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premiums on the outside of the trade to correct the delta in a major market move This strategy may be successful if the market trends in the direction of the options quickly, but as with any short-term outof-the-money option position purchase, the risk of decreasing volatility and accelerated time value decay is signi cant for these additional positions Adding additional call premiums to the spread also has the potential for negating any pro tability for the trade The total reward of the iron butter y can be fairly small, and adding an additional premium will increase risk and reduce reward if it is unsuccessful The iron butter y differs from the long butter y at expiration in that if the spread is placed at the money, some portion of the spread will be in the money if it is held to expiration If both options on one side of the market are in the money, you will experience the maximum loss on the spread The goal is to have the market between the protective strike prices at expiration If the spread is held to expiration and the protective long option positions are not in the money, you will be assigned a long or short on the market depending on which side is in the money You will need to be prepared for the cash and margin or outright margin of the assigned call or put options Ideally, we would be looking to cash in on the time decay sometime shortly before expiration or right at expiration in order to avoid the exercise into the underlying The only time the exercise is preferred is if the value between the bid and offer on the options is disadvantageous to the spread Sometimes with option positions, the volume can get thin and create a disparity between theoretical value and the current market price It may be necessary to allow the option to be exercised and offset it immediately with the opposing underlying position The iron butter y can also be reversed with the base of the trade being the long straddle rather than the short straddle This would.

not easily explained, with pontine-midbrain lesions, there may be unformed auditory hallucinations (page 252) The EEG may show symmetrical, mild generalized slow activity in the range of ve to 10 per second a state that rapidly returns to normal as the delirium clears In other cases, only activity in the fast-beta frequency range is seen; in milder degrees of delirium, there is usually no abnormality at all; this is in stark contrast to the generalized slowing and disruption of EEG activity that accompanies most other forms of confusion Analysis of the conditions conducive to delirium suggests at least three physiologic mechanisms The withdrawal of alcohol or other sedative-hypnotic drugs, following a period of chronic intoxication, is the most common (see Chap 43) These drugs are known to have a strong depressant effect on certain regions of the central nervous system; presumably, the disinhibition and overactivity of these parts after withdrawal of the drug are the basis of delirium In this respect it is of interest that the symptoms of delirium tremens are the antithesis of those of alcoholic intoxication Another mechanism is operative in the case of bacterial infections with sepsis and poisoning by certain drugs, such as atropine and scopolamine, in which visual hallucinations are a prominent feature Here the delirious state probably results from the direct action of the toxin or chemical agent on the same parts of the brain This has been termed septic encephalopathy as discussed below Third, destructive lesions of the types enumerated above tend to damage the temporal lobes may also cause delirium Psychophysiologic mechanisms have also been postulated in the genesis of delirium It has long been suggested that some persons are much more liable to delirium than others, but there is reason to doubt this Many years ago, Wolff and Curran showed that all of a group of randomly selected persons developed delirium if the causative mechanisms were strongly operative This is not surprising, for any normal person may, under certain circumstances, experience phenomena akin to those of delirium After a sustained period of auditory or visual stimulation, the same impressions may continue to be perceived even though the stimuli are no longer present Also, a healthy person can be induced to hallucinate by being isolated for several days in an environment free of sensory stimulation (sensory deprivation) A relationship of delirium to dream states has been postulated; both are characterized by a loss of appreciation of time, a richness of visual imagery, indifference to inconsistencies, and defective reality testing Formulations in the eld of dynamic psychiatry seem more reasonably to explain the topical content of delirium than its occurrence Wolff and Curran, having observed the same content in repeated attacks of delirium due to different causes, concluded that the content depends more on the age, gender, intellectual endowment, occupation, personality traits, and past experiences of the patient than on the cause or mechanism of the delirium The main dif culty in understanding delirium derives from the fact that it has not been possible to ascertain which of the many symptoms have physiologic signi cance Obviously, something has been removed from the perceptive process, something that leaves the patient at the mercy of certain sensory stimuli and unable to attend to others and at the same time incapable of discriminating between sense impression and fantasy.

Confusional States and Delirum Induced by Medications (See also Chap 43)

Variable Value (VARIABLE_VALUES)

In considering the pathophysiology of delirium and confusion, it must be again emphasized that drug intoxication predominantly