle wear and tear. Poverty of content is most often the result of frequent derailment. However, the derailment may be subtle and not easily noticed. The interviewer may continue to listen, expecting the patient to make a significant point at any moment. If poverty of content is the result of derailment, the record of the interview should mention both - these are not mutually exclusive terms. When psychotic patients talk of yoga, spiritualism or quasi-philosophical matters, poverty of content of thought is frequently present. The patient may be attracted to these topics partly because a lack of critical, logical thought is apparently less noticeable in these areas. Also, the patient may find comfort in belonging to these interest groups. When the patient is talking about less concrete topics, FTD may be more difficult to identify. A test of whether there is poverty of content is to listen to the patient talk on a topic for a period and then attempt to make a summary. Where there is poverty of content, there is almost no systematic information to summarise. Poverty of content may be difficult to differentiate from the output of the particularly verbose normal individual or the narcissistic individual. It may be found in schizophrenia, mania and politicians. If you did not smile, you may have not been paying attention. Incoherence Incoherent thought is characterized by extreme loss of logical connections, distortion of grammar and idiosyncratic use of words. From a chronically psychotic, middle aged, itinerant woman. This example is readable, but conveys no sensible message. Andreasen (1979) provides the following example: Interviewer, “What do you think about current political issues like the energy crisis? If we need soap when you can jump into a pool of water, and then when you go to buy your gasoline, my folks always thought they should get pop, but the best thing to get is motor oil, and money. Incoherence can sound like dysphasia and a neurological examination is necessary in the event of sudden onset. Intoxication with various agents needs to be excluded. Incoherence due to psychiatric disorders is not common. It is evidence of severe disorder and occurs in schizophrenia and mania.

Adrenergic innervation of the noradrenergic neurons by C1 adrenergic cells in the rostral ven- rat nucleus locus coeruleus arises from the C1 and C3 cell groups tral medulla effective geriforte 100 mg. The brain nucleus 56 Neuropsychopharmacology: The Fifth Generation of Progress locus coeruleus: restricted afferent control of a broad efferent 54 geriforte 100mg visa. The neurobiology of from the suprachiasmatic nucleus to the locus coeruleus: a trans- opiates. A neural circuit for circa- tivity of locus coeruleus neurons is substantially mediated by dian regulation of arousal. Sleep disturbance in by lesions of the nucleus paragigantocellularis. Brain Res 1989; depression: diagnostic potential and pathophysiology [Proceed- 505:346–350. Overview: toward a dysregulation hypothe- treated rats do not show opiate-withdrawal hyperactivity in sis of depression. Where is the locus cleus locus coeruleus: morphologic subpopulations have differ- in opioid withdrawal? Lateralization and rates and enhanced responses to 8-Br-cAMP in locus coeruleus functional organization of the locus coeruleus projection to the neurons in brain slices from opiate-dependent animals. New response element-binding protein) in the locus coeruleus: bio- York: Oxford University Press:1997. Local opiate withdrawal in locus co- supraoptic nuclei in the rat. Local opioid withdrawal in locus forebrain is critical for opiate withdrawal-induced aversion. Na- coeruleus (LC) neurons suppressed by protein kinase A (PKA) ture 2000;403:430–434. Local opiate withdrawal afferents to the shell subregion of the nucleus accumbens: an- in locus coeruleus in vivo. Molecular and cellular basis of ad- Res 1998;806:127–140. Hypocretin/orexin depolarizes and ents from the ventrolateral medulla to the amygdala in the rat. Orexin A activates locus different afferent pathways to the catecholamine and 5-hydroxy- coeruleus cell firing and increases arousal in the rat. Proc Natl tryptamine innervation of the amygdala: a neurochemical and histochemical study. The medial prefrontal cortex promi- of the solitary tract attenuate the memory-modulating effects of nently innervates a peri-locus coeruleus dendritic zone in rat. Potent excitatory influence chronizes subthreshold activity in locus coeruleus neurons in of prefrontal cortex activity on noradrenergic locus coeruleus vitro from neonatal rats. Activation of locus coeruleus by prefron- in locus coeruleus. Synchronous activity in locus coeru- Res 1997;768:327–332. Inhibitory influence of frontal cor- J Neurosci 1996;16:5196–5204. A network of fast-spiking cells in the neocortex and hippocampus. Glutamatergic influences on the troencephalographic indices of waking following stimulation of nucleus paragigantocellularis: contribution to performance in noradrenergic B-receptors within the medial septal region of avoidance and spatial memory tasks. Attenuation of emotional beta-receptor blockade within the medial septal area on fore- and nonemotional memories after their reactivation: role of beta brain electroencephalographic and behavioral activity state in adrenergic receptors. Intracerebroventricular norepineph- working memory performance in monkeys. Biol Psychiatry rine potentiation of the perforant path-evoked potential in den- 1999;46:1259–1265. The alpha-2a noradrenergic agonist, and beta-adrenoceptor activation. Locus coeruleus activation in- adult rhesus monkeys. Psychopharmacology (Berl) 1998;136: duces perforant path-evoked population spike potentiation in 8–14. Locus coeruleus potentiation methyl-para-tyrosine (AMPT) in drug-free depressed patients. Lesions to terminals of noradrenergic chemical effects of catecholamine depletion on antidepressant- locus coeruleus neurones do not inhibit opiate withdrawal be- induced remission of depression. Venlafaxine: a novel lesion of noradrenergic neurons of the locus ceruleus does not antidepressant that has a dual mechanism of action.

The basics of physical and social development of the child include: 0-6 months: rolls over discount 100 mg geriforte with mastercard, smiles and laughs geriforte 100 mg on line, passes objects hand to hand, places objects in the mouth, vocalises syllables. Middle childhood: schooling, peer group activities, developing autonomy. Adolescence: increasing independence, autonomy and peer group activities. All describe “stages” and tasks/skills which must be mastered during these stages in order to achieve smooth progress through to functional adulthood. No one perspective provides a complete account, and different concepts are helpful is dealing with different patients (or disorders). Freud (Austrian; 1856-1939) provided the first description of “psychosexual development”. His theory of personality development focused on the effects of the sexual pleasure drive upon the mind. He believed that at particular points along the developmental path a body part is particularly sensitive to sexual, erotic stimulation – the erogenous zones: mouth, anus, genitals. The stages the child passes through are the oral (0-18 months), anal (18-36 months), phallic (3-6 years), latency (6 years to puberty) and genital (puberty and beyond). He taught that children are unable to undertake certain tasks until they are psychologically mature enough to do so. Erickson (Swede; 1833-1887) described himself as a Freudian. However, rather than focus on the basic drives (as did Freud), Erickson emphasised the importance of the ego (or executive function of the mental apparatus) in personality development. Successful completion (resolution of a conflict/task) leads to a favourable result (virtue): Stage One (0-1 years) task: trust vs. Attachment (the making of strong affectional relationships with others) is a characteristic of human beings, and many other species. Stable relationships are a source of enjoyment and security, and separation, loss or threatened loss of a relationship is a source of anxiety, anger, sadness and depression. Attachment Theory is the dominant current theory in the study of infant and toddler behaviour and is used in the field of infant mental health diagnosis and treatment. It is based on the attachment work of Bowlby and Ainsworth, among others. The Circle of Security uses “The Strange Situation” paradigm (Ainsworth, 1969) in the assessment of attachment and early psychological difficulties. The Strange Situation is a series of contrived settings which allows staff to observe attachment relationships between the child and caregivers. The child is observed playing for 20 minutes while caregivers and strangers enter and leave the room. Mother sits quietly on a chair, responding if the infant seeks attention 3. A stranger enters, talks to the mother then gradually approaches the infant with a toy. The stranger leaves the infant playing unless he/she is inactive. The stranger then tries to interest the infant in toys. If the child becomes distressed this episode is ended 5. Mother enters and waits to see how the infant greets her. The stranger leaves quietly and the mother waits until the baby settles, and then she leaves again 6. This episode is curtailed if the infant is distressed 7. Reunion behaviour is noted and the situation is ended. The amount the child explores (playing with new toys) and engages, and B. Based on these observations the attachment style is categorized/diagnosed, and management implications are decided. Attachment therapy practitioners explain to parents the needs of the child, the importance of security and the need for the opportunity to explore, and help them to develop good parenting skills. With the advantage of good parenting the child has the opportunity to develop in a health manner.

Prefrontal/cingulate cortex Thalamus Nucleus accumbens (NAc) Globus pallius Ventral tegmental area (VTA) Reward circuit (Insel cheap geriforte 100 mg otc, 2003) Illustration discount geriforte 100mg line. Reward circuit (Insel, 2003) Dopamine is the neurotransmitter of the mesolimbic tract. In a related manner, dopamine is also involved in the nigrostriatal tract, which is dysfunctional in Parkinsons disease, a condition in which ToM is reduced (Bora, et al 2015). Debate continues as to the “key” structures (Ciaramidaro et al, 2007). It is believed that actions performed by others are processed in the visual system, and then mapped onto the motor cortex of the observer, which performs the same action (Rizzolatti et al, 2009). The occurrence of this neural pattern in the observer enables an understanding of the actions of the observed. Along with inferior frontal gyrus (IFG) and inferior parietal lobe (IPL), the posterior superior temporal sulcus (STS) is an important component of the MNS. This region contains cells which activate when actions are observed, but not when activation is executed. Gallagher and Frith (2003) proposed that initial analysis of social cues occurs in this region. When a movement is observed there is a progression of neural activity across the brain in the following order (Nishitani et al, 2002). Further, brain areas involved in emotional process (such as the anterior insula and cingulate cortex) are activated when we observe the emotions of others. And, it is proposed that “motor simulation may be a trigger for the simulation of associated feeling states” (Bastiannsen et al, 2009). While discovery of the MN and the MNS has been exciting, some reservations have been expressed (Pascolo et al, 2010). It is probable that this phenomenon also contributes (along with the MNS and other potential systems) to ToM skills. ToM in clinical disorders ToM skills are recently evolved and finely tuned, and depend on a high degree of biological, psychological and sociological integration. Finely balanced equipment is easily disrupted, and it would be reasonable to expect that some psychiatric disorders are underpinned by disrupted ToM processes (Brune et al, 2003; Brune and Brune- Cohrs, 2006). Developmental disorders Children with autism have difficulties with emotional relationships and language acquisition. They have markedly impaired ToM skills (Baron-Cohen, 1988). With maturation, in the teen years, the performance of people with autism on ToM tests, may improve. Interestingly, the lack of ToM skills means these children are unable to deceive others, or to recognize when they are being deceived by others. People with less severe autistic-spectrum disorders have less impairment of ToM skills. There have been conflicting reports about whether MN dysfunction is (Perkins et al, 2010) or is not (Fan et al, 2010) a feature of autism. However, there is no doubt that ToM is impaired in autism spectrum disorders (ASD; Schneider et al, 2013). Personality disorder People with psychopathy are described as being cold and lacking in empathy. This suggests they would perform poorly on ToM tasks. Contrary to expectations, however, people with psychopathy appear to have unimpaired ToM skills (Blair et al, 1996). It is believed that people with psychopathy are aware of the distress they cause others, but are not distressed by these facts. Delusional disorder (DD) ToM is believed to have roots in the evolutionary process, and the “pure” delusions of DD (fear of gangs, jealousy, erotomania and somatic) have been proposed as having had survival value. These delusions, which arise exclusively in a social context, have been labelled, “Theory of Mind Delusions” (Charlton and McClelland, 1999; Charlton, 2003). However, people suffering DD may perform normally on ToM tests (Walston et al, 2000; Bommer and Brune, 2006). This may suggest that current ToM tests are not valid. Alternatively, there may be an explanation in differences between the DD delusions and the “bizarre” delusions of other psychoses. With respect to delusions in general, not specifically those of DD, Freeman (2007) found that ToM deficits may be present, but “they are certainly not specific or necessary”. With respect to delusions in schizophrenia, Pousa et al (2008) reported, “specific ToM deficits were found associated with delusions”. Schizophrenia Frith (1992) raised the possibility of ToM deficits underpinning schizophrenia.

Developmental trajectories of child to adolescent externalizing behavior and adult DSM-IV disorder: results of a 24 year longitudinal study geriforte 100mg fast delivery. Increased putamen and callosal motor suregion in treatment-naïve boys with Tourette syndrome indicates changes in the bihemispheric motor network order geriforte 100 mg online. Journal of Child Psychology and Psychiatry and Allied Disciplines 1999; 40: 19-55. Sawyer M, Kosky R, Graetz B, Arney F, Zubrick S, Baghurst P. The National survey of mental health and wellbeing: the child and adolescent component. Australian and New Zealand Journal of Psychiatry 2000; 34:214-220. Brain hyperconnectivity in children with autism and its links to social deficits. From Child to adult: The Dunedin multidisciplinary health and development study. The genetics of child psychiatric disorders: focus on autism and Tourette syndrome. Refining the attention deficit hyperactivity disorder phenotype for molecular genetic studies. Molecular Psychiatry 2006; May 16; [Epub ahead of print]. Psychosis and autism: magnetic resonance imaging study of brain anatomy. Individual variation and longitudinal pattern of genome-wide DNA methylation from birth to the first two years of life. Child abuse and epigenetic mechanisms of disease risk. American Journal of Preventive Medicine 2013; 44:101-107. Use of ADHD drugs in the Nordic countries: a population-based comparison study. FEAR AND ANXIETY Introduction “It remains unclear whether anxiety states are to be better conceptualized as several putatively distinct diagnostic entities or as one broadly conceived syndrome within which there are no clear boundaries between various manifestations of anxiety” Vladan Starcevic (2006). Applies to the total organism, it refers to a state of readiness for activity, and involves increased sensory excitability, muscular tone and sympathetic and endocrine activity. Anxiety Most non-medical dictionaries define anxiety in this manner: “a feeling of worry, nervousness, or unease about something with an uncertain outcome” Non-medical synonyms for anxiety include “worry”. This is consistent with medical definitions: “Anxiety is a general term for several disorders that cause nervousness, fear, apprehension, and worrying. In earlier textbooks anxiety disorders were conceptualized as requiring two sets of symptoms - cognitive (worry) and somatic (tremor, sweating, palpitations, etc. This continues to be the case with the current International Classification of Disorders (ICD 10). However, in the DSM5, somatic symptoms in the form of those mentioned above, need not be present. Normal anxiety Normal anxiety has been applied to states of arousal/anxiety which occur in everyday life, in response to stimuli. It has an adaptive role and is a signal to take action. In normal anxiety the assessment of the danger is appropriate and the action taken is effective. The healthy person who has lost her/his pay-packet will be anxious about paying outstanding bills. Experiencing occasional anxiety is a normal part of life (Mayo Clinic, 2015). Fear is generally regarded to be an extreme form of normal anxiety. If an intruder comes into the house, most healthy persons will be fearful. Pathological anxiety Pathological anxiety is diagnosed when there is excessive assessment of danger. The individual may be unable to make any response, or make an excessive protective response. The person with pathological anxiety may be so disabled that he/she is unable to conduct his/her usual duties, such as prepare a meal, or overestimate a danger and make maladaptive adjustments (the person who is unduly anxious about lifts will have to take the stairs).

The Bible provides accounts of suicide and suicidal thinking buy geriforte 100 mg free shipping. Mathew 27: 5 details the actions of Judas when the priests refused to allow him to retract his betrayal of Jesus: “And he cast down the pieces of silver in the temple and departed generic geriforte 100mg online, and hanged himself. These excerpts indicate that individuals in particular circumstances may choose and complete or desire death. In ancient Greek and Roman times suicide was permissible (Anthony and Cleopatra suicided). However, for most of history, suicide, like homicide, has been forbidden. Among East African tribes the tree from which self-hanging had occurred had to be felled and burnt (Bohannan, 1960). From pre-Christian times, in various countries, a stake was driven through the body, which was then buried at the crossroads. The stake was to pin the evil spirit to the ground and the cross roads were chosen so that the evil spirit would be confused by people going in different directions and not know which one to follow. This custom was last performed in Britain, in London, in 1823. Wyder (2004) examined individuals who had survived a suicide attempt; 51% reported acting after thinking about their actions for 10 minutes or less. Of those who had been affected by alcohol, 93% had thought about their actions for 10 minutes or less. Impulsive acts make prevention problematic (WHO, 2014). Dumais et al (2005) investigated cases in which suicide was completed during an episode of major depression. They found that impulsive-aggressive personality disorders and alcohol abuse/dependence were two important, independent predictors of suicide in major depression. When acute suicide risk is the consequence of a mental disorder, appropriate treatments (outlined in other chapters) should be administered without delay. Compulsory admission and treatment may be necessary. Some individuals are at long term (chronic) risk of suicide. Chronic risk is a common feature of personality disorder, particularly borderline personality disorder. The personality disorders differ from conditions such as major depressive disorder, which manifest discrete episodes of difficulties. Personality disorder is diagnosed when features of the personality lead to “distress and impairment”. When the suicide risk is due to personality disorder, as personality disorder is a long-term (rather than episodic) disorder, the suicide risk will be chronic. While personality disorder is a chronic condition, there may be superimposed periods of more acute distress and acute risk of suicide. Borderline personality disorder, characterized by a pervasive pattern of instability of interpersonal relationships and mood, and marked impulsivity, has a 10% lifetime risk of suicide (Plakun et al, 1985). Impulsive suicide is usually triggered by adverse life events (Zouk et al, 2006). The personality of people with personality disorder may mature and distress may lessen over a period of years, particularly with the assistance of ongoing outpatient care. Lengthy inpatient periods in psychiatric facilities are at best useless and at worst, damaging; they remove individuals from the real world in which they need to learn to function, and delay the development of a sense of personal responsibility. However, brief hospitalization of individuals with personality disorder may be helpful during crisis periods (up to 72 hours) to allow the settling of acute episodes of distress (Krawitz & Watson, 2000). Wyder (2004) reports that of those who attempt suicide, in 79% the impulse has passed within 12 hours. The management of patients with borderline personality disorder is legally perilous for doctors because of the lack of understanding in the community of the chronic risk of suicide and the optimal treatment mentioned in the above paragraphs (Gutheil, 1985). There are some informed jurisdictions, however, for example, the Ministry of Health (New Zealand) Guidelines (1998) state, “In order to achieve therapeutic gain, it is sometimes necessary to take risks. A strategy of total risk avoidance, could lead to excessively restricted management, which may in itself be damaging to the individual”. This probably includes those who suicide “for the greater good” of their community, such as political protesters, Kamikaze pilots and suicide bombers. Thich Quang Duc burned himself to death in Saigon (Vietnam) in 1963. He was protesting the way the government was (in his view) oppressing the Buddhist religion. Not infrequently, we learn of the suicide of people who are suffering intractable physical pain. Chronic pain doubles the risk of suicide (Tang & Crane, 2006) Illustration. Jo Shearer, a 56 year old accomplished journalist who suffered intractable pain.