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X. Irhabar. Bryn Mawr College.

In addition buy discount provera 5 mg line, Saab and Willis (2001) found that Purkinje cells in the caudal vermis respond to nociceptive visceral stimulation in the form of early and delayed changes in activity cheap 10mg provera with amex, and proposed a negative feedback circuitry involving the cerebellum for the modulation of peripheral nociceptive events buy cheap provera 2.5 mg. Recently cheap 5mg provera overnight delivery, imaging studies on the nociceptive input to the cerebellum have also appeared provera 5mg lowest price. In positron emission tomography (PET) and functional magnetic reso- nance imaging (fMRI) studies, increases in blood volume or flow in the vermis and paravermal areas were reported during the perception of acute heat pain (Casey et al. The respective cortical areas differ functionally, as seen in electrophysiological and functional imaging studies: thesensory-discriminativeaspectofpain(localization,intensity,duration,quality) is presented in SI and SII, receiving thalamic input from lateral thalamic nuclei, the motivational-affective aspect (subjective suffering, unpleasantness, aversive emotions), and the cognitive-evaluative aspects of pain are presented in the IC, ACC, and PC, receiving thalamic input from medial thalamic nuclei. Primary Somatosensory Cortex The role of SI (located in the postcentral gyrus, Brodmann’s areas 3, 1, 2) in pain perception has been a matter of dispute for decades. Head and Holmes (1911) re- ported that patients with long-standing cortical lesions did not show deficits in pain perception, which lead to an erroneous suggestion that the pain sensation takes place in the thalamus. During epilepsy surgery, Penfield and Boldrey (1937) performed electrical stimulation of patients’ exposed SI and encountered only very few cases (11 out of more than 800 responses) that reported a sensation of pain. Also, the findings from human brain imaging studies have produced rather inconsistent results concerning the role of SI in pain perception (Bushnell et al. Despite certain controversies, an increasing number of PET and fMRI studies found an activation of SI during painful stimuli (Casey et Cortices Involved in Pain Perception and Thalamocortical Projections 45 al. According to Craig (2003a, d), nociceptive activation near the central sulcus in humans probably occurs in area 3a (where the thalamic VMpo projects), but its location is below the level of PET resolution. Two classes of neurons are ac- tivated in SI: neurons with a wide dynamic range react already to stimuli that are not painful; however, they show the highest activity to painful stimuli (Chudler et al. They have small receptive fields, are somatotopically located in the postcentral gyrus and enable the determination of the localization, intensity, and temporal attributes of the painful stimuli. The SI neurons get their afferents from the lateral thalamic nuclei (VPL, VPM, VPI; in primates and humans also from VMpo; Willis 1997), and also heavily project back to these nuclei. The thalamocortical projections are excitatory glutamatergic (Kharazia and Weinberg 1994). Lesions of the respective thalamic nuclei, the tha- lamocortical connections or of SI result (besides loss of somatosensory function) in a dramatic decrease in temperature and pain perception (Bassetti et al. Nevertheless, pain is still interpreted as uncomfortable and unpleasant (Ploner et al. Secondary Somatosensory Cortex SII is located just lateral and slightly anterior to the lateral end of the central fissure in the human brain, roughly occupying Brod- mann’s area 43 and parts of area 40. In contrast to SI, SII neurons do not seem to be involved in discrimination of location and/or intensity of painful stimuli, but seem to have an important role in recognition, learning, and memory of painful events (Schnitzler and Ploner 2000). A number of studies found significant pain-related activation of SII with functional imaging and electrophysiological methods (Talbot et al. The SII neurons get their mostly bilateral afferences from the lateral thalamic nuclei partly different from those projecting to SI, namely from the VPI and the dorsal part of the Po, thus indicating an anatomical and functional segre- gation of the SI- and the SII-nociceptive pathways. Insular Cortex Functional imaging studies showed increased blood flow of the insular cortex during painful stimuli, either contralaterally or bilaterally (Casey et al. It is not yet clear whether 46 Functional Neuroanatomy of the Pain System the anterior (Brodmann’s area 13) or posterior insular cortices (Brodmann’s areas 14–16) are mainly involved in pain perception (Craig 2003c, d). Moreover, patients withlesionsoftheIChadanelevatedpaintoleranceandlossoforinadequate emotional reactions to painful stimuli although recognizing pain (asymbolia for pain; Bertier et al. The IC gets thalamic afferents from the VMpo, the mediodorsal (MD), and intralaminar thalamic nuclei (Craig et al. Also, these connections speak in favor of the importance of the IC in the motivational-affective aspect of pain and in autonomic reactions to noxious stimuli. Anterior CingulateCortex The cingulated cortex is involved in cognition and emo- tion. The subarea involved in the motivational-affective aspect of pain is most probably located in the rostral part of Brodmann’s area 24 and the adjoining area 32. Patients with lesions of the ACC lost the emotional reactions to painful stimuli although pain could be further correctly localized. In the ACC, pain-receptive neurons were found with large, often bilateral receptive fields not allowing localizing information.

Not uncommonly people will report that they almost always have an attack of pain when they are on vacation generic 2.5mg provera overnight delivery, or if they already have pain that it gets worse on weekends trusted provera 5mg. It’s a bit like the delayed reaction; as long as they are on the job they may be “burning up” the anxiety but when they are away from it provera 2.5 mg overnight delivery, supposedly relaxing buy provera 10mg on line, the anxiety accumulates cheap provera 5 mg free shipping. Speaking of relaxing, one often hears the advice “Relax,” as though that’s something one can do voluntarily. There are also numerous techniques around for promoting relaxation, like drugs, meditation and biofeedback, to name a few. However, unless the The Manifestations of TMS 19 relaxation process succeeds in reducing repressed anxiety and anger, people will develop things like TMS and tension headaches despite the attempt to induce relaxation. Some people don’t know how to leave their daily concerns behind them and shift attention to something pleasurable. I remember a patient who said that her pain would invariably begin when she got herself a drink and sat down to relax. He described having been under a lot of stress for a long time, but without any back pain. It wasn’t until he was on his honeymoon that he was awakened one night with a “nightmarish dream” followed immediately by a severe back spasm in which, he said, “my back went completely out. He was still having symptoms when I saw him three months later, no doubt due to the fact that an MRI had shown a disc herniation at the lower end of the spine and the possibility of surgery had been discussed. In fact, it showed that his symptoms could not be due to the herniated disc, for he had weakness in two sets of muscles in his leg, something that the herniated disc could not have caused. Only involvement of the sciatic nerve, as is typical in TMS, could have produced this neurological picture. At any rate, he was delighted to learn that TMS was the basis for his back troubles and had a rapid recovery. Another explanation, often difficult for people to admit to themselves, is that there are great sources of anxiety and anger in 20 Healing Back Pain their personal lives, like a bad marriage, trouble with children, having to care for an elderly parent. We have seen numerous examples of this: women trapped in bad marriages that they cannot stand and yet unable to break out because of their emotional and/or financial dependence on their husbands; people who feel perfectly competent at what they do for a living but who cannot deal with a difficult spouse or child. I recall a woman with a persistent pain problem who lived with a very difficult brother. One day she told me that she had done a very unusual thing; she had gotten furious at her brother, had shouted and ranted at him and stormed out of the house. What should be a time of relaxation and fun often turns out to be unpleasant for some people. I have been struck by the fact that many patients will report the onset of attacks of TMS before, during or shortly after major holidays. The reason is obvious: big holidays usually mean a lot of work, particularly for women, who take the responsibility in our culture for organizing and carrying out the festivities. Usually the women are completely unaware that they are generating great quantities of resentment, and the onset of pain comes as a complete surprise. The Manifestations of TMS 21 THE NATURAL HISTORY OF TMS What are the common patterns of TMS? Conditioning Essential to an understanding of this subject is knowledge about a very important phenomenon known as conditioning. The phenomenon is best known by the experiment reported by the Russian physiologist Pavlov, who is credited with the discovery of conditioning. His experiment demonstrated that animals develop associations which can produce automatic and reproducible physical reactions. After repeating this a few times he found that the dogs would salivate if he rang the bell even without the presentation of food. The process of conditioning, or programming, seems to be very important in determining when the person with TMS will have pain. For example, a common complaint of people with low back pain is that it is invariably brought on by sitting. This is such a benign activity one is mystified by the fact that it initiates pain. But conditioning occurs when two things go on simultaneously, so it is easy to imagine that at some point early in the course of the TMS experience the person happens to be having pain while sitting. The brain makes the association between sitting and the presence of pain and that person is now programmed to expect pain with sitting. In other words, the pain occurs because of its subconscious association with sitting, not because sitting is bad for the back.

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However provera 5 mg without a prescription, a closer reading of the methodology shows that the first group of patients also took antihistamines during the experiment buy provera 2.5 mg with visa, unmonitored by the 13 experimenters order 10mg provera otc. That same year buy provera 5 mg cheap, a new series of experiments was carried out with the intention of establishing the effectiveness of homeopathy discount provera 5 mg mastercard, by con- trasting it with a placebo. Opium 15 H C and Raphanus 5 H C were tested for their ability to aid in re-establishing the transit of gases and matter in the aftermath of abdominal surgical operations. The conclusions of the experiments, which were conducted according to rigorous meth- odological procedures, once again discredited homeopathy and proved instead that it is "effective" on unverifiable clinical signs and ineffective on real clinical signs. No significant difference appeared between a group of patients who received nothing at all, a second that received a placebo, another that was given Opium 15 H C and finally the one that received both Opium 15 H C and Raphanus 5 H C. Homeopathy has survived other such setbacks in the course of its history — for example during a large scale test that was carried out in Germany in the late 1930’s. International Congress of the Society of Homeopathy in the name of the Führer, Rudolf Hess gave an address quivering with emotion in which he issued an appeal in favor of homeopathy. The new Germany considers that it is politically necessary to look into every phenomenon, whatever it may be. However, certain doc- tors have not hesitated to attack and reject not only new therapies, but others whose origins belong to an already distant past (as is the case today for homeopathy), without even taking the trouble to sub- ject these therapies to serious examination. Following this declaration, homeopathy would make great strides, marching forward in time with the lyric fantasies of the Reich. At the same time, tests were ordered, which were carried out under the direction of Dr. Fritz Donner, a renowned homeopath, and under the supervision of a pharmacologist and an internist. However, the results were not published; on the contrary, they were completely hidden from the entire international medical commu- nity, for many long years. A translation of the report written by Donner in 1966 finally appeared in a French journal in 1969 (the report was never published by the German press). Moreover, the book by Henri 14 Broch, who reported these facts, quotes two letters from F. Unseld, President of the Central German Associa- tion of Homeopathic Doctors, and the other to H. These long and closely argued letters show, among other things, that: 38 And Then Came Hahnemann x the results were all negative; x Dr. Donner was pressured to cover up these results; 15 x certain pathogeneses are purely products of the imagination; x one can expect to find approximately 1000 symptoms if one gives 30 testers, for one month, only. Donner adds: The real situation of homeopathy cannot be communicated to the homeopaths and cannot be published in homeopathic newspapers. In the best homeopathic tradition, everyone can utter the greatest nonsense in the world and it will be printed; on the other hand, a paper on the solid bases of an important drug against diphtheria will never be published, and any researcher working on its sources will be threatened with immediate dismissal! Fritz Donner, a homeopath whose critical mind deserves recogni- tion, gave an assessment of this verification of homeopathic methods that requires no further comment: "Complete Failure". And yet, he con- fesses honestly: "I avoided to the maximum extent mentioning in my report anything that would have proven fatal to homeopathy. If all testing procedures suggested are refused by the homeopaths, this refusal is the proof that the treatments are indeed not effective and that the producing laboratories are privately convinced, as are their zealous practitioners, that it would be dangerous to submit to a really inde- pendent series of tests. Oscillococcinum, the Miracle Drug Personalized treatment is the decisive argument advanced by all homeopaths who deny the value of double blind testing, homeopathy against placebo; they say that this type of test cannot apply to homeo- pathic treatment because it is adapted to the individual patient, and is not based on pathology alone but also on the "temperament" and the "biotype" of the patient. However, these same homeopaths, convinced as they are of the need to tailor the treatment to the individual, are strangely quiet when it comes to discussing the value of homeopathic treatments that are broadly prescribed, such as Arnica, for various and sundry afflictions, and especially Oscillococcinum, the miracle anti-influenza drug that en- joys constant publicity in all the media as soon as the weather turns nippy and people start to come down with colds and flus of all kinds. Oscillococcinum is one of the ten top-selling drugs in France and it is prescribed for both the flu and the cold, abandoning all the principles of individualized treatment. Oscillococcinum, so felicitously named, seems to be a weakened form of some unspecified bacillus of the "coccus" family — pneumococcus, en- terococcus, streptococcus and so on. Our oscillococcus is the homeopathic dilution of an extract of duck liver and heart. It should be noted that this "original" product takes advantage of a special ruling in the public health code. It is the only product to have officially bene- fited from a specific measure — allowing it to be manufactured accord- 17 ing to the Korsakovian principle of dilution, which was prohibited in France until 1992. In 1919, during a worldwide flu epidemic, a French doctor named Joseph Roy observed an "oscillating" variation in his patients’ conditions and an "oscillating" amount of a certain microbe, which he decided to call the oscillococcus.

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Bowen family systems concepts (Bowen discount provera 5 mg overnight delivery, 1985)—especially emotional reactivity and dif- ferentiation—offer a way to understand how to assess and assist couples experiencing particularly problematic reactions to physical illness order provera 10 mg mastercard. BACKGROUND AND KEY PRINCIPLES OF THE APPROACH—MEDICAL FAMILY THERAPY Medical family therapy is a metaframework for psychotherapy; it provides overarching principles within which any form of psychotherapy can be Managing Emotional Reactivity in Couples Facing Illness 257 practiced (McDaniel et al 2.5mg provera sale. Medical family therapy is based on a biopsychosocial systems theory (Engel order provera 10mg without a prescription, 1980; McDaniel et al generic 2.5 mg provera fast delivery. This theory, unlike traditional biotechnical medicine, is expressly systemic and sensitive to the effects on health and illness of context, including such vari- ables as gender, race, culture, and class. The goals of medical family therapy are to optimize agency and communion for the patient, the family, and the health professionals involved (Bakan, 1966). Communion refers to a sense of connection—with family, friends, health professionals, community, and spiritual communionity. Taken together, agency and communion are the foundations of individual effectiveness within a relational context. Vicki Hegelson (1994), in a review of the research on agency and communion, con- cludes that both agency and communion are required for optimal health, but that the effects on health are curvilinear. She found that both unmitigated agency and unmitigated communion are associated with negative health outcomes. Medical family therapy emphasizes the development of a collaborative (rather than hierarchical) relationship between the health professional, the patient, and the spouse or partner; this is a necessary corrective to the well- described power problems that can occur in the doctor-patient relationship (McDaniel & Hepworth, 2004; McDaniel et al. This collaborative stance involves respecting the patient’s and family’s agendas, supporting their goals, and providing care from a consultative rather than authoritar- ian position. Techniques for helping couples and families in medical family therapy include the following: (1) recognize the biological dimension along with the psychological, (2) solicit the illness story, (3) respect defenses, (4) remove blame and accept unacceptable feelings, (5) attend to developmental issues, (6) increase sense of agency, (7) facilitate communication, and (8) remain available. Historically, various approaches to family therapy have looked askance on biological explana- tions of human functioning, in part out of an understandable concern with the reductionism of traditional biomedical approaches. In working with couples facing illness, however, it is critical to recognize the importance of biology and its profound impact on the life of the couple. It is often helpful, when possible, to sit with the couple and their physician or other member of their health care team to demystify the illness by discussing their ques- tions, concerns, and reactions to it and to the treatment recommendations. In the context of an ambiguous diagnosis or course of illness, it is im- portant to be open to many possible explanations for the patient’s sympto- matology (Ruddy & McDaniel, 2002). Illness is virtually always both bio- logical and psychological, or at least involves aspects of each. Tolerance for ambiguity in the therapist helps avoid the temptation to attribute the 258 SPECIAL ISSUES FACED BY COUPLES patient’s symptoms definitively to either psychological or biological causes. On the other hand, a clinician’s overemphasis on biological explanations risks en- couraging the patient to avoid looking at the relationship between emotions and symptom expression. It certainly happens that an illness diagnosed as psychological at one point is later found to have a bona fide biomedical cause as the illness progresses or a new diagnostic approach is taken. It can sometimes be helpful to focus on the fact that stress has been shown to ex- acerbate virtually all illnesses, whether the etiology be psychological or bio- logical, and that working to reduce stress through enhancing coping strategies is likely to be beneficial, regardless of ultimate cause. The second technique, soliciting the illness story, involves asking about the patient and couples’ experience with the illness from the time of diagnosis to the present, including the associated feelings. Understanding the emo- tional and family context of the illness is facilitated through inquiry about family illness history, illness meanings, and transgenerational health beliefs and coping strategies. A respectful collaborative relationship greatly facili- tates the eliciting of the illness story from the patient and spouse or partner, and lays the foundation for developing a successful partnership for care. Views of illness and of the relationship with health care providers varies by cultural group, and often by gender. These views can present special challenges to the health professional and the psychotherapist. Because of the power differential, women may need to develop a trusting relationship with their health care provider before being able to share their illness story. For men, sharing their experience of illness may conflict with American male socialization that discourages expression or acknowledgment of vul- nerability; patient, supportive questioning by the therapist may therefore be required. The development of an effective therapeutic relationship in medical fam- ily therapy requires respecting the patient and partner’s defenses, diminishing blame and guilt, and accepting unacceptable feelings in reaction to illness.

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