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Walid Al-Wali MBChB FRCPath

• Professor of microbiology, Consultant
• medical microbiologist, Lead infection
• control doctor, Director for infection
• prevention and control, Medical director
• Department of Medical Microbiology,
• Rotherham NHS Foundation Trust,
• Rotherham, UK

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Lastly, once interviews have been completed, on an offer and cannot hear the good news you will hopefully start to receive offers of until you have made your decision. A few tips: (1) You should never, can narrow your choices down to two and ever feel pressured to make a nal decision release any additional offers you may be before April 15. No program or individual holding, it will help the system move should tell you otherwise. Good luck to everyone in the applica received the details of the offer in writing (by tion and admissions process! Berens If the average applied psychology student is shooting a basketball are actions of that kind. The ultimate pur will shoot hundreds of times a day to keep this pose of applied psychology is to alleviate human skills sharp. Unfortunately, good will does not necessar Sometimes, however, knowledge is best ily imply good outcomes. This were enough, there would never have been a rea approach is especially helpful when a task is com son for psychology in the rst place, since human plex and the outcomes are probabilistic, delayed, beings have always desired a happy life and subtle, and multifaceted. It is not enough for send a rocket to the moon or to build a skyscraper psychology students to want to help: one must through direct experience. Sometimes knowledge is 2,000 years has been the development of the acquired by actually doing a task, perhaps with scientic method as a means of generating and guidance and shaping from others and with a testing rules that work. This approach is advanced most quickly in areas that are most especially helpful when the outcomes of action directly touched by science, as a glance around are immediate, clear, and limited to a specic almost any modern living room will conrm. Berens, PhD Fit Learning, 3953 South McCarran Boulevard, Reno, know how to raise their children. Berens immediate outcomes at the expense of long-term most likely to rely on clinical judgment to success. For example, telling children they are determine what to do next (Stewart & Chambless, doing wonderfully, no matter what, may feel 2008). This suggests that it can be psychologi good initially but the children may grow up with cally difcult to integrate the rules that emerge a sense of entitlement and a poor understanding from research, with the ongoing effort to be of of how hard work is need to succeed. Part of the problem is that science a clinician in psychotherapy can do an innite can suggest courses of action that are not numbers of things. The immediate results are a personally preferred, which takes considerable weak guide to the acquisition of real clinical psychological exibility to overcome (Varra, know how because effects can be delayed, prob Hayes, Roget, & Fisher, 2008). Experience alone may teach clinicians how the ambiguity that lies between the two kinds of to behave in the role of a helper, for example. When agen the situation that can capture students in profes cies convert to the use of such methods, client sional psychology. Even staff turnover happened if the practitioner had done something appears to be reduced (Aarons, Sommerfeld, different. Mere adherence to treatment manuals, for exam Many problems wax and wane regardless of ple, does not necessarily guarantee good out intervention and some features of professional comes (Shadish, Matt, Navarro, & Phillips, 2000) interventions are reassuring and helpful almost and the important work of learning how to use regardless of the specics. Thus, with experience scientically supported methods in more exible most practitioners feel not only condent but also ways to t individual needs is still in its infancy competent, because generally it appears that good (Kendall & Beidas, 2007). Yet even when alter these factors while maintaining their rela faced with clear clinical failures, practitioners are tionship to outcomes (Creed & Kendall, 2005). At the research that will be consumed by others and that onset of the conference not all attendees were in will make a difference in applied work. Some doubted that a practitioner, a reliance on scientically based true realization of this model was even possible. It was hoped that Model research conducted by those interested in prac tice would yield information useful in the guid From the early inceptions of applied psychology, ance of applied decisions. What retards the progress of one, the nal two reasons why the model was ulti retards the progress of the other; what fosters one, fosters the other. But in the nal analysis the mately adopted is the cooperative potential for progress of psychology, as of every other science, the merger of these two roles. It was believed that will be determined by the value and amount of its a scientist who held at hand many clinical ques contributions to the advancement of the human tions would be able to set forth a research agenda race (Witmer, 1907/1996, p. Psychological Association adopted as standard Despite the vision from the Boulder policy the idea that professional psychology Conference, its earnest implementation was still graduate students would be trained as both very much in question. Berens Too often, however, clinical psychologists have from science (Hayes, 1987). As time passes and their skills become more satisfying to themselves and to Grady, 1995). The federal government began to others, the task of thinking systematically and actively promote evidence-based practice, though a impartially becomes more difcult (p. While these conferences tended to psychology began to launch formal efforts to reafrm the belief in the strength of the model, summarize a maturing clinical research literature, they also revealed an undercurrent of dissatisfac such as the Division 12 initiative in developing a tion and disillusionment with the model as it was list of empirically supported treatments (Chambless applied in practice. In 1965 a confer doctoral and internship programs that advocate ence was held in Chicago where the participants science-based clinical training. The penetra created at rst within the University setting and tion of formal scientic evidence into psycho then in free-standing form (Peterson, 1968, logical practice continued to be slow (Nathan, 1976). The Vail Conference went far beyond 2000; Stewart & Chambless, 2007), which began previous conferences in explicitly endorsing the to receive national publicity. The federal govern began to be raised about the dominance of the ment, however, began to fund well-controlled individual psychotherapy model in comparison and large-scale psychosocial research studies, to web and phone-based interventions, self-help providing a growing impetus for the creation of a approaches, and media-based methods (Kazdin research base relevant to practice. A more unusual approach is needed launched the Psychological Clinical Science to do research that makes a difference. Accreditation System; as of 2011 about a dozen Making a difference in psychological research doctoral programs are accredited. At the same scope, and depth and based on veriable experi time, professional training programs that eschew ence. The student of applied psychology needs to Agreements about scientic method within think through these issues and consider their particular research paradigms tell us how and implications for professional values. Professionals when certain things can be said: for example, of tomorrow will face considerable pressures to conclusions can be reached when adequate adopt evidence-based practices. We would argue controls are in place, or when adequate statisti that this can be a good thing, if psychological cal analyses have been done. A great deal of professionals embrace their role in the future emphasis is placed on these issues in psychology world of scientically based professional psy education. It is to those topics ties of importance: organization, analytic utility, that we now turn. That is why theories and models are so central to the vast majority of psychological research mature sciences. The medium number of cita the verbal products of science are meant to be tions for published psychological research useful in accomplishing analytic ends. These approaches zero (Schaffer, 2004) and most psy ends vary from domain to domain and from chology faculty and researchers are little known paradigm to paradigm. In applied psychology, outside of their immediate circle of students and however, the most important analytic ends are colleagues. From this situation we can conclude implied by the practical goal of the eld itself, the following: If a psychology student does what namely, the prediction and inuence of psycho usually comes to mind in psychological research logical events of practical importance. Not all based on the typical research models, he or she research practices are equal in producing particu will make only a limited impact, since that is lar analytic ends. Berens prediction are of little utility in actuallyin uencing directly in the practical situation, but not enough target phenomena if the important components of work has gone into how to the development the theory cannot be manipulated directly. For manuals that are easy to master and capable of that reason, it helps to start with the end goal and being exibly applied to clients with unique com work backward to the scientic practices that binations of needs (Kendall & Beidas, 2007). We will do so shortly by With the proliferation of empirically supported considering the research needs of practitioners. It is often said that practitioners sion, and perhaps for this reason the most empha avoid theory and philosophy in favor of actual sis in the early days of clinical science was the clinical techniques, but an examination of popu development of manuals and technical descrip lar psychology books read by practitioners shows tions that are precise and replicable. Practitioners need knowledge hardest dimension to achieve, however, is scope with scope, because they often face novel situa and, as we will argue in a moment, that is the tions with unusual combinations of features. The Knowledge Needed Broad models and theories are needed in the by Practitioners practice environment because they provide a basis for the use of knowledge when confronted Over 30 years ago, Gordon Paul eloquently with a new problem or situation and suggest how summarized the empirical question that arises for to develop new kind of practical techniques. For that rea Book publishers, workshop organizers, and son, practitioners need scientic knowledge that others in a position to know how practitioners usu tells them what to do to be effective with the ally react often cringe if researchers try to get too specic people with who they work. It must theoretical, but this makes sense given the kind of explain how to change things that are accessible theories often promulgated by researchers, which to the practitioner so that better outcomes are are typically complicated, narrow, limited, and obtained. Worse, many theories do not tell clinicians established know how that is broadly applicable what to do because they do not focus primarily on to the practical situation, and can be learned and how to change external variables. They also need to practitioner is an individual who performs three be as simple as possible in the sense that both they primary roles. This requires well must t the practical and personal realities of the developed practical skills, but it also requires practice environment. The purpose of this technologies that no one will pay for, that are too consumption is too put empirically based proce complicated for systems of care to adopt, that do dures into actual practice. For superb clinician capable of supervising interven that reason, applied psychology researchers must tions, and intervening directly on difcult cases, be intimately aware of what is happening in the but must also be intimately familiar with the pro world of practice. Additive model group Putting all of these factors together, applied research methods, which use existing programs as research programs that make a difference tend to a kind of baseline and thus raise far fewer ethical reach the practitioner with a combination of both issues than group research protocols with no treat a technology and an underlying theory or model ment control groups, are also gaining in popular that is progressive, simplifying, ts with the practi ity in applied settings. This is a challenging formula, both to greater understanding of applied problems because it demands a wide range of skills from and to the evolution of effective systems of care. What is open effectiveness trials in applied settings are more difcult is guring out how to develop highly valued in the empirical clinical literature broadly applicable models that are conceptually. Doing so are large collections of single case experimental requires living in both worlds: science and prac designs and empirical case studies using well tice. The need for this breadth of focus also helps dened treatment approaches and intensive mea makes sense of the need for broad knowledge of surement. Their purpose is to determine rates of psychological science that is often pursued in more successes and failures, and factors that contribute scientically based clinical programs. Berens these kinds of contributions are essential to the presumably because scientic know how is a overall goal of developing scientic known how better guide to effective practices. Clinical is beginning to occur in mental health and replication series provide an excellent example. But while progress has For clinical research to be useful to practitioners, it been made in the identication of techniques that must be known what kinds of client are most likely are effective with specic problems it is clear that to respond to what kinds of treatments in the real we still have a long way to go. Indeed, sometimes methods that will help decide how fast the transition to a succeed in highly controlled efcacy trials, fail in empirically based professional will be.

Patients with Prader-Willi syndrome can present with micropenis in boys or hypoplasia of the labia majora in girls skin care arbonne discount 30 gm elimite fast delivery. Patients with trisomy 18 can have cryptorchidism and hypoplasia of the labia majora acne 1cd-9 elimite 30gm mastercard. The enzymatic conversion of testosterone to dihydrotestosterone is critical for virilization of external male genitalia acne 40 years old cheap elimite 30gm without a prescription. Abnormality in the androgen receptor will cause undervirilization of males because of androgen insensitivity acne jeans review discount elimite 30 gm. In males skin care hospitals in bangalore elimite 30 gm fast delivery, Mullerian-inhibiting hormone is secreted from the testicular Sertoli cells beginning at approximately the seventh week of gestation skin care brands elimite 30 gm low price, and it causes regression of the Mullerian ducts. Differentiation of the Wolffian ducts depends on local testosterone production from the Leydig cells of the testes. Whereas development of the Wolffian ducts and internal genitalia depends on local production of testosterone, development of the external genitalia in males depends on dihydrotestosterone. They typically present with microphallus, perineal hypospadias, and a blind vaginal pouch. Exposure to excess androgens once the vagina and urethra are separate causes clitoromegaly and rugation of the labial folds only. In females the genital tubercle forms the clitoris; in males it forms the phallus. She claims that she does not eat more than others in the family, and she has gym class 3 times weekly. Her typical day consists of going to school, doing homework, and then watching television or playing video games for several hours daily. Which of the following is not an adequate method of measuring the degree of obesity Which of the following features would you not expect to find in the child described in question 5 Her mother is convinced that her daughter has hypothyroidism as a cause of her obesity. On physical examination, your patient is short and has purple striae on the abdomen. On physical examination, your patient is of normal stature, but you notice hirsutism and moderate inflammatory acne. Excess body fat in which area of the body has been associated more strongly with health risks than fat stored elsewhere Which of the following is not a comorbid condition associated with exogenous childhood obesity Body fat mass reflects the long-term balance between energy expenditure and energy intake. Tall children who are proportional will have weights greater than the 90th percentile of normal and not be obese. Age and sex-specific percentiles for triceps and subscapular skinfolds are available, and skinfold thickness more than 85th percentile for age and sex suggests obesity. The disadvantage of using skinfold thickness to classify obesity is that there is significant interobserver error and the measurement becomes less reliable as body fatness increases. Bioelectrical impedance estimates adiposity by measuring resistance to a low-frequency electrical current. The advantage of this method is that it is portable, noninvasive, and reliable in many populations. Disadvantages are that it can be variable, and measurements are compromised with altered hydration and extreme obesity. A history of feeding difficulty and hypotonia as an infant is found in Prader-Willi syndrome, which is the most common genetic syndrome associated with obesity. Laurence-Moon-Bardet-Biedl syndrome, an autosomal recessive disorder characterized by retinal degeneration, mental retardation, obesity, polydactyly, renal dysplasia, and short stature, is a rare cause of pediatric obesity. One of the characteristic features of Prader-Willi syndrome is short stature for the genetic background. Patients present with hyperphagia, relatively small hands and feet, developmental delay, almond-shaped eyes, and a characteristic behavioral disorder. Children with a hormonal cause of obesity are typically short with a poor growth velocity. Long-standing hypothyroidism would cause short stature, delayed bone age, coarse hair, dry skin, and fatigue. With hypothyroidism secondary to autoimmune thyroiditis, there is often a family history of thyroid dysfunction. Short stature associated with obesity should raise the concern of an endocrinologic cause of obesity such as Cushing syndrome or hypothyroidism. In children, the first signs of Cushing syndrome are typically growth attenuation and weight gain. In addition, purple striae are often seen in Cushing syndrome due to stretching of fragile skin. Acanthosis nigricans, or hyperpigmented, thick, velvety areas of skin most commonly on the posterior neck, groin, and axilla, often occurs among obese patients and is a marker of insulin resistance. Although hyperpigmentation occurs in Addison disease, it is most prominent in areas of the skin exposed to the sun and in flexor surfaces such as knees, elbows, and knuckles. Obese children are at risk of developing type 2 diabetes mellitus, which usually has an insidious onset. History of frequent vaginal yeast infections should raise the concern of hyperglycemia. The metabolic syndrome combines atherogenic risk factors with underlying insulin resistance. Key features include hyperinsulinemia, abnormal glucose metabolism (impaired glucose tolerance or type 2 diabetes), hypertension, dyslipidemia, obesity (especially visceral) hyperuricemia, microalbuminuria, and hypercoagulability. With the marked increase in the prevalence of obesity in children, this syndrome will become much more common and eventually lead to increased mortality overall. Other features include menstrual irregularity, hirsutism, acne, and insulin resistance. Measurement of free testosterone is the most sensitive test for the detection of androgen excess. Many studies have shown that excess abdominal fat increases the risk of complications independent of and additive to that caused by the degree of obesity. Overweight children (age 10-16 years) with at least one overweight parent have more than a 70% likelihood of being overweight as an adult. The persistence of obesity into adulthood is among the most serious consequences of pediatric obesity because there is a tight association between length of time spent at an abnormal body weight as an adult and atherosclerosis, cardiovascular disease, type 2 diabetes mellitus, and dyslipidemia. Most children with exogenous obesity are tall for age and may appear older than their chronological age. Obese children are more likely to have high fasting insulin levels, and in the past few years, there has been a significant increase in type 2 diabetes. The prevalence of childhood obesity has been increasing rapidly in the past 20 years and shows no evidence of slowing. There are significant differences in the prevalence of obesity in various ethnic groups, with non Hispanic black girls and Mexican American boys having the highest prevalence of obesity. Many factors can result in an imbalance between energy intake and energy expenditure, leading to the promotion of excess fat deposition. Although genes play an important role in the regulation of body weight, behavioral and environmental factors are likely primarily responsible for the dramatic increase in obesity in the past two decades. A number of human gene mutations have been described that result in severe obesity, including mutations in leptin and melanocortin 4 receptor. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Insights into obesity and insulin resistance from the study of extreme human phenotypes. He had no diarrhea or fever but did complain of right upper quadrant abdominal pain. He was treated with prednisone for 4 days with marked improvement of his symptoms. His symptoms eventually returned, and following further tests, he was diagnosed with delayed emptying of the gallbladder. He tolerated the surgery well, but on postoperative day 1 he became very sleepy and began to have mental status changes. He now presents back to the emergency department and you find him to be hypotensive with a blood glucose of 50 mg/dL. On physical examination, he appears dehydrated, and you notice marked hyperpigmentation on the neck, elbows, knuckles, and lower abdomen. Which of the following would be the most appropriate initial management of this patient Which of the following laboratory results would you expect to find in this patient All of the following signs and symptoms except which one should clue you in to a diagnosis of primary adrenal insufficiency Which of the following would be the preferable treatment for a child in adrenal crisis On physical examination, the patient has candidiasis in the mouth and noticeable vitiligo on the face and trunk. Which of the following statements regarding serum cortisol concentrations is true Your patient is doing well at home on his medications and his skin pigmentation has faded. One year after discharge, the patient notes that his skin pigmentation is beginning to darken again. Which of the following statements regarding secondary adrenal insufficiency is (are) not true Which of the following is the most common cause of tertiary adrenal insufficiency This adolescent can have many clinical manifestations of Addison disease and is likely to manifest an adrenal crisis. An emergency exploratory laparotomy without pretreatment with stress dose glucocorticoids could lead to a catastrophic outcome. Hyponatremia is a common feature of primary adrenal insufficiency secondary to mineralocorticoid deficiency and inappropriate vasopressin secretion caused by glucocorticoid deficiency. Mild hyponatremia can also occur in secondary or tertiary adrenal insufficiency because of inappropriate vasopressin secretion. The presenting signs and symptoms depend on how quickly adrenal function is diminished and whether mineralocorticoid production is affected along with glucocorticoid production. Adrenal insufficiency is often first detected when a stress precipitates an adrenal crisis. Hyperpigmentation in areas exposed to sunlight, areas such, as the palmar creases, axilla, areola, and areas exposed to friction such as the elbows, knees, belt line, and knuckles, is the most characteristic finding of Addison disease and is present in most patients. Dehydration caused by vomiting and diarrhea can often precipitate an adrenal crisis. Although splenomegaly can be seen in primary adrenal insufficiency, hepatomegaly is not a common finding. Unexplained hypoglycemia is found in Addison disease but tends to be more common in younger patients. Although hyperpigmentation is the major manifestation of Addison disease, vitiligo can be seen in patients with autoimmune causes of adrenal insufficiency because of autoimmune destruction of dermal melanocytes. Other clinical manifestations include generalized weakness, fatigue, postural dizziness, diffuse myalgia, behavioral changes, and splenomegaly. The major cause of adrenal crisis is mineralocorticoid deficiency and not glucocorticoid deficiency. Patients with secondary or tertiary adrenal insufficiency typically have normal aldosterone production, which is under the control of the renin-angiotensin system. In a patient in adrenal crisis, it is important to replace both the deficient glucocorticoid as well as the deficient mineralocorticoid. The presence of vitiligo with primary adrenal insufficiency suggests an autoimmune etiology. Autoimmune polyglandular syndrome type 1 is a rare autosomal recessive disorder in which primary adrenal insufficiency is associated with chronic mucocutaneous candidiasis and hypoparathyroidism. The candidiasis and hypoparathyroidism typically appear first in early to mid childhood, and adrenal insufficiency usually develops in mid to late adolescence. Other common associated manifestations include primary hypogonadism and malabsorption syndromes. In contrast, in autoimmune polyglandular syndrome type 2, adrenal insufficiency is typically the initial manifestation. Hypoparathyroidism does not occur in this disorder, and diabetes mellitus and autoimmune thyroiditis are common. The presence of X-linked adrenoleukodystrophy needs to be ruled out in any young man with primary adrenal insufficiency. Not all patients have neurologic symptoms when the adrenal insufficiency is diagnosed. If a patient is diagnosed with adrenoleukodystrophy, all male siblings should be screened. Adrenal hemorrhage in children has been associated with Pseudomonas aeruginosa sepsis, meningococcemia and E coli sepsis (Waterhouse-Friderichsen syndrome), and in neonates following a difficult labor or asphyxia. In the past, infectious adrenalitis caused by tuberculosis was the most common cause of Addison disease, but now infectious adrenalitis occurs in less than 20% of new cases of Addison disease. Adrenal insufficiency occurs at a low incidence in metastatic cancer because a significant proportion of the adrenal gland must be destroyed for adrenal insufficiency to become evident.

Epidemiology Children Around seven per cent of children sufer moderate to severe mental health problems with a further 15 per cent having mild problems skin care brand names generic elimite 30 gm without prescription. The prevalence of conduct disorder is about four per cent acne jaw line order elimite 30gm overnight delivery, while that of emotional disorder is about 2 korean skin care purchase line elimite. The prevalence of mental disorders overall is about twice as high among boys as it is amongst girls skin care gadgets purchase elimite 30gm with amex, though the prevalence of A Manual of Mental Health Care in General Practice 233 emotional disorders may be slightly higher in girls skin care juarez buy elimite with american express. The prevalence in boys peaks in early teens acne description purchase elimite cheap, while in girls it peaks in late teens. The prevalence of mental disorders among adolescents is about twice that in children. Mental disorders presenting in adolescence include both those typical of childhood (for example, enuresis, school refusal), as well as those typical of adult populations (major depression, panic disorder, schizophrenia and agoraphobia). History and examination In general, children and adolescents will be seen together with one or both of their parents and often with their entire family (see also Chapter 5). The problem may in fact be with another family member or in the family system, rather than the child who presents or is brought to see you. Although the psychiatric interview follows a similar format to that of the adult interview, there are some diferences. In assessing the presenting complaint, it is important to note the context in which the problems occur. A specifc learning difculty, for example, may lead to problems at school but not at home. Note important adverse events, for example serious medical procedures, hospital admissions, separations from parents, family bereavements, or frequent changes of address or school. Useful projective tests include asking the child to draw pictures of a person and of the family, and asking what he or she would like if given three wishes. Transference and countertransference reactions may be stronger and less defended than those experienced between two adults. Specifc conditions the following sections deal with the diagnosis and treatment of some of the common child and youth mental disorders. See Chapter 18 for a discussion of alcohol and substance abuse, and Chapter 22 for the treatment of psychoses. The location, duration, intensity, complexity and frequency of tics may vary over time. They tend to be exacerbated by stress, and attenuate during absorbing activities and sleep. Complex motor tics include grooming, holding odd facial expressions, squinting, tapping, hopping, stomping or making rude gestures. Transient tic disorder is characterised by tics occurring on most days for at least four weeks, but for no longer than a year. Chronic motor or vocal tic disorder requires the presence of either motor or vocal tics, but not both, that occur regularly for at least a year. Assess the levels of symptoms in diferent settings, the levels of disability and handicap, the impact of the illness on family functioning and the presence of stressors that may be exacerbating the tics. Diferential diagnosis Descriptions of tics and other abnormal movements are given inTable 24-1. Tics must be diferentiated from Parkinsonian side efects of neuroleptic medications (including tardive dyskinesia). Treatment Education Educate the family and the child about the nature of the illness, its prognosis, treatment and rehabilitation. Doing so will reduce anxiety about the illness and strengthen the therapeutic alliance. Behavioural interventions the tics may be associated with behavioural disturbance, which will in turn lead to further distress, disability and handicap. These should be assessed and appropriate interventions introduced in the classroom. Individual psychotherapy A chronic condition in which a person acts involuntarily, and often in ways that ofend social mores, can lead to rejection and a lowering of self-esteem. These negative reactions can be dealt with in therapy using the counselling and structured problem solving techniques described in Chapter 6. Family therapy Issues addressed in family therapy include the stress of the illness on other family members, the exacerbation of pre-existing marital confict, and the role of family stress and confict in exacerbating symptoms (see Chapter 5). Pharmacological treatment Clonidine, an alpha2-noradrenergic agonist, is used in doses up to 3 to 4 micrograms/kg/day orally to suppress tics. A trial of at least three months is required to assess its full therapeutic efect. Side efects include sedation, dry mouth, headaches, postural hypotension and rebound hypertension on abrupt withdrawal. It has a more rapid onset of action than clonidine, but also more disabling side efects, including extra-pyramidal symptoms, sedation, weight gain and endocrine abnormalities. Particular care must be taken to screen for the development of tardive dyskinesia (see Appendix 10). The treatment of impulsivity, inattention and hyperactivity is more difcult as stimulants may worsen the tics. We recommend referral to a child psychiatrist if clonidine and haloperidol are inefective or poorly tolerated. The treatment of tic disorders involves education of the child and the family about the condition, advice to parents on how to deal with behaviour problems, counselling and structured problem solving to deal with stressors, treating co-morbid condition, and the use of medication to suppress the tics. Pervasive developmental disorders these disorders are characterised by severe impairments in social interaction and communication skills, and the presence of stereotyped behaviours, interests and activities. It is desirable for the general practitioner to be confdent in both making and excluding the diagnosis. As a key person in the coordination of the diferent aspects of care, the general practitioner should also be familiar with the range of treatment and rehabilitation services available. It is desirable for the general practitioner to be confdent in both making and excluding the diagnosis of a pervasive developmental disorder. In his initial description of autism in 1943, Kanner focused on how defcits in social interaction are sometimes accompanied by areas of unexpected competence such as rote memory2. Unfortunately, he also hypothesised that the condition was caused by abnormal patterns of 1Victorian Drug Usage Advisory Committee. He later revised this theory, recognising that abnormal family interactions were usually an efect rather than a cause of the condition. It is important for the general practitioner to be aware of empirically tested interventions and to be sceptical of the dramatic claims of unproven and often expensive approaches to treatment. It can result in profound disability and handicap for the individual suferer and considerable stress for family members. Instead, treatment aims to minimise individual sufering and disability, to promote development, and to support families in coping with their disabled family member. Assessment and diagnosis In Australia, the diagnosis of a pervasive developmental disorder is usually made by a child psychiatrist or a paediatrician. A paediatrician will perform a physical examination and arrange appropriate investigations, including a search for Fragile-X chromosome and an audiological assessment. An occupational therapist or physiotherapist will evaluate sensory and motor integration. Impairment in social interaction There may be limited nonverbal behaviours; a failure to make friends; no interest in sharing activities with others; and a lack of reciprocity in social interactions. Impaired communication There may be a delay in, or a total lack of development of spoken language; an inability to initiate or sustain a conversation with others; stereotyped and repetitive use of language; or a lack of age appropriate spontaneous make-believe or social imitative play. Restricted repetitive and stereotyped patterns of behaviour, interests, and activities these include a preoccupation with one or more restricted patterns of interest; infexible adherence to specifc, non-functional routines or rituals; motor mannerisms; and a preoccupation with parts of objects. Some examples of these impairments, and some commonly associated features, are listed in Table 24-2. The diagnosis of autistic disorder requires symptoms of impaired social interaction, impaired communication, and the presence of restricted repetitive and stereotyped patterns of behaviour, interests, and activities. Nor are there signifcant delays in cognitive development, or in the development of age appropriate self-help skills, adaptive behaviour (other than in social interaction), and curiosity about the environment1. However, despite having normal language development, the higher 1American Psychiatric Association. Diferential diagnosis In contrast to autism, schizophrenia usually develops after a period of normal development and requires the presence of specifc psychotic symptoms. In selective mutism, the communication difculties are restricted to specifc situations. Children with language disorders lack the impairments in social interaction and do not exhibit the repetitive stereotyped behaviours of pervasive developmental disorders. An additional diagnosis of autism is only made in children with mental retardation if the specifc defcits in communication and social interaction and specifc stereotyped behaviours are present. A Manual of Mental Health Care in General Practice 239 Around 75 per cent of children with autism suffer mental retardation. Some Australian studies suggest that the prevalence may be as high as 10 per 10,0001. Familial pattern There is an increased risk among the siblings of those with autism. Few people with autism are able to live and work independently as adults, but some partial independence is achieved in about a third of cases. Treatment the aims of treatment are to minimise symptoms, to promote the development of the child, and to provide support to families and carers. While pharmacological treatments are of use in reducing unwanted behaviours, the main interventions are rehabilitative.

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Fundamentalmente es para que estes mas seguro respecto a alguna creencia y asi logres algo de lo que antes dudabas o que no habias podido llevar a cabo. Esta tecnica necesita ser aplicada con un acompanante, en un lugar apartado, se necesita un papel donde se encuentren las frases para completar y lapiz o pluma para escribir. Dirigete verbalmente a la posicion en la que the encontrabas al principio (1 posicion), diciendo tu nombre, repitiendo la creencia palabra por palabra, y anadiendo la frase de cada uno de los renglones siguientes. Posteriormente, debes leer este ejercicio por lo menos una vez al dia, aunque lo ideal seria hacerlo dos veces, una al despertar y otra al acostarte, acompanandolo de respiraciones cada vez que leas una frase, durante una semana, para que se fundamente perfectamente. The asombraras de como empieza a fluir esta creencia y sus consecuencias en tu vida. Di (mentalmente) una palabra codigo, que ayudara en el futuro a disparar esa sensacion. Permanece en el circulo el tiempo necesario para experimentar la sensacion de tener esos recursos. En el futuro, cuando quieras tener esos recursos activos e intensos, bastara que the imagines que entras al circulo o que estas dentro del mismo (no importa que sea sentado, parado o acostado). El tabaco causa grandes estragos en diferentes partes del cuerpo, considera bien la realidad de los danos para que tu decision de dejar el cigarro sea mas fuerte: En el cerebro: Aumenta la posibilidad de ataques cerebrales. Un hombre que continua fumando cuando su pareja esta embarazada, dana al bebe al convertir a la madre en fumadora pasiva. Cada ano cuatro millones de personas mueren en el mundo por enfermedades relacionadas con el consumo de tabaco. Para la decada de 2020, el numero de victimas relacionadas con el tabaquismo, que podrian evitarse, alcanzara los diez millones de muertes al ano. Esta adiccion, de no detenerse, crecera cada vez mas y se hara mas dificil de erradicar con el tiempo, ya que es una adiccion socialmente permitida y que el fumador asocia cada vez mas a sus estados de animo y conductas diarias, por lo que facilmente pasa de habito a adiccion. El cigarro es una de las drogas mas dificiles de dejar, de ahi que aunque el dano que causa sea evidente, se mantenga el habito de fumar. Considera que el habito lo instalamos en la mente nosotros mismos, por eso es posible que lo desinstalemos tambien nosotros. Fumar empezo con un cigarro, luego otro, y poco a poco fuimos incrementando la cantidad y la frecuencia hasta que nos rebaso. Tu eres el responsable de los habitos que has instalado, porque decidiste promover fumar mas y mas. En este capitulo encontraras ejercicios seriados que facilitan la terminacion de este vicio. Lo unico que se necesita es querer dejar de fumar y tener disciplina y voluntad, que se iran fortaleciendo a traves del proceso que se propone a continuacion. Es muy importante ir erradicando los lugares, situaciones y conductas que hemos ido asociando con el fumar. Es decir, ir cambiando los tiempos en que actualmente fumas, romper poco a poco con los habitos y costumbres en que el fumar se ha vuelto automatico. Trata de romper el cliche que se ha formado entre las dos conductas al separar el alcohol del cigarro, es decir, fuma antes o despues de tomar el cafe o la copa, pero no junto con ellos. Si logras cambiar estas conductas, cada vez fumaras menos, y la necesidad de cigarro ira desapareciendo. Puedes ir haciendolo junto con los ejercicios que the proponemos y de esta forma, lo iras logrando con mas facilidad. No the brinques los ejercicios, realizalos en el orden en que los presentamos para alcanzar mayor efectividad. El movimiento ocular esta relacionado con diferentes campos de informacion en el cerebro. Aunque no vamos a entrar en detalle, para el ejercicio basta con saber que en la mayoria de las personas el movimiento ocular es como a continuacion se describe. Para recuerdos auditivos, sonidos o palabras, movemos los ojos a la izquierda a la altura del oido. Para crear visualmente algo nuevo que no esta en nuestro recuerdo, movemos los ojos arriba a la derecha. Para crear sonidos o palabras nuevas, los movemos a la derecha a la altura del oido. Abajo a la izquierda es donde nos preguntamos y nos contestamos, es el dialogo interno. Aunque puede sonar demasiado sencillo, es una herramienta poderosa para comunicarnos con nuestra mente y asi modificar programas que tenemos instalados. Esto no implica ningun problema, solo hay que definirlas para saber hacia donde debes mover los ojos en el momento en que lo necesites. De ser asi, moveras los ojos a la derecha en vez de a la izquierda y viceversa, aunque el orden de arriba y abajo no cambia. Quiero que pienses y describas detalladamente el patio de recreo de tu escuela primaria. Si los moviste a la izquierda, estas dentro del porcentaje mayor de personas; si los moviste a la derecha, tienes las claves cruzadas, por lo que tendras que cambiar derecha por izquierda y viceversa al realizar el ejercicio siguiente. Este pequeno ritual the ayudara a generar opciones la proxima vez que quieras fumar. Identifica lo que ves a tu alrededor, lo que escuchas y, mientras respiras profundamente, lo que sientes al verte fumar en ese lugar, en forma disociada (como si fuera una pelicula). Este ejercicio se debe repetir cuantas veces sea necesario, hasta formar una nueva programacion que se de por si sola, es decir, en forma automatica. Con esto le estamos ensenando a nuestra mente un nuevo camino, una nueva conducta, con una nueva opcion para erradicar el cigarro. Verificar el tamano de mi objetivo (es posible lograrlo con estas especificaciones Se recomienda que este ejercicio lo repitas durante una semana por lo menos una vez al dia, y continues haciendolo segun lo necesites, hasta que tu mente forme una programacion fuerte. Recomendacion: repetirlo cada vez que se necesite, marca los tres papeles con presente, pasado y futuro. Esta linea marca tu presente y mantiene tu pasado a la izquierda y tu futuro a la derecha. Avanza hacia adelante cada vez que establezcas tu segunda y tercera meta a corto plazo para dejar de fumar. Puede ser tranquilidad, seguridad, paciencia, decision, valor, disciplina, entre otros. Detente cada vez que 622 encuentres ayuda en tu pasado para tu objetivo actual y respira, ve, escucha y siente cada situacion que encuentras, toma tu tiempo. Repite este ejercicio una vez al dia durante una semana, o cuando lo creas necesario. Una vez que hayas cumplido realmente con esta secuencia de ejercicios, habras dejado el cigarro. Solo es cuestion de querer hacerlo porque sabes que es bueno para ti y para los que the rodean. Esta serie de ejercicios son tus mejores aliados y siempre podras hacer uso de ellos con disciplina y decision. Date cuenta de que en un periodo de cinco semanas dejaras el cigarro de una manera mas facil y con muy buenos resultados, pues ya le diste toda la informacion necesaria a tu mente para lograrlo. De todas maneras, no the descuides y recuerda que puedes retomar los ejercicios cuando los necesites. Mediante este ejercicio se manejan los motivos para dejar el cigarro y se instala una imagen contraria a la anterior, la de mi objetivo logrado, para cambiar la programacion negativa de fumar por la de no fumar, grabando la imagen que me motiva y me beneficia. Puede ser el olor de tus manos, el mal aliento, molestar a tus seres queridos y no ser bien aceptado, o sintomas como palpitaciones, falta de aire, etcetera. Forma en ella una imagen de alguna situacion en la que hayas vivido lo anterior y por la que ya the molesta fumar. Agranda esta imagen, hazla mas brillante y siente lo que pasa dentro de ti cuando lo haces. A la cuenta de tres agranda la imagen de tu Yo ideal, cubre la anterior, cierra los ojos, respira profundamente y pon la pantalla en blanco. Si fue asi, el ejercicio obtuvo un buen resultado; si no, tal vez tengas que repetir el punto 5 hasta que la primera imagen haya desaparecido. Esta ultima imagen de tu Yo ideal, de tu conducta lograda, repitela cada vez que vayas a prender un cigarro o este se the antoje. De igual manera, si logras dejar de fumar con este ejercicio no suspendas la secuencia de todo el capitulo. Esta tecnica sirve para erradicar el momento preciso en que estas a punto de fumar, en otras palabras, para que descubras lo que detona esa conducta. Es una buena tecnica para entrenar la mente en lo que queremos y debilitar lo que no queremos. Con este ejercicio le ensenamos a la mente a tomar una nueva direccion en momentos dificiles y de gran tentacion. Puede ser tu mano buscando la cajetilla, tomar el cigarro y estar a punto de encenderlo, que alguien the ofrezca un cigarro Busca que haces justo antes de encenderlo. Segunda escena: 5) En un recuadro abajo a la izquierda de la pantalla crea una imagen tuya de lo que realmente the gustaria hacer. Deja esta escena y piensa nuevamente en algo que no tenga que ver con dejar de fumar. Recuerda que en el recuadro abajo a la izquierda esta la segunda escena, esta se encuentra ahora pequena y oscura. A la cuenta de tres la escena pequena y oscura de tu conducta ideal se agranda rapidamente y se ilumina, cubriendo la primera escena. A la cuenta de tres, agranda e ilumina la escena pequena y cubre la pantalla grande. Cierra los ojos, respira profundamente, pon la pantalla en blanco, relajate y repite el ejercicio. La mente aprende con rapidez, lo unico que tenemos que hacer es ensenarle lo que queremos para que abra nuevos caminos. Durante la semana, y cada vez que lo necesites, evoca tu imagen con la conducta deseada, a la cuenta de tres, cubre la pantalla con ella, repitiendo el proceso cinco veces, cerrando los ojos, respirando profundamente y poniendo la pantalla en blanco cada vez que lo haces. Que la imagen represente tus puntos fuertes, tus mejores habilidades, que the veas como cuando has logrado una meta que habias deseado mucho. Hazle cambios a la imagen que sean muy atractivos y motivadores para ti, por ejemplo: Hazla grande, brillante, en colores, en tres dimensiones, con movimiento. Puedes probar e ir haciendo ajustes, hasta que the sientas bien satisfecho, con cambios en los siguientes parametros: 626 Visual: Color / Blanco y negro Brillo Contraste Foco Plano/ Tres dimensiones Detalles Tamano Distancia Ubicacion Movimiento (o no) Auditivo: De donde viene (el sonido) Tono Volumen Melodia Ritmo Duracion Kinestesico: Tipo se sensacion (calor, frio, tension. La mayoria de las personas que se toman el tiempo para hacer este sencillo ejercicio, descubren que su sensacion de autoestima mejora notablemente. Se ha encontrado que cuando las imagenes que una persona tiene de si misma, son positivas e intensas, sienten un gran autoestima. El dolor o afliccion ante la perdida a veces puede ser enorme y dificil de manejar, puede durar mucho o poco, dependiendo de la persona y las circunstancias, pero lo que es cierto es que eventualmente el duelo debe terminar y la vida debe seguir su cauce. En muchos casos la tristeza o el anhelo de alguien o algo puede paralizarnos o cambiar nuestra vida de maneras que the afectan negativamente, y es dificil dar el siguiente paso. Es importante considerar que cada persona tiene su propio ritmo y carece de sentido tratar de hacer que alguien termine su duelo con estas tecnicas. Si la persona lleva demasiado tiempo en el duelo y no sabe como manejarlo, estas tecnicas seran de gran utilidad, pero si desea persistir en el duelo, sera necesario que se busque otro tipo de ayuda. No puedes forzar a nadie a hacer 627 los ejercicios si no esta convencido, y aunque los haga, probablemente no tendran mucho efecto. El ejercicio consiste en una serie de preguntas, es muy importante que reflexiones profundamente la respuesta. Toma tu tiempo, ya que una contestacion superficial no ayudara, aunque las tecnicas se realicen adecuadamente. Escribe tus creencias acerca del sobrepeso (por lo menos tres) y trata de recordar como las adquiriste. Escribe las creencias que tienes sobre la comida, si la consideras tu amiga o tu enemiga y por que razon. Mientras respiras profundamente, que sentimientos surgen cuando piensas en esto y en que parte del cuerpo los sientes Se facilita el ejercicio si alguien mas lee los pasos a seguir, de manera que respires profundamente y puedas cerrar los ojos. Si no hay nadie mas, lee bien el ejercicio para que tengas que consultarlo lo menos posible.

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