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J. Lee, M.B. B.A.O., M.B.B.Ch., Ph.D.

Deputy Director, Central Michigan University College of Medicine

Examples of environmental 'trig gers" include recently learning of a potentially fatal medical diagnosis such as cancer, experiencing the sudden and unexpected loss of a close relative or partner, loss of employ ment, or displacement from housing. Conversely, features such as talking to others about future events or preparedness to sign a contract for safety are less reliable indicators. In order for the criteria to be met, the individual must have made at least one suicide at tempt. Suicide attempts can include behaviors in which, after initiating the suicide attempt, the individual changed his or her mind or someone intervened. For example, an individual might intend to ingest a given amount of medication or poison, but either stop or be stopped by another before ingesting the full amount. If the individual is dissuaded by another or changes his or her mind before initiating the behavior, the diagnosis should not be made. The act must not meet criteria for nonsuicidal self-injury-that is, it should not involve re peated (at least five times within the past 12 months) self-injurious episodes undertaken to induce relief from a negative feeling/cognitive state or to achieve a positive mood state. If the individual deliberately became intoxicated before initiating the behavior, to reduce anticipatory anxi ety and to minimize interference with the intended behavior, the diagnosis should be made. Development and Course Suicidal behavior can occur at any time in the lifespan but is rarely seen in children under the age of 5. Approximately 25%-30% of persons who attempt suicide will go on to make more attempts. There is sig nificant variability in terms of frequency, method, and lethality of attempts. However, this is not different from what is observed in other illnesses, such as major depressive disorder, in which frequency of episode, subtype of episode, and impairment for a given episode can vary significantly. Culture-Related Diagnostic issues Suicidal behavior varies in frequency and form across cultures. Suicidal behavior that leads to blood loss can be accompanied by anemia, hypotension, or shock. Overdoses might lead to coma or obtundation and associated laboratory abnormalities such as electrolyte imbalances. It is rarely manifested by individuals with no discernible pathology, unless it is undertaken be cause of a painful medical condition with the intention of drawing attention to martyrdom for political or religious reasons, or in partners in a suicide pact, both of which are excluded from this diagnosis, or when third-party informants wish to conceal the nature of the behavior. In the last year, the individual has, on 5 or more days, engaged in intentional self-inflicted damage to the surface of his or her body of a sort likely to induce bleeding, bruising, or pain. The individual engages in the self-injurious behavior with one or more of the following expectations: 1. Note: the desired relief or response is experienced during or shortly after the self injury, and the individual may display patterns of behavior suggesting a dependence on repeatedly engaging in it. Interpersonal difficulties or negative feelings or thoughts, such as depression, anx iety, tension, anger, generalized distress, or self-criticism, occurring in the period immediately prior to the self-injurious act. Prior to engaging in the act, a period of preoccupation with the intended behavior that is difficult to control. Thinking about self-injury that occurs frequently, even when it is not acted upon. The behavior or its consequences cause clinically significant distress or interference in interpersonal, academic, or other important areas of functioning. The behavior does not occur exclusively during psychotic episodes, delirium, sub stance intoxication, or substance withdrawal. In individuals with a neurodevelopmental disorder, the behavior is not part of a pattern of repetitive stereotypies. The behavior is not better explained by another mental disorder or medical condition. Diagnostic Features the essential feature of nonsuicidal self-injury is that the individual repeatedly inflicts shallow, yet painful injuries to the surface of his or her body. Most commonly, the purpose is to reduce negative emotions, such as tension, anxiety, and self-reproach, and/or to re solve an interpersonal difficulty. The individual will often report an immediate sensation of relief that oc curs during the process. When the behavior occurs frequently, it might be associated with a sense of urgency and craving, the resultant behavioral pattern resembling an addiction.

Check levels if Indicated 7 Surgery to remove the tumor may also stop or help control your seizures. Using sophisticated brain mapping techniques, a neurosurgeon may be able to define the exact area of the brain causing the seizures and surgically remove it. Ketogenic Diet Some medications require frequent blood tests in order to check the drug levels in the body. Minimize Possible Drug Interactions the ketogenic diet is a high fat, low carbohydrate diet that may help control ongoing seizures that do not respond to seizure medications. A doctor should carefully prescribe the balance and components of your daily food intake and the diet must be carefully followed on a daily basis. Blood tests and close monitoring are used to watch for side effects and to verify effectiveness of the diet. The ketogenic diet is primarily used to treat children for whom seizure medications are not effective. Inform your doctor of all medications you are taking including vitamins, nutritional supplements and herbal remedies. Risks and Guidelines Your doctor or nurse will tell you how long the antiepileptic medications will be needed. The decision to taper off antiepileptic medication should be carefully planned by the doctor and patient, with all appropriate precautions taken. If itching accompanies the rash, a cool shower may provide relief by constricting the blood vessels in the outer layer of your skin. Do not take additional doses of the medication that may be causing the rash until you have spoken with your doctor. The following information may help you manage some common side effects of seizure medications. Drowsiness or Dizziness Long-term use of seizure medications may cause bone disorders. The amount of calcium in the bone may decrease causing brittle bones and fractures. Decreased levels of vitamin D and phosphorus may also contribute to this side effect. Bone and blood tests can monitor these conditions and supplementation may be recommended. Nausea and Vomiting For your own protection, do not operate equipment or machinery and do not drink alcoholic beverages. Good oral hygiene, with regular brushing and flossing, is key in managing this side effect that is influenced by bacteria levels in the mouth. If your gums are swollen, try using a soft tooth brush or a mouth care sponge (available at most drug stores). If stomach upset continues, ask your doctor about anti-nausea (antiemetic) medication. Do not use over-the-counter antacids or aspirin-containing preparations for upset stomachs without first checking with your doctor since they may interfere with some seizure medications. A rash can indicate an allergic reaction to the seizure medication or may be due to an increased drug Some seizures simply do not respond to a given medication and you may have to try another medication. Flu vaccines, prescription and nonprescription drugs can increase seizure activity. If you suspect that you are experiencing this problem, make a list of all your medications and share it with your doctor or pharmacist. Be sure to let your doctor know the frequency and type of your seizures and if the side effects of a particular drug interfere with your quality of life. Discuss this with your doctor and ask about other options for controlling your seizures. Notify Your Doctor Immediately If You: Have any difficulty breathing Run a temperature Notice the whites of your eyes appear yellow Have tiny purple spots on your skin Develop a rash Become unusually confused Have difficulty urinating Bruise easily Chest pain or inability to awaken someone taking seizure medications is always a medical emergency. Stress Questions for Your Doctor or Nurse about Seizure Medications What is the name of the seizure medication you have prescribed

The man from Hollywood said that if he wanted something-a new pair of running shoes, say, or a bicycle-his father would tell him he had to pay half. I think, looking back, my father wanted me to work there because he knew that if I worked there, I would want to escape. He went to see basketball games with his friend and sat in terrible seats-obstructed by a pillar-and wondered what it would be like to sit in the premium seats courtside. He went to business school and law school in New York, and lived in a bad neighborhood in Brooklyn to save money. After graduation, he got a job in Hollywood, which led to a bigger job, and then to an even bigger job, and side deals and prizes and a string of extraordinary successes-to the point where he now has a house in Beverly Hills the size of an airplane hangar, his own jet, a Ferrari in the garage, and a gate in front of his seemingly never-ending driveway that looks like it was shipped over from some medieval castle in Europe. And he understood money because he felt he had been given a thorough education in its value and function back home on the streets of Minneapolis. Money was a tool that I could use for my aspiration and my desires and my drive," he said. He was successful because he had learned the long and hard way about the value of money and the meaning of work and the joy and fulfillment that come from making your own way in the world. But because of his success, it would be difficult for his children to learn those same lessons. Children of multimillionaires in Hollywood do not rake the leaves of their neighbors in Beverly Hills. Their fathers do not wave the electricity bill angrily at them if they leave the lights on. They do not sit in a basketball arena behind a pillar and wonder what it would be like to sit courtside. Another of his brothers had become a doctor and built a thriving medical practice. His father had produced three sons who were fulfilled and motivated and who had accomplished something for themselves in the world. And his point was that it was going to be harder for him, as a man with hundreds of millions of dollars, to be as successful in raising his children as his father had been back in a mixed neighborhood of Minneapolis. There is an important principle that guides our thinking about the relationship between parenting and money-and that principle is that more is not always better. If you are a working single parent, trying to pay your rent and feed and clothe your family and manage a long and difficult commute to a physically demanding job, it is hard to provide your children with the kind of consistent love and attention and discipline that makes for a healthy home. But no one would ever say that it is always true that the more money you have, the better parent you can be. The scholars who research happiness suggest that more money stops making people happier at a family income of around seventy-five thousand dollars a year. If your family makes seventy-five thousand and your neighbor makes a hundred thousand, that extra twenty-five thousand a year means that your neighbor can drive a nicer car and go out to eat slightly more often. Because when the income of parents gets high enough, then parenting starts to be harder again. For most of us, the values of the world we grew up in are not that different from the world we create for our children. The psychologist James Grubman uses the wonderful expression "immigrants to wealth" to describe first-generation millionaires-by which he means that they face the same kinds of challenges in relating to their children that immigrants to any new country face. Someone like the Hollywood mogul grew up in the Old Country of the middle class, where scarcity was a great motivator and teacher. His father taught him the meaning of money and the virtues of independence and hard work. But his children live in the New World of riches, where the rules are different and baffling. How do you teach "work hard, be independent, learn the meaning of money" to children who look around themselves and realize that they never have to work hard, be independent, or learn the meaning of money He was well past the point where money made things better, and well past the point where money stopped mattering all that much. He was at the point where money starts to make the job of raising normal and well-adjusted children more difficult. They almost never fail to take us by surprise, and one of the reasons we are so often confused about advantages and disadvantages is that we forget when we are operating in a U-shaped world. In her five-year tenure at the school, she has watched the incoming class dwindle year by year.

Syndromes

• MRI of the chest
• Serum immunoglobulin levels (IgE, IgA)
• Dark, rust-colored, or brown urine
• Surgery -- this is usually temporary, but avoid long-term use of sedatives and painkillers
• Fluids given through a vein (IV)
• Blood calcium level
• Polysulfides
• 1 - 3 years: 20 mcg/day

However, since primary brain tumors rarely spread outside the brain and spinal cord, they do not exactly fit the general definition of cancer. For example, cancers of the lung, breast, colon and skin (melanoma) frequently spread to the brain via the bloodstream or a magnetic-like attraction to other organs of the body. All metastatic brain tumors are, by definition, malignant and can truly be called "brain cancer. The tumors grow slowly and have an almost normal appearance when viewed through a microscope. They lack distinct borders due to their tendency to send "roots" into nearby normal tissue. They reproduce rapidly, can have a bizarre appearance when viewed under the microscope and easily grow into surrounding normal brain tissue. The highest or most malignant grade of cell determines the grade, even if most of the tumor is a lower grade. Some tumors undergo change and a benign growth might become malignant or, as previously mentioned, a lower-grade tumor might recur as a higher-grade tumor. Please ask a member of your healthcare team to complete the form on the next page. Use it to learn the exact spelling of your tumor type and its location, your medications, and resources for additional information. The brain is a soft mass of supportive tissues and nerve cells connected to the spinal cord. Learning about the normal workings of the brain and spine will help you understand the symptoms of brain tumors, how they are diagnosed and how they are treated. Note: For a complete glossary of brain tumor terminology, see Chapter 12 "Brain Tumor Terminology" on page 79. Please remember that your tumor is unique and might not conform to the "average" characteristics described. These tumors are "graded" by the pathologist to indicate how normal or how abnormal, the cells of the tumor look under the microscope. Grade I tumors include pilocytic astrocytomas, which are usually localized (limited in growth) tumors, that are often cured through surgical removal. In this section we describe only the more common of these tumors, pilocytic astrocytoma and anaplastic astrocytoma. Some pilocytic tumors, such as most optic gliomas, cannot be safely removed because of their location and initial treatment may involve observation only. The term "anaplastic" (or "malignant") pilocytic astrocytoma is used only when the tumor has developed an extensive blood supply around the tumor or the tumor contains dead cells (necrosis). These rare tumors require more aggressive treatment than a benign pilocytic astrocytoma. They are generally diagnosed in children and young adults under the age of 20 and are rarely seen in older adults. The most common locations include the optic nerve (an "optic glioma"), the optic chiasm near the hypothalamus, thalamus, basal ganglia, cerebral hemispheres and the cerebellum. Pilocytic astrocytomas are generally considered benign tumors and are often cured by surgery alone. Astrocytomas often contain a mix of cells and cell grades, but brain tumors are graded by the highest grade (most abnormal) cell seen in the tumor. These tumors tend to have tentacle-like projections that grow into surrounding tissue, making them difficult to completely remove during surgery. This grade of tumor tends to occur in males more often than females and most frequently in people ages 45 and older. Generally, the first step in the treatment of an anaplastic astrocytoma is surgery. The goals of surgery are to obtain tumor tissue for diagnosis and treatment planning, to remove as much tumor as possible and to reduce the symptoms caused by the presence of the tumor.