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chiatric disorders associated with streptococcal infections, page 96) This disorder is presumably related to another extrapyramidal condition, Sydenham chorea, in which tics and similar movement disorders as well as obsessive behavioral abnormalities have long been known to coexist Functional imaging studies in patients with PANDAS have yielded variable ndings, but generally there has been increased activity in the caudate nucleus and orbitofrontal cortex in temporal association with the patient s compulsive thoughts The neurochemical alterations in obsessive-compulsive disorder have been studied but most of the conclusions have been based on the responses to medications, notably to the serotonin reuptake inhibitors as noted further on These agents are found to be of therapeutic bene t, as are stereotactic neurosurgical lesions in the cingulate gyri (see further on) The Gilles de la Tourette syndrome of multiple tics, including vocal ones, beginning in childhood or adolescence and lasting more than a year, also bears a resemblance to obsessive-compulsive disorder The two conditions often appear together; more than half of Tourette patients have obsessive-compulsive disorder Both occur in a pattern of inheritance that is close to an autosomal dominant trait with incomplete percent penetrance (Kurlan) Because dopamine antagonists are bene cial in the management of the Tourette syndrome, a number of etiologic hypotheses revolve around serotoninergic and dopaminergic neurotransmitter systems (Baxter; Behar et al) More extensive comments on the Tourette syndrome are to be found on page 95

MAA best practices are published as a series of technical whitepapers and blue prints, and assist in deploying highly available Oracle-based applications and platforms that are capable of meeting and exceeding the business service-level requirements The MAA architecture covers all components of the technology stack, includes the hardware and the software, and addresses planned and unplanned downtime MAA provides a framework for high availability by incorporating redundancies into the components of the technology stack, and also by utilizing certain built-in high-availability features of the Oracle software For example, the Database Flashback feature enables you to recover from user errors such as an involuntary DROP TABLE statement by using a simple FLASHBACK TABLE command This cuts down the recovery time drastically, which otherwise would be needed for performing a point-in-time recovery using backups Figure 6-1 represents the MAA architecture using the Exadata Database Machine The Database Machine MAA architecture has identically sized Database Machines on the primary and standby sites The primary site contains a production database configured with Oracle Real Application Clusters (RAC) Oracle RAC provides protection from database server and

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If the parallel port is faulty, it should be replaced In older systems, the parallel port is not integrated with the system board and can be removed If the parallel port is built into the system board, as in newer computers, you must replace the system board From a practical perspective, it may not be cost effective to replace a motherboard if a parallel or serial port fails You can purchase expansion cards that will provide additional ports if you need them These expansion cards are usually very inexpensive and provide higher performance than the integrated ports on the motherboard

Treatment is best left to the psychiatrist At least there should be a trial of therapy using behavioral modi cation techniques In the case of phobic neurosis, the aim of such treatment is to reduce the patient s fear to the extent that exposure to the phobic situation can be tolerated A popular form of therapy is systematic desensitization, which consists of increasing and graded exposure of the patient to the object or situation that arouses the fear Psychotherapy, if undertaken, need not be intensive, consisting instead of repeated explanation, reassurance, and guidance in dealing with symptoms As with phobic neurosis, several reports have indicated that compulsive rituals can often be abolished by the techniques of behavior therapy Much in vogue is cognitive-behavioral psychotherapy alluded to earlier and discussed in the next chapter (page 1315) This too is best left to the experienced psychiatrist Certain medications, particularly the SSRI types such as uoxetine, are considered to be very effective forms of therapy abolishing or greatly reducing obsessions and compulsions in more than half the patients The less-selective agent, clomipramine, is also highly effective, as were more commonly used tricyclic antidepressants in the past, but clomipramine is not nearly as well tolerated as are the conventional SSRI drugs (see review by Stein) Finally, it should be mentioned that cingulotomy has produced symptomatic improvement in both phobic and obsessional neuroses and was at one time considered a reasonable procedure This measure, if it is to be used at all, should be considered only as a last resort in exceptionally severe cases in which the patient has failed to respond to all other methods of medical and behavioral treatment and is totally disabled Perhaps the implantation of a reversible electrical stimulating electrode in this same region is a sensible area for future investigation This and other surgical approaches to these illnesses has been reviewed by Greenberg and colleagues They acknowledge that few adequate trials have been conducted.

For many years a number of psychoanalytic conceptualizations held sway of obsessional neurosis as the product of intrapsychic con icts Only relatively recently has a neurobiologic model been advanced These are largely derived from the ndings of functional imaging, which have been quite consistent Positron emission tomography has demonstrated increased metabolic activity in the orbitofrontal cortex, cingulate, and, to a lesser extent, striatum of affected patients The orbitofrontal cortex and amygdala were reported to be shrunken in other cases However, in a study of 13 patients who developed elements of obsessiveness and compulsive disorder after incurring focal brain lesions, Berthier et al found lesions in diverse loci, including the cingulate, frontal, and temporal cortices as well as the basal ganglia Two of the most accurately localized lesions in their series were a hamartoma of the right parahippocampal gyrus and an infarction in the posterior putamen The presence of brain injuries and seizure disorders in other of their patients made a precise localization more problematic Additional insight into acquired obsessive-compulsive disorder may be obtained from the many cases in which striatal damage is linked to this type of behavior One such entity is a poststreptococcal tic disorder termed PANDAS (pediatric autoimmune psy-

and it should be pointed out that most of the surgical series they discuss took place well before the modern era of psychopharmacology

The components that make up a computer audio system are the sound card, the speakers, and the supporting software All sound system problems can be narrowed down to one or more of these components

HYSTERIA (BRIQUET DISEASE; SOMATIZATION DISORDER)

FIGURE 6-1

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