Cecil APA-736 - History

Cecil APA-736 - History

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A county in Maryland.

The contract for the building of Cecil (APR-4) was cancelled 12 March 1943.

(APA-736: dp. 8,100; 1. 492'; b. 196"; dr. 26'6"; s. 18 k.;
cpl. 575; a. 2 5"; cl. Bayfield)

Cecil (APA-736) was launched as Sea Angler by Western Pipe and Steel Co, San Francisco, Calif., under a Maritime Commission contract: sponsored by Mrs. S. Belither; acquired by the Navy 26 February 1944 placed in reduced commission 27 February 1944 converted at Continental Iron Works, Portland, Oreg; and placed in full commission 15 September 1944, Captain P. G. Hale in command.

Cecil cleared San Francisco 26 November l 944 for amphibious training in the Hawaiians, and preparations for the invasion of Iwo Jima at Eniwetok and Saipan. She cleared Saipan with her task group 16 February, and 3 days later, took position off Iwo Jima for the initial assault. As naval and air bombardment pounded the island, her men skillfully played their part. Remaining off the hard-fought beaches, Cecil completed unloading troops, cargo, and vehicles, and embarked casualties, with whom she sailed 28 February to Saipan.

Cecil continued on to Tulagi and Espiritu Santo, where she loaded men and cargo of the 27th Infantry. On 9 April 1945, she landed these reinforcements through high surf on Okinawa. She remained for a week continuing her unloading under enemy air attacks, aiding in fighting them off as she loaded and landed her boats. On 16 April she got underway for Saipan and Ulithi, where she received minor repairs and replenished. On 21 May Cecil arrived in Subic Bay, P.I., for transport and training duty until 27 August, when she departed Luzon with troops and cargo of the 1st Cavalry, bound for occupation duty in Japan

Cecil called at Yokohama from 2 to 4 September 1945 then returned to the Philippines to load more occupation troops. On the return passage to Japan, she was ordered into Okinawa from 25 September to 3 October to avoid a threatening typhoon, then proceeded on to disembark her troops at Aki Nada. She sailed to San Pedro, Calif., for a minor overhaul in November, then made another voyage to the Philippines to return men and equipment to San Pedro 22 January 1946. In March she sailed to Norfolk, VA., where she was decommissioned 24 May 1946, and returned to the Maritime Commission the next day.

Cecil received two battle stars for World War II service.

Cecil Rhodes

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Cecil Rhodes, in full Cecil John Rhodes, (born July 5, 1853, Bishop’s Stortford, Hertfordshire, England—died March 26, 1902, Muizenberg, Cape Colony [now in South Africa]), financier, statesman, and empire builder of British South Africa. He was prime minister of Cape Colony (1890–96) and organizer of the giant diamond-mining company De Beers Consolidated Mines, Ltd. (1888). By his will he established the Rhodes scholarships at Oxford (1902).


An alternate, widely used classification publication is the International Classification of Diseases (ICD) is produced by the World Health Organization (WHO). [6] The ICD has a broader scope than the DSM, covering overall health as well as mental health chapter 5 of the ICD specifically covers mental and behavioural disorders. Moreover, while the DSM is the most popular diagnostic system for mental disorders in the US, the ICD is used more widely in Europe and other parts of the world, giving it a far larger reach than the DSM.

The DSM-IV-TR (4th. ed.) contains specific codes allowing comparisons between the DSM and the ICD manuals, which may not systematically match because revisions are not simultaneously coordinated. [7] Though recent editions of the DSM and ICD have become more similar due to collaborative agreements, each one contains information absent from the other. [8]

Mental health professionals use the manual to determine and help communicate a patient's diagnosis after an evaluation. Hospitals, clinics, and insurance companies in the United States may require a DSM diagnosis for all patients. [ citation needed ] Health-care researchers use the DSM to categorize patients for research purposes.

An international survey of psychiatrists in sixty-six countries compared the use of the ICD-10 and DSM-IV. It found the former was more often used for clinical diagnosis while the latter was more valued for research. [9]

DSM-5, and the abbreviations for all previous editions, are registered trademarks owned by the American Psychiatric Association. [2] [10]

Census data and report (1840–1888) Edit

The initial impetus for developing a classification of mental disorders in the United States was the need to collect statistical information. The first official attempt was the 1840 census, which used a single category: "idiocy/insanity". Three years later, the American Statistical Association made an official protest to the U.S. House of Representatives, stating that "the most glaring and remarkable errors are found in the statements respecting nosology, prevalence of insanity, blindness, deafness, and dumbness, among the people of this nation", pointing out that in many towns African-Americans were all marked as insane, and calling the statistics essentially useless. [11]

The Association of Medical Superintendents of American Institutions for the Insane was formed in 1844 it has since changed its name twice before the new millennium: in 1892 to the American Medico-Psychological Association, and in 1921 to the present American Psychiatric Association (APA).

Edward Jarvis and later Francis Amasa Walker helped expand the census, from two volumes in 1870 to twenty-five volumes in 1880. Frederick H. Wines was appointed to write a 582-page volume, published in 1888, called Report on the Defective, Dependent, and Delinquent Classes of the Population of the United States, As Returned at the Tenth Census (June 1, 1880).

Wines used seven categories of mental illness, which were also adopted by the American Medico-Psychological Association: dementia, dipsomania (uncontrollable craving for alcohol), epilepsy, mania, melancholia, monomania, and paresis. [12]

American Psychiatric Association Manual (1917) Edit

In 1917, together with the National Commission on Mental Hygiene (now Mental Health America), the American Medico-Psychological Association developed a new guide for mental hospitals called the Statistical Manual for the Use of Institutions for the Insane. This guide included twenty-two diagnoses and would be revised several times by the Association and its successor, the American Psychiatric Association (APA), over the years. [13] Along with the New York Academy of Medicine, the APA provided the psychiatric nomenclature subsection of the U.S. general medical guide, the Standard Classified Nomenclature of Disease, referred to as the Standard. [14]

Medical 203 (1943) Edit

World War II saw the large-scale involvement of U.S. psychiatrists in the selection, processing, assessment, and treatment of soldiers. This moved the focus away from mental institutions and traditional clinical perspectives. Under the direction of James Forrestal, [15] a committee headed by psychiatrist Brigadier General William C. Menninger, with the assistance of the Mental Hospital Service, [16] developed a new classification scheme called Medical 203, which was issued in 1943 as a War Department Technical Bulletin under the auspices of the Office of the Surgeon General. [17] The foreword to the DSM-I states the United States Navy had itself made some minor revisions but "the Army established a much more sweeping revision, abandoning the basic outline of the Standard and attempting to express present-day concepts of mental disturbance. This nomenclature eventually was adopted by all the armed forces, and "assorted modifications of the Armed Forces nomenclature [were] introduced into many clinics and hospitals by psychiatrists returning from military duty." The Veterans Administration also adopted a slightly modified version of Medical 203. [15]

ICD-6 (1949) Edit

In 1949, the World Health Organization published the sixth revision of the International Statistical Classification of Diseases (ICD), which included a section on mental disorders for the first time. The foreword to DSM-1 states this "categorized mental disorders in rubrics similar to those of the Armed Forces nomenclature".

DSM-1 (1952) Edit

An APA Committee, on Nomenclature and Statistics, was empowered to develop a version of Medical 203 specifically for use in the United States, to standardize the diverse and confused usage of different documents. In 1950, the APA committee undertook a review and consultation. It circulated an adaptation of Medical 203, the Standard ' s nomenclature, and the VA system's modifications of the Standard to approximately 10% of APA members: 46% of whom replied, with 93% approving the changes. After some further revisions (resulting in its being called DSM-I), the Diagnostic and Statistical Manual of Mental Disorders was approved in 1951 and published in 1952. The structure and conceptual framework were the same as in Medical 203, and many passages of text were identical. [17] The manual was 130 pages long and listed 106 mental disorders. [18] These included several categories of "personality disturbance", generally distinguished from "neurosis" (nervousness, egodystonic). [19]

In 1952, the APA listed homosexuality in the DSM as a sociopathic personality disturbance. Homosexuality: A Psychoanalytic Study of Male Homosexuals, a large-scale 1962 study of homosexuality by Irving Bieber and other authors, was used to justify inclusion of the disorder as a supposed pathological hidden fear of the opposite sex caused by traumatic parent–child relationships. This view was influential in the medical profession. [20] In 1956, however, the psychologist Evelyn Hooker performed a study comparing the happiness and well-adjusted nature of self-identified homosexual men with heterosexual men and found no difference. [20] Her study stunned the medical community and made her a heroine to many gay men and lesbians, [21] but homosexuality remained in the DSM until May 1974. [22]

DSM-II (1968) Edit

In the 1960s, there were many challenges to the concept of mental illness itself. These challenges came from psychiatrists like Thomas Szasz, who argued mental illness was a myth used to disguise moral conflicts from sociologists such as Erving Goffman, who said mental illness was another example of how society labels and controls non-conformists from behavioural psychologists who challenged psychiatry's fundamental reliance on unobservable phenomena and from gay rights activists who criticised the APA's listing of homosexuality as a mental disorder. A study published in Science, the Rosenhan experiment, received much publicity and was viewed as an attack on the efficacy of psychiatric diagnosis. [23]

The APA was closely involved in the next significant revision of the mental disorder section of the ICD (version 8 in 1968). It decided to go ahead with a revision of the DSM, which was published in 1968. DSM-II was similar to DSM-I, listed 182 disorders, and was 134 pages long. The term "reaction" was dropped, but the term "neurosis" was retained. Both the DSM-I and the DSM-II reflected the predominant psychodynamic psychiatry, [24] although both manuals also included biological perspectives and concepts from Kraepelin's system of classification. Symptoms were not specified in detail for specific disorders. Many were seen as reflections of broad underlying conflicts or maladaptive reactions to life problems that were rooted in a distinction between neurosis and psychosis (roughly, anxiety/depression broadly in touch with reality, as opposed to hallucinations or delusions disconnected from reality). Sociological and biological knowledge was incorporated, under a model that did not emphasize a clear boundary between normality and abnormality. [25] The idea that personality disorders did not involve emotional distress was discarded. [19]

An influential 1974 paper by Robert Spitzer and Joseph L. Fleiss demonstrated that the second edition of the DSM (DSM-II) was an unreliable diagnostic tool. [26] Spitzer and Fleiss found that different practitioners using the DSM-II rarely agreed when diagnosing patients with similar problems. In reviewing previous studies of eighteen major diagnostic categories, Spitzer and Fleiss concluded that "there are no diagnostic categories for which reliability is uniformly high. Reliability appears to be only satisfactory for three categories: mental deficiency, organic brain syndrome (but not its subtypes), and alcoholism. The level of reliability is no better than fair for psychosis and schizophrenia and is poor for the remaining categories". [23]

Seventh printing of the DSM-II (1974) Edit

As described by Ronald Bayer, a psychiatrist and gay rights activist, specific protests by gay rights activists against the APA began in 1970, when the organization held its convention in San Francisco. The activists disrupted the conference by interrupting speakers and shouting down and ridiculing psychiatrists who viewed homosexuality as a mental disorder. In 1971, gay rights activist Frank Kameny worked with the Gay Liberation Front collective to demonstrate at the APA's convention. At the 1971 conference, Kameny grabbed the microphone and yelled: "Psychiatry is the enemy incarnate. Psychiatry has waged a relentless war of extermination against us. You may take this as a declaration of war against you." [27]

This gay activism occurred in the context of a broader anti-psychiatry movement that had come to the fore in the 1960s and was challenging the legitimacy of psychiatric diagnosis. Anti-psychiatry activists protested at the same APA conventions, with some shared slogans and intellectual foundations as gay activists. [28] [29]

Taking into account data from researchers such as Alfred Kinsey and Evelyn Hooker, the seventh printing of the DSM-II, in 1974, no longer listed homosexuality as a category of disorder. After a vote by the APA trustees in 1973, and confirmed by the wider APA membership in 1974, the diagnosis was replaced with the category of "sexual orientation disturbance". [30]

DSM-III (1980) Edit

In 1974, the decision to create a new revision of the DSM was made, and Robert Spitzer was selected as chairman of the task force. The initial impetus was to make the DSM nomenclature consistent with that of the International Classification of Diseases (ICD). The revision took on a far wider mandate under the influence and control of Spitzer and his chosen committee members. [31] One added goal was to improve the uniformity and validity of psychiatric diagnosis in the wake of a number of critiques, including the famous Rosenhan experiment. There was also felt a need to standardize diagnostic practices within the United States and with other countries, after research showed that psychiatric diagnoses differed between Europe and the United States. [32] The establishment of consistent criteria was an attempt to facilitate the pharmaceutical regulatory process.

The criteria adopted for many of the mental disorders were taken from the Research Diagnostic Criteria (RDC) and Feighner Criteria, which had just been developed by a group of research-orientated psychiatrists based primarily at Washington University in St. Louis and the New York State Psychiatric Institute. Other criteria, and potential new categories of disorder, were established by consensus during meetings of the committee chaired by Spitzer. A key aim was to base categorization on colloquial English (which would be easier to use by federal administrative offices), rather than by assumption of cause, although its categorical approach still assumed each particular pattern of symptoms in a category reflected a particular underlying pathology (an approach described as "neo-Kraepelinian"). The psychodynamic or physiologic view was abandoned, in favor of a regulatory or legislative model. A new "multiaxial" system attempted to yield a picture more amenable to a statistical population census, rather than a simple diagnosis. Spitzer argued "mental disorders are a subset of medical disorders", but the task force decided on this statement for the DSM: "Each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome." [24] Personality disorders were placed on axis II along with mental retardation. [19]

The first draft of DSM-III was ready within a year. It introduced many new categories of disorder, while deleting or changing others. A number of unpublished documents discussing and justifying the changes have recently come to light. [33] Field trials sponsored by the U.S. National Institute of Mental Health (NIMH) were conducted between 1977 and 1979 to test the reliability of the new diagnoses. A controversy emerged regarding deletion of the concept of neurosis, a mainstream of psychoanalytic theory and therapy but seen as vague and unscientific by the DSM task force. Faced with enormous political opposition, DSM-III was in serious danger of not being approved by the APA Board of Trustees unless "neurosis" was included in some form a political compromise reinserted the term in parentheses after the word "disorder" in some cases. Additionally, the diagnosis of ego-dystonic homosexuality replaced the DSM-II category of "sexual orientation disturbance".

Finally published in 1980, DSM-III listed 265 diagnostic categories and was 494 pages long. It rapidly came into widespread international use and has been termed a revolution, or transformation, in psychiatry. [24] [25]

When DSM-III was published, the developers made extensive claims about the reliability of the radically new diagnostic system they had devised, which relied on data from special field trials. However, according to a 1994 article by Stuart A. Kirk:

Twenty years after the reliability problem became the central focus of DSM-III, there is still not a single multi-site study showing that DSM (any version) is routinely used with high reliably by regular mental health clinicians. Nor is there any credible evidence that any version of the manual has greatly increased its reliability beyond the previous version. There are important methodological problems that limit the generalisability of most reliability studies. Each reliability study is constrained by the training and supervision of the interviewers, their motivation and commitment to diagnostic accuracy, their prior skill, the homogeneity of the clinical setting in regard to patient mix and base rates, and the methodological rigor achieved by the investigator. [23]

DSM-III-R (1987) Edit

In 1987, DSM-III-R was published as a revision of the DSM-III, under the direction of Spitzer. Categories were renamed and reorganized, with significant changes in criteria. Six categories were deleted while others were added. Controversial diagnoses, such as pre-menstrual dysphoric disorder and masochistic personality disorder, were considered and discarded. "Ego-dystonic homosexuality" was also removed and was largely subsumed under "sexual disorder not otherwise specified", which could include "persistent and marked distress about one's sexual orientation." [24] [34] Altogether, the DSM-III-R contained 292 diagnoses and was 567 pages long. Further efforts were made for the diagnoses to be purely descriptive, although the introductory text stated for at least some disorders, "particularly the Personality Disorders, the criteria require much more inference on the part of the observer" [p. xxiii]. [19]

DSM-IV (1994) Edit

In 1994, DSM-IV was published, listing 410 disorders in 886 pages. The task force was chaired by Allen Frances and was overseen by a steering committee of twenty-seven people, including four psychologists. The steering committee created thirteen work groups of five to sixteen members, each work group having about twenty advisers in addition. The work groups conducted a three-step process: first, each group conducted an extensive literature review of their diagnoses then, they requested data from researchers, conducting analyses to determine which criteria required change, with instructions to be conservative finally, they conducted multicenter field trials relating diagnoses to clinical practice. [35] [36] A major change from previous versions was the inclusion of a clinical-significance criterion to almost half of all the categories, which required symptoms causing "clinically significant distress or impairment in social, occupational, or other important areas of functioning". Some personality-disorder diagnoses were deleted or moved to the appendix. [19]

DSM-IV Definitions Edit

The DSM-IV characterizes a mental disorder as "a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significant increased risk of suffering death, pain, disability, or an important loss of freedom" [37] It also notes that "although this manual provides a classification of mental disorders it must be admitted that no definition adequately specifies precise boundaries for the concept of 'mental disorder." [38]

DSM-IV Categorization Edit

The DSM-IV is a categorical classification system. The categories are prototypes, and a patient with a close approximation to the prototype is said to have that disorder. DSM-IV states, "there is no assumption each category of mental disorder is a completely discrete entity with absolute boundaries" but isolated, low-grade, and non-criterion (unlisted for a given disorder) symptoms are not given importance. [39] Qualifiers are sometimes used: for example, to specify mild, moderate, or severe forms of a disorder. For nearly half the disorders, symptoms must be sufficient to cause "clinically significant distress or impairment in social, occupational, or other important areas of functioning", although DSM-IV-TR removed the distress criterion from tic disorders and several of the paraphilias due to their egosyntonic nature. Each category of disorder has a numeric code taken from the ICD coding system, used for health service (including insurance) administrative purposes.

DSM-IV multi-axial system Edit

The DSM-IV was organized into a five-part axial system. Axis I provided information about clinical disorders, or any mental condition other than personality disorders and what was referred to in DSM editions prior to DSM-V as mental retardation. Those were both covered on Axis II. Axis III covered medical conditions that could impact a person's disorder or treatment of a disorder and Axis IV covered psychosocial and environmental factors affecting the person. Axis V was the GAF, or global assessment of functioning, which was basically a numerical score between 0 and 100 that measured how much a person's psychological symptoms impacted their daily life. [ citation needed ]

DSM-IV Sourcebooks Edit

The DSM-IV does not specifically cite its sources, but there are four volumes of "sourcebooks" intended to be APA's documentation of the guideline development process and supporting evidence, including literature reviews, data analyses, and field trials. [40] [41] [42] [43] The sourcebooks have been said to provide important insights into the character and quality of the decisions that led to the production of DSM-IV, and the scientific credibility of contemporary psychiatric classification. [44] [45]

DSM-IV-TR (2000) Edit

A text revision of DSM-IV, titled DSM-IV-TR, was published in 2000. The diagnostic categories were unchanged as were the diagnostic criteria for all but 9 diagnoses. [46] The majority of the text was unchanged however, the text of two disorders, pervasive developmental disorder not otherwise specified and Asperger's disorder, had significant and/or multiple changes made. The definition of pervasive developmental disorder not otherwise specified was changed back to what it was in DSM-III-R and the text for Asperger's disorder was practically entirely rewritten. Most other changes were to the associated features sections of diagnoses that contained additional information such as lab findings, demographic information, prevalence, course. Also, some diagnostic codes were changed to maintain consistency with ICD-9-CM . [47]

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the DSM-5, was approved by the Board of Trustees of the APA on December 1, 2012. [48] Published on May 18, 2013, [49] the DSM-5 contains extensively revised diagnoses and, in some cases, broadens diagnostic definitions while narrowing definitions in other cases. [50] The DSM-5 is the first major edition of the manual in 20 years. [51]

A significant change in the fifth edition is the deletion of the subtypes of schizophrenia: paranoid, disorganized, catatonic, undifferentiated, and residual. [52] The deletion of the subsets of autistic spectrum disorder—namely, Asperger's syndrome, classic autism, Rett syndrome, childhood disintegrative disorder and pervasive developmental disorder not otherwise specified—was also implemented, with specifiers regarding intensity: mild, moderate, and severe.

Severity is based on social communication impairments and restricted, repetitive patterns of behaviour, with three levels:

  1. requiring support
  2. requiring substantial support
  3. requiring very substantial support

During the revision process, the APA website periodically listed several sections of the DSM-5 for review and discussion. [53]

Future revisions and updates Edit

Beginning with the fifth edition, it is intended that subsequent revisions will be added more often, to keep up with research in the field. [54] It is notable that DSM-5 uses Arabic rather than Roman numerals. Beginning with DSM-5, the APA will use decimals to identify incremental updates (e.g., DSM-5.1, DSM-5.2) and whole numbers for new editions (e.g., DSM-5, DSM-6), [55] similar to the scheme used for software versioning.

Reliability and validity Edit

The revisions of the DSM from the 3rd Edition forward have been mainly concerned with diagnostic reliability—the degree to which different diagnosticians agree on a diagnosis. Henrik Walter argued that psychiatry as a science can only advance if diagnosis is reliable. If clinicians and researchers frequently disagree about the diagnosis of a patient, then research into the causes and effective treatments of those disorders cannot advance. Hence, diagnostic reliability was a major concern of DSM-III. When the diagnostic reliability problem was thought to be solved, subsequent editions of the DSM were concerned mainly with "tweaking" the diagnostic criteria. Unfortunately, neither the issue of reliability or validity was settled. [56] [ better source needed ]

In 2013, shortly before the publication of DSM-5, the director of the National Institute of Mental Health (NIMH), Thomas R. Insel, declared that the agency would no longer fund research projects that relied exclusively on DSM diagnostic criteria, due to its lack of validity. [57] Insel questioned the validity of the DSM classification scheme because "diagnoses are based on a consensus about clusters of clinical symptoms" as opposed to "collecting the genetic, imaging, physiologic, and cognitive data to see how all the data – not just the symptoms – cluster and how these clusters relate to treatment response." [58] [59]

Field trials of DSM-5 brought the debate of reliability back into the limelight, as the diagnoses of some disorders showed poor reliability. For example, a diagnosis of major depressive disorder, a common mental illness, had a poor reliability kappa statistic of 0.28, indicating that clinicians frequently disagreed on diagnosing this disorder in the same patients. The most reliable diagnosis was major neurocognitive disorder, with a kappa of 0.78. [60]

Superficial symptoms Edit

By design, the DSM is primarily concerned with the signs and symptoms of mental disorders, rather than the underlying causes. It claims to collect them together based on statistical or clinical patterns. As such, it has been compared to a naturalist's field guide to birds, with similar advantages and disadvantages. [61] The lack of a causative or explanatory basis, however, is not specific to the DSM, but rather reflects a general lack of pathophysiological understanding of psychiatric disorders. As DSM-III chief architect Robert Spitzer and DSM-IV editor Michael First outlined in 2005, "little progress has been made toward understanding the pathophysiological processes and cause of mental disorders. If anything, the research has shown the situation is even more complex than initially imagined, and we believe not enough is known to structure the classification of psychiatric disorders according to etiology." [62]

"The DSM's focus on superficial symptoms is claimed to be largely a result of necessity (assuming such a manual is necessary at all), since there is no agreement on a more explanatory classification system. Reviewers note, however, that this approach is undermining research, including in genetics, because it results in the grouping of individuals who have very little in common except superficial criteria as per a DSM or ICD-based diagnosis." [63] [2] [64]

"Despite the lack of consensus on underlying causation, advocates for specific psychopathological paradigms have nonetheless faulted the current diagnostic scheme for not incorporating evidence-based models or findings from other areas of science. A recent example is evolutionary psychologists' criticism that the DSM does not differentiate between genuine cognitive malfunctions and those induced by psychological adaptations, a key distinction within evolutionary psychology but one that is widely challenged within general psychology." [63] [65] [66] [67] Another example is the strong operationalist viewpoint, which contends that reliance on operational definitions, as purported by the DSM, necessitates that intuitive concepts like depression be replaced by specific measurable concepts before they are scientifically meaningful. One critic states of psychologists that "Instead of replacing 'metaphysical' terms such as 'desire' and 'purpose', they used it to legitimize them by giving them operational definitions. the initial, quite radical operationalist ideas eventually came to serve as little more than a 'reassurance fetish' (Koch 1992) for mainstream methodological practice." [68] [69]

A 2013 review published in the European Archives of Psychiatry and Clinical Neuroscience states "that psychiatry targets the phenomena of consciousness, which, unlike somatic symptoms and signs, cannot be grasped on the analogy with material thing-like objects." As an example of the problem of the superficial characterization of psychiatric signs and symptoms, the authors gave the example of a patient saying they "feel depressed, sad, or down," showing that such a statement could indicate various underlying experiences: "not only depressed mood but also, for instance, irritation, anger, loss of meaning, varieties of fatigue, ambivalence, ruminations of different kinds, hyper-reflectivity, thought pressure, psychological anxiety, varieties of depersonalization, and even voices with negative content, and so forth." The structured interview comes with a "danger of over confidence in the face value of the answers, as if a simple 'yes' or 'no' truly confirmed or denied the diagnostic criterion at issue." The authors gave an example: A patient who was being administered the Structured Clinical Interview for the DSM-IV Axis I Disorders denied thought insertion, but during a "conversational, phenomenological interview", a semi-structured interview tailored to the patient, the same patient admitted to experiencing thought insertion, along with a delusional elaboration. The authors suggested 2 reasons for this discrepancy: either the patient did not "recognize his own experience in the rather blunt, implicitly either/or formulation of the structured-interview question", or the experience did not "fully articulate itself" until the patient started talking about his experiences. [70]

Overdiagnosis Edit

Dr. Allen Frances, an outspoken critic of DSM-5, states that "normality is an endangered species," because of "fad diagnoses" and an "epidemic" of over-diagnosing, and suggests that the "DSM-5 threatens to provoke several more [epidemics]." [71] [72] Some researchers state that changes in diagnostic criteria, following each published version of the DSM, reduce thresholds for a diagnosis, which results in increases in prevalence rates for ADHD and autism spectrum disorder. [73] [74] [75] [76] Bruchmüller, et al. (2012) suggest that as a factor that may lead to overdiagnosis are situations when the clinical judgment of the diagnostician regarding a diagnosis (ADHD) is affected by heuristics. [74]

Dividing lines Edit

Despite caveats in the introduction to the DSM, it has long been argued that its system of classification makes unjustified categorical distinctions between disorders and uses arbitrary cut-offs between normal and abnormal. A 2009 psychiatric review noted that attempts to demonstrate natural boundaries between related DSM syndromes, or between a common DSM syndrome and normality, have failed. [2] Some argue that rather than a categorical approach, a fully dimensional, spectrum or complaint-oriented approach would better reflect the evidence. [77] [78] [79]

In addition, it is argued that the current approach based on exceeding a threshold of symptoms does not adequately take into account the context in which a person is living, and to what extent there is internal disorder of an individual versus a psychological response to adverse situations. [80] The DSM does include a step ("Axis IV") for outlining "Psychosocial and environmental factors contributing to the disorder" once someone is diagnosed with that particular disorder.

Because an individual's degree of impairment is often not correlated with symptom counts and can stem from various individual and social factors, the DSM's standard of distress or disability can often produce false positives. [81] On the other hand, individuals who do not meet symptom counts may nevertheless experience comparable distress or disability in their life.

Cultural bias Edit

Psychiatrists have argued that published diagnostic standards rely on an exaggerated interpretation of neurophysiological findings and so understate the scientific importance of social-psychological variables. [82] Advocating a more culturally sensitive approach to psychology, critics such as Carl Bell and Marcello Maviglia contend that researchers and service-providers often discount the cultural and ethnic diversity of individuals. [83] In addition, current diagnostic guidelines have been criticized [ by whom? ] as having a fundamentally Euro-American outlook. Although these guidelines have been widely implemented, opponents argue that even when a diagnostic criterion-set is accepted across different cultures, it does not necessarily indicate that the underlying constructs have any validity within those cultures even reliable application can only demonstrate consistency, not legitimacy. [82] Cross-cultural psychiatrist Arthur Kleinman contends that Western bias is ironically illustrated in the introduction of cultural factors to the DSM-IV: the fact that disorders or concepts from non-Western or non-mainstream cultures are described as "culture-bound", whereas standard psychiatric diagnoses are given no cultural qualification whatsoever, is to Kleinman revelatory of an underlying assumption that Western cultural phenomena are universal. [84] Other cross-cultural critics largely share Kleinman's negative view toward the culture-bound syndrome, common responses [ by whom? ] included both disappointment over the large number of documented non-Western mental disorders still left out, and frustration that even those included were often misinterpreted or misrepresented. [85]

Mainstream psychiatrists have also been dissatisfied with these new culture-bound diagnoses, although not for the same reasons. Robert Spitzer, a lead architect of DSM-III, has held the opinion that the addition of cultural formulations was an attempt to placate cultural critics, and that they lack any scientific motivation or support. Spitzer also posits that the new culture-bound diagnoses are rarely used in practice, maintaining that the standard diagnoses apply regardless of the culture involved. In general, the mainstream psychiatric opinion remains that if a diagnostic category is valid, cross-cultural factors are either irrelevant or are only significant to specific symptom presentations. [82] One result of this dissatisfaction was the development of the Azibo Nosology by Daudi Ajani Ya Azibo in 1989 as an alternative to the DSM in treating patients of the African diaspora. [86] [87] [88]

Historically, the DSM tended to avoid issues involving religion the DSM-5 relaxed this attitude somewhat. [89]

Medicalization and financial conflicts of interest Edit

There was extensive analysis and comment on DSM-IV (published in 1994) in the years leading up to the 2013 publication of DSM-5. It was alleged that the way the categories of DSM-IV were structured, as well as the substantial expansion of the number of categories within it, represented increasing medicalization of human nature, very possibly attributable to disease mongering by psychiatrists and pharmaceutical companies, the power and influence of the latter having grown dramatically in recent decades. [90] In 2005, then APA President Steven Sharfstein released a statement in which he conceded that psychiatrists had "allowed the biopsychosocial model to become the bio-bio-bio model". [91] It was reported that of the authors who selected and defined the DSM-IV psychiatric disorders, roughly half had financial relationships with the pharmaceutical industry during the period 1989–2004, raising the prospect of a direct conflict of interest. The same article concluded that the connections between panel members and the drug companies were particularly strong involving those diagnoses where drugs are the first line of treatment, such as schizophrenia and mood disorders, where 100% of the panel members had financial ties with the pharmaceutical industry.

William Glasser referred to DSM-IV as having "phony diagnostic categories", arguing that "it was developed to help psychiatrists – to help them make money". [92] A 2012 article in The New York Times commented sharply that DSM-IV (then in its 18th year), through copyrights held closely by the APA, had earned the Association over $100 million. [93]

However, although the number of identified diagnoses had increased by more than 300% (from 106 in DSM-I to 365 in DSM-IV-TR), psychiatrists such as Zimmerman and Spitzer argued that this almost entirely represented greater specification of the forms of pathology, thereby allowing better grouping of similar patients. [2]

Clients, survivors, and consumers Edit

A client is a person who accesses psychiatric services and may have been given a diagnosis from the DSM, while a survivor self-identifies as a person who has endured a psychiatric intervention and the mental health system (which may have involved involuntary commitment and involuntary treatment). [ citation needed ] A term adopted by many users of psychiatric services is "consumer". This term was chosen to eliminate the "patient" label and restore the person to an active role as a user or consumer of services. [94] Some individuals are relieved to find that they have a recognized condition that they can apply a name to and this has led to many people self-diagnosing. [ citation needed ] Others, however, question the accuracy of the diagnosis, or feel they have been given a label that invites social stigma and discrimination (the terms "mentalism" and "sanism" have been used to describe such discriminatory treatment). [95]

Diagnoses can become internalized and affect an individual's self-identity, and some psychotherapists have found that the healing process can be inhibited and symptoms can worsen as a result. [96] Some members of the psychiatric survivors movement (more broadly the consumer/survivor/ex-patient movement) actively campaign against their diagnoses, or the assumed implications, or against the DSM system in general. [97] [98] Additionally, it has been noted that the DSM often uses definitions and terminology that are inconsistent with a recovery model, and such content can erroneously imply excess psychopathology (e.g. multiple "comorbid" diagnoses) or chronicity. [98]

Critiques of DSM-5 Edit

Psychiatrist Allen Frances has been critical of proposed revisions to the DSM-5. In a 2012 New York Times editorial, Frances warned that if this DSM version is issued unamended by the APA, "it will medicalize normality and result in a glut of unnecessary and harmful drug prescription." [99]

In a December 2012, blog post on Psychology Today, Frances provides his "list of DSM 5's ten most potentially harmful changes:" [100]

  • Disruptive Mood Dysregulation Disorder, for temper tantrums
  • Major Depressive Disorder, includes normal grief
  • Minor Neurocognitive Disorder, for normal forgetfulness in old age
  • Adult Attention Deficit Disorder, encouraging psychiatric prescriptions of stimulants
  • Binge Eating Disorder, for excessive eating
  • Autism, defining the disorder more specifically, possibly leading to decreased rates of diagnosis and the disruption of school services
  • First-time drug users will be lumped in with addicts
  • Behavioral Addictions, making a "mental disorder of everything we like to do a lot."
  • Generalized Anxiety Disorder, includes everyday worries
  • Post-traumatic stress disorder, changes "opened the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings." [100]

A group of 25 psychiatrists and researchers, among whom were Frances and Thomas Szasz, have published debates on what they see as the six most essential questions in psychiatric diagnosis: [101]

  • Are they more like theoretical constructs or more like diseases?
  • How to reach an agreed definition?
  • Should the DSM-5 take a cautious or conservative approach?
  • What is the role of practical rather than scientific considerations?
  • How should it be used by clinicians or researchers?
  • Is an entirely different diagnostic system required?

In 2011, psychologist Brent Robbins co-authored a national letter for the Society for Humanistic Psychology that has brought thousands into the public debate about the DSM. Over 15,000 individuals and mental health professionals have signed a petition in support of the letter. [102] Thirteen other APA divisions have endorsed the petition. [103] Robbins has noted that under the new guidelines, certain responses to grief could be labeled as pathological disorders, instead of being recognized as being normal human experiences. [104]

Austin Flint Murmur

Mechanism: Occurs in aortic regurgitation as a result of the vibration of the anterior leaflet of the mitral valve due to the regurgitant jets from the left atrium and aorta. The striking of these regurgitant jets often cause the premature closure of the mitral leaflets, commonly mistaken for mitral stenosis.

Sign Value: Opinions vary, most likely to be heard in the setting of severe AR. Sensitivities range from 25 to 100% depending on the study. One review suggested the murmur to predict moderate-severe AR with a likelihood ratio of 25.

  • The absence of an opening snap and loud S1 distinguishes the pure aortic regurgitation of an Austin flint murmur from that of mitral stenosis
  • An ECG may show a sinus rhythm with left ventricular hypertrophy, left axis deviation and prolonged PR interval.
History of the Austin Flint Murmur

1862 – Flint published his extremely detailed account ‘On Cardiac Murmurs‘ and in depth analysis of cardiac murmurs in the setting of valvular heart disease. He described, for the first time, a presystolic murmur in the setting of aortic regurgitation.

The murmur is oftener rough than soft. The roughness is often peculiar. It is a blubbering sound, resembling that produced by throwing the lips or the tongue into vibration with the breath of respiration

Austin Flint, On Cardiac Murmurs 1862: 50

Two patients, both with signs of with aortic regurgitation and aortic stenosis, and with the described distinct presystolic murmur at the apex were found to have normal mitral valves without gross pathology at postmortem.

In some cases in which free aortic regurgitation exists, the left ventricle becoming filled before the auricles contract, the mitral curtains are floated out and the valve closed when the mitral current takes place, and, under the circumstance, the murmur may be produced by the current just named, although no mitral lesion exists.

Austin Flint, On Cardiac Murmurs 1862:53

95-year-old becomes oldest organ donor in US history

Cecil Lockhart, a 95-year-old man from West Virginia, recently became the oldest organ donor in United States history after he died last week.

Cecil Lockhart, of Welch, West Virginia died on May 4, and his liver was donated to a woman in her 60’s.

The Center for Organ Recovery & Education (CORE) announced the news on Monday.

“CORE is incredibly proud to have been able to make this historic organ donation possible,” said Susan Stuart, CORE president & CEO. “This landmark in the field of transplantation is just another example of CORE’s pioneering legacy and commitment to innovation, which, over the last 40 years, has given 6,000 people in the United States the opportunity to save more than 15,000 others as organ donors.”

Lockhart’s family said he chose to become an organ donor over 10 years ago after his son Stanley passed away and helped heal 75 lives through tissue and cornea donation following his death.

Cecil is survived by his wife Helen, who he was married to for 75 years. He is also survived by his daughter, Sharon White, and his son Brian Lockhart, in addition to grandchildren and great-grandchildren.

“He was a generous person when he was alive, and we are filled with pride and hope knowing that, even after a long, happy life, he is able to continue that legacy of generosity,” Cecil’s daughter, Sharon White, said. “When my brother was a donor after he passed away a few years ago, it helped my dad to heal. And today, knowing his life is continuing through others really is helping us through our grief too.”

Another serial killer, Austrian Jack Unterweger, also frequented the Cecil

Unterweger was suspected of killing nearly a dozen women, primarily sex workers, in both Austria and the United States from 1990 to 1991.

While he was in California, three sex workers were strangled with their own bras — much like Unterweger's Austrian victims.

Unterweger himself stayed at the Cecil during his trip to Los Angeles, in what some suspect was a macabre tribute to his fellow serial killer, Ramirez.

The native Austrian was later apprehended in Miami after fleeing law enforcement in both Europe and the United States.

Story [ edit | edit source ]

Final Fantasy IV [ edit | edit source ]

Cecil was born to a Lunarian named Kluya and a woman named Cecilia from Earth. Cecil's father was killed before he was born, and his mother died in labor. His older brother, Theodor, ran away with the newborn, but abandoned him. The King of Baron found him and named him Cecil, since he resembled his late mother.

Cecil was raised by the king, initially causing friction between him and the young Kain Highwind who thought Cecil received special treatment and wanted to fight him, but Rosa intervened. As the three grew up, they became close friends. Kain and Rosa followed in the footsteps of their parents and became a Dragoon and a White Mage respectively, while the king had Cecil train to be a Dark Knight. Cecil harnessed the job's dark powers and became one of the kingdom's top warriors and was promoted the captain of Baron's airship fleet, the Red Wings. Cecil had a strong bond with Baron's airship engineer, Cid Pollendina, whom he viewed almost like a father to him. Α]

Cecil talking to the King of Baron.

Cecil commands a raid on the town Mysidia to steal the Water Crystal for the king. He succeeds, but he and his crew grow suspicious of the king, wondering whether robbing national treasures from innocent people is right. Cecil reminds his crew they are the Red Wings, and must represent Baron at all times.

When Cecil returns to Baron Castle, Baigan, the captain of the guards of Baron, notices something strange about Cecil, and takes him to meet the king. Cecil hands over the Crystal, and is appalled the king does not even thank him. Cecil complains he and his crew do not understand the reasons for robbing Crystals from innocent people.

The king discharges Cecil from the captaincy and orders him to hunt Eidolons in the Mist Valley, and to deliver the Carnelian Signet to the village of Mist. Kain comes to Cecil's defense, but the king orders him to accompany Cecil. That night, Rosa comes to Cecil's room to show him sympathy. Cecil is torn between doing what he believes in and doing what the king orders and swears to never perform another act of evil on behalf of Baron. Despite loving Rosa, he knows they can never be together because of his profession as a Dark Knight.

Cecil and Kain leaving Baron, from the official novelization.

The next morning, Cecil and Kain leave for Mist. They pass through the Mist Cave where a voice orders them to return to Baron, and when Cecil and Kain refuse, the mist gathers and the pair battles the Mist Dragon. After slaying the dragon they head to Mist, but the package they were supposed to deliver turns out to be an incendiary bomb that torches the village. A little girl who stays alongside her dead mother explains that whenever a summoned monster dies, its summoner dies as well. Cecil and Kain realize they defeated the Mist Dragon and thus accidentally killed the girl's mother, and offer to take her to safety and pledge not to follow any more orders from the king. She does not listen and summons Titan and an earthquake separates Mist from the rest of the valley.

Cecil wakes up with Kain gone and the girl lying wounded. Cecil takes her to Kaipo and allows her to recover at the inn, but she refuses to speak to him. That night soldiers from Baron arrive and demand Cecil hand over the girl, saying the king decreed the summoners of Mist too dangerous to be left alive. Cecil does not allow the soldiers to kidnap her, and fights them off. The next morning the girl thanks Cecil for protecting her, introduces herself as Rydia of Mist and joins Cecil's party formally.

Cecil and Rydia hear of a sick girl from Baron who had contracted Desert Fever and find Rosa resting in a nearby home. The doctors say they have to find the Sand Pearl to cure her and Cecil and Rydia go north through the Underground Waterway to Damcyan meeting an old man, Tellah, on the way. The three arrive at Damcyan in time to see the Red Wings, now commanded by a man called Golbez, steal the Fire Crystal and find Tellah's daughter, Anna, who dies of her wounds. Tellah vows revenge on Golbez and leaves despite Cecil's protests.

Anna's lover, Prince Edward, mourns for her death but Cecil and Rydia snap him out of it. Cecil tells him he is now the king of Damcyan and must act as such. Edward agrees to take them to the Antlion's Den where they find the Sand Pearl and use it to cure Rosa. They decide to defend the remaining Crystals, deducing the Air Crystal in Fabul the next target.

To reach Fabul, the party crosses Mt. Hobs, and on the summit finds a Monk named Yang Fang Leiden fighting off Golbez's troops. Cecil and his friends help Yang defeat them. Cecil warns Yang of the danger ahead, and joins Yang in the journey back to Fabul.

In Fabul, Yang warns the king of Baron's incoming attack, and Cecil and Edward back him up. The king is skeptical because he cannot trust the Dark Knight Cecil. Yang convinces him of Cecil's loyalty, and Cecil, Yang, and Edward help defend the castle with Rosa and Rydia put on relief. After the battle against the Baronian army, Kain, who is now working for Golbez, corners Cecil in the crystal room. The two duel, but Cecil fails to beat Kain. Golbez defeats Edward and Yang and takes Rosa hostage, while Kain takes the Crystal.

Cecil decides to sneak into Baron and get an airship from Cid Pollendina, who was also skeptical of Baron's activities. The party boards a ship provided by the king of Fabul and sets sail to Baron, but on the way the ship is attacked by Leviathan and Cecil, Rydia, Edward, and Yang are blown off the deck.

Cecil lands on a beach near Mysidia, the town he raided as the captain of the Red Wings, and learns he is unwanted. Cecil meets the Elder of Mysidia and explains him his plight. The Elder tells Cecil if he wants to defeat Golbez he would have to relinquish his Dark Sword and acquire the acceptance of the Holy Light by becoming a Paladin. Cecil accepts the challenge, and the Elder sends him to Mount Ordeals with Palom, a Black Mage, and Porom, a White Mage. On Mount Ordeals they meet Tellah again, who has been searching for the legendary magic Meteor to defeat Golbez.

Tellah agrees to help them and at the mountain summit they arrive at a room full of mirrors, and a mysterious light who refers to Cecil as "my son" commands him to take a sword, which transforms him into a Paladin. Cecil has to overcome his hatred by facing himself as a Dark Knight. Succeeding by not raising his sword against his darkness, Cecil becomes a full-fledged Paladin. Tellah learns Meteor but finds he is not strong enough to cast it.

Cecil's transition into a Paladin in the opening FMV.

Cecil, Tellah, Palom, and Porom return to Mysidia where the Elder congratulates them and speaks of the Mysidian Legend of the sword Cecil now holds, and how only a chosen one can wield it. Cecil agrees to defeat Golbez and the Elder opens the Devil's Road to Baron where Cecil and his friends learn Cid has a new airship, but was arrested when he refused to let the king see it. Cecil tries to enter the castle, but the guards stop him.

Cecil overhears a martial-artist was invited to be an officer in Baron, and that he hangs out at the inn. Cecil discovers it is Yang who orders the guards to attack Cecil, and then attacks him himself. Cecil snaps Yang back to reality, and Yang realizes he was under the control of the king of Baron. Yang rejoins Cecil's party and finds the Key of Baron in his pocket, which the party uses to enter Baron Castle via the Ancient Waterway.

Cecil's party reaches the castle and meets up with Baigan who tells Cecil he is not under Golbez's control, and that he is loyal only to the King of Baron. He offers to help Cecil, and Cecil accepts it, but Palom and Porom smell a monster in the area and point Baigan out. Cecil's party fights Baigan, and Cecil meets the king who is upset Cecil has become a Paladin. When Cecil mentions the king of Baron's true name, the king lets out that he killed the real king, and Cecil demands the king reveal himself.

The king is Cagnazzo, the Archfiend of Water, whom Cecil's party defeats in battle. Cid escapes prison and joins Cecil's party, but Cagnazzo has one last trick up his sleeve: when Cecil tries to escape, the walls cave in. Palom and Porom save Cecil's party by petrifying themselves to hold the walls back. Tellah tries to heal them, but to no avail, and Cid takes them to his newest airship: the Enterprise.

Kain issues an ultimatum: Cecil must either get the Earth Crystal in Troia or Rosa will die. In Troia Cecil learns from the Epopts that the Dark Elf, a monster who lives in Lodestone Cavern to the north, has stolen the Crystal. He finds Edward recovering from the Leviathan attack who gives Cecil a Whisperweed as he is too weak to help Cecil out.

Cecil's party heads to the cave to meet with the Dark Elf, but the cave is covered in a magnetic field and Cecil and his friends cannot equip metallic weapons or armor. The Dark Elf thus defeats Cecil. Edward plays a melody on his harp and the Whisperweed reacts making the Dark Elf lose control of himself and allowing Cecil to attack him with his sword. Cecil claims the Earth Crystal and he and his party return to Troia, where Kain makes him get on the Enterprise.

Kain guides Cecil's party to the Tower of Zot where Golbez is holding Rosa prisoner. Cecil's party climbs the tower and meets Golbez at the top who takes the Crystal but does not free Rosa. Tellah wounds Golbez by casting Meteor and Cecil rushes forward to strike, but Golbez knocks him down. As Golbez is about to strike the finishing blow he stops and backs away, silently realizing Cecil is his younger brother. He tells Cecil it is not over, and escapes. Everyone surrounds Tellah, who is dying due to the effects of casting Meteor. He asks Cecil, Yang, and Cid to avenge Anna for him, and dies.

Kain is freed of Golbez's control and takes the party to Rosa and Cecil, who share a kiss. Rosa and Kain join the group, but they cannot escape the tower without fighting Barbariccia, the Archfiend of Air. Before she dies, Barbariccia tries to kill the party by collapsing the tower, but Rosa casts the Exit spell and the party is warped to Cecil's room in Baron.

Golbez now possesses all four Crystals, but Kain speaks of the Dark Crystals hidden in the Underworld and explains Golbez needs the Crystals to open "the way to the Moon". Cecil decides to head underground to protect the remaining Crystals and Kain shows Cecil the Key of Magma used to enter the Underworld. The party enters the Underworld via the Enterprise, but they are too late: the Red Wings are already battling the dwarves' tanks.

The Enterprise is damaged and Cecil's party seeks help from the dwarves in the Dwarven Castle where they meet King Giott. He asks the party for help, but Cid has to take a leave of absence to repair the Enterprise and wrap its body in Mystic Silver to help the airship withstand the intense heat of the Underworld. Yang senses something in the crystal room behind the throne and Giott opens it up for Cecil's party. They find Luca's dolls, the Calcabrina, under Golbez's control and Cecil's party defeats them.

Golbez shows up and places the party in a magical hold. He summons the Shadow Dragon to eliminate everyone except for Cecil. The Mist Dragon appears and defeats the Shadow Dragon releasing Cecil and an adult Rydia appears and defeats Golbez. The party, Cecil and Rosa in particular, are happy to see Rydia who has been living in the Feymarch ever since the Leviathan incident and thus aged into adulthood in a faster pace than normal, and she offers her help. The weakened Golbez steals the Crystal and escapes.

The party heads for the Tower of Babil to retrieve the other Crystals and finds Dr. Lugae, a scientist under Golbez working with Rubicante, the Archfiend of Fire. Rubicante is teleported away and Cecil's party defeats Lugae. The party finds the key to stopping the Super Cannon, but when they reach the cannon its operators would not go down without a fight or making the cannon unstoppable. Yang is determined to stop the cannon himself, and is left behind.

Golbez catches the party escaping the tower and drops them off a bridge, but Cid catches them on the Enterprise before they fall into the lava. The Red Wings chase the Enterprise, and Cid sacrifices himself to save the party and the airship, which escapes the Underground back into the Overworld. Before he jumps off the Enterprise Cid asks Cecil to return to Baron and talk to his workers. Cecil does so, and the workers attach a hook to the airship used to pick up and carry the Hovercraft which is used to enter Cave of Eblan.

Paladin Cecil mounted on a black chocobo in the Chronicles opening.

In the cave, the party finds Rubicante fighting Edge, the prince of Eblan. Rubicante defeats Edge and the party tries to convince him to join them. Edge agrees because he has taken a liking to Rydia. The party enters the upper half of the Tower of Babil and finds Edge's parents at the top murdered by Rubicante and transformed into monsters by Dr. Lugae. Edge brings them to their senses and Rubicante appears and attacks the party. Cecil's party defeats him and enters the crystal room, where they fall back to the Underground and find a new airship: the Falcon.

The Falcon cannot fly over the lava, so the party returns to the Dwarves' Castle to visit King Giott who says it is time to defend the last Crystal in the Sealed Cave. He gives Cecil's party the key to opening the cave. To get the Falcon fly over the lava Cecil heads for the hospital to find Cid recovering who remodels the airship.

The party heads for the Sealed Cave and work their way to the bottom where they find the Crystal. Golbez possesses Kain who steals the Crystal and runs off. The party heads back to the Upper World (after Cid attaches a drill to the head of the Falcon) and heads for Mysidia, where the Elder prays for something to help the party. That something is the Lunar Whale, the "Ship of Light from The Moon", which lets the party fly to the Moon.

On the Moon the party finds a palace where a man named Fusoya sleeps. Fusoya wakes up and explains Golbez is being controlled by a Lunarian named Zemus and reveals the real reason Golbez is gathering the Crystals: the Crystals are the key to activating the Giant of Babil which can grant wishes. Zemus wishes for the Earth to be destroyed, and he is using Golbez to do it. The party returns to Earth with Fusoya, but they are too late: the Giant of Babil has awakened, and goes on a destructive spree.

A fully-recovered Cid leads an army of leaders from all over the world, as well as Cecil's friends, to do battle with the Giant. They help Cecil and his friends enter the Giant and after defeating the CPU an angry Golbez appears. Fusoya knocks Golbez back to reality and Cecil learns he is his older brother, Theodor. Fusoya and Golbez head to the Moon to fight Zemus, and Kain rejoins the party.

On the Lunar Whale, Cecil asks Rydia and Rosa to leave the ship as he feels it is too dangerous for them to go to the Moon. They oblige but stow away to the Moon anyway, and convince Cecil they should join. They head to the Lunar Core where they witness Fusoya and Golbez defeat Zemus. The hatred possessing Zemus, Zeromus, jumps out and attacks the party. With help from old friends, they defeat Zeromus using the crystal.

Back on Earth, Cecil and Rosa marry and take the throne of Baron with all but Kain attending.

Final Fantasy IV -Interlude- [ edit | edit source ]

While attending the ceremony of Damcyan's reconstruction one year later, Cecil joins Yang in investigating an incident at Mt. Hobbs by the Dad Bomb. Saving the two monks, Cecil accompanies Yang to Fabul and learns of Yang's daughter Ursula being born, naming him as the baby girl's godfather. The Falcon arrives and Cecil joins Cid, Palom, Porom and Luca in dealing with the monsters emerging from the Sealed Cave while Rosa remains in Fabul.

Finding Rydia, Cecil takes her to the Tower of Babil where he and the twins lose her and Edge comes to their aid. Upon finding her, Edge realizes it is not the real Rydia and the group nearly loses to her until the real Rydia arrives, and they defeat the imposter together. Though he never discovers the fake Rydia's true identity, Cecil learns Rosa is to bear him a child and reveals the news to his friends.

Final Fantasy IV: The After Years [ edit | edit source ]

A paladin of Lunarian ancestry. Ascending to the throne of Baron has done nothing to change the love he has for his people, and both the military and his citizens trust him deeply.

Sixteen years later, Cecil rules over Baron with Rosa as his queen and their son, Ceodore, as prince. While Ceodore is at Mythril training to be a knight, Baron Castle is attacked by monsters. Cecil, Rosa and Cid fight them off but Cecil has Cid take Rosa away to Damcyan via airship when their numbers don't relent. Shortly after a Mysterious Girl arrives, riding Bahamut, and unleashes him on Cecil, who slumps down.

Ceodore returns to Baron with a Hooded Man who rescued him from monsters after his airship crashed, and the two find Baron peaceful, the townsfolk claiming Cecil fended off the monsters. When the two sneak into the castle the Hooded Man finds Cecil in the throne room, not recognizing him and acting strangely. Suspicious and unwilling to let Ceodore see his father this way, the Hooded Man takes him out of the castle and they flee Baron. However, Cecil is also suspicious of him, and sends soldiers to pursue them.

Word spreads that Baron's Red Wings are again attacking kingdoms and stealing Crystals, and several of the former heroes seek to travel to Baron to investigate. Edward sails to Baron and meets with Cecil when Cecil orders Damcyan to leave the investigation of the meteor impact to Baron. Though Cecil acts strangely, he is reassuring and friendly and gives Edward a gift to take home to Damcyan. Edward in turn gives Cecil a bouquet of flowers and Cecil not recognizing them alerts him that something is wrong—the flowers are Whisperweed, and if Cecil was himself he would recognize them. Edward eavesdrops on Cecil through the Whisperweed, the conversation revealing he is working with the Mysterious Girl to seize the Crystals, and the item he has given Edward is a Carnelian Signet.

Ceodore, Rosa, Kain, Cid and Edward confront Cecil at Baron Castle. Cecil engages them using the Mysterious Girl's power to summon Odin, but Odin, being the spirit of the former King of Baron, recognizes his enemies as "[his] children of Baron" and returns to his senses, refusing to harm them. He strikes down Cecil breaking the Mysterious Girl's hold on him, but rendering Cecil in a pseudo-comatose state, because he was possessed by the Dark Knight (hinted by the dreams he had about the Hooded Man, Edward, and his family meeting him on Baron Castle). Unable to speak but for grunts and moans, Cecil's abilities in battle are hampered. The party travels to the True Moon to follow the Mysterious Girl, hoping to find the answer to restoring Cecil's mind.

In the Subterrane, the group comes upon a Dark Knight who attacks them, claiming to be the true Cecil. Cecil protects them from its blows, and is protected himself by Golbez. Rosa and Ceodore help Golbez stand against the Dark Knight and Cecil comes to his son's aid to save his life. Cecil absorbs the Dark Knight as the embodiment of his repressed darkness, and is restored to his senses and power.

After the Creator's destruction and the True Moon's departure, Cecil returns to his throne as the King of Baron and continues to train Ceodore as a knight.

The Catcher in the Rye Symbolism

In The Catcher in the Rye, Salinger the author, weaved a variety of symbols into the novel. One symbol that contributed to the overall theme of the painfulness of growing up was the ducks in Central Park. From start to end, Holden wondered and asked people where the ducks went. In the novel, Holden states, I was wondering if it would be frozen over when I got home, and if it was where did the ducks go, I was wondering where the ducks went when the lagoon got all icy and frozen over. I wondered if some guy came in a truck and took them away to a zoo or something. Or if they just flew away (Salinger 13). With more reading and critical thinking, one can make the connection that the ducks in the story actually represent the people which he has lost. For Holden, the ducks being gone is like growing up and losing people every year.

Even though Holden does not make it very obvious in the novel, he finds it very painful to grow up and lose the people he is close to. Holden failing classes and being kicked out of school may be an effect of him feeling the pain of growing up and acting out. Another part of the story where the ducks stood out was on Holden’s taxi ride in New York. Holden said, You know those ducks in the lagoon near Central Park south? That little lake? By any chance, do you happen to know where they go, the ducks, when it all gets frozen over? Do you know by any chance? (Salinger 90) . Once again, Holden is bringing up the ducks and wondering where they are. Holden just can not get used to the fact that things will not always be the same. He is stuck in the past and is having trouble realizing that Allie is gone and times are no longer the same. In the novel, he refers a lot to Allie and past memories that they have had together.

Such as the drummer boy and influences they have brought upon each other. Holden seems to be in denial about the fact that things have changed and he does not like it. In Catcher in the Rye, the author also states, The best thing, though, in that museum was that everything always stayed right where it was. Nobody’d move. . . . Nobody’d be different. The only thing that would be different would be you, (Salinger 121). The importance of that quote is to show how Holden does not like change and is opposed to it, it tends to make him uncomfortable and feel out of place. The last major part of where the ducks contributed to the overall theme of the story was in chapter twenty. After Luce leaves, Holden decides to stay at the bar and eventually gets very drunk. Holden drunkenly takes the walk to Central Park where Salinger then goes to writes, I walked around the whole damn lake-I damn near fell in once, in fact-but I didn’t see a single duck. I thought maybe if there were any around, they might be asleep or something near the edge of the water, near the grass and all. That’s how I nearly fell in. But I couldn’t find any. (Salinger 154).

Holden looking for the ducks could be seen as representing him looking for the people he has lost in the process of growing up. Such as Jane, the girl whom he really liked, and him talking to Allie as he crossed each street. As he looks he realizes that there is no one there anymore. Everyone has grown up and it is causing him a lot of pain. A big role for Holden feeling like he has lost many people could be the fact that he was away at school. It has made him depressed losing his brother and being away from his family. Holden then goes on to make the decision to try and move out west in an attempt to escape New York. The ducks leaving is can be seen similar to Holden running from his problems. All in all, the symbolism of the ducks in The Catcher in the Rye tie back to the overall theme of the painfulness of growing up. Holden’s seeing the ducks leaving is similar to him leaving his problems.

Static magnetic field therapy for symptomatic diabetic neuropathy: a randomized, double-blind, placebo-controlled trial

Objective: To determine if constant wearing of multipolar, static magnetic (450G) shoe insoles can reduce neuropathic pain and quality of life (QOL) scores in symptomatic diabetic peripheral neuropathy (DPN).

Design: Randomized, placebo-control, parallel study.

Setting: Forty-eight centers in 27 states.

Participants: Three hundred seventy-five subjects with DPN stage II or III were randomly assigned to wear constantly magnetized insoles for 4 months the placebo group wore similar, unmagnetized device.

Intervention: Nerve conduction and/or quantified sensory testing were performed serially.

Main outcome measures: Daily visual analog scale scores for numbness or tingling and burning and QOL issues were tabulated over 4 months. Secondary measures included nerve conduction changes, role of placebo, and safety issues. Analysis of variance (ANOVA), analysis of covariance (ANCOVA), and chi-square analysis were performed.

Results: There were statistically significant reductions during the third and fourth months in burning (mean change for magnet treatment, -12% for sham, -3% P<.05, ANCOVA), numbness and tingling (magnet, -10% sham, +1% P<.05, ANCOVA), and exercise-induced foot pain (magnet, -12% sham, -4% P<.05, ANCOVA). For a subset of patients with baseline severe pain, statistically significant reductions occurred from baseline through the fourth month in numbness and tingling (magnet, -32% sham, -14% P<.01, ANOVA) and foot pain (magnet, -41% sham, -21% P<.01, ANOVA).

Conclusions: Static magnetic fields can penetrate up to 20mm and appear to target the ectopic firing nociceptors in the epidermis and dermis. Analgesic benefits were achieved over time.

Every Creepy Detail You Need to Know About the Cecil Hotel

Netflix&rsquos new series The Vanishing at the Cecil Hotel dived into all the details surrounding the very tragic death of Elisa Lam. There&rsquos a lot to be upset about when it comes to that tragedy, but the hotel itself had a very questionable history even before she set foot in it. The four-part docuseries not only gets into all the theories behind the young Canadian&rsquos death at the L.A. hotel but also gives you a peek at the hotel&rsquos super-seedy past, and oh my god, you guys, it&rsquos WILD.

The Cecil Hotel is all kinds of creepy and has had more deaths in it (including multiple murders!!) than any hotel should ever have. And let&rsquos not forget about all the very questionable guests who have allegedly stayed there (*cough cough* Richard Ramirez). The hotel is so spooky, in fact, that it&rsquos inspired tons of TV and movie projects, including the fifth season of American Horror Story. Yikes!

So with that in mind, here&rsquos a definitive timeline of every weird and creepy thing that&rsquos happened at the Cecil Hotel from the day it opened until now.

1920s: The Cecil Hotel opens

There seems to be some conflicting info about the exact year the Cecil Hotel opened. Some sources say it was 1924, while others say 1927. But if the mother of all sources (aka Wikipedia) is to be trusted, the hotel opened on December 20, 1924. It stood at 15 stories high, had 700 guest rooms, and cost just a mere $1.5 million to build.

Also 1920s: The first death at the Cecil Hotel

Whether it opened in 1924 or 1927, the Cecil didn&rsquot make it very long before it had its first death. The death was that of 52-year-old Percy Ormond Cook, who died by suicide inside his hotel room on January 22, 1927, after not being able to reconcile with his wife and child.

1930s: Even more deaths

The 1930s saw a set of suicides at the hotel. Four different people took their lives there in that time frame. Another, Grace E. Magro, fell from a ninth-floor window and died. It was never confirmed whether it was a suicide or foul play.

1940s: Skid Row becomes the hotel&rsquos downfall

The Cecil was at its peak in the 1940s, with its swanky marble lobby and high-end finishes. But as the City of Los Angeles began pushing its homeless population to the nearby Skid Row (rather than, you know, actually helping them), the grand appeal of the hotel went away and it started to take a turn, quickly becoming a popular spot for housing among transient people.

1944: The first confirmed murder

In 1944, a 19-year-old woman named Dorothy Jean Purcell was staying at the hotel and gave birth to a baby boy on the bathroom floor. She then threw the baby out the window, killing him. She claimed that she thought he was stillborn so she threw him out the window rather than telling her boyfriend at the time, but the coroner found that the baby had, in fact, been alive when he was thrown out the window. Purcell was charged with murder but found not guilty by reason of insanity.

1947: The Black Dahlia maybe stayed there

Elizabeth Short, aka the Black Dahlia, was rumored to have been drinking at the Cecil bar shortly before her gruesome murder. This fact remains unverified and her murder is still unsolved, so I guess we&rsquoll never know the truth on this one.

There was one confirmed death that year though: Robert Smith, who fell from the building. Two other falls and one other confirmed suicide happened between 1954 and 1962.

1964: A staff member is brutally murdered inside the hotel

This is possibly the most terrifying death to have happened at the Cecil. A 65-year-old telephone operator for the hotel named Pigeon Goldie Osgood had been staying at a room in the hotel for the past five years. But on June 4, 1964, she was found dead in her room, having been raped, beaten, and stabbed. Newspapers reporting on the murder at the time said her friends claimed to have seen her just minutes before her body was found by a man delivering new telephone directories. Her murder is still unsolved.

1980s to 1990s: Serial killers make themselves at home

At least two serial killers are known to have stayed at the hotel during this time, which, TBH, is two too many for me. Both Jack Unterwegger and Richard Ramirez (also known as the Night Stalker) are alleged to have stayed there IN THE MIDDLE OF THEIR KILLING SPREES. If that doesn&rsquot prove that this hotel has some bad energy, I don&rsquot know what will.

2007 to 2011: An attempted rebranding of the hotel

The Cecil got new owners in 2007, who tried to refurbish parts of the hotel. In 2011, they rebranded part of the hotel as Stay on Main, but as we all know from the documentary, the hotel was in need of a much MUCH bigger face-lift than just some lobby upgrades and a name change.

2013: Elisa Lam dies

University of British Columbia student Elisa Lam checked into the Cecil Hotel on January 26, 2013. She was originally staying in one of the hostel-style shared rooms, but after several complaints were made, she was moved to a room by herself. On January 31, she was declared missing after her family hadn&rsquot heard from her like they normally would.

Three weeks later, guests started to complain about low water pressure and tainted water with a funny look and taste. A hotel worker went to check on the building&rsquos rooftop water tanks and found Lam&rsquos body floating in one. Her death was later ruled an accident.

Today: The Cecil Hotel has undergone major renovations

A new owner bought the hotel in 2014 and shut it down in 2017 to do major renovations and add a few high-class (and perhaps unfortunately placed) amenities, like a rooftop pool. The hotel is expected to open back up sometime this year.

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