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By E. Sancho. Boston University.

Definition The exact definition of this syndrome remains elusive buy discount sevelamer 800 mg on line gastritis sore throat, despite many publications apparently describing similar events (19 purchase sevelamer 800mg otc gastritis diet óëűáęŕ,20) safe 800mg sevelamer gastritis questionnaire. Indeed proven 400mg sevelamer gastritis diet áîëüřčĺ, the many different names given to these apparently similar conditions (Bell’s mania, agitated delirium, excited delirium, and acute exhaustive mania) throughout the years indicate that it is a syndrome that may have many different facets, not all of which may be present in any single case. However, all of these descriptions do comment on the high potential for sudden collapse and death while the individual is in the highly excited states that they all describe. It is now accepted that such syndromes do exist, and although it is now com- monly associated with use and abuse of cocaine (21), it is important to note that it was described in 1849 well before cocaine use and abuse became com- mon (19). Features The clinical features of excited delirium are generally accepted to be the following: • A state of high mental and physiological arousal. In addition to these clinical observable features, there will certainly also be significant physiological and biochemical sequelae, including dehydration, lactic acidosis, and increased catecholamine levels (22). These biochemical and physiological features may be such that they will render the individual at considerable risk from sudden cardiac arrest, and the descriptions of cases of individuals suffering from excited delirium (23) indicates that the sudden death is not uncommon. Shulack (23) also records that: “the end may come so sud- denly that the attending psychiatrist is left with a chagrined surprise,” and continues: “the puzzlement is intensified after the autopsy generally fails to disclose any findings which could explain the death. In the context of restraint associated with death in cases of excited delirium, the presence of injuries to the neck may lead to the conclusion that death resulted from asphyxia, but this interpretation needs careful evaluation. What is perhaps of greater importance is that in all of the cases described in the clinical literature (19,20,23–25), there has been a prolonged period of increasingly bizarre and aggressive behavior, often lasting days or weeks before admission to hospital and subsequent death. The clinical evidence avail- able for the deaths associated with police restraint indicates that although there may have been a period of disturbed behavior before restraint and death, the duration of the period will have been measured in hours and not days. This change in time scale may result from the different etiology of the cases of excited delirium now seen, and it is possible that the “natural” and the “cocaine-induced” types of excited delirium will have different time spans but a common final pathway. The conclusion that can be reached concerning individuals displaying the symptoms of excited delirium is that they clearly constitute a medical emergency. The police need to be aware of the symptoms of excited delirium and to understand that attempts at restraint are potentially dangerous and that forceful restraint should only be undertaken in circumstances where the indi- vidual is a serious risk to himself or herself or to other members of the public. Ideally, a person displaying these symptoms should be contained and a forensic physician should be called to examine him or her and to offer advice to the police at the scene. The possibility that the individual should be treated in situ by an emergency psychiatric team with resuscitation equipment and staff available needs to be discussed with the police, and, if such an emer- gency psychiatric team exists, this is probably the best and safest option. If such a team does not exist, then the individual will need to be restrained with as much care as possible and taken to the hospital emergency room for a full medical and psychiatric evaluation. These individuals should not be taken directly to a psychiatric unit where resuscitation skills and equipment may not be adequate. From consideration of the medical aspects of these deaths recorded in their report, it would appear that six of the deaths resulted from natural disease and four were related to drug use or abuse. Of the remaining six cases, one was associated with a baton blow to the head, two to asphyxiation resulting from pressure to the neck, two to “restraint asphyxia,” and one to a head injury. Therefore, in the deaths during the 7 years that this group considered, a total of four deaths (<1. However, the close association of these deaths with the actions of the police in restraining the individual raises questions about the pathologists’ con- clusions and their acceptance by the courts. It is common for several pathologi- cal opinions to be obtained in these cases; in a review of 12 in-custody deaths, an average of three opinions had been obtained (range 1–7) (27). Indeed, in one of the cases cited as being associated with police actions, seven pathological opinions were sought, yet only one opinion is quoted. This points to the consid- erable difficulty in determining the relative significance of several different and, at times, conflicting areas of medical evidence that are commonly present in these cases. The area of restraint that causes the most concern relates to asphyxiation during restraint. It has been known in forensic circles for many years that indi- viduals may asphyxiate if their ability to breathe is reduced by the position in which they are placed or into which they fall (Subheading 7. This type of asphyxiation is commonly associated with alcohol or drug intoxication or, rarely, with neurological diseases that prevent the individual from extract- ing themselves from a position that either partially or completely occludes their mouth and nose or limits the freedom of movement of the chest wall. Death resulting from these events has been described as postural asphyxia to indicate that it was the posture of the individual that resulted in the airway obstruction rather than the action of a third party. Reay concluded that positional restraint (hog-tieing) had “measurable physiological effects. This article raised 346 Shepherd the possibility that asphyxiation was occurring to individuals when they could not move themselves to safer positions because of the type of restraint used by the police. The concept of “restraint asphyxia,” albeit in a specific set of cir- cumstances, was born. Since the description of deaths in the prone hog-tied position, Reay’s original concepts have been extended to account for many deaths of indi- viduals simply under restraint but not in the hog-tied position. The term restraint asphyxia has been widened to account for these sudden and unex- pected deaths during restraint. Considerable pathological and physiological controversy exists regarding the exact effects of the prone position and hog- tieing in the normal effects upon respiration. Although the physiological controversy continues, it is clear to all those involved in the examination and investigation of these deaths that there is a small group of individuals who die suddenly and apparently without warning while being restrained. Recent physiological research on simulated restraint (33,34) revealed that restraint did produce reductions in the ventilatory capacity of the experimental subjects but that this did not impair cardiorespiratory function. In two of the eight healthy subjects, breath holding after even moderate exercise induced hypoxia-related dysrhythmias, and it was noted that arterial oxygen saturation fell rapidly even with short breath hold times, especially if lung volume was reduced during exhalation. The problem that currently faces the forensic pathologist is the determi- nation of the cause or causes of these deaths. This is made harder because there are seldom any of the usual asphyxial signs to assist and, even if those signs are present, it is difficult to assign weight or significance to them because similar changes can be caused simply by resuscitation (35,36). The major features of asphyxiation are cyanosis, congestion, and pete- chial hemorrhages (14). These features are seen to a greater or lesser extent in many, but not all, cases of asphyxiation. They often are completely absent in many plastic bag asphyxiations and in hanging, they have variable presence in manual strangulation, and they are most commonly seen in ligature stran- gulation. However, their most florid appearances are in deaths associated with postural asphyxia or crush asphyxia cases where death has occurred slowly and where it is associated with some form of pressure or force reducing the ability of the individual to maintain adequate respiratory movement, either from outside the body or from the abdominal contents splinting the diaphragm. Deaths in Custody 347 It is of interest then that these features, if present at all in these cases are, at most, scant and do not reflect their appearance in other cases of crush asphyxia, suggesting that different mechanisms are the cause of death in these two sets of circumstance. The individuals who die during restraint are not infrequently under the influence of drugs (particularly cocaine) or alcohol; they may be suffering from some underlying natural disease (particularly of the cardiovascular sys- tem), or they may have suffered some trauma. These “additional” factors are sometimes seized by pathologists and courts to “explain” the death, some- times even in the face of expert opinion that excludes the additional factor from playing a major part in the death. It would seem that there is a subgroup of the population that is either permanently or temporarily susceptible to the effects of restraint, whether those effects be mediated entirely or partially through decreased respiratory effort or some other factor. There is a separate entity, the exact cause of which is not yet clear, where otherwise fit and healthy individuals die suddenly while being restrained and yet do not show significant features of asphyxiation. It is hoped that further research on the physiology of restraint will elucidate the mechanisms that cause death in these cases. Until these mechanisms are established, it is reasonable to propose that these deaths should be classified for what they are—rapid unex- plained death during restraint—rather than to conclude that the cause of death cannot be determined or to ascribe a doubtful medical or toxicological cause of death that does not bear close scrutiny. Deaths classified as rapid unexplained death during restraint must fulfill several of the following criteria: 1. The death must have occurred during restraint, and the individual must have col- lapsed suddenly and without warning. A full external and internal postmortem examination must have been performed by a forensic pathologist, which did not reveal macroscopic evidence of signifi- cant natural disease, and subsequently a full histological examination of the tis- sues must have been performed, which did not reveal microscopic evidence of significant natural disease. There must be no evidence of significant trauma or of the triad of asphyxial signs. A full toxicological screen must have been performed that did not reveal evi- dence of drugs or alcohol that, alone or in combination, could have caused death. The small numbers of these deaths in any single country or worldwide makes their analysis difficult; indeed, to search for a single answer that will explain all of these deaths may be futile.

Te notes element may be used to provide any information that the compiler of the reference feels is useful purchase sevelamer 400mg on-line symptoms of gastritis mayo clinic. Quantifcation and comparison of signal amplifcation and non- amplifcated immunohistochemical reactions of the rat brain by means of image analysis purchase sevelamer 400 mg line gastritis diet dr oz. Enders D (Institut fur Organische Chemie buy 400mg sevelamer with mastercard gastritis diet ěŕéë, Technische Hochschule Aachen discount sevelamer 800mg without prescription chronic gastritis group1, Aachen, Germany. Immobilized triazolium salts as precursors to chiral carbenes: rhodium-catalyzed asymmetric hydrosilylation as a frst test reaction. Tumori gastrici nel cane: osservazioni personali [Gastric tumors in dogs: personal reports]. Te efect of base mismatches in the substrate recognition helices of hammerhead ribozymes on binding and catalysis. Quantifcation and comparison of signal amplifcation and non- amplifcated immunohistochemical reactions of the rat brain by means of image analysis. Quantifcation and comparison of signal amplifcation and non- amplifcated immunohistochemical reactions of the rat brain by means of image analysis. Quantifcation and comparison of signal amplifcation and non- amplifcated immunohistochemical reactions of the rat brain by means of image analysis. Te efect of base mismatches in the substrate recognition helices of hammerhead ribozymes on binding and catalysis. Figure 9, Important ophthalmoscopic fndings in the patient with diabetic retinopathy are retinal hemorrhage and pallor of the optic nerve and retina; [about 1 screen]. Quantifcation and comparison of signal amplifcation and non- amplifcated immunohistochemical reactions of the rat brain by means of image analysis. If a journal is still being published, as shown in the frst example, follow volume and date information with a hyphen and three spaces. If a journal ceased publication, as in example two, separate beginning and ending volume and date information with a hyphen with a space. It is important to cite the journal name that was used at the time of publication. An R afer the component name means that it is required in the citation; an O afer the name means it is optional. Tis rule ignores some conventions used in non-English languages to simplify rules for English-language publications. Tis rule ignores some conventions used in non-English languages to simplify rules for English-language publications. Dutch Uitgave Uitg Editie Ed Finnish Julkaisu Julk French Edition Ed German Ausgabe Ausg Greek Ekdosis Ekd Italian Edizione Ed Norwegian Publikasjon Pub Portuguese Edicao Ed Box 54 continues on next page... Language Word Abbreviation Russian Izdanie Izd Spanish Edicion Ed Swedish Upplaga n. Romanization, a form of transliteration, means using the roman (Latin) alphabet to represent the letters or characters of another alphabet. Tis rule ignores some conventions used in non-English languages to simplify rules for English-language publications. Language Word for Editor French redacteur editeur German redakteur herausgeber Italian redattore curatore editore Russian redaktor izdatel Spanish redactor editor Examples for Editor 9. Tis rule ignores some conventions used in non-English languages to simplify rules for English-language publications. Place all translated publisher names in square brackets unless the translation is given in the publication. Designate the agency making the publication available as the publisher and include distributor information as a note. Add the name of the distributor, the city and state, and the accession or order number. For those publications with joint or co-publishers, use the name provided frst as the publisher and include the name of the second as a note, if desired, as "Jointly published by the Canadian Pharmacists Association". Oct 1999-Mar 2000 Dec 7, 2002-Jan 9, 2003 • Separate multiple months of publication and multiple days of the month by a hyphen Mar-Apr 2005 Dec 1999-Jan 2000 Feb 1-7, 2005 Jan 25-31, 2001 • Separate multiple seasons by a hyphen, as Spring-Summer. Specific Rules for Physical Description • Language for describing physical characteristics Box 74. Sponsored by the American College of Physicians and Massachusetts General Hospital. Sponsored by the American College of Physicians and Massachusetts General Hospital. Database records are usually related by a common denominator such as subject matter or the source of the material in them. Text-oriented databases are generally bibliographic or full-text, where each record has a bibliographic citation to a publication or the complete text of a document. Number-oriented databases cover many types, including statistical, time series, and transactional. Serial databases contain records or other entries that have been collected over a period of time, with new or updated versions issued at stated intervals. Open databases continue to have new records added to them or to have existing records updated; in closed databases no records are being added or updated. Tese are collections of records published only once, usually with no intention of updating or adding records at a future date, although minor corrections/changes may be made. When citing a database, always provide information on the latest title and publisher unless you are citing an earlier version. If you wish to cite all years for a database that has changed title, provide a separate citation for each title. For citing a part of these databases, such as an individual record, combine the guidelines presented in this chapter with those in Chapter 24B Parts of Databases on the Internet and Chapter 2C Parts of Books. For citing a contribution to a database, which occurs when an author(s) submits text or data to a database, combine the guidelines presented in this chapter with those in Chapter 24C Contributions to Databases on the Internet and Chapter 2D Contributions to Books. Note, however, that entries for the books and journal articles in a bibliographic database should not be cited as a contribution; the original item should be sought when possible. When citing a part of a database, begin with the citation to the database, then add information on the part. Because a reference should start with the individual or organization responsible for the intellectual content of the publication, begin a reference to a contribution with the author and title of the contribution, followed by the word "In:" and the citation for the entire database. As when citing parts and contributions to books, provide the length of the part or contribution to a database whenever possible. If traditional page numbers are not present, calculate the extent of the part or contribution using the best means possible, i. Since screen size and print fonts vary, precede the estimated number of screens and pages with the word, "about", and place extent information in square brackets, such as [about 3 screens]. For parts and contributions that contain hyperlinks, however, such as the second sample citation in example 35, it will not be possible to provide the length. An R afer the component name means that it is required in the citation; an O afer the name means it is optional. Tis rule ignores some conventions used in non-English languages to simplify rules for English-language publications. Names in non-roman alphabets (Cyrillic, Greek, Arabic, Hebrew, Korean) or character-based languages (Chinese, Japanese). Romanization, a form of transliteration, means using the roman (Latin) alphabet to represent the letters or characters of another alphabet. Tis rule ignores some conventions used in non-English languages to simplify rules for English-language publications. An organization such as a university, society, association, corporation, or governmental body may be an author. International Union of Pure and Applied Chemistry, Organic and Biomolecular Chemistry Division.

Journal article in a microform Date of Publication for Journal Articles (required) General Rules for Date of Publication • Include the year generic 400 mg sevelamer with amex symptoms of gastritis ulcer, month buy discount sevelamer 800mg gastritis chronic nausea, and day of publication in that order order sevelamer 800 mg mastercard gastritis chronic diet. Journals 35 Specific Rules for Date of Publication • Multiple years cheap sevelamer 800 mg with mastercard gastritis rectal bleeding, months, or days of publication • Non-English names for months • Seasons instead of months • No volume or issue follows the date • Options for dates Box 31. However, the month and day of the month or the season must be included when citing a journal that has no volume or issue number. Journal article with multiple days of publication Supplement/Part/Special Number to a Date for Journal Articles (required) General Rules for Supplement/Part/Special Number to a Date • Place a supplement, part, special number, or other division to a year afer the date • Abbreviate these: Suppl, Pt, Spec No 38 Citing Medicine • Include numbers and letters accompanying them. A supplement, part, or special number to a date will occasionally have another subdivision. For example: - date with supplement - with a part 2005;Suppl: 2005;Suppl Pt 1: 2005;Suppl 2: 2005;Suppl 2 Pt A: 2005 Jan;Suppl: 2005 Jan;Suppl Pt 2: - date with part - with a supplement 2004;(Pt 2): 2004;(Pt 2 Suppl): - date with special number - with a part 2003;Spec No: 2003;Spec No Pt 2: Specific Rules for Supplement/Part/Special Number to a Date • Non-English names for supplements, parts, etc. To help identify these, see the following examples: Language Suppl Spec No Pt French supplement nombre speciale partie annexe part Box 36 continues on next page... Infrequently, supplements are given a name rather than the usual letter or number. Journal article with year having a part Volume Number for Journal Articles (required) General Rules for Volume Number • Omit "volume", "vol. Occasionally a journal is published in a series of issues without volumes or is published with a supplement, part, or special number to a date of publication rather than to a volume or issue. Journal article with no volume or issue Supplement/Part/Special Number to a Volume for Journal Articles (required) General Rules for Supplement/Part/Special Number to a Volume • Place a supplement, part, special number, or other division to a volume afer the volume number • Abbreviate these: Suppl, Pt, Spec No • Include numbers and letters accompanying them. A supplement, part, or special number to a volume will occasionally have another subdivision. For example: - volume with supplement - with a part Box 42 continues on next page... Infrequently, supplements are given a name rather than the usual letter or number. Journal article volume with special number Issue Number for Journal Articles (required) General Rules for Issue Number • Omit "number", "no. A supplement, part, or special number to an issue will occasionally have a further subdivision. For example: - issue with supplement with a part 2005;15(1 Suppl): 2005;15(1 Suppl Pt A): 2005;(12 Suppl A): 2005;(12 Suppl A Pt 2): 2005 Mar;87(3 Suppl): 2005 Mar;87(3 Suppl Pt B): - issue with part with a supplement 2004;66(1 Pt 2): 2004;66(Pt 2 Suppl): 2004 Dec;124(Pt A): 2004 Dec;124(Pt A Suppl) - issue with special number with a part 2003;6(2 Spec No): 2003;6(2 Spec No Pt 2): Specific Rules for Issue Number • Non-English names for issue • No volume number present • No issue number present • Options for issues Box 45. Journal article with no volume or issue Supplement/Part/Special Number to an Issue for Journal Articles (required) General Rules for Supplement/Part/Special Number to an Issue • Place a supplement, part, special number, or other division to an issue afer the issue number and inside the parentheses • Abbreviate these: Suppl, Pt, Spec No • Include numbers and letters accompanying them. Language Suppl Spec No Pt Spanish adjunto numero especial parte suplemento anejo • Capitalize and abbreviate them: Supplement = Suppl Part = Pt Special Number = Spec No Box 51. Infrequently, supplements are given a name rather than the usual letter or number. Journal article issue with special number Journals 49 Location (Pagination) for Journal Articles (required) General Rules for Location (Pagination) • Give the inclusive page numbers on which the article appears • Do not repeat page numbers unless they are followed by a letter. Journal article with roman numerals for page numbers (upper or lower case as found) 61. Journal article with no page number provided Physical Description for Journal Articles (optional) General Rules for Physical Description • Give information on the location of an article and its physical characteristics when the journal appears in a microform (microflm, microfche, etc. For example, if the volume or issue consists of 5 microfche and the particular article being cited is on the third fche, cite it as "microfche 3 of 5 microfche. Because microflm reels carry a large amount of text, a volume is usually contained within one reel. Examples of complete physical description statements: 1 reel: color, positive, 35 mm. Damit die "Spanische Grippe" nicht zuruckkehrt [How "Spanish fu" is not recognized]. Journal article in a language other than English with optional original language title included 20. Errata (error notices) range from simple indications of a misspelling to serious errors in drug dosages or mathematical calculations. Error notices that are inserted unbound into a journal issue or tipped in are not considered part of the permanent bibliographic record. Enter the phrase "Erratum in: " followed by the journal title abbreviation, date of publication, volume, issue, and location (pagination). Enter the phrase "Erratum for: " followed by the journal title abbreviation, date of publication, volume, issue, and location (pagination). Enter the phrase "Retraction in: " followed by the names of the authors, the journal title abbreviation, date of publication, volume, issue, and location (pagination). Enter the phrase "Retraction of: " followed by the names of the authors, the journal title abbreviation, date of publication, volume, issue, and location (pagination). Provide months in English and abbreviate them to the frst three letters, such as Jan for January. Post- streptococcal autoimmune neuropsychiatric disease presenting as paroxysmal dystonic choreoathetosis. Polymer-carbon black composite sensors in an electronic nose for air-quality monitoring. Other types of notes for journal articles Examples of Citations to Journal Articles 1. Links between dietary salt intake, renal salt handling, blood pressure, and cardiovascular diseases. Towards a mutant map of the mouse--new models of neurological, behavioural, deafness, bone, renal and blood disorders. Journal article with optional limit to the number of authors to 3 authors Rastan S, Hough T, Kierman A, et al. Towards a mutant map of the mouse--new models of neurological, behavioural, deafness, bone, renal and blood disorders. Towards a mutant map of the mouse--new models of neurological, behavioural, deafness, bone, renal and blood disorders. Magnetic resonance cholangiopancreatography accurately detects common bile duct stones in resolving gallstone pancreatitis. Magnetic resonance cholangiopancreatography accurately detects common bile duct stones in resolving gallstone pancreatitis. Journal article with organization as author, with subsidiary part of the organization included American College of Dentists, Board of Regents. Draf additional protocol to the Convention on Human Rights and Biomedicine, on biomedical research. Journal article with multiple organizations as author American Dietetic Association; Dietitians of Canada. Journal article with multiple organizations as author, with subsidiary part of the organization included American Academy of Pediatrics, Committee on Pediatric Emergency Medicine; American College of Emergency Physicians, Pediatric Committee. Policy on the inclusion of women and racial and ethnic minorities in externally awarded research; notice. Te efect of metformin and intensive lifestyle intervention on the metabolic syndrome: the Diabetes Prevention Program randomized trial. Comparative sequencing provides insights about the structure and conservation of marsupial and monotreme genomes. Te efect of metformin and intensive lifestyle intervention on the metabolic syndrome: the Diabetes Prevention Program randomized trial. Te short form-12 and the measurement of health status in patients with cerebral aneurysms: performance, validity, and reliability. Journal article authors with compound last names (give as found in the article) Bruno-Ambrosius K, Yucel-Lindberg T, Twetman S. Salivary bufer capacity in relation to menarche and progesterone levels in saliva from adolescent girls: a longitudinal study.

All of us must necessarily suffer some frustration by the very fact of being human and therefore imperfect purchase sevelamer 400 mg free shipping gastritis spanish, incomplete cheap sevelamer 400 mg with amex corpus gastritis definition, unfinished sevelamer 800mg overnight delivery gastritis chest pain. As we grow older we should learn that all desires cannot be satis- fied immediately generic 400mg sevelamer visa xiphoid gastritis. We also learn to accept the fact that perfection is not necessary nor required, and that approximations are good enough for all practical purposes. We learn to tolerate a certain amount of frus- tration without becoming upset about it. It is only when a frustrating experience brings excessive emotional feelings of deep dissatisfaction and futility that it becomes a symptom of failure. Chronic frustration usually means that the goals we have set for ourselves are unrealistic, or the image we have of ourselves is inadequate, or both. But, nevertheless, he felt chronically frustrated because none of these mea- sured up to his unrealistic goals. He should be such a perfect husband and father, that his wife would never find cause to dis- agree with him, and his children never misbehave. Three times he had been on the verge of landing the job he wanted and each time "something happened"—something was always de- feating him just when success seemed within his grasp. His self-image was that of an unworthy, incompetent, inferior person who had no right to succeed, or to enjoy the better things in life, and unwittingly he tried to be true to that role. Frustration as a Way of Solving Problems Does Not Work Feelings of frustration, discontent, dissatisfaction are ways of solving problems that we all "learned" as infants. If he is uncomfortable, he again expresses his dissatisfaction with the status quo, and the same warm hands appear magically again and solve his problem by making him comfortable. Many children con- tinue to get their way, and have their problems solved by over-indulgent parents, by merely expressing their feelings of frustration. All they have to do is feel frustrated and dissatisfied and the problem is solved. Yet many of us continue to try it, by feeling discontented and expressing our grievances against life, apparently in the hope that life itself will take pity— rush in and solve our problem for us—if only we feel badly enough. His habitual defeatist feel- ings helped create a picture of himself as a defeated per- son. This is the reason that you have been advised throughout this book to imagine how you would feel if you succeeded—and then feel that way now. This was proved conclusively by a group of Yale scientists some years ago in their book, Frustration and Aggressiveness (John Dollard, et al. Aggressiveness itself is not an abnormal behavior pat- tern as some psychiatrists once believed. We must go out after what we want in an aggressive rather than in a defensive or tentative manner. The mere fact of hav- ing an important goal is enough to create emotional steam in our boiler, and bring aggressive tendencies into play. Instead it is used in such self-destructive channels as ulcers, high blood pressure, worry, excessive smoking, compulsive overwork, or it may be turned upon other persons in the form of irritability, rudeness, gossip, nag- ging, fault-finding. The answer to aggression is not to eradicate it, but to understand it, and provide proper and appropriate chan- nels for its expression. They indicate, he said, that providing a proper outlet for aggression is as important, if not more so, than providing for love and tenderness. Knowledge Gives You Power Merely understanding the mechanism involved helps a person handle the frustration-aggression cycle. If you feel like snapping at someone; stop and ask your- self—"Is this merely my own frustration at work? It also takes much of the sting away when someone is rude to you, if you realize that it is probably not a willful act, but an automatic mechanism at work. The other fellow is letting off steam which he could not use in achieving some goal Many automobile accidents are caused by the frustration-aggression mechanism. Especially good are those games where you hit or smash something—golf, tennis, bowling, punching the bag. Many frustrated women intuitively recognize the value of heavy muscular exercise in draining off aggressiveness, when they feel an urge to rearrange all the furniture in the house after becoming upset. The best channel of all for aggression is to use it up as it was intended to be used—in working toward some goal. Work remains one of the best therapies, and one of the best tranquilizers for a troubled spirit. A great deal of insecurity is not due to the fact that our inner resources are actually inadequate, but due to the fact that We use a false measuring stick. We compare our actual abilities to an imagined "ideal," perfect, or absolute self. But they should be thought of, at least in their absolute sense, as goals to be achieved, as something to reach for, rather than as "shoulds. Man maintains his balance, poise, and sense of security only as he is moving forward—or seeking. When you think of yourself as having attained the goal, you become static, and you lose the security and equilibrium you had when you were moving towards something. The man who is convinced that he is "good" in the absolute sense, not only has no incentive to do bet- ter, but he feels insecure because he must defend the sham and pretense. Paul is generally regarded as a "good" man, yet his own attitude was, "I count myself not to have achieved. When a championship team begins to think of itself as "the champions," they no longer have something to fight for, but a status to defend. If you are perfect and superior now—then there is no need to fight, grapple and try. But it is the extreme and chronic feeling of loneliness—of being cut off and alienated from other people—that is a symp- tom of the failure mechanism. The person who is alienated from his real self has cut himself off from the basic and fundamental "contact" with life. Because of his feeling of alienation from self, human contacts are not very satisfy- ing, and he becomes a social recluse. Doing things with other people and enjoying things with other people, helps us to forget ourselves. In stimulating conversation, in dancing, playing together, or in working together for a common goal, we become inter- ested in something other than maintaining our own shams and pretenses. The more we do this the more we feel we can afford to dispense -with the sham and pretense and feel more comfortable just being ourselves. Lines of com- munication with other people—and especially any emo- tional ties—are cut down. The lonely person often complains that he has no friends, and there are no people to mix with. In most cases, he unwittingly arranges things in this manner because of his passive attitude, that it is up to other people to come to him, to make the first move, to see that he is entertained. It never occurs to him that he should contribute something to any social situa- tion. After the first cold plunge, you will find yourself warming up and enjoying it if you per- sist. Develop some social skill that will add to the happi- ness of other people: dancing, bridge, playing the piano, tennis, conversation. It is an old psychological axiom that constant exposure to the object of fear immunizes against the fear. As the lonely person continues to force himself into social relations with other human beings—not in a passive way, but as an active contributor—he will gradu- ally find that most people are friendly, and that he is accepted. It is based upon the fallacious premise that if no decision is made, nothing can go wrong. Being "wrong" holds untold horrors to the person who tries to conceive of himself as perfect.

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