Escitalopram

By G. Goran. Colorado Technical University.

Summary We began the chapter by asking a series of questions: Is the presenting problem a function of the personality? We must end the chapter by stating that the answer most certainly de- pends upon the client purchase escitalopram 10 mg mastercard social anxiety, for the function of personality does not rest on one theory buy escitalopram 5 mg with visa anxiety symptoms returning, one belief, or one therapeutic intervention. As humans, we are complex creatures, for we are not the same today as we were 10 years prior, nor will we remain unchanged by life’s events 10 years into the future. Thus, a basic understanding of the norms of development can offer the cli- nician insight into the complexity of issues that may besiege a client at any given point in life. For the purposes of this book only three theorists, out of a host of researchers, are featured, because their models have been use- ful in assessing the difficult client. In the end, the clinician should seek the repetition of behavior that is calling out for mastery. The recurrence of be- havior in clients’ life stories; their behavior outside of the therapeutic hour; their self-concept, fears, and defenses; and of course the symbolism inher- ent in their art is what I refer to as a symbolic abundance of ideas. This patient, a regressed schizophrenic, had a propensity to- ward theft, flushing rolls of toilet paper down commodes, and hoarding found items. All of this information was offered by staff, and these habits were definitely a point of contention in the dorm where the client lived. Arieti (1955) outlined four stages of the progression of the disease of schizophrenia. In the third stage he not only discusses hoarding but also in- dicates that an absence of symptoms prevails, as the client has learned to conceal his hallucinations and delusions, if only on a surface level. He states: The schizophrenic seems to hoard in order to possess; the objects he collects have no intrinsic value; they are valuable only inasmuch as they are pos- sessed by the patient. The patient seems almost to have a desire to incorpo- rate them, to make them a part of his person.... Thefact remains that this tendency is a non-pathognomonic manifestation of advanced schizophrenic regression. At this juncture, it was becoming more and more ap- parent that this patient was "screaming" to collect, to possess. When developing a treatment plan, one must meet the client within and slightly above his or her level of development to encour- age further developmental growth. Thus, in this case the therapist chose ages 6 to 12: the stage of latency (Freud), concrete operations (Piaget), and industry versus inferiority (Erikson). It was of the utmost importance for the client to complete this treat- ment plan with another person (to promote a sense of social participation and action) and for the clinician to follow through on statements in a timely manner (to circumvent the client’s feeling that only one chance is available and to promote trust). However, the client was not merely pre- sented with an array of models: He had to earn them through a token econ- omy system and incorporate budgeting into his thinking. Consequently, if he was going to "incorporate" as part of his fixation and collect as part of 98 Adaptation and Integration his need to possess, he should do so in a manner that bespoke of mastery and production. Ultimately, utilizing the steps outlined in this chapter, therapists can base treatment plans on not only knowledge of the client (their needs, fears, and defenses), but also knowledge of the existing literature by a wide range of researchers, clinicians, and theorists. In the end Piaget believed that the individual must master emerging conflict in order to prepare for future growth and integrity. It is this pattern of living that provides us with our self-concept, our identity, our abilities, and our worth. This ethereal quality that lives nowhere but ex- ists within us all changes for the better or the worse with time and em- braces our anxieties, joys, resentments, responsibilities, pleasures, and fears. How does one break through the well-honed defenses that protect us from psychic pain and emerge with an unvarnished view? In its use the disguise of language, developed ever so carefully over a lifetime, is dropped, and in its place a psyche is projected onto a blank piece of paper—a reflection of not only an individual’s self-concept but his or her concept of others. A pro- jection of ourselves and our environment as we see it, from our own view- point, without any influence from external subjective material. Projective testing has always had many detractors, and we review this literature later in the chapter; however, it is my belief that although the un- conscious nature of art certainly makes its study difficult such study is by no means impossible. In that vein, this chapter focuses on projective methods of personality analysis and spotlights three techniques: the Draw-A-Person (DAP), the House-Tree-Person (HTP), and the Eight-Card Redrawing Test (8CRT). I have selected the first two procedures because they are the most frequently utilized of the art projective tests.

CHOOSING YOUR PHYSICIAN A good relationship with your doctor is among the more important associations for a person with MS generic escitalopram 10 mg otc anxiety symptoms checklist 90. However generic 10mg escitalopram free shipping anxiety scale 0-10, finding a physician with whom you relate well may be not only difficult but also stressful. Some basic principles should be understood when making a decision about the right doctor for you. Despite the fact that insur- ance companies and other health care plan administrators act as if 12 CHAPTER 1 • What Is Multiple Sclerosis? Family physicians are trained to take care of general problems, but MS is not considered a general medical problem. A person with MS does need a general physician, but clearly he or she also needs someone more specialized. Internists specialize in many complicated med- ical problems, but most of them probably have seen few cases of MS. Physiatrists are specialists in rehabilitation and are increasing- ly involved as MS doctors, especially for those who have significant disability. However, neurologists—physicians who specialize in dis- eases of the nervous system—usually manage MS. Although neurologists are trained to make detailed and difficult diagnoses of neurologic dis- orders, many of them are not particularly capable of, or interested in, managing a disease after it has been diagnosed. The person with MS needs to work with a physician who will care for him or her on a long-term basis. People with MS deserve specialized care, but choosing a professional caregiver is not always easy. Although all physicians want to be helpful, some personalities sim- ply do not mesh. Some patients want their doctor to tell them what to do, whereas others want more choices in the process. Neither is intrinsically good or bad, but if you are with the wrong type of physician, the personal chemistry might not allow for a pleasing experience. Try to be aware of the type of person you are and try to find a physician with whom you are compatible. Remember that a patient who wants to entirely direct his or her own care is wasting money by paying a physician for advice. A physician who takes care of himself is said to have a fool both for a patient and for a doctor. All patients would like their physician to spend a lot of time with them, and that is a fair expectation. Before visiting your physi- 13 PART I • The Disease and Its Management cian, write down the specific questions that you want answered. Get right down to your questions because they may raise other important questions from the physician. It helps to have a list of all your medications and their dosages, because your physician may not be aware of all the medications that you are taking. It is hoped that he or she will be able to help with problems, but you should not have too high an expectation. There may be no physician in your area who is understanding, capable, and competent to meet your needs. Talk with other people who have MS and try to discover where your needs may be met. Although it is vitally important to have a relationship with a specialist, it may not be nec- essary to see that specialist more than once or twice a year. It is important to see the doctor at least once a year to develop a strong and understanding relationship. It also is important to be able to con- tact his or her office with questions that arise between appointments. Before the advent of modern medi- cine, the life span of many people with MS was not much beyond 40 years of age. Medications should not be taken without a purpose, but they should not be feared if they are used properly. MS is a highly variable disease, and no single management pro- gram fits everyone.

CASE STUDY Recall Maria Elena and Jose whom we met at the beginning of the chapter generic 5mg escitalopram anxiety symptoms mental health. In our intake with the couple cheap 5mg escitalopram with visa symptoms of anxiety, we learn about Maria Elena’s sexual molesta- tion by her stepfather at age 9. Al- though Maria Elena has been in ongoing individual therapy to work on her incest issues, it will be important for her to continue to do so while the cou- ples therapy is undertaken. The couples therapy is important because, even though she has been working on her abuse issues in individual therapy, the couples issues have persisted. Nonetheless, while working in a couples modality, issues related to the sexual abuse must be seen as primary and other issues must often take a back seat. Models such as TRIAD provide a framework for understanding Maria Elena’s molestation. TRIAD is a trauma assessment tool developed by Ann Burgess (Burgess, Hartman, & Kelley, 1990), which allows identifica- tion of key aspects of Maria Elena’s molestation experience. The "T" in TRIAD refers to the type of abuse experienced, with sexual abuse having more serious emotional consequences than either physical or psychological abuse. Whether the molestation consisted of a single episode or multiple ones over time will inform us as to the amount of damage we can expect. The nature of the perpetration and whether vaginal penetration was involved is also re- lated to severity of symptoms. Sexual abuse survivors can look highly functional on the out- side—most are very competent but focused on controlling their environ- ment—and that makes it more difficult to identify it and to counter their denial. As with the intensity of the perpetration, the period of time over which molestation occurred will also relate to the severity of symptoms one can expect. In this case, the apparent sexual dysfunction that Maria Elena and Jose bring to couples therapy is symptomatic of the underlying sexual abuse is- sues. Maria Elena’s behavior in compensating for her abuse and Jose’s reac- tions to Maria Elena’s behavior are reflective of the circular interactions that become problematic in some couples and these become the focus of couples therapy. In the case of Maria Elena and Jose, both Latino, the therapist is wise to consider the traditional family structure of their culture. According to Sue and Sue (2003), "traditional Hispanic families are hierarchical in form with special authority given to the elderly, the parents, and males. Also, the therapist must consider the role of machismo, Jose’s reactions to Maria Elena’s lack of sexual interest and the importance of Jose’s sexual function- ing on the couple’s interaction. Other interactional issues that are common in couples where childhood sexual abuse is a factor include: difficulties with trust, emotional expres- siveness and intimacy, communication, substance abuse, eating disorders or other addictions, and issues related to household, money, time manage- ment, and parenting (Oz, 2001). Although these issues are common in many types of couples, when they occur in the context of sexual abuse, the etiology of these problematic relational patterns and their impact on the re- lationship can be decidedly different than in other couples. The assessment Treating Couples with Sexual Abuse Issues 281 includes identifying which of these relational issues are operating but look- ing at them through the context of sexual abuse. In the context of couples therapy, it may be a useful tool to identify areas of the relationship that are most likely to be impacted. For example, the "R" in TRIADS refers to the relationship between victim and perpetrator. Attachment the- ory would suggest that the rupture of this primary relationship (between father/father figure and young daughter) is likely to impact adult attach- ments. Therefore, the possibility of trust issues within Jose and Maria Elena’s relationship must be explored. Even though Maria Elena’s stepfa- ther was her only abuser, the fact that the abuse continued until she was 16 suggests that the degree of damage to her sense of self may be great and that her identity as a competent adult has been impaired. Even though she was highly functional both at home and at work, when she began her individual therapy, she regressed to an earlier stage of development. Jose comments that he was attracted to her strength and is distressed at having to take over many of the household and parenting chores. In assessing Maria Elena’s affective state (the "A" of TRIADS), it is obvi- ous that she is highly emotional but she indicates that early in her individ- ual therapy she was largely cut off from her feelings. She indicates that now she is acutely aware and intensely reactive in ways that differ from her pre- vious demeanor. TREATMENT CONSIDERATIONS In exploring Maria Elena’s control issues with respect to the time, location, and means of their sexual interaction, it is clear that she does so in an at- tempt to protect herself from the memories of the abuse and to prevent any recurrence of the aversive sexual interactions. As Jose understands the dy- namics of their sexual interaction (that is, that she is not rejecting him but attempting to keep herself safe), his concern about his sexual performance diminishes. At the same time, it would be unrealistic to assume that the is- sues in their sexual relationship have been resolved.

The disadvantage of Fibrin Glue Patch 329 the commercial product is the higher cost if a large amount of fibrin glue is needed buy 20mg escitalopram with mastercard anxiety love. Both blood-banked cryoprecipitate and the commercial fibrin glue have been administered percutaneously for treatment of postoperative dural tears and for treatment of PDPS and SIH order escitalopram 5mg line anxiety symptoms get xanax. Fibrin glue has been reported in a single case report to be successful in treating SIH that was unresponsive to two epidural blood patches. The fibrin patch may be used in patients with CSF hypo- volemia who have concurrent HIV infection, leukemia, severe anemia, or lack of venous access. A fibrin glue patch can also be considered in patients who have persistent CSF hypovolemia symptoms despite epidural blood patching. Fibrin glue has greater adhesive strength than a blood patch, and there is no risk of injecting blood into the sub- arachnoid space. Fibrin glue is probably a better treatment for post- surgical dural tears than EBP. Transient fever and headache after fibrin patch were described in one patient and may be indicative of aseptic meningitis. The pa- tient should be informed that he or she will be receiving a blood prod- uct. Some hospitals may have a separate consent form for patients who are about to receive blood products. There is a rare potential risk of vi- ral transmission, although this has not been reported in connection with fibrin glue patches. Prophylactic fibrin glue injection for prevention of CSF leak has been studied in an animal and an in vitro model, but there are no published human studies. Fibrin Patch Technique A CT-guided fibrin patch may be successful in treating postlaminec- tomy headache secondary to dural tear (Figure 17. MRI may be help- ful to help identify and characterize the site of the tear and the extent of pseudomeningocele formation (Figure 17. CT guidance can then be used to drain the pseudomeningocele and patch the tear at the same time, thereby saving the patient from a major repeat surgery. Most spine surgeons dread such a complication and are grateful for this serv- ice. The fibrin patch can also be administered under fluoroscopic guid- ance by means of the same technique described for EBP. If frozen cryoprecipitate is to be used, the blood bank will need 30 minutes’ notice to allow time for thawing. Twenty thousand (20,000) units of thrombin is reconstituted in 10 mL of 10% calcium chloride solution and 0. The thrombin solution and cryoprecipitate are drawn up into sep- arate 3 mL Luer syringes. Equal volumes of thrombin and fibrinogen are then injected simultaneously by means of a three-way stopcock, through an 18-gauge spinal needle placed at the site of the suspected 330 Chapter 17 Epidural Blood and Fibrin Patches FIGURE 17. Axial image after percutaneous aspiration of the pseudomeningocele through an 18-gauge needle and application of fibrin glue patch through the same nee- dle. The commercial fibrin glue is usually stocked in hospital operating rooms, not in the hospital pharmacy. Tisseel and Hemaseel are actually the same product but packaged under the two different names by dif- ferent distributors. The commercial glue is available in vials of 2 or 5 mL, both of which reconstitute to make a slightly larger volume. The commercial glue comes as a kit comprising sealer protein concentrate (the main component is pooled human cryoprecipitate), fibrinolysis in- hibitor (bovine aprotinin) solution, thrombin (human), calcium chloride solution, and a double-barreled syringe with a common plunger. This plunger ensures that equal volumes of the two main components (fib- rinogen and thrombin) are drawn up separately but can be fed through a common needle for administration. Once the kit has been opened, the product must be used within 4 hours following reconstitution. By demon- strating the site of laminectomy and pseudomeningocele, MRI may be helpful in characterizing a postoperative CSF leak prior to intervention. Conclusion Both epidural blood patch and fibrin glue patch injections may be use- ful in the treatment of CSF leaks. The fibrin glue patch has a more rapid and greater adhesive effect than the autologous blood patch. It is also readily available and may be useful when injection of autologous blood is contraindicated.