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PAG and RVM resulting in activation of descending Initial evidence for such a pain-modulating pathway was pain-modulating pathways purchase extra super cialis 100 mg with amex. Other neurotransmitter provided by the phenomenon of stimulation produced systems are also involved order 100mg extra super cialis amex. Electrical stimulation of the grey matter that are transmitters found in the projection neurones surrounds the third ventricle cerebral aqueduct (peri- from the brain stem (RVM and pons) to DH. Direct aqueductal grey (PAG)) and fourth ventricle can application of 5-HT or norepinephrine to the spinal induce profound analgesia. This has been demonstrated cord results in analgesia, while destruction of these in human patients; electrodes placed for therapeutic neurones blocks the action of systemically adminis- purposes in this region reduce the severity of pain, tered morphine. Recent studies have focussed on the whereas tactile and thermal sensibility is unchanged. The PAG integrates mission of noxious information at the level of the DH information from multiple higher centres, including via their action on cannabinoid receptor type 1 (CB1), the amygdala, hypothalamus and frontal lobe. The PAG controls the processing of nociceptive Some of their actions are mediated via the opioid sys- information in the DH via a projection to the rostro tem (e. With the application of an environmental stressor the The endogenous opioid peptides and their receptors normal behavioural response to pain may in fact be are heavily expressed within this pathway. Stress results in a reduced sensitivity to of opioids are not restricted to the DH of the pain, the duration of which depends on the timing spinal cord. Stress induced analgesia is partially mediated by the pain inhibitory system described above. Rudimentary evidence for this comes from the fact that opioid antagonists, such as naloxone, can block stress induced analgesia. It is simplistic to think that a complex phenomenon, F such as stress will only act mechanistically at the A level of the spinal cord. It is also likely to have impor- H tant implications for pain processing at much higher levels. In the absence of a nociceptive stimulus, higher PAG centre activity (induced by learning and also fun- nelled through the PAG) may facilitate pain, as evidenced by: DLPT • Activity in DH nociceptive neurones. RVM • Activity in higher centres, demonstrated by positron emission tomography (PET) scanning. Regions of the frontal lobe (F), hypothal- amus (H) and amygdala (A) project to the PAG in the imaging as applied to the human brain has provided midbrain. The PAG controls the transmission of nociceptive fantastic insights into higher cognitive functions, information in the rostroventral medulla (RVM), DH via relays including the perception of pain. These regions – ‘the pain matrix’ – The influences of attention and emotion include the thalamus, the 1° and secondary (2°) on pain somatosensory cortex, the insular cortex, the anterior Many of the pain modulating mechanisms so far dis- cingulate cortex and motor regions, such as the pre- cussed can be accessed not only by pharmacological motor cortex and cerebellum. Pain is not a unitary means, but also by contextual and/or cognitive manipu- phenomenon. Pain perception can be altered by variables, unpleasantness are distinct from the simple sensory such as: dimension of pain (which includes location and intensity of a noxious stimulus). This makes more sense however, when one con- Most levels of the CNS are thought to be involved in siders that sensory processing does not occur in the attentional modulation of pain. Activation in the isolation, but actually in the context of an appropriate PAG is significantly increased during a condition in motor response. The level of PAG activity is predictive of the reduction in pain Thunberg’s thermal grill illusion provides some intensity produced by distraction. Attention has also insight into the complexity of the central processing been shown to modulate nociceptive responses in of pain. Clinical studies demonstrate that emotional states However, if they are applied simultaneously in the affect the pain associated with chronic disease. Mood form of a grid, a painful burning sensation is experi- appears to selectively alter the affective response to enced. The anterior cingulate cortex is thought to be an ing phenomenon, revealing the central inhibition of important site for the modulation of pain by mood. Interestingly the The cognitive manipulation of pain should be remem- thermal grill illusion produces activation of the anter- bered as a therapeutic avenue in chronic pain states. It has been proposed that disrup- tion of thermosensory and pain integration can lead Key points to the central pain syndrome, which may follow a thalamic stroke. There is evidence for ‘top-down’ control, with the • brain controlling its own input from lower centres. This finding however needs further con- have an important influence on pain perception.

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And while Judaism reports few accounts of heal- ing discount extra super cialis 100 mg with mastercard, it does put in the mouth of Isaiah the words that evoke the Mes- siah’s power of healing buy generic extra super cialis 100 mg. But he would do so upon one condition, that of faith: "Believe in me and you will be cured. Healings are not only physiological acts, they are signs of the arri- val of the Messiah, a revelation from God or the essence of the prophet. Then, as a side-effect, illness automatically becomes a sign of the evil one, a sign of sin, making the patient responsible for his condition and to blame for both his disease and his sin. In the current revival of ritual healing within charismatic groups, and through the propagation of karmic concepts in those cults that look to Buddhist, Hindu or theosophic sources, the role of offering a doctor’s ministrations is transferred to the pastor or to the guru. The esoteric language of the cults serves to create and maintain the confu- sion between the field of the psyche and that of the spirit. However, if illness is invested with spiritualistic connotations and made into an expression of the individual’s failings, or bad karma that has to be expiated, it is not because the disease has any psychic origin or because medical wisdom shows it to be a psychosomatic pathology. Disease has always been a favorite field for guru-healers; indeed, once the body is weakened, the mind is much more inclined to accept the fables that are offered as supposed cures. Denunciations of Official Medicine’s Alleged Abuses An atmosphere of medical catastrophism that seems to pick up the echoes of those fears of global conspiracies lends support to the 209 Healing or Stealing? One such association, led by a doctor who opposes routine vaccinations, put out a brochure calling for "genuine health care policies" that would. Very often, this kind of denunciation of alleged abuses plays on contemporary fears and develops a perverse series of arguments built on known failures of science that are held up as irrefutable proof that contemporary medical practices are no good. This has already occurred and is still occurring with the vaccines against polio (virus SV 40 or STL V3), yellow fever (hepatitis B) or influenza in particular; 2. Any foreign substance inoculated into the organism across its natural barriers necessarily sets off a reaction from the organism, to reject the intruder. This intrusion breaks down the immune system and throws it into disarray, opening the door to AIDS and to the de- generative diseases that are literally exploding these days: cancer, multiple sclerosis, rheumatism, diabetes, insulin-dependencies, and 11 all the auto-immune diseases. Thus, the Horus Cult is happy to produce fake certificates for the vaccine against tetanus. And Tabitha’s Place, by refusing a surgical op- eration for a new-born baby under the pretext of respecting divine will, had no qualms about condemning to death a young child who was born with a cardiac malformation. Patamedicine, Magic, and the Third Way Between belief in divine healing and confidence in a completely mechanistic scientific process, patamedicine represents a third way that is basically a primitive belief in magic. Absolute confidence in God or in a doctor removes the patient from any active role in deciding how to deal with his condition, as his illness evolves. By contrast, patamedi- cal magic gives the patient back an active part in the process of his healing. W hile magic may originally have meant the practices of the sacer- dotal caste of the Medes, who were followers of pseudo-sciences such as astrology or hermetic medicine, the word gradually has taken on a broader meaning to encompass beliefs and practices that have little to do with the rites of organized worship and that presuppose a belief in 11 supernatural forces immanent in nature. For this reason, patamedicine always presupposes the belief in a principle that "animates" the human being and that explains the "inexplicable" aspects of physiology. Energy, in Chinese medicine, or white holes in the memory of water, all derive from this basic approach. They calibrate their responses to health questions and propose to the patient techniques that gradually move away from the scientific ap- 211 Healing or Stealing? Some ethnologists, like Frazer, saw magic as a form of prescience, for this practice includes references to determinism. Frazer described two principles in magical belief, two principles that agree with certain laws of the association of ideas and that are found in patamedicine — even if they may not be overtly stated. The principle of similarity says that the similar calls the similar, like goes to like. Thus, every practice that has been observed as being si- multaneous to an effect is considered to be an inductive principle — and reproducing the practice is expected to generate the same effect. The principle of contiguity, the second principle, states that things that once were in contact continue to act upon each other even after the contact has ceased. Thus, in magic, a photograph is an extension of the being that was photographed, and magic that is practiced on the photo will have its effect upon the individual. It is all the harder to criticize since it seems to respect the scientific laws of causality. But to accept the principle of similarity as flawless scientific reasoning means maintaining confusion between an action and the sign of an action. In the same vein, when a person recov- ers after such and such technique has been applied, that is not absolute proof that the technique was valid.

In brief safe extra super cialis 100 mg, SSCT utilizes techniques from SFT to provide a micro view order 100 mg extra super cialis free shipping, or a close- up view of particular issues facing each person in the couple. Solution- focused therapists, in addition, aim at an egalitarian relationship between the therapist and the client from the very beginning of therapy and can fit per- fectly with a lot of clients. It is evident that perceiving and conceptualizing Strategic and Solution-Focused Couples Therapy 203 an issue from these diagonally opposite viewpoints can offer the therapist a balanced and enhanced view of maintaining the normative/collective and individualistic foci at the same time. Third, both approaches have made unique contributions in effectively and efficiently conceptualizing human dilemmas, engaging clients, orga- nizing the therapeutic process, asking questions of impact, and facilitating changes. This integration provides the therapist more flexibility and versa- tility to draw on a broader range of knowledge and skills to accommodate a myriad of needs, motivations, and expectations of clients and their prob- lems. By selectively integrating principles and techniques from SCT and SFT, SSCT provides the therapist the ability and framework to serve a wider range of clientele with a wider range of problems than a therapist armed with only SCT or SFT. The guidelines for integration are as follows: First and foremost, begin where your client is. Because most clients come with a distressing problem with the hope of some removal of or relief from it, the therapist starts with the problem-solving emphasis of SCT by exploring with the client the pre- senting problem, offering emotional validation of his or her attempted so- lution, and instilling realistic hope for change in order to combat the client’s demoralization and despair. Second, specific therapy goals are set and the ways to reach the goals are explored. Depending on the couple’s cultural expectations of therapy, problems, and interpersonal styles, the therapist may stay problem focused for a while, because a premature shift from problem talk to solution talk may be construed as a lack of empathy for, or an utter disrespect of, the client’s suffering. Third, when the client is connected to the therapist and the therapeutic process, the therapist skill- fully uses the various solution-focused questions and interventions to highlight current and past successes, and tap into the client’s internal and external resources to generate creative and effective solutions to his or her problems. CASE STUDY The following case of an individual demonstrates one of the most common ways a couple comes for therapy as Haley observes. A combination of indi- vidual and couples therapy sessions was offered to meet the intrapersonal and interpersonal needs of the situation. Cathy, a 24-year-old Caucasian single female, was referred for treatment of bulimia of eight years’ duration. She admitted to bingeing once a day and purging from three to four times a day to no purging for several days. She was cohabiting with her fiance David, who had proposed that they get married within a year; neverthe- less, her father was strongly against their relationship. Recently, David’s 204 THEORETICAL PERSPECTIVES ON WORKING WITH COUPLES information technology business had required much more of his time in traveling (that is, he spent three to four days a week away from home). Cathy had lately realized the deterioration of her condition resulting from the aggravation of her bulimic problems and decided to seek help. Ever since her parents’ divorce when she was 10 years old, she had been reared by her paternal grandmother. She had very little contact with her mother, who had remarried shortly after the divorce and moved out of the country. She remained close to her father, who in her eyes was a perfection- ist and whom she strove to please. Within the year, at the suggestion of her friends, she experimented with different dieting methods, including the use of laxatives and self-induced vomiting. David was invited to all the sessions, but due to his schedule he began at- tending the couple sessions only after Cathy had completed three individ- ual sessions. Before Cathy’s first session, the therapist formulated the following systemic hypotheses: 1. The decompensation of Cathy’s bulimic symptoms was used to deal with her loss, stress, and loneliness. She might have used her bulimic symptoms to take a one-down posi- tion in relation to David and to delay her decision to marry him against her father’s wishes. She had been exerting her independence from her perfectionistic fa- ther, which she experienced as disloyal to him, and she seemed to deal with her guilt with her self-handicapping symptoms. In the first session, efforts were made to establish rapport, clarify the pre- senting problems, and set treatment goals. Cathy admitted to feeling dis- traught especially when she was alone at home after work. She reported that bingeing and purging had been her usual attempted solution and requested that a quick fix be prescribed. The therapist used the hypotheses above to guide his systemic information gathering about the specific nature and severity of the problem, and the attempted solutions and their efficacy so as to confirm and disconfirm the hypotheses. Because Cathy insisted that she obtain a fast relief from her problem and asked for solutions from the thera- pist, he respected Cathy and began where she was by employing a strategic model to ascertain what had predisposed, precipitated, and perpetuated the prob- lem.

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If extra super cialis 100mg overnight delivery, in similar circumstances extra super cialis 100mg with amex, a patient of mine of abstracts of the remainder took an evening. There elected to proceed with further investigations, I would were no systematic reviews—the best form of evidence. This does not address matters of gatekeeping Two articles were clearly useful because they described (resource allocation), which probably should be dealt large studies with long term follow up of people with with away from the consultation. The The evidence main difference was the change in clinical thinking that In a British study, 2. Some a serious condition that was amenable to cure—two answers are difficult to find. We a prognosis of the outcome someone like me (my situ- also need a forum of peers and those skilled at ation being similar to screening) would expect. It evidence based medicine in which test out our ideas so suggested that I was unlikely to have a serious that we can reassure ourselves that we are not condition that was amenable to cure. If health authorities are serious this may be an overestimate of the benefits of about promoting evidence based medicine in clinical screening. Perhaps those three people would have practice, they may have to consider providing a service developed symptoms such as frank haematuria or (perhaps like pathology, radiology, or referred special- dysuria sufficiently early to negate the beneficial effect ist opinions) to help clinicians to take these steps. Paul Glasziou constructively read earlier drafts and checked, Another study was done in California. In: outcome of people whose dipstick test was not positive; Fauci AS, Braunwald E, Isselbacker KJ, Wilson JD, Martin JB, et al, eds. New York: McGraw Hill, their probability of developing urological cancer was 1998:258-62. Dipstick urinalysis screening, asymptomatic microhematuria, and subsequent urological cancers in a population- were probably the best match with my situation that I based sample. The second study, particularly, seemed 7 Froom P, Gross M, Froom J, Caine Y, Margaliot S, Benbassat J. Is the net benefit of Health Policy, Summary points Oxfordshire Health investigation worth the cost? At a recent discussion in Authority,Oxford our general practice it soon became apparent that our OX3 7LG Chlamydia infection is the commonest treatable views and practices varied widely. Was there any N R Hicks, sexually transmitted disease in the United consultant evidence to help us reach a consensus? We resolved to Kingdom; it is most common in sexually active Hollow Way try and find out. D Goldman, The discharge was slight, clear, watery, and non- 60-80% of genital chlamydia infections in women general practitioner offensive, and she had no abnormal vaginal bleeding. J Hamling, may be asymptomatic Ms A had changed her sexual partner two months pre- general practitioner viously. Soon after this she had contracted genital In one randomised trial, screening high risk L J Hicks, general practitioner thrush, which responded to topical clotrimazole. She women and treating those found to be infected Correspondence to: uses a combined contraceptive pill and does not use reduced the incidence of pelvic inflammatory DrNRHicks condoms. Ms A has no other sexual partners, and disease by about half in 12 months nicholas. Access to the internet allows valid, relevant BMJ 1999;318:790–2 The only noteworthy finding at vaginal examina- information to be identified and retrieved tion was that Ms A’s cervix bled easily when swabbed. A quickly—but appraising the evidence and deciding high vaginal swab was taken from the posterior fornix, how best to reflect it in practice takes considerably and two swabs were taken from the endocervix and the longer urethra—a standard cotton swab and a plastic shafted chlamydia swab respectively. Ms A was prescribed doxycycline (200 mg for seven days) and metronida- ated with proactive case finding or whether any net zole (400 mg three times daily for seven days). Ms A was invited back to the surgery and was upset to be told that she might Search for evidence have had a sexually transmitted disease. She and her It is frequently written that the first step in evidence partner were referred to the local sexually transmitted based practice is to turn the clinical problem into an diseases clinic for further investigation and follow up. This proved more difficult than we first thought, as we wanted answers to several Our uncertainty questions: The case of Ms A prompted discussion in the practice x Is genital chlamydia an important cause of clinically about who we should investigate and treat for chlamy- important morbidity?

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