By L. Cronos. Massachusetts College of Pharmacy and Health Sciences. 2018.
Others order caverta 100mg mastercard, however buy 100 mg caverta, would argue that given the importance of relationships to women’s sense of self cheap 100mg caverta with amex, sexual abuse is likely to have a greater impact on women’s relationships than on men’s purchase caverta 50 mg free shipping. Gilligan (1982) and Erikson (1968) suggest that in gaining a sense of themselves, young women rely more on interpersonal relationships than do young men, thus women who were abused by someone of a close famil- ial nature may have difficulties developing a healthy self-identity. In either case, however, a focus on male survivors and their partners is beyond the scope of this chapter. Because most perpetrators of sexual abuse are likely to be men, the impact of having been sexually abused on a later ro- mantic relationship is different when the partner is female (as in a lesbian relationship) than when the partner is male. However, to limit the scope of issues to be considered in this chapter, we focus exclusively on heterosex- ual relationships. Prior to discussing how couples therapists might proceed in treating a couple such as Maria Elena and Jose, and before meeting other couples with similar histories, this chapter includes an overview of the impact and nature of sexual abuse and considers the experience of the sexual abuse survivor’s partner. We next discuss assessment issues looking at the case of Maria Elena and Jose in more detail. We conclude the chapter with the cases of Sharon and Luke, and Glenda and James, illustrating key issues in the treatment of these couples. NATURE AND IMPACT OF SEXUAL ABUSE Sexual abuse by a family member or by someone outside of the family may involve a child or adolescent. This abuse can include a variety of forms of sexual violations ranging from fondling, to sexual intercourse, to more un- usual forms of sexual behavior. The form of the sexual abuse, how long it 274 SPECIAL ISSUES FACED BY COUPLES lasted, whether it encompassed a single violation or multiple violations, whether there was a single or multiple perpetrators, the nature of the relationship between perpetrator and victim (e. Females are more likely to be abused by a family member (Finkelhor, Hotaling, Lewis, & Smith, 1990), and those sexually abused by a father figure exhibit the most long-lasting effects and the worst adjustment outcomes (Finkelhor, 1979; Herman, Russell, & Trocki, 1986; Russell, 1986; Tsai, Feldman-Summers, & Edgar, 1979). Briere (1992), in describing the long-term impacts of child abuse, indi- cates that these reflect "(a) the impacts of initial reactions and abuse- related accommodations on the individual’s later psychological develop- ment and (b) the survivor’s ongoing coping responses to abuse-related dys- phoria" (p. Of particular interest here, will be the way in which those individual reactions in turn impact the couple relationship. Recent thinking suggests that experiencing sexual abuse (or any type of trauma) may actually impact the biological processes of brain development. Further, early severe trauma may give rise to "a form of divided attention (such as entering a state of intense imagination or trance)" and explicit (conscious) memory for the trauma may be impaired. Implicit (unconscious) memory may encode the more frightening aspects of the trauma that can later be "automatically reacti- vated, intruding on the traumatized individual’s internal experience and external behaviors without the person’s conscious sense of recollection or knowledge of the source of these intrusions" (pp. Memories are biologi- cally encoded then stored, and when repeatedly active at the same time be- come associated so that they facilitate each other. The varieties of symptomology displayed by survivors of childhood sex- ual abuse are impressive. Stein, Golding, Siegel, Burnam, and Sorensen’s (1988) study of more than 3,000 Los Angeles adults, identified a subgroup that had been sexually abused as children and studied the lifetime preva- lence of emotional reactions. Seventy six percent of those abused developed some type of symptom, with 83% of women and 66% of men becoming symptomatic. Eighty-six percent of Hispanics and 73% of non-Hispanic whites, respectively, developed some symptom. For the group as a whole, 50% developed symptoms of anxiety, 48% had difficulty with anger, 48% felt guilty, 45% were depressed. Thirty three percent were fearful, and 24% to 28% experienced behavioral restrictions, diminished sexual interest, fear Treating Couples with Sexual Abuse Issues 275 of sex, diminished sexual pleasure or insomnia. Among women, the above symptoms were experienced by as many as 10% more participants in each category. The type of symptoms described in the above-cited study are con- sistent with those reported by others (for example, Briere & Conte, 1993; Browne & Finkelhor, 1986; Chu & Dill, 1990; D. In regard to symptoms that manifest themselves in the sexual arena, Becker, Skinner, Gene, Axelrod, and Cichon (1984) suggest that the survivor’s inhibition of sexual feelings leads to avoidance behavior and allows the negative attitude toward sex to endure. While the fear or avoidance of sex may exist for women with a history of sexual abuse, women survivors may also present with histories of high-risk sex, promiscuity, and prostitution (Maltz, 2002) in an effort to resolve intrapsychic conflicts (Scharff & Scharff, 1994), fac- tors that may further confound their sense of self and sexuality and impact their relationships with a spouse or partner. Browne and Finkelhor (1986) conclude that about 20% of adults who were sexually abused as children ev- idence serious psychopathology as adults. Other researchers (Kessler, Abel- son, & Zhao, 1998) found that lifetime depression for women survivors of sexual abuse was 39.
Large neurons along the lateral border of the ventral horn at lumbar levels may also contribute nonprimary afferents to the ipsilateral DCN discount caverta 100 mg visa. In the cat (Rustioni and Kaufman 1977) purchase caverta 50 mg mastercard, the cells of origin are numerous in the upper cervical 50mg caverta fast delivery, brachial discount caverta 100 mg mastercard, and lumbosacral SC, but are sparse in the thoracic segments. In the brachial and lumbosacral cord, the neurons of origin are mainly localized in lamina IV and more ventrally. In the lumbar segments, the cells of origin are located within a narrow band extending across the ipsilateral DH, subjacent to substantia gelatinosa. The non-PAs to the DCN ascend mainly in the dorsal columns and, to a lesser extent, in the dorsal part of the lateral funiculus both in monkeys (Rustioni et al. The data on the role of the postsynaptic fibers in somatosensory processing are contradictory. On the other hand, Giesler and Cliffer (1985) remained skeptical that the postsynaptic fibers are involved in nociception. However, numerous studies showed a broad diversity of its functions (reviewed by Saab and Willis 2003). Data indicating that the cerebellum is also involved in nociception has been abundant in recent years, although Chambers and Sprague (1955a, b) described an analgesic effect follow- ing cerebellar cortical lesions. Siegel and Wepsic (1974) observed antinociceptive effects following electrical stimulation of the superior cerebellar peduncle in the monkey. Spiegel (1982) speculated that impulses generated by posterior column stimulation may lead to relief of pain and spasticity by activating the cerebellum. The first reliable evidence that nociceptive stimulation evokes activity in path- ways and neurons of the cerebellum was provided by Ekerot et al. They reported that climbing fiber-evoked responses were recorded in Purkinje cells and as field potentials from the surface of the cerebellum upon stimulation of the ip- silateral superficial branch of the radial nerve. Similar data were reported by Wu and Chen (1990) following stimulation of C-fibers in the saphenous nerve. The stimulation increased the responses of all isolated cells to vis- 44 Functional Neuroanatomy of the Pain System ceral stimuli (colorectal distension), while the effect on the responses to somatic stimuli was less clear. In addition, Saab and Willis (2001) found that Purkinje cells in the caudal vermis respond to nociceptive visceral stimulation in the form of early and delayed changes in activity, and proposed a negative feedback circuitry involving the cerebellum for the modulation of peripheral nociceptive events. Recently, imaging studies on the nociceptive input to the cerebellum have also appeared. In positron emission tomography (PET) and functional magnetic reso- nance imaging (fMRI) studies, increases in blood volume or flow in the vermis and paravermal areas were reported during the perception of acute heat pain (Casey et al. The respective cortical areas differ functionally, as seen in electrophysiological and functional imaging studies: thesensory-discriminativeaspectofpain(localization,intensity,duration,quality) is presented in SI and SII, receiving thalamic input from lateral thalamic nuclei, the motivational-affective aspect (subjective suffering, unpleasantness, aversive emotions), and the cognitive-evaluative aspects of pain are presented in the IC, ACC, and PC, receiving thalamic input from medial thalamic nuclei. Primary Somatosensory Cortex The role of SI (located in the postcentral gyrus, Brodmann’s areas 3, 1, 2) in pain perception has been a matter of dispute for decades. Head and Holmes (1911) re- ported that patients with long-standing cortical lesions did not show deficits in pain perception, which lead to an erroneous suggestion that the pain sensation takes place in the thalamus. During epilepsy surgery, Penfield and Boldrey (1937) performed electrical stimulation of patients’ exposed SI and encountered only very few cases (11 out of more than 800 responses) that reported a sensation of pain. Also, the findings from human brain imaging studies have produced rather inconsistent results concerning the role of SI in pain perception (Bushnell et al. Despite certain controversies, an increasing number of PET and fMRI studies found an activation of SI during painful stimuli (Casey et Cortices Involved in Pain Perception and Thalamocortical Projections 45 al. According to Craig (2003a, d), nociceptive activation near the central sulcus in humans probably occurs in area 3a (where the thalamic VMpo projects), but its location is below the level of PET resolution. Two classes of neurons are ac- tivated in SI: neurons with a wide dynamic range react already to stimuli that are not painful; however, they show the highest activity to painful stimuli (Chudler et al. They have small receptive fields, are somatotopically located in the postcentral gyrus and enable the determination of the localization, intensity, and temporal attributes of the painful stimuli.
Inventorying and analyzing patamedicines and the theories be- hind them shows how severely the rational mind can be paralyzed by the desire of the patients — and even those who are in good health — "to believe" caverta 100mg discount. Medical charlatans do not base their claims on scientific proof but trusted 100mg caverta, quite to the contrary buy 50mg caverta mastercard, on peremptory assertions — the kind of as- sertions that they challenge when they come out of the mouths of those who defend "real" medicine cheap caverta 100 mg on-line. Most of the offers to provide experimental verification of patamedicine are never carried out — and for good reason. In some cases, the pataphysicians have agreed to abide by the verdict of the ex- periments. That didn’t turn out so well for them: as we have seen, dou- ble-blind testing of homeopathy and acupuncture led to the discredit- ing of these techniques. It is understandable that other pata-physicians refuse to yield to the demands of proper scientific experimental proto- cols. The attitude that the pataphysicians take is something like that of the folks who believe in mind-reading and psycho-kinesis. The "believers" "explain" any scams that may be revealed by saying that the behavior of the in- spectors disturbed the medium or the parapsychologist, and therefore the experiment was not conducted under proper conditions. A para- psychologist, caught "red-handed", may admit having cheated but he will say that it was only in order to protect his image, and his supposed powers are never questioned by the "believers". Given the lack of critical thinking exhibited by their followers, the pataphysicians have a merry time presenting their techniques as universal answers to every question on physical or psychic health. An Act of Faith Patamedicine is essentially a sign of absolute belief in principles that most often arise from a cosmo-divine interpretation of what it is to be human; the constantly drawn parallels between microcosm and macrocosm reflects this. References to esoteric data such as the Emer- ald Tablet give the beliefs a veneer of historical pseudo-veracity and creates a supposed traditional heritage. Historical medical references (the medicine of the Pharaohs, of the wise Indians, of eternal China) are woven in to strengthen the belief. They are generated by a special disposition of the patient’s mind: confidence, credulity, sug- gestibility, as we say today, which are constitutive of faith-healing [the faith that heals], which is active in varying degrees in different people. Generally, faith-healing does not develop spontaneously in all its healing intensity. A patient hears people say that in such and such a sanctuary, miraculous healings are taking place. He questions the people he knows, and requests information in full detail on the mar- velous cures about which he hears such rumors. He hears only en- couraging words, not only from his own direct acquaintances, but often even from his doctor. In any event, any contradic- tion at this point would only serve to exalt the patient’s belief in the possibility of a miracle cure. Faith-healing starts to take shape, it grows, it incubates, and the pilgrimage to be achieved becomes an obsession. Under these conditions, it is not long before the mental state dominates the physical state. One last effort: immersion in a special pool, some formal worship, and faith-healing produces the 1 desired effect; the miracle cure becomes a reality. Miracle Cures For pataphysicians, faithful followers bearing witness to their healing are like manna from heaven. All practitioners of alternative, natural or traditional medicine have up their sleeves a personal experi- ence to relate, proving the cogency of such and such technique. In No- vember 1993, the Association of Life and Action held a conference en- tirely devoted to this topic, under the title: "They were called incurable, 197 Healing or Stealing? Efforts to promote patamedicine frequently use artifices such as references to the phenomena of immunity — especially given the fear caused by AIDS, which results in an attack on the immune sys- tem. Through a skilful and misleading amalgam, official medicine is thus associated with the development of major pathologies. The intel- lectual game is complete: according to patamedical logic, it is the offi- cial doctor who is responsible for AIDS! From the first moment when you go to see the doctor, the neurologist, who supposedly cures the mind, from the moment he gives you a little pill, he induces in you something very serious. And you have, there, one of the essential bases of the suppression of the immune system, first of all, and secondly, of the tendency that the child will then develop to look toward artificial drugs and chemical paradises. And it is medicine that creates that, it is our synthetic agro-alimentary habit that pro- 3 duces it.
Key questions Diuretics Antineoplastic agents to ask concerning mouth care include the following: Is the Interleukin-2 mouth dry? Dry mouth Good hydration purchase caverta 100 mg otc, high-protein and -carbohydrate diets discount caverta 100 mg visa, Semifrozen fruit juice and vitamin C supplements encourage healing discount 100mg caverta with visa. Frequent sips of cold water or water sprays Gel or colloid dressings that keep the area moist Petroleum jelly rubbed on lips reduce pain and can be left in place for several days order caverta 100 mg fast delivery. Dirty mouth Painful changing of dressings can be eased by extra anal- Regular brushing with soft toothbrush and toothpaste 33 Pineapple chunks gesia before each change. Cider and soda mouthwash Encourage family and caregivers to keep skin clean Infected mouth and dry. Absorbent surfaces, urinary catheters, and rectal Topical corticosteroids: Betamethasone 0. Cover Tetracycline mouthwash, 250 mg every 8 h (one capful dissolved in 5 mL water) pressure points with thin, hydrocolloid dressings. Painful mouth Pressure ulcer management should be consistent with Coating agents: Sucralfate suspension as mouthwash, carmellose goals of care. If overall maintenance or improvement of paste, carbenoxolone function is the goal and prognosis is weeks to months, Topical anesthesia: Benzadymine mouthwash, choline salicylate, then treat the ulcer with expected management guide- Mucasine, lozenges containing local anesthetics lines. For uncomplicated malignant ulcers, pain relief and wound care are managed in the same way as pressure and may be preferred by patients. However, malignant wounds present special prob- (Salagen) may be used (5–10 mg q 8 h) if these measures lems such as bleeding, odor, and disfigurement. Side effects may include nausea, diarrhea, urinary ing malignant ulcer should be treated with radiation frequency, and dizziness. Dirty ulcers should be debrided, which can be accom- Oral Ulcers/Mucositis plished chemically. Apht- listening is often therapeutic in itself, but anxiety, anger, hous ulcers are common and can be helped by topical 33 or depression will need specific support. Oral candidi- asis usually presents as adherent white plaques but can Foul-Smelling Wounds also present as erythema or angular cheilitis. Nystatin suspension is the usual treatment, but a 5-day course of Odors may be very distressing to patients, families, and oral ketoconazole 200 mg can be used as well. Severe caregivers and may lead to poor-quality care, as even viral infection (herpes simplex or zoster) requires acy- professional caregivers avoid sickening smells. Malignant ulcers usually caused by anaerobic infections or poor hygiene are often associated with anaerobic bacteria and may or both. Treat superficial infections with topical metron- respond to metronidazole at 400–500 mg orally or rectally idazole or silver sulfadiazine. To control odors, place open kitty litter or activated charcoal in a pan under the patient’s bed, provide ade- quate room ventilation, place an open cup of vinegar in Skin Symptoms the room, or burn a candle. Special charcoal-impregnated Pressure Sores dressings placed over the odorous wound may also be helpful. Prevention and Dizziness/Dysequilibrium treatment require reduction in pressure (frequent turning and repositioning, foam or low-pressure mattresses), Dizziness is a well-recognized problem among older maintaining dryness and cleanliness, avoidance of shear, persons. How a patient moves or is moved by care- nursing home placement, stroke, and death. Even with Dizziness and associated fear of falling often lead to pro- regular turning and careful lifting and positioning, special gressive immobility and deconditioning. Potential causes and contributing factors of chologic, and social disability should be paramount. Facing a life- Cervical spondylosis threatening illness brings to surface questions as to what Drop attacks life is all about. Family members may have to reshape their identities and redefine their basic commitments when their loved one is ill or dying. Long-unresolved family issues threaten to become permanently unresolv- quency of dizziness and its associated morbidity, much able.
The pa- tients with profiles declined from nearly one-half of the dispositions to less than 25 percent cheap caverta 50 mg fast delivery, while returns without leave increased purchase 50mg caverta otc. Other dispositions remained relatively constant buy discount caverta 50mg line, ranging between 5 and 13 percent for immediate referrals and between 6 and 10 percent for assignment to quarters safe caverta 100mg. On average, there was one inpatient admis- sion due to low back pain per month for active duty personnel. The chart review performed at the CTMC in March 1999 showed that form 695-R was present in a relatively high portion of the medical charts, but there was a low rate of documentation that the provider had checked the patient for red-flag conditions. For these 27 patients with a 695-R form, 67 percent were appropriately coded as having low back pain, 19 percent had documentation that the red flags had been checked, and 56 percent had a profile in the chart. Appropriateness of referrals was not being monitored as of the time of our final site visit. PT staff estimated that 5 percent of the referrals they received were inappropriate, while neurosurgery staff estimated that 10 percent of the referrals they received were inappropriate. Reported Effects on Clinical Practices In general, the Site D staff perceived that the low back pain guideline had little, if any, effect on clinical practices for care of acute low back pain. Staff believed conservative care was already being provided to acute low back pain patients, and the emphasis continued to be placed on getting soldiers back to training. Some staff indicated, Reports from the Final Round of Site Visits 151 however, that the low back pain guideline contributed to the decline in the relative number of profiles written and to the increase in the number of referrals to MEB. Some staff in the family practice clinic indicated that staff at that clinic had not been familiar with low back pain treatment, and the guideline education and the key element cards they received had been helpful. Clinical practice for chronic cases has changed with the designation of a gatekeeper for referrals and coordinator for complicated cases. According to the team members, "This has helped standardize the treatment of chronic care cases. Es- tablishment of the gatekeeper function is also credited with reducing the backlog in neurosurgery from three months to two weeks. Conclusions Site D is seeking to integrate the implementation of the low back pain guideline into the hospital’s new paradigm of care that places more emphasis on primary care and prevention. Having the percep- tion that conservative treatment was already being provided for acute low back pain cases, the MTF focused initially on the portion of the guideline addressing management of chronic cases. An emphasis was placed on designating one clinic as the gatekeeper to resolve ex- isting difficulties with inappropriate referrals of low back pain pa- tients to neurosurgery and inadequate coordination with the numer- ous relevant specialties available at the medical center. At the same time, the MTF sought to formally implement use of the guideline in its CTMC and other primary care clinics. There was substantial initial buy-in for the guideline recommendations, but turnover and other pressures reportedly led to a decline in compliance over time. MTF leadership at Site D believes that full compliance with the low back pain guideline, and eventually any guideline for primary care, cannot occur without increasing electronic applications related to the guideline, especially online documentation of care. To this end, the MTF developed its own computerized algorithm for management of low back pain that follows the guideline in steps and allows online checks of the examinations performed and treatment provided. This 152 Evaluation of the Low Back Pain Practice Guideline Implementation approach was being tested at the CTMC at the time of our final visit. An important issue, which is a chronic problem in MTFs, is that this automated system was created by one entrepreneurial, computer savvy military person, who left in the summer rotations, and his computer skills will be difficult to replicate. This issue speaks to the need for systemwide applications to institutionalize such systems. Appendix C MULTIVARIATE ANALYSES OF LOW BACK PAIN METRICS To test for effects of the introduction of the DoD/VA low back pain guideline on service utilization and prescription patterns, we fit a se- ries of regression models to predict each of the six measures of guideline effects during the treatment of acute low back pain. We calculated the following measures for activity within six weeks of the initial low back pain encounter: • whether a patient was referred to PT • the number of follow-up primary care visits • whether a patient was referred to specialty care • whether a patient was prescribed muscle relaxants • whether a patient was prescribed narcotics • whether an NSAID prescription was for a high-cost NSAID. The unit of analysis for the first five measures was the episode of care, so there was one record in the data file used for each episode of care with variables for the five measures. As described in Chapter Two, this study was limited to episodes of low back pain care for ac- tive duty Army personnel. The variables for PT referrals, specialty referrals, muscle relaxant prescriptions, and narcotic prescriptions were dichotomous variables (equal to one if one of these events had occurred).