What is outpatient treatment for addiction?

Causes of Addiction

The reasons people abuse drugs and alcohol are innumerable and often complex. Some become addicted to a drug after the first recreational use. Others find comfort in the escape that the effects of drugs and alcohol provide them: Any physical or emotional pain or memories of past trauma are numbed as are any thoughts or emotions that may be causing anxiety or stress. Still others abuse medications that doctors prescribe for particular ailments or illnesses.

Research has shown that a high percentage of drug are survivors of past emotional and/or physical trauma and have resultant PTSD (post-traumatic stress disorder). Many have experienced physical, emotional, verbal, or sexual abuse as children or adolescents. Others survived being raised in violent households with quarreling parents who were not able to meet the emotional needs of their children. Women in physically or sexually abusive marriages are more likely to seek comfort in drugs and alcohol than are women in healthy relationships.

Men who are domestic violence offenders also are more likely to abuse drugs and alcohol—and act violently toward others while intoxicated—than men who are not violent. It is important to note, however, that drug and alcohol abuse is not a proven cause of domestic violence and that domestic violence is not a proven cause of drug and alcohol abuse. These situations are known as correlated rather than causal.

Lesbian, gay, bisexual, and transgendered (LGBT) men and women are more likely to use drugs—and continue to use them throughout their lifetime—than are heterosexual individuals. The drug use is often in response to the frequent and perceived discrimination and abuse that LGBT individuals may face because of their sexual orientation or gender expression.

When a person abuses a drug too frequently, he or she can become addicted to that substance. Another cause of drug addiction is genetics. It is true that some people are predisposed to addiction because of family history and genetics. Abuse also may lead to addiction if the person has a mental illness, such as antisocial personality disorder, bipolar disorder, or schizophrenia. Drugs may ease the symptoms of these conditions or can make living with them more bearable. Thus, people may become addicted to drugs or alcohol as they attempt to self-medicate their disorders.

People also are more likely to abuse drugs if they enjoy the effects the substances have on their brains. Opioids, for example, block the nerve receptors in the brain that help the body to sense pain. Opioids also engage the receptors in the brain that detect pleasure. The drug causes users to enter a euphoric state in which they experience stress relief and a carefree emotional state. People who enjoy this sensation may come to think they need the drug to be happy. Users report feeling an intense desire to use the drug again after their first encounter with it, despite the fact that their body is not physically addicted to it at that point. Repeated and ongoing use of opioids causes significant and detectable changes in the brain and the brain's chemistry. Chronic use requires a period of one to three years of abstinence for the brain to heal.

The first step in treating drug abusers and addicts typically involves their loved ones—people who take notice of their behavioral changes, physical appearance, and drug use. These persons may convince or force the substance abuser to seek treatment, which is usually first in the form of calling call his or her primary physician or family doctor. After an initial screening in which the doctor runs a series of tests and asks the patient questions about his or her drug use, the doctor may refer the patient to a specialist for an accurate diagnosis. If the individual requires detoxification from the substance, they are referred to a medical facility or specialized detox and recovery program.

Research has found that people living with mood disorders have a greater likelihood of becoming addicted to drugs than do individuals without such mental health conditions. In addition, patients with drug disorders are two times as likely to be diagnosed with a mood or anxiety disorder. Men seeking help for drug abuse are often diagnosed with antisocial personality disorders while women are likely to exhibit behavior indicative of depression, anxiety, or post-traumatic stress disorder.

Screening and Diagnosis

The first step in treating drug abusers and addicts typically involves their loved ones—people who take notice of their behavioral changes, physical appearance, and drug use. These persons may convince or force the substance abuser to seek treatment, which is usually first in the form of calling call his or her primary physician or family doctor. After an initial screening in which the doctor runs a series of tests and asks the patient questions about his or her drug use, the doctor may refer the patient to a specialist for an accurate diagnosis. If the individual requires detoxification from the substance, they are referred to a medical facility or specialized detox and recovery program.

Another important part of the screening and diagnosis process is the discovery of other physical ailments, coexisting drug addictions, or mental health issues, which is referred to as comorbidity. Specific medications and methods used in addiction treatment may counteract other drugs the patient is using or may interfere with other conditions the patient may have; it is crucial to discover all illnesses, diseases, and dependencies before treatment begins. Often times, mental health issues cannot be addressed unless and until the individual is free from drugs and alcohol for a period of time.

Diagnosing comorbidity is a critical step in addictions treatment; treating a patient addicted to cocaine requires a different approach than the one taken to treat a patient addicted to prescription painkillers who is simultaneously struggling to overcome depression, anxiety, or a personality disorder. According to the National Institute on Drug Abuse, 60 percent of substance abusers also have a mental illness. A mental illness may be present before a person starts using drugs, or a person might start using drugs before becoming mentally ill. Both conditions also may be the result of similar risk factors, such as genetic predisposition and environmental triggers (such as high stress or trauma).

Through laboratory screenings, medical professionals may discover that vital organs such as the lungs, liver, or heart have been damaged by repetitive drug abuse. They also may discover conditions such Hepatitis C or HIV, which are common among individuals who share needles used for intravenous drug use.

Outpatient Treatment for Addiction and Substance Abuse

Ideally, a person who is abusing or is addicted to one or more substances and who is also dealing with an emotional disorder should be treated in the same facility, often referred to a duel diagnosis facility. This does not often occur in the United States, however, and duel diagnosis facilities are often difficult find. Too often, a patient's substance use disorder is view as separate and unrelated to the patient's mental health disorder, and patients are sent to multiple facilities to speak to a variety of medical and mental health professionals, psychotherapists, and drug and alcohol counselors. Holistic approaches to addressing addiction, whereby one team of professionals with a variety of specialties cares for all of an individual's medical and mental health needs, are becoming more commonplace in the United States as the stigma of addiction is reduced and acceptance of substance use disorder as a brain disease becomes more accepted.

A common course of outpatient treatment for addiction an Intensive Outpatient Program (IOP), where individuals attend daily group therapy sessions and one-on-one counseling. IOP attendees also meet weekly with a psychiatrist to discuss medication needs such as medications to help calm cravings, fight depression, or reduce anxiety. Naltrexone, Antabuse, and Campral are common drugs administered to alcohol addicts. Naltrexone also can be distributed to opioid addicts. Even those addicted to nicotine can use bupropion or Verenicline (Chantix) in addition to nicotine gum, patches, nose sprays, or other nicotine replacement products. IOPs typically meet every day for an average of six hours a day, five days a week for anywhere from three to six weeks, depending the participant's need and desire as well as what the individual's insurance will approve.

In group therapy sessions, members speak about their drug use in front of other persons who understand what they are going through. If they are uncomfortable with—or in are in need of supplementing—group therapy, a drug and alcohol counselor or psychologist may counsel them independently. Therapy helps patients learn to deal with their cravings, the issues that led them to drugs in the first place, and to learn to begin to live a drug-free life. It enables them to set goals for the future and to repair strained or broken relationships with friends and family members.

To prevent relapse, people recovering from substance abuse and addiction are reminded to pay attention to their bodies and minds and to ask for help when they need it. The relapse process includes three stages: emotional, mental, and physical. If a patient feels anxious, defensive, or angry and misses group meetings or doctors’ visits, he or she could be in the first stage of relapse. Combined with poor sleeping and eating habits and mood swings, this first stage may lead a patient to postacute withdrawal. Patients are instructed to reach out to medical professionals, friends, or family members if they feel they are in danger of relapse.

Persons suffering from a drug or alcohol addiction may require rehabilitation to overcome their physical and emotional dependencies and resume a normal life. Rehabilitation for addiction often involves a series of steps.

If an individual is addicted to alcohol or benzodiazepines, medical detoxification is required because detoxification from these substances can result in death if not monitored by health officials. Opioid detoxification, while not usually fatal, is extremely painful and patients find the process much more bearable in a supervised, medical setting. Detox is a process that removes the toxic substances from the body. Even if the ultimate goal is to attend an outpatient program, patients are required to be drug- and alcohol-free, and detox is often the first step.

Many addicts also have a mental illness. Therefore, many types of therapy are used to help the addicted individual deal with whatever situation has most likely contributed to the addiction. Cognitive behavior therapy, family therapy, and group therapy are often used to help individuals understand their patterns of maladaptive behavior and to teach them better strategies for identifying, thinking about, and coping with situations or people that may trigger the addictive behavior and cravings. Medications such as Campral may be used to help people with alcohol addictions. Suboxone may be used to assist opioid addicts by reducing withdrawal symptoms and cravings. Therapists also may introduce a twelve-step program, which involves group therapy and support to keep addicts clean and sober.

Research has found that the majority of those seeking help for addiction are men, as women are less likely to admit that they have substance abuse problems and are traditionally responsible for child care, thus making it difficult to attend inpatient programs or even IOPs unless their children are older and in school during the day. Most rehabilitation facilities or drug and alcohol centers are not equipped to care for children and do not offer babysitting or daycare services.

Outpatient treatment is most often used for persons who come from a somewhat stable environment and home life. For example, someone who is married and has a steady job would benefit from outpatient treatment. However, a celebrity who travels from city to city or someone who lives in an extremely unstable, chaotic environment would most benefit from an inpatient program. Additionally, someone with a severe psychiatric illness would benefit from an inpatient program.

Bibliography

Capuzzi, David, and Mark D. Stauffer. Foundations of Addictions Counseling. 3rd ed. Boston: Pearson, 2015. Print.

Desai, Anjuli, and Frank John English Falco. "Substance Abuse Recovery Groups." Substance Abuse. New York: Springer, 2015. 331–36. Print.

Gifford, Steven. "Differences Between Outpatient and Inpatient Treatment Programs." Psych Central. Pych Central, 30 Jan. 2013. Web. 3 Nov. 2015.

Gottheil, Edward, ed. Intensive Outpatient Treatment for the Addictions. New York: Haworth Medical, 1997. Print.

Kaye, Alan David, et al. Substance Abuse: Inpatient and Outpatient Management for Every Clinician. New York: Springer, 2015. Print.

"National Survey of Substance Abuse Treatment Services (N-SSATS), 2013: Data on Substance Abuse Treatment Facilities." SAMHSA. Dept. of Public Health and Human Services, Sept. 2014. Web. 4 Nov. 2015.

"Substance Abuse Therapy: Inpatient vs. Outpatient Therapy." UT San Diego. San Diego Union-Tribune, 2015. Web. 3 Nov. 2015.

What is restless legs syndrome?

Causes and Symptoms

Patients with restless legs
syndrome complain about unpleasant sensations, especially in the evening or at night, that drive them to move their limbs in order to alleviate the discomfort. Sufferers typically describe an inability to tolerate sitting, lying, or remaining still for even short periods of time, accompanied by an intense urge to walk, run, or move about.

The specific etiology of restless legs syndrome remains to be determined, although a number of theories have been proposed. Several of these include central nervous system (CNS) iron deficiency (especially in the brain’s substantia nigra) leading to dopamine defects, CNS hypersensitivity and arousal, disrupted circadian rhythm, and genetic predisposition. Given the complexities of the human brain, more than one process is probably implicated in restless legs syndrome.

As for secondary causes, medications that can produce similar symptoms include caffeine, theophylline, antidepressants (with their anticholinergic effects), dopamine antagonists that cross the blood-brain barrier (the majority of antipsychotic medications), and metoclopramide, as well as withdrawal from any of a number of drugs.

The condition appears to be relatively common, with an estimated prevalence in the general population of up to 10 percent. Further, a greater prevalence appears to exist among first-degree relatives of patients than in those without the condition, suggesting at least some heritability. In fact, evidence initially points to a genetic locus mapped for restless legs syndrome on chromosome 12q.

Although excessive leg movements can be demonstrated during a sleep study test (nocturnal polysomnography), restless legs syndrome is diagnosed by history only. Four essential criteria are used in this process. First, the patient experiences a compelling urge to move the legs (or affected body parts) as a result of unpleasant sensations. Second, the unpleasant sensations and urge to move the legs worsen during the evening or at night and can significantly interfere with relaxation and sleep. Third, the unpleasant sensations and urge to move the legs worsen during periods of inactivity or rest, including sitting in a chair or lying in bed. Fourth, the unpleasant sensations and urge to move the legs are partially or completely relieved by activity, including stretching or walking, but only as long as the activity continues. In addition, patients reporting symptoms of restless legs syndrome should undergo toxicology studies, as well as have their iron, electrolyte, and medication levels checked. Comorbid psychiatric disorders must also be identified.

The symptoms and sensations of restless legs syndrome are typically depicted in negative terms—“fidgety,” “creepy crawlies,” “insect crawlies,” “painful,” and “electric,” among other descriptors. Most report that these sensations can become so intense that they must “jiggle” or “shake,” before ultimately resorting to getting up and walking. Spouses may also complain that patients move their limbs while asleep, thus disturbing the quality of sleep for both partners.

Restless legs syndrome is not limited to the evening hours, bedtime, or sleeping, nor is it necessarily limited to the lower extremities. It can involve an inability to tolerate confinement or immobility—at any time of the day—on airplanes, buses, and cars, as well as in meetings, in movie theaters, and during medical testing, such as magnetic resonance imaging (MRI) or computed tomography (CT) scanning. It can also involve, in more severe cases, other areas of the body, including the hips, upper back, shoulders, and arms. Patients report that it is difficult or impossible to ignore the negative sensations, which adversely affect not only sleep but also daily activities.

Treatment and Therapy

Difficulties arise when attempting to treat restless legs syndrome, as the disorder appears to involve multiple brain processes. The mainstay of medical therapy today consists of daily low-dose dopamine agonists (dopaminergics), the most popular of which are ropinirole and pramipexole, the only medications approved for “idiopathic” restless legs syndrome. Doses of these medications are slowly titrated until therapeutic results are attained. For example, pramipexole is started at 0.125 milligrams taken two hours prior to bedtime for five days and then increased to the usual evening dose of 0.25 milligrams.

The side effects of ropinirole and pramipexole are representative of the dopamine agonists as a class: headaches, nausea, insomnia, “sleep attacks,” and problems related to impulse control (gambling, drinking, shopping, hypersexuality). Anticonvulsants, opioids, and sedative-hypnotics have also been used to treat restless legs syndrome, all with varying success depending on individual patient profiles.

Additionally, sufferers should be instructed to stay away from caffeine, tea, chocolate, alcohol, or tobacco in the evening (after 5 p.m.). They should also be taught to engage in good sleep hygiene (obtain sufficient hours of rest, have a regular time to retire and awaken), to avoid exercising too close to bedtime, to avoid aggravating medications, and to take ferrous sulfate supplements if iron studies show this to be warranted.

Perspective and Prospects

Restless legs syndrome is an underappreciated disorder that causes millions of people a great deal of distress and misery. While many may think of the condition as a new disease, it has been described for centuries. Yet, only since the 1980s has this complex neurological disorder captured the attention of medical scientists and researchers. Such interest has led to the development of medical therapies tailored to relieve the symptoms of restless legs syndrome. Much remains to be done. Primary care physicians, neurologists, psychiatrists, rheumatologists, and other health care professionals are beginning to take this problem seriously as a disorder with a significant morbidity resulting from chronic interruption of sleep and daily activities. Further, future directions in pharmacology will hopefully take into account the need for longer-acting medications and nondopaminergic options.

Bibliography

Allen, Richard P., and Merrill M. Mitler. "Restless Legs Syndrome (RLS) and Sleep." National Sleep Foundation, 2011.

Badash, Michelle, and Michael Woods. "Restless Legs Syndrome." Health Library, Mar. 15, 2013.

Buchfuhrer, Mark J., Wayne Hening, and Clete Kushida. Restless Legs Syndrome: Coping with Your Sleepless Nights. New York: Demos, 2007.

Maheswaran, Murali, and Clete A. Kushida. “Restless Legs Syndrome in Children.” Medscape General Medicine 8, no. 2 (June 20, 2006): 79.

"Restless Legs." MedlinePlus, Mar. 5, 2013.

"Restless Legs Syndrome Fact Sheet." National Institute of Neurological Disorders and Stroke, Nov. 25, 2011.

What are natural treatments for ulcerative colitis?

Introduction

Ulcerative colitis is a disease of the colon that is closely related to Crohn’s disease. The two are grouped in a category called inflammatory bowel disease (IBD) because they both involve inflammation of the digestive tract.

The major symptoms of ulcerative colitis include abdominal pain and bloody diarrhea. When the disease becomes severe, those affected may develop fever, weight loss, dehydration, and anemia. Sometimes, constipation develops instead of diarrhea. Arthritis, skin sores, and liver inflammation also may occur.

One of the most feared consequences of ulcerative colitis is dramatic dilation of the colon, which can lead to fatal perforation of the colon. Ulcerative colitis also leads to a greatly increased risk of colon cancer.

Ulcerative colitis tends to wax and wane, with periods of remission punctuated by severe flare-ups. Medical treatment aims at reducing symptoms and inducing and maintaining remission.

Sulfasalazine is one of the most common medications for ulcerative colitis. Given either orally or as an enema, it can both decrease symptoms and prevent recurrences. Corticosteroids, such as prednisone, are used similarly in more severe cases, sometimes combined with other immunosuppressive drugs, such as azathioprine and cyclosporine. Partial removal of the colon may be necessary in severe cases.

Principal Proposed Natural Treatments

People with ulcerative colitis can easily develop deficiencies in numerous nutrients. Chronic bleeding leads to iron deficiency. Malabsorption, decreased appetite, drug side effects, and increased nutrient loss through the stool may lead to mild or profound deficiencies of protein, folate, calcium, copper, magnesium, selenium, zinc, and vitamins A, B12, C, D, E, and K. For persons with ulcerative colitis, supplementation to restore adequate body stores of these nutrients is highly advisable and may improve specific symptoms and overall health. One should work closely with a physician to identify any nutrient deficiencies and to evaluate the success of supplementation in correcting them.

Essential fatty acids. Fish oil and evening primrose oil contain healthy fats called essential fatty acids. According to some of the small, double-blind, placebo-controlled trials reported, fish oil might be helpful for reducing symptoms of active ulcerative colitis. Evening primrose oil also has shown promise. However, larger studies will be necessary to discover for certain whether fish oil or evening primrose oil really help. Regular use of fish oil alone, or in combination with gamma-linolenic acid (found in evening primrose oil), has not been found effective for preventing disease flare-ups in people whose ulcerative colitis has gone into remission.

Probiotics
. Friendly bacteria, or probiotics, might be helpful in ulcerative colitis. A double-blind trial of 116 people with ulcerative colitis compared probiotic treatment with a relatively low dose of the standard drug mesalazine. The results suggest that probiotic treatment might be just as effective as low-dose mesalazine for controlling symptoms and maintaining remission. Evidence of benefit was seen in other trials too. However, probiotics may be less useful for inducing remission; when they were added to standard medications used for induction of remission, no additional benefits were seen in a study of people with mild-to-moderate ulcerative colitis.

Probiotics might be useful for people with ulcerative colitis who have had part or all of the colon removed. Such persons frequently develop a complication called pouchitis, inflammation of part of the remaining intestine. Two double-blind, placebo-controlled studies found that probiotics can help prevent pouchitis and also reduce relapses in people who already have it. The probiotic mixture used in these trials contained four strains of Lactobacillus, three strains of Bifidobacterium, and one strain of Streptococcus salivarius. In addition, some evidence hints that probiotics might reduce the joint pain that commonly occurs in people with IBD.

Aloe
. In a double-blind, placebo-controlled trial, forty-four people hospitalized with severe active ulcerative colitis were given oral aloe gel or placebo twice daily for four weeks. The results showed that aloe was more effective than placebo in inducing full or partial remission of symptoms.

Other Proposed Natural Treatments

Researchers are now interested in the use of phosphadylcholine as a supportive treatment in severe ulcerative colitis. There may be an insufficient quantity of phosphatidylcholine in the mucus lining the colon in persons with ulcerative colitis. Taking phosphatidylcholine may correct this deficiency. A small, double-blind, placebo-controlled study of sixty persons whose ulcerative colitis was poorly responsive to corticosteroids were randomized to receive either phosphadylcholine (2 grams [g] per day) or placebo for twelve weeks. One-half of the participants taking phosphadylcholine showed a significant improvement in symptoms, compared to only 10 percent taking placebo. Moreover, 80 percent taking phosphadylcholine were able to completely discontinue their corticosteroids without disease flare-up, compared to 10 percent taking placebo.

A double-blind, placebo-controlled study of twenty-four people with ulcerative colitis examined the effects of wheat grass juice taken daily for one month. According to various measures of disease severity, participants given wheat grass juice improved to a greater extent than those given placebo. However, wheat grass juice is rather bitter, and it seems unlikely that the study could truly be blind, meaning that participants and doctors did not know who was getting the wheat grass juice and who was getting the placebo. Indeed, when researchers polled the participants, a majority of those given wheat grass juice correctly identified it. For this reason, as well as its small size, the results of the study are not convincing.

The substance curcumin (from the spice turmeric) has shown some promise for helping to maintain remission. In a double-blind, placebo-controlled study, eighty-nine people with quiescent ulcerative colitis were given either placebo or curcumin (1 g twice daily) with standard treatment. During the six-month treatment period, relapse rate was significantly lower in the treatment group than in the placebo group.

Glutamine, boswellia, bromelain, blue-green algae, colostrum, mesoglycan (glycosaminoglycans), and an extract of soy called Bowman-Birk inhibitor concentrate (BBI) have been suggested for the treatment of ulcerative colitis, but the evidence that they work remains preliminary at best. There are also weak indications that allergies to foods, such as milk, may play a role in ulcerative colitis. One study failed to find real acupuncture more effective than fake acupuncture for this condition.

Herbs and Supplements to Use Only with Caution

Various herbs and supplements may interact adversely with drugs used to treat ulcerative colitis.

Bibliography

Ben-Arye, E., et al. “Wheat Grass Juice in the Treatment of Active Distal Ulcerative Colitis.” Scandinavian Journal of Gastroenterology 37 (2002): 444-449.

Do, V. T., B. G. Baird, and D. R. Kockler. “Probiotics for Maintaining Remission of Ulcerative Colitis in Adults.” Annals of Pharmacotherapy 44 (2010): 565-571.

Gionchetti, P., et al. “Prophylaxis of Pouchitis Onset with Probiotic Therapy.” Gastroenterology 124 (2003): 1202-1209.

Joos, S., et al. “Acupuncture and Moxibustion in the Treatment of Ulcerative Colitis.” Scandinavian Journal of Gastroenterology 41 (2006): 1056-1063.

Kato, K., et al. “Randomized Placebo-Controlled Trial Assessing the Effect of Bifidobacteria-Fermented Milk on Active Ulcerative Colitis.” Alimentary Pharmacology and Therapeutics 20 (2004): 1133-1141.

Langmead, L., et al. “Randomized, Double-Blind, Placebo-Controlled Trial of Oral Aloe Vera Gel for Active Ulcerative Colitis.” Alimentary Pharmacology and Therapeutics 19 (2004): 739-748.

Lichtenstein, G. R., et al. “Bowman-Birk Inhibitor Concentrate: A Novel Therapeutic Agent for Patients with Active Ulcerative Colitis.” Digestive Diseases and Sciences 53 (2008): 175-180.

Mallon, P., et al. “Probiotics for Induction of Remission in Ulcerative Colitis.” Cochrane Database of Systematic Reviews (2007): CD005573. Available through EBSCO DynaMed Systematic Literature Surveillance at http://www.ebscohost.com/dynamed.

Stremmel, W., et al. “Phosphatidylcholine for Steroid-Refractory Chronic Ulcerative Colitis.” Annals of Internal Medicine 147 (2007): 603-610.

What is chronic bronchitis? |

Causes

With chronic bronchitis, the airways in the lungs experience inflammation. When these airways become irritated, thick mucus forms inside the airways, making it difficult to breathe.

The most common causes of chronic bronchitis include cigarette smoking and exposure to secondhand cigarette smoke. Air pollution, infections, and allergens worsen the symptoms of bronchitis.

Risk Factors

Cigarette smoking is the single greatest risk factor for developing chronic bronchitis. More than 90 percent of chronic bronchitis patients are or have been smokers, and about 15 percent of all smokers develop the disease. The more a person smokes and the longer he or she smokes, the greater the risk is of developing chronic bronchitis. Frequent and long-term smoking also increases the risk that the chronic bronchitis will be severe.

Other factors that may increase the chance of developing chronic bronchitis include long-term exposure to chemicals, dust, and other substances that have been inhaled; long-term cigar or marijuana smoking; uncontrolled asthma; and long-term exposure to air pollution.

Symptoms

Symptoms of chronic bronchitis include coughing up mucus, coughing up mucus streaked with blood, and shortness of breath (difficulty breathing). Difficulty breathing may especially occur after mild activity or exercise. Other symptoms include recurring respiratory infections that cause symptoms to worsen; wheezing when breathing; fatigue; swelling of the ankles, feet, and legs; and headaches.

Screening and Diagnosis

To diagnose chronic bronchitis, symptoms of productive cough must have been present for three or more months in at least two consecutive years, and not have been caused by another condition. A doctor will ask about symptoms and medical history and perform a physical examination.

Tests may include breathing tests to check lung function, arterial blood gas tests, chest X-ray (a test that uses radiation to take a picture of structures inside the chest), blood tests to determine complete blood count and oxygen saturation of the blood, exercise stress testing to test lung function, and a CT scan of the chest (a type of X-ray that captures 3-D images of the internal organs).

Treatment and Therapy

There is no cure for chronic bronchitis, but there are treatments that can reduce symptoms and improve lung function. The best way to reduce symptoms is to stop smoking. Short-acting bronchodilator medications may be prescribed to help open the airways in the lungs and improve breathing. Long-acting bronchodilator medication may be prescribed as well, and steroids may be prescribed to help improve breathing. Antibiotics are rarely prescribed to treat bronchitis. However, they may be needed to treat a lung infection that often accompanies the illness. A small percentage of patients may need chronic antibiotic therapy.

Oxygen therapy can restore oxygen to parts of the body depleted because of chronic bronchitis. Exercise can also help. Breathing exercises can help to improve lung function, and are usually done under the supervision of a respiratory therapist. A regular exercise program can reduce symptoms and improve lung function.

Prevention

The best way to prevent chronic bronchitis is to stop smoking, or avoiding smoking altogether for nonsmokers. Inhalation of other triggers such as air pollution, chemicals, and dust should also be avoided as much as possible. Early diagnosis and treatment of the condition will preserve lung function and reduce symptoms.

Bibliography

"Chronic Bronchitis." MedlinePlus. US National Library of Medicine, 12 Aug. 2015. Web. 28 Oct. 2015.

"Chronic Obstructive Pulmonary Disease (COPD) Includes: Chronic Bronchitis and Emphysema." CDC. US Dept. of Health and Human Services, 29 Apr. 2015. Web. 28 Oct. 2015.

Halbert, R. J., et al. “Global Burden of COPD: Systematic Review and Meta-Analysis.” European Respiratory Journal 28.3 (2006): 523–532. Print.

Lopez, A.D., et al. “Chronic Obstructive Pulmonary Disease: Current Burden and Future Projections.” European Respiratory Journal 27.2 (2006): 397–412. Print.

Mayo Clinic Staff. “Bronchitis.” Mayo Clinic. Mayo Foundation for Medical Education and Research. 1 Apr. 2014. Web. 28 Oct. 2015.

Answer in reference to "A Dialogue on Personal Identity and Immortality." On the third night of their conversation, Weirob discloses that she would...

John Perry's work, "Dialogue on Personal Identity and Immortality," is a truly fascinating journey of human reasoning. As Weirob is faced with the choice before her, allowing her brain to be placed in a stranger's body, the debate is almost disturbingly reasonable and logical considering the enormity of the potential consequences.

Her argument in the negative is that were the operation to succeed the resulting survivor would not be her, but the one into whose body...

John Perry's work, "Dialogue on Personal Identity and Immortality," is a truly fascinating journey of human reasoning. As Weirob is faced with the choice before her, allowing her brain to be placed in a stranger's body, the debate is almost disturbingly reasonable and logical considering the enormity of the potential consequences.

Her argument in the negative is that were the operation to succeed the resulting survivor would not be her, but the one into whose body her brain had been placed. In her opinion, (as to the central point of the argument - "Identity"), the only basis for identity is the recognition of and comfort with "this unworthy material object" that we call a body, so that even if the survivor were to have her memories there would be no recognition nor comfort and the so called "memories" would be mere anticipation or delusion.

As to whether she proves her point or not is a matter of personal opinion. Both positions are presented extremely well and the side to which one leans will be determined by the amount of importance one places on the human brain and its place in what truly determines who we are.

Describe a possible scenario for the formation of a large elliptical galaxy.

Astronomers have two main ideas about how elliptical galaxies formed. I first need to explain a little bit of background in order for those two methods to make better sense.  

Space is relatively empty, but it does have matter spread all across it. The distribution of matter is not uniform, which means certain areas have a higher density of mass and consequently a higher gravitational force. The areas of higher gravity pulled in large...

Astronomers have two main ideas about how elliptical galaxies formed. I first need to explain a little bit of background in order for those two methods to make better sense.  

Space is relatively empty, but it does have matter spread all across it. The distribution of matter is not uniform, which means certain areas have a higher density of mass and consequently a higher gravitational force. The areas of higher gravity pulled in large clouds of dust and gas. Those are the beginnings of galaxies and nebulae. As the galaxy material collapsed, it either began spinning or didn't. Galaxies that began to spin eventually flattened out with long spiral arms. That flattening due to spinning is explained by angular momentum. Those galaxies are the spiral galaxies.  

One way to form an elliptical galaxy is to have the material for the galaxy present, but not have it spin or not have enough spin to flatten itself out. It would then be a round structured galaxy with no set axis of rotation.  

A second theory is that elliptical galaxies formed from the collisions of spiral galaxies. This theory works as long as an expanding universe is present. In the early universe, galaxies were much closer together; therefore, galaxy collisions happened. The spiral shape would have been destroyed, and what was left was an elliptical galaxy.  

How can the last paragraph in Chesnutt's The Marrow of Tradition be analyzed prophetically?

At the end of Chesnutt's The Marrow of Tradition, Olivia Carteret finally recognizes Janet Miller as her mulatto half-sister when she wants Janet's husband, Dr. William Miller, to treat her dying child. Though Janet Miller has longed for this moment, her supposed moment of victory is bittersweet:

"Janet's eyes slowly filled with tears--bitter tears--burning tears...This, then, was the recognition for which, all her life, she had longed in secret...It had come, not with frank...

At the end of Chesnutt's The Marrow of Tradition, Olivia Carteret finally recognizes Janet Miller as her mulatto half-sister when she wants Janet's husband, Dr. William Miller, to treat her dying child. Though Janet Miller has longed for this moment, her supposed moment of victory is bittersweet:

"Janet's eyes slowly filled with tears--bitter tears--burning tears...This, then, was the recognition for which, all her life, she had longed in secret...It had come, not with frank kindliness and sisterly love, but in a storm of blood and tears; not freely given, from an open heart, but extorted from a reluctant conscience by the agony of a mother's fears" (pages 327-328).

In other words, this is not the reunion that Janet Miller has long dreamed about. Janet's half sister, Olivia, does not welcome her with open arms and love but only out of fear because her child is sick. Janet refers to her sister's recognition as "tainted with fraud and crime and blood" (page 328) and rejects her sister's recognition, even as her husband, Dr. Miller, goes to help Olivia Carteret's child.

This section can be seen as prophetic because African-Americans had long sought equality and reconciliation with their white neighbors. However, this equality was long in coming and had to wait until long after this novel was published in 1901. During the Civil Rights movement of the 1950s and 1960s, whites in the south were forced, mainly through federal laws, to grant some forms of legal equality to African-Americans. At this point, however, many African-Americans were embittered by their long suffering and by the fact that whites granted them rights because they were forced to do so. In the very last line of the book, the other doctor tells Dr. Miller that the white child can be saved but that there's no time to spare. This section is also prophetic because in the end, the south (like the child) was reclaimed, though it had to go through much agony beforehand. 

What is crystal healing? |

Overview

Crystals fall into seven structural types, but individual examples range in the
thousands, each with its own alleged traditional uses in healing. For example,
agate is used for gastritis and skin diseases, chrysoprase is used in the
treatment of depression and alcoholism, and jade is used for improving kidney
function and emotional balance. These forms are subdivided into more descriptive
varieties. In some crystal directories, for instance, agate is divided into blue
lace, dendritic, fire, and moss, which may be used, respectively, for throat
infections, neuralgia, vision problems, and fungal infections.

The use of crystals to promote healing and well-being is attested in many ancient cultures, including Egyptian, Indian, and Native American. Traditional and mythological lore about crystals has continued from the Middle Ages to the present day.

One modern discovery added a scientific veneer to the notion that crystals emit
forces. In 1880, brothers Jacques and Pierre Curie found that crystals
subjected to mechanical pressure yielded a measurable electrical discharge. This
process is called the piezoelectric effect.

Mechanism of Action

The mechanism of action in crystals varies according to culture. In
Ayurvedic
medicine, crystals are said to interact with the energy
system of the body, the aura and seven chakras, which are the energy vortices
located at different points in the body.

Uses and Applications

Crystal healing is said to help alleviate physical, mental, emotional, and spiritual problems.

Scientific Evidence

Unsubstantiated scientific explanations often cite the piezoelectric effect as
evidence of the positive effects of crystal healing and construct models such as
lasers or capacitors (as in the use of quartz to amplify and focus a healer’s
bioenergy). The absence of a standard transcultural crystal directory that would
be recognized by theoreticians and practitioners of crystal healing renders
biomedical testing difficult. Remedies vary from directory to directory and depend
on cultural context, tradition, and mythology; remedies also depend on the
practitioner’s own usage or even the intuition of the person seeking help. The
notion that agate, because of its layered appearance, is useful in
treating organs with different layers of tissue is a type of magical thinking of
which the ancient Egyptian physicians would have approved. Also, biomedical
explanations would include a placebo effect. Crystal healing may be
better accepted by basing itself not on a Western biomechanical paradigm but on an
Eastern paradigm of vitalism or energetics.

Safety Issues

With some exceptions, there exists no obvious risk in wearing or carrying crystals, in temporarily applying a crystal to a person seeking care, in placing crystals around a person in a circular pattern, or in simply placing crystals in view for contemplation. Certain imported gemstones (such as blue topaz, which is sometimes used to treat digestive problems or to stimulate the metabolism) are irradiated to enhance or intensify color. In this case, the blue topaz’s radioactivity could be harmful if exposure were repeated or prolonged.

Bibliography

Gerber, Richard. Vibrational Medicine: The Number One Handbook of Subtle-Energy Therapies. 3d ed. Rochester, Vt.: Bear, 2001.

Gienger, Michael. Crystal Power, Crystal Healing: The Complete Handbook. Translated by Astrid Mick. London: Cassell, 2009.

Jerome, Lawrence E. Crystal Power: The Ultimate Placebo Effect. Buffalo, N.Y.: Prometheus Books, 1989.

What are never events? |

Never events are serious errors, oversights, and crimes that occasionally take place in the health care industry and can cause serious injury or death to patients. As the term suggests, these events should never be allowed to occur. As of 2011, seven main categories of never events existed that were broken down into a total of twenty-nine specific events. While rare, never events are the subject of serious investigation and calls for improvement.

Definition of Never Events

Ken Kizer, a physician and former chief executive officer of National Quality Forum (NQF), coined the term never event in 2001. In its first usages, the term referred to serious medical errors that should never be allowed to happen. The NQF, an organization that supports patient rights and protections, conducted studies of such medical errors and reported its findings in the hopes of drawing attention to never events and creating new safeguards against them.

By 2002, the NQF compiled a list of never events. The concept began spreading and gained greater acceptance by the medical community and public. Over time, the concept expanded to include a wider range of harmful events experienced by patients. These events had to fit three criteria; they had to be serious enough to result in a patient's death or disability, clear enough to identify and measure, and potentially avoidable.

Categories and Events

The NQF modified its list of never events in 2011 to include twenty-nine specific events divided into seven main categories. These events cover a wide range of patient experiences and medical personnel actions before, during, and after medical procedures. The categories include surgical events, product or device events, radiologic events, environmental events, patient protection events, care management events, and criminal events.

One of the main categories of never events involves surgical procedures. Surgery is a delicate and complicated task. If performed improperly, it can lead to an array of hazards for patients. Some of these hazardous events include surgeries performed on the wrong patient, surgeries performed on the wrong body part, or incorrect surgical procedures performed. Another risk involving surgeries includes retained objects, or surgical tools such as towels or sponges being accidentally left inside a patient's body. According to a 2007/2008 medical report on never events in Minnesota, 12 percent of reported events involved retained objects, 7 percent involved wrong-site surgeries, and 5 percent involved the wrong procedures being performed.

Medical products and devices also contribute to never events. Risks include medical machines and tools being used incorrectly or for purposes other than those intended. This category also extends to hazards from medication and other drugs, which can become contaminated and pose risks or harmful side effects. Harm that occurs during a procedure that uses MRI (magnetic resonance imaging) technology is categorized as a radiologic event.

Patient harm that occurs due to the physical surroundings of a health care establishment falls under the category of environmental never events. During care, patients may receive burns or electric shocks that can cause death or serious injury. In addition, lines carrying oxygen or other gases may be contaminated or used incorrectly and result in various hazards. Sometimes, even seemingly innocuous environmental features such as bedrails employed improperly could contribute to never events.

Health care providers have a responsibility to provide reasonable protection to their patients. Failing to do so may lead to never events in the patient protection category. These events may occur if patients are released from care when they are unable to make decisions or if patients disappear from a health care facility. The most serious breach of patient protection involves a patient attempting or committing suicide within a health care facility.

The care management category is also related to patient protection but involves a wider range of cases. These cases may involve errors in medications and prescriptions, failure to communicate test results, or loss or misuse of specimens. According to the Minnesota study, the most common care management event (at 39 percent of all reported cases) involved pressure ulcers or
bedsores
, serious skin injuries that often occur among bedridden people who are neglected by caretakers. Patients sustaining injury or death during falls accounts for 30 percent of cases. These also are part of the care management category. Serious medication errors comprised 2 percent of reported cases.

The final category of never events involves criminal acts perpetrated against patients in health care facilities. These cases may range from sexual abuse to physical assault against patients, as well as abduction of patients. In addition, any actions taken by people falsely impersonating health care personnel such as doctors or nurses fall into the category of criminal events.

Responses and Rarity

Generally, when never events occur, authorities perform a root cause analysis, an in-depth examination of the event and factors that contributed to it. Based on these findings, offenders usually are expected to disclose their errors and officially report them to medical authorities. Offenders typically apologize to patients and their loved ones and waive any costs related to the medical procedure in question. In many events—particularly criminal ones—legal action also becomes an important factor.

Never events can be severe and tragic. Some individuals and organizations have called for stringent standards to eradicate all never events from medical procedures. Despite these strong reactions to never events, medical experts point out that such events are not common. While about four thousand surgical never events take place annually in the United States, that figure should be measured against the millions of procedures medical practitioners perform correctly.

Bibliography

"Johns Hopkins Malpractice Study: Surgical 'Never Events' Occur at Least 4,000 Times Per Year." Johns Hopkins Medicine. Johns Hopkins University, Johns Hopkins Hospital, and Johns Hopkins Health System. 19 Dec. 2012. Web. 4 Feb. 2015. http://www.hopkinsmedicine.org/news/media/releases/johns_hopkins_malpractice_study_surgical_never_events_occur_at_least_4000_times_per_year

Lembitz, Alan, and Ted J. Clarke. "Clarifying 'Never Events' and Introducing 'Always Events.'" Patient Safety in Surgery. National Center for Biotechnology Information, U.S. National Library of Medicine. 2009. Web. 4 Feb. 2015. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2814808/

"Never Events." AHRQ Patient Safety Network. U.S. Department of Health & Human Services. Dec. 2014. Web. 4 Feb. 2015. http://psnet.ahrq.gov/primer.aspx?primerID=3

"Sentinel Event." Joint Commission. Joint Commission. Web. 4 Feb. 2015. http://www.jointcommission.org/sentinel_event.aspx

What is the relationship between eyewitness testimony and memory?

Introduction

Knowledge of how the memory process operates has been applied to the analysis of eyewitness testimony to assess the likelihood that a witness is correct in making an identification. The task of eyewitness identification depends on the three stages of the memory process: encoding, storage, and retrieval. The last stage, retrieval, can be divided into two parts: recall and recognition. Each of these stages is subject to the influence of several factors that may contribute to error in the process.

Encoding is the stage of acquiring information. In the case of eyewitness identification, it is the sighting of a person during an event. The circumstances of the event will affect the ability of a person to encode information, including the facial appearance of another person. A short period of viewing time, poor lighting, greater distance, and an obtuse angle of view will reduce the observer’s ability to acquire information about appearance. Any distractions present will reduce the attention paid to the face of the person and reduce the facial information encoded. If there are other people present, they serve as distractions. If a weapon is present, it attracts the attention of the observer and reduces the attention to faces. This phenomenon is called the weapons effect. If the weapon is used in a threatening manner, it will be likely to attract even more attention and further reduce the encoding of facial detail. Highly salient features of the face may dominate the encoding of the face. For example, a prominent scar may attract attention and reduce the attention to other facial details. When this happens, the witness may easily mistake another person with a similar scar for the original person, even though other features are different. Only information that is encoded can be retained and retrieved later, so the encoding stage sets the limits for later identification.

Once information is encoded, it must be stored until it is retrieved for use. One is not constantly aware of the information one has; such information is held in storage until one retrieves it. The brain holds information by some electrochemical process. It is not known exactly how it works, but it is clear that the storage stage of memory is not passive and inert like a videotape. Memories can change while they are stored. The memory may change in two ways: it may fade, or it may be distorted. Information fades away over time. This effect of time on memory is one of the oldest findings in the field of psychology, documented by Hermann Ebbinghaus in 1885. His findings indicate that memory fades rapidly at first and continues to fade over time at a reducing rate. This fading could be evidenced by loss of details or a less accurate recall of details. Sometimes witnesses may still believe that they recall a face, but the memory has really changed so that their identification is inaccurate.

The other major factor affecting memory during the storage period is interference. Events that occur during the storage period may change the memory without the awareness of the witness. A witness may be exposed to information after an event and, without knowing it, incorporate that information into the memory of the event. One example of this type of effect is called unconscious transference. This occurs when a person seen in one setting is remembered as having been in another. Sometimes a witness will mistakenly identify someone seen in another setting as the one who committed a crime. The witness has, without knowing it, transferred the memory of the face of the innocent person into the crime memory.

The third stage of memory is retrieval. Witnesses may be asked to retrieve information by either recall or recognition. Giving a description of a person is an example of free recall. There are no external stimuli from which to select; witnesses simply retrieve whatever information they can. In the case of recognition, the witness is asked to identify someone from a photograph, in person, or from a group of photographs (a photo lineup) or a group of people (a live lineup). Sometimes lineups are videotaped. Recall may be distorted by suggestive questions or nonverbal cues. Elizabeth F. Loftus reported in her 1979 book Eyewitness Testimony that when people were asked, “How tall was the basketball player?” their descriptions averaged seventy-nine inches. When they were asked, “How short was the basketball player?” they estimated sixty-nine inches. This ten-inch difference was caused simply by the change in the wording of the question.

The accuracy of a witness’s recognition in lineup situations can be greatly affected by the nature of the lineup. If a witness is asked to identify a person from a single photograph or a one-person lineup, there is a possibility of error attributable to the witness’s expectation that this must be the person or the police would not produce the person. In multiple-choice lineups, the similarity of the alternative choices to the suspect is the major determinant of error. If only one or two people in the lineup are similar to the original description of a suspect, a witness really has few choices, and the result is similar to the single-choice lineup. Witnesses may sometimes select a person in a lineup who is similar to the one seen or who looks familiar for some other reason.

Eyewitnesses and the Justice System

In some cases, the only evidence against a person accused of a crime is an identification by an eyewitness. In their 1973 book Wrongful Imprisonment: Mistaken Convictions and Their Consequences, Ruth Brandon and Christie Davies describe seventy cases in which an incorrect identification by an eyewitness led to a conviction. In 1973, after conducting his own study of the subject, New York surrogate court judge Nathan Sobel concluded that incorrect eyewitness identification led to more miscarriages of justice than all other factors combined. Because of the serious consequences of an incorrect identification and the possibility that misidentifications frequently occur, psychologists have applied their expertise in memory to the study of the factors that would affect the accuracy of eyewitness identification.

Loftus has reported a case of eyewitness testimony that illustrates one of the most important applications of the field, a criminal trial. The background to the trial began on October 12, 1977, at approximately 8:30 in the evening. Two men entered a liquor store in Watsonville, California. The first man stood directly across from a young male clerk and pointed a gun at him, demanding all the money. The second man stood four or five feet away, pointing a gun at an older clerk, who stood behind the first clerk. The first robber demanded the money from the cash register and the clerks’ wallets. As the young clerk turned to replace his wallet, he heard a shot and dove to the floor. When he looked up, the first robber was almost out the door, and the second robber stood in the doorway smiling; the older clerk lay dead on the floor. As soon as the robbers left, the young clerk hit the alarm. A security guard responded immediately, and the clerk, in a state of shock, could only say, “Two men, one with a mustache, two men, one with a mustache.”

The clerk was interviewed by police the next day, and he described one robber as a male Mexican, thirty-two to thirty-seven years old, about five feet, ten inches tall, 175 to 180 pounds, with black collar-length, unkempt hair. A composite drawing was made. During the next week, the clerk viewed two live lineups and a large set of black-and-white photographs. Two of the photographs were of a man named José Garcia. The clerk said that one of them looked similar to the robber. About a week later, the clerk viewed the set of photographs again and again said one of them was similar to the robber. Another week went by, and the clerk was shown a different set of color photographs. He picked out Garcia as “the guy; I wouldn’t forget the face.” Three days later, the clerk picked a man from a live lineup whose voice sounded like the robber. This man was an innocent police officer, so the clerk went back to the color photographs and said that Garcia was definitely the murderer.

Garcia was arrested and charged with murder and robbery. He was thirty-nine years old; he was five feet, ten inches tall, and he weighed 242 pounds. He spoke with a heavy Spanish accent and had tattoos lining both arms; his left hand was deformed from a sawblade accident.

Loftus was hired by the defense to testify about the factors that might cause the eyewitness to be inaccurate. After she was sworn in, her qualifications as an expert in eyewitness memory were presented to the court. The prosecution argued that the data from experiments only allowed general conclusions and not conclusions about the eyewitness in this case, and that experiments were not performed on real-life crimes. The judge ruled that the testimony would be heard by the jury. Through a long series of questions, the defense attorney attempted to bring before the jury the factors from the psychological research that are known to affect the ability of an eyewitness to make a correct identification. Some of the factors Loftus mentioned were the storage interval (there were several weeks between the crime and an identification), the high stress level of the witness during encoding, the possibility that the weapon used in the crime may have created a weapons focus, and the possibility that the viewing of pictures of the suspect several times before making an identification could have allowed for unconscious transference to occur.

The jury, after hearing Loftus’s expert testimony, was unable to reach a verdict. The defendant was tried again a few weeks later; the process was repeated, and again the jury could not reach a verdict, so the defendant was set free. Interviews with the jury indicated that they valued the expert testimony of Loftus in their deliberations; nine were for acquittal and three were for conviction.

The Science of Testimony

In 1900, French psychologist Alfred Binet (later famous for the development of intelligence testing) argued for the creation of a practical science of testimony. German psychologist William Stern was publishing studies of eyewitness testimony as early as 1902. In 1903, Stern testified in German courts of law as an expert on eyewitness testimony. Beginning in 1909, American psychologist Guy Montrose Whipple began a four-year series of articles in Psychological Bulletin in which he translated and interpreted European work on the subject as well as presenting his own.

Although it appeared that the field was ready to develop rapidly, it did not. Probably because most psychologists of the time focused more on theoretical issues than on applied problems and because the early psychologists working on eyewitness testimony were criticized for overgeneralization, the explosion of research on eyewitness testimony did not occur until the 1970s. Ulric Neisser, in his book Cognition and Reality: Principles and Implications of Cognitive Psychology (1976) and later in Memory Observed: Remembering in Natural Contexts (1982), presented the view that the advances in understanding human memory and social perception called for a new emphasis on observations made in a natural context. The majority of the research on memory applied to eyewitness testimony has been carried out since then.

Modern research has developed a large database on variables that affect the accuracy of an eyewitness, as well as on such issues as the best way to interrogate a witness, how to construct fair lineups, and how to help witnesses remember more accurately. A major topic of the 1980s and 1990s was the usefulness and appropriateness of the testimony of psychological experts in court proceedings. Some judges do not allow psychologists to testify about eyewitness reliability; however, other judges do allow such testimony. Psychologists disagree on whether this testimony serves a good purpose. It is clear that if testimony is given, the psychologist cannot say whether a given witness is correct or not. The psychologist may provide the jury members with information that can help them to evaluate the eyewitness testimony better. There may be scientific data about the circumstances of the case being tried that jurors do not know. Telling the jurors about the data can give them a better basis for evaluating the credibility of a witness. This can lead to improvement of the judicial process by more often convicting the guilty as well as saving the innocent.

Bibliography

Ainsworth, Peter B. Psychology, Law, and Eyewitness Testimony. New York: Wiley, 1999. Print.

Greene, Robert L. Human Memory: Paradigms and Paradoxes. New York: Psychology, 2014. Print.

Lindsay, R. C. L., et al., eds. The Handbook of Eyewitness Psychology. New York: Psychology, 2012. Digital file.

Loftus, Elizabeth F. Eyewitness Testimony. Rpt. 4th ed. Newark: LexisNexis, 2007. Print.

McCloskey, Michael, Howard Egeth, and Judith McKenna. “The Experimental Psychologist in Court: The Ethics of Expert Testimony.” Law and Human Behavior 10.1–2 (1986): 1–13. Print.

Thompson, Charles P., et al. Eyewitness Memory: Theoretical and Applied Perspectives. New York: Psychology, 2014. Digital file.

Wells, Gary L., and Elizabeth F. Loftus, eds. Eyewitness Testimony: Psychological Perspectives. New York: Cambridge UP, 1987. Print.

Wrightsman, Lawrence S. “Crime Investigation: Eyewitnesses.” Psychology and the Legal System. 6th ed. Belmont: Wadsworth, 2007. Print.

Yarmey, A. Daniel. The Psychology of Eyewitness Testimony. New York: Free, 1979. Print.

Point of view affects characterization. From whose point of view is this story told? When furiously and furious both turn up in the first...

This story is told in third-person omniscient narration from Farrington's point of view. This narrator has access to all of Farrington's thoughts, and he focuses the story closely on the main character, following him from the office to the bar, back to the office, back to the bars, and finally to his home.

You could say that this unremittingly focused point of view is the main tool with which Joyce characterizes Farrington; the narration allows...

This story is told in third-person omniscient narration from Farrington's point of view. This narrator has access to all of Farrington's thoughts, and he focuses the story closely on the main character, following him from the office to the bar, back to the office, back to the bars, and finally to his home.

You could say that this unremittingly focused point of view is the main tool with which Joyce characterizes Farrington; the narration allows us to see how Farrington thinks, acts, and speaks throughout the unbroken description of his afternoon and evening.

At the same time, the third-person narration slightly distances us from Farrington, allowing the more erudite voice of the narrator to provide insight into Farrington: consider, for example, how Farrington looks at his boss's egg-like head, "gauging its fragility" and not "thinking about how he could maybe smash it."

When furiously and furious both turn up in the first paragraph, this is, of course, the author's contribution: Joyce carefully selected these words to set the tone for the story.

But more importantly, the character, Farrington, contributes the idea of fury: yes, objectively, there's a bell ringing, and yes, there literally is a voice shouting out a demand, but the story is focused on Farrington, who projects his own anger and fury onto everyone and everything around him. So to him, the bell sounds furious, and to him, the boss's demand sounds furious.

The question of whether this choice of words ("furiously" and "furious") belongs more to the author, to the narrator, or to the main character is a very fine point. It belongs to all of them, but it's Farrington himself who embodies fury.

This question also reveals the skillful way in which Joyce's third-person narration blurs its own lines, seeming to offer descriptions heavily influenced by the main character himself.