COGNITIVE-BEHAVIORAL THERAPY FOR BDD: STARTING CBT FOR BDDOnce you decide to start CBT, there are a few things you and your therapist will do to lay the groundwork for learning the core CBT skills. These building blocks include (but aren’t limited to) the following:1) Learning more about BDD and CBT: Your therapist will discuss BDD and CBT with you (i.e., provide psychoeducation) and answer your questions.2) Developing a model of your BDD: It’s helpful to discuss your BDD symptoms in detail with your therapist so you can develop a model of how your symptoms seem to have developed and are maintained. You can use Figure 8 as a guide, filling in whether you experienced any life events that seem to have contributed to BDD, what rituals you do, what situations you avoid, etc. You and your therapist can use this model to help tailor the treatment specifically to you.3) Setting goals: It’s important to set goals for your treatment—what you’d like to accomplish. This will help you and your therapist stay on track during treatment. For example, one goal might be to return to school. Another might be to go shopping during the day rather than only at night when fewer people are in the store. The more specific you make your goals, the better.You’ll then begin to learn the core CBT skills defined above and discussed in more detail below. It isn’t known what’s the best order to learn them in, although some experts begin with response prevention or cognitive restructuring. Response prevention will probably give you some immediate relief. And learning cognitive techniques early in treatment may make exposure easier. It isn’t known whether all core aspects of CBT are necessary, or whether some are more effective than others. Usually, they’re all combined. Until research is done which answers these questions, it’s probably best to learn all the core skills, as well as some additional skills such as habit reversal (for skin picking), refocusing, and mirror retraining.*297\204\8*
HOW ASTHMA MEDICATIONS CAN BE EFFECTIVELY DELIVERED? IHHALATION METHOD – INHALERS AND CHILDRENInhalers are usually not used correctly. In one study, doctors estimated that on an average only about half of the users of inhalers used them correctly. The biggest problem is the lack of proper coordination between activating the inhaler for medicine release, and breathing the medicine in.As a rule, it is better for parents to take the inhalers with them when they visit their doctor. The doctor can personally supervise its use by the asthmatic child. MDI must be used correctly since only 10 per cent of the inhaled dose penetrates the distal airways> even with optimal techniques.For a better penetration to distal airways, a slow and deep inhalation to maximum lung capacity is desirable. Slow inhalation leads to uniform and equal spread of inhaled aerosol particles in the lungs. The proportion of particles remaining in the lungs also increases if breath is held for about 10 seconds.Some doctors suggest that an inhaler held approximately 2 to 4 cm, in front of an open mouth is superior to an MDI held in, and activated in, a closed mouth. The theoretical advantage of an inhaler held slightly away from open mouth is due to the fact that the particles become smaller as they travel a slightly longer distance from the activated canister orifice to the mouth. This increases distal airway deposition; its disadvantage is the formation of deposits on the lips, face and teeth.Inhalers can be dangerous if not used properly. Some doctors believe that their use by children should be controlled or supervised by adults. Others recommend that children should not have the inhaler in their possession, but have access to it through an adult. However, this is a personal matter which depends on the age and sense of responsibility of each child. Some young school-going children have learnt to be responsible with inhalers and to use them wisely while others have to be closely supervised. The final decision should be left to the parents who can arrive at a decision after councelling the doctor and other adults, such as school personnel.Children have to be taught to use all medicines properly, and gradually given the responsibility of taking medicines independently. It is important to remember that children become responsible only when they are given opportunities to practise their skills specially in situations demanding extra care. As in everything else, medication management involves taking small steps towards the ultimate goal of giving the total responsibility to the children.*72\260\8*
The acquired immune deficiency syndrome (AIDS) characterised by ‘the presence of a reliably diagnosed disease at least moderately indicative of an underlying cellular immune deficiency in a person with no known underlying cause of cellular immune deficiency nor any other cause of reduced resistance reported to be associated with that disease’ was recognised in 1981 in male homosexuals. The patient population was subsequently found to contain intravenous drug abusers, prostitutes, persons who had received blood transfusions and some blood products, individuals from some African and Caribbean countries and the sexual partners and children of persons in these groups.
AIDS was subsequently discovered to be the most severe clinical expression of infection with human immunodeficiency virus (HIV), an RNA virus containing the enzyme reverse transcriptase. HIV is cytopathic for the CD4+ subset of T-lymphocytes and for various other cell types
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At present, no cure is available. Treatment is largely symptomatic and consists of sedatives and analgaesics. Acyclovir (Zovirax), an antiviral agent, can shorten the clinical course of the primary lesion and may benefit patients with frequent severe recurrences. Indications for acyclovir are:
treatment of moderate or severe first episodes of genital herpes (200 mg 5 times daily — each 4 hours while awake — for 10 days);
suppressive treatment for patients with moderate to severe recurrent genital herpes (more than 10 attacks per year with microbiological confirmation) (200 mg 2 to 4 times per day);
treatment of acute lesions in immunosuppressed patients (5 mg/kg by slow IV infusion every 8 hours for 5 days);
suppressive treatment an in immunosuppressed patient with recurrent HSV;
treatment of neonatal infection; and
treatment of ophthalmic infections where idoxuridine proved ineffective (ophthalmic ointment).
Because genital herpes is recurrent and untreatable, patients with HSV are likely to be depressed. Patients and their partners can be assisted by counselling and support. Sexual abstinence should be practised while lesions are active. Patients can be taught to recognise the prodrome and minor symptoms which may indicate recurrence of infectivity. Condoms offer some protection.
Pregnant women should be asked if they or their partners have a history of HSV infection. Caesarean section should be considered for pregnant women with active lesions at term and patients with genital herpes should be referred for specialist opinion at least 4 weeks before term.
Deep ulcerated anogenital lesions and disseminated infections may occur in patients with HfV infection and other deficiencies of immune functioa
The diagnosis can usually be made on clinical grounds; the differential diagnosis includes syphilis, chancroid and lymphogranuloma venereum. HSV may coexist with other STDs and appropriate investigations should be undertaken. HSV infection may be associated with a false positive FTA-ABS test (see p.25) but may also coexist with syphilis.
The diagnosis of HSV can be confirmed by culture of the virus. A positive diagnosis is usually available in 1 to 4 days but 14 days are required for a negative result. Rapid diagnosis may be made by examination of smears from ulcers for multinucleated cells and characteristic intranuclear inclusions or by the use of commercially available kits for the detection of HSV-2 antigens by ELISA or immunofluorescence techniques.
Microbiological confirmation is desirable if acyclovir is to be used and is required for an NHS authority to prescribe acyclovir to suppress recurrent infections.
Serological tests have no role in diagnosis. The only practical role for serology is to define persons who are seronegative and therefore susceptible.
In females, herpetic infection may be complicated by urinary retention due either to local pain or to neurogenic bladder due to radiculitis. Herpes may cause an extensive necrotising lesion of the cervix which causes a sanguineous vaginal discharge and may resemble cervical carcinoma.
HSV infection may produce no symptoms and asymptomatic viral shedding from the cervix or other sites may occur.
Relapse may be attributed to emotional or physical stress, fever, trauma, hormonal changes, menstruation, sunlight, alcohol etc. Relapses are characterised by a milder prodromal period, lesions of 4 to 5 days average duration healing in 1 to 2 weeks and a milder degree of lymphadenopathy.
HSV has a high morbidity and mortality in neonates. The infection can be transmitted from mother to infant during parturition if the mother is actively shedding the virus. A higher rate of neonatal infection occurs if primary infection occurs late in the pregnancy and there is insufficient time for maternal antibody to develop and be transferred to the foetus.
The incubation period is usually from 3 to 6 days but may be longer.
In males, primary lesions usually occur on the penile shaft, prepuce or glans or the anal region.
In females, primary lesions occur commonly on the labia, clitoris, introitus and vagina. The cervix is involved in at least 50% of cases. In about 25%, the cervix is the only site of lesions and these cases may be asymptomatic.
Lesions may occur in the mouth or throat following oral sex.
Lesions may occur on the fingers, buttocks, torso and the eyes as a result of autoinoculation. Transmission may also occur on fomites.
Lesions are usually preceded by a 12-24 hour prodromal period characterised by local hypersensitivity or discomfort.
Multiple vesicles appear. They are surrounded by an areola of erythema. After 24 to 72 hours, the vesicles rupture to form painful superficial ulcers. Lesions of varying age and size coexist. Symptoms persist for 1 to 3 weeks. In 75% of cases, regional lymph nodes are enlarged and tender for up to 6 weeks.
Herpes is an increasingly common sexually transmitted infection caused by herpes simplex virus (HSV). There are two types, HSV-1 and HSV-2, which are clinically and epidemiologically similar. HSV-1 is often associated with lesions on the face and fingers and sometimes with genital lesions; it is usually acquired during childhood. HSV-2 is usually acquired after sexual activity commences and is almost entirely associated with genital herpes.
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The incubation period is extremely variable ranging from 3 to 30 days. An herpetiform vesicle or papule develops at the site of infection. The vesicle ruptures and becomes a small painless punched-out ulcer which heals rapidly. The transient lesion may not be noticed. The primary lesion may take the form of a urethritis. In males, the primary lesion usually occurs on the penis. In females, the primary lesion usually develops on the vaginal wall or occasionally on the cervix and is rarely seen.
Up to 4 months later, unilateral or bilateral inguinal lymphadenopathy develops, often in association with headache, chills, sweats, weight loss, splenomegaly and migratory polyarthritis. Within 1 to 2 weeks, the nodes become tender and fluctuant and frequently ulcerate discharging purulent exudate. Buboes are more common in men. In women, deep iliac lymph nodes are usually involved.
In women, strictures of rectum and urethra and elephantiasis of the external genitalia (esthiomene) may develop. Rectal infections in homosexual men may progress from proctitis to rectal stricture.
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