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Behavior therapy rests on two ideas: (1) Maladaptive behaviors womens health 092013 buy generic dostinex 0.25mg line, cognitions womens health 40-60 buy cheapest dostinex and dostinex, and emotions stem from previous learning menstrual twice in one month discount dostinex 0.25 mg free shipping, and (2) new learning can allow patients to pregnancy 22 weeks ultrasound cheap generic dostinex uk develop more adaptive behaviors, cognitions, and emotions. In contrast, cognitive therapy rests on these ideas: (1) Mental contentsin particular, conscious thoughtsinfluence a persons feelings and behavior; (2) irrational thoughts and incorrect beliefs contribute to mood and behavior problems; and, (3) correcting such thoughts and beliefs leads to more rational thoughts and accurate beliefs and therefore will lead to better mood and more adaptive behavior. Lets look first at the unique elements of each type of therapy and then consider cognitive-behavior therapy. The Goals of Behavior Therapy Founded by Joseph Wolpe (19151997) behavior therapy is based on well-researched principles of learning (see Chapter 2). Behavior therapy stresses changing behavior rather than identifying unconscious motivations or root causes of problems (Wolpe, 1997). Behavior therapy has appealed to psychologists in part because of the ease in determining whether the treatment is effective: the patients maladaptive behavior either changes or it doesnt. 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. For instance, Leon may not necessarily view avoiding social interactions as a problem, but he may worry about losing his joba consequenceif he doesnt adequately suBehavior therapy pervise his employees because of his social anxiety. The ultimate goal is for the the form of treatment that rests on the ideas patient to replace problematic behaviors with more adaptive ones; the patient acthat (1) maladaptive behaviors, cognitions, and emotions stem from previous learning and quires new behaviors through classical and operant conditioning (and, to a lesser (2) new learning can allow patients to develop extent, modeling). The antecedents the form of treatment that combines methods might include his (irrational) thoughts about what will happen if he goes into a from cognitive and behavior therapies. 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. With sustained exposure, the symptoms diminish within 2030 minutes or less; that is, habituation to the fearor anxiety-inducing stimuli occurs. Over multiple sessions, this process is repeated with items higher in the hierarchy until all items no longer elicit significant symptoms. Exposureand therefore habituationto fearor 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. Situation Fear Avoidance Give a 1-hour formal lecture to 30 coworkers 100 100 Go out on a date 98 100 Ask a colleague to go out on a date 97 100 Attend a retirement party for a coworker who is retiring 85 100 Habituation Have a conversation with the person sitting next to me on the bus 70 100 the process by which the emotional response Ask someone for directions or the time 60 99 to a stimulus that elicits fear or anxiety is reduced by exposing the patient to the Walk around at a crowded mall 50 98 stimulus repeatedly. Patients in therapy can experience exposure in three ways: imaginal exposure, which relies on forming mental images of the stimulus; virtual reality exposure, which consists of exposure to a computer-generated (often very realistic) representation of the stimulus; and in vivo exposure, which is exposure to the actual stimulus. Leons social phobia could be treated in any or all of these ways: He could vividly imagine interacting with others, he could use virtual reality software to have the experience of interacting with others without actually doing so, or he could interact with others in the fiesh. Virtual reality exposure combines aspects of the other two types of exposure: As with imaginal exposure, the patient isnt actually exposed to the fearor anxiety-producing stimulus, and, as with in vivo exposure, the patient experiences a vivid situation that isnt totally under his or her controlsimilar to a real situation. 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 Exposureimaginal, in vivo, or virtual reality (Powers & Emmelkamp, 2008). Whereas exposure relies on habituation, systematic desensitization relies on (Krijn et al. 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. Once the patient has mastered this ability, the therapist helps the patient construct a hierarchy of possible experiences relating to the feared stimulus, ordering them from least to most feared, just as is done for exposure (see Figure 4. Over multiple therapy sessions, the patient practices becoming relaxed and then continuing to remain relaxed while imagining increasingly feared experiences. Although systematic desensitization and biofeedback both involve relaxation, systematic desensitization uses relaxation as the first step in reducing anxiety in response to feared stimuli and does not utilize any equipment. In contrast, the goal of biofeedback is learning to control what are generally involuntary responses. Treating Compulsive Behaviors In some cases, avoidance or fear of a specific stimulus is not the primary maladaptive behavior. After grocery shopping, for example, a person may feel compelled to reorganize all the canned goods in the cupboard so that the contents remain in alphabetical order. Similarly, some people with bulimia nervosa feel compelled to make themselves throw up after eating even a bite of a dessert. These Systematic desensitization compulsive behaviors temporarily serve to decrease anxiety that has become part of the behavioral technique of learning to relax a conditioned emotional response to a particular stimulus. Foundations of Treatment 125 To treat compulsive behaviors, behavior therapists may use a variant of exposure called exposure with response prevention, whereby the patient is carefully prevented from engaging in the usual maladaptive response after being exposed to the stimulus (Foa & Goldstein, 1978). Using this technique with someone who compulsively alphabetizes his or her canned goods, for instance, involves exposing the person to a cupboard full of canned goods arranged randomly and then, as agreed, preventing the typical maladaptive response of alphabetizing the cans. Similarly, someone with bulimia might eat a bite or two of a dessert and, as planned, not throw up. As part of behavioral treatment, someone with bulimia may use stimulus control initially to limit Treating Habitual Maladaptive Behaviors Some disorderssubstance-related her intake of foods that she is likely to purge. For instance, some people drink alcohol for instance, she may want to avoid eatingor to excess (habitual maladaptive behavior) only when they are in bars or clubs (the buyingcookies. Once she is out of the habit of purging, she may use exposure with response stimulus). Others may binge (habitual maladaptive behavior) when they eat dessert prevention to learn to eat cookies without (the stimulus). To treat such disorders, the behavior therapist may seek to limit the patients contact with the stimulus. This technique, called stimulus control, involves changing the frequency of a maladaptive conditioned response by controlling the frequency or intensity of exposure to the stimulus that elicits the response. For example, the person who drinks too much in bars would refrain from going to bars; the person who binges after eating even a bit of dessert might avoid buying desserts or going into bakeries. Stimulus control will be described more fully when we discuss treatment for substance abuse (Chapter 9). The Role of Operant Conditioning in Behavior Therapy Whereas classical conditioning methods can be used to decrease maladaptive behaviors related to conditioned emotional responses, operant conditioning techniques can be used to modify maladaptive behaviors more generally. When operant conditioning principles such as reinforcement and punishment are used to change maladaptive behaviors, the process is called behavior modification. Making Use of Reinforcement and Punishment the key to successful behavior modification is setting appropriate response contingencies, which are the specific consequences that follow maladaptive or desired behaviors.

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Long-term use of methamphetamine disrupts the functioning of these transporter molecules women's health boutique houston memorial 0.5mg dostinex with amex. The images in the figure show the distribution of dopamine transporters in the brain of a person who 9 pregnancy 29 weeks discount 0.25 mg dostinex with mastercard. As is evident diagnosis women's health issues buy discount dostinex 0.25mg online, even 2 years after the person stopped usingb d Reversible and Irreversible methamphetamine breast cancer vector purchase dostinex 0.5 mg on-line, the neurological effects of chronic abuse are not totally reversed. This is methamphetamine over a period of years; as is evident, even 1 month after true of stimulant abuse in particular, and substance abuse in general. Although the this person stopped using the drug, the dopamine reward system plays a crucial role in leading people to abuse drugs, it is dopamine transporters are still in short not the whole story. The glutamate systemwhich consists of neurons that rely on the neurotransmitter glutamatealso plays a role in the shift from drug use to abuse and dependence. Glutamate receptors abound throughout the cortical and limbic regions that play a role in drug abuse, and researchers have shown that such receptors help to produce the reinforcing effects of drugswhich lead some people to become abusersand also the negative effects experienced during withdrawal (Kenny & Markou, 2004). In fact, drugs that block glutamate receptors have been used to treat cocaine dependence and nicotine dependence (Ait-Daoud et al. Finally, the serotonin systemwhich consists of neurons that rely on the neurotransmitter serotoninplays a role in the abuse of stimulants. This is not surprising, given that this system is critical for the regulation of many basic biological functions, such as eating, drinking water, sexual behavior, and response to pain (Pihl & Peterson, 1995). Serotonin has been shown, for example, to play a role in producing the desire for cocaine (Aronson et al. However, its important to remember that the different neurotransmitters and brain systems work together and that their effects emerge from their interactions. These systems can cause the drug to have rewarding effects and make other rewards (such as a good meal, an interesting conversation, or a paycheck) feel less valuable (Kalivas & Volkow, 2005). Thus, although stimulants in general engage the dopamine reward system, this effect is not the only reason why some people come to abuse such drugs. However, high levels of serotonin in the synapse not only affect the receiving neuron, but also cause the sending neuron to produce less serotonin in the future. For example, nicotine acts on a specific type of acetylcholine receptor called the nicotinic receptor. Such re Stimulants bind to dopamine transporters, leading to increased dopamine ceptors are located on the cell bodies of dopamine-releasing in the synapse. Activation of these receptors leads to increased Substance activates the dopamine reward system, specifically the nucleus accumbens and ventral tegmental area. Psychological Factors: From Learning to Coping Various psychological factors contribute to stimulant abuse and dependence, and to substance abuse and dependence in general. One type of psychological factor is observational learning: Through observing others, people develop expectations about when to use drugs and what the experience of using a given substance should be like. These expectations in turn act as feedback that affects how the brain actually N responds to a drug (Nitschke et al. Another psychologiP S cal factor is operant conditioning: When the consequences (effects) of drug use are rewarding, the person is likely to use drugs again and again. Repeated drug use, in turn, can produce classical conditioning, whereby stimuli associated with drug use, such as the vial containing crack, elicit a craving (a strong urge or desire) for the drug (Epstein et al. Such factors affect each other and can become feedback loops that create a spiral of substance abuse and dependence. Lets examine these psychological factors in more detail, first considering observational learning and then moving on to operant and classical conditioningwhich are involved in the progression from use to abuse and dependence and in the maintenance of abuse and dependence once they develop. Observational Learning People may develop substance abuse or dependence, in part, through observing use N or abuse of drugs by modelsfamily members, peers, celebrities, or mentors. Not P S everyone who observes substance use or abuse will follow suit, but simply observing how other people use substances as a coping strategy can provide a model for that particular way to cope (Winfree & Bernat, 1998). For example, suppose a girl witnesses her respected older brother having an argument with their father. The brother and sister leave the house after the fight, and the brother proceeds to smoke crack while complaining about the father. Through observation, the younger sister learns that one way to cope with stress is through substance use. Similarly, studies have found that if a persons peers use or abuse substances, that person is likely to do the same (Dishion & Medici Skaggs, 2000; Fergusson, Swain-Campbell, & Horwood, 2002). It is possible that those who are at risk for developing substance abuse (perhaps because of a family history) may be more likely to seek out peers who are substance users. For instance, consider that people who have a high need for social approval are more likely to model their peers behavior. So, it is possible that if peers abuse drugs, those desperate for social approval are more likely to use or abuse drugs than are people who resist peer pressure and do not respond strongly to peer approval (Caudill & Kong, 2001). And it is possible that P S by watching otherssuch as parents or peers, for instancechildren and young adults learn to expect drugs to produce certain kinds of experiences, even if they do not use substances as a coping strategy (Brown et al. For instance, when the Beatles began smoking cigarettes during their early teens, they did so in part because such behavior was modeled by their parents and their community; in addition, they probably developed the expectation that smoking would be fun and might make them appear more attractive to girls. These positive expectancies, developed through observational learning, may have led them to continue to smoke, even if smoking was initially unpleasant. Operant Conditioning Operant conditioning exerts its infiuence on stimulant use and abuse (and substance N use, abuse, and dependence more generally) in several ways. First, if stimulant use is followed by pleasant consequences, those consequences act as positive reinforceP S ment (which leads to recurrent use). Research on the dopamine reward system shows that aspects of this type of learning have neurological underpinnings. In fact, the dopamine reward system begins to be activated with the expectation of a drugs positive effects (that is, the expectation of reinforcement), which leads to reward cravingthe desire for the gratifying effects of using a substance (Verheul, van den Brink, & Geerlings, 1999). Reward craving occurs even if recent experiences of drug use have not been positive. Second, stimulant use and abuse can independently lead to negative reinforcementalleviating a negative state, thereby producing a desirable experience (remember that negative reinforcement is not the same as punishment). In fact, such negatively reinforcing effects contribute to substance abuse among people trying to manage the psychological aftereffects of physical or emotional abuse (Bean, 1992; Catanzaro & Laurent, 2004; Ireland & Widom, 1994; Stewart, 1996); in particular, using drugs may (temporarily) distract them from painful memories or their present circumstances, and hence be reinforcing. Drug use may provide transient relief from negative states, but persistently using substances as the means of gaining such relief (as the coping strategy)which may have been learned, in part, through observing how other people copedoesnt generally work, despite the fact that while the drug is in the system it may seem to the person that it helps. Substance use may temporarily make a person less aware of or make him or her care less about lifes difficulties, but it doesnt make those difficulties go away. When the substance wears off, the person is in the same situation, if not worse off because of the consequences of the substance use. These continuing life challenges in turn require more coping, and the person can enter a downward spiral. If substance use becomes the dominant coping strategy, it inevitably becomes substance abuse and possibly dependence. The temporary emotional relief provided by substance use can create cravings for the drug when an individual experiences negative emotions; this type of craving is someReward craving times referred to as relief craving (Verheul, van den Brink, & Geerings, 1999). Both the desire for the gratifying effects of using a reward craving and relief craving can cause substance-dependent people to use drugs substance. Thus, cravings are thought to play a Relief craving primary role in maintaining substance dependence (Torrens & Martin-Santos, 2000). The desire for the temporary emotional relief A third way that operant conditioning contributes to substance abuse and that can arise from using a substance. That is, once a substance develops dependence, he or she probably will experience withdrawal as the substance wears offwith symptoms that can range from mildly unpleasant to extremely unpleasant and potentially lethal. Substance use eliminates the unpleasant withdrawal state, which increases the likelihood of subsequent use. Research has revealed that compared to people who dont abuse substances, people who do abuse substances are more likely to prefer smaller amounts of reinforcement that occur immediately after a behavior to larger amounts of delayed reinforcement (Bickel & Marsch, 2001). They also prefer larger but delayed losses (punishment) over smaller but more immediate losses (Higgins, Heil, & Lussier, 2004). Thus, when a substance abuser can choose between taking a drug (with immediate reinforcement, along with possible delayed losses or punishment) and not taking it (with a loss of immediate reinforcement), he or she may choose the immediate reward of drug use. Classical Conditioning Stimuli associated with drug use (such as drug paraphernalia) are referred to as N drug cues, and they come to elicit conditioned responses through their repeated P S pairings with drug use.

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Dies ist allem Anschein nach der Grund dafur breast cancer youth football socks purchase dostinex uk, dass rein pharmakologische Panikbehandlungen keine befriedigenden bzw menopause over the counter medications generic dostinex 0.5mg with amex. Die beschriebenen Medikamente dampfen die efferente Angstreaktion menopause type 8 safe dostinex 0.5mg, ohne die im Zuge der Storung automatisierten Stimulusverarbeitungsprozesse zu beeinflussen pregnancy gifts buy genuine dostinex on line. Um die Panikstorung effektiver zu behandeln, musste eine wirksame Hemmung auf die der Amygdala ubergeordneten Prozesse ausgeubt werden. Neuroanatomisch gesehen, kamen dem prafrontalen und dem cingularen Cortex die Aufgabe zu, das Verhalten der die Angstreaktion steuernden Amygdala zu moderieren (Gorman et al. Anxiolytische Medikamente sind in der Angstbehandlung wirksam (vergleiche zum Beispiel die Meta-Analyse von Clum et al. Gut ein Drittel der rein medikamentos behandelten Patienten zeigt keine Verbesserung, und die, die sich gebessert fuhlen, sind in der Regel nicht frei von Angsten. Als weit wichtigerer Nachteil der medikamentosen Angstbehandlung erweist sich die Tatsache, dass diese keinen nachhaltigen, ein Rezidiv verhindernden Effekt zeitigt: In 54 bis uber 70 Prozent der Falle kommt es nach Absetzen der Antidepressiva oder Benzodiazepine zu einem Wiederauftreten der Panikstorung (zum Beispiel Mavissakalian und Perel, 1999; Noyes et al. Erwahnenswert ist auch, dass Panikpatienten korperliche Nebenwirkungen der Antidepressiva wenig tolerieren. Dies hat in klinischen Studien eine auffallend hohe Abbrecherquote zur Folge (Cassano et al. Dabei erweist sich die Hoffnung auf einfache und griffige Pathomechanismen, die sich nach dem Schalter-an-Schalter-aus-Prinzip effektiv therapeutisch beeinflussen liefien, nahezu regelhaft als trugerisch. Als Alternative zu diesem synchrone, lineare und wenig komplexe Verhaltnisse unterstellenden Ansatz bietet sich der Entwicklungsansatz an. Dieser ist zwar bislang kaum uber die grobe Rekonstruktion pathogener Entwicklungsschritte hinaus gekommen; er bietet jedoch in Zukunft die Aussicht, die (funktionelle) Plastizitat des Nervensystems sowohl in der Krankheitsentstehung als auch unter einer effektiven Behandlung zu verstehen. In allgemeiner Form lasst sich ein solches Entwicklungsmodell folgendermafien darstellen (siehe Abbildung 4): Psychischen Storungen 160 liegt eine mehr oder weniger starke genetische Vulnerabilitat zugrunde. Das Risiko, an einer bestimmten psychischen Storung zu erkranken, bleibt gleichwohl nicht konstant. Die Erfahrungen, die im Laufe der Entwicklung gemacht werden, konnen sich sowohl pathogen, das heifit die Vulnerabilitat vergrofiernd, als auch protektiv, das heifit das Erkrankungsrisiko verringernd, auswirken. Beispielhaft seien die nicht gluckende Bewaltigung belastender Life Events, fehlende soziale Unterstutzung oder das Unvermogen, kompensatorische Fertigkeiten zu entwickeln, genannt. Die ursprunglich rein konstitutionelle, dann aber durch Reifungsprozesse veranderte Krankheitsbereitschaft ist schliefilich so beschaffen, dass es infolge von mehr oder weniger schwerwiegenden Belastungen bzw. Auslosungsbedingungen zur Dekompensation und damit zur Manifestation von Krankheitszeichen kommt. Genetische Vulnerabilitat Erfahrungen (pathogen/protektiv) Ausloser Reaktionen/Storungsmechanismen Chronifizierung/Outcome Abb. Die initiale Symptomatik veranlasst den Betroffenen haufig zu Gegenreaktionen auf den verschiedenen Ebenen (siehe Abbildung 2, oben). Gerade bei Angststorungen ist dieses Bewaltigungsverhalten oft geeignet, das Storungsgeschehen zu verfestigen und die Symptomatik zu verschlimmern. Verhaltensanderung fortbesteht, desto mehr bestimmen Chronifizierungsprozesse den Outcome. Die vorhandenen Befunde sprechen fur die deskriptive Angemessenheit eines solchen Entwicklungsmodells der Panikstorung: Der Einfluss einer genetisch bedingten Vulnerabilitat ist nicht von der Hand zu weisen. Die Konkordanz fur das Merkmal Panikstorung liegt bei monozygoten Zwillingen bei 23,3 Prozent (Kendler et al. Diese Befunde sprechen fur die Erblichkeit einer Panikbereitschaft, die sich nicht zwingend in einer Panikstorung manifestieren muss (Bellodi et al. Als interessante Kandidaten der genetischen Forschung gelten Polymorphismen des Cholezystokinins (Kennedy et al. Eine Vielzahl von Untersuchungen sprechen dafur, dass die im weiteren Verlauf erfolgenden Lernerfahrungen einen pathogenen Einfluss auf die spatere Panikbereitschaft haben. So finden sich post hoc bei Panikpatienten haufiger als bei Kontrollen ein behutender, rigider Erziehungsstil (Marks, 1969) sowie dysfunktionale Muster in der Eltern-Kind-Beziehung (Guidano und Liotti, 1983). Signifikante Trennungserfahrungen sind in 53 Prozent der Falle nachweisbar (Raskin et al. Bei vielen Panikpatienten findet sich zudem eine lebenslange bestehende dependente Personlichkeit (Nystrom und Lyndegard, 1975). Dass fruhe Deprivationserfahrungen einen nachhaltigen Einfluss auf die Entwicklung des Gehirns von Saugetieren haben konnen, ist in den letzten Jahren durch Tierexperimente eindrucksvoll belegt worden. Die entsprechenden Nachkommen zeigen als erwachsene Tiere eine signifikant starkere Stressreaktion. Vor der Manifestation der eigentlichen Panikstorung finden sich haufig prodromale Symptome. So weisen etwa 55 Prozent der spateren Panikpatienten kindliche Angststorungen auf (Pollak et al. Phobische und hypochondrische Symptome sind bei fast allen spateren Panikpatienten (etwa 90 Prozent) im Vorfeld nachweisbar (Fava et al. Zur Erstmanifestation einer Panikstorung kommt es meist in Phasen gesteigerter psychischer Anspannung. So etwa liefien sich im Zeitraum von sechs Monaten vor der Erstmanifestation gehauft ernsthafte Life Events eruieren (Faravelli und Pallanti, 1989). Zur ersten Panikattacke kommt es zudem fast regelmafiig (92 Prozent) in einer phobischen Situation (Lelliott et al. Ist der oben beschriebene Teufelskreis erst einmal eingerastet, ist es fur den Betroffenen nur noch schwer moglich, die Angste und das Vermeidungsverhalten eigenstandig in den Griff zu bekommen. Viele Patienten sind sich der oben beschriebenen Zusammenhange durchaus 163 bewusst und kennen ihre typischen Auslosebedingungen, ohne aber das Problem insgesamt abstellen zu konnen (Boulenger und Bisserbe, 1992). Um einen nachhaltigeren Behandlungserfolg zu erzielen, bedarf es deshalb nach heutigem Verstandnis eine storungsspezifische Re-Programmierung der relevanten Anteile des Angstnetzwerks. Die moderne kognitiv behaviorale Therapie versteht sich als Selbstmanagementtherapie (Kanfer et al. Der Patient soll durch die Therapie in die Lage versetzt werden, die Wechselwirkungen seines problematischen Erlebens und Verhaltens zu erkennen und zielgerichtet zu andern. Das therapeutische Vorgehen orientiert sich dabei an der individuellen Problemanalyse (Casper, 1996) und erarbeitet auf den Einzelfall zugeschnittene Strategien, die zunachst unter therapeutischer Anleitung, dann mehr und mehr in der Eigenregie des Patienten in die Tat umgesetzt werden. Dabei kommen Interventionen zum Einsatz, die auf den verschiedenen Symptomebenen (siehe Abbildung 2, oben) wirken. Ihr Ziel ist es im Falle der Panikstorung, die korperliche Angstsymptomatik (vegetative Erregung), die wahrgenommene Bedrohung (katastrophisierende Uberzeugungen, Hypervigilanz) und die geringe Selbstwirksamkeitserwartung (Bandura, 1977) des Patienten effektiv zu andern. Einige Autoren beklagen jedoch, dass kontrollierte Studien oftmals Patienten mit co-morbider Symptomatik ausschliefien. Es wird befurchtet, dass diese Patienten von kognitiver Verhaltenstherapie nicht profitieren konnen. So wiesen Martinsen, Olsen und Kollegen (1998) in einer Studie im naturalistischen Setting nach, dass auch Patienten mit co-morbiden Storungen (zum Beispiel Depression, selbstunsicher-vermeidende Personlichkeitsstorung) eine effektive Veranderung ihres Vermeidungsverhaltens zeigen. Ein Jahr nach Therapieende berichteten 84 Prozent der Panikpatienten, ihre Angststorung habe sich stark oder sehr stark gebessert. Dass Denken und Verhalten die wesentlichere Bedeutung fur die Entstehung und Aufrechterhaltung der Panikstorung zukommt, lasst sich durch folgende Beobachtungen belegen: 36 Prozent der Allgemeinbevolkerung berichten davon, gelegentlich Panikattacken zu erleben (Norton et al. Aber nur zwei bis drei Prozent der Betroffenen erfullen die Kriterien einer Panikstorung (Norton et al. Somit ist es nicht die korperliche Angstsymptomatik per se, hinsichtlich derer sich Panikpatienten von Normalpersonen mit gelegentlichen Panikattacken unterscheiden; vielmehr ist es die Angst vor der korperlichen Angstreaktion eine kognitive Variable. Die zu Panikattacken neigenden Normalpersonen furchten sich viel weniger vor moglichen katastrophalen Konsequenzen der korperlichen Angstsymptomatik, zum Beispiel Tod oder Kontrollverlust (Telch et al. Hieraus folgt, dass es Unterschiede in der Bewertung der Korpersymptome sind, welche die Entwicklung einer Angststorung mafigeblich bestimmen. Erfolgreich therapierte Panikpatienten berichten eine deutliche Reduktion der Angst, ohne dass sich ihre physiologische Reaktionsbereitschaft geandert hatte (Vermilyea et al. Daruber hinaus zeigte sich, dass Mafie der korperlichen Angstsymptomatik schlechtere Pradiktoren fur den Therapieerfolg sind als kognitive Mafie (Griegel et al. Die Expositionstherapie ist die wirksamste Behandlungsform zur Reduktion von korperlichen Angstsymptomen (Ruhmland und Margraf, 2001). Hierfur steht ein breites Spektrum sinnvoller Expositionsubun166 gen zur Verfugung. So werden Panikpatienten angeleitet, sich auf das Erleben korperlicher Vorgange zu konzentrieren und gleichzeitig die damit einhergehenden katastrophisierenden Gedanken und Befurchtungen abzurufen (interozeptive Exposition). Um die korperliche Angstreaktion zu verstarken, werden physiologische Symptome etwa durch Hyperventilation, Koffein oder korperliche Anstrengung provoziert.

Not only has she made mood disorders her Understanding Depressive Disorders area of professional expertise women's health clinic brisbane northside buy 0.25 mg dostinex visa, but she has also lived with such Treating Depressive Disorders a disorder women's health clinic queen elizabeth buy 0.5mg dostinex. She describes her father women's health quizzes cheap 0.5mg dostinex otc, a meteorologist Understanding Bipolar Disorders and Air Force officer breast cancer 90 year order generic dostinex from india, as expansive, with infectious good moods, Treating Bipolar Disorders and impulsive, often giving the children gifts. However, Suicidal Thoughts and Suicide Risks he also suffered periods when he was immobilized by depresUnderstanding Suicide sion, and he generally had trouble regulating his emotions. Preventing Suicide As well see in this chapter, Jamison herself developed difficulties regulating her emotions. I would read the same passage over and over again only to realize that I had no memory at all for what I had just read. I was totally exhausted and could scarcely pull myself out of bed in the mornings. I wore the same clothes over and over again, as it was otherwise too much of an effort to make a decision about what to put on. The category of psychological disorders called mood disorders encompasses prolonged and marked disturbances in mood that affect how people feel, what they believe and expect, how they Mood disorders think and talk, and how they interact with others. Depressive disorders are mood disorders in which someones mood is consistently low; in contrast, bipolar disorders are mood disorders in which a persons mood is sometimes decidedly upbeat, perhaps to the point of being manic, and sometimes may be low. Note that the mood disturbances that are part of depressive disorders and bipolar disorders are not the normal ups and downs that we all experience; they are more intense and longer lasting than just feeling blue or happy. Similarly, as with all clinical disorders, in order to be classified as a disorder, the symptoms of the mood disorder must cause significant distress, impair daily life, or put a person at risk of harm. The significant distress and suffering, along with a pervasive hopelessness that can arise with depression, sometimes lead people to contemplate or attempt suicide. Should a patient experience additional I became exceedingly restless, angry, and irritable, types of mood episodes over time, his or her diagnosis may change. But what, exactly, does it mean to A major depressive episode involves say someone is depressedfi Mood (which is a type of affect) is not the only symptom of a major depressive episode. Some people also suffer from a loss of pleasure, referred to as anhedonia, Anhedonia a state in which activities and intellectual pursuits that were once enjoyable no longer A difficulty or inability to experience pleasure. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood (symptom 1, below) or (2) loss of interest or pleasure (symptom 2, below). Note: Do not include symptoms that are clearly due to a general medical condition or mood-incongruent [i. Note: In children, consider failure toin a month) or decrease or increase in appetite nearly every day. The symptoms do not meet criteria for a mixed episode [discussed later in this chapter]. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation. Major depressive episode includes affective/mood (green), behavioral/vegetative (orange), and cognitive (blue) symptoms. Other moodrelated symptoms of depression include weepinesscrying at the drop of a hat or for no apparent reasonand decreased sexual interest or desire. Behavioral and Physical Symptoms of Depression People who are depressed make more negative comments, make less eye contact, are Psychomotor agitation less responsive, speak more softly, and speak in shorter sentences than people who An inability to sit still, evidenced by pacing, are not depressed (Gotlib & Robinson, 1982; Segrin & Abramson, 1994). Depreshand wringing, or rubbing or pulling the skin, sion is also evident behaviorally in one of two ways: psychomotor agitation or psyclothes or other objects. Psychomotor agitation is an inability to sit still, evidenced Psychomotor retardation by pacing, hand wringing, or rubbing or pulling the skin, clothes, or other objects. A slowing of motor functions indicated by In contrast, psychomotor retardation is a slowing of motor functions indicated by slowed bodily movements and speech and slowed bodily movements and speech (in particular, longer pauses in answering) lower volume, variety, or amount of speech. Vegetative signs (of depression) these two psychomotor symptoms, along with changes in appetite, weight, Psychomotor symptoms as well as changes in and sleep, are classified as vegetative signs of depression. In addition, people who are depressed may feel less energetic than usual or feel tired or fatigued even when they dont physically exert themselves. In fact, many people who are depressed had sleep disturbances up to a month before the depression began, which suggests that sleep irregularities may be a harbinger of a depressive episode (Perlis et al. In order to meet the diagnostic criteria, the vegetative signs should be observable by others, not just reported as subjective experiences. For instance, if a new patient reported difficulty getting to sleep, poor appetite, and feeling agitated, the clinician would ask the patient for more details before determining that these were vegetative signs of depression: How long does it actually take the patient to get to sleepfi The clinician would also observe the patient for signs of psychomotor agitation, such as a leg constantly bobbing up and down or fingers tapping on the armrest. Cognitive Symptoms of Depression When in the grip of depression, people often feel worthless or guilt-ridden, may evaluate themselves negatively for no objective reason, and tend to ruminate over their past failings (which they may exaggerate). They may misinterpret ambiguous statements made by other people as evidence of their worthlessness. For instance, a depressed man, Tyrone, might hear a colleagues question How are youfi Depressed patients can also feel unwarranted responsibility for negative events, to the point of having delusions that revolve around a strong sense of guilt, deserved punishment, worthlessness, or personal responsibility for problems in the world. They blame themselves for their depression and for the fact that they cannot function well. During a depressive episode, people may also report difficulty thinking, remembering, concentrating, and making decisions, as author William Styron describes, in Case 6. Note, however, that depression is heterogeneous, which means that people with depression experience these symptoms in different combinations. Hypersomnia In depression this faith in deliverance, in ultimate restoration, is absent. So the decision-making of daily life involves not, as in normal affairs, shifting from one Premorbid Referring to the period of time prior to a annoying situation to another less annoyingor from discomfort to relative comfort, or from patients illness. One does not abandon, even briefiy, ones bed of nails, but is attached to it wherever one goes. The more severe the depression, the longer the episode is likely to last (Melartin et al. Normal bereavement has characteristics that What distinguishes depression from simply having the bluesfi One distinare similar to symptoms of a major depressive guishing feature is the number of symptoms. However, bereaved people are not generally overcome with feelings of hopelessness or depressed has severe symptoms for a relatively long period of time and is unable anhedonia. Moreover, pervasive hopelessness and loss of pleasure are usually absent in normal sadness. Some people have increasingly frequent episodes over time, others have clusters of episodes, and still others have isolated depressive episodes followed by several years without symptoms (American Psychiatric Association, 2000; McGrath et al. Unfortunately, the documented rate of depression in the United States in increasing (Lewinsohn et al. By 2020, depression will probably be ranked second among disabling diseases in the United States (right after heart disease; Schrof & Schultz, 1999); it is currently associated with more than $30 billion dollars of lost productivity among U. Major depressive disorder leads to lowered proEvidence also suggests that the risk of developing depression is increasing for ductivity at workboth from missing days at work each age cohort, a group of people born in a particular range of years. The risk and from presenteeism, being present at work of developing depression is higher among people born more recently than those but less productive than normal (Adler et al. In addition, if someone born more recently does develop depres2006; Druss, Schlesinger, & Allen, 2001; Stewart et al. For people whose jobs require high sion, that individual probably will first experience it earlier in life than someone in levels of cognitive effort, even mild memory or an older cohort (American Psychiatric Association, 2000). Source: Unless otherwise noted above, the source for information is American Psychiatric Association, 2000. Because of the high comorbidity between depression and anxiety disorders (about 50%), researchers propose that the two types of disorders have a common cause, presently unknown. We will further discuss reasons for the high comorbidity between these two types of disorders when we consider anxiety disorders in Chapter 7. Specifiers help clinicians and researchers identify or note variants of a disorder, which is important because each variant may respond best to a particular treatment or have a particular prognosis. For instance, depression with melancholic features includes complete anhedoniathe patient doesnt feel any better after positive events.

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