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These causes of hyponatremia menopause how long does it last order danazol with a mastercard, in which the water content is in excess in relation to sodium menopause 2 order danazol 100 mg on-line, comprise dilutional hyponatremia; this is the most common form of hyponatremia. Water retention and sodium depletion can occur with diarrhea and vomiting in the context of a normal thirst mechanism. Hypertonic hyponatremia, sometimes referred to as pseudohyponatremia, can occur in the context of elevated osmotically active solutes. The most common presentation is in the setting of hyperglycemia in diabetic ketoacidosis. In response to hyperosmolality, water moves from the intracellular to the extracellular compartment, and dilutes the plasma sodium. Factitious hyponatremia occurs when severe hyperproteinemia and hyperlipidemia cause a laboratory artifact, falsely lowering the serum sodium level. Because these compounds occupy volume in the sample, the sodium distributed in the aqueous compartment of the sample is measured at a lower concentration. Decreased dietary intake of sodium rarely causes hyponatremia, as the minimum dietary requirement of sodium is easily met, outside of extreme starvation. Hypoaldosteronism can cause hyponatremia, but the aldosterone axis is usually increased in patients with congestive heart failure. Renal excretion of sodium can be increased in cases of cerebral salt wasting, renal tubular dysfunction, or diuretic use, but none of these is present in the boy in the vignette. Pseudohyponatremia can occur in certain hyperosmolar conditions, such as diabetic ketoacidosis, but no such conditions are present in the boy in the vignette. She says she can stop the twitching for a short time if she concentrates really hard. You ask her about stressors, and she reports that she broke up with her boyfriend a month ago but she is "over it" now. A review of systems reveals fatigue, headaches, chest pain, shortness of breath, abdominal pain, nausea, vomiting, muscle aches, generalized weakness, and a 10-pound weight gain over the past 2 months. However, after the formal examination, you observe irregular, low-amplitude jerks of her fingers and hands that appear involuntary. Chorea is an involuntary, quick, jerky movement that can involve any part of the body, including the fingers, limbs, trunk, face, or tongue. The most commonly seen chorea in children in the United States is Sydenham chorea. Other causes of chorea include basal ganglia brain injury, due to systemic lupus erythematosus or other causes of small vessel vasculitis; medications such as phenytoin; or thyrotoxicosis. For the 17-year-old girl in the vignette, who has new-onset chorea but no signs of Sydenham chorea on laboratory testing, serum human chorionic gonadotropin level is the best response choice to reveal an underlying diagnosis. Magnetic resonance imaging of the brain and testing for hyperthyroidism would also be appropriate. Electroencephalography would be helpful if the jerking were more suggestive of seizures. Focal seizures can present with focal jerking or twitching, but usually these involve just 1 side of the body, and there is often alteration of consciousness. The girl in the vignette may also have anxiety or depression, and she has many acute life stressors, so conversion disorder is an appropriate diagnosis to consider. In conversion disorder, the symptoms often increase during formal examination and dissipate with distraction. Psychological evaluation would be the next best step if conversion disorder were the most likely diagnosis. Hypocalcemia can cause tetany, a muscle spasm usually presenting in the hands, fingers, or toes. Tetany is not suppressible, and the girl in the vignette has no reason to have hypocalcemia, so an ionized calcium level would not be the best next test. She has a respiratory rate of 16 breaths/min, heart rate of 70 beats/min, and blood pressure of 130/80 mm Hg. Her height is 110 cm (less than fifth percentile), and her weight is 25 kg (fifth percentile). You discuss her underlying kidney disease, glomerular filtration rate, and the associated complications with her parents.

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The resultant medullary ischemia may impair sodium chloride transport in the ascending limb and thus diminish medullary tonicity womens health 042013 purchase danazol 200mg on-line. Transfusions of normal blood have been shown to restore renal concentrating capacity in children menopause definition purchase 50 mg danazol, thus indicating that the sickled red blood cells have a role in the defect. Medullary infarcts occur with more prolonged disease, and the concentrating defect is no longer reversible with transfusions. The diminished maximal urine osmolality also occurs in sickle cell anemia in association with papillary edema, thus providing a situation analogous to experimental papillectomy. Dietary Abnormalities As noted in the discussion of primary polydipsia, excessive water intake culminates in an impairment of maximal urinary concentration. A marked restriction in sodium chloride intake also impairs the urinary concentrating mechanism. Because urea and sodium chloride account for virtually all interstitial tonicity, their decreased availability may account in large part for the observed defect. An increase in circulating vasopressinase leading to excessive catabolism explains vasopressin resistance (58). Hypernatremia supervenes during resuscitative efforts with hypertonic sodium bicarbonate, inadvertent intravascular infusion of hypertonic saline in therapeutic abortions, inadvertent dialysis against a high sodium concentration dialysate, seawater drowning, and even after ingestion of large quantities of sodium chloride tablets. Patients with primary hyperaldosteronism and Cushing syndrome have slight, clinically unimportant elevations in serum sodium concentration. The most prominent manifestations of hyperosmolar disorders are of a neurologic nature. These follow movement of water out of cells, resulting in cellular dehydration, particularly in the brain. Restlessness, irritability, depression of sensorium, lethargy, muscular twitching, hyperreflexia, and spasticity may occur and culminate in coma, seizures, and death. In children, the mortality of acute hypernatremia ranges between 10% and 70%, with a mean of approximately 45%. Unfortunately, neurologic sequelae are common even in survivors, affecting as many as two-thirds of the children. In adults, acute elevation of serum sodium above 160 mEq/L is associated with 75% mortality, whereas the mortality in chronic cases is approximately 60%. Recent studies in acute care settings have clearly shown that patients who present with (59) or acquire (60) hypernatremia have a higher risk of mortality. It must be pointed out, however, that hypernatremia frequently occurs in the adult in the setting of serious underlying diseases, which may be the primary cause of the high mortality. The signs and symptoms of hypernatremia are most likely related to a variety of anatomic derangements. The loss of volume and shrinkage of brain cells associated with the hyperosmolar states cause tearing of cerebral vessels. In addition to these gross anatomic changes, the brain sustains alterations in the composition of water and solutes that may be of great importance in the pathophysiology of the symptoms of hypernatremia (61). These are responses designed to regulate volume and restore cell size; thus, the water losses are not as severe as would be predicted. In the early phase, the entry of sodium and chloride into brain 57 cells greatly mitigates the loss of water that would otherwise occur from ideal osmotic behavior. After 7 days of hypernatremia, brain water returns to control levels because brain osmolality remains elevated. At this time, newly generated idiogenic osmoles account for as much as 60% of the increase in intracellular osmolality. Some of these idiogenic osmoles result from an increase in intracellular amino acids, particularly taurine. In addition, accumulation of osmolytes such as urea, glutamine, glycerophosphorylcholine, and myoinositol has been documented in hypernatremic rats (62). Prevention of Hypernatremia Because hypernatremia occurs in predictable clinical settings, early recognition may allow prevention or decreased severity of injury. Elderly persons, hospitalized patients receiving hypertonic infusions, those suffering increased insensible losses or undergoing osmotic losses, diabetic patients, and patients with previous symptoms of polydipsia and polyuria should invoke a high index of suspicion when displaying neurologic alterations. Compared with younger individuals, geriatric patients have impaired thirst responses, decreased urinary concentrating ability, and lower baseline levels of total body water. As a result, elderly patients are the group most likely to develop severe hypernatremia in the outpatient setting, and hypernatremia in the elderly accounts for 1% to 2% of all hospital admissions.

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Behind the couch menstrual depression syndrome discount danazol 200mg on line, I am musing on my countertransference towards a patient who sought analysis women's health week 2013 buy 200mg danazol amex. Thus I would rather think, "She really is discontented", "Why is she carping at her husband Perhaps she might recognize this pattern from earlier relationships and that she is repeating a sadomasochistic drama with me. But, it may also signal that he needs to wake up and realize he has become a father. More commonly, they have voiced concern about her welfare, helplessness in supporting her, bewilderment in their new role as a father, tensions in relation to his or her parents, worries about combining job duties with family commitments, etc. I have often noticed a shift in the mother, from a plaintive appearance to one of appreciation and warmth. Sometimes, this leads me to suggest we switch to couple therapy, which we discuss in Chapters 12 and 13. I would guess she wanted to come alone to her first hour to get space to talk about her resentment, without being interrupted by that little person whom she unconsciously might regard as a competitor for love. If the mother has been depressed or overly anxious for some time, he may indeed be affected. There might be signs of gaze avoidance, a low-keyed mood, fretfulness, and other indications of malaise. If she complains about not loving him, he needs to be invited to our efforts at setting things right. This is precisely what is holding their relationship padlocked and confined; the mother has this mix of feelings and thinks it will harm the baby irreparably were she to say it. The result is often the obverse; the baby notes that her ways of being with him are incomprehensible. Inviting father and/or baby; these are two examples of the need to be flexible about setting. When a relationship issue with the baby gets dissolved through therapy, the mother may become aware of a personal difficulty, such as her limited access to warm emotions. When the baby has become free of symptoms and if the mother wants to work with her personal issues, it would be senseless to retain the baby in treatment. It implies to "read between the lines", "read the text underneath", or to understand the unconscious currents beneath conscious messages. It has an ingredient of unmasking and translating, such as asking myself, "what does s/he want to say now This pertains to its paternal aspect, if we use that term similarly to when we explored containment in Chapters 2 and 3. There is also a maternal aspect to the frame; feeling compassion with anyone who has entered parenthood only to find hopes and expectations torn to threads by emotions surging from the depths like pristine sea monsters. Another argument is one that Freud (1913a) admitted was personal: I cannot put up with being stared at by other people for eight hours a day (or more). Since, while I am listening to the patient, I, too, give myself over to the current of my unconscious thoughts, I do not wish my expressions of face to give the patient material for interpretations or to influence him in what he tells me. The work of translating and unmasking is an intellectual and an emotional endeavour. The analyst tries to reach a mindset that is unanchored to everyday and concrete matters and has more of a dreamy quality. Would that not overwhelm the patient(s) with a lot of perceptions of me and disrupt my reverie Indeed, I may want to be left at peace with my deliberations to understand better what is going on. Second, the presence of mother and baby provides stimuli that further my regression and inspires reverie. I said earlier that the classical frame provides the patient with the possibilities of a maternal holding.

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These agents include calcineurin inhibitors women's health center madison wi buy danazol online from canada, corticosteroids menopause itching order danazol now, mammalian targets of rapamycin inhibitors (eg, sirolimus, everolimus), antimetabolites (eg, 6-mercaptopurine, azathioprine), and newer biologic agents (eg, infliximab, rituximab, adalimumab). Six months ago, he was diagnosed with autism by a developmental pediatrician after he was referred for evaluation of expressive language delay, repetitive stereotyped movements, and abnormal social development. You are unable to perform a thorough physical examination because he screams and cries when you attempt to touch his body. His family moved before he was able to have this testing completed, and they are interested in testing at this time. He would likely need to be sedated to undergo auditory brainstem response testing, making this an inappropriate first test. With his limited communication and cooperation, pure-tone and speech audiometry would not be feasible. Early identification and prompt intervention are associated with improved language and developmental outcomes. All states have universal newborn hearing screening programs, which aim to identify children with permanent congenital hearing loss by 3 months of age and begin interventions by 6 months of age. Sound triggers the cochlea to respond; this response can be sensed by a recorder within the ear canal insert. This test is quick, inexpensive, and does not require the infant to be cooperative or sedated. Results can be affected by cerumen, fluid, or debris in the external ear canal or the middle ear. Auditory brainstem response testing measures electrical activity along the auditory nerve. Electrodes are placed on the scalp to record the electrical activity as speakers in the ear canal emit clicks or tones. Results can be affected by movement; newborns are best tested when sleeping, and older children may require sedation for an accurate test. Hearing cannot definitively be considered normal until a reliable audiogram can be obtained. Audiometry evaluates hearing thresholds at a variety of frequencies and can determine the degree and type of hearing loss. Various types of audiometric testing can be used with patients of different ages (Item C220A). This probe measures pressure and can identify normal middle ear pressure, decreased tympanic membrane mobility, or tympanic membrane retraction caused by eustachian tube dysfunction. Beyond the newborn period, children with risk factors for hearing loss should have ongoing screening as well as a formal diagnostic audiology assessment by 24 to 30 months of age. Over the past several days, she has vomited approximately 5 times per day, and has had 8 to 10 stools per day. She refuses to eat solids, but has been drinking fluids adequately, including milk, juice, and water. On physical examination, she is awake and alert, and has slightly dry mucous membranes. Laboratory results are as follows: Sodium Potassium Chloride Bicarbonate Serum urea nitrogen Creatinine Glucose Capillary blood gas pH Partial pressure of carbon dioxide 130 mEq/L (130 mmol/L) 5. Evidenced by a normal anion gap, the most important contributor to her acidemia is intestinal losses of bicarbonate. Acute gastroenteritis is a very common cause of emergency department visits for children. Denuding of epithelium and dysfunction of small intestinal villi can result in malabsorption, and if severe, can impair intestinal absorption of bicarbonate causing metabolic acidosis. Electrolyte and serum bicarbonate levels can provide useful information about the severity of illness and guide management. Children with bicarbonate levels higher than 15 mEq/L (15 mmol/L) are unlikely to be more than 10% dehydrated, and those with bicarbonate levels less than 14 mEq/L (14 mmol/L) are less likely to tolerate an oral fluid challenge. Other electrolyte disturbances seen in acute gastroenteritis can include hypernatremia, hyponatremia, and hypokalemia.

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Developmental lactase deficiency is observed in premature infants born at less than 34 weeks of gestation breast cancer icd 9 cheap danazol 100mg without a prescription. Cow milk protein allergy is the most common food allergy in young children and may be IgE mediated women's health issues class 200mg danazol with visa, mixed, or related to non-IgE reactions. Exclusive breastfeeding during the first 4 to 6 months after birth reduces the risk for cow milk protein allergy. The clinical manifestations usually appear in the first few weeks to months after birth. Cow milk protein allergy may be associated with respiratory, cutaneous, and gastrointestinal reactions. Milk protein allergy that is IgE mediated may present with wheezing, stridor, otitis media with effusion, urticaria, angioedema, atopic dermatitis, vomiting, diarrhea, colic, or anaphylactic shock. Individuals with cow milk protein allergy often have stools that contain mucus and occult or frank blood, which helps to differentiate them from individuals with lactose intolerance. On physical examination, you note jaundice, mild hypertelorism, and a 2/6 systolic ejection murmur radiating to the back. Although she has not regained birthweight by 2 weeks of age, her number of bowel movements suggests adequate milk intake. Her elevated conjugated bilirubin level, in combination with findings of hypertelorism and a murmur of peripheral pulmonic stenosis, suggest the diagnosis of Alagille syndrome. Hyperbilirubinemia in a neonate can be characterized as physiologic jaundice, breastfeeding jaundice, or pathologic jaundice. Many neonates have physiologic jaundice, with an elevated unconjugated bilirubin because of decreased activity of glucuronyl transferase and increased enterohepatic circulation. Significant hyperbilirubinemia is concerning in the first days after birth because neonates have increased permeability of the blood-brain barrier. Bilirubin can pass into the brain and cause permanent neuronal damage, resulting in the clinical syndrome of acute bilirubin encephalopathy. Typically, these neonates present with fever, high-pitched shrill cry, opisthotonos, and retrocollis posturing. Cholestasis is defined as a conjugated bilirubin concentration greater than 2 mg/dL (34. All neonates who are more than 14 days old with jaundice should be evaluated with a total and conjugated bilirubin level. Evaluation of a neonate with cholestasis should include transaminase levels, a glutamyltransferase level, and urinalysis. Because the Kasai procedure to surgically correct biliary atresia is most successful in the first 2 months after birth, any neonate with evidence of cholestasis must undergo gallbladder ultrasonography to confirm the absence of biliary atresia. Urinalysis can screen for both a urinary tract infection and reducing substances suggestive of galactosemia. Clinical characteristics include cardiac defects (peripheral pulmonic stenosis is the most common), short stature, vertebral anomalies, and cholestatic liver disease because of a paucity of bile ducts. Characteristic facial features include a prominent forehead, pointed chin, hypertelorism, deep-set eyes (Item C155). Affected children may also have posterior embryotoxon, an opaque ring around the cornea, due to thickening of the ring of Schwalbe. Rimsza Mild cholestasis is seen with congenital cytomegalovirus infection, but typically there are no associated cardiac defects. Neonates with galactosemia present with feeding intolerance, failure to thrive, and possibly cataracts.

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Following Freud (1900) womens health youngkin generic 50 mg danazol amex, Aulagnier speaks of the screaming baby who tries to bypass distress by hallucinating satisfaction menstrual urination order 50mg danazol with mastercard. When, finally, nipple and mouth meet and the need is satisfied, the primal (originaire, not to be confused with primary) process creates an image of a complementary object zone or a pictogram. The positive affect in a pictogram arises (1) because it was created during satisfaction and (2) the representative activity is pleasurable per se. There is also a parallel track, ignited by dissatisfaction and energized by Thanatos. One could suspect that Aulagnier emphasizes the role of visual perception (Valabrega, 2001), but any sensory perception may yield a pictogram. The sound of breastfeeding, its odour, vibration, taste, touch, or sight all may be represented as pictograms and therefore, I think sensogram is a more apt term. During the reign of the pictogram, the outside world can only be given as "image-of-self" (Aulagnier, 2001, p. Specifically, the pictogram is a representation constituted of an object and a complementary erogenous zone in an affective link. The concept is enigmatic because it is self-referential and inexpressible, but it helps us grasp the most primitive editions of "the laws that govern the activity of representation" (da Rocha Barros, 2000, p. When the psyche recognizes that a body and a psychic space other than its own do exist, the primary process starts functioning. The baby begins to suspect that the other human being desires yet another; a triangle is created and the oedipal drama has begun. This would correspond to a stage that Gaddini covers with the term "instinctual activity of the ego". The baby now recognizes the other as being separate and having intentions towards him/her. Conclusions I have sought to name the nameless, or to explicate what a panicking baby might feel. This enticing question in perinatal psychology is abstruse and meets with deep resistances, but it also needs our theorizing the most. Like all of us, they had to base their conclusions on observations, intuitions, and existing theories. The word "is" is not identical to when I say, "My anxiety is about Carla and our upcoming date. This obstructs the baby from sorting out his representations to make them less threatening by experiencing that someone "on the other side" can imagine, feel into, and translate them into more succinct and explicit messages. The next chapter will look at these distressful situations from another vantage point. The difficulty is similar to when two nations mobilize military forces; tensions escalate and peace is endangered. Chapter 18 Babies and their defences Eyes have magical powers as mirrors of the soul and messengers of emotions. This may befall parents looking into the eyes of their baby who turns away the gaze. Or, is it related to mechanisms that we, with older persons, name psychological defence If a country builds up a defence against its "hostile" neighbours, we get the logic. Cain envied his brother Abel, Sarah was jealous of young and fertile Hagar, and Oedipus, as Freud intuited, unconsciously avoided discerning that his bride was his mother. These characters suffered an emotional pain so weighty that they must make interior changes to avert it. He coined the bellicose metaphor of defence (1892, 1894, 1895/1950, 1896) hand in hand with another metaphor, that of the drive. It fell upon his daughter, Anna Freud (1937), to systematize these "defence mechanisms". If a mother looks at her baby and he turns away his eyes, does this signify a defensive manoeuvre That would imply that we see him as an intentional agent who can accomplish internal changes to ward off some inner turmoil. On a larger scale, we will ask if the defence concept applies to disordered behaviours in infants.

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Intercalation means incorporation of new endothelial cells in patches women's health big book of exercises pdf free download 100mg danazol amex, followed by rearrangement of endothelial cells womens health garcinia cambogia article buy 100 mg danazol with mastercard, leading to an increase in surface area and other dimensions. It can also involve the incorporation of tumor cells or trophoblasts, which could give rise to a mosaic vessel with vascular mimicry. It may involve transendothelial migration and mural insertion of circulating pericyte progenitors. Vessel fusion, sometimes called "homing" in embryology, may also be grouped by some authors under this category. It is seen in the endometrium during the proliferative phase of the menstrual cycle (Gambino et al. Angiogenesis in psoriatic skin and its mechanism are further discussed in Section 5. It happens commonly in intracranial tumors, especially high-grade glioma and meningiomas, but also in a wide variety of other tumors. It should not be confused with angiogenesis in the renal glomerulus, where a capillary loop splits by intussusception, whereas glomeruloid angiogenesis in intracranial lesions is possibly nonbranching. Controversies exist regarding whether the later stages of glomeruloid formations are Angiogenesis and Roles of Adhesion Molecules in Psoriatic Disease 57 similar to convoluted version elongation or involve vessel-within-vessel formation, for example, those forming within dilated mother vessels, which can happen through processes somewhat similar to those for intussusception. Although glomeruloid bodies look structurally hyperpermeable, they are underperfused; thus, actual leaking of transudate is low. The incorporating cells often show an endothelial-like phenotype and sometimes also develop mural layers through mimicry. It is more frequently observed in cancer of densely vascularized organs, including the brain, lung, and liver, where the primary tumor cells co-opt the adjacent quiescent blood vessels of the host tissue. This involves a three-step process of (1) degradation of noncompliant basement membrane, (2) mural or pericyte detachment, and (3) extensive rapid enlargement through vesiculovacuolar fusion in the endothelial cells, usually leading to a three- to fivefold increase in cross-sectional area. They are not supposed to be permeable to plasma proteins (unlike the mother vessel). Progenitors can also be recruited from the adventitia of an existing vessel, especially arteries, to participate in another type of angiogenesis or arteriogenesis related to repair for damaged vessels. Intercalation can sometimes also be used to mean vascular fusion (homing in embryology), which is more vascular remodeling than angiogenesis. Intussusception is described above in simple terms, and the most well-known example of infolding is mentioned as the mechanism of intravascular pillar formation. But actually, there are many different mechanisms described in the literature (Patan 2013), for example, pillar formation by folding of the vessel wall, connection of adjacent pillars, "in situ loop formation," pillar formation by connection of opposing intraluminal tissue folds, segmentation, apposition, recanalization of the 58 Psoriasis and Psoriatic Arthritis thrombotic vein by remodeling, and arterial recanalization through fibroblastic invasion, followed by pillar formation. Segmentation, apposition, and recanalization are relatively more common in adult angiogenesis and are based on intra- and extravascular fibrin deposits. Although angiogenesis in psoriatic skin mostly follows the elongation type, angiogenesis in PsA possibly also involves other modes of angiogenesis/remodeling. Normal endothelial cells in a stable vessel are quiescent and form a monolayer of "phalanx" cells. They rarely proliferate and do not migrate out of the basement membrane layer, which they share with the pericytes. Their need for proliferation is less (about 1 in 1000 cells) because of their low apoptosis frequency. Endothelial cells become "activated" and initiate the process of angiogenesis, which may include a cascade of events. They are selected by lateral inhibition (Notch signaling) and lead the tips of sprouts. Tip cells stay individual; do not divide, but have long filopodia that help in pathfinding and migration; and eventually fuse with opposite tip cells (with the help of a myeloid bridge cell) during anastomosis formation. The other phenotype is stalk cells that follow the tip cell and initially make a solid cord or column by proliferation and later form the lumen. Low-level baseline signaling is important, as shifting the balance of this signaling in either direction can activate the endothelial cell. For example, a higher level of Notch activation activates the Wnt pathway, which produces a proliferating stalk cell phenotype. The oxygen sensing machinery described below is part of the homeostatic mechanism that also fine-tunes the vessel shape to optimize tissue perfusion and oxygen levels.

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Falling in love has many similarities to the overwhelming breast cancer nails design discount danazol online master card, searing menopause cream order 50mg danazol otc, and yearning emotions whirling about between parent and child. In thousands of pop tunes the singer cries out, "Oh baby, I love you so," or asks "My baby", where did "our love" go. Manifestly, they refer to adult love but we can also apply them to the emotions between parent and child. She had a long-lasting fear of letting go, losing control, and falling into the abyss of love. The previous chapters told of other mothers with similar issues; longstanding as in the case of Donna, or recent as in the case of Karen who might lose her foetus. After all, the girl had been alright from the second hour of her life and onwards. Soon, we discovered other factors beneath her panic; her narcissistic preoccupation, fear of surrendering to warm emotions, and efforts at circumventing these issues by being a workaholic. In Chapter 2, Delivery trauma and the maternal introject 41 I mentioned that the previous relationship between a woman and her mother will impact on her primary occupation. During pregnancy and afterwards, matters are often brought to a head between the two. As therapy progressed, Leyla became warmer and, in parallel, she began to see similar assets in her mother. We can express this in terms of a change of balance in her identifications; Leyla progressed, from identifying with harsh and blunt aspects of her mother to those that indicated empathy and wisdom. The maternal introject I introduced Leyla and Jenny as a case where the delivery trauma punctured someone whose history and personality contained so many thorns that she was ill prepared for dealing with it. Leyla could hardly sleep, take a walk, or leave Jenny in bed; death lured everywhere, threatening to take her child away. Anxiety among new mothers is common and any line between normal and pathological anxiety is artificial. I take a pragmatic stance; if an anxious woman asks for a consultation, she deserves attention. This does not prevent me from wondering why anxiety is so common among parents and what is it all about Females, whether elephants, bears, or humans, protect and anxiously look after their offspring. Yet, this explanation does not illuminate the clinical phenomena we are discussing. We thus need to go deeper to interpret the constant and debilitating anxiety in some mothers. Earlier, I tended to attribute such anxieties to reaction formation, a mundane defence mechanism. The point with such hypocrisy, like with other defence mechanisms, is to make a compromise between your official persona and the one you are underneath. Enough steam gets out to make you feel relieved and affect the other, but little enough for you to seem polite and remain unconscious of the full import of your emotions. When I began meeting mothers who feared harming their baby or that he would die, I used to conceptualize such apprehensions in terms of reaction formations. They were indeed angry, but to feel that way 42 Part I: Clinic with a little helpless creature is frightening and shameful. It is as if they feel that the baby will obstruct their freedom, impoverish their resources, and lay a hand on all the good that their own infantile self yearns for.