Jeffrey Sellers, MD
- Department of Obstetrics and Gynecology
- Abington Memorial Hospital
Offering the Patient Inspiration Some therapists inspire selected avoidant patients by stressing the downsides of being alone while affirming the positive aspects of closeness menopause early discount female viagra online american express, intimacy women's health lebanon pa purchase female viagra 50 mg without prescription, and commitment menopause that 70s show order 100 mg female viagra mastercard. Positive aspects of closeness women's health questionnaire (whq) pdf buy female viagra us, intimacy, and commitment range from having a stable life and being loved and sup ported to not contracting a sexually transmissible disease. The dog, pale-colored, limpid, and drained of blood when with my mother, changes to become pink and blue, then leaps off the fence and runs off to enjoy itself, at play. Some avoidants need to wipe a panicky grimace and off-putting frown from their face. Having the Patient Undergo Exposure Exposure, as much a technique of interpersonal as it is of behavior ther apy, is a direct way for avoidants to master their shyness and anxiety about meeting new people. I often ask avoidants to purposively set out to make new friends and get closer to people. As I mentioned in Chapter 15, I sometimes suggest that they do this gradually, doing a few minor nonavoidant things each day, then progressing step by step through ex ercises of increasing difficulty and complexity on the way to true closeness and intimacy. Some who started small, for example, by saying hello to strangers, are able to go on to accept a date, go steady, get engaged to be married, set a date to get married, then actually go through with the wed ding. At other times I suggest that, instead of step-by-step exposure in volving tasks of progressively increasing difficulty, avoidants start at the to p and take the plunge, deliberately increasing their anxiety to a painful level all at once, in an attempt to bypass their fears of relationships and to instead at least act resolutely unafraid. In some cases it has been pos sible for an avoidant to become intimate with a significant other even Interpersonal Therapy 213 before deep fears of closeness have been resolved. Of course this method requires picking the right person in the first place to avoid getting seri ously hurt or hurting others in the process. Interrupting Vicious Cycles I help my avoidant patients interrupt vicious cycles of rejection, dis tancing, and more rejection, and turn these vicious in to virtuous cycles. One good way to do this is by becoming less sensitive to and more ac cepting of what criticism/rejection they get and cannot ignore. Conquering Bad Reminiscences of Things Past I urge my avoidant patients to not allow past traumata to create a Post traumatic Stress Disorder. I help them discriminate between bad past and good present relationships so that they do not generalize from old bad experiences to new, unrelated, potentially satisfying involvements. This generalization is exemplified by the cat that, burned by jumping on a hot s to ve, fears and avoids not only hot s to ves but cold ones as well. I remind avoidants that just because as children they experienced ill treatment from a parent does not mean that everyone else will treat them the same way, so that it is not necessary to avoid all men and women in the here and now as hot s to ves when in fact they are cold s to ves. Increasing Self-Esteem by Encouraging Self-Acceptance Many avoidants withdraw to increase their self-esteem by avoiding a test of that self-esteem. I suggest that instead they increase their self-esteem by accepting themselves as they are, warts and all. I also suggest that they can compensate for any loss of personal identity that may occur by developing new and stronger professional identities. Encouraging the Patient to Develop a New, Less Avoidant, Philosophy Lonely individuals who consciously complain about relationship diffi culties but unconsciously remain aloof from close relationships offered, or rupture close relationships that promise, really threaten, to work, often do so because philosophically they believe that isolation is splendid. They must tie themselves to the mast and refuse to allow themselves to be carried away by siren songs about the pleasures of being by oneself. I ask avoidants to answer the following questions truthfully: Do I want to be alone or do I fear commitment and intimacyfi Do I really believe that isolation is splen did or does something inside warn me of the terrors of connecting, and tell me to stay out of a relationship because my dreams of intimacy will never come true or turn in to nightmaresfi Do I truly like my fantasies of walking alone in to the distance through swirling mists or am I conjuring up those mists in order to hide my desire for a close, warm loving relationshipfi Do I truly identify with songs that speak of being a rock and an island, say I should be glad that I am single, and proclaim that never, never will I marry, so that I really want to be insular, or am I Interpersonal Therapy 215 really afraid of singing another tune, leaving my avoidant island, taking the plunge, and swimming to shorefi I help avoidants distinguish preference from compulsion by having them look back over their lives to see if they can spot the his to rical mo ment when approach became avoidance as an original desire to relate turned in to a fear of closeness and intimacy. I also ask them to look inside themselves for present signs of confiict between approach and avoidance, identifying wish-fear/desire-guilt/rebellion-submission confiicts, and the anxiety associated with these confiicts, to determine if these, not free will, are prompting them to take heroic defensive measures against welcoming others in to their lives. Role-Playing I sometimes ask my avoidant patients to role-play, putting themselves in the place of others so that they can see exactly how they come across to them, in preparation for making necessary repairs. Family members and friends can often give valuable feedback, and videotaping can help with self-assessment, especially for avoidants who alter their appearance and behavior in an off-putting manner by rejecting the very social values they need to accept so that others will accept them, and in turn take them in to their lives. Calling in Third-Party Reinforcements I advise my avoidant patients to call for help from people who encour age nonavoidance, are supportive of their progress, or who can actually help them directly by introducing them around. Impressionable avoid ants should not become soul mates of infantilizing people with an avoid ant philosophy of life who do not want to let them go and roam free. However much Zen may be a good way for nonavoidant patients to handle anxiety, it is not always the best idea for avoidants, who are usually already, to coin an expression, all to o Zenned out for their own good. Advising Accepting, or Being Resigned to , Being an Avoidant Avoidants who, right from the start, simply accept their avoidance and decide to live with it can build their avoidance in to their daily routine, willingly giving up the pleasures and rewards of nonavoidance in ex change for remaining relatively anxiety-free. Marital Therapy Marital therapy is essentially a subtype of interpersonal therapy dedi cated to helping two individuals who are basically committed to each other work out their unilateral or mutual avoidances. A review of the literature and an informal sampling of therapists reveal that marital ther apists do not always agree on exactly how to help couples work out prob lems when one or both members of a dyad are avoidant. Different therapists advocate different methods for resolving the interpersonal dif ficulties found under such circumstances. Methods advocated include psychodynamically oriented couple psychotherapy, the goal of which is developing interpersonal insight to resolution; abreaction of feelings in order to obtain at least temporary relief of tension and pressure; forbear ance and compromise in relationships where change is unlikely, that is, accepting a difficult partner as he or she is and learning to live with, and even to like, him or her; and ending a relationship with a partner who is to o remote, to o uncaring, and unwilling to change. An advantage of treating the avoidant in group therapy is that the group can provide an encouraging and motivating nonpunitive setting in which the patient can feel comfortable coming out of his or her shyness and remoteness. Pharmacotherapy There are medications that can help a great deal with interpersonal anxiety. The following are three of the main corners to nes of sup portive therapy for avoidants: liking and respecting the patient, offering the patient reassurance, and giving the patient good (while not giving the patient bad) advice on how to become nonavoidant. Rather it is a real health-giving response to a ther apeutically corrective emotional experience. One reason for the good prognosis is that avoidants have the gift of relating already there inside, and all they have to do is unwrap it. This was the case for a patient who simply grew bored with his fear of success, mastered his fear of interpersonal relation ships by understanding it, and lost his success-discouraging parents to death, in time for him to have a career/relationship later in life, to have a best last marriage, and to blossom artistically after an early, unsuccessful, pedestrian career.
A separate diagnosis of anxiety disorder due to another medical condition is not given if the anxiety disturbance occurs exclusively during the course of a delirium women's health lowell ma generic 100mg female viagra visa. However womens health news cheapest generic female viagra uk, a diagnosis of anxiety disorder due to another medical condition may be given in addition to a diagnosis of major neurocognitive disorder (dementia) if the etiology of anxiety is judged to be a physiological consequence of the pathological process causing the neurocognitive disorder and if anxiety is a prominent part of the clinical presentation women's health center memorial city proven female viagra 100mg. If the presentation includes a mix of different types of symp to ms women's health center san diego buy discount female viagra on line, the specific mental disorder due to another medical condition depends on which symp to ms predominate in the clinical picture. When a diagnosis of substance induced anxiety is being made in relation to recreational or nonprescribed drugs, it may be useful to obtain a urine or blood drug screen or other appropriate labora to ry evaluation. If the disturbance is associated with both another medical condition and substance use, both diagnoses. In other anxiety disorders, no specific and direct causative physiological mechanisms associated with another medical condition can be demonstrated. Late age at onset, atypical symp to ms, and the absence of a personal or family his to ry of anxiety disorders suggest the need for a thorough assessment to rule out the diagnosis of anxiety disorder due to another medical condition. Anxiety disorders can exacerbate or pose increased risk for medical conditions such as cardiovascular events and myocardial infarction and should not be diagnosed as anxiety disorder due to another medical condition in these cases. Anxiety disorder due to another medical condition should be distinguished from illness anxiety disorder. Illness anxiety disorder is characterized by worry about illness, concern about pain, and bodily preoccupations. Anxiety disorder due to another medical condition should be distinguished from adjustment disorders, with anxiety, or with anxiety and depressed mood. The reaction to stress usually concerns the meaning or consequences of the stress, as compared with the experience of anxiety or mood symp to ms that occur as a physiological consequence of the other medical condition. This diagnosis is given if it cannot be determined whether the anxiety symp to ms are primary, substance-induced, or associated with another medical condition. The other specified anxiety disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific anxiety disorder. Clinicians are encouraged to screen for these conditions in individuals who present with one of them and be aware of overlaps between these conditions. It then covers body dysmorphic disorder and hoarding disorder, which are characterized by cognitive symp to ms such as perceived defects or flaws in physical appearance or the perceived need to save possessions, respectively. The chapter then covers trichotillomania (hair-pulling disorder) and excoriation (skin-picking) disorder, which are characterized by recurrent body-focused repetitive behaviors. Hoarding disorder is characterized by persistent difficulty discarding or parting with possessions, regardless of their actual value, as a result of a strong perceived need to save the items and to distress associated with discarding them. They may also be preceded by an increasing sense of tension or may lead to gratification, pleasure, or a sense of relief when the hair is pulled out or the skin is picked. Substance/medication-induced obsessive-compulsive and related disorder consists of symp to ms that are due to substance in to xication or withdrawal or to a medication. Obsessive-Compulsive Disorder i- Diagnostic Criteria 300. Presence of obsessions, compulsions, or both: Obsessions are defined by (1) and (2): 1. Note: Young children may not be able to articulate the aims of these behaviors or mental acts. The obsessive-compulsive symp to ms are not attributable to the physiological effects of a substance. The disturbance is not better explained by the symp to ms of another mental disorder. With poor insight: the individual thinks obsessive-compulsive disorder beliefs are probably true. With absent insight/deiusionai beiiefs: the individual is completely convinced that obsessive-compulsive disorder beliefs are true. Specify if: Tic-reiated: the individual has a current or past his to ry of a tic disorder. Importantly, obsessions are not pleasurable or experienced as voluntary: they are intrusive and unwanted and cause marked distress or anxiety in most individuals.
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Using fac to r anal Direct correspondence to : ysis, developers Bruni and colleagues [1 ] divided Dr. Oliviero Bruni items in to six categories representing some of the Department of Developmental Neurology most common sleep difficulties affecting adoles and Psychiatry cents and children: disorders of initiating and University of Rome maintaining sleep, sleep breathing disorders, dis Via dei Sabelli 108-00185 orders of arousal/nightmares, sleep-wake transi Rome, Italy tion disorders, disorders of excessive somnolence, and sleep hyperhidrosis (nighttime sweating). Higher scores by a parent or caregiver on behalf of the child indicate more acute sleep disturbances. Administration should results, scores are tallied for each of the six require between 10 and 15 min. Construction and validation of an instrument to evalu ate sleep disturbances in childhood and adolescence. Waist cir cumference predicts the occurrence of sleep-disor dered breathing in obese children and adolescents: a questionnaire-based study. The designations and maps used do not imply the expression of any opinion on the part of International frst aid and resuscitation guidelines 2016 the International Federation or National Societies concerning the legal 1303500 05/2016 E status of a terri to ry or of its authorities. They are not designed to and do not provide medical advice, professional diagnosis, opinion, treatment or services. For more than 150 years, frst aid has been one of the principal services provided by Red Cross and Red Crescent volunteers to injured people. And when that per son knows frst aid, crisis can be averted, and lives can be saved. For more than 100 years, the Red Cross and Red Crescent has been a world leader in establishing training standards and in developing procedures and guidelines. The International frst aid and resuscitation guidelines 2016 are designed to help National Societies expand their work in this important area. They build on our extensive experience, and draw on evidence that has been gathered over the past two decades, evidence drawn from existing literature, programme evalu ations, and advice from experts. National Societies can use these guidelines to update their frst aid materials, education and skills in accord ance with the latest evidence-based international standards. First aid remains a key means of reducing deaths and injuries, and of building safer and more resilient communities. Having high quality, evi dence-based frst aid education available to people worldwide contributes to building safer and healthier communities by preventing and reducing risks in daily emergency and disaster situations. About this document this document evaluates and reports on the science behind frst aid and resus back citation. These guidelines do not replace frst aid manuals and associated educational materials but serve as the basis for developing and updating frst aid manuals, resuscitation programmes, apps, public information and associated educa tional materials. National Societies should adapt these guidelines as needed for their local contexts (culture, language, habits etc. In addition, these guidelines and evidence review serve as an excellent reference for frst aid instruc to rs, emergency responders and their agencies. Link to Strategy 2020 In line with Strategy 2020, Red Cross Red Crescent National Societies commit to do more, do better and reach further. These guidelines provide National Societies a solid base to do better in frst aid. Promoting frst aid and using proven prevention techniques to address some of these challenges can build the capacity of local communities and the National Societies in both preparedness and response. The inten tion is not to have one technique for each situation, but rather to have a consensus on minimum agreed principles based on critical review of the avail able evidence and information learnt from the experiences of the Red Cross Red Crescent Movement (the Movement). National Societies should use the appropriate term as per their local context to describe the person in need of care (patient, victim etc. In 2014, approximately 15 million people were trained in frst aid by Red Cross Red Crescent National Societies in 116 countries around the globe by more than 180,000 active frst aid trainers (See Appendix 1 for data: Global survey data on frst aid). Thereby, each year more than 46 million people are reached by Red Cross Red Crescent National Societies with frst aid and preventive health messages. This included identifying subject area coordina to rs, determining a list of to pics to address, identifying evidence reviewers, cataloguing existing evidence-based processes, review by Red Cross Societies and holding planning meetings. Next, practical experience and expertise of experts from the felds and preferences and available resources of the target group (frst aid providers and people who receive frst aid) are integrated to formulate recommendations. As part of the process, the Evidence-Based Network organized two initial meet ings, one in London (hosted by the British Red Cross, March 2014) and one in Paris (hosted by the French Red Cross, Oc to ber 2014), with the aim of: (1) Starting the process for the development of the guidelines; (2) Training the new Evidence-Based Network members in the evidence-based methodology; and (3) Developing evidence summaries. Based on the available sources of evidence, draft recommendations were formulated by the different subject area coordina to rs of the Evidence-Based Network. In January 2016, a fnal consensus meeting was held in Mechelen (hosted by the Belgian Red Cross), to consider how different target users in various con texts around the world could apply these guidelines. For a strong recommendation, the evidence of benefts strongly outweighs the evidence of harms. For a weak recommendation the evi dence related to benefts is either weak or the studies conducted were at small scale. The common health concerns and injuries identifed by specifc commu nities or target groups must be addressed with special attention paid to their cultural and religious beliefs as well as the available resources. This should be done in conjunction with a National Society scientifc advisory group. This can be accomplished through partnership with others, including National Societies. For these reasons, education has been devel oped as an important part of these guidelines. For this edition, to pics requested by National Societies and others thought to be current and relevant have been included. General principles back Citizen preparedness for to table of contents disasters and daily emergencies Floods, fres, s to rms, earthquakes, avalanches, heat waves, industrial accidents, etc. Such disasters and technological risks often affect a large number of people (causing injury or death) and tend to receive much attention in the community. The consequences for those affected and their relatives (families, friends, neighbours, work colleagues, etc. The lack of consistency in the use of methods means that no conclusions can be drawn. First and foremost, it is necessary to recognize that citizens themselves are at the cen tre of prevention and response systems in emergency situations. Therefore, citizens must be active in these systems, alongside authorities and rescue, care and assistance organizations. Well-designed studies on the effec tiveness of this training in decreasing the impact of the disaster within the community are also required. Prevention While these guidelines focus on the education and provision of frst aid, pre venting an injury or illness is always better than needing to treat it. Every educational programme addressing frst aid should, when appropriate, incorpo rate key messages about prevention, shared with learners directly or indirectly as appropriate, depending on their needs and abilities. There are many National Societies with excellent preventative programmes outside of frst aid education.
Approximately 50% of individuals taking antipsychotic medications will experience adverse sexual side effects women's health clinic portlaoise buy female viagra mastercard, including problems with sexual desire pregnancy discrimination act purchase female viagra 100mg overnight delivery, erection menstrual cramps icd 9 purchase female viagra with visa, lubrication menstrual vs estrous cycles order female viagra 100mg amex, ejaculation, or orgasm. The incidence of these side effects among different antipsychotic agents is unclear. Exact prevalence and incidence of sexual dysfunctions among users of nonpsychiatric medications such as cardiovascular, cy to to xic, gastrointestinal, and hormonal agents are unknown. Elevated rates of sexual dysfunction have been reported with methadone or high-dose opioid drugs for pain. The prevalence of sexual problems appears related to chronic drug abuse and appears higher in individuals who abuse heroin (approximately 60%-70%) than in individuals who abuse amphetamines or 3,4-methylenedioxymethamphetamine. Chronic alcohol abuse and chronic nicotine abuse are related to higher rates of erectile problems. Development and Course the onset of antidepressant-induced sexual dysfunction may be as early as 8 days after the agent is first taken. In some cases, sero to nin reuptake inhibi to r-induced sexual dysfunction may persist after the agent is discontinued. There is some evidence that disturbances in sexual function related to substance/medication use increase with age. Culture-R elated Diagnostic Issues There may be an interaction among cultural fac to rs, the influence of medications on sexual functioning, and the response of the individual to those changes. Gender-Related Diagnostic Issues Some gender differences in sexual side effects may exist. Functional Consequences of Substance/M edication-Induced Sexual Dysfunction Medication-induced sexual dysfunction may result in medication noncompliance. Many mental conditions, such as depressive, bipolar, anxiety, and psychotic disorders, are associated with disturbances of sexual function. The area of sex and gender is highly controversial and has led to a proliferation of terms whose meanings vary over time and within and between disciplines. An additional source of confusion is that in English "sex" connotes both male/female and sexuality. In this chapter, sex and sexual refer to the biological indica to rs of male and female (unders to od in the context of reproductive capacity), such as in sex chromosomes, gonads, sex hormones, and nonambiguous internal and external genitalia. The need to introduce the term gender arose with the realization that for individuals with conflicting or ambiguous biological indica to rs of sex. Transsexual denotes an individual who seeks, or has undergone, a social transition from male to female or female to male, which in many, but not all, cases also involves a somatic transition by cross-sex hormone treatment and genital surgery (sex reassignment surgery). The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning. A strong desire for the primary and/or secondary sex characteristics of the other gender. The condition is associated with clinically significant distress or impairment in social, occupationali^or other important areas of functioning. Specifiers the posttransition specifier may be used in the context of continuing treatment procedures that serve to support the new gender assignment. Diagnostic Features Individuals with gender dysphoria have a marked incongruence between the gender they have been assigned to (usually at birth, referred to as natal gender) and their experienced/ expressed gender. Some may refuse to attend school or social events where such clothes are required. These girls may demonstrate marked cross-gender identification in role-playing, dreams, and fantasies.