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Behavior therapy stresses changing behavior rather than identifying unconscious motivations or root causes of problems (Wolpe impotence quoad hanc proven fildena 50mg, 1997) erectile dysfunction age 35 25mg fildena visa. In some cases, a behavior itself may not be immediately maladaptive, but it may be followed by unwanted consequences at a later point in time. The ultimate goal is for the patient to replace problematic behaviors with more adaptive ones; the patient acquires new behaviors through classical and operant conditioning (and, to a lesser extent, modeling). Cognitive therapy the form of treatment that rests on the ideas that (1) mental contents influence feelings and behavior; (2) irrational thoughts and incorrect beliefs lead to psychological problems; and, (3) correcting such thoughts and beliefs will therefore lead to better mood and more adaptive behavior. The antecedents might include his (irrational) thoughts about what will happen if he goes into a social situation ("They will laugh at me, and I will feel humiliated"), which in turn Foundations of Treatment 1 2 3 lead him to feel anxious. The consequences of his avoidant behavior include relief from the anticipatory anxiety. The therapist assigns homework, important tasks that the patient completes between therapy sessions. Homework for Leon, for instance, might consist of his making eye contact with a coworker during the week, or even striking up a brief conversation about the weather. To prepare for this task, Leon might spend part of a therapy session practicing making eye contact or making small talk with his therapist. The success of behavior therapy is measured in terms of the change in frequency and intensity of the maladaptive behavior and the increase in adaptive behaviors. The Role of Classical Conditioning in Behavior Therapy As we saw with Little Albert in Chapter 2, classical conditioning can give rise to fears and phobias and, more generally, conditioned emotional responses. To treat the conditioned emotional responses that are associated with a variety of symptoms and disorders and to create new, more adaptive learning, behavioral therapists may employ classical conditioning principles. Treating Anxiety and Avoidance A common treatment for anxiety disorders, particularly phobias, is based on the principle of habituation: the emotional response to a stimulus that elicits fear or anxiety is reduced by exposing the patient to the stimulus repeatedly. The technique of exposure involves such repeated contact with the (feared or arousing) stimulus in a controlled setting, and usually in a gradual way. The patient first creates a hierarchy of feared events, arranging them from least to most feared (see Table 4. Over multiple sessions, this process is repeated with items higher in the hierarchy until all items no longer elicit significant symptoms. Exposure-and therefore habituation-to fear- or anxiety-related stimuli does not normally occur outside of therapy because people avoid the object or situation, Table 4. The "Fear" column contains the rating (from 0 to 100, with 100 = very intense fear) that indicates how the patient would feel if he or she were in the given situation. The "Avoidance" column contains the rating (from 0 to 100, with 100 = always avoids the situation) that indicates the degree to which the person avoids the situation. Although Leon avoids almost all the situations on the completed form, some situations arouse more fear than others. Fear 100 98 97 85 70 60 50 30 Avoidance 100 100 100 100 100 99 98 85 Habituation the process by which the emotional response to a stimulus that elicits fear or anxiety is reduced by exposing the patient to the stimulus repeatedly. Exposure the behavioral technique that involves repeated contact with a feared or arousing stimulus in a controlled setting. Virtual reality exposure has been used to treat a variety of psychological disorders, including posttraumatic stress disorder (Ready et al. Patients are less likely to refuse treatment with virtual reality exposure than with in vivo exposure (Garcia-Palacios et al. Moreover, virtual reality exposure may be more effective than in vivo exposure for some people and some disorders (Powers & Emmelkamp, 2008). Another technique for treating fear, anxiety and avoidance is systematic desensitization, which is learning to become relaxed in the presence of a feared stimulus. Whereas exposure relies on habituation, systematic desensitization relies on the fact that a person cannot be relaxed and anxious at the same time. Systematic desensitization is used less frequently than exposure because it is usually not as efficient or effective; however, it may be used to treat a fear or phobia when a patient chooses not to try exposure or has tried it but was disappointed by the results. The first step of systematic desensitization is learning to become physically relaxed through progressive muscle relaxation, relaxing the muscles of the body in sequence from feet to head.
Such interventions help family members (and indirectly erectile dysfunction caused by heart medication buy fildena 25mg amex, the patients themselves) function as well as possible under the circumstances impotence at 60 buy discount fildena 25mg on line. She was asked about activities that she enjoys, and we explored ways of increasing her opportunities for these activities with her attendant. She was encouraged to give her current living situation a longer try, working Cognitive Disorders 7 1 3 with her daughter and staff to improve the most bothersome aspects of the situation. Feedback was also provided by telephone to the daughter and the referring psychiatrist to answer questions about results and to further discuss approaches to care. Recommendations included continuing psychotherapy and antidepressant medication, negotiating brief written contracts between Mrs. Her "fit" in the board-andcare home continued to deteriorate, and after much discussion, she moved back to a nursing home. For a time, she was taking multiple psychoactive medications and her cognitive function deteriorated at a rapid rate. A year later, after an intervening small stroke, her memory function is slightly worse, but her mood is brighter, she communicates well, and she has fewer complaints about staff and other residents than she did in the board-and-care home. Although symptoms may emerge before age 65 (early onset, which is highly heritable), the late-onset form (which also has a genetic basis but is less heritable) is much more common. Vascular dementia is caused by reduced or blocked blood flow to the brain, usually because of narrowed arteries or strokes. Methods include the use of memory aids, reality orientation therapy, reminiscence therapy, and restructuring the environment. However, fluid intelligence and the related abilities of processing speed, recalling verbal information on demand, maintaining attention and multitasking do decline in older adults. Although older adults are less likely than younger adults to have a psychological disorder, the disorders that are most common in older adults are depression and generalized anxiety disorder; symptoms of these disorders and of schizophrenia may superficially resemble symptoms of a cognitive disorder. Among the deficits that may follow a stroke or a head injury are aphasia, agnosia, and apraxia. In addition, legally prescribed medications or illegal substances can alter awareness, emotional states, and cognitive functioning. Summary of Amnestic Disorder Amnestic disorder is characterized by significant deficits solely in memory-other cognitive functions remain relatively intact. People with amnestic disorder may confabulate to fill in memory gaps, and they may not be able to report their history accurately during a clinical interview. Amnestic disorder is caused exclusively by two types of neurological factors: (1) substance use, or (2) a medical condition, such as stroke, head trauma, or the effects of surgery. Rehabilitation focuses on helping amnestic patients learn to use organizational strategies and memory aids. When delirious, people may not know where they are, who they are, or what day (or year) it is. They may also misinterpret stimuli and experience illusions or have hallucinations. Because they believe that these perceptual alterations are real, patients may behave accordingly and get hurt-or hurt other people-in the process. Delirious people may become either restless and agitated or sluggish and lethargic, or they may rapidly alternate between these two states. Symptoms of depression, anxiety, dissociation, psychosis, and substance use can appear similar to some symptoms of delirium. Delirium can arise from substance intoxication or withdrawal, as well as from a medical condition such as an infection, head trauma, or following surgery. Treatment for delirium that targets neurological factors often addresses the underlying physical cause, typically through medication. Thinking like a clinician Sixty-five-year-old Lucinda recently retired from her job as corporate vice-president of marketing. Lucinda lives alone but frequently visits her son, his wife, and their young daughter.
For instance impotence causes and cures order fildena 25 mg visa, someone who compulsively checks that doors and windows are locked may demand that family members similarly-and repeatedly-check the locks throughout the day erectile dysfunction from a young age purchase fildena amex. For much of his 20s, 30s, and early 40s, he was able to function relatively well, given the freedom his wealth and position provided. Although he was often preoccupied with work-staying up for 40 hours at a time to work on a film or on a design for a plane-he was able to keep his obsessions and compulsions at bay well enough to do his work. However, there were occasional periods of time when the external demands of his life became intense-deadlines, fights with associates, or legal problems-and his symptoms worsened. During one particularly stressful period in his late 30s, "Hughes began repeating himself at work and in casual conversations. In a series of memoranda on the importance of letter writing, he dictated, over and over again, `a good letter should be immediately understandable. By the time Hughes was in his 50s, however, the stressors increased and his functioning diminished. At other times, his symptoms ebbed enough that he was able to focus somewhat on running his empire. For instance, religious obsessions and praying compulsions are more common among Turkish men than French men (Millet et al. In contrast, devout Jews or Muslims may have symptoms that focus on extreme adherence to religious dietary laws. A person with such a neurological vulnerability might learn early in life to regard certain thoughts as dangerous because they can lead to obsessions. When these thoughts appear later in life at a time of stress, someone who is vulnerable may become distressed and anxious about the thoughts and try to suppress them. But a conscious attempt to suppress unwanted thoughts often has the opposite effect: the unwanted thoughts become more likely to persist (Salkovkis & Campbell, 1994; Wegner et al. Thus, the intrusive thoughts cause additional distress, and so the person tries harder to suppress them, creating a reinforcing cycle (psychological factor). When a person wants to suppress the unwanted thoughts, he or she develops rituals and avoidance behaviors to increase a sense of Anxiety Disorders 3 0 7 control and decrease anxiety; these behaviors temporarily lessen anxiety and are thus reinforced. Yet the thoughts cannot be fully controlled and become obsessive; the obsessions and compulsions impair functioning and can affect relationships as well. As biographers Barlett and Steele (1979) note, his living situation was like a mental institution, but it was run by the patient, and no one was telling him that he had problems. His aides carried out whatever compulsive demands Hughes made, never challenging him about the irrationality of his orders. However, medication alone is not as effective as medication combined with behavioral treatment, such as exposure and response prevention (discussed in Chapter 4 and in the next section). Targeting Psychological Factors Treatment that targets psychological factors focuses on decreasing the compulsive behaviors and the obsessional nature of the thoughts. The patient is exposed to the feared stimulus (such as touching dirt) or the obsessive thought (such as the idea that the stove was left on) and is prevented from engaging in the usual compulsion or ritual. For instance, if someone were afraid of touching dirt, she would touch dirt but would not then wash her hands. Medication may help such people when beginning exposure treatment-it can help them tolerate the anxiety that arises. Then, as the exposure treatment progresses, Anxiety Disorders 3 0 9 the medication is tapered off and the behavioral method is continued. This form of combined treatment may help minimize relapse when medication is stopped, compared to medication alone (Ellison & McCarter, 2002; Foa et al. Sometimes he spent hours methodically cleaning the telephone, going over the earpiece, mouthpiece, base, and cord with Kleenex, repeating the cleaning procedure again and again, tossing the used tissues into a pile behind his chair" (Bartlett Steele, 1979, p. Clearly, such behavior was at odds with rational attempts to protect against germs. Medication works by changing neurochemistry, which in turn affects thoughts, feelings, and behaviors. Could it be that therapy changes brain functioning in the same way that medication does? The neuropsychosocial approach leads us to examine the types of factors and their feedback loops (see Figure 7. Both behavior therapy and Prozac decreased activity in a part of the basal ganglia that is involved in automatic behaviors (the right caudate). Prozac also affected activity in two parts of the brain involved in attention: the thalamus and the anterior cingulate (Baxter et al.
A third group of patients erectile dysfunction medications otc generic 100mg fildena with amex, with the combined type erectile dysfunction medication and heart disease cheap 100 mg fildena with amex, has symptoms of each of the other two types. However, symptoms may change over time; as some children get older, the particular set of symptoms they exhibit can shift, most frequently from hyperactive/ impulsive to the combined type (Lahey et al. Problems with attention are likely to become more severe when sustained attention is necessary or when a task is thought to be boring, which is what happened to Javier. In contrast, symptoms are likely to become more severe in group settings, where the individual receives less attention or rewards. In syndromatic remission, symptoms improve and no longer meet diagnostic criteria; in symptomatic remission, symptoms improve but diagnostic criteria are still met (Biederman et al. Symptoms of inattention, however, do not tend to decrease as much (Biederman, Mick, & Faraone, 2000). In addition, symptoms of inattention may overlap with some of the symptoms of dissociative disorders (Chapter 8). Moreover, symptoms of substance-related disorders (Chapter 9) and personality disorders (Chapter 13) may overlap with both inattention and hyperactive/ impulsive symptoms. But even these two factors may not allow a clinician to distinguish disruptive behaviors that arise from hyperactivity or impulsivity from disruptive behaviors that arise from defiance associated with oppositional defiant disorder or conduct disorder. Third, symptoms of hyperactivity may be different in females than in males: Girls who have hyperactive symptoms may talk more than other girls or may be more emotionally reactive, rather than hyperactive with their bodies (Quinn, 2005). Other studies find that white children are more often diagnosed-and treated-than black children (Stevens, Harman, & Kelleher, 2005). Unfortunately, researchers are only beginning to consider the different possible types of the disorder separately-and thus at present only a very coarse picture is beginning to emerge. Two sorts of findings that support this view focus on brain structure and on brain function. Regarding brain structure, children and adolescents with this Childhood Disorders 6 6 1 disorder have smaller brains than do children and adolescents without the disorder, and the deficit in size is particularly marked in the frontal lobes (Schneider, Retz et al. Parts of the temporal lobes are smaller than normal in children and adolescents who have the disorder (Sowell et al. Perhaps critically, at least some of the differences found in the brains of children-notably those in the basal ganglia-do not persist into adulthood (Castellanos et al. In general, neural structures involved in attention, including portions of the frontal and parietal lobes, tend not to be activated as strongly (during relevant tasks) in people with this disorder as in people without it. That is, these people could engage in stimulation-seeking behavior in order to obtain an optimal level of arousal. For one, dopamine apparently does not function effectively in the brains of people with this disorder (Volkow et al. This malfunction may arise for any of various reasons, including too few of the relevant receptors or problems in removing dopamine from the synapse (Swanson et al. But dopamine functioning is not the only issue: Imbalances in serotonin and norepinephrine may also contribute to the disorder (Arnsten, 2006; Gainetdinov et al. Given the number of brain areas that are involved, it is not surprising that problems with multiple neurotransmitters are likely to be associated with the disorder. Indeed, not only does this disorder runs in families, but also parent and teacher reports indicate that it is highly correlated among monozygotic twins (with correlations ranging from 0. In addition, a large set of data reveals that this disorder is among the most heritable of psychological disorders (Martin et al. In fact, over a dozen different genes have so far been identified as possibly contributing to this disorder (Guan et al. Many of these genes have been shown to affect the activity of the neurotransmitters that likely are involved in the disorder. In addition, some of these genes may also contribute to conduct disorder and oppositional defiant disorder, which would, at least in part, account for the high comorbidity among these disorders (Dick et al.
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