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Absorbable materials like fibrin (prepared from human plasma and dryed as sheet or foam), gelatin foam, oxidized cellulose (as strips which can be cut and placed in the wound) provide a meshwork which activates the clotting mechanism and checks bleeding. Thrombin obtained from bovine plasma may be applied as dry powder or freshly prepared solution to the bleeding surface in haemophiliacs. Astringents such as tannic acid or metallic salts are occasionally applied for bleeding gums, bleeding piles, etc. Parenteral anticoagulants (i) Indirect thrombin inhibitors: Heparin, Low molecular weight heparins, Fondaparinux, Danaparoid (ii) Direct thrombin inhibitors: Lepirudin, Bivalirudin, Argatroban B. Oral anticoagulants (i) Coumarin derivatives: Bishydroxycoumarin (dicumarol), Warfarin sod, Acenocoumarol (Nicoumalone), Ethylbiscoumacetate (ii) Indandione derivative: Phenindione. Thus, heparin is present in all tissues containing mast cells; richest sources are lung, liver and intestinal mucosa. Anticoagulant Heparin is a powerful and instantaneously acting anticoagulant, effective both in vivo and in vitro. At low concentrations of heparin, factor Xa mediated conversion of prothrombin to thrombin is selectively affected. Thus, low concentrations interfere selectively with the intrinsic pathway, affecting amplification and continuation of clotting, while high concentrations affect the common pathway as well. This probably explains why low molecular weight heparin, which is insufficient to provide a long scaffolding, selectively inhibits factor Xa. However, it could be used clinically only in 1937 when sufficient degree of purification was achieved. It contains polymers of two sulfated disaccharide units: D-glucosamine-Lchain length and proportion iduronic acid of the two disaccharide units D-glucosamine-D- varies. Sudden stoppage of conventional-dose therapy may result in rebound increase in coagulability for few days. Antiplatelet Heparin in higher doses inhibits platelet aggregation and prolongs bleeding time. Lipaemia clearing Injection of heparin clears turbid post-prandial lipaemic plasma by releasing a lipoprotein lipase from the vessel wall and tissues, which hydrolyses triglycerides of chylomicra and very low density lipoproteins to free fatty acids. This action requires lower concentration of heparin than that needed for anticoagulation. Facilitation of fatty acid transport may be the physiological function of heparin; but since, it is not found in circulating blood and its storage form in tissues is much less active, this seems only conjectural. Heparin does not cross blood-brain barrier or placenta (it is the anticoagulant of choice during pregnancy). Heparin released from mast cells is degraded by tissue macrophages-it is not a physiologically circulating anticoagulant. If this test is not available, whole blood clotting time should be measured and kept at ~2 times the normal value. Needle used should be fine and trauma should be minimum to avoid haematoma formation. This regimen has been found to prevent postoperative deep vein thrombosis without increasing surgical bleeding. However, it should not be used in case of neurosurgery or when spinal anaesthesia is to be given. In some patients antibodies are formed to the heparinplatelet complex and marked depletion of platelets occurs-heparin should be discontinued in such cases. Hypersensitivity reactions are rare; manifestations are urticaria, rigor, fever and anaphylaxis. Severe hypertension (risk of cerebral haemorrhage), threatened abortion, piles, g. Subacute bacterial endocarditis (risk of embolism), large malignancies (risk of bleeding in the central necrosed area of the tumour), tuberculosis (risk of hemoptysis). Aspirin and other antiplatelet drugs should be used very cautiously during heparin therapy. They are eliminated primarily by renal excretion; are not to be used in patients with renal failure. Prophylaxis of deep vein thrombosis and pulmonary embolism in high-risk patients undergoing surgery; stroke or other immobilized patients.
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Gastroesophageal reflux Antacids afford faster symptom relief than drugs which inhibit acid secretion, but do not provide sustained benefit. Sucralfate polymerizes at pH < 4 by cross linking of molecules, assuming a sticky gel-like consistency. It preferentially and strongly adheres to ulcer base, especially duodenal ulcer; has been seen endoscopically to remain there for ~ 6 hours. Surface proteins at ulcer base are precipitated, together with which it acts as a physical barrier preventing acid, pepsin and bile from coming in contact with the ulcer base. Sucralfate has no acid neutralizing action, but delays gastric emptying-its own stay in stomach is prolonged. It attaches to the surface epithelium beneath the mucus, has high urease activity- produces ammonia which maintains a neutral microenvironment around the bacteria, and promotes back diffusion of H+ ions. Resistance develops rapidly, especially to metronidazole/ tinidazole and clarithromycin, but amoxicillin resistance is infrequent. In tropical countries, metronidazole resistance is more common than clarithromycin resistance. This is a higher degree of round-theclock acid suppression than is needed for duodenal ulcer healing or for reflux esophagitis. One week regimens are adequate for many patients, but 2 week regimens achieve higher (upto 96%) eradication rates, though compliance is often poor due to side effects. For patients who have, in the near past, received a nitroimidazole (for other infections) or a macrolide antibiotic, metronidazole or clarithromycin, as the case may be, should be excluded. All regimens are complex and expensive, side effects are frequent and compliance is poor. Repeated reflux of acid gastric contents into lower 1/3rd of esophagus causes esophagitis, erosions, ulcers, pain on swallowing, dysphagia, strictures, and increases the risk of esophageal carcinoma. Hormonal: gastrin increases, progesterone decreases (reflux is common in pregnancy). Stage 2: > 3 episodes/week of moderately severe symptoms, nocturnal awakening due to regurgitation, esophagitis present or absent. Stage 3: Daily/chronic symptoms, disturbed sleep, esophagitis/erosions/stricture/extraesophageal symptoms like laryngitis, hoarseness, dry cough, asthma. Dietary and other lifestyle measures (light early dinner, raising head end of bed, weight reduction and avoidance of precipitating factors) must be taken. Intragastric pH >4 maintained for ~18 hr/day is considered optimal for healing of esophagitis. Prolonged (often indefinite) therapy is required in chronic cases because symptoms recur a few days after drug stoppage. Antacids are no longer employed for healing of esophagitis, which they are incapable of. Sodium alginate It forms a thick frothy layer which floats on the gastric contents like a raft may prevent contact of acid with esophageal mucosa. Combination of alginate with antacids may be used in place of antacids alone, but real benefit is marginal. Alginate floats on gastric contents and prevents contact of esophageal mucosa with gastric acid 5. Upper gastrointestinal endoscopy reveals an ulcer measuring 12 mm X 18 mm in the 1st part of duodenum. His medical records show that he suffered similar episode of pain about 9 months ago. Subsequently, nearly 3 months back, he suffered from loose motions and abdominal pain which was treated with a 5 day course of metronidazole + norfloxacin. The vestibular apparatus generates impulses when body is rotated or equilibrium is disturbed or when ototoxic drugs act.
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The neuropsychology of anxiety: An enquiry into the functions of the septo-hippocampal system (1st ed. The neuropsychology of anxiety: An enquiry into the functions of the septo-hippocampal system (2nd ed. Cognitive dysfunction resulting from hippocampal hyperactivity: A possible cause of anxiety disorder. Such testing is important for selection efforts, such as determining who has the greatest likelihood of excelling in a school, career, or training program. Aptitude testing also is central to personnel classification-that is, matching individuals to jobs or job tasks on the basis of aptitudes. Since many aptitudes exhibit developmental change, aptitude testing also is important for validating theories of the nature and course of such change (English, 1998). Assessment can be concurrent, in which case the aptitude test, or predictor, and the outside criterion against which the predictor is being validated occur at the same point in time. In these efforts, the predictor occurs in the present, and the criterion will occur in the future. Alternatively, the assessment can be postdictive, as when the predictor occurs in the present, and the criterion has occurred in the past. The results of aptitude assessment can fruitfully be linked to interventions in educational, occupational, and clinical settings (Sternberg, Torff, & Grigorenko, 1998). Such learning tests are designed to foster learning during assessment (Dempster, 1997). Psychometric issues include standardizability, reliability, validity, and adverse impact. Test administration issues include the time available for testing, resources and technology needed for administration and scoring of aptitude tests, and adaptability of tests and testing equipment for different test sites. Test utility issues include ease of administration, costs associated with training test administrators, maintaining test sites and equipment, and preparing test materials. Implementation of testing programs that have broad applicability in a timely manner remains an important challenge. Furthermore, tests should be designed so that the resulting information, when used in selection and classification efforts, minimizes attrition. Considerable attention has been paid to issues in special education testing (Carver & Clark, 1998; Forness, Keogh, & MacMillan, 1998; Greenspan & McGrew, 1996) and aptitude testing in gifted education programs (Sternberg, 1998). Methods of Test Administration and Measures Taken From Tests Methods of test administration and data collection include computerized adaptive testing, dynamic testing (Dillon, 1997; Sternberg & Grigorenko, 2002), paper-and-pencil testing, observational data collection, document analysis, portfolio assessment, and job sample measures. Conceptions of aptitude differ in the nature of the databases on which the different models rest. Some researchers use complex and extensive statistical methods to uncover mental structures and processes. Other researchers base their conceptions of aptitude on interpretations of psychological observations and experimental findings. Still other researchers employ psychophysiological, neurophysiological, electrophysiological, or information-processing paradigms, sometimes coupled with experimental manipulations. Conceptions of Aptitude Theoretical notions regarding the origins of aptitude guide approaches to aptitude testing and directly address the above issues (Dillon, 1997; Flanagan, McGrew, & Ortiz, 2000). Performance on aptitude tests may result from a range of biological, cognitive, and social factors including (1) activation of competence, (2) trainability, (3) changes in learning and development resulting from mediated learning experiences, (4) guided experience, and (5) direct experience (Gottfredson, 1997). Aptitude Testing Framework Testing paradigms can be considered along four dimensions: aptitudes, methods, measures, and timing. Aptitude Dimensions the level of specificity of predictors, domains tapped, and the prior-knowledge demands of aptitude tests are all important factors in aptitude testing. Aptitude dimensions range from neurophysiological, electrophysiological, and perceptual processes to information-processing components (Dillon, 1997) and metacomponents (Sternberg, 1998; Sternberg, Torff, & Grigorenko, 1998); knowledge and reasoning aptitudes (Dillon & Vineyard, 1999); school subject aptitudes (Jacobs, 1998; Skehan, 1998; Sparks & Ganschow, 1996); sociocultural attributes (Lopez, 1997); personality, temperament, attitude, and motivational attributes; and interpersonal attributes such as social problem-solving aptitudes, including environmental adaptation aptitudes. Researchers have studied the functioning of these component processes during complex thinking and problem solving. Subsequent to job selection, testing is used for the purpose of classification to particular jobs. Testing also is undertaken for job enhancement, such as for retention, promotion, or selection to advanced training programs. Aptitude models are validated against a variety of school and occupational arenas. Common criterion measures include performance in (1) high school and college, (2) military training, (3) medical school preparation courses and medical school, and (4) complex workplace activities.
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The organization began under another name but became officially known as Psi Chi in 1930. In 1930 a newsletter was initiated, and the first Psi Chi Handbook appeared in 1932. Issues confronted early on by Psi Chi included appropriate activities for the organization, who should be admitted to membership-with one exception the early chapters were all from larger colleges and universities-and the question of honorary members. Boring, Otto Klineberg, Jerome Bruner, Rollo May, Neal Miller, Carl Rogers, and B. More recently, changes in the organization have involved the addition of several awards and grants, changes in the structure of the National Council, and the designation and affirmation of Psi Chi as an honor society rather than a professional society. Over the years Psi Chi has enjoyed and benefited from strong leadership from the National Council, the National Office, and local chapters. Cousins, who from 1958 to 1991-during most of which she served as executive director-provided tireless and inspired leadership that shaped the identity and efficiency of the modern Psi Chi organization. In its 73 years of existence it has also become an important source of opportunities for the intellectual, ethical, and social responsibility development of psychology students as it seeks to promote the highest ideals of the science and profession of psychology. Psi Chi is the oldest student organization in psychology still in existence and has the largest membership of any psychology-related organization in the world. At both the local and national levels, Psi Chi seeks to enhance excellence in psychology. Membership is open to undergraduate and graduate students for whom psychology is a primary interest and who meet or exceed the minimum qualifications for membership. It undertakes cooperative and mutually beneficial programming with Psi Beta, the National Honor Society for Community and Junior colleges. A council of elected members functions as a governing body, making decisions, setting policy, and facilitating the ongoing operation of the organization with the approval of the local chapters. Invited speakers; student recognition of excellence in teaching; sessions on applying to graduate school; research fairs; student-faculty social gatherings; volunteering at mental health, childcare, medical, and charitable facilities; group research projects; university and collegiate service activities; field trips; and tutoring services are just a few examples of the many varied activities undertaken by local chapters. Individually, these activities afford opportunities for incidental and direct learning, professional exploration, recognition of accomplishments, good-natured fellowship, and the exercise of leadership. Collectively, these activities augment and enrich the curricular experiences of students in psychology. The national organization sponsors student paper and poster sessions at regional and national meetings and provides certificate recognition of outstanding student scholarship, as well as supporting student research more generally. For example, it now provides monetary support for undergraduate research conferences. It provides research awards for undergraduate and graduate students, research grants for students and faculty, and recognition awards for outstanding chapters and faculty advisors. Currently, Psi Chi provides $180,000 annually through its grants and awards programs. Psi Chi publishes Eye on Psi Chi, a quarterly magazine featuring articles of interest to psychology students and faculty. Issues such as preparing for graduate school, career planning, and increasing the vitality of Psi Chi chapters, as well as information regarding meetings and Psi Chi awards and grant programs are routinely presented. Finally, the organization publishes the Psi Chi Journal of Undergraduate Research, which presents original empirical research primarily designed, conducted, and written by undergraduate members. More specifically, Freud theorized that the central theme running through personality development is the progression of the sex instinct through four universal stages-oral, anal, phallic, and genital. A period of latency intervenes between the latter two psychosexual stages but, strictly speaking, it is not a stage. Freud assigned crucial significance to the first three stages, termed pregenital stages, in the formation of adult character structure. The Oral Stage During the oral stage of psychosexual development, which lasts approximately throughout the first year of life, the primary erogenous zone is the mouth. Through activities associated with the mouth-sucking, swallowing, biting-infants experience their first continuous source of pleasure, and thus the mouth region becomes a focal point of rudimentary psychosexual satisfaction. Fixation in the oralaggressive phase (enter teeth), earmarked by biting and chewing activities, may result in a bitingly sarcastic, argumentative, and hostile adult personality. From the psychoanalytic perspective, then, there is little wonder why people experience serious difficulties in giving up such verbal behaviors-ultimately their psychological roots can be traced back to the first year of life. The Anal Stage During the second and third years of life, the primary erogenous zone is the anus.
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Key characteristics of dependency are bonding, obligation, reciprocity, trust, continuity, and involvement. Every culture or subculture defines "normal" dependency on the basis of its own value system. Modern Colonial the interruption of traditional dependency patterns has been a major and often underestimated effect of colonial contact since the fifteenth century. As Mannoni has shown, a major factor in the conquest of native peoples was their own tendency to transfer dependency expectations from familiar authority figures to European authority substitutes. Aggressive European cultures exploited native dependency while at the same time exporting values of independence, individualism, and progress, which did as much to weaken native resistance as the horses of Cortez or the firearms of the British. With its emphasis on competition, the Protestant work ethic dealt a heavy psychological blow to traditional notions of reciprocity, obligation, and trust. Under long-term colonization, the native personality is thought to have been severely stressed by the need to reconcile warring dependency-belief systems. During this same period in the Western world, dependency appears to have been systematically downgraded to neurotic behavior. Sigmund Freud theorized that the helplessness of the infant was the source of lifelong dependency bonds against which the maturing ego must implacably struggle. In modern thought-strongly influenced by Freudian theory-individuals must struggle to break free from dependence on groups as well as from a variety of others, beginning with Mother. Postcolonial In the Western world since about 1945, the belief has begun to emerge that undue stress on independence, change, and competition has contributed to massive alienation, anomie, and even morbidity rates. One response has been a trend toward the reinterpretation of dependency, as seen in a variety of recent developments. Carl Rogers, through his work on group dynamics, has encouraged a variety of lay and professional approaches that stress dependency interaction. More recently, "networking" has become a major drive among persons who recognize their need to relate to other individuals, especially in urban settings. Another dependency development is affiliated families, in which nonblood kin members of two or three generations pool their needs and resources in a common dwelling or at least in the same community. A number of matters should be considered in determining the appropriateness of the dependent variable selected. One obvious concern is that a dependent measure should reflect the construct being studied. If a researcher is investigating anxiety, the dependent variable should relate to the construct of anxiety. A dependent variable should also be both sensitive and reliable in the context of the phenomenon under study. The measure should be sufficiently sensitive to detect accurately behavioral or performance changes when they occur. The dependent measure should be able to reflect such changes in a reliable fashion. Generally, a researcher will select the most sensitive and reliable dependent variable possible. If using a particular measure appears to be obtrusive, another dependent variable may be preferred so that the data obtained are not contaminated. Thus, the measure of choice is one that is maximally sensitive, reliable, and unobtrusive. Another consideration related to selection of a dependent variable involves avoiding ceiling or floor effects in the data. A ceiling effect occurs when the performance range of the task is limited so that subjects "top out. In experimental research the dependent variable is what is being assessed to determine the effect of manipulating an independent variable. The dependent variable may involve behavioral, physiological, or social characteristics depending on the nature of the study. It may involve assessment of performance, such as the amount of information a subject might learn as measured by the number of correct responses on a test. A dependent variable is what is being measured to ascertain the effects of some treatment in an investigation or to use as a description of the status of subjects in the study. For example, suppose two methods of math instruction were being compared: the dependent variable might be the number of correct responses on a math test administered after instruction is completed.
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The modern pastoral counseling movement began in the 1920s as a reaction against both traditional theological education, which tended to have little practical and pastoral emphasis, and early psychiatric treatment, which had little place for religious perspectives on healing. Much of its work has been in providing standards and guidelines for the training of pastoral counselors; demonstrating to both hospital personnel and theological educators that pastoral involvement is relevant and effective in the treatment of psychological and physical illness; investigating ways in which theology and the psychological sciences can be related; and showing that the personal and spiritual development of seminarians is at least as important as intellectual training for the ministry. Pastoral counselors of all theological persuasions deal with personal, social, marital, family, and religious problems. Much of the emphasis in pastoral counseling is on coping with present problems, helping those who suffer, and giving spiritual guidance. Hospital and military chaplains usually identify themselves as pastoral counselors, as do college chaplains and chaplains associated with major league sports teams. As pastoral counseling has become more popular and its effectiveness more recognized, increasing numbers of pastors are finding themselves swamped with requests for counseling. To meet these needs, several trends have become apparent within the pastoral counseling movement. These include increased communication and cooperation among pastors and professionals in the helping fields; the development of better training programs in seminaries; the stimulation of lay counseling within and through the local congregation; the establishment of pastoral counseling centers; the involvement of pastors in new and established counseling clinics and community centers; the consideration of ways in which problem prevention can be stimulated by and through the church or synagogue; the increased use of sermons and small study groups as ways of stimulating mental and spiritual health; and the development of films, seminars, and training programs that can supplement, replace, and prevent the need for counseling. The term adherence is used rather than compliance because its meaning is more consistent with views of patients as active participants in health care rather than passive recipients of services. While this article is limited to medication adherence, the issues are relevant for adherence to other prescribed regimens. It requires that patients take a medication at the prescribed time, in the correct amount, using indicated conditions. Since adherence failures involve errors of omission, commission, or timing, reported adherence rates need to be defined. Ideal adherence is dependent on the specific medication, treatment goals, and individual factors including age, disease severity, and health-related quality of life. They propose that nonadherence is influenced by illness representation, cognitive function, and external aids. Multifactor models recognize that patients must understand how to adhere, accept the prescribed regimen, develop an adherence plan that integrates information for all medications, and then implement the plan (Morrow & Leirer, 1999). Predictors of Nonadherence Nonadherence occurs for many reasons: Patients may nonadhere intentionally to avoid side effects (Cooper, Love, & Raffoul, 1982), unintentionally because of barriers. Illness and Treatment Variables Nonadherence increases with regimen complexity. Measurement Adherence measures should be unobtrusive, objective, and practical (Rudd, 1979). Although practical, self-reports of adherence and pill counts have been shown to overestimate adherence to medications and therefore are a less desirable method of measuring adherence (Guerrero, Rudd, Bryant-Kosling, & Middleton, 1993; Lee et al. Patient Variables There is little evidence that nonadherence varies with gender, socioeconomic, or ethnic factors (Dunbar-Jacob et al. Less educated patients tend to have lower health literacy (ability to understand basic medical and services information), leading to poor health outcomes and lower utilization of services (Gazmararian et al. Extent and Consequences of Nonadherence Estimates of nonadherence range from 30 to 60% for a variety of patients, diagnoses, and treatments. Nonadherence to medication reduces health outcomes by lowering drug efficacy and producing drug-related illness due to incorrect doses or drug combinations. Because adherence is often not monitored (Steele, Jackson, & Gutman, 1990), inadequate assessment of treatment efficacy can occur (Dunbar-Jacob, Burke, & Puczynski, 1995). Provider-Patient Communication Theories of Nonadherence Social-behavioral theories used to explain nonadherence include the Health Belief Model (Strecher & Rosenstock, Patient adherence also relates to improved physician communication variables, such as amount of information and partnership building (Hall, Roter, & Katz, 1988). Moreover, interventions targeting adherence alone are not sufficient because the goal is to improve clinical outcomes. The literature suggests the importance of several interventions, although they tend to be complex and difficult to implement. More convenient care, improved instruction, reminders, self-monitoring, reinforcement, counseling, family therapy, attention, and tailoring the regimen to daily habits are among successful approaches (Haynes et al. Conclusions Although there are many adherence studies, few have adequately measured adherence, and nonadherence remains a pervasive health care problem.
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Gehringer and Engel (1986) tested an assertion made by Gibson (1966) that the illusion is destroyed if the front surface is removed to permit head motion. In fact, motion had a much weaker effect in reducing the illusion than did binocular viewing, a result corroborated by research in which observers viewed single trapezoidal or triangular surfaces differing in their slant-in-depth (Reinhardt-Rutland, 1996). How is the conflicting evidence from simulations and real stimuli to be reconciled? A first point is that visual motion is ambiguous: the moving observer may be viewing static objects, the static observer may be viewing moving objects, or the moving observer may be viewing moving objects (Reinhardt-Rutland, 1988). To resolve this ambiguity, effective motion parallax requires cumulative processing over time. In contrast, pictorial information is available for immediate processing, while binocular disparity relies on simultaneous comparison of the retinal images. Studies of real stimuli entail competition between motion and pictorial information; while motion parallax may have a role, rapid judgment is based on pictorial information. This even applies in a motion-rich activity such as driving, where depth judgments of child pedestrians or small automobiles may be wrong because pictorial information based on the sizes of "average" pedestrians and motor vehicles is applied inappropriately (Stewart, Cudworth, & Lishman, 1993). Depth-from-motion simulations probably rely on the motion of the dots introducing information that is normally conveyed pictorially. An edge conveys the existence of two surfaces; the surface of one side of the edge is at a different distance than the surface of the other side of the edge. Edges are specified pictorially, even by something as simple as a line in a pen-and-ink drawing, but may also be defined by a spatial discontinuity in depth-from-motion simulations. Now an edge does not convey which surface is the closer; other information is required. Rogers and Rogers (1992) suggest that early depth-from-motion simulations had inadvertently included pictorial information in the display that allowed the observer to decide which parts of the array of dots appeared closer and which parts further away. At another point, the more distant object may become partially or totally occluded. To conclude, motion parallax has a role in depth perception, but it is less important than some have asserted. Its limitation is that it requires time-consuming cumulative processing, while other sources of depth information are available for immediate processing. Visual and nonvisual information disambiguate surfaces specified by motion parallax. Whether it is the name of a relative, an item to purchase at the store, or, more rarely, entire events from our lives, we have all ex- perienced the phenomenon of forgetting. Unlike a digital camcorder, the human memory system does not encode and retrieve data in a mechanical fashion. Only a portion of what is available to our senses is stored in memory (longterm storage), and only a portion of what is stored is available at any given moment to be retrieved. Sometimes, we forget because our old memories fade with the passage of time or are interfered with as new memories become stored. Other times, we find it harder to remember more recent events and easier to remember our older memories because something interfered with the process of storing or retrieving these recent events; this is known as proactive interference. Both are unconscious forms of forgetting; that is, we are unable to recollect information despite energetic efforts to do so. A less prosaic type of forgetting, however, is labeled "motivated," and it has nothing to do with the passage of time or interference from subsequent experiences. Many of the original ideas regarding "motivated forgetting" stem from Sigmund Freud, who stated that "besides the simple forgetting of proper names, there is another forgetting which is motivated by repression" (Freud, 1938, p. According to Freud, this is particularly the case when dealing with memories of traumatic experiences. Since Freud, many writers and memory researchers frequently mixed these two types memory failure (repression and motivated forgetting) or used them interchangeably. Some writers and researchers, however, distinguish between repression and motivated forgetting. For some, repression deals with the unconscious process of blockading potentially painful memories in order to protect the individual. Motivated forgetting, on the other hand, occurs when the individual consciously forgets about painful or embarrassing events (Thompson, Morton, & Fraser, 1997). Therefore, unlike the unconscious forms of forgetting and interference mentioned above, motivated forgetting has at its root a conscious desire to forget or "suppress" events.
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Most paradoxical interventions involve some combination of prescribing, reframing, and positioning. Prescribing means telling people what to do (giving tasks, suggestions, and so on) either directly or indirectly. For example, a therapist might ask a patient to have a panic attack deliberately or prescribe that an overinvolved grandmother take full responsibility for a misbehaving child, expecting that she will back off and let the mother take charge. Reframing involves redefining the meaning of events or behavior in a way that makes change more possible. Although reframing resembles interpretation, its goal is to provoke change rather than provide insight-and the accuracy of redefinition is less important than its impact. Prescribing, reframing, and positioning are interwoven, with each at least implicit in any paradoxical strategy or intervention. Applications of paradox tend to be most varied and complex in marital and family therapy. In another case, a therapist asked a depressed husband to pretend to be depressed and asked his wife to try to find out if he was really feeling that way. For extreme marital stuckness, a therapist may recommend paradoxical interventions such as prescribing indecision about whether a couple should separate. The most dramatic examples of paradox with families come from the early work of the Milan team (Selvini-Palazzoli et al. After complimenting a severely obsessional young woman and her parents for protecting each other from the sadness associated with the death of a family member several years earlier, the team prescribed that the family meet each night to discuss their loss and suggested that the young woman behave symptomatically whenever her parents appeared distraught. Clinical reports describe successful applications of paradoxical intervention with a wide variety of problems including anxiety, depression, phobia, insomnia, obsessivecompulsive disorder, headaches, asthma, encopresis, enuresis, blushing, tics, psychosomatic symptoms, procrastination, eating disorders, child and adolescent conduct problems, marital and family problems, pain, work and school problems, and psychotic behavior (Seltzer, 1986). Paradoxical strategies appear least applicable in situations of crisis or extreme instability, such as acute decompensation, grief reactions, domestic violence, suicide attempts, or loss of a job, but there have been too few controlled studies to list indications and contraindications with any degree of certainty. While some authors advocate reserving paradoxical approaches for difficult situations where more straightforward methods have not succeeded or are unlikely to succeed, paradoxical strategies are too diverse for this to make sense as a blanket rule. For example, paradoxical symptom prescription could reasonably be a first line of approach for involuntary symptoms like insomnia that to some extent are maintained by attempts to stave them off. Change Processes Explanations of how and why paradoxical interventions work are as diverse as the interventions themselves. Behavioral, cognitive, and motivational processes-alone and in combination-have been proposed to explain change in both individuals and families. At the individual level, a behavioral account of why symptom prescription helps involuntary problems such as insomnia, anxiety, and obsessive thinking is that, by attempting to have the problem, a patient cannot continue in usual ways of trying to prevent it, thus breaking an exacerbation cycle. Here the client presumably rebels to reduce psychological reactance, a hypothetical motive state aroused by threats to perceived behavioral freedom (Brehm & Brehm, 1981). Not surprisingly, explanations of how paradoxical interventions promote change at the family-systems level are more diverse and more abstract. Some paradoxical interventions are assumed to interrupt problem-maintaining interaction cycles between people (Fisch et al. Motivational explanations of systems-level change suggest that paradoxical interventions work by activating relational dynamics such as "compression" and "recoil" (Stanton, 1984) or by creating disequilibrium among systemic forces aligned for and against change (Hoffman, 1981). Some theories of paradoxical intervention attempt to combine or integrate various change processes. For example, Rohrbaugh and colleagues (1981) proposed a compliance-defiance model distinguishing two types of paradoxical interventions. Compliance-based symptom prescription is indicated (a) when an "unfree" (involuntary) symptom like insomnia is maintained by attempts to stave it off, and (b) when the potential for reactance is low (i. Defiance-based interventions, on the other hand, work because people change by rebelling. These are indicated when clients view the target behavior as relatively "free" (voluntary) and when the potential for reactance is high. Studies by Shoham-Salomon and her colleagues provide empirical support for this "two paths to change" model.
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These findings about memory and storage retrieval suggest that the restriction of conscious capacity that occurs as a result of stress could have obvious effects on memory functions. Under conditions of stress we tend to remember fewer things that occur and these less well; thus, events will be less elaborately coded under stress. Unfortunately, there is little experimental evidence on the effects of stress on complex storage and retrieval processes. Available data tend to be rather dated and are limited to supporting the point that stress (frequently defined as failure) impairs memory. The only extensive set of data concerns the effect of stress on short-term memory, and shows that practically any kind of stress, failure experience, or uncontrollable noise will impair short-term memory retrieval. Since short-term memory, as used in the experimental research literature, is to some extent coextensive with span of attention or consciousness, such a finding is not surprising and adds little to our understanding of more complex processes. Both lay people and mental health professionals recognize the phenomenon that when under stress, the thought processes involved in problem solving demonstrate a kind of narrowing and stereotyping. Because much of problem solving requires the manipulation in consciousness of alternatives, choices, probable and possible outcomes, consequences, and alternative goals, the internal noise of stress and autonomic nervous arousal should and does interfere with problem solving. The restriction on memory elaboration leads to a similar restriction on elaboration that is present during problem solving under stress. Examples of these consequences appear in the discussions of available data on the problems of central and peripheral processing under stress. Understanding more precisely the impact of stress on memory and problem solving requires experimental research studies dealing with analyses of problem solving processes under stress. How and when does the introduction of stress (however produced or defined) constrain the available alternatives in the conscious state? Does the stress-induced inability to solve a problem synergistically further stress reactions because of the failure to solve the problem? Under what circumstances can the focusing that occurs under stress be beneficial, promoting more efficient problem solving? The research potential is great, yet our preoccupation with the unstressed mind has restricted experimental work on these problems. Memory storage and retrieval: Some limits on the reach of attention and consciousness. The menstrual cycle refers to the time from the menstrual flow until the day before the next bleeding (commonly called a "period") begins. This taboo has lessened during the past decades, and varies with gender and age as well as cultural background. A young woman in North America has her first men- struation (menarche) at about age 12, although between 10 and 14 years is normal. Menstruation continues cyclically for several decades until the final menstrual period at an average age of 51. The menopause transition (or perimenopause) occurs during the final years of menstruation and lasts about four years from the start of irregular periods. Perimenopause is a time of change with high or variable estrogen levels, ovulation disturbances, and consequent changes in flow, unpredictability of menstrual cycles, and more intense premenstrual experiences. The menstrual cycle may also describe the cyclic hormonal changes that are orchestrated by coordination of signals from the brain and pituitary with hormones from the ovary. All estrogen produced during a given cycle is made by the cells of one particular dominant follicle (larger nest of cells surrounding one egg). This follicle begins to grow during menstrual flow, increasing in size and in the amount of estrogen it makes to the middle of the cycle. As it enlarges it develops a cyst (small sack) of fluid that may normally grow to 2 to 3 cm in size. Following ovulation, cells that lined the follicle form a new body, called the corpus luteum, that makes progesterone as well as estrogen. If ovulation does not occur, progesterone levels do not rise and the ovary is left containing a cyst. Although the typical menstrual cycle is 28 days long and ovulation ideally occurs on day 14, there is wide variation in the length of menstrual cycles and the timing of ovulation. Luteal phase length (the number of days from ovulation until the next flow starts) is also variable.
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To meet diagnostic criteria, these symptoms must endure for at least one month and must cause problems in life functioning. A traumatic event is one in which an individual experiences actual or threatened serious injury or death (American Psychiatric Association [ApA], 2000). In addition, the individual must experience some dissociative symptoms either during or after the event. Dissociative symptoms include feeling emotionally numb or detached from the situation, feeling in a daze, and having the sense that the experience is somehow unreal or that the experience is not happening (ApA, 2000). The symptoms must cause the individual distress or cause impairment in functioning. Metaanalysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Objective assessment of peritraumatic dissociation: Psychophysiological indicators. Trauma and the Vietnam War generation: Report of findings from the National Vietnam Veterans Readjustment Study. Combat, dissociation, and posttraumatic stress disorder in Australian Vietnam Veterans. Dissociation and the fragmentary nature of traumatic memories: Overview and exploratory study. Hypothalamic-pituitary-adrenal functioning in posttraumatic stress disorder: Expanding the concept of the stress response spectrum. Deficits in memory specific to the trauma, as well as deficits in shortterm memory in general, have also been noted (Bremner et al. Not only psychological reactions, but also sustained physiological reactions have been well documented (Friedman, 2001; Yehuda, Giller, Levengood, Southwick, & Siever, 1995). Risk Factors It is important to note that not all individuals who experience a traumatic event develop a psychological disorder. Researchers have begun to identify risk factors for developing a psychological disorder after exposure to trauma. Individuals lacking social support are also at greater risk for developing a psychological disorder (Brewin et al. Individuals with trichotillomania experience internal sensations of anxiety or tension that immediately precede pulling (and/or an attempt to resist pulling) and subside only after pulling. Cosmetic complaints resulting from hair loss are a primary concern for persons with trichotillomania, but complications in social, occupational, psychological, and medical functioning are also common. Although hair pulling is rarely performed in public, hair loss often results in negative social interactions and the avoidance of many social and occupational settings. In addition to these social and occupational disturbances, a variety of physical and psychological sequelae can accompany trichotillomania. Although hair pulling resembles a compulsion, trichotillomania appears to be more of a problem with impulse control and is therefore classified as an impulse control disorder. Because individuals are unaware of their pulling, they frequently catch themselves pulling, often after removing a considerable number of hairs. Automatic pulling most commonly occurs when an individual is engaged in an activity that requires a high degree of concentration. Focused pulling, in contrast, involves pulling in which the individual is fully aware of the act. Individuals who engage in this type of hair pulling often seek specific situations or settings in which to pull. Individuals who engage in focused pulling often report an overwhelming urge or need to pull and report that pulling satisfies this urge by making it less intense or making it go away. In addition, individuals who engage in focused pulling report that attempts to suppress pulling makes the urge more intense. Typically, persons with trichotillomania engage in both automatic and focused pulling. Etiology Although the cause of trichotillomania is unknown, some experts contend that trichotillomania has genetic or neurobiological underpinnings.