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By: T. Tjalf, M.B.A., M.D.
Assistant Professor, Kaiser Permanente School of Medicine
What type of person is most likely to do this or medications elavil side effects best buy for cytoxan, in other words medications overactive bladder buy cheap cytoxan 50mg on line, to have a pain-prone personality? Engel (1959) suggested that those with psychiatric conditions symptoms bacterial vaginosis discount cytoxan express, as described by diagnostic nomenclature of the day (e. Amendments to Engel’s model, such as Blumer and Heil- broon’s (1982) position on chronic pain as a variant of major depressive dis- order, or masked depression, added depressed affect, alexithymia, family history of depression and chronic pain, and discrete biological markers (e. The results of a large number of studies suggest that the prevalence of current psychiatric conditions is, indeed, elevated in patients with chronic pain relative to base rates in the general population (e. It is questionable, however, whether the presence of psychiatric morbidity makes one more likely to use pain as an unconscious defense mechanism and, thereby, more prone to persistent pain (see, e. With few exceptions (Adler, Zlot, Hürny, Minder, 1989), the psychody- namic formulations have not fared well against empirical scrutiny (see re- views by Gamsa, 1994; Large, 1986; Roth, 2000; Roy, 1985), and now have di- minished popularity in mainstream psychology. Notwithstanding, they did play a key role in drawing attention to the importance of psychological (and contextual) factors in the experience of pain at a time when treatment for pain was primarily directed by the biomedical model. This attention led to increased and continuing research into a wide array of psychosocial vari- ables (e. Indeed, the interest in psychological factors spawned by psychodynamic theorists served as an essential precursor to the development of contemporary biopsychosocial approaches. However, using Roth’s (2000) analogy of the double-edged sword, it is noteworthy that there are lingering and unwanted scars of this psychodynamic thrust. These include the general tendency to assume (a) that all cases of pain in the absence of identifiable physical pathology are the result of psychological factors, and (b) that these are equally relevant to all people with persistent pain. Although incorrect, these assumptions can (and still often do) have a negative impact on opinions and general treatment of people who suffer from persistent pain conditions. GATE CONTROL THEORY As noted earlier, Melzack and colleagues’ seminal papers on the gate con- trol theory of pain (Melzack & Casey, 1968; Melzack & Wall, 1965) are fre- quently cited as the first to integrate physiological and psychological mech- 40 ASMUNDSON AND WRIGHT anisms of pain within the context of a single model. It is beyond the scope of this chapter to provide a detailed synopsis of the theory; however, given its contribution to current conceptualizations of pain, a brief overview is warranted. Melzack and Wall (1965) proposed that a hypothetical gating mechanism within the dorsal horn of the spinal cord is responsible for allowing or disal- lowing the passage of ascending nociceptive information from the periph- ery to the brain. These essential elements are as follows: · The gating mechanism is influenced by the relative degree of excitatory activity in the spinal cord transmission cells, with excitation along the large-diameter, myelinated fibers closing the gate and along the small- diameter, unmyelinated fibers opening the gate. Since this original proposal we have, of course, moved beyond believing that the key to understanding pain is knowing what happens in the dorsal horn. Melzack and Casey (1968) further proposed that three different neural networks (i. They also recog- nized that processing of input could occur in parallel, at least at the sensory and affective level. This revised model allowed for “perceptual information regarding the location, magnitude, and spatiotemporal properties of the noxious stimulus, motivational tendency toward escape or attack, and cog- nitive information based on analysis of multimodal information, past experi- ence, and probability of outcome of different response strategies” (pp. Think back to the case of Jamie, who had pain associated with muscle strain in the low back. Applying the postulates of the gate control theory, Jamie’s pain experience might be understood as follows: Stimulation of nociceptors in the region of muscle strain facilitated transmission of infor- mation along ascending fibers, through an open gate, and on to Jamie’s brain. At the same time, Jamie’s brain was sending information about her current cognitions and emotional state (i. The summation of the ascending nociceptive input and descending information regarding cognition and 2. BIOPSYCHOSOCIAL APPROACHES TO PAIN 41 emotion, in this case, kept the gate open. Medical and behavioral interventions ultimately served to close the gate, reducing pain, and improving Jamie’s mood state and overall functional ability. Based on this brief overview it should be apparent that the gate control theory challenged the primary assumptions of the traditional biomedical and psychodynamic models.
Diseases
Remarks on the various resection methods Another way of qualifying resections is provided by the Intralesional resection R system medications ending in ine order cytoxan with a visa, which is based on the investigation of the tis- Intralesional resection in bone is equivalent to a curettage medications erectile dysfunction order cytoxan once a day. If the resected margins Stage 1 tumors can be curetted symptoms 6 days after embryo transfer buy genuine cytoxan on-line, although a surgical proce- are free of tumor this is described as R0. The recurrence rate for a simple tumor residues are observed, the resection is classified as bone cyst depends not on the completeness of the curet- R1. If macroscopic tumor sections remain, the classifica- tage, but on the activity of the cyst. Follow-up is required in such type of resection can be both »conservative« and ablative cases however. For stage 2 and stage 3 tumors, the recurrence rate curs, a subsequent clean resection generally proves to be depends directly on the quality of the curettage. The recurrence Whereas the recurrence rate for giant cell tumors, rate for aneurysmal bone cyst depends greatly on its ac- aneurysmal bone cysts, chondromyxoid fibromas tivity. A curettage enced surgeons, this figure can be reduced to 10% can never be complete if it is implemented only with the in treatment centers in which bone tumors are fre- curettage spoon. Consequently, the 4 The high recurrence rate is particularly problematic for tumor cavity must always be burr drilled with a special giant cell tumor, since this tumor usually spreads through drill with an angled end for reaching into all the corners. If a recurrence oc- At the end of the procedure we usually illuminate the ⊡ Table 4. Recommendations for the type of resection depending on the tumor stage Stage Typical tumors Resection Benign, stage 1 (inactive) Bone: juvenile bone cyst, enchondroma, fibrous dysplasia, (If indicated at all:) intralesional Langerhans cell histiocytosisa (curettage) Soft tissues: mucous cyst, pigmented villonodular synovitis Bone: osteochondroma Marginal Soft tissues: lipoma – Benign, stage 2 (active) Bone: osteoid osteoma, osteoblastoma, chondroblastoma, Marginal, poss. It may prove neces- Surgeons have attempted to reduce the recurrence sary to resect the relevant vessel or nerve with subsequent rate still further through the use of necrotizing substances : bridging. This is particularly important for an osteosar- liquid nitrogen (cryosurgery) , phenol , methyl methacrylate coma. Liquid nitrogen and phenol can only be sarcoma, this must be followed by radiotherapy. If a leak is present these liquids can escape into the surrounding soft tissues and Radical resection cause considerable damage. The drawback with methyl In a radical resection the whole compartment in which methacrylate is that, once set, it can be very laborious, the tumor develops must be removed. Since high-grade and occasionally very difficult as well, to remove the hard malignant tumors generally spread out of the bone into plug at a later date. On the other hand, large cement plugs the surrounding muscles, both the whole bone and all (particularly if they are above and close to joints) should affected muscles must be resected at the same time. Because of its hardness and weight, principle, with a few exceptions, this implies amputation. These are not visible on a normal bone tumors are relatively young, cement plugs should x-ray and can mean that significant tumor sections are not be left in situ. Since the The quality of the curettage is much more important development of modern imaging techniques, particularly than the use of necrotizing substances in achieving a low the MRI scan, skip metastases are now readily detectable. Recent studies have shown that equally Nowadays, the borders of the tumor can be assessed much low recurrence rates can be achieved with and without the more accurately, thereby dispensing with the need for a use of such aids [4, 26]. In fact, a radical resection is no longer necessary Marginal resection even for high-grade tumors, and the current emphasis This should be attempted for all stage 2 or stage 3 benign is on limb-preserving methods. Nevertheless, amputa- tumors and is also usually possible provide the tumor is tions are sometimes unavoidable in exceptional cases not located in the epiphysis close to a joint. The resection involving very large, extensive or unfavorably located may be relatively limited and is performed through the tumors or recurrences, particularly if major nerves are pseudocapsule of the tumor.
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However medications on airplanes purchase cytoxan once a day, positive reinforcements and punishments form only a small portion of the many events that encompass our social relationships with family medicine keri hilson lyrics purchase cytoxan 50 mg on-line, friends symptoms hepatitis c buy generic cytoxan online, colleagues, and so on. Al- though a neo-behaviorist approach has adopted a rationalist, cognitive style in adapting Fordyce’s work, only relatively recently has the model ex- plicitly incorporated and addressed important emotional factors that di- rectly affect the experience, reporting, and management of pain. Likewise, the acknowledgment of social influences on pain behavior is present, but as yet, this is only selectively elaborated within the model, and hence in the model’s clinical application. Critical developments in understanding and managing pain in acute and chronic settings have also arisen from the application of the gate control theory (GCT) of pain (Melzack & Wall, 1965, 1982) and the subsequent dem- onstration of the plasticity of the nervous system. These advances in clari- fying mechanisms and opening new avenues for pain relief are addressed extensively elsewhere (see chap. This perspective provides a foun- dation for understanding the role of the biopsychosocial model in the study of pain and pain treatments (see chap. This systems theory approach (Engelbart & Vranken, 1984) has been used by health psycholo- gists to develop comprehension and, from this perspective, psychological interventions suited to many different health problems and diseases. A so- cial model of pain based on research evidence can be developed within this framework, by organizing social elements that affect and are affected by pain and then using the model to direct how treatment is conducted. Once the model is established, it can be reused to provide guidance on how ther- apeutic elements can be systematically changed and tested, with the aim of improving outcomes. In short, there is nothing as practical as a good the- ory, as GCT illustrates. This way, micro-level processes, for example, changes in heart rate, are nested in those at a macro level—for example, stereotypic profes- sional views about people with chronic back pain. Consequently, changes at a micro level can have macro-level effects, and vice versa. Because bio- logical processes connected with pain are commonly at the micro level, and psychological and social processes are more likely to be macro-level phenomena, it requires commitment to multidisciplinary thinking to be able to select and use this diverse multivariate information appropriately and effectively in problem solving. Work to date on biopsychosocial mod- els already points to the urgent need to understand and address all three components in these models, if we are to create successful treatments (Taylor, 1999). We argue here that pain researchers have been very successful with the application of biological approaches to pain relief (McQuay & Moore, 1998), and to some extent with psychological approaches, such as cognitive be- havior therapy. But the contribution of social factors to the study of pain is poorly defined, weakly elaborated, and infrequently conducted, compared to other types of research on pain. It will be necessary to show which social factors directly and significantly affect and exacerbate pain if this approach is to gain acceptance as an important, independent, and equal contributor to the biopsychosocial triad. Important social factors will need to be prop- erly evaluated for their potential to generate new types of treatment or styles of management. On the basis of existing evidence about the effective- ness of the model, it is increasingly clear that an integration of sociocultural factors is essential to achieving positive outcomes, relieving suffering, and diffusing action from the narrow medicalization of pain, in ongoing pro- grams of care. A MODEL OF THE PSYCHOSOCIAL FACTORS IMPLICATED IN THE ETIOLOGY AND MAINTENANCE OF CHRONICALLY PAINFUL ILLNESS Although health professionals who work in pain research and practice have become pioneers in the design and running of smoothly functioning multi- disciplinary teams, it is arguable that when examining the key social influ- ences that affect pain and pain behavior, we have been slow to draw on contributions from the wider range of social science disciplines available, and to extend and apply them to improve our understanding of the pain re- sponse and its management. SOCIAL INFLUENCES ON PAIN RESPONSE 183 the social factors that affect pain, illness, and treatments, with the aim of il- luminating the inherently complex interaction between a pain sufferer and their psychosocial environment. Furthermore, it is not possible to do this properly without taking a multidisciplinary approach but within the per- spective of a different but overlapping set of disciplines. The model developed by Skevington (1995) proposes four levels of un- derstanding that provide a framework within which the social aspects of chronic pain may be better appreciated, and this is shown in Fig. Level 1 defines the individual processes affected by social influences, such as per- ceived bodily sensations. In contrast, Level 2 characterizes salient interper- sonal behaviors, in particular, that person’s relationship with significant others. Level 3 defines group and intergroup behaviors such as group be- liefs, experience, and influences, whereas Level 4 encompasses some of the higher order factors that affect sociopsychological processing, such as health ideology and health politics.
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