Steve Yentis

• Consultant Anaesthetist, Chelsea and Westminster Hospital
• Honorary Reader, Imperial College, London, UK

At age seventeen medicine used for anxiety order 600mg sustiva, she’s at no loss for words or body language to communicate her displeasure medicine 100 years ago cheap 200 mg sustiva mastercard. Because my internal world is dominated by obsession medicine zalim lotion buy sustiva 200mg overnight delivery, I have little to say and what I do say rings hollow in my own ears medicines sustiva 200 mg for sale. Because my attention is pulled inward symptoms 7dp3dt buy sustiva 200 mg free shipping, the interest I offer her becomes dutiful symptoms enlarged prostate buy cheap sustiva online, rather than genuine medicine rap song buy 600 mg sustiva with visa. When I’m in one of my addictive cycles medicine synonym order sustiva online now, it’s almost as if I were engaged in a sexual affair, with all the attendant obsession, lying and manipulation. It’s impossible to be fully present when you’re putting up walls to keep from being seen. Something’s got to give, and it does–sometimes for days, sometimes for weeks and months. When they were much younger, I’d keep my children waiting or hurry them along to suit my purposes. If I could, I’d expunge from my personal history the time I left my eleven-year-old son at a comic-book shop after a soccer game, with one of his teammates. I’d not only run to the store across the street; I’d also driven to another one, downtown, on my quest for whatever was at that moment my must have-immediately recording. My son’s face was clouded with anxiety and bewilderment when he finally saw me at the comic-book shop door. I’d rush into the house, stashing my latest purchases on the porch, pretending to be home and grounded. When the reckoning came, as it always did, I made guilty confessions and soon-to-be-broken promises. I hated myself, and this self-loathing manifested itself in the harsh, controlling and critical ways I’d deal with my sons and my daughter. When we’re preoccupied with serving our own false needs, we can’t endure seeing the genuine needs of other people—least of all those of our children. Perhaps the nadir, but certainly not the end, of my addictive years came when I left a woman in labour to run over the bridge, in midday traffic, to Sikora’s. Even then, I would have had time to return to the hospital for the delivery had I not begun to cast about for other recordings to buy. I enjoyed a reputation in Vancouver as a physician who extended himself for his pregnant patients and would support them compassionately through their delivery. And the truth is that as of this writing, neither my public acknowledgments of my behaviour nor my thorough understanding of its impact on myself and my family has stopped me from repeating the cycle. I’ve authored three books and receive letters and emails from readers the world over, thanking me for having helped them transform their lives. Yet I have continued to choose patterns that darken my spirit, alienate those closest to me and drain my vitality. I haven’t seen him for a long time, but he did call regularly, proudly reporting on his progress and his determination to stay clean. He’s been living in the streets for weeks but plans to admit himself to a Christian rehabilitation camp. Sean eagerly downs his first dose before recounting the details of this most recent relapse. Annoyed by his neediness and weakness of will—that is, by my own—I want to teach him a lesson. I’m talking about telling your family the truth about how you feel and what you’re up to . I’ve never tried cocaine or opiates, partly due to the fear that I’d like them too well. Both incidents ended with bouts of vomiting—the first time in the vehicle of Lieutenant Jeunesse, my company commander at the Canadian Officers Training Corps summer boot camp at Borden, Ontario. He was driving me and several comrades back to the barracks after an evening of carousing at the Officers’ Club. For months or years at a time, their minds and bodies have been tortured by the craving for substances. They’ve been racked by withdrawal pangs, their throats parched, their brains beset by terrors and hallucinations. How can I mention my petty dysfunctions alongside the tales of affliction I’m likely to hear tonight? What right do I have to claim even the dubious distinction of being a real addict? Calling myself an addict in such company may be nothing more than an attempt to excuse my selfishness and lack of discipline. In that context my public self revelations are received as honest, authentic and even courageous. It’s quite another matter to confess as a peer—to a group who have had a much closer confrontation with life’s gritty realities than I have— that I’m “powerless,” that my addictive behaviours often get the better of me. Without my achievements and the opportunity to display my status, intelligence and wit, I fear I do not cut a very impressive figure. Behind a lectern at the front, a middle-aged woman whose amiable features reveal shyness mixed with authority calls to order a raucous, polyglot crowd of people seated on wooden chairs. I survey the audience through the gradually subsiding din: calloused hands; jeans; cowboy boots; ravaged faces; hardened looks; nicotine-stained teeth; whisky-gravel voices; earthy, back-slapping humour; easy camaraderie—a rough-edged, blue-collared, East Vancouver gathering. The scalp of the old man in front of me gleams between rows of thin, white hair like shiny furrows in a ploughed winter field. As if in response to my inner commentator, a tall, burly man strides to the lectern. He speaks with the authority of someone who’s looked himself in the eye without blinking. My last binge, six years ago, ended with three days in the bathroom where I kept puking, sweating and shitting myself. In my case it looked like a large green Glad garbage bag into which I gathered all my drug paraphernalia, along with my little phone books of ‘business contacts. The greatest teaching I have received is that I can be happy without imposing my will on you or you or anyone else, even when I feel like doing so. As you study the Big Book and you serve people and help the community, your heart softens. It took me a long time of coming to these meetings before I could hear anything, and that didn’t sit well with me. I didn’t learn no matter how hard people tried to love me, no matter what facts I knew and no matter how many times life taught me harsh lessons. If I had known how good it felt to work, I would have been done with drinking long ago. Boy, if I’d known how great that was, I might never have drank in the first place. Elaine is about to leave the lectern amidst nods of approval, but she steps behind the microphone once more. From the moment I had a mind of my own, I knew there was no all knowing, all-powerful, all-loving God. In Eastern Europe under the Stalinist regimes there used to be a saying: “You can be honest or intelligent or be a member of the Communist Party. How else to explain the murder of my grandparents in the gas chambers of Auschwitz or my own near-death as an infant in the Budapest ghetto? My moment of rebellion over, I know better and remember Peter’s words: “My goal is only that each day I should become closer to the God that I understand. If, Jonah-like, I’d rather hide in the stinking belly of a whale than face the truth I know so well, it’s not because of intelligence but because of the refusal to surrender. When I step outside, I see why—they’re all in the parking lot, drawing puffs on their cigarettes and holding animated conversations in pairs or small groups. Smoke, bluish in the light thrown by the church windows, hangs in the air and dissipates slowly above them. He’s conversing with two or three other men, their faces intermittently lit by cigarette glow. What I’ve witnessed here are humility, gratitude, commitment, acceptance, support and authenticity. A manic-depressive with a long history of alcoholism, she’s been attending for fifteen years, and she’s been urging me to do so. I chuckle inwardly: my ego’s yearning to be recognized, and the fear of it, realized at the last possible moment. This provides the basis for a different view: that drug addiction is a disease of the brain, and the associated abnormal behavior is the result of dysfunction of brain tissue, just as cardiac insufficiency is a disease of the heart. In this section of the book we’ll look at the subject from a scientific perspective, beginning with a working definition of addiction. In our day, it most commonly refers to a dysfunctional dependence on drugs or on behaviours such as gambling or sex or eating. For centuries before then, at least back to Shakespeare, addiction referred simply to an activity that one was passionate about or committed to , gave one’s time to . In the nineteenth-century Confessions of an English Opium Eater, Thomas De Quincey never once refers to his narcotic habit as an addiction, even if by our current definition it certainly was. The Victorian-era British politician William Gladstone wrote about “addiction to agricultural pursuits,” implying a perfectly admirable vocation. But the Romans had another, more ominous usage that speaks to our present-day interpretation: an addictus was a person who, having defaulted on a debt, was assigned to his creditor as a slave—hence, addiction’s modern sense as enslavement to a habit. De Quincey anticipated that meaning when he acknowledged “the chain of abject slavery” forged by his narcotic dependence. In the words of a consensus statement by addiction experts in 2001, addiction is a “chronic neurobiological disease… characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. I’ve heard some people shrug off their addictive tendencies by saying, for example, “I can’t be an alcoholic. If users show the pattern of preoccupation and compulsive use repeatedly over time with relapse, addiction can be identified. There is a fundamental addiction process that can express itself in many ways, through many different habits. The use of substances like heroin, cocaine, nicotine and alcohol are only the most obvious examples, the most laden with the risk of physiological and medical consequences. Many behavioural, nonsubstance addictions can also be highly destructive to physical health, psychological balance, and personal and social relationships. Addiction is any repeated behaviour, substance-related or not, in which a person feels compelled to persist, regardless of its negative impact on his life and the lives of others. Compulsion, impaired control, persistence, irritability, relapse and craving—these are the hallmarks of addiction—any addiction. Not all harmful compulsions are addictions, though: an obsessive-compulsive, for example, also has impaired control and persists in a ritualized and psychologically debilitating behaviour such as, say, repeated hand washing. The difference is that he has no craving for it and, unlike the addict, he gets no kick out of his compulsion. She makes promises to herself or others to quit, but despite pain, peril and promises, she keeps relapsing. Some addicts never recognize the harm their behaviours cause and never form resolutions to end them. On the biochemical level the purpose of all addictions is to create an altered physiological state in the brain. So an addiction is never purely “psychological” all addictions have a biological dimension. As we delve into the scientific research, we need to avoid the trap of believing that addiction can be reduced to the actions of brain chemicals or nerve circuits or any other kind of neurobiological, psychological or sociological data. A multilevel exploration is necessary because it’s impossible to understand addiction fully from any one perspective, no matter how accurate. Addiction is a complex condition, a complex interaction between human beings and their environment. We need to view it simultaneously from many different angles—or, at least, while examining it from one angle, we need to keep the others in mind. Addiction has biological, chemical, neurological, psychological, medical, emotional, social, political, economic and spiritual underpinnings—and perhaps others I haven’t thought about. To get anywhere near a complete picture we must keep shaking the kaleidoscope to see what other patterns emerge. Because the addiction process is too multifaceted to be understood within any limited framework, my definition of addiction made no mention of “disease. It does have some of the features of illness, and these are most pronounced in hardcore drug addicts like the ones I work with in the Downtown Eastside. But not for a moment do I wish to promote the belief that the disease model by itself explains addiction or even that it’s the key to understanding what addiction is all about. Note, too, that neither the textbook definitions of drug addiction nor the broader view we’re taking here includes the concepts of physical dependence or tolerance as criteria for addiction. Although tolerance is a common effect of many addictions, a person does not need to have developed a tolerance to be addicted. As defined in medical terms, physical dependence is manifested when a person stops taking a substance and, due to changes in the brain and body, she experiences withdrawal symptoms. Although a feature of drug addiction, a person’s physical dependence on a substance does not necessarily imply that he is addicted to it. The withdrawal syndrome is different for each class of drug—in the case of opiates such as morphine or heroin it includes nausea, diarrhea, sweats, aches and pains and weakness, as well as severe anxiety, agitation and depressed mood. But you don’t have to be addicted to experience withdrawal—you just have to have been taking a medication for an extended period of time. As many people have3 discovered to their chagrin, with abrupt cessation it’s quite possible to suffer highly unpleasant withdrawal symptoms from drugs that are not addictive: the antidepressants paroxetine (Paxil) and venlafaxine (Effexor) are but two examples. Withdrawal does not mean you were addicted; for addiction, there also needs to be craving and relapse. In fact, in the case of narcotics, it turns out that the addictive, “feel good” effect of these drugs seems to act in a different part of the brain than the effects that lead to physical dependence. When morphine is infused only into the “reward” circuits of a rat’s brain, addiction-like behaviour results, but there’s no physical dependence and no withdrawal. The addict comes to depend on the substance or behaviour in order to make himself feel momentarily calmer or more excited or less dissatisfied with his life. That’s the meaning I’ll be referring to unless I am specifically describing physical dependence, the narrower medical phenomenon. Father Sam Portaro, author and former Episcopalian Chaplain to the University of Chicago, said it admirably well in a recent lecture: “The heart of addiction is dependency, excessive dependency, unhealthy dependency—unhealthy in the sense of unwhole, dependency that disintegrates and destroys. In the cloudy swirl of misleading ideas surrounding public discussion of addiction, there’s one that stands out: the misconception that drug taking by itself will lead to addiction—in other words, that the cause of addiction resides in the power of the drug over the human brain. Compulsive gambling, for example, is widely considered to be a form of addiction without anyone arguing that it’s caused by a deck of cards. A celebrity, for instance, might announce when checking himself into a rehab centre, that he became hooked on narcotics after they were prescribed for, say, a back injury. The addiction is devastating, because you’re not even clear anymore why you’re taking it. I had already discussed a variety of options, one of which was to kill myself,” he said. After a wisdom tooth extraction about thirty years ago I developed a condition called “dry socket syndrome,” which I’d never heard about before and never wish to hear of again. I was swallowing Percodan in higher than recommended doses and more frequently than prescribed. Finally the third dental surgeon I consulted diagnosed the problem and cleaned and packed the infected socket. Clearly, if drugs by themselves could cause addiction, we would not be safe offering narcotics to anyone. Medical evidence has repeatedly shown that opioids prescribed for cancer pain, even for long periods of time, do not lead to addiction except in a minority of susceptible people. If the pain was alleviated by other means—for example, when a patient was successfully given a nerve block for bone pain due to malignant deposits in the spine—the morphine could be rapidly discontinued. Yet if anyone had reason to seek oblivion through narcotic addiction, it would have been these terminally ill human beings. An article in the Canadian Journal of Medicine in 2006 reviewed international research covering over six thousand people who had received narcotics for chronic pain that was not cancerous in origin. There was no significant risk of addiction, a finding common to all studies that examine the relationship between addiction and the use of narcotics for pain relief. It is true that some people will become hooked on4 substances after only a few times of using, with potentially tragic consequences, but to understand why, we have to know what about those individuals makes them vulnerable to addiction. Mere exposure to a stimulant or narcotic or to any other mood-altering chemical does not make a person susceptible. Heroin is considered to be a highly addictive drug—and it is, but only for a small minority of people, as the following example illustrates. It’s well known that many American soldiers serving in the Vietnam War in the late 1960s and early 1970s were regular users. Along with heroin, most of these soldier addicts also used barbiturates or amphetamines or both. According to a study published in the Archives of General Psychiatry in 1975, 20 per cent of the returning enlisted men met the criteria for the diagnosis of addiction while they were in Southeast Asia, whereas before they were shipped overseas fewer than 1 per cent had been opiate addicts. The researchers were astonished to find that “after Vietnam, use of particular drugs and combinations of drugs decreased to near or even below preservice levels. For alcohol, marijuana and cocaine the rate is about 15 per cent and for heroin the rate is 23 per cent. Taken together, American and6 Canadian population surveys indicate that merely having used cocaine a number of times is associated with an addiction risk of less than 10 per cent. This doesn’t prove, of course, that nicotine is “more”7 addictive than, say, cocaine. We cannot know, since tobacco—unlike cocaine—is legally available, commercially promoted and remains, more or less, a socially tolerated object of addiction.

It was a chance to set up an ideal facility withdrawal symptoms discount sustiva, where people could plan for the realization of the hacker dream with sophisticated machines medications look up order discount sustiva online, shielded from the bureaucratic lunacy of the outside world symptoms 9 weeks pregnancy buy discount sustiva 200mg on-line. Meanwhile medications vitamins order on line sustiva, the hacker dream would be lived day by day by devoted students of the machine symptoms knee sprain trusted sustiva 600mg. Marvin Minsky and Jack Dennis knew that the enthusiasm of brilliant hackers was essential to bring about their Big Ideas medications and mothers milk purchase 200mg sustiva with amex. As Minsky later said of his lab: "In this environment there were several things going on treatment 2 lung cancer buy discount sustiva online. But there was the question of how do you make the programs that do these things and how do you get them to work treatment plant buy discount sustiva on line. It was the general rule to play the game with all the room lights turned off, so the people crowded around the console would have their faces eerily illuminated by this display of spaceships and heavy stars. It was because of the students, who were more of an intellectual match for nine-year-old Ricky Greenblatt than were his classmates. He would go there to play chess, and he usually had no problem beating the college students. To a nine-year-old whose intelligence might have made him uncomfortable with his chronological peers, a child affected by a marital split which was typical of a world of human relations beyond his control, electronics was the perfect escape. Houghton, who ran a local radio shop, and that became a second home to the youngster through high school. The course work was rigid during his first term, but Greenblatt was handling it without much problem. Also, his roommate, Mike Beeler, had been taking a course in something called Nomography. Greenblatt would often accompany Beeler to the 1620, where you would punch up your card deck, and stand in line. Around Christmas time, he finally felt comfortable enough to hang out at the Model Railroad Club. There, around such people as Peter Samson, it was natural to fall into hacker mode. Just why he decided to do this is something he could never explain, and chances are no one asked. It seems that the plaster in the room (which was always pretty grungy anyway, because custodial people were officially barred entry) kept falling, and some of it would get on the contacts of the system that Jack Dennis had masterminded in the mid-fifties. Also, there was something new called a wire-spring relay which looked better than the old kind. While a computer is very complex, it is not nearly as complex as the various comings and goings and interrelationships of the human zoo; but, unlike formal or informal study of the social sciences, hacking gave you not only an understanding of the system but an addictive control as well, along with the illusion that total control was just a few features away. Naturally, you go about building those aspects of the system that seem most necessary to work within the system in the proper way. Just as naturally, working in this improved system lets you know of more things that need to be done. The ninth floor of this building, where the computers were, would be home to a generation of hackers, and none would spend as much time there as Greenblatt. Greenblatt was getting paid (sub-minimum wages) for hacking as a student employee, as were several hackers who worked on the system or were starting to develop some of the large programs that would do artificial intelligence. He was turning out an incredible amount of code, hacking as much as he could, or sitting with a stack of printouts, marking them up. To hold that concentration for a long period of time, he lived, as did several of his peers, the thirty-hour day. It was conducive to intense hacking, since you had an extended block of waking hours to get going on a program, and, once you were really rolling, little annoyances like sleep need not bother you. The idea was to burn away for thirty hours, reach total exhaustion, then go home and collapse for twelve hours. A minor drawback of this sort of schedule was that it put you at odds with the routines which everyone else in the world used to do things like keep appointments, eat, and go to classes. Hackers could accommodate this one would commonly ask questions like "What phase is Greenblatt in? He was placed on academic probation, and his mother came to Massachusetts to confer with the dean. But the things he was doing on the computer were completely state-of-the art no one was doing them yet. His worst moment came when he was so "out of phase" that he slept past a final exam. So Greenblatt went looking for work, fully intending to get a daytime programming job that would allow him to spend his nights at the place he wanted to spend his time the ninth floor at Tech Square. More verbal than Greenblatt, he was better able to articulate his vision of how the computer had changed his life, and how it might change all our lives. Gosper was thin, with birdlike features covered by thick spectacles and an unruly head of kinky brown hair. But even a brief meeting with Gosper was enough to convince you that here was someone whose brilliance put things like physical appearance into their properly trivial perspective. Years later, Gosper still spoke with excitement of "the rush of having this live keyboard under you and having this machine respond in milliseconds to what you were doing. He was involved with the math department, where people kept telling him that he would be wise to stay away from computers they would turn him into a clerk. Somewhere in that term, he wrote a program to plot functions on the screen, his first real project, and one of the subroutines contained a program bum so elegant that he dared show it to Alan Kotok. Gosper was rapturous when Kotok not only looked over his hack, but thought it clever enough to show to someone else. Every hole but one is filled by a peg: you jump pegs over each other, removing the ones you jump over. The counterintuitive solution sprang from understanding the magical connections between things in the vast mandala of numerical relationships on which hacking ultimately was based. More than that, both were major contributors to the still nascent culture that was beginning to flower in its fullest form on the ninth floor of Tech Square. For various reasons, it would be in this technological hothouse that the culture would grow most lushly, taking the Hacker Ethic to its extreme. It stood among other machines on the harshly lit, sterilely furnished ninth floor of Tech Square, where one could escape from the hum of the air conditioners running the various computers only by ducking into one of several tiny offices. Sometimes people would literally scream at each other, insisting on a certain kind of coding scheme for an assembler, or a specific type of interface, or a particular feature in a computer language. These differences would have hackers banging on the blackboard, or throwing chalk across the room. The Right Thing implied that to any problem, whether a programming dilemma, a hardware interface mismatch, or a question of software architecture, a solution existed that was just. He liked to work with an audience, and often novice hackers would pull up a chair behind him at the console to watch him write his clever hacks, which were often loaded with terse little mathematical points of interest. Gosper would act as tour guide as he progressed, sometimes emphasizing that even typing mistakes could present an interesting numerical phenomenon. He maintained a continual fascination with the way a computer could spit back something unexpected, and he would treat the utterances of the machine with infinite respect. Sometimes the most seemingly random event could lure him off into a fascinating tangent on the implications of this quadratic surd or that transcendental function. Certain subroutine wizardry in a Gosper program would occasionally evolve into a scholarly memo, like the one that begins: On the theory that continued fractions are underused, probably because of their unfamiliarity, I offer the following propaganda session on the relative merits of continued fractions versus other numerical representations. Kotok would sometimes drive Gosper back to South Jersey for holiday breaks, talking as he drove about how this new computer would have sixteen independent registers. The instruction set had everything you needed, and the overall architecture was symmetrically sound. The sixteen registers could be accessed three different ways each, and you could do it in combinations, to get a lot done by using a single instruction. The Tool Room discussions and arguments would often be carried over to dinner, and the cuisine of choice was almost always Chinese food. Gosper took to the cuisine with even greater vigor; he would prowl Chinatown looking for restaurants open after midnight, and one night he found a tiny little cellar place own by a small family. It was fairly dull food, but he noticed some Chinese people eating fantastic-looking dishes. Wong, reluctantly complied, and Gosper, Samson, and the others pored over the menu as if it were an instruction set for a new machine. What was called "Beef with Tomato" on the English menu had a literal meaning of Barbarian Eggplant Cowpork. They had been inside the machine, and lived to tell the tale (they would tell it in assembly language). For reasons best known to himself, Gosper decided to have it with sweet-and-sour sauce, and he wrote down the order in Chinese. So, even though he knew his order was a preposterous request, he acted indignant, telling the daughter, "Of course it says Sweet-and-Sour Bitter Melon we Americans always order Sweet-and-Sour Bitter Melon the first of April. Sweet-and-Sour Bitter Melon turned out to be every bit as hideous as the owner promised. Combined with the ordinarily vile bitter melon, it created a chemical that seemed to squeak on your teeth, and no amount of tea or Coca-Cola could dilute that taste. Chinese restaurants offered hackers a fascinating culinary system and a physically predictable environment. To make it even more comfortable, Gosper, one of several hackers who despised smoke in the air and disdained those who smoked, brought along a tiny, battery-powered fan. The hackers, who considered physical combat one of the more idiotic human interfaces, watched in astonishment. The incident ended as soon as the jock noticed a policeman sitting across the restaurant. Often, people would have their printouts with them and during lulls in conversation would bury their noses in the reams of assembly code. On occasion, the hackers would even discuss some events in the "real world," but the Hacker Ethic would be identifiable in the terms of the discussion. They did not spend much time discussing the social and political implications of computers in society (except maybe to mention how utterly wrong and naive the popular conception of computers was). They generally kept their own emotional and personal lives as far as they had any to themselves. And for a group of healthy college-age males, there was remarkably little discussion of a topic which commonly obsesses groups of that composition. It was the predictability and controllability of a computer system as opposed to the hopelessly random problems in a human relationship which made hacking particularly attractive. You would hack, and you would live by the Hacker Ethic, and you knew that horribly inefficient and wasteful things like women burned too many cycles, occupied too much memory space. No one knows why There were women programmers and some of them were good, but none seemed to take hacking as a holy calling the way Greenblatt, Gosper, and the others did. Even the substantial cultural bias against women getting into serious computing does not explain the utter lack of female hackers. He worked on several mammoth projects in the mid-sixties, and would often get so wrapped up in them that his personal habits became a matter of some concern to his fellow hackers. Cleanliness was apparently a low priority, since tales abounded of his noticeable grunginess. One or two milliblatts was extremely powerful, and one full blatt was just about inconceivable. To decrease the milliblatts, the story goes, hackers maneuvered Greenblatt to a place in the hallway of Building 20 where there was an emergency shower for cases of accidental exposure to chemicals, and let it rip. He was the way he was because of conscious priorities: he was a hacker, not a socialite, and there was nothing more useful than hacking. He worked summers for the Navy, which paid half his tuition and required him to work there for three years after graduation. During his summer employment stints he had been exposed to a pathetic system that was antithetical to the Hacker Ethic. Programmers were kept in a room totally separated from the machine; sometimes, as a reward for years of service, they would let a particularly obedient worker venture into the computer room and actually see his program run. There was no way in hell Bill Gosper was going to work under a man who did not know why the logarithm of the sum was not the sum of the logarithms. He considered the Univac machine a grotesque parody of a computer, a Hulking Giant. The Navy had to know it was a basically phony computer, he figured, but used it anyway it was a classic example of the inevitably warped outcome of Outside World bureaucracy. Gosper used computers to seek things that no one had ever found before, and it was essential that the computer he used be optimal in every way. He fulfilled these rigid criteria by landing a job with the firm that Greenblatt had worked for that past year, Charles Adams. In his senior year, Gosper had been put to work by Minsky on a display that would test whether a certain visual phenomenon was binocular or monocular. Gosper did manage to come close with a clever, clover-leaf shape which at least displayed the phenomenon, but generally was banging his head against the wall trying to make the machine do more than it could do. It was a powerful language that would help the field of artificial intelligence move forward: it was the language by which computers would do extremely difficult tasks, by which they could actually learn. Greenblatt was just starting then to have a certain vision of the future, an inkling of a technical implementation of the hacker dream. And it was better to rely on two or three people than on a single crusader so that when one person was at the end of his thirty-hour phase, someone else could come in and keep hacking. The Right Thing to do was to make sure that any good program got the fullest exposure possible, because information was free and the world would only be improved by its accelerated flow. Like any good hacker, no sooner did he decide to do something than he began work on it. The program was debugged, given features, and generally juiced up over the next few months. To hackers, his criticism was particularly noxious, since the computer was their implicit model of behavior, at least in their theories of information, fairness, and action. His coup de grace was the blunt assertion that no computer program would be able to play a good enough game of chess to beat a ten-year-old. The hackers gathered round to watch the computer surrogate of Richard Greenblatt play this cocky, thin, red-headed, bespectacled anti-computer opponent. Artificial intelligence pioneer Herbert Simon, who watched the match, later was quoted as saying that it was. And the only way the opponent could get out of this was to keep Dreyfus in check with his own queen until he could fork the queen and king and exchange them. Even Minsky, who never really immersed himself in the thirty-hour-day, seven-day week assembly-language baptistery, had not experienced what the hackers had. The hackers, the Greenblatts and the Gospers, were secure in having been there, knowing what it was like, and going back there producing, finding things out, making their world different and better. As for convincing skeptics, bringing the outside world into the secret, proselytizing for the Hacker Ethic all that was not nearly as interesting as living it. The third leg of the triangle arrived in the fall of 1963, and his name was Stewart Nelson. Not long after his arrival, Stew Nelson displayed his curiosity and ability to get into uncharted electronic realms, traits which indicated his potential to become a master magician in service to the Hacker Ethic. He was a short kid, generally taciturn, with curly hair, darting brown eyes, and a large overbite which gave him the restlessly curious look of a small rodent. He saw this friendly computer which you could put your hands on, and with a confidence that came from what Greenblatt might call born hackerism he got to work. He had programmed some appropriate tones to come out of the speaker and into the open receiver of the campus phone that sat in the Kluge Room. As it turned out, things were going to go much further before Stewart Nelson was through. It was as natural as walking, and by the time he was five he was building crystal radios. He would later tell stories of his equipment flying halfway across the room and exploding into smithereens. But after about two days he was back at it, a young loner working on fantastic projects. His family had moved to Haddonfield, New Jersey, and he soon found out that by clicking the switches on which the receiver rests, you could actually dial a number. Stewart Nelson was soon building things that few of his neighbors in the mid-1950s had seen, like automatic dialers and gadgets that could connect to several phone lines, receiving a call on one line and automatically calling out on the other. He learned to handle telephone equipment with the deftness with which an artist wields his tools; witnesses would later report how Nelson, when confronted with a phone, would immediately dismantle it, first removing the filter which prevents the caller from hearing the dialing signals, and then making a few adjustments so that the phone would dial significantly faster. Essentially, he was reprogramming the telephone, unilaterally debugging Western Electric equipment. He struck a deal with his high school teachers wherein he would fix their radios and televisions in exchange for not having to go to class. Instead, he spent time at a small radio station starting up nearby Nelson "pretty much put it together," he later explained, connecting the elements, tuning the transmitter, finding sources of noise and hums in the system. When the radio station was running, he was the main engineer, and sometimes he would even be the disc jockey. Every glitch in the system was a new adventure, a new invitation to explore, to try something new, to see what might happen. To Stew-art Nelson, wanting to find out what might happen was the ultimate justification, stronger than self-defense or temporary insanity. There had already been avid interest in "phone hacking" around the club; with Nelson around, that interest could really flower. Besides being a technical genius, Nelson would attack problems with bird-dog perseverance. But even as Nelson set off on these electronic journeys, he adhered to the unofficial hacker morality. You could call anywhere, try anything, experiment endlessly, but you should not do it for financial gain. They would get hold of priority phone company lines to various locations around the country and test them.

Cause-specific mortality in patients with severe psoriasis: A population-based cohort study in the uk symptoms enlarged spleen 200 mg sustiva free shipping. Efficacy and safety results from the randomized controlled comparative study of adalimumab vs medicine 0552 sustiva 600mg mastercard. An intensified dosing schedule of subcutaneous methotrexate in patients with moderate to severe plaque-type psoriasis (metop): A 52 week treatment kidney disease order 600 mg sustiva fast delivery, multicentre treatment depression order sustiva 200 mg with visa, randomised medications ocd best order for sustiva, double-blind symptoms valley fever discount sustiva 200mg amex, placebo-controlled medicine used to stop contractions purchase sustiva without prescription, phase 3 trial treatment diverticulitis order sustiva no prescription. Consensus document on the evaluation and treatment of moderate-to-severe psoriasis: Psoriasis group of the spanish academy of dermatology and venereology. International Nonproprietary Names (inn) for Biological and Biotechnological Substances. Comparison of ixekizumab with etanercept or placebo in moderate-to-severe psoriasis (uncover-2 and uncover-3): Results from two phase 3 randomised trials. Safety and efficacy of alefacept, efalizumab, etanercept and infliximab in treating moderate to severe plaque psoriasis: A meta-analysis of randomized controlled trials. A randomized, double-blind, placebo-controlled phase iii study evaluating efficacy and tolerability of 2 courses of alefacept in patients with chronic plaque psoriasis. An international, randomized, double-blind, placebo-controlled phase 3 trial of intramuscular alefacept in patients with chronic plaque psoriasis. T-cell modulation for the treatment of chronic plaque psoriasis with efalizumab (raptiva (tm)): Mechanisms of action. Efalizumab in the treatment of psoriasis: Mode of action, clinical indications, efficacy, and safety. Clinical experience acquired with the efalizumab (raptiva) (clear) trial in patients with moderate-to-severe plaque psoriasis: Results from a phase iii international randomized, placebo-controlled trial. Efficacy and safety observed during 24 weeks of efalizumab therapy in patients with moderate to severe plaque psoriasis. Efalizumab: Results of a 3-year continuous dosing study for the long-term control of psoriasis. Etanercept in the treatment of psoriatic arthritis and psoriasis: A randomised trial. Etanercept treatment of psoriatic arthritis: Safety, efficacy, and effect on disease progression. Fda Approves Expanded Use of Enbrel (Etanercept) to Treat Children with Chronic Moderate-to-Severe Plaque Psoriasis. Etanercept and clinical outcomes, fatigue, and depression in psoriasis: Double-blind placebo-controlled randomised phase iii trial. A global phase iii randomized controlled trial of etanercept in psoriasis: Safety, efficacy, and effect of dose reduction. Long-term safety and efficacy of 50 mg of etanercept twice weekly in patients with psoriasis. Tofacitinib versus etanercept or placebo in moderate-to-severe chronic plaque psoriasis: A phase 3 randomised non-inferiority trial. Efficacy of systemic therapies for moderate-to-severe psoriasis: A systematic review and meta-analysis of long-term treatment. Intermittent infliximab maintenance regimens over 1 year in the treatment of moderate-to-severe plaque psoriasis. Infliximab induction and maintenance therapy for moderate-to-severe psoriasis: A phase iii, multicentre, double-blind trial. Infliximab monotherapy for chinese patients with moderate to severe plaque psoriasis: A randomized, double-blind, placebo-controlled multicenter trial. Infliximab monotherapy in japanese patients with moderate-to-severe plaque psoriasis and psoriatic arthritis. Long-term study of infliximab for psoriasis in daily practice: Drug survival depends on combined treatment, obesity and infusion reactions. Infliximab induction therapy for patients with severe plaque-type psoriasis: A randomized, double-blind, placebo-controlled trial. Effectiveness and risk associated with infliximab alone and in combination with immunosuppressors for crohn’s disease: A systematic review and meta-analysis. Adalimumab for the treatment of patients with moderately to severely active psoriatic arthritis: Results of a double-blind, randomized, placebo-controlled trial. Adalimumab therapy for moderate to severe psoriasis: A randomized, controlled phase iii trial. Long-term efficacy and safety of adalimumab in patients with moderate to severe psoriasis treated continuously over 3 years: Results from an open-label extension study for patients from reveal. Adalimumab in japanese patients with moderate to severe chronic plaque psoriasis: Efficacy and safety results from a phase ii/iii randomized controlled study. Efficacy and safety of adalimumab in chinese patients with moderate-to-severe plaque psoriasis: Results from a phase 3, randomized, placebo-controlled, double-blind study. Methotrexate use and monitoring in patients with psoriasis: A consensus report based on a danish expert meeting. A phase iiib, multicentre, randomized, double-blind, vehicle-controlled study of the efficacy and safety of adalimumab with and without calcipotriol/betamethasone topical treatment in patients with moderate to severe psoriasis: the believe study. A prospective randomized controlled trial comparing infliximab and etanercept in patients with moderate-to-severe chronic plaque-type psoriasis: the psoriasis infliximab vs. Efficacy and tolerability of biologic and nonbiologic systemic treatments for moderate-to-severe psoriasis: Meta-analysis of randomized controlled trials. Anti-drug antibodies in psoriasis: A critical evaluation of clinical significance and impact on treatment response. Presence of antidrug antibodies correlates inversely with the plasma tumor necrosis factor (tnf)-alpha level and the efficacy of tnf-inhibitor therapy in psoriasis. The risk of tuberculosis in patients with psoriasis treated with anti-tumor necrosis factor agents. Efficacy and safety of ustekinumab, a human interleukin-12/23 monoclonal antibody, in patients with psoriasis: 76-week results from a randomised, double-blind, placebo-controlled trial (phoenix 1). Efficacy and safety of ustekinumab, a human interleukin-12/23 monoclonal antibody, in patients with psoriasis: 52-week results from a randomised, double-blind, placebo-controlled trial (phoenix 2). Efficacy and safety of ustekinumab in japanese patients with moderate-to-severe plaque-type psoriasis: Long-term results from a phase 2/3 clinical trial. Efficacy and safety of ustekinumab for the treatment of moderate-to-severe psoriasis: A phase iii, randomized, placebo-controlled trial in taiwanese and korean patients (pearl). Efficacy and safety of ustekinumab in chinese patients with moderate to severe plaque-type psoriasis: Results from a phase 3 clinical trial (lotus). Comparison of long-term drug survival and safety of biologic agents in patients with psoriasis vulgaris. Differential drug survival of biologic therapies for the treatment of psoriasis: A prospective observational cohort study from the british association of dermatologists biologic interventions register (badbir). Long-term efficacy of ustekinumab in patients with moderate-to-severe psoriasis treated for up to 5 years in the phoenix 1 study. Long-term efficacy and safety of ustekinumab, with and without dosing adjustment, in patients with moderate-to-severe psoriasis: Results from the phoenix 2 study through 5 years of follow-up. Long-term safety experience of ustekinumab in patients with moderate to severe psoriasis (part ii of ii): Results from analyses of infections and malignancy from pooled phase ii and iii clinical trials. Interleukin (il)-12 and il-23 are key cytokines for immunity against salmonella in humans. Interleukin-17a: A unique pathway in immune-mediated diseases: Psoriasis, psoriatic arthritis and rheumatoid arthritis. Secukinumab administration by pre-filled syringe: Efficacy, safety and usability results from a randomized controlled trial in psoriasis (feature). Efficacy, safety and usability of secukinumab administration by autoinjector/pen in psoriasis: A randomized, controlled trial (juncture). Secukinumab is superior to ustekinumab in clearing skin of subjects with moderate-to-severe plaque psoriasis up to 1 year: Results from the clear study. Secukinumab is superior to ustekinumab in clearing skin of subjects with moderate to severe plaque psoriasis: Clear, a randomized controlled trial. Secukinumab long-term safety experience: A pooled analysis of 10 phase ii and iii clinical studies in patients with moderate to severe plaque psoriasis. Ixekizumab, an interleukin-17a specific monoclonal antibody, for the treatment of biologic-naive patients with active psoriatic arthritis: Results from the 24-week randomised, double-blind, placebo-controlled and active (adalimumab)-controlled period of the phase iii trial spirit-p1. Ixekizumab for the treatment of patients with active psoriatic arthritis and an inadequate response to tumour necrosis factor inhibitors: Results from the 24-week randomised, double-blind, placebo-controlled period of the spirit-p2 phase 3 trial. Efficacy and safety of open-label ixekizumab treatment in japanese patients with moderate-to-severe plaque psoriasis, erythrodermic psoriasis and generalized pustular psoriasis. Efficacy and safety of ixekizumab treatment for japanese patients with moderate to severe plaque psoriasis, erythrodermic psoriasis and generalized pustular psoriasis: Results from a 52-week, open-label, phase 3 study (uncover-j). Efficacy and safety of switching to ixekizumab in etanercept non-responders: A subanalysis Int. Efficacy of ixekizumab compared to etanercept and placebo in patients with moderate-to-severe plaque psoriasis and non-pustular palmoplantar involvement: Results from three phase 3 trials (uncover-1, uncover-2 and uncover-3). Effect of ixekizumab treatment on work productivity for patients with moderate-to-severe plaque psoriasis: Analysis of results from 3 randomized phase 3 clinical trials. Short and long-term safety outcomes with ixekizumab from 7 clinical trials in psoriasis: Etanercept comparisons and integrated data. The emerging role of il-17 in the pathogenesis of psoriasis: Preclinical and clinical findings. Functional characterization of il-17f as a selective neutrophil attractant in psoriasis. Characterization of the interleukin-17 isoforms and receptors in lesional psoriatic skin. A prospective phase iii, randomized, double-blind, placebo-controlled study of brodalumab in patients with moderate-to-severe plaque psoriasis. Brodalumab, a human anti-interleukin-17-receptor antibody in the treatment of japanese patients with moderate-to-severe plaque psoriasis: Efficacy and safety results from a phase ii randomized controlled study. Th17 cells and il-17 receptor signaling are essential for mucosal host defense against oral candidiasis. Chronic mucocutaneous candidiasis in humans with inborn errors of interleukin-17 immunity. Secukinumab treatment shows no evidence for reactivation of previous or latent tb infection in subjects with psoriasis: A pooled phase 3 safety analysis. Increased granulopoiesis through interleukin-17 and granulocyte colony-stimulating factor in leukocyte adhesion molecule-deficient mice. Efficacy and safety of guselkumab, an anti-interleukin-23 monoclonal antibody, compared with adalimumab for the continuous treatment of patients with moderate to severe psoriasis: Results from the phase iii, double-blinded, placebo and active comparator-controlled voyage 1 trial. Efficacy and safety of guselkumab, an anti-interleukin-23 monoclonal antibody, compared with adalimumab for the treatment of patients with moderate to severe psoriasis with randomized withdrawal and retreatment: Results from the phase iii, double-blind, placebo and active comparator-controlled voyage 2 trial. Switching from originator infliximab to biosimilar ct-p13 compared with maintained treatment with originator infliximab (nor-switch): A 52-week, randomised, double-blind, non-inferiority trial. The first part of this chapter is dedicated to review the scientific evidence for the use of different drugs; in the second part, we propose therapeutic protocols dealing with specific organ involvement; finally, comorbidities and non-adherence will be discussed. Specific treatment for the antiphospholipid syndrome is described in another chapter. Thus, survival rates have increased from 50% at 3 years in the 1950s (Jessar, 1953) to 92% at 10 years in recent series (Cervera, 2003). Interestingly, the initial dose of prednisone in the first month of treatment is predictive of the prednisone doses over the following 11 months (Ruiz-Irastorza, 2016). Tapering schedules are mainly based on physician’s experience and clinical judgment. Although pioneering, this was not a randomized controlled trial and patients represented a population without much extra renal disease (Condon, 2013). In another cohort, the accrual of organ damage was found to correlate with the mean daily prednisone dose, with the risk increasing for doses higher than 6 mg per day (Thamer, 2009). In these studies the possible confounding effect of disease activity itself should be noted (higher disease activity is associated with both higher dosages of prednisone and damage accrual) and despite statistical modelling remains difficult to completely correct for. Patients must be immunized against influenza (every year) and Streptococcus pneumoniae (every 5 years) (Naveau, 2005). Other antimalarials such as chloroquine (125-250 mg/day; maximum 4 mg/kg/day) and quinacrine (100 mg/day) are preferred for severe cutaneous cases (Okon, 2013). It can inhibit toll like receptor signalling, the accumulation of nucleic fragments in lysosomes, the autophagic degradation and it can inhibit the binding of beta-2-glycoprotein to phospholipids (Ponticelli, 2017). Besides better lupus disease control, antimalarials display many other interesting properties, such as lipid profile improvement (Tam, 2000), prevention of thrombotic events, influence on cardiovascular risk, and a beneficial effect on bone mineral density (Ruiz-Irastorza, 2006 and 2010; Espinola, 2002). Side-effects include digestive intolerance (diarrhoea), skin rash, aqua genic pruritus, blue-grey or brown lower leg hyperpigmentation (Jallouli, 2013), cardiomyopathy, myopathy and retinopathy. Retinopathy can present with photophobia, blurred distance vision, missing or blacked out areas in the vision field (or while reading) and light flashes. New data about the prevalence of retinopathy has led to a recent update of the American Guidelines of Ophthalmology for toxicity screening (Marmor, 2016). Therefore, a maximum recommended dose of 5 mg/kg of observed (rather than ideal) body weight is proposed. In addition, a baseline fundoscopy and annual screening starting after 5 years, for patients on acceptable doses without major risk factors, is recommended. For patients on higher dosages or patients with risk factors more frequent examinations are recommended. Risk factors include age over 60 years, pre-existing macular degeneration, retinal dystrophy, obesity, liver disease and renal failure (Marmor, 2002; Mosca, 2009) and should be assessed regularly. The rheumatology world has not yet adopted these new recommendations and some critical comments have been published. Bone marrow suppression, increased risk of infections, hepatitis and hypersensitivity reaction are potentially severe but rare adverse events. However, genotyping is not done routinely by many rheumatologists ; a frequent approach is to start and titrate therapy in steps from a low dosage (50mg) up to the desired dose and check tolerability and blood count after every increase, for example every two weeks. A recent cohort study showed its efficacy in refractory to standard of care non-renal manifestations and reduction of corticosteroid use (Tselios, 2016). They mainly consist of gastrointestinal manifestations (diarrhoea, nausea, vomiting), hepatitis and anaemia, the latter mainly observed in patients with renal impairment. Other side effects such as pancreatitis and febrile pancytopenia have been observed rarely. The drug is strictly contraindicated in pregnancy (at least during the first trimester) because of proven teratogenicity, with peculiar involvement of the face (Perez-Aytes, 2008). It is not always well tolerated: transient increase in serum creatinine, hypertension, hypertrichosis, gum hypertrophy, tremor and seizures may occur (Conti, 2000). They can be useful in selected cases with persistent proteinuria despite standard immunosuppression. In the early 1960s, it was found to be dramatically teratogenic (phocomelia) and was withdrawn. Further studies have shown its efficacy in the treatment of leprosy and multiple myeloma. The mechanism of action of the drug is poorly understood, but it appears to display antiangiogenic effects. Thus, polyneuropathy is frequent (at least 20% of patients), can be disabling and is mostly irreversible (Briani, 2004). In some countries, a monthly negative pregnancy test is required before the drug can be prescribed and obtained. Relapses after discontinuation are frequent and may justify the use of a lower maintenance dose such as 50 mg three times weekly. Lenalidomide was recently studied in refractory cases of cutaneous lupus (Cortes-Hernandes, 2012). It is suggested to start with 100 mg daily and then to taper to the minimally efficacious dose in 2-3 months. In the absence of proper controlled trial its use should be limited to selected cases. Treatment cost and lack of evidence-based recommendations clearly limit their use. Basically, only patients with very severe uncontrolled disease and at risk for permanent organ damage or death should be considered for this procedure. The design and choice of outcome measures in trials for a heterogeneous disease such as lupus is a challenge and may have contributed to negative results in the past. Rituximab has an acceptable safety profile, although a concern has been raised based on two cases of progressive multifocal leukoencephalopathy (Molloy, 2012). B-cell depletion usually occurs within 2 weeks after the first infusion and B-cell repopulation after 3 to 40 months. Flares of disease activity have been reported in about 40% of treated patients, mostly concomitant with B-cell reconstitution. However, it is not clear whether patients should be pre-emptively re-treated at the time of reconstitution of B-cells. Of note, 1 case of progressive multifocal leukoencephalopathy has been reported in a belimumab-treated patient (Fredericks, 2014). Several molecules were currently developed to block this pathway (Lauwerys, 2013a). Two dosages (300mg and 1000mg) were tested against placebo in moderate to severe lupus in addition to standard therapy. Herpes zoster and influenza infections were reported more frequently in the anifrolumab groups. It was shown to display tolerogenic and immunomodulatory effects in preclinical lupus models, i. Two randomized controlled trials, performed in patients with inactive or stable disease without a history of thrombosis, suggest that the use of combined oral contraceptives, containing 30-35 mcg of ethynyl oestradiol, does not increase the incidence of flares, nor the rate of thrombotic events (Petri, 2005; Sanchez-Guerrero, 2005). In patients with the antiphospholipid syndrome (excluded in the study by Petri et al. Severe flares were not more frequent in the treated group but there were significantly more mild and moderate flares (relative risk: 1.

Efficacy Evidence concerning the utility of specific psychosocial interventions for patients with bipolar disorder is slowly building treatment juvenile rheumatoid arthritis 600mg sustiva visa. The research summarized here involves the specific forms of psy chotherapy that have been studied in randomized 5 asa medications sustiva 200mg low price, controlled clinical trials treatment conjunctivitis quality 200 mg sustiva. When compared with a group randomly assigned to a treatment-as-usual condition treatment water on the knee discount 600 mg sustiva with amex, pa tients receiving psychoeducation (in addition to pharmacotherapy) experienced a significant re duction in risk of manic relapses as well as improved social and vocational functioning medications covered by medicare cheap sustiva 200 mg overnight delivery. A brief (approximately six sessions) inpatient family intervention (409) has been developed for patients with schizophrenia or bipolar disorder treatment tracker order sustiva 200 mg without prescription. Goals include accepting the reality of the illness medications 3601 purchase sustiva 600mg overnight delivery, identifying precipitating stressors and likely future stressors inside and outside the fam ily medicine pills order sustiva 600mg on line, elucidating family interactions that produce stress on the patient, planning strategies for managing or minimizing future stressors, and bringing about the patient’s family’s acceptance of the need for continued treatment after hospital discharge. In the initial study (410), the fam ily intervention resulted in improved outcomes for female patients with affective disorders but not for male patients. In a subsequent study by this group (410), ongoing couples therapy (ex tending for up to 11 months after hospitalization) was found to significantly enhance treat ment adherence and improve global functioning. Unfortunately, this study was too small (intent-to-treat N=42) to reliably detect more modest effects, such as a reduction of relapse risk. When the functional impairments of bipolar disorder are severe and persistent, other services may be necessary, such as case management, assertive community treatment, psychosocial rehabil itation, and supported employment. These approaches, which have traditionally been studied in patients with schizophrenia, also show effectiveness for certain individuals with bipolar disorder. Family-focused treatment was developed for patients who have recently had an episode of ma nia or depression (411). Family-focused therapy is behaviorally based and includes psychoeduca tion, communication skills training, and problem-solving skills training. One adequately sized trial of behavioral family treatment has been completed; the investigators found that behavioral family management (in concert with adequate pharmacotherapy) resulted in a substantial decrease in de pressive relapse rates when compared with a treatment-as-usual control condition (412). A cognitive behavior therapy program for patients with bipolar disorder has been developed by Basco and Rush (413). The goals of the program are to educate the patient regarding bipolar disorder and its treatment, teach cognitive behavior skills for coping with psychosocial stressors and attendant problems, facilitate compliance with treatment, and monitor the occurrence and severity of symptoms. A large study of the impact of cognitive behavior therapy for prophylaxis against bipolar recurrences is underway. Preliminary studies suggest that this approach may help reduce depressive symptoms (414), improve longer-term outcomes (415), and improve treatment adherence (416). The observation that many patients with bipolar disorder experience less mood lability when they maintain a regular pattern of daily activities (including sleeping, eating, physical ac tivity, and emotional stimulation) has led to the development of a formalized psychotherapy called interpersonal and social rhythm therapy (417). This form of psychotherapy builds upon the traditional focus of interpersonal psychotherapy by incorporating a behavioral self-moni toring program intended to help patients with bipolar disorder initiate and maintain a lifestyle characterized by more regular sleep-wake cycles, meal times, and other so-called social zeit gebers. The ultimate goal is to help regulate circadian disturbances that may provoke or exag gerate episodes of mood disorder. Frank and colleagues have reported several findings from their ongoing study of inter personal and social rhythm therapy. First, interpersonal and social rhythm therapy (in combi nation with pharmacotherapy) was associated with significant increases in targeted lifestyle regularities when compared with a clinical management plus pharmacotherapy control group (418). However, interpersonal and social rhythm therapy was not associated with a faster time to recovery from manic (419) or depressive (420) episodes. The withdrawal of interpersonal and social rhythm therapy after stabilization was associated with a significant increase in relapse rates (421). Across 2 years of maintenance treatment, interpersonal and social rhythm therapy led to a reduction of both depressive symptoms and manic/hypomanic symptoms and an in crease in days of euthymia when compared with treatment as usual (unpublished 2001 study by E. Finally, preliminary results of a trial comparing group psychoeducation to standard medical care alone among a group of patients with bipolar disorder suggest that patients receiving psychoedu cation had significantly fewer manic episodes, depressive episodes, and hospitalizations (422). Psychotherapeutic treatment of mania Psychosocial therapies alone are generally not useful treatments for acute mania. Perhaps the only indications for psychotherapy alone are when all established treatments have been refused, involuntary treatment is not appropriate, and the primary focus of therapy is focused and crisis oriented. In one study of bipolar I dis order patients with acute mania or hypomania, treatment with the combination of interper sonal and social rhythm therapy and pharmacotherapy did not produce an additive effect on manic symptoms or reduce time to remission when compared with an intensive clinical para digm plus medication (419). Moreover, patients withdrawn from this psychotherapy after completion of acute treatment had a poorer prognosis when compared with those who either received monthly maintenance psychotherapy sessions or recovered with intensive clinical management and pharmacotherapy (421). Psychotherapeutic treatment of depression Several psychotherapeutic approaches, including cognitive behavior therapy (423) and interper sonal therapy (424–426), have demonstrated efficacy in patients with unipolar depression, either in lieu of or in addition to pharmacotherapy. Treatment of Patients With Bipolar Disorder 53 Copyright 2010, American Psychiatric Association. For unipolar depression, the application of a specific, effective psychotherapy in lieu of phar macotherapy may be considered for patients with mild to moderate symptoms. For bipolar de pression, the use of focused psychotherapy instead of antidepressant pharmacotherapy has potential appeal, particularly with respect to avoiding antidepressant side effects and minimizing the risk of treatment-emergent mania or induction of rapid cycling. However, only a handful of reports have described such an approach, and there have been no definitive studies to date. Patients were randomly assigned to receive weekly interpersonal and social rhythm ther apy sessions or treatment as usual. All patients received pharmacotherapy (principally lithium salts); about two-thirds of the patients also received antidepressants. They com pared their patients’ outcomes to a contemporaneous group of age and sex-matched patients with unipolar depression. Further, no depressed patient receiving cognitive behavior therapy developed treatment-emergent mania or hypomania. All studies used “add-on” designs, with patients continuing pharmacotherapies such as lithium and divalproex. Many of these re ports described preliminary or pilot studies; nevertheless, results of three larger, more definitive studies have been published for psychoeducation (27), interpersonal and social rhythm therapy (427), and family-focused (412) interventions. Overall, these studies demonstrated that the addition of a time-limited individual psycho social intervention appropriately modified for bipolar disorder is likely to improve outcomes across 1–2 years of follow-up. When feasible, group psychoeducational interventions also ap pear useful (428), which may improve the cost efficiency of treatment. Despite these promising results, however, improvements have not been consistently documented across studies on the full range of syndromal, functional, adherence, and interpersonal domains. On the basis of a methodological review of the more numerous studies of unipolar depression (429), such incon sistencies in findings are more likely to be attributable to differences in patient populations and statistical power than true therapeutic specificity. Nevertheless, the weight of the evidence suggests that patients with bipolar disorder are likely to gain some additional benefit during the maintenance phase from a concomitant psychosocial intervention, including psychotherapy, that addresses illness management. The more commonly practiced supportive and dynamic-eclectic therapies have not been studied in randomized, controlled trials as maintenance treatments for patients with bipolar disorder. Addressing comorbid disorders and psychosocial consequences Patients in remission from bipolar disorder suffer from the psychosocial consequences of past episodes and ongoing vulnerability to future episodes. In addition, patients with this disorder remain vulnerable to other psychiatric disorders, including, most commonly, substance use dis orders (66) and personality disorders (430, 431). Psychosocial treatments, including psychotherapy, should address issues of comorbidity and complications that are present. The majority of in formation available about pharmacological treatments for bipolar disorder in youth relies upon open studies, case series, and case reports. Lithium There are more data available for lithium than for any other medication in the treatment of bipolar disorder in children and adolescents. There was significantly greater improvement in global functioning with lithium treatment than with placebo. Significantly more patients in the lithium-treatment group experienced thirst, polyuria, nausea, vomiting, and dizziness. In four double-blind, placebo-controlled, crossover studies of children with bipolar disorder, significant improvement in mood lability, explosive outbursts, aggressive behavior, and psychosis was found with lithium compared with placebo (433–436). However, small study group sizes, diagnostic issues, and short treatment durations limit the interpretation of these findings. There have also been open studies, case series, and case reports with clinical responses ranging from 50% to 100% (437–455). Valproate/divalproex There have been no placebo-controlled studies of divalproex in the treatment of bipolar disor der in children and adolescents, but divalproex response rates in four open studies ranged from 60% to 83% (127, 456–458). In the only multisite open study of divalproex treatment for children and adolescents with bipolar disorder (458), 40 subjects ages 7–17 years received divalproex for 2–8 weeks. Sixty one percent of the subjects showed a ≥50% improvement from baseline scores on the Young Mania Rating Scale. The most commonly occurring side effects (>10% incidence) were headache, nausea, vomiting, diarrhea, and somnolence. There have also been four case reports or series of divalproex sodium treatment of bipolar disorder in youth. Divalproex also showed efficacy in an active-comparator study in which 42 children and ad olescents (ages 8–18 years) with bipolar disorder were randomly assigned to 6 weeks of open treatment with lithium, divalproex, or carbamazepine (463). No significant differences in re sponse rates (>50% change from baseline to last Young Mania Rating Scale score) were found among the patients receiving divalproex (53%), lithium (38%), or carbamazepine (38%). In the continuation phase of this study, 35 patients received open treatment for an additional 16–18 weeks (463). Response during the continuation phase was defined as a score of 1 or 2 on the Bipolar Clinical Global Improvement Scale. Thirty patients (85%) were classified as having responded at the end of the continuation phase. Only 13 patients (37%) were receiving a single study drug (lithium, divalproex, or carbamazepine) and no other psychotropic medication at the end of the continuation phase. For the 22 patients who required additional psychotropic medi cation, 11 received a second study drug (lithium, divalproex, or carbamazepine), and 11 received a stimulant. Treatment of Patients With Bipolar Disorder 55 Copyright 2010, American Psychiatric Association. Carbamazepine Information about the use of carbamazepine in the treatment of adolescent bipolar disorder is limited to case reports. Woolston (464) described three cases of carbamazepine monotherapy for adolescents with bipolar disorder in whom clinical improvement of manic symptoms was demonstrated. A positive response was reported with the combination of carbamazepine and lithium in seven adolescents with bipolar disorder (192, 449). Atypical antipsychotics There are two case series and one open trial of olanzapine as primary or adjunctive treatment for children and adolescents with bipolar disorder. In an open study, 23 children ages 5–14 years with bipolar disorder received olanzapine 2. Response was defined as ≥30% improvement in score on the Young Mania Rating Scale, and the response rate was 61%. In case reports of three youths (ages 9–19 years) with bipolar disorder, olanzapine was used as an adjunctive treatment in addition to existing medication regimens (466). Finally, in a report of seven cases of adolescents with bipolar disorder (467), olanzapine was used as adjunctive treatment to existing psychotropic medication regimens. A retrospective chart review of 28 outpatient children and adolescents ages 4–17 years with bipolar disorder assessed adjunctive risperidone treatment (468). No serious adverse effects were reported, although common side effects were weight gain and sedation. Newer antiepileptics There are few reports of the use of the newer antiepileptic agents in the treatment of children and adolescents with bipolar disorder. Sixteen of the adolescents who continued gabapentin treat ment had cessation of cycling. Gabapentin was also reported to be effective in the treatment of an adolescent patient with mania (470). Moreover, fundamental questions remain to be addressed about the nature of bipolar disorder itself. Is there a more clinically and scientifically useful definition of a “mood stabilizer”? What medication dosage and treatment duration can be considered an adequate trial? Can true antimanic properties of medications be distinguished from sedative properties of medications? How and when can they best be combined with other pharmacotherapies, such as lithium and valproate? In treating an episode of bipolar depression, at what point in time is the addition of an antidepressant appropriate? Which pharmacotherapy regimens are most effective in the treatment of rapid cycling? Do newer antidepressants or other medications truly differ in their propensity to induce rapid cycling or switches into hypomanic episodes? Treatment of Patients With Bipolar Disorder 57 Copyright 2010, American Psychiatric Association. What are the predictors of response or nonresponse to maintenance pharmacotherapy? How can the side effects seen with all maintenance pharmacotherapies be minimized? To what extent do interventions in bipolar disorder improve functional status rather than symptoms? What are the relative efficacies of (and indications for) different psychotherapeutic approaches in the acute and maintenance phases of treatment? Educational Sources for Depression and Bipolar Disorder Internet Mental Health National Foundation for Depressive Illness, Inc. A study of an intervention in which subjects are prospectively followed over time; there are treatment and control groups; subjects are randomly as signed to the two groups; both the subjects and the investigators are blind to the assign ments. Some people experience this Advisory provides behavioral health a “mixed state” that combines the features of professionals with information on the symptoms mania and depression at the same time. Mania of bipolar disorder and the potential complications does not always involve feeling good, however. Some people feel irritable instead, especially Readers will also learn about screening for bipolar when substance use is involved. Also, manic disorder, challenges in diagnosing it, theories episodes can vary in severity. The core patterns disorder reported a significantly greater incidence of of bipolar disorder are illustrated in Exhibit 1. Another study found a history of childhood trauma in Bipolar Disorder approximately 50 percent of individuals with bipolar Some research suggests that bipolar disorder is disorder, and multiple forms of abuse were present underdiagnosed. One reason for underdiagnosis may in approximately 33 percent of individuals with 18 be that people with bipolar disorder tend to seek bipolar disorder. Other studies have also found an treatment during a depressive phase, when manic association between childhood trauma and a more 18,19 or hypomanic episodes (or subthreshold symptoms) complex or severe course of bipolar disorder. To be diagnosed with bipolar I disorder, an individual must have had at least one However, there is also evidence that bipolar disorder episode of mania. A study of psychiatric outpatients experience depression, but having a major depressive found that less than half of those diagnosed with episode is not necessary for the diagnosis. For example, one study found that 40 reclassifies their condition as bipolar I disorder. Symptoms that appear to be caused by bipolar depression-like symptoms, including apathy, disorder may instead be symptoms of acute substance anhedonia (inability to feel pleasure), and thoughts misuse or withdrawal. Chronic use of central nervous system nervous system stimulants, such as cocaine and depressants, such as alcohol, benzodiazepines, and amphetamines, can produce manic-like symptoms, opioids, can result in poor concentration, anhedonia, including euphoria, increased energy, grandiosity, and sleep problems, whereas withdrawal can make and paranoia, whereas withdrawal can produce people agitated and anxious. However, it is not only individuals tools for mental disorders should remember that meeting full criteria for bipolar disorder who are at these tools are not for diagnosis. The same is true co-occurring alcohol use disorder are less likely to for clients who are not formally screened but who respond and adhere to treatment and more likely appear to have mental disorders. Treatment can be divalproex sodium is contraindicated in pregnant complex and is often individualized according women). Treatment generally involves marijuana can cause a dramatic and even toxic both pharmacological and psychosocial therapies, as increase in lithium levels. The goal (Seroquel) or olanzapine (Zyprexa) are often used is to decrease the individual’s degree of emotional alone or in combination with other medications, 1,55 distress over troubling situations. One such study found grief, role transitions, or disputes) may be that divalproex sodium, an anticonvulsant mood related to changes in mood that may signal the stabilizer often used to treat manic episodes, was beginning of new mood episodes, such as new associated with a reduction in alcohol consumption or increased depression or mania/hypomania. Integrated to contribute to poorer treatment outcomes for treatment involves a provider or a team of providers addressing the disorders simultaneously. Another model for month of treatment when compared with individuals integrated treatment follows basic principles that are 68 who participated in group drug counseling (45. An approach focusing be encouraged to view co-occurrence as a single on wellness and recovery is strengths based and disorder—“bipolar substance abuse. Dimensions of Recovery and Dimensions of Wellness Dimensions of Recovery Dimensions of Wellness Health. Physical: Recognizing the need for physical activity, healthy foods, and sleep; managing chronic illnesses. Emotional: Coping effectively with life and creating satisfying relationships Home. Environmental: Occupying pleasant, safe, stimulating environments that support well-being. Financial: Obtaining satisfaction with current and future financial situations Purpose. Intellectual: Recognizing creative abilities and finding ways to expand knowledge and skills. Occupational: Obtaining personal satisfaction and enrichment from one’s work or daily activity. Social: Building a sense of connection and belonging; building a well developed support system Health Services Administration has identified several Resources essential dimensions of a holistic approach to recovery Behavioral Health Treatment Services Locator and wellness (see Exhibit 3).

In the work of this French choreographer and dancer medications gabapentin generic sustiva 200mg free shipping, the au dience members are admitted in a room in which they can choose to lie down on the foor medicine zolpidem buy cheap sustiva 200 mg on-line, each person on a yoga mat medicine 832 trusted sustiva 200 mg. They can also stay sitting medicine for nausea 200 mg sustiva visa, but the majority of people—in the performance I attended in Oslo in June 2017—lay down with their eyes closed treatment yellow fever purchase sustiva from india, some eventually falling asleep symptoms 4dp5dt cheap sustiva 600 mg. For the whole duration symptoms of appendicitis purchase genuine sustiva on line, the perform er—Juren herself— speaks in a quiet yet suggestive voice symptoms 2 weeks pregnant purchase discount sustiva online. The performance begins with these words: A hand gets in contact with your skin It tries to touch it Trying to grasp it Something to hold on to . It feels the inner warmth of your body, 90 underneath your skin its palm can feel the round belly muscles It slides easily under them it fnds a place to rest on your liver, feeling its visceral texture, massaging it a bit so as to understand its structure, its texture then another hand, a children’s hand plunges inside the long and soft structure of your small intestinal tubes It holds them tight in a grip, pressing them (…) From the beginning, that seems plausible in compari son with a physiological image, the narration becomes more and more quirky. After a hand, it is the beetle and then the performer’s “I,” her whole body entering “your” body and then the cavities of the body become rooms and houses out of which people loom. The narrator’s body explores “your” body combining the elasticity of a superdancer with the accuracy of a quasi-scientist. Her body eventually gets entangled with your body, extend ing or losing its own body parts. While it pays studious homage to so many details that make up a sensation, the action told is a fction, drawing itself semantically close to the root verb fngo, meaning, I shape or fashion. The words weave a seamless texture, touching the body as if they would like to envelop it, not just penetrate it but also infltrate its fesh on a molecular scale. The words skillfully describe the feel of the bodily architecture, the texture of tissues, the body 91 heat—the places in the body and its sensations that are commonly unknown to us. Lapsing into a hypnotizing repetition—“A tongue… licks your knee… it licks your thighs… your vulva… your belly…”—asks for surren dering to one’s own imagination. An image that is readily present for us to recall must give rise to an absent image, or as Bachelard remarks, “if an occasional image does not give rise to a swarm of aberrant images, to an explosion of images, there is no imagination. The “imaginary radiance” of an image is, then, the measure of its value for Bachelard. Myriads of body practices have surfaced in Europe, each claiming to have discovered a truer and more insightful access into viscera. Most of the time, this knowledge is framed as personal, contingent upon the idiosyncratic techniques of the practitioners. On a more rational view, some dance practitioners admit that it is a matter of imag 92 ination. For the notion “feigning,” we have to jump back to the pre-Kantian philosophy, frst Descartes, for whom, feigning is the reason why imagination is worse than useless. Descartes believed that it was a danger ous detraction from clarity and distinctness of rational thought, and so he dedicated his eforts to bring it down to earth by dissecting the heads of various animals in search of it. In so far as it is an af fection of the body, imagination is more of a hindrance than a help in metaphysical speculations. In Spinoza’s theory of knowledge, imagination or feigning has a place, even if it acquires fctions rather than truths. It is a way of knowing which is half way, as it were, between truth and falsehood, fctions giv ing access to adequate ideas without being themselves adequate. Therefore, feigning should be regarded as an expression of our lack of complete knowledge, it is a positive response to our limitations as knowers: “The less the mind understands and the more things it perceives, the greater its power of feigning is; 93 and the more things it understands, the more that pow er is diminished. Toni Negri reads it as the savage power that imagination endows reason with: it is constitutive rath er than distorting; it shifts emphasis from the knowing subject to the world as object of knowledge; it gives delirious, fantastic and crazy material for analysis. The goal of a pursuit of knowledge is not to spurn imagination but to complement it and collaborate with it. As long as we treat it as an aid to , rather than a substitute for, understanding, feigning is a point of access to truth. What would happen if we regarded all somatic practices as imaginative exer cises of feigning? If we considered feigning as a specifc faculty of explorations of the body (and many other things we have no certain knowledge of), then our propositions would be relieved from the intimidating ethos of necessity and would embrace contingency. Imagining is the sort of pretending that typically aims at convincing oneself rather than others. This could be the epis temic horizon of somatic explorations, a pretend-true game. Let us close this brief prolegomenon of the perfor mance poetics of imagination with the words of one more thinker of imagination, Denis Diderot. In his poetics, refecting the spirit of Enlightenment, the artist, scientist and philosopher share a common activity: “Each imagines rather than sees; produces rather than fnds, seduces rather than guides. In the same book, Bachelard contends that “To perceive and to imagine are as antithetic as presence and absence. This performance belongs to a phase in the work of the Hungarian cho reographer (after and then, 2009), in which dance is sidelined in favor of text and an intensifed aesthetic dimension of a spectacle which is nonetheless staged with a choreographic mind of setting movement, words, lights and sound. Cited in Michael Moran “Metaphysical Imagination” in Dictionary of the History of Ideas (ed. In front of me there is a big mirror with lights around that are not switched on, so the bulbs have a milky grey color, which bulbs typ-ically have when they are not switched on, unless they are clear bulbs, but these ones are not. When I look up from my com put-er screen I see two grapefruits, the one that is next to me and the one in the mirror. Perhaps some fast notes, or answer ing some emails, but not really sitting down to write something. It’s not a space that is meant for writing, it’s a space for the body, but not for writing. This is where I spend the last mo-ments before going on stage, and also the frst moments right after a performance is over. It’s not a private space (private space is overrated), it’s a 99 space that is connected to the stage. Like the prompter has, or used to have, back in the days, her prompter’s box, a hole in the ground, this is the hole in the ground for the performer. It has a shower and toilets, a coat rack, a water boiler, a frst aid kit, an ironing board, fresh towels, and the programs of the theatre. When the mirror lights are on the space breathes the glow of glamour, it’s the button for fction and make-believe, and is part of the prepa-ration for the stage. Depending on each particular dressing room I might put the lights on or not, before the shows, but never after—that would feel nostalgic. Like a Christmas tree, where the lights are everything to the feeling of Christmas, and without the context of Christmas, the magic spell of the lights is broken. In fact, that’s the one thing about Christmas that I like, the tree with the lights that welcome the dark, greeting the darkness with light. In the dressing room, the lights are perhaps of a more practical or der, and also they give some heat, which is usually the reason why I switch them on, to warm up the room and myself. Nevertheless, the bulbs around the mirrors re-mind me that we are, unmistakably, in a theatre and that it is something special. This space is a hole, with and without lights, with and without warmth, a space for me to go inside, a sort of non-space space. The kind of chairs we used to have in school when I was a child, partly wood and partly metal, the seat and back of the chair in wood, legs in painted metal. I sit a bit towards the front of the seat, connecting my sit bones with the seat of the chair. My feet are on the foor, and my knees in a right angle above my feet, aligned with my hips. My body is almost shaped like the chair, with my head on top of the spine, above the sit bones, knees in a right angle in front of my hips, so that the upper leg, or thighs, makes a parallel line with the foor. If I would make a drawing in profle the chair would almost trace my body like a shadow, or a visual echo, a sort of scafold, an exterior skeleton to 101 my body, a supportive structure. My weight is equal-ly distributed between my two feet and my two sit bones, which are connected to the ground through the legs of the chair. I lean a bit back from my computer, my neck moves down and I can now see my two feet on the foor, my shoes, they are white with 1984 written in dark blue. The spine follows the movement of the neck and my whole back curves, as I am rolling over my sit bones and my weight is now press-ing towards the back of the sit bones. I look straight in front into the mirror again, and feel myself sitting upright, on top of my sit bones, connect ing into the seat of the chair. I repeat this movement, rolling down and up again, a couple of times, keeping the connection to my feet on the ground, and distrib uting the weight equally between my feet and sit bones. I can feel how my hips are moving, and as I am rolling up and down, my sit bones are moving a bit back and forwards again. After doing this gentle bounce a couple of times, and as the movement becomes a bit smoother and easier, it also becomes clearer and more precise, then smaller, until I stop. In sitting, I look at myself in front of me, and I shift my weight a bit forwards and back, moving closer to the mirror and further away. Then, moving from side 102 to side, I stop looking, but my eyes are open, shifting the weight from left to right, not so far, but just enough to feel that the weight shifts from one sit bone to the other, feeling how it is pressing into the chair, perhaps diferently on one side than the other. I move a bit around like this, only shifting the weight, making small circles, in one direction and then the other. I try to feel the connection of the sit bone to the chair, to feel the shape of this bone, and to see if I can fnd where the middle is, remembering to keep the weight also sup ported by the feet on the foor. Is there a movement in my upper body, in my ribs, my head, am I moving my head, or can I remain quiet and only focus on the sit bones and the weight shifting? The chair feels hard to the bone, even if there is the softness of skin, fesh and muscles in between the two. I place my right hand under the sit bone on the right side, so that I am sitting in the palm of my hand, or more precisely on my fngers. I can feel the fatter, middle part of the bone more dis tinctly, like there is a plateau or a surface. For the front of the hand, how-ever, the knuckles of my fngers, it’s a bit painful, as it is being pressed into the hardness of the chair, and I gently remove my hand from under 103 my sit bone and bring it to rest on the thigh in front of the hip. As I sit back on the chair, now with the hand removed, I feel my right sit bone expanding into the seat of the chair, as if I am sitting further into the chair on that side, that my right side is widening and mak ing me sit more grounded and also with greater ease and comfort. I want to be complete so I immediately do the same exploration on the other side, sitting now on my left hand, until the left sit bone also expands into the seat of the chair, bringing my whole left side more or less in balance with the right. I observe diferences between my right and left side, the usual things when I have not been tuning in with myself like this for a while, or just because it’s early in the morning. Still, and even if a mountain is not exactly the image of softness, I feel grounded like a mountain, sitting in the chair, I could sit like this for a thousand years, without any efort, just there, solid, calm. Yes, this gets closer to the 104 feeling of sinking into the chair, the soft-ness of this sponge like texture. I get up to wash my hands, which are now full of grapefruit juice, so I cannot continue writing on my computer. I make two or three steps around in the room, and then I stand still and close my eyes. If there are some places I feel heavier than others, if there are some parts of my body that catch my attention. I feel my feet on the ground, how is my right foot in relation to my left, how much distance is there be tween my two feet, how do I feel my knees, are they soft or is there ten-sion around my knees, at the back of my knees. Where under the feet do I feel my weight, more to-wards the back and the heels of the foot, on the inside or outside of the foot, towards the front, or the toes—are the toes grasping the foor, or just there, relaxed, and is this diferent on the right and the left side? How is my breathing, is my breathing circulating through my whole body, or are there parts where no air is entering? Can I feel any movement in my ribs, the ribs on both sides, towards the back of the ribs as well? If I try to visualize my spine, what does it look like, if I would draw it on a piece of paper, what shape would it have, how would it curve? How is my head balancing on 105 the top of the spine, is it tilting a bit towards the front, a bit more to one side than the other, where is my nose pointing? If I were to measure the distance between my left ear lobe and my left shoul-der, then my right ear lobe and my right shoulder, would that distance be the same on the right and left side? The face, the muscles of the face, the jaw, the tongue, the eyelids, the forehead. I contin-ue like this for a moment, tracing my whole body, feeling how my body is this morning. I think about how the foor can give very clear feedback to the body, detecting where there are tensions, how the body is organized, diferent on one side and the other, by be ing a clear and stable reference. I want to lie down, but the foor here is too cold, and besides, a chair, provided that it has the right size, and that it is not too soft, can do the same. I will have wrestled and tried to resist, leaning forwards, rubbing my arm, squeezing my hands. I will have felt my body getting heavier, my weight slowly sinking further into the seat. I will have tried to just let it be, let the prickling pass, it will surely have passed, and then I will have been able to move it again, like normal, change my position, shift my weight. I will have taken my sweater of, the warmth will have made it even worse, I will have imagined. I will have woken up, suddenly, with my arms crossed in front of the chest and both legs pulled up, as if I will have been cold. Maybe my body has received signals corresponding to physical experiences that were very common thousands of years ago and have been buried in the more recent period of our civiliza tion, but are still existent and are faintly resonating now without stirring the sur-face. Something that was up to just a moment ago not in line with my mind-driven re ality that dominates my mode of operation when I sit in the theatre audience. It could be a certain odor or subtle fragrance, caused by one or more volatilized chemi cal compounds that register with the deeper levels of myself. Yes, now I can locate this certain smell that undisturbed escapes into the room when certain body parts are exposed to the air, without insulating layers of clothing. When I look into the room and my eyes adjust to the dim light, I can slowly make out the con-tours of the people around me. The slender shapes, the unusual curves, the narrower frames of bodies without clothes, bodies otherwise covered and formed by the outlines and surfaces of the fabrics; the hard angles of the shoul ders of a suit jacket, the gentle folds of a silk blouse, the thickness of a woolen turtle neck, have given way to the awkward diferences of nakedness. I carefully keep my knees towards the front, in order to not touch the thighs of the person sitting next to me. From the corner of my eye, I look silently to the person on my left, and take in an impres-sion of this body sit ting there before I cover up my deliberate look with the gesture of a cough. Self-awareness and curiosity resonate in the movements that fll the room; a room full of peo ple sitting together, in the dark, naked, looking towards the empty stage in front. The cover of the seat, brushing against my skin, reminds me of where I am: without a doubt, in a theatre. I can’t help visu alizing the pattern of the woven material leaving its structure imprinted on my skin, complementing the impression of the per-formance, remaining for some time after it is over, as an experience or a memory. This struc-ture, like a relief painting, a literal impression of the experience of the performance, is ofering a tactile reading on the surfaces of our bodies to the touch of a hand. Will this physical imprint, the patterns on our backs and be hinds, enter the exchange of our conversation in the 109 bar after the performance? Do they gradually fade, like the light, or is it more like memory, a more porous and unstable matter that slips away and reappears without warning? Sitting here in the dark watching in front of us, we are an audience watching a show, and at the same time bodies co-existing in a total situation. What if it is just a convention, and nudity is a common, like in a sauna, and we don’t think about that people are naked, and at the same time we do? A breeze of air is coming from the doors at the back, and is immediately felt on our exposed bodies. A reminder of the vulnerability of the naked body in a physical sense and a metaphor for the exposure we feel when nakedness is experienced un-moderated in a social context. I count the cofee cups, six; they are not completely empty, there’s still some cofee left inside of them, cold of course. I move my whole upper body towards the front and back again, and feel how the sit bones are pressing into the chair. Then I gently shift my weight from side to side, let ting the weight shift from the left to the right sit bone, 110 a couple of times. With both hands on the key-board and eyes closed, I slowly let my head fall towards the front, making my spine curve and my sit bones roll towards the back. My body is folding itself together, so that head moves closer towards the tail, or the sit bones, and my spine is being elongated with each vertebrae coming up to the surface, nearly visible under my knitted pullover. I roll back up again, starting the movement simultaneously from the head and the pelvis, so that the sit bones fnd again the contact with the chair, this fatter part of the bone, following each vertebra, until the spine and the upper body have unfolded and I am sitting in an upright position. I continue writing, folding and unfolding my upper body like this, and paying attention to where I can feel the movement, so that it’s not just a mechan ical repetition. I place one hand on the top of my head, without adding pressure, but to accompany the movement, the other hand behind my back, trying to touch the tail bone. I do the movement of folding and unfolding, between my two hands, on my head and my tail. Then I move my hand from my head to the front of my chest, my pullover is dark green and very soft. The hand 111 on my chest continues reaching further up towards my neck and makes a V-shape with my fngers touching the collarbone on both sides. My fngers are gen tly touch-ing the vertebrae at the top of my spine, and observe how they move in and out as the body is folding and unfolding, rolling up and down. I notice that my shoulder blades are sliding out to-wards the side when the body is folding together, and move back towards each other again when I roll up. I place my hands on diferent parts of my body, feeling how the sides are be ing moved, my ribs, I touch my ribs, and I can feel how my lungs fll with air and empty out again, as the front of the body gets smaller and expands in the movement of folding and unfolding. Only breathing, still perceiving the movement of the pelvis rolling back and forwards, how the breathing is mov ing the body, feeling the whole body in sitting.

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