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By A. Renwik. The Julliard School. 2018.

In relation to the dissociative be- haviors buy duloxetine 40mg on line anxiety heart palpitations, what concerns the couples therapist generic duloxetine 40 mg online anxiety 1 mg, however, is how these may impact the relationship. We assess this by using a number of psychological inventories including the Impact of Events Scale (Horowitz, Wilner, & Alvarez, 1979), the Trauma Symptom Checklist (Briere, 1996), and the PTSD subscale from the MMPI (Keane, Malloy, & Fairbank, 1984). Luke may also require individual treatment related to his own trauma and this may retard the onset of the couples therapy. Shannon and Luke represent a dual-trauma couple and their dynamic appears to be a cycle of angry outbursts (Shannon) and retreat (Luke), leav- ing the couple feeling confused. The therapist will need to be alert to a pos- sible additional diagnosis of substance abuse in either or both persons. Throughout the couples therapy, Shannon and Luke need to develop con- scious awareness of those moments when Shannon experiences angry out- bursts or dissociation. Shannon tells us in therapy that she finds Luke "insensitive and uncaring" as he continues to become more withdrawn from her and "leaves the house for hours" after her outbursts. Luke states that Shannon’s angry outbursts "scare me" and he leaves because, "I don’t know what to do when she’s like that. Shannon’s outbursts may be triggered by environmental cues (the smell of alcohol and tobacco during sex with Luke). This likely stimulates thoughts and feelings from the past that intrude on her present reality, causing Shannon to believe that she is in danger. As Siegel (1999) describes it, the brain is an anticipation machine and Shannon’s sense of anticipation is heightened due to her traumatic experience of the past. Shannon’s dissociative behavior at work suggests that she may also be dis- sociating when she is with Luke. Luke’s withdrawal from Shannon may rekindle feelings of abandonment related to her earlier abuse. Knowing that Shannon’s mother was aware of but did not stop the sexual abuse, Treating Couples with Sexual Abuse Issues 283 helps the therapist understand Shannon’s feelings of abandonment and her vulnerability to her stepfather’s victimization. The therapist can help her separate memories of these early attachment failures from the interper- sonal workings of the relationship with Luke. This in turn will reduce the personalization and reactivity that is taking place within the context of the current relationship. Educating the couple about the etiology of dissocia- tion, helping them understand that it is a protective measure, is a first step to mitigating this issue. The couples therapist can reframe each of Shannon and Luke’s behaviors as providing protection in moments of fear and can help them find alternative methods to communicate their fears to each other. Shannon’s rage can also be explained as a normal response to her abuse and its expression as a part of her healing process. The therapist must help Shannon become aware of the triggers that cause her outbursts and help her develop the conscious awareness of her fear, so as to better com- municate her fear with Luke and ease her distress. Somatic cues that pre- cede problematic behaviors (for example, muscle tension and stomach upset) can serve as early warning signals of these reactive behaviors. For example, Shannon’s reactions to the smells of alcohol and tobacco may now be associated with traumatic memories of her abuse and these surface when she is having sexual contact with Luke. In addition to olfactory mem- ories, other somatic memories might include body, tactile, and visual ones and should be explored with the couple. Learning communication skills and practicing them through role playing in session provides the couple with alternatives to problematic behaviors and can instill a sense of compe- tence in each of them. Role playing in session allows the therapist to help the couple refine their responses to each other. As treatment continues, the therapist can support the couple in communicating their fears, particularly as issues of trust, intimacy, and sexuality surface. Identification of cognitive distortions that are common in trauma survivors can be changed from "I am damaged goods" (Sgroi, 1982) to statements of empowerment such as, "I am strong for having survived this pain" or "I will not allow what others have done to me to stop me from having a happy life. CASE STUDY In contrast to the other couples we have described, both of whom have been comprised of relatively high-functioning individuals, Glenda and James re- flect a different picture. She has been married four times and presents for couple’s therapy with her fifth husband, James (58), who was a construction worker until his accident two years ago.

But given that only around 1% of clinical trials are said to be beyond criticism in term s of m ethodology 30mg duloxetine with mastercard anxiety symptoms high blood pressure, the practical question is how to ensure that a "sm all but perfectly form ed" study is given the weight it deserves in relation to a larger study whose m ethods are adequate but m ore open to criticism purchase 40 mg duloxetine fast delivery anxiety symptoms eye pressure. H ence, one of the tasks of a system atic reviewer is to draw up a list of criteria, including both generic and particular aspects of quality, against which to judge each trial. In theory, a com posite num erical score could be calculated which would reflect "overall m ethodological quality". In reality, however, care should be taken in developing such scores since there is no gold standard for the "true" m ethodological quality of a trial11 and such com posite scores are probably neither valid nor reliable in practice. If you don’t understand what this question m eans, look up the tongue in cheek paper by Carl Counsell and colleagues in the Christm as 1994 issue of the BMJ, which "proved" an entirely spurious relationship between the result of shaking a dice and the outcom e of an acute stroke. H owever, the sim ulation of a num ber of perfectly plausible events in the process of m etaanalysis – such as the exclusion of several of the "negative" trials through publication bias (see section 3. You cannot, of course, cure anyone of a stroke by rolling a dice, but if these sim ulated results pertained to a genuine m edical controversy (such as which groups of postm enopausal wom en should take horm one replacem ent therapy or whether breech babies should routinely be delivered by caesarean section), how 127 H OW TO READ A PAPER would you spot these subtle biases? W hat if the authors of the system atic review had changed the inclusion criteria? W hat if all the unaccounted for patients in a trial were assum ed to have died (or been cured)? If you find that fiddling with the data like this in various ways m akes little or no difference to the review’s overall results, you can assum e that the review’s conclusions are relatively robust. If, however, the key findings disappear when any of the what ifs change, the conclusions should be expressed far m ore cautiously and you should hesitate before changing your practice in the light of them. Question 5 Have the numerical results been interpreted with common sense and due regard to the broader aspects of the problem? As the next section shows, it is easy to be "phased" by the figures and graphs in a system atic review. But any num erical result, however precise, accurate, "significant" or otherwise incontrovertible, m ust be placed in the context of the painfully sim ple and (often) frustratingly general question which the review addressed. The clinician m ust decide how (if at all) this num erical result, whether significant or not, should influence the care of an individual patient. A particularly im portant feature to consider when undertaking or appraising a system atic review is the external validity of included trials (see Box 8. A trial m ay be of high m ethodological quality and have a precise and num erically im pressive result but it m ay, for exam ple, have been conducted on participants under the age of 60 and hence m ay not be valid for people over 75. The inclusion in system atic reviews of irrelevant studies is guaranteed to lead to absurdities and reduce the credibility of secondary research, as Professor Sir John G rim ley Evans argued (see section 9. The 128 PAPERS TH AT SU M M ARISE OTH ER PAPERS m etaanalysis, defined as a statistical synthesis of the numerical results of several trials which all addressed the same question, is the statisticians’ chance to pull a double wham m y on you. First, they phase you with all the statistical tests in the individual papers and then they use a whole new battery of tests to produce a new set of odds ratios, confidence intervals, and values for significance. As I confessed in Chapter 5, I too tend to go into panic m ode at the sight of ratios, square root signs, and half-forgotten G reek letters. But before you consign m etaanalysis to the set of newfangled techniques which you will never understand, rem em ber two things. A good m etaanalysis is often easier for the non-statistician to understand than the stack of prim ary research papers from which it was derived, for reasons which I am about to explain. Second, the underlying statistical techniques used for m etaanalysis are exactly the sam e as the ones for any other data analysis – it’s just that som e of the num bers are bigger. H elpfully, an international advisory group have com e up with a standard form at for m eta-analyses (the QU OROM statem ent,20 analogous to the CON SORT form at for random ised controlled trials I m entioned in Chapter 4). The first task of the m etaanalyst, after following the prelim inary steps for system atic review in Figure 8. In trials of a particular chem otherapy regim en for breast cancer, for exam ple, som e authors will have published cum ulative m ortality figures (i. The m etaanalyst m ight decide to concentrate on 12 m onth m ortality because this result can be easily extracted from all the papers. H e or she m ay, however, decide that three m onth m ortality is a clinically im portant endpoint and would need to write to the authors of the rem aining trials asking for the raw data from which to calculate these figures. In addition to crunching the num bers, part of the m etaanalyst’s job description is to tabulate relevant inform ation on the inclusion criteria, sam ple size, baseline patient characteristics, withdrawal ("dropout") rate, and results of prim ary and secondary endpoints of all the studies included. If this task has been done properly, you 129 H OW TO READ A PAPER will be able to com pare both the m ethods and the results of two trials whose authors wrote up their research in different ways. Although such tables are often visually daunting, they save you having to plough through the m ethods sections of each paper and com pare one author’s tabulated results with another author’s pie chart or histogram.

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The primary side effect is sleepiness order duloxetine 20 mg without prescription anxiety symptoms feeling cold, so the drug may be started in low doses and then given in higher doses until the pain is controlled cheap duloxetine 20mg with mastercard anxiety symptoms or something else. It is also possible that phenytoin, which has a milder action than that of carbamazepine, may be used, or less commonly, baclofen, which is usually given for spasticity. Another approach is to try and block the inflammation; if this is associated with a relapse, steroid therapy is given. If there is a continual problem of trigeminal neuralgia linked to several relapses, then a prostaglandin analogue called misoprostal (Cytotec) can bring relief. In some cases, various surgical operations, including the ‘gamma knife’, can destroy the relevant nerve pathways. Even if the trigeminal neuralgia reappears, as it can do, then the treatment can be started again, and it will almost certainly reduce the pain. Jaw pain There are other types of pain that may affect the facial area, which may not be linked to particular forms of myelin damage: temporomandibular joint (TMJ) pain affects the jaw area, or you may get more general migraine or tension headaches. Drug therapy can help counteract this pain, but in each case will be dependent on a careful investigation of the cause of the pain, and particularly the extent to which it appears to be linked to the MS, or to something else. Pain from unusual posture and walking patterns Pain from poor posture when sitting or lying, and from unusual walking patterns, is quite common. In most cases the pain does not result from the neurological damage of MS, but from its effects on movement. In fact one of the most common kinds of pain treated by neurologists in relation to MS is low back pain, often arising from an abnormal sitting posture or from a way of walking that has developed as a result of damage to the control of leg muscles. This may result in a pinched 74 MANAGING YOUR MULTIPLE SCLEROSIS nerve from ‘slipped discs’, or other back problems, which can also be caused by unusual turning or bending motions. So it is important to pay careful attention to how you sit and how you move in order to lessen such difficulties. You may need to seek advice from a physiotherapist in relation to both posture and movement. Comfort may be obtained by: • massage of the back, if carefully undertaken • ultrasound • TENS • specific exercises, to relieve muscle spasms • drugs designed to reduce spasms, and finally • surgery, if there are disc problems. Other painful conditions, particularly painful swelling of the knee(s) or ankle(s), can result through problematic patterns of walking. It is possible that orthopaedic doctors, recommending conventional orthopaedic exercises for such conditions, may not fully realize that having MS could mean that such exercises fail to work. It is likely that the swelling/pain of one joint may be easier to remedy through what is called an ‘assistive device’ (e. Several muscles contract simultaneously, both those assisting movement and those normally countering it. These muscles will feel very tense and inflexible – this is because what is medically called their ‘tone’ increases, and movement becomes more difficult, less smooth and possibly rather ‘jerky’. Spasticity is quite a common symptom in MS and is often very painful: it can occur in the calf, thigh or buttock area, as well as the arms and, occasionally, the lower back. Spasticity can lead to ‘contractures’, where the muscle shortens, making disability worse. There are a number of ways of managing spasticity in MS: • Use your muscles as much as possible in everyday activities, and undertake regular stretching exercises to help reduce muscle shortening. Devices to assist in the management of spasticity There are specific devices that may be useful for people with MS when spasticity occurs regularly in key muscle groups, and exercises alone do not appear to deal with the problem. What are called ‘orthoses’ – in effect braces – keep the hand, wrist or foot in an appropriate position or prevent ranges of movement that may result from, or cause, spasticity. A particularly useful brace may be one that places the ankle in a good position in relation to the foot (called an ankle–foot orthosis – see also Chapter 8) and thus lessens the possibility of local muscle contractures, as well as lessening the stress on the knee. It is important that all orthoses are specifically suitable for the individual concerned, as of course body shapes and sizes vary considerably. Drugs There are several drugs available to help muscles relax, and ensure that as few of your activities as possible are affected. It is difficult to target spasticity specifically, so some people may need medication occasionally, in the day or at night, and others may require more continuous medication. It is difficult to get the balance and the dose right, and this often has to be done on a trial and error basis.

It is crucial to review prior imaging studies (ide- ally MR) of the cervical spine before performing the discography trusted duloxetine 40 mg anxiety symptoms of going crazy. Discography should not be performed at any level where frank spinal cord compression exists quality duloxetine 60mg anxiety 12 year old boy, with or without myelopathy. Any disc level manifesting spinal cord deformity should be either avoided or studied with extreme care, depending upon individual circumstances. For a right- handed discographer, the needle is introduced from the right side, from approximately 30 to 45° oblique to and slightly below the target disc. A single 25-gauge needle is carefully advanced toward (ideally into) the disc, while the left index and middle fingers are used to palpate the cervical spine. The needle is directed between these fingers and passes directly through the skin and ideally into the disc, or as close to the disc as is possible. Neck palpation with the index and third fin- gers from the nondominant hand allows the proceduralist to push the carotid artery either laterally (most often) or medially and the esoph- agus (almost always medially) away from the intended needle tract. A 25-gauge needle, held in the right hand between the index finger and thumb, is carefully advanced through the skin and either into the disc or against the spine immediately adjacent to the disc. After needle insertion, we remove our hands from the field and perform flu- oroscopy for a few milliseconds to assess needle position. After needle position has been determined, fluoroscopy is used to assist with fine adjustments until optimal needle position within the intended disc has been achieved. In most cases, if the needle tip is within millimeters of the inferior disc margin, it can be manipulated upward and into the disc without difficulty. If, however, the needle is noted to be above the desired disc, we recommend needle removal and reintroduction. The performance of lateral fluoroscopy during needle placement helps one eliminate the risk of unintended needle advancement through the disc 114 Chapter 6 Discography FIGURE 6. Lateral view obtained during in- jection reveals full-thick- ness posterior tear (curved arrow), with epidural leak- age of contrast (straight ar- row). Patient reported 9/10 concordant diffuse neck and bilateral trapezius muscle pain. Following successful needle placement into the disc, fluoroscopy is performed during the injection of either contrast or saline. Injection volume, end-point characteristics, patient response, concordance/non- concordance and intensity rating are recorded after the disc has been filmed. It is recommended17,18,28 that one study as many cervical discs as are accessible (C3-4 through C6-7 in most individuals), since pure imaging studies have been proven to be inaccurate in detecting painful annular lesions in the cervical spine. In special cases, especially when headache of suspected cervical origin is a prominent clinical complaint, discography at C2-3 may be indicated. Postdiscography Care After completion of each discographic examination, patients are advised to expect some pain and discomfort, lasting up to 4 days, especially dur- ing the first 36 hours. They are warned that if they experience symp- toms such as worsening pain, fever, chills, malaise, and night sweats within one week of the procedure, a disc infection could be developing, and they should call us immediately. Patients are urged to contact the Conclusion 117 discographer and/or assisting technologist, one of whom is on call at all times, to deal with any procedure-related complaints or questions. We discourage patients from visiting emergency rooms, since too often in- experienced physicians overdiagnose disc infection that is not in fact present. In our experience to date, we have confirmed only six cases of postdiscography disc infection in more than 12,000 patients and more than 40,000 injected discs. Patients are given a nonrenewable narcotic prescription intended to last 3 to 4 days. All postdiscography patients are called 2 to 5 days later to check on their status. Reporting of Discography Results The formal reporting of discography should be performed within hours of the examination so that important details of each study can be re- called. In our practice, discography films and previous spine imaging studies of the same region are displayed for comparison at the time of formal interpretation. Injection volume, injection pressure, end-point characteristics (no end point, soft/firm, or voluntary termination of injection). Concordance vs nonconcordance of the experience relative to clini- cal complaints.

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