By Z. Benito. Jarvis Christian College.
Some do not want to be involved in discussions purchase pamelor 25 mg amex, while for others buy pamelor 25mg fast delivery, there is an irresistible outpouring of words and emotion. People seeking to assist victims must be well trained to recognize the different reactions. They must also be assisting for the benefit of the traumatized individuals, and not to gratify their own psychological needs. Opponents of the debriefing industry have drawn an analogy with physical trauma. The argument is that if trauma results in a gash, the doctor does not keep poking his/her finger into the wound, asking if it still hurts. The doubters conclude that the debriefing industry has the potential to disturb the healing process. No metaphor is perfect and this one is perhaps less perfect than most. Nevertheless, some people do not want to talk about their trauma, they want to forget, and there is concern that compulsory debriefing could lead to unnecessary psychological scars (Zohar et al, 2009). Controlled trials of debriefing indicate that debriefing was of no benefit (Sijbrandij et al, 2006) and may actually harm patients (Bisson et al, 1997; Mayou et al, 2000). Consequently, authorities have strongly recommended that debriefing should cease and that intervention should not be provided to unscreened populations (McFarlane, 2003). Attention has been drawn to “social referencing” (Klinnert et al, 1986), the concept that the meaning children attach to events is greatly influenced by the reactions of those around them. Drawing attention to the frightening nature of traumatic events can be expected to inadvertently increase the risk of ongoing distress in children. This would be even more likely if conducted in group settings, which is one method by which debriefing was delivered. Attention is directed instead to assisting people to recover with appropriate support and acknowledgement of loss and grief. This media release of February 9, 2009, followed devastating bush-fires in Victoria (Australia) which cost 200 lives and great loss of property. Prevention – preferred action In the immediate aftermath of trauma, the most necessary and suitable assistance is social and practical support (Ehlers & Clark, 2000). Helpers should reinforce to survivors that they are now safe and the situation is under control. Survivors should be provided with food, shelter, transport and emotional support. People may benefit from being informed about the “normal reaction” to trauma. For example, visual flashbacks may be misunderstood, by victims, as evidence of psychosis or moral weakness. Some may be distressed by their own reactions, particularly when these have involved loss of control, freezing, or surrender. Initiation of active treatment Treatment should be available when needed. But, it is important not to impair the spontaneous adjustment/recovery which occurs in the majority of survivors. It is unclear when active/intrusive treatment should commence. Initial post trauma screening should be to be done by a trained mental health professional and not left to teachers, police or employers. There is some evidence that screening at 10 days post trauma can identify individuals at risk of PTSD (Ehlers & Clark, 2000). Treatment should be provided when there is delayed adjustment or clear evidence of significant symptoms. THE MINORITY VIEW A minority of mental health professionals and social scientists have complaints about the status of PTSD. This is an area in the region of the cross roads of pathology and normality. A sense of the arguments (Brenner et al, 2017): “Currently we are further isolating soldiers with trauma symptoms by treating them as if they are diseased persons suffering from a pathogen inside their brains. Instead, we need to cultivate genuine empathic curiosity about what most soldiers suffer from, which is an altered way of being in the world”. The leading complaints are that PTSD is “over diagnosed” and “over treated”, and that unnecessary treatment may do harm rather than good. This introduces the term “medicalization” by which is meant, non-medical problems are wrongly managed using medical concepts and resources, as though they are medical issues (Summerfield, 2001; Pupavac, 2001; Lerner and Micale, 2001; see in Chapter 32). It makes upsetting (not quite PTSD level) reading, describing how Western trauma experts invaded the country and applied Western “treatments” where they were unnecessary, and culturally damaging. Social scientists Horwitz and Wakefield (2011) drew attention to earlier versions of the DSM and state that “trauma has moved from the battlefield into the realm of everyday life”. Some reports state that traumatized soldiers who did not enter treatment had better outcomes than those who received treatment (Milikan et al, 2007). There are also reports that treatment can worsen symptoms and interpersonal problems (McHugh, 2008).
This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed discount 25mg pamelor with amex, the full report) may be included in professional journals 139 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising generic pamelor 25mg fast delivery. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 141 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. APPENDIX 5 • • o • o o • • o • • • • 142 NIHR Journals Library www. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 143 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 145 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. APPENDIX 5 • • o o o o • o o • • • • • • o • o • 146 NIHR Journals Library www. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 147 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. Stretching (including positional constraint-induced movement therapy) Eye-gaze skills stretching, splints) l Sensory/sensory integration l Adaptive/problem-solving skills Language development Endurance training (specific approaches mentioned: l Occupational performance coaching; Narrative/storytelling skills Cardiovascular fitness training Cognitive Orientation to daily Occupational Performance Reciprocal communication (e. Specific techniques: l Self-care/life skills baby-signing; intensive interaction) Constraint-induced movement Adjusting/changing a task to support a Aided Language Simulation therapy child to manage it independently Articulation therapy Bimanual training Providing equipment to enable child to engage in activities Breath support skills Proprioceptive neuromuscular facilitation l Seating Facial oral tract therapy l Postural management Hip and spine surveillance l Mobility (including powered) Dysphagia (swallowing, saliva control) l Small items (e. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 149 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. APPENDIX 6 Physiotherapy Occupational therapy Speech and language therapy Hydrotherapy Changing the environment to support Augmentive and alternative engagement in activities or address communication systems Functional electrical stimulation care needs Feeding/drinking equipment Botulinum (botox) l Housing adaptations l Hoists Sports (e. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health Published by the NIHR Journals Library . He also reports a grant from the NIHR Public Health Research programme during the conduct of the study. Colin Green served as a member of the funding panel for the NIHR Programme Grants for Applied Research programme from 2009 to 2013. Colin Green (2007–13) and Siobhan Creanor (2013–present) served as members of the NIHR Research Funding Committee for the South West Region of the Research for Patient Benefit Programme. Intervention costs for this study were paid for by the Peninsula College of Medicine and Dentistry. Stuart Logan (NF-SI-0515–10062) and Rod Taylor (NF-SI-0514–10155) are NIHR senior investigators. This study was undertaken in collaboration with the Peninsula Clinical Trials Unit (CTU), a UK Clinical Research Collaboration-registered CTU in receipt of NIHR CTU support funding. None of the funders had any involvement in the Trial Steering Committee, data analysis, data interpretation, data collection or writing of the report. Cluster randomised controlled trial and economic and process evaluation to determine the effectiveness and cost-effectiveness of a novel intervention [Healthy Lifestyles Programme (HeLP)] to prevent obesity in school children. Public Health Research ISSN 2050-4381 (Print) ISSN 2050-439X (Online) This journal is a member of and subscribes to the principles of the Committee on Publication Ethics (COPE) (www. Print-on-demand copies can be purchased from the report pages of the NIHR Journals Library website: www. PHR programme The Public Health Research (PHR) programme, part of the National Institute for Health Research (NIHR), evaluates public health interventions, providing new knowledge on the benefits, costs, acceptability and wider impacts of non-NHS interventions intended to improve the health of the public and reduce inequalities in health. The scope of the programme is multi-disciplinary and broad, covering a range of interventions that improve public health. The Public Health Research programme also complements the NIHR Health Technology Assessment programme which has a growing portfolio evaluating NHS public health interventions. For more information about the PHR programme please visit the website: http://www. The final report began editorial review in November 2016 and was accepted for publication in February 2017. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. However, they do not accept liability for damages or losses arising from material published in this report. This report presents independent research funded by the National Institute for Health Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, NETSCC, the PHR programme or the Department of Health.
Changesin the roleof mesencephalicversus cortical inputto the nucleusaccumbens with repeated exposure to natural motivational stimuli (A) and drug reward (B) safe pamelor 25mg. Both a novel stimulus and acute drug administration increase dopamine transmission generic pamelor 25 mg with amex. After repeated exposure the natural stimulus produces little or no increase in extracellular dopamine and the behavioral response to the stimulus arises primarily from cortical and allocortical interactions with the basal ganglia. Similarly, repeated drug use results in a recruitment of cortico-accumbens circuitry, but is also associated with augmented dopamine transmission. It is postulated that a portion of the pathology of addiction arises from both an overstimulated cortico-accumbens projection and a hyperresponsive mesoaccumbens dopamine projection. The apparent recruitment of gluta- matergic cortical regions by a drug-associated stimulus con- Circuitry of Learning current with the manifestation of behavioral characteristics A complete review of the current knowledge of the neural of addiction argues for a transition from primarily dopa- circuitry involved in learning and memory is beyond the mine-dependent behaviors elicited by acute drug adminis- scope of this chapter (53–56); however, it is clear that corti- tration to primarily glutamate-dependent behaviors pro- cal regions receiving dopaminergic axon terminations, such duced by drug or environmental stimuli in drug addicts. As glutamate-dependent behaviors akin to what occurs during illustrated in Fig. However, given the initial cleus accumbens and synapse on the same neurons that re- pharmacologic activation of dopamine transmission pro- ceive dopaminergic afferents from the VTA (57,58). This duced by most drugs of abuse, the ensuing recruitment of arrangement provides an anatomic substrate whereby cortical glutamatergic neurons may also contain nonphysio- learned information can be integrated and guide adaptive logic constituents that contribute to the pathology of addic- behavioral responding to environmental stimuli. Moreover, repeated administration of most drugs of or not these glutamatergic afferents to the nucleus accum- abuse, including psychostimulants, opioids, alcohol, and bens influence the behavioral effects of drugs of abuse and nicotine, increases the capacity of subsequent drug adminis- play a role in the neuroplasticity associated with the develop- tration to release dopamine in the nucleus accumbens (2,63, ment and expression of addictive behaviors is a subject of 65). This neurochemical reverse-tolerance or sensitization is much recent interest (13,59). For example, antagonists of opposite to what typically occurs with repeated exposure to the NMDA subtype of glutamate receptors block the devel- motivationally relevant environmental stimuli, such as food, opment of behavioral neuroadaptations (e. Of note, the indirect tion of most drugs of abuse, including alcohol, psychostim- measurement of dopamine release using methylphenidate- ulants, and opioids (59,60). Moreover, it has been shown induced displacement of radiolabeled D2 receptor antago- that drug craving induced in addicts by environmental stim- nist revealed an apparent decrease in dopamine release in uli previously paired with the drug experience is associated cocaine addicts compared with control subjects (66). As- with metabolic activation of the anterior cingulate and suming the veracity of D2 ligand displacement as an in vivo Chapter 95: Neurocircuitry of Addiction 1361 measure of dopamine release (67), this indicates a poten- prefrontal cortex and amygdala. In general, in animal tially important distinction between data in animal models models the repeated administration of drugs of abuse, in- and human cocaine addicts. The enhanced releas- Motivational Circuitry as a Site of ability may result in part from increased excitability of dopa- Addiction Pathologies mine cells (24,78–80), but also clearly involves increased The circuit shown in Fig. Following repeated am- the transition from dopamine- to glutamate-dependent be- phetamine and cocaine administration the elevated pre- haviors. This circuit has been a focus for research aimed synaptic release of dopamine arises from enhanced at determining how the neuroplastic changes produced in presynaptic calcium signaling through calmodulin kinase II various nuclei by repeated drug action at a molecular level (83–85). A number of enduring changes in postsynaptic are integrated with environmental stimuli to form the mal- dopamine signaling have also been identified. Most of these adaptive behaviors characteristic of addiction. Studies in this changes can be traced to alterations in gene expression fol- regard are most numerous for psychostimulants; the find- lowing stimulation of the D1 receptor-signaling cascade (2, ings employing this class of addictive drugs provide the pri- 86). Interestingly, among the genes showing changed mary buttresses of the model. However, emerging data with expression are protein products, including preprodynor- other drugs of abuse are generally consistent with this view; phin, NAC-1, and delta-Fos-B, that appear to dampen en- moreover, there is an abundance of behavioral data support- hanced dopamine transmission and/or the expression of be- ing the possibility that the neuroplastic changes elicited by haviors potentially related to addiction, such as motor repeated administration of one drug impinge on circuitry sensitization and conditioned place preference (87–89). For example, the This poses the likelihood that many changes produced by repeated administration of some drugs of abuse promotes repeated drug administration are not necessarily promoting the acquisition of addiction-related behaviors to another addictive behaviors but may constitute homeostatic altera- mechanistically similar drug of abuse (68,69). Similarly, a tions to minimize the impact of pathologic neuroadapta- number of overlapping cellular neuroadaptations, such as tions elicited by repeated drug injection. In addition to changes in G proteins, tyrosine hydroxylase, and certain changes in gene expression in the nucleus accumbens that immediate early genes, have been identified after repeated affect dopamine transmission, repeated administration of exposure to different drugs of abuse (70–73). Also, a num- psychostimulants also increases or decreases the synthesis ber of studies indicate behavioral and neurochemical overlap of proteins affecting glutamate transmission that may alter between the effects of repeated drug administration and postsynaptic corticofugal neurotransmission (see the follow- motivationally relevant environmental stimuli (e. This includes drug-induced changes in glutamate re- sensitization and cross-tolerance to stress) (65,69,74,75). In addition to the nucleus accumbens, more recent stud- Drug-Induced Changes in Presynaptic ies have examined the effect of repeated drug administration and Postsynaptic Dopamine Transmission on dopamine transmission in the PFC. In general, repeated As described in the preceding, most addictive drugs produce systemic drug administration reduces the releasability of do- significant elevations in cortical and subcortical dopamine pamine in the PFC. Such a blunting of stimulus- or drug- transmission, and repeated drug-induced dopamine release induced dopamine transmission in the PFC has been most causes enduring alterations in presynaptic and postsynaptic clearly shown after repeated cocaine and phencyclidine ad- dopamine transmission. These changes have been character- ministration (50,92). Further implicating reduced cortical ized using animal models of addiction, including behavioral dopamine transmission, destruction of dopamine afferents sensitization studies involving repeated investigator admin- to or blockade of dopamine receptors in the PFC promotes istered drug, as well as studies in which the acquisition, behavioral sensitization and drug self-administration maintenance, and reinstatement of drug self-administration (93–95). Moreover, the blunting of PFC dopamine trans- is measured (9,76,77).
Comparative map- DNA pools and its application to allelic association studies cheap pamelor 25 mg. Am ping of the human and mouse VCFS/DGS syntenic region dis- J Hum Genet 1998;62:1189–1197 discount 25 mg pamelor with amex. QTLs for general cognitive ability in children on chromosome 173. GEYER BITA MOGHADDAM Animal models used to study schizophrenia include both effects of antipsychotic treatments. Here, the behavior of models of the full syndrome and models of specific signs the model is intended to reflect only the efficacy of known or symptoms. As reviewed elsewhere (1), models are com- therapeutic agents and so lead to the discovery of related monly explored initially because of indications of so-called pharmacotherapies. Because the explicit purpose of the face validity, but they are evaluated scientifically in terms model is to predict treatment efficacy, the principle guiding of their construct and etiologic and predictive validity with this approach has been termed pharmacologic isomorphism respect to both clinical phenomena and responsiveness to (2). The fact that such models are developed and validated antipsychotic drugs. Here, models are organized by the ma- by reference to the effects of known therapeutic drugs fre- nipulations used to mimic the clinical phenomena. Thus, quently limits their ability to identify new drugs with novel in some of these models, only specific dependent measures mechanisms of action. Similarly, an important limitation are utilized, whereas others are evaluated by using a range inherent in this approach is that it is not designed to identify of dependent measures. Typically, models are animal proach to the development of relevant animal models relies preparations that attempt to mimic a human condition, in on focusing on specific signs or symptoms associated with our case the human psychopathology associated with the schizophrenia, rather than mimicking the entire syndrome. In developing and assess- In such cases, specific observables that have been identified ing an animal model, it is important to specify the purpose in schizophrenic patients provide a focus for study in experi- intended for the model because the intended purpose deter- mental animals. The particular behavior being studied may mines the criteria that the model must satisfy to establish or may not be pathognomonic for or even symptomatic of its validity. At one extreme, one can attempt to develop an schizophrenia, but it must be defined objectively and ob- animal model that mimics the schizophrenia syndrome in served reliably. It is important to emphasize that the reliance its entirety. In the early years of psychopharmacology, the of such a model on specific observables minimizes a funda- term animal model often denoted such an attempt to repro- mental problem plaguing animal models of the syndrome duce a psychiatric disorder in a laboratory animal. Specifically, the difficulties inherent in nately, the group of schizophrenia disorders is characterized conducting experimental studies of schizophrenic patients by considerable heterogeneity and a complex clinical course have limited the number of definitive clinical findings with that reflects many factors that cannot be reproduced readily which one can validate an animal model of schizophrenia. Thus, the frequent attempts to model the syn- The validation of any animal model can only be as sound dromes of schizophrenia in animals usually met with failure as the information available in the relevant clinical literature and so prompted skepticism regarding this entire approach. By focusing on specific signs or symptoms rather than At the other extreme, a more limited use of an animal syndromes, one can increase the confidence in the cross- model related to schizophrenia is to study systematically the species validity of the model. The narrow focus of this ap- proach generally leads to pragmatic advantages in the con- duct of mechanistic studies addressing the neurobiological Mark A. Geyer: Department of Psychiatry, School of Medicine, Univer- substrates of the behavior in question. By contrast, in sity of California at San Diego, La Jolla, California. Bita Moghaddam: Departments of Psychiatry and Neurobiology, Yale models intended to reproduce the entire syndrome of schiz- University School of Medicine, New Haven, Connecticut. Another approach to the development of animal models is based more theoretically on psychological constructs be- lieved to be affected in schizophrenia. Such identification Behavioral Phenotypes of underlying psychological processes or behavioral dimen- Locomotor and Stereotypy sions (2,3) involves the definition of a hypothetical con- struct and the subsequent establishment of operational defi- Changes in locomotor activity in rodents have often been nitions suitable for experimental testing of the validity of used to assess both models of schizophrenia and the effects the construct. Constructs such as selective attention, persev- of antipsychotic treatments. The original impetus for the eration, sensorimotor gating, and working memory have use of locomotor activity measures was derived from the been used in this manner in schizophrenia research. This psychostimulant models based on the dopamine hypothesis approach is most fruitful when conceptually or procedurally of schizophrenia, as reviewed elsewhere (3–5). These related experiments are undertaken in both the relevant pa- models arose because of the apparent similarity (i. In other validity') between the symptoms of schizophrenia and the words, studies of appropriate patients are needed to establish effects of high doses of amphetamine in presumably normal the operational definitions of the hypothetical construct and humans (6). Cross-species studies in animals treated with the relevance of the construct to schizophrenia. In concert, psychostimulants revealed both locomotor hyperactivity parallel studies of the potentially homologous construct, and, at higher doses, striking stereotyped or perseverative process, or dimension are required to determine the simi- behaviors, which were seen as having face validity for the larity of the animal model to the human phenomena. An stereotyped behavior induced by amphetamine in humans important and advantageous aspect of this approach is that (4,6,7).