Program Director, Department of Emergency Medicine, Maine Medical
Center, Portland, ME, USA
Sit at the front of the classroom for about five minutes; this will allow most of the students to experience a mild panic attack erectile dysfunction icd 9 code 2012 discount 60 mg levitra extra dosage overnight delivery. Stop the demonstration and tell the students that they will not be graded on this pop quiz erectile dysfunction treatment covered by medicare 60 mg levitra extra dosage amex. The level of panic they experienced is relatively low; use this time to summarize the symptoms of panic attack impotence yohimbe order 60mg levitra extra dosage free shipping. Invite a clinical professional to be a guest lecturer for your class on the topic of anxiety disorders erectile dysfunction when cheating buy 40 mg levitra extra dosage fast delivery. A person who deals with individuals who have these disorders can give a short introduction with some examples and then invite discussion impotence zinc buy 100mg levitra extra dosage visa. Real examples will help the students understand the types of problems these individuals experience and how they are treated by the professional community erectile dysfunction medications causing generic levitra extra dosage 40 mg mastercard. It incorporates three of the major techniques in relaxation training: progressive muscle relaxation, breathing control, and visualization. Students should practice relaxation training for 15 to 20 minutes twice per day for five days or so. After that amount of practice they should be able to determine which component-muscle tightening, breathing, or visualization-is most relaxing. They can modify the script to increase the amount of time they spend on the relaxation that works best for them. Relaxation practice should be done in a place and at a time when few interruptions are likely. Practicing in bed late at night may interfere with acquiring the relaxation response, because rather than practicing, the person will simply go to sleep. This result is valuable for people with insomnia, but not for those with test anxiety. Sit in a comfortable position with your legs uncrossed and your arms at your sides. Note the contrast between the tension that was there and the relaxation that you now feel. To tighten the muscles in your shoulders, try to touch your shoulders to your ears. Each time you breathe out, think the word relax and let your body grow just a bit more limp. The sky is blue with small puffy clouds; the ocean is a sparkling blue with small white waves. When I count to three, you will be back in the class but feeling relaxed and alert. Your instructor is interested in group data and will compute only the average scores for males and females in your class. For each item, respond by circling a phrase (very little, a little, some, much, or very much). When I notice that my heart is beating rapidly, I worry that I might have a heart attack. It is not a test in any sense because the questions do not have right or wrong answers. Do you get anxious if you have to speak or perform in any way in front of a group of strangers Do you worry if you make a fool of yourself or feel you have been made to look foolish Are you afraid of falling when you are on a high place from which there is no real danger of falling-for example, looking down from a balcony on the tenth floor Do you daydream frequently, that is, indulge in fantasies not involving concrete situations At a reception or tea, do you go out of your way to avoid meeting the important person present Do you hesitate to volunteer in a discussion or debate with a group of 0 1 people whom you know more or less Do you lack confidence in your general ability to do things and to cope with situations Are you self-conscious about your appearance even when you are well-dressed and groomed Are you scared at the sight of blood, injuries, and destruction even though there is no danger to you To be considered a panic attack, the episode must be accompanied by four or more of the following symptoms: 1. Palpitations, pounding heart, or accelerated heart rate Sweating Trembling or shaking Sensations of shortness of breath or of smothering Feeling of choking Chest pain or discomfort Nausea or abdominal distress Feeling dizzy, unsteady, lightheaded, or faint Derealization (feelings of unreality) or depersonalization (being detached from oneself) 10. Describes the causes and types of anxiety as well as physiological and psychological reactions. Deep muscle-relaxation training and pairing of relaxation and imagined scenes are depicted. Part of a series of case histories, this video explores the symptoms and experience of being obsessive-compulsive. The film uses compulsive behavior to illustrate how irrational thinking leads to self-defeating behavior and exaggerated fears. Defense mechanisms are shown, as well as means for exploring and facing them so as to reduce neurotic symptoms. A disturbed office worker experiences panic and terror when he is unable to suppress his hostilities. Judith Rapport, author of the book by the same title considers symptoms, diagnosis, and possible cures. Dissociative disorders dissociative amnesia, dissociative fugue, dissociative identity disorder (multiple personality), and depersonalization disorder A. Most are rare, but reports of dissociative identity disorder in United States have increased B. Dissociative amnesia: partial or total loss of personal information (due to traumatic event) 1. Types a) Localized amnesia-loss of all memory for a short time (most common type) b) Selective amnesia-loss of details about an incident c) Generalized amnesia-total loss of memory for past d) Systemized-loss of memory for selected types of information e) Continuous amnesia-inability to recall any events from a specific time until present (least common type) 2. Dissociative fugue: dissociative amnesia plus travel; usually incomplete change of identity; recovery usually abrupt and complete D. Characteristics a) Two or more independent personalities exist in one person b) One personality evident at a time; usually amnesia in personality that is not present, although personalities may have awareness of other personalities c) Often opposite personalities d) More prevalent in women in United States, but no gender differences found in Switzerland e) Conversion symptoms, depression, and anxiety are common 2. Hard to separate faking from real; reliable diagnostic methods do not currently exist 2. Behavioral perspective a) Avoidance of stress by indirect means b) Iatrogenic or therapist-produced G. Three-part group format a) Psychoeducation b) Use of group resources c) Develop cognitive and social skills 3. Depersonalization disorder has slower rate of spontaneous remission, so treatment focuses on relieving anxiety, depression, or fear of going insane 5. Dissociative identity disorder a) Treatment more likely successful with those who can integrate their personalities b) Combination of psychotherapy and hypnosis c) Develop coping skills, even if personalities not integrated d) Problem-focused therapy holds patients responsible for their behavior as a whole person Somatoform disorders: physical symptoms without physiological basis A. Undifferentiated somatoform disorder: not fully meeting criteria, but at least one physical complaint for six months 3. Overall prevalence rate of 2 percent; more prevalent among females and African Americans C. Differentiate from physical by lack of atrophy in paralyzed extremity, neurological impossibility (glove anesthesia), relation to stress 3. Characteristics: severe or excessive pain with no physiological basis or long after injury has healed 2. Pain is complex phenomenon with both physiological and psychological bases, but descriptions of the pain and its location are vague. Characteristics: preoccupation with health, anxiety and depression; reassurance has no impact 2. Predisposing factors: history of physical illness, parental attention to somatic symptoms, low pain threshold, greater sensitivity to somatic cues F. Diagnostic problems a) Normal dissatisfaction with appearance high (46 percent of college students have some preoccupation with appearance) b) Overlap with delusional disorder or obsessive-compulsive disorder Etiology of somatoform disorders 1. Diathesis-stress: hypervigilance and sensitivity to body sensations followed by stressor 2. Psychodynamic perspective a) Repression of conflict converted to physical b) Primary gain: protected from anxiety c) Secondary gain: attention and dependency needs met 3. Behavioral perspective a) Assume sick role for reinforcement/avoidance b) Modeling important c) Fordyce (1988) reports physicians unwittingly reinforce; male patients with supportive wives experience more pain when wife is present 4. Biological perspective a) High arousal levels, higher sensitivity to bodily sensations Treatments of somatoform disorders 1. Psychodynamic treatment a) Psychoanalysis to relive feelings associated with repressed event b) Hypnotherapy 2. Family systems treatment a) Explore function of the problem b) Teach the family adaptive ways to support each other and to deal with problems 2. Discuss the fundamental characteristics involved in dissociative disorders, and list the four types of dissociative disorders. Chapter 6: Dissociative Disorders and Somatoform Disorders Describe the characteristics of dissociative identity (multiple personality) disorder and its prevalence. List and describe the five subtypes of somatoform disorder, including somatization disorder, conversion disorder, pain disorder, hypochondriasis, and body dysmorphic disorder. Describe and discuss the causes of somatoform disorders from the psychodynamic, behavioral, sociocultural, and biological perspectives, and the diathesis-stress model. Describe and discuss the treatment of somatoform disorders with psychoanalytic, behavioral, and family systems therapies. Dissociative identity disorder (multiple personality) is a favorite topic for discussion and evaluation because it is so bizarre and dramatic. A good way to start a discussion is to contrast this disorder with schizophrenia, even if the psychoses have not yet been presented, since there are many misconceptions about what "split personality" means. One way of clarifying the difference is to draw a set of partially interconnected circles on the board to show the relatively distinct components that make up multiple personality and a dotted circle next to these to indicate the fractured nature of schizophrenia, where not even one intact personality is found. Once these differences are established, it is useful to examine the functions of separate personalities for a person who has endured prolonged physical or sexual abuse. The cases of Billy Milligan (Keyes, 1981), Sybil (Schreiber, 1973), and Jonah (Ludwig et al. Ask the class to imagine the events that might produce such dissociated personalities. Students who are skeptics of psychoanalysis are often impressed with this tripartite split among personalities. It even seems that Eve (who had some 21 faces before she was successfully treated) had personalities that came out in groups of three (Sizemore & Pittillo, 1977). Students can better understand the behavioral and family systems view on somatoform disorder by looking at the positive consequences of making somatic complaints. Ask students how many of them when they were younger faked or exaggerated illnesses to get out of difficult academic or interpersonal situations. Chapter 6: Dissociative Disorders and Somatoform Disorders 91 these complaints, and what effect did the reactions have If parents helped these children avoid responsibilities, we can expect that illness complaints increased in frequency. On the other hand, if parents routinely ignored such complaints, children probably learned to face responsibility. This discussion should raise questions about soft- and hard-heartedness and the danger of parents wrongly suspecting fakery. This mirrors the dilemma of the physician or psychologist with a client who repeatedly complains of pain or other problems in the absence of a physiological explanation. Instructors can suggest a reasonable middle ground: that complaints need to be thoroughly checked out for possible physical causes before one assumes that there are other reasons. Even so, it is dangerous to assume that medical assessment has reached the zenith of accuracy. The instructor can help students to appreciate how therapists react to "interesting" cases. Therapists tend to spend more time thinking about these clients, consulting books and colleagues to better understand them, and paying attention to their subtle verbal and nonverbal messages. Like other people, clinicians become enthused by puzzles they have trouble solving. In some ways, it may be a disappointment to find an interesting case becoming an ordinary case, so some clinicians may inadvertently influence clients to exaggerate the symptoms of multiple personality. The opposite of this effect may also occur with clients whose problems seem more pesky than interesting. Conversations with hypochondriacal clients are continuous battles to steer the topic away from their health concerns. The therapist then works at reducing or discounting complaints-the opposite of what goes on in the iatrogenic process of fostering dissociative identity disorder. Boon and Draijer (1993) gave the Structured Clinical Interview for Dissociative Disorders, the Structured Trauma Interview, and the Dissociative Experiences Scale to 71 patients being treated for dissociative identity disorder. For each item, the percentage of the sample reporting or qualifying for that item is given. Item Childhood physical or sexual abuse Sexual abuse Physical abuse Suicide attempts Drinking problem Street drugs Some form of amnesia Boon & Draijer (1993) 94. Multiple personality disorder in the Netherlands: A clinical investigation of 71 patients. Structured interview data on 102 cases of multiple personality disorder from four centers. Rabinowicz (1989) describes a way of demonstrating dissociative identity disorder in the classroom.
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P08 Includes: the listed conditions erectile dysfunction beat filthy frank purchase levitra extra dosage 40 mg on line, without further specification erectile dysfunction treatment with injection purchase 100mg levitra extra dosage with visa, as causes of or newborn mortality erectile dysfunction reversible buy 60 mg levitra extra dosage overnight delivery, morbidity or additional care erectile dysfunction drugs side effects levitra extra dosage 100mg sale, in fetus P08 erectile dysfunction latest medicine buy levitra extra dosage 40 mg low cost. Post-term infant impotence propecia generic levitra extra dosage 100 mg mastercard, not heavy for gestational age Fetus or infant with gestation period of 42 completed weeks or more (294 days or more), not heavy- or large-for-dates. Asphyxia with 1-minute Apgar score 0-3 White asphyxia Mild and moderate birth asphyxia Normal respiration not established within one minute, but heart rate 100 or above, some muscle tone present, some response to stimulation. Neonatal jaundice due to swallowed maternal blood Neonatal jaundice due to other specified excessive haemolysis Neonatal jaundice due to excessive haemolysis, unspecified 1267 P58. Other congenital malformations of aortic and mitral valves Congenital malformation of aortic and mitral valves, unspecified Other congenital malformations of heart Excludes: endocardial fibroelastosis (I42. Duplications seen only at prometaphase Duplications with other complex rearrangements Extra marker chromosomes Triploidy and polyploidy Other specified trisomies and partial trisomies of autosomes Trisomy and partial trisomy of autosomes, unspecified Monosomies and deletions from the autosomes, not elsewhere classified Whole chromosome monosomy, meiotic nondisjunction 1382 Q92. Signs and symptoms that point rather definitely to a given diagnosis have been assigned to a category in other chapters of the classification. In general, categories in this chapter include the less well-defined conditions and symptoms that, without the necessary study of the case to establish a final diagnosis, point perhaps equally to two or more diseases or to two or more systems of the body. Practically all categories in the chapter could be designated "not otherwise specified", "unknown etiology" or "transient". The Alphabetical Index should be consulted to determine which symptoms and signs are to be allocated here and which to other chapters. The conditions and signs or symptoms included in categories R00-R99 consist of: (a) cases for which no more specific diagnosis can be made even after all the facts bearing on the case have been investigated; (b) signs or symptoms existing at the time of initial encounter that proved to be transient and whose causes could not be determined; (c) provisional diagnoses in a patient who failed to return for further investigation or care; (d) cases referred elsewhere for investigation or treatment before the diagnosis was made; (e) cases in which a more precise diagnosis was not available for any other reason; (f) certain symptoms, for which supplementary information is provided, that represent important problems in medical care in their own right. Palpitations Awareness of heart beat Other and unspecified abnormalities of heart beat Cardiac murmurs and other cardiac sounds Excludes: those originating in the perinatal period (P29. Finding of opiate drug in blood Finding of cocaine in blood Finding of hallucinogen in blood Finding of other drugs of addictive potential in blood Finding of psychotropic drug in blood Finding of steroid agent in blood Finding of abnormal level of heavy metals in blood Finding of other specified substances, not normally found in blood Finding of abnormal level of lithium in blood 1435 R78. Where multiple sites of injury are specified in the titles, the word "with" indicates involvement of both sites, and the word "and" indicates involvement of either or both sites. The principle of multiple coding of injuries should be followed wherever possible. Combination categories for multiple injuries are provided for use when there is insufficient detail as to the nature of the individual conditions, or for primary tabulation purposes when it is more convenient to record a single code; otherwise, the component injuries should be coded separately. The following subdivisions are provided for optional use in a supplementary character position where it is not possible or not desired to use multiple coding to identify fracture and open wound; a fracture not indicated as closed or open should be classified as closed. The following subdivisions are provided for optional use in a supplementary character position where it is not possible or not desired to use multiple coding to identify intracranial injury and open wound: 0 without open intracranial wound 1 with open intracranial wound S06. Excludes: when combined with dislocations, sprains and strains of other body region(s) (T03. It may be used as a supplementary code, if desired, with categories T20-T29 when the site is specified. Burns involving less than 10% of body surface Burns involving 10-19% of body surface 1582 T30. For multiple coding purposes this category may be used as an additional code to identify the effects of conditions classified elsewhere. The "sequelae" include those specified as such, or as late effects, and those present one year or more after the acute injury. Sequelae of fracture of skull and facial bones Sequelae of injury classifiable to S02. Sequelae of other specified injuries of head Sequelae of injury classifiable to S03. Sequelae of dislocation, sprain and strain of upper limb Sequelae of injury classifiable to S43. Sequelae of burns, corrosions and frostbite Sequelae of burn, corrosion and frostbite of head and neck Sequelae of injury classifiable to T20. Sequelae of complications of surgical and medical care, not elsewhere classified Sequelae of complications classifiable to T80-T88 T98. Where a code from this section is applicable, it is intended that it shall be used in addition to a code from another chapter of the Classification indicating the nature of the condition. Categories for sequelae of external causes of morbidity and mortality are included at Y85-Y89. This subclassification should not be confused with, or be used instead of, the recommended fourth-character subdivisions provided to indicate the place of occurrence of events classifiable to W00-Y34. The vehicle of which the injured person is an occupant is identified in the first two characters since it is seen as the most important factor to identify for prevention purposes. Any object such as a coaster, skateboard, sled, trailer, or wagon being towed by any such device is considered a part of the specified device. A public highway[trafficway] or street is the entire width between property lines (or other boundary lines) of land open to the public as a matter of right or custom for purposes of moving persons or property from one place to another. A roadwayis that part of the public highway designed, improved and customarily used for vehicular traffic. A vehicle accident is assumed to have occurred on the public highway unless another place is specified, except in the case of accidents involving only off-road motor vehicles, which are classified as nontraffic accidents unless the contrary is stated. A nontraffic accident is any vehicle accident that occurs entirely in any place other than a public highway. A pedestrian is any person involved in an accident who was not at the time of the accident riding in or on a motor vehicle, railway train, streetcar or animal-drawn or other vehicle, or on a pedal cycle or animal. Excludes: (h) person travelling on outside of vehicle -see definition (h) A person on outside of vehicle is any person being transported by a vehicle but not occupying the space normally reserved for the driver or passengers, or the space intended for the transport of property. Includes: bicycle tricycle Excludes: motorized bicycle - see definition (k) (j) (k) A pedal cyclist is any person riding on a pedal cycle or in a sidecar or trailer attached to such a vehicle. A motorcycle is a two-wheeled motor vehicle with one or two riding saddles and sometimes with a third wheel for the support of a sidecar. A three-wheeled motor vehicle is a motorized tricycle designed primarily for on-road use. A trailer or caravan being towed by a vehicle is considered a part of the vehicle. The local usage of the terms should be established to determine the (q) (r) (s) Includes: (t) coach A railway trainor railway vehicle is any device, with or without cars coupled to it, designed for traffic on a railway. Includes: interurban electric car or streetcar, when specified to be operating on a street or public highway tram (car) trolley (car) (v) A special vehicle mainly used on industrial premises is a motor vehicle designed primarily for use within the buildings and premises of industrial or commercial establishments. Includes: combine harvester self-propelled farm machinery tractor (and trailer) Excludes: accident(s) not occurring on highway (W30) (x) A special construction vehicle is a motor vehicle designed specifically for use in the construction (and demolition) of roads, buildings and other structures. Includes: bulldozer digger dumper truck earth-leveller mechanical shovel road-roller Excludes: accident(s) not occurring on highway (W31) (y) A special all-terrain vehicle is a motor vehicle of special design to enable it to negotiate rough or soft terrain or snow. Examples of special design are high construction, special wheels and tires, tracks, and support on a cushion of air. If an event is unspecified as to whether it was a traffic or a nontraffic accident, it is assumed to be: (a) A traffic accident when the event is classifiable to categories V02-V04, V10-V82 and V87. For these categories the victim is either a pedestrian, or an occupant of a vehicle designed primarily for off-road use. When accidents involving more than one kind of transport are reported, the following order of precedence should be used: aircraft and spacecraft (V95-V97) watercraft (V90-V94) other modes of transport (V01-V89, V98-V99) 3. If more than one vehicle is mentioned, do not make any assumption as to which vehicle was occupied by the victim unless the vehicles are the same. Instead, code to the appropriate categories V87-V88, V90-V94, V95-V97, taking into account the order of precedence given in note 2. Where a transport accident involving a vehicle in motion for these listed conditions: accidental poisoning from exhaust gas generated by breakage of any part of explosion of any part of fall, jump, thrown, or being accidentally pushed from fire starting in vehicle in motion hit by object thrown into or onto injured by being thrown against some part of, or object in injury from moving part of object falling in or on resulted in a subsequent collision, classify the accident as a collision. If an accident other than a collision resulted, classify it as a noncollision accident according to the vehicle type involved. If victim was thrown from vehicle and struck, classify victim as occupant of the vehicle type involved. Pedestrian injured in transport accident (V01-V09) Excludes: collision of pedestrian (conveyance) with other pedestrian (conveyance) (W51. It includes self-inflicted injuries, but not poisoning, when not specified whether accidental or with intent to harm (X40-X49). The sequelae include conditions reported as such, or occurring as "late effects" one year or more after the originating event. The morphology code numbers consist of five digits; the first four identify the histological type of the neoplasm and the fifth, following a slash or solidus, indicates its behaviour. For example, chordoma is assumed to be malignant and is therefore assigned the code number M9370/3; the term "benign chordoma" should, however, be coded M9370/0. Similarly, superficial spreading adenocarcinoma (M8143/3) should be coded M8143/2 when described as "noninvasive", and melanoma (M8720/3), when described as "secondary", should be coded M8720/6. For example, nephroblastoma (M8960/3), by definition, always arises in the kidney; hepatocellular carcinoma (M8170/3) is always primary in the liver; and basal cell carcinoma (M8090/3) usually arises in the skin. Thus nephroblastoma is followed by the code for malignant neoplasm of kidney (C64). Occasionally a problem arises when a site given in a diagnosis is different from the site indicated by the site-specific code. For neoplasms of lymphoid, haematopoietic and related tissue (M959-M998), the relevant codes from C81-C96 and D45-D47 are given. A coding difficulty sometimes arises where a morphological diagnosis contains two qualifying adjectives that have different code numbers. In such circumstances, the higher number (M8120/3 in this example) should be used, as it is usually more specific. But even as respects truths, meaning is the wider category; truths are but one class of meanings, namely, those in which a claim to verifiability by their [deduced empirical] consequences is an intrinsic part of their [validated] meaning. Beyond this island of meanings which in their own nature are true or false lies the ocean of meanings to which truth or falsity are irrelevant. This is a research/review paper, distributed under the terms of the Creative Commons AttributionNoncommercial 3. Understanding and Cognitive Meaning: An Introduction Mark Crooks Institute of Mind and Behavior eaning is wider in scope as well as more precious in value than is truth. Two Epistemologies the following prolegomenon is intended as an heuristic regarding an empirical epistemology, an interpretive framework that properly delineates our reason, the human understanding. The contrast between the two views may be put in terms of their respective emphases, namely, the Cartesian gnostic rather an alternative Semantikal hypothesis. Gnosis in Greek signifies knowledge and hence the focus of the gnostic schema, respecting its analysis of cognition, is upon knowing and certainty. Semantikos in Attic Greek denoted meaning or signification, with its implications of meaningfulness, ambiguity, meaninglessness, and understanding. Certain Hellenic philosophers were oriented perhaps more toward a Semantikal perspective than the gnostic view, inasmuch as Plato and Aristotle alluded frequently to the inherent intelligibility of the cosmos, a universe discernible by reason, rather than to any absolute certainty attainable by dialectic. In modern philosophy, Descartes and Kant are foremost expositors of the Gnostic view, with mathematics construed by them as by Plato as the exemplar of indefeasible knowledge. Probably all ancient and modern philosophers who have written on epistemology have referenced both meaning and understanding in varying degrees, as these are folk psychological categories that constantly inform every deliberation on such matters, no less so than the equally ubiquitous categories of truth, certainty, and knowing. Beginning the seventeenth century, epistemic enquiry shifted dramatically with Descartes to an outright fixation upon certainty as the proper terminus of ratiocination, said to be consummated through a rather unspecified cognitive function called knowing. Perhaps more accurately and charitably, folk epistemology has it that thinking leads or leads not, per each particular cognitive attempt to tentative certainty, while knowing is usually characterized as the outcome of exploratory thought, the grasping and retention of a truth finally achieved that preceding thought had studiously uncovered. But this progressive thinking is no other than understanding by stages, as sketched below. Hence, by implication the gnostic folk epistemology willy-nilly shades into our alternative Semantikal schema that highlights intelligible cognitive meaning: semantikos, hereby defined. The Cartesian gnostic desideratum is epitomized by the master as follows: I shall. Archimedes, to move the earth from its orbit and place it in a new position, demanded nothing more than a fixed and immovable fulcrum; in a similar manner I shall have the right to entertain high hopes if I am fortunate enough to find a single truth which is certain and indubitable. By analogy, we might allow that cognition in an ultimate construal is somehow "one" with its intelligible objects, in the sense of a heretofore inexplicable ontological and epistemic conformance of them. This then is the challenge: to explain naturalistically how knowledge can arise between a discrete conceiver and the conceived universe. The Semantiks model discloses how our proprietary abstract conceptuality furnishes access to its intelligible cosmos, which clairvoyantly transcends the deliverances of sensorial immediacy. Civilization represents a corporate understanding among reasoners together possessed of linguistic conceptuality, all housed within a shared acculturating context. Ex hypothesi, it is possible to ascertain how the actual cognitive coherence involved between the intellect and its intelligible cosmos obtains. Semantiks suggests that ratiocinative understanding can account for progressive science without suppositional recourse to either Cartesian certainty or its generative "coming to know. By Semantikal hypothesis, there would exist an actual cognitive function that generates intelligible meanings, while "understood truths" would be produced by a further, higher order cognitive determination. Contrarily, even if there were such an actual gnostic faculty of knowing that in a consummating intellectual operation grants us certainty, then before one could attain to that status of absolute certitude one provisionally first must have understood the meaning of the proposition under scrutiny. This assessment may be illustrated by a pair of antithetical statements: It is raining. These contradictories, to an incarcerated and incommunicado person locked in a dungeon, would be completely indeterminate as regards their respective truth values. Notwithstanding, the prisoner would be able to comprehend unequivocally the cognitive meaning of both disjunctive propositions, though would not be able to verify in such opaque circumstances which one were the veridical disjunct. That this is not an unusual or contrived example can be seen, if someone were asked (say), "Was the sun shining all day or not on October 3rd, 1900 in your hometown And always keep in mind that such objective truth value is epistemically distinct from (fictitious) subjective Cartesian certainty about such truth.
At older ages problems with erectile dysfunction drugs cheap levitra extra dosage 60mg otc, this growth-and-tissue-repair function of growth hormone becomes less available erectile dysfunction and alcohol discount levitra extra dosage 60mg with mastercard. The heliotrope folds its leaves at night and opens them in the morning erectile dysfunction natural treatment reviews purchase 60 mg levitra extra dosage, but it is not directly guided by the light of the sun erectile dysfunction pump hcpc buy levitra extra dosage 100 mg low cost. Even in a dark room it continues opening and closing do herbal erectile dysfunction pills work purchase levitra extra dosage 40mg online, according to daily cycles and according to some internal timing mechanism erectile dysfunction treatment new york buy levitra extra dosage 60mg without a prescription. The daily internal clock must have a way to resynchronize according to the light/dark cycle. In fact, if left without any natural light cues, humans will revert to about 25-hour/day cycles of waking and sleeping. Natural light, or in some cases an alarm clock, apparently resynchronizes the human circadian clock each day for functioning in accord with a 24-hour day. When this internal clock runs amok, sleep patterns can be greatly, even fatally, disrupted (see Neuropsychology in Action 16. Scientists do not yet know how the human circadian clocks signal sleep onset each night and awakening each morning-perhaps through qualitatively different signals, or via a gradual change in the release of neurotransmitter molecules. Clifford Saper, of Harvard University, and his colleagues (Saper, Chou, & Scammell, 2001) have suggested that the ventrolateral preoptic area of the hypothalamus may be the "master switch" to arousal (see Figure 16. Researchers have observed this somnolence region to be the only brain center that is more active during sleep than wakefulness. Other researchers have identified a peptide molecule named "factor S" and claim it may be one of the neurotransmitters most directly responsible for setting off the downward drift into sleepiness. Injected into the hypothalamus, factor S induces sleep and increases body temperature. It also appears to trigger the release of interleukin-1, which raises many interesting questions about the immunoprotective function of sleep. This collective evidence points to a strong role for the hypothalamus as the "biological sandman. Gradually, the brain moves from a state of processing external sensory information to a closing off of inputs from vision, hearing, and touch. During alertness, the thalamus relays inputs from most sensory systems, except for smell. The thalamus constantly communicates with the cortex through a feedback system of millions of thalamocortical loops. Any external sensory "noise" against this background is easily picked up because the brain discriminates it from the high-frequency background rhythm by its irregularity or novelty. As alertness drops, at a certain point the thalamocortical loops start oscillating to their own rhythm, in a sort of internal dance between the thalamus and the cortex. With the slowed frequency of thalamocortical firing, orientation to and processing of external stimuli is less likely. The brain turns inward, attention drifts, and the sleeper becomes oblivious to his or her surroundings. Currently, the thalamocortical loop stands as the primary mechanism in sleep onset and in maintenance of reduced attention to external stimuli. As sleep continues to deepen, responsiveness to the outward environment lessens even further. Perhaps future research will reveal whether another mechanism monitors the environment during sleep, or whether sleep remains lighter for those who must remain alert. Animals in the wild, which must retain more alertness to danger, show lighter and more fragmented sleep than zoo and domestic animals. Willful movement is impossible, because the motoneurons have temporarily lost communication with the spinal cord. For all practical purposes, more than any other stage of sleep, the sleeper is in a cocoon, insulated from the out- side world and unable to act on it, yet with a very active mind. The lateral geniculate nucleus is part of the visual pathway from the retina to the occipital cortex. This is an additional indication that the thalamus may be synchronizing brain rhythms. But they appear somehow calibrated to move in conjunction with scene changes of dreams. Researchers think that bursts from the pons also stimulate nearby oculomotor neurons, resulting in corresponding eye movements (Hobson, 1995). In rats, rabbits, and cats, single-neuron recording has demonstrated that the theta rhythm emanates from the hippocampus, specifically in the dentate gyrus and the entorhinal cortex (Winson, 1972). Although we may see or sense movement in dreams, through active central motoneuronal activity, the motoneurons responsible for actually carrying out the action are "turned off " at the level of the spinal cord. This greatly reduces muscle tone (atonia), and for all practical purposes paralyzes the sleeper. They stalked, attacked, hissed, and otherwise acted out the drama of their dreams. The pontine excitement also inhibits peripheral nerve pathways where they synapse with the spinal cord. During all stages of sleep, after an initial increase in the first 2 hours, respiration rate and body temperature gradually diminish. The neurophysiological processes provide the fuel for the mechanical processes we have just discussed. Hobson also postulates that serotonin and norepinephrine act as long-term neuromodulators on the brain. With a nod to Freud, neuropsychologists now conceptualize the psychological function of dreaming somewhat differently from Freud. Because scientists have again blessed the study of personal internal conscious processes, the study of dream function is once more opening up. Next, we introduce an area of study that is likely to provide many insights into the functioning of the conscious and subconscious minds. Researchers have long thought that memory consolidates during sleep, because people can remember more after sleep. Now animal and human experiments have provided more evidence that memory is processed during sleep. Using rats, a team of researchers have recorded from individual neurons of the hippocampus (Pavlides & Winson, 1989). While the rats were awake, and moving about learning their position, only specific spatial coding neurons fired. Later during sleep, and particularly during production of the theta rhythm, these same neurons, and only these same neurons, fired at an even higher rate than during waking learning. This finding suggests that rats were reprocessing and strengthening the information during sleep. In another experiment, a group of Israeli researchers studied memory consolidation and sleep under three different conditions. The task involved having to identify perceptual targets embedded in a visually noisy background. With learning and practice, people can usually improve their speed in picking out targets. In the first condition, researchers let people sleep normally after their initial practice session. In the same manner, in the third condition, researchers deprived people of delta sleep within stages 3 and 4. Except for those who are "lucid" dreamers, dreaming minds wander from scene to scene with no conscious guidance. After a history of much debate on the function that dreams may serve, scientists are returning to the premise that dreams have a psychological core. Aspects of the mind state of dreams may correlate with the physical aspects of a brain temporarily divorced from a body. Alan Hobson (1995) has suggested that dreamers may feel they move effortlessly during dream states because they are being moved or guided by internally generated states and active central motoneurons. Perhaps in some measure, dream experiences of floating or flying also result from the brain being allowed to "float free" from the body, or perhaps in combination with, as Hobson suggests, spontaneous stimulation of orientation and position control centers in the brain. Hobson notices that when dreamers try to "will" dream movement while trying to escape from a pursuer, their feet and bodies may become leaden because of the conflicting motor messages of "voluntarily commanded movement (saying go) and the involuntarily clamped muscles (saying stop). This is an interesting area of study in its own right, and work in it will help to explain "how" people dream. Another question fundamental to understanding consciousness is "why" people dream. Biological functions of the brain could all occur without being brought to waking attention. But many dream researchers have come back to a version of psychological interpretations. Freud laid some of the basic groundwork in thinking about the psychological function of dreams from which other theories could spring. Today, most dream theorists do not attribute the same negative sexual and aggressive motivations to dream images that Freud did, but some of his methods and ideas may still be useful in uncovering the psychological meaning of dreams for the dreamer. With expansion from recent conceptualizations, researchers may be closer to a neuropsychological understanding of dreaming. This conceptualization is not unlike recent ideas of explicit versus implicit information processing. However, as in memory processing and in some disorders such as neglect, a level of processing and recognition may exist outside conscious awareness. Freud did not have the ability to look deep into the brain, but his ideas that unconscious thoughts emerge from more primitive areas of the brain are not inconsistent with theories of implicit processing taking place in the more primitive subcortical and limbic centers of the brain. However, some of the greatest understanding available of the meaning in a dream involves self-interpretation in light of personal current life circumstances. Self-interpretation may involve not only the content, but the associated emotion that the dream invokes. Troubling life circumstances provide the fodder for sleep researcher Rosalind Cartwright (Cartwright, Lloyd, Knight, & Trenholme, 1984; Cartwright, Kavits, Eastman, & Wood, 1991). Cartwright found that dream content and topics differed among subjects, but the themes were congruent with the waking response to the problem. Indeed, the content and themes of dreams may be useful in helping to solve many personal problems. We once treated depression in a patient who was also a smoker trying to kick the habit. In his dream, his whole body was turned grotesquely inside out, showing his lung, which was full of tumors and pus, to the outside world. An interesting exercise in exploring your own "dream consciousness" is to keep a dream journal for collecting and analyzing the content and themes of your dreams. Alan Hobson reminds us that the absurdity of dreams and the temporary "impairment" of judgment and cognition that occur during dreaming are common phenomena. Temporary disinhibition of the cortex may very well represent a physiological disconnection of aspects of the frontal lobes from other cortical and limbic centers. This may help to explain our often bizarre logic and lack of self-reflection during dreams. But what of those brain-impaired individuals who have structural damage resulting in waking disinhibition For some people, however, sleeping can become a medical emergency, as during sleep apnea, or intrude into wakefulness, as in narcolepsy. Sleep Apnea Sleep apnea has become the most common disorder the sleep literature describes and the most common presenting problem that sleep disorder centers evaluate (Guilleminault, 1982). This, of course, presents an immediate crisis for the body, because of the danger of hypoxia and of increased rapid heart rate and blood pressure. The apnea finally stops when, in an effort to breathe, the patient arouses, gasping for air. If repeated apnea and awakening occur more than five times an hour, the patient is diagnosed with sleep apnea (Figure 16. Serious cases may show more than 500 apneas per night, each one lasting more than 10 to 120 seconds and terminating with at least partial arousal. In addition to markedly disrupted sleep characterized by a significant absence of the normal progression of sleep stages, dangerously low levels of oxygen to the brain may result. Apnea periods usually produce declines in sleep-related blood oxyhemoglobin saturation and increases in carbon dioxide. This condition, known as hypoxia, is associated with below-average levels of oxygenated blood, often below 60% (normal is 95%). At point 3, the patient is fully asleep (notice the relaxation of the chin electromyogram and absence of breathing). In the second mechanism of sleep apnea, central sleep apnea, disordered breathing is related to the brain failing to send the necessary signals to breathe. In either case, the disorder is serious and often associated with severe O2 desaturation. Complications of apnea result in poor physical health and associated neuropsychological deficits of poor concentration and memory (Barth, Findley, Zillmer, Gideon, & Surrat, 1993). The cause of sleep apnea is not well understood, although age, obesity, and being male are all risks. Generally, researchers consider sleep apnea episodes to be caused by a complex interaction of physiologic and anatomic factors. Clinical features that are characteristic of the syndrome include excessive daytime sleepiness, heart failure, hypertension, headaches, disturbing snoring, irritability, sleep disruption, and personality changes. Hypoxia may also lead to disturbed fluid and electrolyte distribution within the sodium-potassium pump, and it alters brain adenosine levels in animals. In addition, in patients with sleep apnea, cerebral blood flow studies demonstrate abnormally decreased blood flow, which may further compromise neuropsychological functioning because of decreased neuronal activity (Guilleminault & Dement, 1978). Sleep apnea can have serious psychosocial effects as well, including significant changes in adaptive functioning (Zillmer, Ware, Rose, & Bond, 1989).
Furthermore impotence injections purchase levitra extra dosage 40 mg amex, Reiss and associates (2000) found that the decreased volume was primarily in the white matter impotence thesaurus generic 60 mg levitra extra dosage overnight delivery, although there was significant loss of gray matter evident in the right occipital lobe erectile dysfunction treatment injection cost quality 40mg levitra extra dosage. There were also indications of greater posterior (occipitoparietal) than anterior volume loss erectile dysfunction doctor memphis generic 40 mg levitra extra dosage visa. This finding may be related to the relatively spared auditory functions (language and music) and unusual reactions to auditory stimuli such as hyperacusis (Levitin erectile dysfunction best medication buy 40mg levitra extra dosage with amex, Cole impotence in the bible levitra extra dosage 60mg with amex, Chiles, Lai, Lincoln, & Bellugi, 2004). This profile includes intellectual impairment, relatively preserved language skills, increased attention to facial processing, visuoconstructive skill weaknesses, significant interest and relative proficiency in music, and high levels of sociability. Particular weaknesses are often evident in higher order conceptual reasoning and problem solving (Levitin et al. Generally, measures of verbal intelligence reveal higher levels of functioning than measures of nonverbal intelligence, particularly if visuospatial abilities are assessed. Particular verbal strengths are evident in vocabulary development, phonologic processing, auditory short-term memory, auditory working memory, and verbal fluency (Robinson et al. In the normal population, language and global intelligence are generally highly correlated with each other. Specifically, anomalies in the development of semantics, complex syntax, grammar, pragmatic language (Laws & Bishop, 2004), and comprehension of nonliteral language (Sullivan, Winner, & Tager-Flusberg, 2003) are evident. Furthermore, the onset of novel twoword combinations is even more delayed, ranging from 26 to 50 months of age. For example, a series of recent studies (Robinson, Mervis, & Robinson, 2003; Volerra et al. Two areas of visuoconstructive, drawing and replication of block patterns, have been examined extensively. Thus, the drawings reveal deficits in global organization and spatial integration. Yet, the two groups demonstrated comparable performance related to inhibiting a pictorial-verbal (nonspatial) response. Although executive dysfunction is suggested, the basis of the deficit remains unanswered. As the authors correctly conclude, the inhibitory deficit may relate to a disturbance of the dorsolateral frontal region, parietal region, and/or interconnecting pathways of the two systems. To test this possible confound, Atkinson and colleagues (2003) have investigated the relation of visual sensory deficits to visuospatial and visuoconstructive performance. Approximately 50% of the children and adolescents sampled for study exhibited some form of visual sensory deficit. The children and adolescents were administered a battery of tests sensitive to visuospatial and visuoconstructive abilities. The results demonstrated a negligible relation between the occurrence of visual sensory deficits and severity of spatial deficits. That is, they rely on local processing when task performance involves the manipulation and construction of spatial elements. If the elements of the task are spatially invariant, and mentalmotor manipulation is not required, they are able to use a global processing approach. Dorsal versus Ventral Processing-Because of the significant deficits in visuospatial relative to facial processing, neuroscientists and neuropsychologists have sought to determine whether the disparity represents a dissociation between the ventral and dorsal streams of visual processing. The ventral stream ("what" processing; see Chapter 8) conveys visual object and face recognition to the temporal lobes, whereas the dorsal stream ("where" processing) carries information to the parietal lobes necessary for the processing of spatial relations. Using tasks sensitive to ventral and dorsal processing, investigations (Atkinson et al. Analysis determined that the hypoactivation of the dorsal stream could be attributed to impaired input from this isolated region. A small anomaly (A) of the occipitoparietal region that may disrupt the "downstream" activation of the "where" dorsal stream. The regional activation of the dorsal stream is evident in visuospatial processing of location (B) and construction (C). She later noted, "There are two kinds of Mozart: the kind that hurts and the kind that does not hurt" (Levitin et al. They tend to be overly happy and friendly, yet are also prone to irritability (which appears to abate with age) and moodiness. They are known to approach and speak indiscriminately with others and to be excitable, restless, and inattentive. In addition, they experience high levels of anxiety, worry, fearfulness, and somatic complaints. Although they are proficient at understanding the feelings of others, they find it difficult to recognize their own fears (Lai, 1998). Interestingly, in contrast with healthy children, they do not show an age-related reduction in their fears. The basis of their overfriendliness and sociability is unclear, but it is believed that their extreme focus on the faces of others may play a role in shaping these characteristics (Mervis et al. The amygdala is implicated in the support of a number of emotion-related functions, including the monitoring of environmental events for danger. For healthy control participants, the amygdala showed greater activation when processing threatening faces than threatening scenes. That is, the decreased activation may indicate an attenuation of normal social fear or apprehension. In contrast, the greater activation of the amygdala to threatening scenes may underpin their high rates of nonsocial anxiety, worry, and fears. Hypercalcemia contributes to these gastrointestinal disturbances, requiring medical attention and dietary restrictions. Orthopedic and physical/occupational services are often needed to address these problems. Accordingly, environmental modifications to reduce or alleviate the occurrence of loud and disturbing noises are needed. For example, the child might be removed from the classroom in advance of a fire drill and placed in a room where the sound of the fire alarm is muffled or be allowed to use ear plugs or ear phones. During the preschool and elementary school years, the child often warrants special or remedial educational services because of general cognitive delays. These children frequently demonstrate greater success in reading and spelling relative to math and handwriting. Behavioral modification techniques and psychostimulant medication may be warranted to address poor attentional focus, distractibility, and impulsivity. Social skills training is important to facilitate social acceptance by peers because of their overfriendliness and indiscriminate approaching of others. The child or adolescent may need to learn verbal self-protective skills to cope with teasing or abuse by peers. Often, medications addressing anxiety or depression are needed to augment treatment; however, careful monitoring by medical professionals is imperative for those individuals with cardiovascular disease or other significant medical issues. Environmental toxins, radiation, infections, anoxia, malnutrition, tumors, and traumatic head injuries can result in anomalies of the developing brain. Of these agents, traumatic head injuries, such as concussions, lacerations, and contusions, are the cause of most brain damage in children and adolescents. Regardless of the nature of the insult, a one-to-one relation between brain disturbance and behavior is not evident. The prediction of functional outcomes is contingent on a host of factors including: (1) age at which the lesion is incurred; (2) type, severity, and status (static or progressive) of the lesion; (3) premorbid personality and intelligence of the child; (4) quality and timeliness of medical attention; and (5) accessibility of acute and long-term services. Increasingly, it is being realized that the prenatal embryo/fetus is at risk even with social drinking. Lemoine, Harrowsseau, Borteryu, and Menuet (1968) are credited with being the first to describe the effects of alcohol on a group of children with alcoholic parents. Central nervous system deficits include microcephaly (abnormally small head), infantile irritability, seizures, tremors, poor coordination, poor habituation (difficulty in tuning out repeating stimuli), and reduced muscle tone. Journal of the American Medical Association, 235[14], 1459, by permission of the American Medical Association; [c] reproduced from Streissguth, A. That is, the exposed children may manifest sensory and sensorimotor impairments, speech and language delays, cognitive and learning weaknesses, and regulatory deficits such as inattention, impulsivity, and hyperactivity (Jacobson, Jacobson, Sokol, Martier, & Ager, 1993). The relation of the teratogenic effects of prenatal alcohol exposure to intake (amount, frequency, and drinking patterns), period of brain development, and maternal health/lifestyle variables during pregnancy remains poorly understood. The children of mothers who consumed relatively low levels of alcohol are less likely to exhibit either physical or structural stigmata, but they may still experience behavioral disturbances, social maladjustment, and cognitive deficits (Mattson et al. Although the risk to the developing embryo/fetus is much greater for pregnant mothers who chronically abuse alcohol or frequently "binge" (multiple drinks consumed in a relatively short period), the point in brain gestation that alcohol is introduced appears to have a differentially damaging impact. Alcohol exposure appears to cause greater damage to the developing brain during the early months of gestation (first trimester). However, the greatest disruption occurs when the exposure spans the entire pregnancy (Carmichael Olson et al. That is, maternal alcohol use can significantly affect one twin more than the other twin, despite their sharing the same prenatal environment. Children of alcoholics are subject to high levels of neglect, abuse, inconsistent parenting, and out-of-home placements. The assessment results showed that both groups, relative to healthy control children, demonstrated impairment in language skills, verbal learning and memory, academic performance, finemotor speed, and visuomotor integration skills. Thus, individuals with a history of prenatal alcohol exposure are likely to demonstrate significant neuropsychological deficits, even though they appear physically normal. Specifically, children with the disorder present with dysgenesis or agenesis of the corpus callosum, hippocampal damage, reduced basal ganglia volume, cerebellar anomalies, expanded ventricles, and reduction in white matter (Archibald, Mateer, & Kerns, 2001; Kaemingk & Paquette, 1999; Streissguth & Connor, 2001). Wass and colleagues (2001) studied living fetuses exposed to alcohol with ultrasound sonography and identified a reduction in size of the frontal cortex. Executive dysfunctions (Kaemingk & Paquette, 1999) consistent with disturbances of the frontal circuitry have been identified. Similarly, studies of animals exposed to prenatal alcohol report a wide range of brain anomalies, including reduction in brain weight and volume, and structural disturbances or loss of neurons, dendritic spines, and subcortical and cortical white matter circuitry (Chen, Maier, Parnell, & West, 2004). Thus, multiple cognitive domains of functioning are vulnerable to in utero alcohol exposure including intellect, language, learning and memory, and executive functions (Lee, Mattson, & Riley, 2004). Moreover, there are indications that poor attention may be a more sensitive marker of prenatal alcohol exposure than either low global intelligence or facial stigmata (Mattson & Riley, 2000). Clearly, a comprehensive neuropsychological evaluation is needed to identify and interpret the cognitive, behavioral, and adaptive dysfunctions that characterize the child. Because of the increased risk for cardiac, skeletal, and other physical conditions (see Table 10. By 4 years of age, deficits appear in gross- and fine-motor skills, attention, memory, academic achievement, and reaction time. In addition, enuresis (age-inappropriate bedwetting) and communication disorders are quite frequent. Cognitive deficits, microcephaly, small physical stature, and poor socialization skills often interfere with peer acceptance. With the advent of adolescence, communication disorders and disturbances of basic functions decline, although other cognitive and behavioral deficits persist. Treatment-It goes without saying that the best form of treatment for an acquired disorder is prevention. Although public awareness discourages many mothers from drinking during pregnancy, the alcoholic mother is of special concern. The physician, or other personnel who encounter a pregnant women who abuses alcohol, should immediately apprise her of the risk to the fetus. A referral to persons or agencies that can assist the mother in altering her drinking behavior is a priority. The aforementioned interventions must be continued into adolescence and modified in accordance with the changing learning and behavioral needs of the teenager. Summary the developing brain is vulnerable to a myriad of insults that can lead to damage and dysfunction. Yet, a degree of plasticity allows limited compensation, or return of function, after cerebral insults. Critical Thinking Questions In light of the devastating effects of many of the genetic and chromosomal disorders, do you think that potential parents should seek genetic counseling before having children In recent years, an increasing number of teratogens have been identified in the environment. Are our children at greater risk for brain anomalies than children of earlier generations Overview this chapter discusses learning, pervasive developmental, disruptive behavioral, and tic disorders of childhood. Although the pervasive developmental disorders occur less frequently, the impact of these conditions is profound, generally precluding self-sufficiency and independence and necessitating lifelong supervision. The developmental disorders reviewed in Chapter 10 are often considered biological rather than psychological in origin because prominent anatomic brain defects and physical anomalies often accompany the disorders. Moreover, the cause of these disorders is generally traceable to genetic/chromosomal defects or prenatal disruption. In contrast, the causes of childhood learning and neuropsychiatric disorders are not as easily linked to congenital anomalies. Accordingly, theorists have often proposed psychological factors as determinants of these disorders. However, ongoing research and advances in neuroimaging are providing evidence that brain disturbances may, in fact, play a prominent role in the etiology of both learning and neuropsychiatric disorders. This chapter examines, in detail, specific disorders that represent learning, pervasive developmental, disruptive behavioral, and tic disorders. The first disorder, dyslexia, has received considerable attention because of the importance of reading skills in our technologically advanced society. The third disorder, autism, is a pervasive developmental disorder that has attracted a voluminous body of research.
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