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As described above buy kamagra gold with amex, a global improvement in seizure severity was also assessed in the Lennox-Gastaut trial cheap kamagra gold 100 mg. Table 2: Efficacy Results in Double-Blind discount kamagra gold 100 mg line, Placebo-Controlled, Add-On TrialsProtocol Efficacy ResultsPartial Onset Seizures Studies in AdultsPrimary Generalized Tonic-ClonicLennox-Gastaut SyndromeImprvmnt. The results of 2 multicenter, randomized, double-blind, placebo-controlled, parallel-group clinical trials established the effectiveness of TOPAMAX^ in the prophylactic treatment of migraine headache. The design of both trials (one study was conducted in the U. Patients with a history of cluster headaches or basilar, ophthalmoplegic, hemiplegic, or transformed migraine headaches were excluded from the trials. Patients were required to have completed up to a 2 week washout of any prior migraine preventive medications before starting the baseline phase. Patients who experienced 3 to 12 migraine headaches over the 4-weeks in the baseline phase were equally randomized to either TOPAMAX^ 50 mg/day, 100 mg/day, 200 mg/day, or placebo and treated for a total of 26 weeks (8-week titration period and 18-week maintenance period). Treatment was initiated at 25 mg/day for one week, and then the daily dosage was increased by 25-mg increments each week until reaching the assigned target dose or maximum tolerated dose (administered twice daily). Effectiveness of treatment was assessed by the reduction in migraine headache frequency, as measured by the change in 4-week migraine rate from the baseline phase to double-blind treatment period in each TOPAMAX^ treatment group compared to placebo in the intent to treat (ITT) population. In the first study a total of 469 patients (416 females, 53 males), ranging in age from 13 to 70 years, were randomized and provided efficacy data. Two hundred sixty five patients completed the entire 26-week double-blind phase. The mean migraine headache frequency rate at baseline was approximately 5. The change in the mean 4-week migraine headache frequency from baseline to the double-blind phase was -1. The differences between the TOPAMAX^ 100 and 200 mg/day groups versus placebo were statistically significant (p<0. In the second study a total of 468 patients (406 females, 62 males), ranging in age from 12 to 65 years, were randomized and provided efficacy data. Two hundred fifty five patients completed the entire 26-week double-blind phase. The mean migraine headache frequency rate at baseline was approximately 5. The change in the mean 4-week migraine headache period frequency from baseline to the double-blind phase was -1. The differences between the TOPAMAX^ 100 and 200 mg/day groups versus placebo were statistically significant (p=0. In both studies, there were no apparent differences in treatment effect within age, or gender, subgroups. Because most patients were Caucasian, there were insufficient numbers of patients from different races to make a meaningful comparison of race. TOPAMAX^ (topiramate) Tablets and TOPAMAX^ (topiramate capsules) Sprinkle Capsules are indicated as initial monotherapy in patients 10 years of age and older with partial onset or primary generalized tonic-clonic seizures. Effectiveness was demonstrated in a controlled trial in patients with epilepsy who had no more than 2 seizures in the 3 months prior to enrollment. Safety and effectiveness in patients who were converted to monotherapy from a previous regimen of other anticonvulsant drugs have not been established in controlled trials. TOPAMAX^ (topiramate) Tablets and TOPAMAX^ (topiramate capsules) Sprinkle Capsules are indicated as adjunctive therapy for adults and pediatric patients ages 2 - 16 years with partial onset seizures, or primary generalized tonic-clonic seizures, and in patients 2 years of age and older with seizures associated with Lennox-Gastaut syndrome. TOPAMAX^ (topiramate) Tablets and TOPAMAX^ (topiramate capsules) Sprinkle Capsules are indicated for adults for the prophylaxis of migraine headache. The usefulness of TOPAMAX^ in the acute treatment of migraine headache has not been studied. TOPAMAX^ is contraindicated in patients with a history of hypersensitivity to any component of this product. Hyperchloremic, non-anion gap, metabolic acidosis (i. This metabolic acidosis is caused by renal bicarbonate loss due to the inhibitory effect of topiramate on carbonic anhydrase. Such electrolyte imbalance has been observed with the use of topiramate in placebo-controlled clinical trials and in the post-marketing period. Generally, topiramate-induced metabolic acidosis occurs early in treatment although cases can occur at any time during treatment. Bicarbonate decrements are usually mild-moderate (average decrease of 4 mEq/L at daily doses of 400 mg in adults and at approximately 6 mg/kg/day in pediatric patients); rarely, patients can experience severe decrements to values below 10 mEq/L. Conditions or therapies that predispose to acidosis (such as renal disease, severe respiratory disorders, status epilepticus, diarrhea, surgery, ketogenic diet, or drugs) may be additive to the bicarbonate lowering effects of topiramate. In adults, the incidence of persistent treatment-emergent decreases in serum bicarbonate (levels of <20 mEq/L at two consecutive visits or at the final visit) in controlled clinical trials for adjunctive treatment of epilepsy was 32% for 400 mg/day, and 1% for placebo. Metabolic acidosis has been observed at doses as low as 50 mg/day. The incidence of persistent treatment-emergent decreases in serum bicarbonate in adults in the epilepsy controlled clinical trial for monotherapy was 15% for 50 mg/day and 25% for 400 mg/day. The incidence of a markedly abnormally low serum bicarbonate (i. Serum bicarbonate levels have not been systematically evaluated at daily doses greater than 400 mg/day. In pediatric patients (<16 years of age), the incidence of persistent treatment-emergent decreases in serum bicarbonate in placebo-controlled trials for adjunctive treatment of Lennox-Gastaut syndrome or refractory partial onset seizures was 67% for TOPAMAX (at approximately 6 mg/kg/day), and 10% for placebo. The incidence of a markedly abnormally low serum bicarbonate (i. Cases of moderately severe metabolic acidosis have been reported in patients as young as 5 months old, especially at daily doses above 5 mg/kg/day. In pediatric patients (10 years up to 16 years of age), the incidence of persistent treatment-emergent decreases in serum bicarbonate in the epilepsy controlled clinical trial for monotherapy was 7% for 50 mg/day and 20% for 400 mg/day. The incidence of a markedly abnormally low serum bicarbonate (i. The incidence of persistent treatment-emergent decreases in serum bicarbonate in placebo-controlled trials for adults for prophylaxis of migraine was 44% for 200 mg/day, 39% for 100 mg/day, 23% for 50 mg/day, and 7% for placebo. The incidence of a markedly abnormally low serum bicarbonate (i. Some manifestations of acute or chronic metabolic acidosis may include hyperventilation, nonspecific symptoms such as fatigue and anorexia, or more severe sequelae including cardiac arrhythmias or stupor. Chronic, untreated metabolic acidosis may increase the risk for nephrolithiasis or nephrocalcinosis, and may also result in osteomalacia (referred to as rickets in pediatric patients) and/or osteoporosis with an increased risk for fractures. Chronic metabolic acidosis in pediatric patients may also reduce growth rates. A reduction in growth rate may eventually decrease the maximal height achieved.

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He set about to know everything there is about the psychopathic narcissist generic 100 mg kamagra gold visa. He knows everything there is to know about narcissistic and psychopathic abusers and how to cope with them effectively buy 100 mg kamagra gold amex. Anthony Benis generic kamagra gold 100 mg without a prescription, Mount Sinai Hospital, New York, and author "Towards Self and Sanity - On the Genetic Origins of the Human Character")"Sam Vaknin is a leading authority on the topic of narcissism. The author has done probably more than anyone else to educate others to this poorly understood condition. In this, his twelfth book, he shares his considerable knowledgeand experience of narcissism in a comprehensive yet easy to read style. Sam has plugged all the loopholes, exposed all the plots, and introduced a new language to confront the Narcissist. If you want to breathe again, if you are at your wits end, if everything has been tried and failed, if you NEED a change, then Malignant Self Love can give you your life back. The result: Our members go zooming up the learning curve of understanding the Narcissistic Personality Disorder. The ICD-10, the International Classification of Diseases, published by the World Health Organisation in Geneva [1992] regards the Narcissistic Personality Disorder (NPD) as "a personality disorder that fits none of the specific rubrics". It relegates it to the category "Other Specific Personality Disorders" together with the eccentric, "haltlose", immature, passive-aggressive, and psychoneurotic personality disorders and types. The American Psychiatric Association, based in Washington D. The DSM-IV-TR defines Narcissistic Personality Disorder (NPD) as "an all-pervasive pattern of grandiosity (in fantasy or behaviour), need for admiration or adulation and lack of empathy, usually beginning by early adulthood and present in various contexts", such as family life and work. Five (or more) of these criteria must be met for a diagnosis of Narcissistic Personality Disorder (NPD) to be rendered. Demands automatic and full compliance with his or her unreasonable expectations for special and favourable priority treatment;Is "interpersonally exploitative", i. Is unable or unwilling to identify with, acknowledge, or accept the feelings, needs, preferences, priorities, and choices of others;Constantly envious of others and seeks to hurt or destroy the objects of his or her frustration. Suffers from persecutory (paranoid) delusions as he or she believes that they feel the same about him or her and are likely to act similarly;Behaves arrogantly and haughtily. Feels superior, omnipotent, omniscient, invincible, immune, "above the law", and omnipresent (magical thinking). Rages when frustrated, contradicted, or confronted by people he or she considers inferior to him or her and unworthy. According to the DSM IV-TR, between 2% and 16% of the population in clinical settings (between 0. Most narcissists (50-75%, according to the DSM-IV-TR) are men. We must carefully distinguish between the narcissistic traits of adolescents - narcissism is an integral part of their healthy personal development - and the full-fledge disorder. These inevitably involve narcissistic assertiveness which is not to be conflated or confused with Narcissistic Personality Disorder (NPD). Almost 75 percent of individuals diagnosed with NPD are male (APA, DSM IV-TR 2000). In certain situations, such as under constant public scrutiny and exposure, a transient and reactive form of the Narcissistic Personality Disorder (NPD) has been observed by Robert Milman and labelled "Acquired Situational Narcissism". There is only scant research regarding the Narcissistic Personality Disorder (NPD), but studies have not demonstrated any ethnic, social, cultural, economic, genetic, or professional predilection to it. Narcissistic Personality Disorder (NPD) is often diagnosed with other mental health disorders ("co-morbidity"), such as mood disorders, eating disorders, and substance-related disorders. Patients with Narcissistic Personality Disorder (NPD) are frequently abusive and prone to impulsive and reckless behaviours ("dual diagnosis"). Narcissistic Personality Disorder (NPD) is commonly diagnosed with other personality disorders, such as the Histrionic, Borderline, Paranoid, and Antisocial Personality Disorders. The personal style of those suffering from the Narcissistic Personality Disorder (NPD) should be distinguished from the personal styles of patients with other Cluster B Personality Disorders. The narcissist is grandiose, the histrionic coquettish, the antisocial (psychopath) callous, and the borderline needy. As opposed to patients with the Borderline Personality Disorder, the self-image of the narcissist is stable, he or she are less impulsive and less self-defeating or self-destructive and less concerned with abandonment issues (not as clinging). Contrary to the histrionic patient, the narcissist is achievements-orientated and proud of his or her possessions and accomplishments. Narcissists also rarely display their emotions as histrionics do and they hold the sensitivities and needs of others in contempt. According to the DSM-IV-TR, both narcissists and psychopaths are "tough-minded, glib, superficial, exploitative, and unempathic". But narcissists are less impulsive, less aggressive, and less deceitful. As opposed to psychopaths, few narcissists are criminals. Patients suffering from the range of obsessive-compulsive disorders are committed to perfection and believe that only they are capable of attaining it. But, as opposed to narcissists, they are self-critical and far more aware of their own deficiencies, flaws, and shortcomings. The onset of pathological narcissism is in infancy, childhood and early adolescence. It is commonly attributed to childhood abuse and trauma inflicted by parents, authority figures, or even peers. The narcissist uses the False Self to regulate his or her labile sense of self-worth by extracting from his environment narcissistic supply (any form of attention, both positive and negative). There is a whole range of narcissistic reactions, styles, and personalities - from the mild, reactive and transient to the permanent personality disorder. Patients with Narcissistic Personality Disorder (NPD) feel injured, humiliated and empty when criticized. They often react with disdain (devaluation), rage, and defiance to any slight, real or imagined. To avoid such situations, some patients with Narcissistic Personality Disorder (NPD) socially withdraw and feign false modesty and humility to mask their underlying grandiosity. Dysthymic and depressive disorders are common reactions to isolation and feelings of shame and inadequacy. The interpersonal relationships of patients with Narcissistic Personality Disorder (NPD) are typically impaired due to their lack of empathy, disregard for others, exploitativeness, sense of entitlement, and constant need for attention (narcissistic supply). Though often ambitious and capable, inability to tolerate setbacks, disagreement, and criticism make it difficult for patients with Narcissistic Personality Disorder (NPD) to work in a team or to maintain long-term professional achievements. Patients with Narcissistic Personality Disorder (NPD) are either "cerebral" (derive their Narcissistic Supply from their intelligence or academic achievements) or "somatic" (derive their Narcissistic Supply from their physique, exercise, physical or sexual prowess and romantic or physical "conquests"). Patients with Narcissistic Personality Disorder (NPD) are either "classic" (meet five of the nine diagnostic criteria included in the DSM), or they are "compensatory" (their narcissism compensates for deep-set feelings of inferiority and lack of self-worth). Some narcissists are covert, or inverted narcissists. As codependents, they derive their narcissistic supply from their relationships with classic narcissists.

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There were over 90 categories in 24 topic areas for every participant purchase kamagra gold 100 mg with mastercard. Once the Relationship Coding Sheet was developed purchase generic kamagra gold online, each interview was coded and scored independently by two raters (one male cheap kamagra gold 100mg free shipping, one female), who noted themes and categories as they emerged from the transcripts. One of the authors coded all 216 interviews to ensure continuity in the operational definitions of variables and consistency of judgments from case to case. The agreement between raters, determined by dividing the number of identical judgments by the total number of codes, was 87%. When discrepancies occurred the raters met to discuss their differences and to re-examine the original transcripts until a consensus was reached on how a particular item was to be scored. HyperResearch software (Hesse-Biber, Dupuis, & Kinder, 1992) enabled the researchers to perform a thorough content analysis of interview transcripts (totalling over 8,000 double-spaced pages) and identify, catalogue, and organize specific interview passages on which categorical codes were based. In the second or current phase of the study, we re-examined the codes so as to prepare the data for quantitative analysis. Many variables were re-coded into dichotomous categories. For example, psychological intimacy was originally coded into three categories (positive, mixed, and negative). Because we were interested in understanding factors that contributed to psychological intimacy during recent years, the positive category was retained and compared with a recoded mixed/negative category. Vignettes from the transcripts are used in the following pages to illustrate the meaning of psychological intimacy to participants during recent years. The coded data from the scoring sheets yielded frequencies that were analyzed using SPSS software. The chi-square statistic seemed appropriate, since certain conditions were met. First, it has been very difficult to ensure randomness of samples in social and behavioral research, especially in studies that focus on new territory. This nonprobability sample was selected deliberately to include older couples who have been understudied in previous research--namely, heterosexual and same-gender relationships that had lasted an average of 30 years. The goal was to identify factors that contributed to satisfaction from the perspectives of individual partners rather than to test hypotheses. Second, compared to other tests of statistical significance, chi-square has fewer requirements for population characteristics. Third, the expected frequency of five observations in most table cells was met. To assess the strength of the associations between psychological intimacy and the independent variables, a correlation analysis was conducted. Because of the dichotomous nature of the variables, a phi coefficient was computed for the dependent variable and each independent variable. Variables that had been related significantly to psychological intimacy in the chi-square analysis and identified in previous studies as having importance to understanding psychological intimacy were selected for building a theoretical model. Based on the phi coefficients, communication was not included in the model (see next section). Two models were tested using logistic regression: one model included the sexual orientation of couples (heterosexual, lesbian, and gay males), the other substituted gender (male and female) for the sexual orientation of couples. Logistic regression was a useful tool in this exploratory research, where the goal was to develop theory rather than test it (Menard, 1995). TOWARD A DEFINITION OF PSYCHOLOGICAL INTIMACY The dependent variable was psychological intimacy. Participants talked of experiencing psychological intimacy when they were able to share their inner thoughts and feelings they felt to be accepted, if not understood, by the partner. Such experiences were associated with feelings of mutual connection between partners. When participants talked of being psychologically intimate with their partners, a sense of peace and contentment permeated their remarks. Coding this variable involved an assessment of responses to questions that asked each partner to talk about their relationships. These questions included a range of topics such as what the partner meant to the participant, how their relationships may have been different from other relationships, how participants felt about being open with their partners, what words best described the meaning of the partner to a participant, etc. Of particular importance were questions that elicited responses about the quality of communication such as, "How would you describe the communication between you? Although positive communication could be present without having a sense that the relationship was psychologically intimate, at least in a theoretical sense, the two factors were correlated substantially (phi =. Therefore, we decided not to include communication as an independent variable in the regression analysis. Psychologically intimate communication captures what we are referring to as "psychological intimacy. I can say stuff to her that I would never say to anyone else. The partner spoke of how their psychological intimacy had evolved:Although we like a lot of the same things, our interests are different... I think we both each really like the other one a lot... There was a bond early on, in part because it was a different kind of relationship... As the couples in this study grew older together the experience of psychological intimacy was marked by a deepening sense of relational communion between them, yet a respect for their differences, as illustrated in the relationships of that couple. A heterosexual couple reflected on the meaning of intimacy in their relationship that had lasted 30 years. The wife experienced her spouse as: My best friend, best lover... Unfortunately, we have not had parents for many years. He is the person who most cares what is happening to me. The meaning of intimacy to her husband was described by him:I just like her to be next to me, near me. I think we are our own people, but we do it together. The responses of these four partners reflected several themes that were central to understanding and defining psychological intimacy. The second theme, interdependence, referred to maintaining separateness within the attachment to a partner. Maintaining interpersonal boundaries in these relationships apparently helped to sustain a sense of psychological intimacy; that is, individuals felt "safe" in revealing their inner thoughts and feelings because they could count on a partner to respect their separateness and to accept, if not understand, them. For both women and men, themes of connectedness, separateness, and mutuality were apparent in their responses, although men tended to emphasize proximity and women mutuality.

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