Para compra cialis puede ser visto como un desafío. Aumenta Smomenta, y todos los que se poco a poco abrumado, como es lógico, cada vez más hombres están diagnosticados con disfunción eréctil.
Depression and Pain
Richard’s tongue had been burning for more than a year. He told me
that its severity was seven on a pain scale of ten, and that it was there
24/7. I scanned his medical records. He had been seen several times byhis primary care doctor and his dentist. He had also consulted a throatspecialist, an allergist, and a dermatologist. All the necessary tests, andsome unnecessary ones also, had been performed and were unrevealing.
Richard had been advised to change his toothpaste and even to change histoothbrush. He had been prescribed a variety of mouthwashes, as well asantihistamines and antibiotics. None helped.
He was fifty-nine years of age and an imposing presence. Handsomely
dressed with coat and tie, he had a great head of white hair parted andcombed with not a single member out of place. He spoke slowly and withperfect articulation. Each word was uttered as if it represented some sortof small treasure. I sensed that Richard was someone who was used tobeing looked at and listened to.
“Richard, we will talk about your burning tongue shortly but first, tell
me about yourself. Are you married? Do you have children?”
“Yes, I am happily married and have been so for thirty years. I have
three children and four grandchildren.”
“All doing well?”“Yes, quite well, thank you.” “What do you do for a living?”
“I am a public speaker, Dr. Cochran. I work for a large publishing
house that specializes in inspirational books. I travel all over the worldgiving speeches.”
Curing Chronic Pain
“Yes, it is very interesting. I meet many people, and I have been to all
“Well, I must ask you, does public speaking, an activity in which one
uses the tongue a lot, make your pain worse?”
“No, I have often wondered about that myself, but no, speaking has
“And the travel? You fly across continents, you change time zones and,
I would gather, shift from one climate to another. Does all that changehave any influence on your pain?”
“Not in the least.”Oh boy. This one is going to be fun
, I thought.
“Richard, tell me how your pain began.”
“It began right on the tip of my tongue, right in the middle at the
“Did it hurt badly at first, or did it gradually become more severe?”“As I recall, it was just a sense of irritation at first, maybe for a matter
of a few weeks. And then it started spreading backwards, and when it did,it became more and more painful.”
“And now the pain is all over your tongue?”“Yes, my entire tongue hurts.”“If you place your tongue to the side of your mouth and apply pres-
sure to it by biting down, does your pain increase?”
“No, my pain level does not change at all. My disease, whatever it is,
“Yes, but let me try to comfort you. I am used to treating, and many
“That is comforting indeed, Dr. Cochran.”“A few more questions. Do you ever feel pain in your gums, your
He raised his hand to his mouth, brushed his index finger across his
lips, and said, “Only the lips. Sometimes my lips hurt, although not nearlyso bad as my tongue.”
“How are you sleeping?”“Usually I sleep quite well. Sometimes after a long trip, I have to take
a sleeping pill, but that is really very infrequent. I think I see where you
are taking me with this. My pain tends to worsen as the day goes on, andthe pain is quite severe, but it almost never keeps me from sleeping.”
“Then it is not 24/7.”He smiled and said, “You are right, it is 16/7.”
When my office schedules a new patient appointment, we send that
person a request for the usual demographic and insurance information.
Included is an intake history form on which the patient is to list currentsymptoms, medications, prior illnesses,and family history. On the reverse, there is
with the request that they be answered yes
or no. Richard’s system review wasextraordinarily negative. Only under the
acknowledge that he suffered anxiety.
Beside it he wrote “slight.” His medication list was quite short. He wastaking the antacid Protonix and the antidepressant Lexapro. A goodplace to start,
“Richard, I see that you are taking Lexapro. I suppose you were given
“Yes, I have been taking Lexapro for six years now. It has been
extremely helpful to me. I really don’t have any problem with depressionat all now, but my primary care doctor thought it best that I continuetaking the drug.”
“Tell me what was going on when your depression began.”
“I was in a bad automobile accident. I had a concussion and was
unconscious for several days. Several of my ribs were broken, and myspleen ruptured. I required surgery and was in the hospital for overtwo weeks. I was also under a lot of personal stress. I was in sales backthen, and it wasn’t nearly as pleasant as being a public speaker. Ibecame very anxious and depressed.”
“Were you suicidal?”“No, nothing like that, but I was constantly fatigued, and I had a
great deal of trouble sleeping. I have always been an emotional person,
Curing Chronic Pain
but this was something different. I was on a roller coaster. My emotionswere running amok.”
“Did you see a psychiatrist?”“No, my primary care doctor prescribed the antidepressant.”“That was the Lexapro?”“No, the first drug he gave me was Celexa. It helped quite a lot for
several months, but then I became listless. Nothing seemed to matter. Ididn’t care about anything. That is when my doctor changed me toLexapro. My improvement was dramatic. I have had absolutely no prob-lems with depression since I have been on Lexapro.”
Many readers have probably experienced the flattening-out effect
of the SSRI antidepressants. They can be very effective in relievingdepression, but in its place they sometimes lead to a state of emotionaltorpor and evenness that deprives the user of the normal experiencesof sadness and joy. There is nothing unique about Celexa in thisregard, but it is curious that Lexapro, almost an identical drug, had nosuch effect.
“Richard, I see that you have a slight problem with anxiety. Could you
“I do become anxious from time to time. Fortunately, it doesn’t last
very long. I can usually make it go away by doing some sort of exercise.
Taking a walk will always relieve it.”
“Is there any trigger? Can you identify anything that makes you nervous?”
“I have been quite unable to do that, although I have certainly tried.”“Richard, I do believe that I can relieve your pain and maybe pretty
quickly. But I have one more question.”
“Sure.”“You have a disease that I recognize as chronic pain. Sometimes it just
appears out of the blue, but most of the time, indeed almost all the time,there is some injury to the body from which the victim of chronic pain,for whatever reason, doesn’t recover. Can you think of any kind of injuryto your tongue when this started? Could you have bitten it or burned iton some hot food?”
“No, I have no memory of anything like that.”
“Is it possible that you had some kind of dental work done shortly
He hesitated as he searched his memory. I could sense that he was
“Yes, I do remember now. One of my front teeth was chipped. It was
a few weeks before I could arrange a dental appointment to have itrepaired, and I do recall that I frequently rubbed the tip of my tongueagainst the broken tooth. I remember a certain sense of irritation in mytongue then. I think you have hit on something, Dr. Cochran. That iswhen the pain actually began.”
I elected to treat Richard with Clonazepam and Imipramine. The two
drugs, or for that matter, the two classes of drugs (benzodiazepines andtricyclics) seem to have a synergistic effect. That is, they work welltogether, and they create a thing that is greater than the sum of its parts.
Richard was well within a week. “My pain is almost nonexistent. It is less than a one.”I thought that Richard would respond to my drugs because he carried
the legacy of depression and because he experienced the curiousphenomena, so common in chronic pain, of the migration of pain beyondthe bounds of its origin. Recall Bill fromthe preceding chapter. His pain began on
one side of his tongue and migrated into his
Richard’s pain was somehow a derivative of
his depression, it appeared at a time when
that Richard’s depression was totally incontrol. Recall his tentative response to my
questionnaire inquiring about the presence
of anxiety. “Yes,” he wrote, but “slight.”
Perhaps his depression was only partially
controlled, and his anxiety was a persistent
symptom of that disorder. (Yes, anxiety can
Curing Chronic Pain
certainly be a symptom of depression.) Moreover, Richard was on treat-ment with Lexapro, an SSRI that, although quite helpful in thetreatment of depression, is often ineffective in the treatment of pain. His
the drug, and his symptoms of anxiety,nearly so, but his pain was not.
Mark’s pain began in his right eye.
suddenly died. It was severe, and it kept
him from sleeping through the night. Itcontinued into the next day, and as he was
lifting a suitcase from a shelf in his closet, he experienced an excruci-ating pain in the back of his head. His vision became doubled andblurred. He was unable to speak, and both his arms and legs felt tinglyand weak.
“It was a hemorrhage in the back of my brain. I remember going to
the hospital. They did an MRI in the emergency room and then took meup to the operating room. I could hear them talking, but I couldn’trespond or move. I remember one of them saying, ‘He is a lucky man. Hedoesn’t have an aneurysm, and he is not going to need an operation.’”
“And then?”“I was in the hospital for a week. My speech gradually returned, and
within a few days I was able to walk. My headache went away slowly, butwhen I left the hospital, I was still seeing double, and glare hurt my eyes.
I had to wear sunglasses. It was a month before I could drive a car again,but my recovery from my hemorrhage was complete except for someoccasional, pretty severe headaches.”
“What were they like?”“They would strike me in the back of the head and in the right eye, just
like before. They were bad but not nearly as bad as when I first got sick.”
“How long would they last?”“Oh, maybe an hour, sometimes longer.”“How often?”
GOVERNO DO DISTRITO FEDERAL SECRETARIA DE ESTADO DE SAÚDE DO DISTRITO FEDERAL HOSPITAL DE BASE DO DF - UNIDADE DE REUMATOLOGIA FORMULÁRIO DE REGISTRO E AUTORIZAÇÃO PARA USO DE TERAPIA BIOLÓGICA DA SES NOME: _______________________________________________________________________ DATA DE NASCIMENTO: ____/____/____ IDENTIDADE N.º __________________ ENDEREÇO COMPLETO: _____
PODIATRIC MEDICINE II 100. 0 101. 0.5 102. 0.6 103. 1 104. 10 105. 100 106. 101 107. 110 108. 130 109. 15 110. 150 111. 18 112. 1000 113. 105 114. 12 115. 12.5 116. 120 117. 125 118. 126 119. 13000 120. 1500 121. 2 122. 20 123. 200 124. 2200 125. 24 126. 25 127. 250 128. 27 129. 3 to 4 130. 3.0 131. 3.1 132. 3.375 133. 30 134. 300 135. 35 136. 4 137. 40 138. 400 139. 4.5 140. 45 141. 5 142. 5