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STUDENT DIGITAL NEWSLETTER ALAGAPPA INSTITUTIONS |
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David Ashley, MBBS, PhD
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Our work sets the stage for investigations of these biomarkers and molecular pathways for prognostic and interventional purposes does oral antibiotics for acne work generic ivermectin 3 mg mastercard. Background: Earlier detection of type 2 diabetes is associated with improved management of diabetes antibiotic cream for dogs generic ivermectin 3mg on line. Populations with barriers to care are more likely to have type 2 diabetes and are more likely to be diagnosed at an advanced stage of the disease antibiotics osteomyelitis discount ivermectin 3mg with visa. However antimicrobial fabric manufacturers generic ivermectin 3 mg without prescription, in states which did not adopt Medicaid expansion, 24% of Latinos are uninsured compared to 10% of non-Hispanic whites. California went further by expanding coverage to non-citizens, which increased the number of non-citizens covered by about 31%. Results: Our analysis identified several genes associated with kidney function decline (estimated glomerular filtration rate), many also responsible for the progressive increase in interstitial fibrosis and/or associated with lymphocytic infiltration. Cell type specific gene signatures used with deconvolution algorithms revealed that several immune cells, mostly T lymphocytes, are active since the early stages of the disease. As alternative splice isoforms are poorly annotated, an integrated analysis using structure, function and motif predictions was performed and non-canonical isoforms with differential regulation and function from their canonical isoforms were further studied. The protein products of 9 of these 39 transcripts are annotated as alternative /non-canonical isoforms. Background: Diabetes mellitus is a heterogeneous group of diseases which is a leading cause of renal cell and tissue damage, fibrosis and eventual renal failure. In view of recent therapies aimed at the pathogenesis of fibrosis generation and progression, sensitive and quantitative techniques for recording fibrosis becomes necessary. The goal of this study was to identify whether or not alternative splice isoforms were expressed in biopsy tissues from patients with diabetes. Inflammatory responses and cellular signaling and proliferation pathways were the prominent functions enriched within these shared structural traits. Further evaluation of these pathways could provide early intervention targets and novel noninvasive biomarkers with predictive clinical utility. MiR-23a and miR-27a are known to regulate proteins that are involved in the atrophy and fibrosis process. We hypothesized that treatment with miR-23a/27a would reduce both diabetes-induced muscle wasting and renal fibrosis through exosome-mediated musclekidney crosstalk. After 3 months, mice were killed and muscles and kidneys were analyzed for protein markers of atrophy and fibrosis. Serum exosomes and kidneys of mice that received intramuscular injections of miR-23a/27a showed levels of those miRs that were higher than the un-injected control mice. Conclusions: Overexpression of miR-23a/27a in muscle prevents diabetes-induced muscle loss and attenuates renal fibrosis lesions via exosome-mediated muscle-kidney crosstalk. Background: Poor glycemic control, even with subsequent periods of wellcontrolled glycemia, increases risk for diabetic complications. Renal function improvement was accompanied by decreased glomerular mesangial matrix, increased macrophage infiltration, restoration of podocyte foot processes and an increase in podocyte number. An average of 2 days of 24-hour dietary recalls were used to estimate protein intake. Protein intake was converted to kcal by multiplying each g by 4 kcal; to calculate protein intake as percentage of dietary intake, we divided by total daily kcal. Conclusions: the percentage of the population exceeding protein intake recommendations remained high in 2003-2008 and 2009-2014. Differences in Prevalence of MuscleWeakness (Sarcopenia) in Haemodialysis Patients Determined by Hand Grip Strength According to Variation in Sarcopenia Guidelines Rachel Hung,2 Kamonwan Tangvoraphonkchai,1 Omid sadeghi-alavijeh,3 Andrew Davenport. The prevalence of muscle weakness varies according to cut off, and whether age and gender matched normative data is used. In addition, patient characteristics in terms of age and co-morbidity also determine the prevalence of muscle weakness. Methods: Medical records of prevalent hemodialysis patients as of 30Jun2016 were reviewed. Statins group included patients taking statins 6 months prior to 1Jan2016 and continued statins until 30Jun2016. No statins group included patients never taking statins or who stopped taking statins >6 months prior to 1Jan2016. Exclusion consisted of 20 new patients, 98 with active infection or hospitalization, 5 on omega-3, 6 on steroid, 9 on statins <6 months, 7 started statins after 31Dec2015, 3 stopped statins between 1Jan30Jun2016, and 5 received blood transfusion. In remaining 71 patients, 36 patients (24 males, 11 diabetics) aged 61±17 years never used or discontinued statins >6 months prior to 1Jan2016 while 35 patients (22 males, 22 diabetics) aged 70±13 years (p=0. In statins group, 2 were on low intensity, 26 were on moderate intensity, and 7 were on high intensity statins. Lack of statins impact on markers of thrombosis and inflammation in end stage renal disease may explain lack of mortality benefit observed in previous literature. Low exercise capacity has been shown to be an independent predictor of mortality in patients with end-stage renal disease. Results: There were a total of 108 combined events (death, cerebrovascular accident and hospitalisation for chronic heart failure) during the follow-up period. Determinants of functional ability, Sit to Stand 60 test (>18 complete transfers; p<0. The outcomes on handgrip strength, blood biochemistries, appetite change, and quality of life were also examined. There was no significant difference in the parameters of quality of life and the profiles of blood biochemistries. Biochemical investigations, included serum albumin, hemoglobin, sodium, potassium, calcium, phosphorus, and blood glucose were done at baseline (visit 1) and at 10 months (Visit 2). Conclusions: Ketoanalogue supplementation preserves nutritional status and prevents decline renal function. Effects of Resistant Starch Supplementation on Inflammatory and Oxidative Stress Status in Hemodialysis Patients: A Pilot Randomized, Double-Blind, Placebo-Controlled Clinical Trial Denise Mafra, Marta Esgalhado, Milena B. In this context, prebiotics use has been pointed out as a promising non-pharmacological therapeutic strategy by reestablishing the gut microbiota balance. Results: There was no significant difference between baseline values for any variable in both groups. Background: Accumulating amounts of evidence suggest that mitochondria play a major role in maintenance of renal function and pathogenesis of kidney diseases. Mitochondria are a dynamic organelle that actively changes its shape, number and site of residence, thereby making it critical to analyze them in vivo. In order to establish in vivo tools to study mitochondria, we applied the genetically encoded biosensor technology to the zebrafish, an optically accessible and genetically tractable model system. Live imaging of the transgenic zebrafish was performed by sequential excitation at 405 nm and 488 nm for ratiometric measurements. Results: We found that mitochondrial structure and dynamics in podocytes can be imaged in living zebrafish by two-photon microscopy. Upon exposure to a nephrotoxic antibiotic, puromycin aminonucleoside, mitochondria appeared to relocalize to primary and secondary processes from the cell body. Conclusions: these transgenic zebrafish represent a novel tool to investigate mitochondrial structure and function in vivo. In addition, transgenic zebrafish with biosensors for other metabolic parameters, such as glucose, are also being validated. These transgenic zebrafish offer a versatile and accessible in vivo system to study mitochondrial dynamics and activity as well as their associated metabolism in the kidney in health and disease. Moreover, definition of sarcopenia was made only in considering the low muscle mass in most of the previous studies. Low muscle strength was defined as hand grip strength of < 26 kg for males and < 18 kg for females. Age was significantly higher, and body mass index and serum albumin were significantly lower in patients with sarcopenia than in those without sarcopenia (63. Prevalence of sarcopenia in diabetic patients was significantly higher than that in nondiabetic patients (51 % vs. Poster Saturday Nutrition, Inflammation, Metabolism: Clinical Trials, Biomarkers, Epidemiology patients, especially elderly patients with low physical activity, present unexplained cardiac or neurologic symptoms. Budoff,2 Tracy Nakata,1 Alejandra Novoa,5 Gregory Brent,7 Kamyar Kalantar-Zadeh,4 Danh V. Background: Thyroid status is known to control metabolism, with subsequent effect upon body composition.
We compared death-censored graft failure for kidneys based on histologic category bacteria que come carne humana purchase ivermectin 3mg otc. Given the small sample size infection ebola generic ivermectin 3mg on-line, variables that were statistically significant at level = 0 virus encrypted my files buy ivermectin 3mg lowest price. Regardless of histologic category antibiotics that start with c order 3mg ivermectin mastercard, transplantation was associated with a significant survival advantage compared to remaining on dialysis (5-year overall patient survival 87. Conclusions: Frozen section procurement kidney biopsies are poorly reproducible, but may help determine long term allograft function. Background: Psychosocial factors are common in patients with advanced and end stage kidney disease and they may be associated with post kidney transplant outcomes. When these patients are referred for transplant evaluation psychosocial and nutrition history is an important component of evaluation however there is lack of data on post-transplant implication of these factors. The aim of this study was to determine the correlations between pretransplant, nonclinical and psychosocial factors to posttransplant clinical outcomes. Methods: We selected the following pre-transplant factors: gender, food stamp, marital relationship, insurer, education, Karnofsky score, history of depression, exercise, albumin level history of substance abuse, distance from transplant center. The posttransplant clinical outcomes selected were quality of kidney allograft at 6 months expressed as serum creatinine. We had 72 Hispanics (53%), 33 African Americans (24%), 22 Whites (16%), 9 Asians (7%). We used nominal logistic regression analysis and multinominal logistic regression analysis to identify the significant relationship between one dependent nominal variable and one or more continuous-level independent variables. Results: Factors associated with significantly better serum creatinine at 6 months included: Female gender (p 0. Patient primary insurer, family support, mariatal status, exercise, food stamp status, history of depression, history of substance abuse, education level, race, distance from transplant center, and retransplant status was not found to be associated with 6 months serum creatinine. Conclusions: Pretransplant psychosocial factors are associated with the post transplant kidney allograft function. This also shows the pre transplant psychosocial history is an integral but often ignored part of evaluation and should be stressed upon. Background: the allocation of deceased donor kidneys has become more complex because of the increasing spectrum of donor and recipient co-morbidities. In this study, we evaluted the prognostic value of pre-implantation histopathological parameters in predicting the graft function after transplantation. Methods: Deceased donor recipients transplanted between January 2012 and March 2016 were followed up to four years were included in this study. Conclusions: A multiparametric approach may be developed by incorporating pre-implantation biopsy information along with important clinical variables to predict outcome. Background: Biopsies taken at the time of deceased donor kidney procurement are frequently used to assess organ quality and are cited as a leading reason for discard. However, the reproducibility and prognostic capability of these biopsies are controversial. Methods: We compiled a retrospective, single institution, continuous cohort of deceased donor kidney transplants with complete biopsy reads from 2006-2009 (n=301). Histology was classified as optimal if glomerulosclerosis and interstitial fibrosis/tubular atrophy were each 10%, and vascular disease was mild or none. Cox proportional hazards and Kaplan-Meier methods were used for time to event analysis. Results: the reproducibility of procurement biopsies was poor: in the 119 kidneys that were biopsied twice, 44. However, its role in the management of these grafts and the impact on outcomes are not fully described. Conclusions: Implantation biopsy is independently associated with better one year graft survival. Methods: All deceased donor kidney transplants at our institution from 07/01/2016 to 03/15/2017 that had a time-zero biopsy were included. There was no correlation between Banff scores and the occurrence of delayed graft function. Rate of patient and graft survial in the matched cohort was 100% at 1 & 2 years post transplant. All of them have had acceptable early patient and allograft survival and function with intensive and individualized monitoring and follow up. However care of these patients is very resource itensive and needs a dedicated and specialized group of care givers for post transplant care for a successful outcome that benefits a very specific subset of patients. Background: In recent years, there has been a marked increase in the number of older patients (> 65) undergoing kidney transplantation. While there is increasing evidence that the ageing immune system is characterised by immunosenescence, many centres do not have age-specific protocols for immunosuppression. In this study, we sought to examine the effect of recipient age on the development of complications of over- and underimmunosuppression post-transplantation. The rate of rejection was markedly increased in the control group compared to those aged > 65 years (19. Given the significant morbidity consequent to overimmunosuppression, consideration should be given to the development of age-specific protocols for immunosuppression. We used Kruskal-Wallis and chi-square test to examine race differences in non-medical factors. Results: We found significant racial differences in baseline characteristics[Tab1]. Background: the impact of donor factors on kidney allograft outcomes and infectious complications has been suggested in many previous studies. However, analysis of left or right donor kidney pairs are rarely performed, although individual recipients risk factors may be analyzed in a paired difference test and significantly reduce donor cofounders. Methods: Here, we studied all transplanted left/right deceased donor kidney pairs at our center between 2003 and 2015. To account for identical donor characteristics among left/right donor kidney pairs a paired difference testing was performed. Results: Patient survival, allograft survival and allograft function were not correlated among left/right donor kidney pairs (p>0. Delayed allograft function was more likely detected in both kidney pairs than one pair only (p<0. Male gender was associated with delayed allograft function among kidney pairs (p=0. Re-transplantation in one pair was associated with a higher incidence of acute cellular rejection. Conclusions: Despite an increased incidence of delayed allograft function in left/right kidney pairs, our results suggest low impact of donor factors on patient and allograft outcomes. The nephrology community and their patients should be aware of the benefits of accepting these grafts. History of cerebrovascular disease in the recipient was associated with an increased risk of recipient mortality, while history of diabetes in the recipient was associated with increased risk of graft loss. Further studies are needed to identify pretransplant clinical factors associated with increased risk of graft failure and recipient mortality in this population in order to improve allocation of these old allografts in the elderly patients. Methods: the present study was conducted to obtain baseline data that will facilitate future annual assessments of the impact of this program. There were no significant differences in referral or refusal rates across racial groups. Referral & refusal rates, respectively, did not differ significantly by race, sex or diabetes status. To accomplish these objectives innovative educational programs need to be developed & implemented for both dialysis facility staff & patients across the full-range of providers. Santiago,1 Teresa Cavero escribano,1 Candela Moliz,1 Beatriz Redondo navarro,2 Teresa Bada bosch,2 Manuel Praga,1 Esther Gonzalez monte. Background: Kidney transplantation is the best option for elderly patients with end stage renal disease. The major limitation in this group of patients is shortage of donors since kidneys from young donors are assigned to younger recipients. Kidneys from these donors can be assigned to older patients without detriment to young recipients. Methods: We performed a retrospective analysis of pretransplant clinical factors associated with graft and recipient survival in elderly patients (70 years) that received a kidney transplant from a very old donor (70 years) at our institution from October 2004 to December 2013 (and followed through April 25, 2017) (n = 155).
The anterior and posterior chambers communicate with each other through the pupil and are filled with fluid called the aqueous humor produced by the ciliary process of the ciliary body virus zapping robot purchase ivermectin 3mg with amex. The clear aqueous humor circulates from the posterior chamber into the anterior chamber providing nutrients for the avascular cornea and lens infection care plan order 3mg ivermectin free shipping. From the anterior chamber natural antibiotics for acne discount 3mg ivermectin otc, the fluid passes through the scleral venous sinus (canal of Schlemm) at the iridocorneal angle where it is resorbed into the bloodstream virus 1980 imdb purchase ivermectin 3 mg line. Here, it forms the hyaloid vessels, which during intrauterine life supply the lens and form the vascular layer on the inner surface of the retina. The interstitial spaces of this network later fill with a transparent gelatinous substance, forming the vitreous body. The hyaloid vessels in this region are obliterated and disappear during fetal life, leaving behind the hyaloid canal. The nerve fibers of the retina returning to the brain lie among cells of the inner wall of the stalk. During the seventh week, the choroid fissure closes, and a narrow tunnel forms inside the optic stalk. As a result of the continuously increasing number of nerve fibers, the inner wall of the stalk grows, and the inside and outside walls of the stalk fuse. Cells of the inner layer provide a network of neuroglia that support the optic nerve fibers. Its center contains a portion of the hyaloid artery, later called the central artery of the retina. On the outside, a continuation of the choroid and sclera, the pia arachnoid and dura layer of the nerve, respectively, surround the optic nerve. Initially, this transcription factor is expressed in a band in the anterior neural ridge of the neural plate before neurulation begins. At this stage, there is a single eye field that later separates into two optic primordia. Instead, this process is regulated by interactive signals between the optic vesicle and surrounding mesenchyme and the overlying surface ectoderm in the lens-forming region. Thus, the lens ectoderm is essential for proper formation of the optic cup, such that without a lens placode, no cup invagination occurs. In turn, the optic vesicle secretes Outer layer of optic stalk Lumen of optic stalk Nerve fibers Hyaloid artery Optic nerve fibers Central artery of retina A Choroid fissure B C Figure 20. Drawings of the cranial neural plate region depicted in A showing the initial stages of eye development. When the optic vesicle begins to invaginate to form the pigment and neural layers of the retina, the lens placode invaginates to form the lens vesicle. Through a groove at the inferior aspect of the optic vesicle, the choroid fissure, the hyaloid artery (later the central artery of the retina) enters the eye. Nerve fibers of the eye also occupy this groove to reach the optic areas of the brain. The cornea is formed by (a) a layer of surface ectoderm, (b) the stroma, which is continuous with the sclera, and (c) an epithelial layer bordering the anterior chamber. Epithelial mesenchymal interactions between prospective lens ectoderm, optic vesicle, and surrounding mesenchyme then regulate lens and optic cup differentiation. In taking a history of a young woman in her 10th week of gestation, you become concerned that she may have contracted rubella sometime during the fourth to eighth weeks of her pregnancy. Physical examination of a newborn reveals clefts in the lower portion of the iris bilaterally. Epidermis Initially, the embryo is covered by a single layer of ectodermal cells. In the beginning of the second month, this epithelium divides, and a layer of flattened cells, the periderm, or epitrichium, is laid down on the surface. With further proliferation of cells in the basal layer, a third, intermediate zone is formed. Finally, at the end of the fourth month, the epidermis acquires its definitive arrangement, and four layers can be distinguished. This layer later forms ridges and hollows, which are reflected on the surface of the skin in the fingerprint. A thick spinous layer consists of large polyhedral cells containing fine tonofibrils. The horny layer, forming the tough scalelike surface of the epidermis, is made up of closely packed dead cells containing keratin. Cells of the periderm are usually cast off during the second part of intrauterine life and can be found in the amniotic fluid. During the first 3 months of development, the epidermis is invaded by cells arising from the neural crest. As melanosomes accumulate, they are transported down dendritic processes of melanocytes and are transferred intercellularly to keratinocytes of the skin and hair bulb. Ectoderm Mesenchyme A Periderm Basal layer Horny layer Granular layer B Intermediate layer Spinous layer Melanocyte Germinative layer Corium C D. The invaginations, the hair papillae, are rapidly filled with mesoderm in which vessels and nerve endings develop. Soon, cells in the center of the hair buds become spindle-shaped and keratinized, forming the hair shaft, while peripheral cells become cuboidal, giving rise to the epithelial hair sheath. A small smooth muscle, also derived from mesenchyme, is usually attached to the dermal root sheath. Continuous proliferation of epithelial cells at the base of the shaft pushes the hair upward, and by the end of the third month, the first hairs appear on the surface in the region of the eyebrow and upper lip. The first hair that appears, lanugo hair, is shed at about the time of birth and is later replaced by coarser hairs arising from new hair follicles. The epithelial wall of the hair follicle usually shows a small bud penetrating the surrounding mesoderm. Cells from the central region of the gland degenerate, forming a fat-like substance (sebum) secreted into the hair follicle, and from there, it reaches the skin. Epidermis Sebaceous gland Smooth muscle fibers Hair bud Dermal root sheath A Hair shaft Epithelial hair sheath Hair papilla Blood vessel B C Figure 21. Proliferation of mammary ridge Epidermis Mesenchyme Position of accessory nipples A Epithelial pit Mammary line Lactiferous duct B C 344 Part 1I Systems-Based Embryology 20 weeks, the fetus is covered by downy hair, lanugo hair, which is shed at the time of birth. Sebaceous glands, sweat glands, and mammary glands all develop from epidermal proliferations. Supernumerary nipples (polythelia) and breasts (polymastia) are relatively common. A woman appears to have accessory nipples in her axilla and on her abdomen bilaterally. What is the embryological basis for these additional nipples, and why do they occur in these locations? During the process of induction, one group of cells or tissues (the inducer) causes another group (the responder) to change its fate. The responding cells must have the competence to respond, which is conferred by a competency factor. Most inductive processes during embryo development involve epithelialmesenchymal interactions, and these include the kidneys, gut derivatives, limbs, and many others. For example, even subtle alterations of the ligand and/or its receptor can alter signaling because of the high degree of specificity between these proteins. Also, if any of the proteins in the signaling cascade downstream from receptor activation have been altered, then normal signaling may be disrupted. Fortunately, there is redundancy built into the system that can circumvent alterations in the pathways. The most common cause for abnormal chromosome number is nondisjunction during either meiosis or mitosis. If fertilization occurs between a gamete lacking a chromosome and a normal one, monosomy results; if it occurs between a gamete with two copies and a normal one, trisomy results. Trisomy 21 (Down syndrome), the most common numerical abnormality resulting in birth defects (intellectual disability, abnormal facies, heart malformations), is usually caused by nondisjunction in the mother and occurs most frequently in children born to women older than 35 years of age, reflecting the fact that the risk of meiotic nondisjunction increases with increasing maternal age. Other trisomies that result in syndromes of abnormal development involve chromosomes 8, 9, 13, and 18. Monosomies involving autosomal chromosomes are fatal, but monosomy of the X chromosome (Turner syndrome) is compatible with life.
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High meaning-attribution (offering explanations of what they observed and information on how to change) antibiotic cement spacer 3mg ivermectin. McNeel (1977a virus 72 hours discount 3mg ivermectin mastercard, 1977b vyrus 986 m2 purchase 3mg ivermectin mastercard, 1982) examined the effects of an intensive weekend group workshop conducted by R antibiotic 9 letters effective ivermectin 3mg. Interviews before and after the workshop provided qualitative verification for the changes indicated on the assessment instruments. Participants also indicated distinct changes they made as a result of specific segments of work they had done. Bader (1976, 1982) studied the outcomes of five families who participated in a seven-day residential family therapy workshop using redecision therapy as compared with five similar families who served as controls. The primary research on personality adaptations theory has been the development of two personality adaptations assessment instruments, one by Joines (Joines Personality Adaptation Questionnaire [3rd Edition], © 2002) and the other by Kahler (Kahler Personality Assessment Profile, © 1982). Joines developed a 72-item questionnaire (12 items for each of the six adaptations), which was administered to 1,500 individuals (both clinical and normal populations). An exploratory factor analysis conducted on the three surviving adaptations and again on the three performing adaptations revealed that they all loaded on their respective factors. Based on this research, there is good evidence that the six adaptations exist in reality and can be measured using the questionnaire developed. The three judges agreed on 97 assessments, yielding an interjudge reliability significant at >. An additional number of people were assessed and selected by the judges independently so that a minimum number of 30 individuals were available for each personality type, yielding a total sample of 180 identified "assessed" people. Two hundred and thirteen items were administered to 112 randomly selected subjects. Analysis of this data indicated once again a natural loading on six criteria-the six personality adaptations. Two hundred and four of these items were administered to the 180 identified personality types. Gilbert (1999) found that educators are predominantly reactor (enthusiasticoverreactor), workaholic (responsible-workaholic), and persister (brilliant-skeptic) personality types, who demonstrate little potential to interact with the three other personality types-dreamer (creative-daydreamer), rebel (playful-resister), and promoter (charming-manipulator), which comprise 35% of the general (student) population. The most compelling finding was that miscommunication between teachers and students due to a difference in personality type may be the reason many students are referred for and consequently labeled with AttentionDeficit Hyperactivity Disorder. An understanding of the particular personality adaptations of the individuals being treated is crucial in appreciating the value of how they have learned to survive psychologically and in knowing how best to work with them in therapy. When this information is combined with redecision therapy, the therapist has a very powerful tool for enabling change. The combined approach offers a nonpathological method of allowing clients to experience their own emotional truth, which both helps them to appreciate the original value of their behavior and frees them to make new choices in the present. Redecision in family therapy: A study of change in an intensive family therapy workshop (Doctoral dissertation, California School of Professional Psychology, 1976). Redecisions in family therapy: A study of change in an intensive family therapy workshop. An Investigation of personality types of adolescents who have been rated by classroom teachers to exhibit inattentive and/or hyperactive-impulse behaviors. Transactional analysis in psychotherapy: A systematic individual and social psychiatry. Why educators have problems with some students: Understanding frames of reference. Personality adaptations: A new guide to human understanding in psychotherapy and counseling. Predicting academic underachievement in ninth and twelfth grade males with the Kahler Transactional Analysis Script Checklist. Redecisions in psychotherapy: A study of the effects of an intensive weekend group workshop (Doctoral dissertation, California School of Professional Psychology, 1976). Redecisions in psychotherapy: A study of the effects of an intensive weekend group workshop. They often present with multiple severe and chronic behavioral problems, including suicidal and other self-injurious behaviors. They usually are difficult to treat and some forms of treatment even may lead to their problems becoming more severe; therefore, treating clinicians may feel frustrated, incompetent, or hopeless about the patient. Furthermore, behaviors such as suicide attempts or anger directed at the therapist may elicit fear, anger, and other emotions that the therapist needs to manage appropriately to maintain an effective therapeutic relationship. It integrates behavioral and cognitive treatment principles and strategies with others derived from client-centered and process-experiential therapies, Zen Buddhism, and dialectical philosophy (Robins, Ivanoff, & Linehan, 2001). The term dialectical in the name of the treatment reflects its emphasis on synthesis of apparent polarities or oppositions. Although cognitive-behavioral treatment strategies can help patients to change many behaviors, they usually have not focused on promoting acceptance (Sanderson & Linehan, 1999). Emotion Dysregulation Borderline personality disorder may involve a dysfunction of parts of the central nervous system involved in regulation of emotions. Other causal factors might include events during fetal development and early life trauma, which can have enduring structural effects on the developing limbic system (Sapolsky, 1996). Communications of negative emotions may be ignored or punished, but extreme communications are taken more seriously. Consequently, the individual may come to self-invalidate; not learn to set appropriate goals; not learn how to accurately label, communicate about, or regulate emotions; and learn instead to inhibit emotional expression or respond to distress with extreme behaviors. His or her responses are likely to be puzzling to others, who may conclude that the person is faking his or her response to manipulate a situation, or is being entirely unreasonable and "crazy," or is not trying to control his or her behavior. If this belief is communicated, explicitly or Theoretical Components of Model 223 implicitly, the sensitive individual is likely to feel even more emotionally vulnerable. Thus, in this transactional model, the individual and those in his or her interpersonal environment continuously influence one another. However, our own clinical experience is that borderline patients are at least as likely to be underexpressive of anger. Frantic efforts to avoid abandonment may reflect this relationship history and/or rejection, neglect, or abandonment in childhood. Individuals who are helpful or nurturing may be idealized and those who fail to meet these needs devalued. Strong emotions tend to produce extreme and biased cognitions, so borderline patients, who experience strong emotions frequently, tend to view themselves and others in extreme and mood-dependent ways. For example, although parasuicide can serve an interpersonal communication function, as implied by phrases such as "suicide gesture" and "manipulative suicide attempt," its most common function seems to be to escape or decrease aversive emotions (Brown, Comtois, & Linehan, 2002). Substance abuse, binge eating, and other "impulsive" behaviors can serve the same function. Treatment, therefore, needs to help patients develop more adaptive ways to regulate and/or to tolerate strong emotions. These biased or distorted perceptions and beliefs may reflect the influence of strong emotions on cognitive processes. Three primary ways in which organisms learn are through respondent or classical conditioning, operant or instrumental conditioning, and modeling. After a person is raped in a dark alley, being near a dark alley may elicit a fear response. Maladaptive positive emotional responses may also be learned in this way, such as an association between the sight of a knife used previously to self-injure and emotional relief. It is primarily involuntary responses such as emotional reactions that are learned through classical conditioning. When previously reinforced behavior no longer is reinforced, the behavior will decrease, a process called extinction. When desired or adaptive behavior does not occur and, therefore, cannot be reinforced, reinforcement of successively closer approximations of the behavior can lead to the desired behavior, a process referred to as shaping. These and other operant learning principles, though widely known, often are not considered by therapists in relation to patient behaviors and therapist-patient interactions. Maladaptive behaviors may have been learned through modeling by parents, siblings, other patients, and others. Characteristics of the model that increase the probability that the observer will enact the behavior include perceived expertise or credibility and perceived similarity between model and observer. In the context of a strong therapeutic alliance, therapists can serve as effective models of skillful behavior. Zen Whereas learning theory emphasizes how behavior can change, an important principle of Zen Buddhism is that everything is as it should be at this moment.
Catastrophizing: Treating actual or anticipated negative events as intolerable catastrophes rather than seeing them in perspective virus 3 game generic 3mg ivermectin with amex. Maximization/Minimization: Treating some aspects of the situation virus 85 cheap 3 mg ivermectin fast delivery, personal characteristics treatment for gbs uti in pregnancy buy ivermectin 3 mg without prescription, or experiences as trivial and others as very important independent of their actual significance antimicrobial silver generic ivermectin 3 mg on line. For example, concluding that since you feel hopeless, the situation must really be hopeless. Theoretical Components of the Model 171 shows how poor he is at managing his time," or perhaps "This shows how busy he is. According to cognitive therapy, each of us interprets experiences on the basis of beliefs and assumptions we acquired through previous experience. Another aspect of cognition that can contribute to misperceptions of situations is the errors in reasoning that cognitive therapy refers to as cognitive distortions. To continue our previous example: If I am prone to "dichotomous thinking," I will be more likely to react as though being kept waiting reveals total disregard for my feelings. This, in turn, elicits a much stronger reaction than would be elicited by a more moderate evaluation of the situation. A large body of research has demonstrated that affect tends to influence both cognition and behavior in mood-congruent ways (Isen, 1984). For example, a number of studies have demonstrated that even a mild, experimentally induced depressed mood biases perception and recall in a depression-congruent way (Watkins, Mathews, Williamson, & Fuller, 1992). If negative automatic thoughts tend to elicit a depressed mood and a depressed mood biases cognition in a depression-congruent way, this sets the stage for a self-perpetuating cycle in which a depressed mood increases the likelihood of negative automatic thoughts, these negative thoughts Beliefs and Assumptions External Events Biased Perception and Recall Automatic Thoughts Responses of Others Mood Interpersonal Behavior Figure 9. The cognitive model does not simply assert that dysfunctional cognitions cause psychopathology. We view cognition as an important part of the cycle through which humans perceive and respond to events and thus as having an important role in pathological responses to events. However, we view cognition as part of a cycle and as a promising point for intervention, not as the cause of psychopathology. Rather, the cognitive model focuses on the interplay among cognition, affect, and behavior in psychopathology. For example, if I passively tolerate being kept waiting and my physician makes no comment about my wait, the fact that he did not apologize for keeping me waiting is likely to reinforce my conclusion that he has no regard for my feelings. However, if I comment about the long wait and my physician explains why I was kept waiting so long in a way that shows consideration for my feelings, this response may lead me to different conclusions. When an individual interacts with others in ways that elicit responses that reinforce his or her beliefs and assumptions, those beliefs and assumptions are likely to be persistent. If we consider the way in which moods bias cognition in mood-congruent ways, we can understand how a disturbed mood and dysfunctional cognitions can persist during a particular episode, but it does little to explain the broad, persistent patterns of dysfunctional cognition and behavior that are observed in individuals diagnosed with personality disorders. However, if we also consider the impact of self-perpetuating cognitive-interpersonal cycle such as described previously, this provides one way of understanding how dysfunctional behavior can be so persistent and resistant to change. For example (continuing the scenario discussed previously), if I conclude that my physician has no regard for my feelings and believe that I have to make people take me seriously, I am likely to react strongly to his lack of punctuality. If he responds to my tirade in a way that leaves me feeling that he understands my dissatisfaction and is taking me seriously, I am likely to be satisfied for the time being but this also reinforces my conviction that I have to make people take me seriously. Experiences that should contradict his or her assumptions are overlooked, discounted, or misinterpreted. At the same time, his or her interpersonal behavior results in experiences that seem to confirm the dysfunctional beliefs. The cognitive view of personality disorder, is that this term is the label currently used to refer to individuals with pervasive, self-perpetuating cognitive-interpersonal cycles that are dysfunctional enough to come to the attention of mental health professionals (Pretzer & Beck, 1996). Beck, Rush, Shaw, & Emery, 1979) and has subsequently been applied with a wide range of disorders such as anxiety disorders (A. Beck, Wright, Newman, & Liese, 1993), marital and family problems (Epstein & Baucom, 2002), and even schizophrenia (Perris & McGorry, 1998). However, although the principles of cognitive therapy apply across the full range of psychiatric problems, the treatment approach needs to be modified to take into account the characteristics of the individuals being treated. Cognitive therapy of depression is a protocol for treating depression and somewhat different protocols are used in treating other disorders. There is a consensus among investigators developing cognitive therapy approaches to the treatment of personality disorders that it is important to develop conceptualizations and treatment approaches tailored to specific personality disorders rather than relying on a generic approach that does not distinguish between the various personality disorders. Unfortunately, a discussion of cognitive therapy with each of the personality disorders is beyond the scope of this chapter. This chapter discusses the general principles of cognitive therapy with personality disorders. For approaches to understanding and treating each of the personality disorders, see A. Not surprisingly, all of these are important targets for intervention in cognitive therapy. However, if therapy stops at this point, the client would be at risk for a relapse whenever he or she experienced events similar to the ones that precipitated the current problems. To achieve lasting results, it would also be important to modify the factors that predispose the client to his or her problems and to help the client plan effective ways to handle situations that might precipitate a relapse. Cognitive therapy is an "eclectic" approach in the sense that cognitive therapy provides a coherent conceptual framework within which a wide range of intervention techniques Table 9. The focus is on specific problem situations and on specific thoughts, feelings, and actions. Therapist and client focus on modifying thoughts, coping with emotions, and/or changing behavior as needed. Interventions later in therapy focus on identifying and modifying predisposing factors including schemas and core beliefs. At the close of treatment, therapist and client work explicitly on relapse prevention. As therapist and client endeavor to work together toward shared goals, the therapist is free to select from a wide range of intervention techniques. The therapist guides the client by asking questions, making observations, and asking the client to monitor relevant aspects of the situation. This helps therapist and client to develop an understanding of the problems, to explore possible solutions, to develop plans for dealing with the problems, and to implement the plans effectively. In addition, because the client is actively involved in the process of developing an understanding of the problems and coming up with a solution, he or she has an opportunity to learn to deal with problems effectively and should be better able to handle future problems as they arise. It is possible to identify these cognitions through guided discovery during the therapy session. Frequently, cognitive therapists have clients observe their thoughts, feelings, and actions as they occur in problem situations and write them down in the hope of providing more complete, detailed information. A detailed discussion of the process through which therapists help clients master the process of "talking back" to their dysfunctional thoughts is beyond the scope of this chapter. Cognitive therapy incorporates many experiential interventions intended to increase the impact of therapy. One experiential intervention that cognitive therapy uses extensively is the behavioral experiment. He or she then helps the client find a practical way to collect observations to test the thought or belief. It might seem that changes in thoughts and Treatment Methods and Technical Aspects or Interventions 177 feelings would inevitably lead to changes in behavior, but this is not necessarily the case. What to do if I notice a warning sign: Start writing out thought sheets again (and sticking with it until my responses seem convincing). Therapist and client develop explicit plans for maintaining gains, handling high-risk situations, and heading off potential relapse. Cognitive therapy is not a one-size-fits-all approach in which standard techniques are applied to all clients. The therapist endeavors to work with the client to help him or her recognize the factors that contribute to problems, to test the validity of the thoughts, beliefs, and assumptions that prove important, and to make the necessary changes in cognition and behavior. Although it is clear that very different therapeutic approaches, ranging from philosophical debate to operant conditioning, can be effective with at least some clients, collaborative empiricism has substantial advantages. By actively collaborating with the client, the therapist minimizes the resistance and oppositionality that is often elicited by taking an authoritarian role, yet the therapist is still in a position to structure each session as well as the overall course of therapy to be as efficient and effective as possible (A. To take a strategic approach to therapy, the therapist must develop an initial understanding of the client and his or her problems. Therefore, the first step in cognitive therapy is an initial assessment, which provides a foundation for intervention (A. By beginning with a systematic evaluation, the therapist can develop an initial conceptualization quickly and thus be in a position to intervene effectively early in therapy.
References