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Introduction

When she was thirty-one, she began a long-distance relationship with Rob Wipond, a Canadian journalist. Everything was new to her. It felt synthetic. I did it! She felt fortunate that her sexuality had returned in a way that eluded other people who were withdrawing from drugs. Although it is believed that people return to their sexual baseline, enduring sexual detachment is a recurring theme in online withdrawal forums. Audrey Bahrick, a psychologist at the University of Iowa Counseling Service, who has published papers on the way that S.

Cognitive behavioral therapy

There was this assumption that the symptoms would resolve once you stop the medication. I just kept thinking, Where is the data? Where is the data? Laura felt as if she were learning the contours of her adult self for the first time. When she felt dread or despair, she tried to accept the sensation without interpreting it as a sign that she was defective and would remain that way forever, until she committed suicide or took a new pill.

Laura tried to find language to describe her emotions and moods, rather than automatically calling them symptoms. She wrote several letters to Dr. Roth, her favorite psychiatrist, requesting her medical records, because she wanted to understand how the doctor had made sense of her numbness and years of deterioration.

After a year, Dr. Roth agreed to a meeting. Laura prepared for hours. How do you make sense of that? Roth opened the front door. She had always loved Dr. By the time Dr. Roth walked into the waiting room, Laura was crying. They hugged and then took their usual positions in Dr. But Laura said that Dr. It was only when Laura left that she realized she had never asked her questions.

Laura started a blog, in which she described how, in the course of her illness, she had lost the sense that she had agency. People began contacting her to ask for advice about getting off multiple psychiatric medications. Some had been trying to withdraw for years.

They had developed painstaking methods for tapering their medications, like using grass-seed counters to dole out the beads in the capsules. Laura, who had a part-time job as a research assistant but who still got financial help from her parents, began spending four or five hours a day talking with people on Skype. I needed to know that someone else had gone through it and survived. I know that I would lay down my life for her. Laura realized that she was spending her entire workday on these conversations.

Because she needed to become financially self-reliant, she began charging seventy-five dollars an hour on a sliding scale to talk to people. Few psychiatrists are deeply engaged with these questions, so a chaotic field of consultants has filled the void. The groups offer instructions for slowly getting off medications—they typically recommend that people reduce their doses by less than ten per cent each month—and a place to communicate about emotional experiences that do not have names.

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For many people on the forums, it was impossible to separate the biochemical repercussions from the social ones. The medicines worked on their bodies, but they also changed the way people understood their relationships and their social roles and the control they had over elements of their lives. It has not worked. I am not an angry person—I am gentle, I am affectionate, I am open—but in withdrawal I found that these qualities were less clear.

I was more irritable. We are trained to understand the evidence base as paramount—it is the primary basis for mental-health prescriptions around the world, and I fully subscribe to it—but this evidence base can never be complete without listening to the wider story. There were few precedents. In the late nineties, Heather Ashton, a British psychopharmacologist who had run a benzodiazepine-withdrawal clinic in Newcastle, had drafted a set of guidelines known as the Ashton Manual, which has circulated widely among patients and includes individual tapering schedules for various benzodiazepines, along with a glossary of disorienting symptoms.

She and Rob whom she was no longer dating created it with a grant from a small foundation, which gave her enough money to pay herself a salary, to hire others who had consulted with people withdrawing from medications, and to cull relevant insights about tapering strategies. The Web site helps people withdrawing from medications find others in the same city; it also offers information on computing the percentage of the dosage to drop, converting a pill into a liquid mixture by using a mortar and pestle, or using a special syringe to measure dosage reductions.

Swapnil Gupta, an assistant professor at the Yale School of Medicine, told me that she is troubled that doctors have largely left this dilemma to patients to resolve. They routinely encounter patients who, like Laura, are on unnecessary combinations of psychiatric medications, but for different reasons: Laura saw her therapists as gurus who would solve her problems, whereas poor or marginalized patients may be overtreated as they cycle in and out of emergency rooms.

It is a loss of identity, a different way of living. Suddenly, everything that you are doing is yours—and not necessarily your medication. Put me back on my meds. Now they had just returned from spending the holiday with her family in Maine.

10 Signs of Vindictive Narcissism

He asked if a number of different household items were safe for the dishwasher, before saying he had one last question and pulling an engagement ring out of his pocket. Laura had met Cooper, who works at an agency that supports people with psychiatric and addiction histories, two years earlier, at a mental-health conference in Connecticut.

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Cooper had been given Adderall for attention-deficit hyperactivity disorder at seventeen and had become addicted. I need tweaking, I need adjusting. His work made him unusually welcoming of the fact that people in various states of emotional crisis often want to be near Laura. A few months after they were engaged, Bianca Gutman, a twenty-three-year-old from Montreal, flew to Hartford to spend the weekend with Laura. Susan paid Laura for Skype conversations, until Laura told her to stop. Laura had come to think of Bianca, who had been diagnosed as having depression when she was twelve, as a little sister navigating similar dilemmas.

While Bianca was visiting, a friend from out of town who was in the midst of what appeared to be a manic episode was staying at an Airbnb a few houses down the street.

Bianca, who is barely five feet tall, moved and talked more slowly than Laura, as if many more decisions were required before she converted a thought into words. She had been on forty milligrams of Lexapro—double the recommended dose—for nearly nine years. Bianca, who worked as an assistant at an elementary school, was down to five milligrams of Lexapro.

She sat on the couch with her legs curled neatly into a Z—a position that she later joked she had chosen because it made her feel more adult. Like Laura, Bianca had always appreciated when her psychiatrists increased the dosage of her medications. It dodges all language. Hopeful about what? Just hopeful, I think, because I felt that connection with someone. At my request, Laura had dug up several albums of childhood photographs, and the three of us sat on the floor going through them.

Laura looked radically different from one year to the next. She had had a phase of wearing pastel polo shirts that were too small for her, and in this phase, when Laura was pictured among friends, Bianca and I struggled to tell which girl was her. She had taken a new interest in clothes and was wearing high-waisted trousers from Sweden with a tucked-in T-shirt that accentuated her waist. She agreed. She was too sensitive. She let situations escalate. How could you possibly think otherwise, you poor thing?

In many of our conversations, Laura said, she was trying to ignore the thought: Who do you think you are, speaking with this journalist? However, this definition is not applicable to clinical practice. In this handbook, the categories of 'mild' and 'moderate' acute asthma have been merged to avoid confusion between terminologies traditionally used at different levels of the health system. Mild acute asthma can usually be managed at home by following the person's written asthma action plan. National Asthma Council Australia. Recommendation types.

Home Acute asthma Clinical management. Managing acute asthma in clinical settings Overview Wheezing infants younger than 12 months old should not be treated for acute asthma. Acute wheezing in this age group is most commonly due to acute viral bronchiolitis. When AK is disentangled from standard orthopedic muscle testing, the few studies evaluating unique AK procedures either refute or cannot support the validity of AK procedures as diagnostic tests.

Cuthbert and Goodheart recently published a narrative review on the reliability and validity of manual muscle testing MMT in the Journal [ 1 ]. They concluded that "The MMT employed by chiropractors, physical therapists, and neurologists was shown to be a clinically useful tool, but its ultimate scientific validation and application requires testing that employs sophisticated research models in the areas of neurophysiology, biomechanics, RCTs, and statistical analysis.

Most importantly, a misunderstanding of the review could easily arise, because the authors did not distinguish the general use of manual muscle strength testing from the specific applications that distinguish the AK chiropractic technique. The purpose of this commentary is to provide a critical appraisal of the review to expose important flaws, suggest conclusions consistent with the literature reviewed and omitted, and disentangle conclusions that can be made about AK in particular from those that can be made about MMT.

Note that we have not conducted a full systematic review. The validity of this review of MMT inevitably depends on the quality of the review process. It does not appear to have been the intent of the authors to conduct a full systematic review of the literature, and we do not hold them to that standard. However, design elements of a good systematic review of diagnostic tests [ 2 — 4 ], as well as critical appraisal of the measurement evaluation literature [ 5 — 14 ], are pertinent to the discussion at hand.

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Even the more traditional narrative review shares many of these elements [ 15 ]. We have compiled questions that must be considered in order to draw valid inference on the usefulness of AK diagnostic procedures Table 1 ; these questions are based on research and synthesis methodology from the citations above. The answers to these few questions pose a serious challenge to the authors' conclusion about the usefulness of AK. AK has a long and rich history in chiropractic [ 1 , 16 ].

Many chiropractors report use of the technique in some form [ 17 , 18 ]. MMT, as performed by chiropractors, does not necessarily differ in its execution and interpretation from manual muscle testing as performed and interpreted by the standards applied in physical medicine. To either practitioner, a weak muscle might suggest a primary muscular or neurological pathology. However, AK technique uses manual muscle testing not just to evaluate the functional integrity of muscle and nerve supply, but also as a means to "diagnose structural [and functional], chemical, and mental dysfunctions [ 1 ].

MMT is a standard component of the neuromusculoskeletal physical examination [ 22 ]. We agree with the authors that MMT is useful in the assessment of weakness of muscles directly involved with pain, injury, and neuromusculoskeletal disorders. The authors also confuse two uses of the term validity: test accuracy and diagnostic validity. A test may be extremely accurate, let us say for example dynamometric evaluation of muscle force in newtons, but still have no sensitivity or specificity for the diagnosis of a specific condition [ 5 , 6 ]. The review by Cuthbert and Goodheart illustrates how failure to utilize a fastidious search strategy can miss critical citations and impact review findings.

There are several problems pertaining to the scope of the search that may have led to the omission of relevant articles. In our search of PubMed, the addition of the search term "muscle testing" increased the number of papers found from to 13, The authors may also have failed to use another important search strategy, namely checking article references to identify further pertinent studies. The authors stated that they selected studies based on relevance, but did not include an operational definition.

Taylor's Diagnostic and Therapeutic Challenges - A Handbook | Alan K. David | Springer

It appears that any MMT article on a pain-related disorder was considered relevant. Negative studies were certainly omitted. Had the authors used the search term "muscle testing" and included the MANTIS database, they would not have failed to identify randomized trials designed specifically to evaluate the contribution of an AK-challenge procedure to MMT results [ 23 — 25 ]. In any event, the authors should have been aware of the study by Triano that was conducted with the assistance of the International College of Applied Kinesiology [ 23 ] and critiqued by Goodheart in a letter to the editor [ 26 ].

One selection criterion introduced clear and significant bias into the review. Clearly this inclusion criterion was not uniformly applied, since many of the included studies did not address reliability and thus did not report a kappa value. More importantly, the use of this criterion was based on a misunderstanding of Swinkles et al [ 27 ]. The biased inclusion criterion clearly set up a tautology that pre-determined a positive conclusion about the usefulness of MMT. Evaluation of study quality is an important aspect of literature reviews [ 15 , 28 ], and certainly there are many methods for doing this [ 29 ].

TAYLORS DIAGNOSTIC AND THERAPEUTIC CHALLENGES: A HANDBOOK

Cuthbert and Goodheart write in the methods section that a quality assessment was performed. It is not until the end of the paper that the authors acknowledge that internal and external validity have not been critically evaluated. The authors had no formal criteria or algorithm for synthesizing the literature to reach a conclusion about MMT in general and AK specifically. Without quality assessment, studies of great merit are inevitably given no more weight than studies with serious design flaws and unsupported conclusions. In particular, it is not advisable to take authors' conclusions from included articles at face value.

Misinterpretations occur. Some examples in the chiropractic literature of conclusions inconsistent with study design and results are identified in several reviews [ 9 , 30 , 31 ]. Cuthbert and Goodheart attempt to infer clinical relevance for MMT diagnosis from studies with positive treatment outcomes.


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One example cited by the authors in their Table 4 is an observational study by Moncayo et al [ 32 ]. The implied logic is that if an AK procedure is used to identify the need for treatment and patients have positive outcomes, then there is evidence that the AK procedure is a valuable diagnostic tool. The flaw in this line of reasoning is that patients can improve despite the diagnostic procedures used. This has actually been demonstrated in a randomized trial evaluating the efficacy of a commonly used chiropractic diagnostic procedure [ 33 ]. An efficacious treatment e. The authors note several times in the text that MMT has been investigated in randomized trials.

This assertion requires some clarification. In all the randomized trials cited, patients were randomized to treatment or treatment control, and not to diagnostic test or diagnostic test control. This means that the efficacy of treatment was under investigation, rather than the efficacy of the MMT. The efficacy contribution to patient outcomes of diagnostic tests and manipulation indicators can and should be evaluated in blinded randomized trials [ 7 , 33 , 34 ].

We thus agree with the authors' statement that more randomized trials are necessary to validate AK applications of MMT. However, randomized trials of treatment efficacy will not validate AK diagnostics as the authors contend. Blinded randomized trials can be used not only to evaluate test efficacy, but also to investigate construct validity and the contribution of provocative tests e.

Several construct validity trials of tests used in AK are discussed under construct validity below [ 23 , 24 ]. Reliability is usually considered a necessary but insufficient condition for establishing the usefulness of a diagnostic test [ 5 , 6 ]. That is, poor reliability generally rules out the usefulness of a test at least in the context of how it is measured [ 25 ] , but good reliability does not ensure usefulness. Several such double-blind studies were omitted from the review [ 25 , 35 — 37 ].

Jacobs showed good reliability in an unblinded test of sugar solutions but only fair reliability in a double-blind test of MMT response to orally administered oil solutions [ 35 ]. Haas et al found poor interexaminer reliability of MMT of a vertebral challenge muscle "strength" change following directional pressure on the vertebral spinous process [ 25 ].

Two small double-blind studies looked at MMT response to bottled substances held in the patient's hand. Ludtke et al found that response was no better than guessing for both wasp venom and inert substance [ 36 ], Garrow showed no test-retest reproducibility of MMT for identifying potential allergens [ 37 ]. Pothmann et al. Note that we only viewed the English abstract translated from German.

Other reliability studies not included in the review are described below. These were either poorly designed or had negative results.