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By I. Killian. Globe Institute of Technology.

The patient is usually dealing with the problem at the level of the symptom buy cialis soft 20mg online, whereas the physician seeks a diagnosis explaining the symptoms and as a key to definitive treatment buy cialis soft 20 mg with amex. We have seen that symptoms are the literal and most basic core elements out of which concepts of illness develop. There is a focus of judgment, not a decision node in a protocol, about deciding whether and when symptoms should or can be alleviated prior to the establishment of a diagnosis. Diagnostic protocols, however, prescribe and judge evaluations solely on the basis of adherence to themselves, never minding that the patient has a say in whether to sign on. There is little appreciation of the fact that patients undergo pain or discomfort, delay, anxiety, indignity and expense in the pursuit of a diagnosis. There is almost no provision in any diagnostic algorithm for measures needed to elicit consent and intelligent participation on the part of the patient. The quality of participation in a medical history or exam is often influenced, for example, by the presence of pain, nausea, vertigo, anxiety or fever. Relief of at least some symptoms is an end-in-view which serves as a means to reaching the sometimes more distant end of a diagnosis and definitive treatment. The process of diagnosis needs the kind of attention which has heretofore been paid only to the outcome. For another, failure to address issues of comfort, combined with the imposition of various indignities, expenses and ordeals, discourages some people from seeking or co-operating in needed care at all. Therefore, problem-defining activities work best when tailored to individual personality, symptom severity and tolerance. Any protocol, guideline or algorithm for diagnosis needs to be supplemented and tempered with compas- sionate discretion. Unfortunately, retrospective reviews for "quality of care" fail to acknowledge the existence of individual factors at all. A robot applying the protocol FULL SPECTRUM MEANS AND ENDS REASONING 159 mechanically would get higher ratings on such a review than a compassionate and flexible clinician. The robot would do less of use, but look better in retrospect, solely because of the myopic view of value incorporated in the protocol.. In the instances when problems are not clear cut, a degree of leisure may be required to formulate a problem constructively. Very few problematic encounters requiring means/ends reasoning are so emergent that rapid decisions are worth the concomitant risk of tackling the wrong job. In medicine, a relationship of mutual understanding and trust needs to be established, often before much else can be accomplished. Stories and anecdotes must be told and insights shared, often unrelated to the apparent trouble. Frequently, several visits giving routine, minor service in a conscientious way open up the possibility for more significant service later. Another detour frequently needed to facilitate problem formulation is simply letting time pass. Patients need time to assimilate first impressions and reflect on them, as well as to decide how to use opportunities which have been offered. In the case of the physician, time for imaginative reflection and research can be essential. There are innumerable instances in most practices when reflection at the end of a busy day facilitates the formulation of a problem. Also, the passage of time is the best of all diagnostic tests whenever it is feasible to wait for a disease or problem to "declare itself. Finally, problems can be so unique that they do not sort well into diagnostic slots. In such cases, the problem discovered and its relation to established categories can afford new knowledge. For example, one patient with all the findings of a type of vascular inflammation called Kawasaki disease developed shock (low blood pressure with inadequate organ perfusion) and disseminated intravascular coagulopathy (diffuse clotting with consumption of clotting factors then leading to bleeding). Initially, this patient was treated for toxic shock syndrome and septic shock, since no expert had heard of shock or coagulopathy with Kawasaki disease. But "just in case," she also received intravenous gamma globulin, the treatment of Kawasaski’s. So when the patient had a relapse, she was treated solely for Kawasaki disease with a complete response. From this case alone it could be concluded that Kawasaki disease may lead to shock and disseminated intravascular coagulopathy. A focus of judgment within the general category of defining the problem is thus how to classify a constellation of findings when they fit all known categories imperfectly. Whether to consider such a problem as allied best with one category, or as truly partaking of characteristics of two or more is critical for planning action. Most patients perceive themselves even at a given time to have several actual and potential medical concerns, not just one problem. Doctors recognize their patients to have multiple problems as well, although the list might not be the same. And prevention often requires imaginative rehearsals to conjure up visions of covert or future trouble. Primary 160 CHAPTER 6 care relationships (whether they be with a generalist or a specialist) have long been recognized as vehicles for working on these problem lists, in contrast to episodic care focused mainly on a single priority. But in either setting, the complete ensemble of problems affects the inquiry into and the resolution or palliation of whatever problem gets cast as the first order of business. Determining the degree to which that problem can be treated in isolation from the rest requires clinical acumen, and is another focus of judgment related to problem setting. Suppose, for example, that there were standardized guidelines for the treatment of diabetes, asthma and depression, but one patient suffered from all three.

SUMMARY AND IMPLICATIONS FOR THE FUTURE The premise of this chapter is that cognitive and behavioral interventions are used in nearly every active form of couple therapy trusted cialis soft 20 mg, and an attempt has been made to delineate the distinct components that are specific to the Cognitive Behavioral Couple Therapy 135 cognitive and behavioral realms buy generic cialis soft 20 mg on-line. At the same time, it is clear that CBCT in- tegrates aspects of other models and, as is true of psychotherapy in general, these integrative elements are not always clearly identified as to their ori- gin. The more that clinicians are able to identify the foundations of specific interventions and constructs, the better they are able to grasp the best con- text and most comprehensive methods for applying them. Although there is evidence that both behavioral and cognitive techniques are effective for specific problems that appear in couple therapy (e. However, because most areas of psychotherapy outcome research re- main equivocal at best, there is no reason to exclude cognitive or other tech- niques that may enhance compliance, produce greater understanding, and appear to be positive from both the couple’s and therapist’s perspectives. An intensive review of past experiences, attention to the therapist-client rela- tionship, or a focus on spiritual concerns may be included in treatment from an intuitive or practical viewpoint, even though these are not a formal aspect of CBCT tradition. A caveat is that techniques need to be selected thought- fully, and not contraindicated (e. Treatment approaches always need to be based on assessment and carefully matched with client needs and expectations. Random eclecticism has been decried both in this chapter and else- where, and integration is being promoted widely. Although an informed use of techniques from various models can be logically assimilated into a solid theoretical framework, true integration of seemingly disparate theories is a more difficult matter. A solid grounding in diverse theoretical models and techniques is essential for successful integration to occur. Novice clinicians in particular are advised to develop competence before using a theoreti- cally integrated model. Because of its wide range of techniques and pragmatic foundations, CBCT can be used for many types of issues presented in couple therapy, and it is effective for clients who vary greatly by culture, presenting prob- lem, sexual orientation, age, setting, disability, and other factors. The em- pirical basis for CBCT provides ethical grounding for its diverse methods. However, because of the complexity that is often involved in using CBCT techniques appropriately, clinicians are advised to be skilled in applying them. Continuing education, reading, and supervision can assist in devel- oping competence for ethical, effective practice. Therapists need to be open to using a systematic approach in order for CBCT to be successful. A large number of therapists from all disciplines identify themselves as cognitive behavioral. Training programs and continuing education are increasingly emphasizing CBCT methods. It is clear that CBCT is highly adaptable to short-term and managed-care models as well, and extensive, ongoing CBCT research will 136 THEORETICAL PERSPECTIVES ON WORKING WITH COUPLES continue to demonstrate its applicability to clients, insurers, and clinicians. Psychotherapy integration is also a growing trend, and the natural appeal of blending theories and techniques will undoubtedly persist and increas- ingly be validated by research. It is hoped that these trends will be accom- panied by recognition by all in the psychotherapy field of the need for a complete understanding and thorough training in the foundations of cogni- tivism, behaviorism, and other relevant integrative approaches. Short-term behavior interventions with delinquent families: Impact on family process and recidivism. A comparison of behavioral contracting and problem solv- ing/communications training in behavioral marital therapy. The role of cogni- tions in marital relationships: Definitional, methodological, and conceptual is- sues. The usefulness of cognitive restructuring as an adjunct to behavioral marital therapy. Supplementing behavioral mari- tal therapy with cognitive restructuring and emotional expressiveness train- ing: An outcome investigation. Assessing the effects of behavioral mar- ital therapy: Assumptions and measurement strategies. Theoretical foundations and clinical applications of the premack principle: Review and critique. Cognitive and behavioral interventions: A com- parative evaluation with clinically distressed couples. Behavioral couple therapy for male substance-abusing patients: Effects on relationship adjustment and drug-using behavior. The effects of communication skills training and contracting on marital relations. A marital/family discord model of depres- sion: Implications of therapeutic intervention. Effectiveness of behavioral marital ther- apy: Empirical status of behavioral techniques in preventing and alleviating marital distress. Effects of behavioral marital therapy on couples’ communication and problem-solving skills. A comparison of the gen- eralization of behavioral marital therapy and enhanced behavioral marital therapy. A component analysis of behavioral marital therapy: The relative effectiveness of behavior exchange and communication/problem solv- ing training. Clinical significance of improvement re- sulting from two behavioral marital therapy components. Variability in outcome and clinical significance of behavioral marital therapy: A reanalysis of outcome data. Component analysis of behavioral marital therapy: 2-year follow-up and prediction of re- lapse. Differential effects of experiential and problem-solving interventions in resolving marital conflict.

Professional help with swallowing As soon as you notice any difficulties with swallowing cheap cialis soft 20 mg with amex, it is worth asking the advice of your GP or neurologist at this early stage purchase cialis soft 20 mg free shipping. Increasingly there are more formal evaluations of swallowing problems in order to try and understand exactly where the problems lie. Sometimes this assessment may include what is called ‘videofluoroscopy’, which allows the process of your swallowing to be seen on X-ray following a barium swallow. Occasionally it may also include an endoscopic examination – this involves passing a small fibreoptic tube through and past the throat so that additional information can be obtained. Professional help for swallowing difficulties centres on teaching exercises to try and: • strengthen your muscles involved in swallowing; • enhance the coordination of your breathing and swallowing (so as to avoid choking); • strengthen the muscles controlling your lips and tongue that help in managing the food in your mouth in preparation for swallowing. Self-help in relation to swallowing It is possible to give general guidelines as to what you can do yourself to help swallowing, although it must be remembered each person has slightly different problems, and thus not every strategy will work for everyone. However, things to try yourself include: • changing the type and preparation of your food – solid foods, particularly those that are only half chewed, are much more difficult to swallow than those which are softer, so you may need to consider chopping or blending food; • changing the ways in which you eat and swallow – eating little and often may help; • exercising to strengthen the relevant muscles as much as possible; • making sure that you do not talk (or laugh) and eat at the same EATING AND SWALLOWING DIFFICULTIES; DIET AND NUTRITION 131 time – problems of swallowing can often be linked to trying to do two things at once! In MS, coordination of the swallowing reflex with the amount of saliva you have may become a problem. It is not that you are producing more saliva, but the swallowing of it becomes far more noticeable. In general you have to become more conscious of the process of swallowing, and try and systematically swallow. Indeed swallowing exercises may help you and, paradoxically, by stimulating more regular production of salivation through sucking a sweet (preferably sugar free! A problem often arises when you ‘forget’ to swallow for a period of time and then suddenly notice the saliva. You might try a sequence of events as you eat or drink a little at a time, based on the following: ‘Hold your breath, swallow, clear your throat, then swallow again. Some people still have great difficulty but, if food or drink gets into your lungs, which could possibly lead to pneumonia, then more drastic action may be required. The time being taken to eat and drink may also be now so substantial that you run the risk of not getting adequate nutrition or liquids over a period of time. If this happens, then you may find yourself losing weight, getting weaker and having further problems. It is an important decision to move from normal feeding by mouth (oral feeding and drinking) to non-oral feeding, where food is directly channelled into the stomach (often avoiding the mouth and swallowing completely), but this step may be necessary if problems with nutrition and/or concern over choking becomes substantial. For example, after certain kinds of surgery in hospital, not associated with MS, people may be fed on a short-term basis through a tube that passes through the nose and then through the throat directly to the stomach (a ‘nasogastric tube’). This particular kind of arrangement has to be temporary because the throat and nose may become irritated after a while. A more long-term arrangement is to have a PEG (‘percutaneous endoscopic gastrostomy’) in which a tube is inserted through the abdominal wall directly into the stomach. As with any surgical openings through the skin, hygiene is particularly important, and great care has to be taken to prevent infections arising. Although it is a particularly difficult step to move to non-oral feeding, for social reasons as well as because of the loss of the pleasures associated with normal eating and drinking, in some cases it may be the best decision, in order to build up your strength if you have been losing a lot of weight, and to prevent fears associated with choking. If you are very careful, it may also be possible to continue to eat or drink a few things orally, at least to retain some of the pleasures of eating normally. You should keep an eye on how your swallowing goes, and always consult with your professional advisors about the possibility of gradually changing the balance between oral and non-oral feeding, so that you can try and resume a greater proportion of oral feeding, with a view to removing the PEG method of feeding if you can. Diet and nutrition There are two broad ways in which diet and nutrition can be considered in relation to MS. The first and less contentious relates to your general health: ideas about what is a good diet for general health do, of course, change from time to time. The second deals with the possible beneficial or harmful effects that some diets themselves might have on either symptoms or, more fundamentally, on the underlying cause of the MS. Diet is the most obvious and easy to implement factor that could be changed by people with MS, and many people have focused on this issue. Also, health care professionals are often very interested in diet and its effects on all aspects of general health. Although there has been research on diet and MS, it has not been a core interest of most EATING AND SWALLOWING DIFFICULTIES; DIET AND NUTRITION 133 researchers because Western populations are largely well-nourished – obesity and overeating, on the contrary, are major health concerns. There have been many diets that have been suggested to affect either specific symptoms or the cause of MS. There is little evidence that any of these diets has the effects that their supporters suggest – however, we here discuss a number of the more plausible diets. Essential fatty acids One of the areas of nutrition that has been researched in relation to MS has been that of ‘essential fatty acids’, which form part of the building blocks of the brain and nervous system tissue, and are essential to the development and maintenance of the CNS. Actually essential fatty acid is rather an odd phrase in lay terms, for we are used to thinking of anything ‘fatty’ as very bad for you. However, there are many kinds of ‘fats’, ranging from the saturated fats, often found in meat and dairy produce, too much of which is not good for you, to the unsaturated and polyunsaturated fats, many of which are found in vegetable sources, and from some of which key essential fatty acids are derived – these are broadly very good for you. About 60% of normal nervous system tissue is made up of these ‘essential fatty acids’. Some research has suggested that several of these essential fatty acids are present in lower quantities in the CNS of people with MS than in that of people without the disease; one theory has been that MS arose because, in their early years such people were deprived of (or unable to assimilate) these essential fatty acids in the development or maintenance of the structure and function of the CNS. However, the reasons for this lower level of fatty acids remain a matter of speculation. Some scientists have thought that the obvious remedy would be to increase the intake of these fatty acids. However, things did not prove to be as simple as that, for many of the essential fatty acids are produced indirectly by the breakdown in the body of particular constituents from the food that we eat.

TMS is an example of a mind-body disorder mediated through the autonomic nervous system; the immune system is not involved discount cialis soft 20 mg online. I suspect the immune system does not participate in the interaction of emotions and the cardiovascular system generic cialis soft 20 mg line. Once more, one is intrigued by the fact that the brain crosses boundaries in responding to its psychological needs. Thus patients with the same Mind and Body 149 psychological diagnosis (though differing in severity) may develop TMS, autonomically mediated; allergic rhinitis, immune system mediated; or psychogenic regional pain, direct action on the sensorimotor system. Extremely important work is being done in the brain biochemistry section of the National Institutes of Mental Health on the subject of brain-body interaction. One of the pioneers in this research is Candace Pert, once chief of that section, whose work is demonstrating communication between the brain and different parts and systems of the body. For those interested, an excellent review of this work appeared in the June 1989 issue of Smithsonian, written by Stephen S. The mind and body interact in numerous ways; the following part of the chapter reviews some of those more common interactions. MIND AND THE CARDIOVASCULAR SYSTEM The subjects of interest to us in the category mind and the cardiovascular system are hypertension, coronary artery disease, arteriosclerosis (hardening of the arteries), cardiac palpitations and mitral valve prolapse. High blood pressure (hypertension), as everyone knows, is very common and a little scary because of its connection with heart trouble and stroke. Its association with emotions has been assumed by many, though never demonstrated in the laboratory. Neal Miller, a psychologist working at Rockefeller University, demonstrated that laboratory animals could be conditioned to lower their blood pressure, and modify, many other bodily processes too, clearly showing that the brain could be recruited to influence the body. Herbert Benson, a Harvard cardiologist, has described what 150 Healing Back Pain he calls the relaxation response and demonstrated that the blood pressure can be reduced by the application of this meditationlike process. A very important study appeared in the Journal of the American Medical Association in the April 11, 1990, issue (Vol. Schnall and a team from the Cardiovascular and Hypertension Center, New York Hospital– Cornell Medical College, in collaboration with doctors from two other New York area medical schools, published a paper which established a clear relationship between psychological pressure at work (“job strain”) and high blood pressure. The study also established the fact that there was an increase in the size of the heart in these people, which is one of the undesirable effects of sustained hypertension. Experts have long suspected that psychological factors were implicated in high blood pressure. Schnall’s study is that it was so carefully designed and executed that it may convince some of the skeptics of the importance of the mind-body connection. Many people with TMS report a history of hypertension, suggesting that the same emotional states may bring on either of these. Just a few weeks ago a patient called and reported that her back pain was gone but that she had now developed hypertension— a clear example of equivalency. By contrast, it is rare for a TMS patient to report a history of coronary artery disease or subsequently to develop it. I can document the former but I do not have statistics to support the latter; it is a clinical impression. Almost everyone has heard of the so-called Type A behavior pattern and of the susceptibility of Type A people to coronary artery disease, described by Dr. Type A people were described as extremely ambitious, aggressive, loving competition, obsessively hard workers, often putting themselves under great time pressure, having much need Mind and Body 151 for recognition and very hostile. Because of their tendency to be compulsive, perfectionistic and very responsible and conscientious, people with TMS often describe themselves as Type A. Many TMS patients are the antithesis of hostile; they often have a strong need to be good, nice, pleasant, accommodating and helpful. Though they may be ambitious and often very accomplished, they do not necessarily pursue their goals with the intensity that seems to be characteristic of the Type A person. After the publication of Type A Behavior and Your Heart a great deal of research was done in an attempt to clarify the relative importance of the various Type A traits. It has been suggested that of all those listed above, hostility may be the only one that predisposes someone to coronary artery disease. To someone who is aware of being angry a lot this can be disturbing, whether or not he or she has TMS. It is of great interest to me because of the increasing evidence that repressed anger is important in the psychological dynamics of TMS. But then how does one reconcile those facts with the clear statistical evidence in the TMS population that coronary artery disease is very rare? It is apparent that a great deal more research and thinking is needed to unravel this mystery. It is dangerous to focus on a trait like hostility without knowing a great deal more than we do about the psychodynamics of anger, or about the myriad details of people’s personalities. The man who swears at taxi drivers as he drives down the street may be displacing his anger at his boss this way, for it is far better than losing his job. The problem with the behavioral research typified here is that it is unidimensional. In an attempt to produce statistically valid conclusions it must use criteria that are measurable, and while this is appropriate, it places a great burden on the 152 Healing Back Pain investigator to be absolutely sure that he knows what he is measuring. To make matters worse for the poor person who sees himself angry a lot of the time, it is suggested that he stop doing it! He has been told that this kind of behavior is liable to give him a heart attack and to avoid it he had better stop being who he is.

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