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By L. Tom. Pikeville College. 2017.

The relationship each member of the couple has with his or her own cul- tural background may shed light on the impasses that illness has created for them buy cleocin gel 20gm otc. For example cheap 20 gm cleocin gel with visa, a couple who has moved to the United States from an- other country five years ago may be experiencing different rates of assimila- tion, which in turn leaves them speaking a different language from each other (Landau-Stanton, 1982). In such a context, the development of a seri- ous illness in one spouse may cause a smoldering resentment to burst into open conflict as they struggle with their now-different expectations for management of the illness. These differences, in turn, may bring up compli- cated feelings relating to immigration and the dilemma of assimilation to the new culture versus maintenance of traditional values. Unresolved fam- ily of origin issues may serve to further intensify the struggle with cultural transition. For example, if one partner has significant guilt about leaving family in the home country, significant unresolved and unexpressed guilt about betrayal of family and cultural loyalties may function as a source of emotional reactivity in their current conflict over management of illness (McDaniel, Harkness, & Epstein, 2001). BOWEN THEORY AND CULTURE Western culture places particular stress on the individual over the group, on self-assertion over self-sacrifice, nonconformity over conformity, intel- lect over affect, novelty over tradition, youth over age, and doing over being. Many other cultures, especially those with collectivist traditions, emphasize the opposite of each of these polarities. Bowen theory has been criticized from a feminist perspective for valuing thinking and devaluing feeling, and emphasizing the differentiation side of the differentiation- togetherness pole in emotional functioning (Bograd, 1988; Lerner, 1985; Luepnitz, 1988). Cautions regarding Bowen theory and its implementation have also been offered from a cultural perspective for similar reasons. For example, Managing Emotional Reactivity in Couples Facing Illness 269 Tamura and Lau (1992), note that "the preferred direction of change for Japanese families in therapy is toward a process of integration—how a person can be effectively integrated into the given system—rather than a process of differentiation. This discussion of differentiation from the perspective of Japanese culture illustrates that the interpretation of healthy relatedness is heavily influenced by cultural values. As therapists, it is important to be mindful of our own cultural biases and the cultural values of the couples with whom we work, just as it is important to be aware of our own areas of reac- tivity as we help couples address theirs. SUMMARY From a holistic approach, all couples therapy should include a careful analysis of the impact of health concerns on relational functioning, and vice versa.

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Antibodies to nerve growth factor • Loss of tonic inhibition generated by these systems (NGF) suppress this redistribution of CGRP as well contributes to the increased responsiveness and as pain-related behaviours and abnormal responsive- enlargement of receptive fields of neurones in pain ness of wide dynamic range neurones buy 20gm cleocin gel visa. Patients Patients Referred sensations to a de-afferented region generic 20 gm cleocin gel mastercard, after The importance of neuronal spontaneous and evoked stimulation in a reference zone at or above the level of hyperactivity for central pain has been confirmed in a lesion, suggest a re-organization of the CNS. At cord level, spinal cord injury (SCI) Functional magnetic resonance imaging (MRI) has patients with central pain have significantly more demonstrated co-activation of non-adjacent cortical sensory hypersensitivity at-level than pain-free SCI representations after contact in a reference zone of a patients. High levels of cortical re-organization projecting to the cortex after spontaneous activity and evoked hyperactivity during a central injury. Central nerve lesions are also related C-fibre electrical stimulation are recorded in the to re-organization in the thalamus. Receptive and NERVE DAMAGE AND RELATIONSHIP TO NEUROPATHIC PAIN 47 projected field dissociation is observed, with receptive Further reading fields located on the border zone and projected fields referred to anaesthetic body areas. Peripheral and central Key points hyperexcitability: differential signs and symptoms in per- sistent pain. Lambert Pain serves a vital biological defensive function, often • Selectivity: The ability of a ligand to be selective associated with other psychological and central dis- (i. It is a physiological condition, which is • Stereoselectivity: The selectivity of a receptor for a detected by refined receptors within the damaged body particular stereoisomer of a ligand. It has two components: the motivational- • Co-localization: Similar anatomical distribution affective (emotional) component and the sensory- patterns (e. Nociception is the term applied • Down- and upregulation: Decrease or increase in to perception of nociceptor activation by noxious stim- levels of expression of cellular components. For example, Gq-protein- cology and then some of the more important and coupled receptors activate the enzyme phospholipase unusual receptors in the ‘pain pathway’. General terminology Some of the terms used in receptor pharmacology are described below: Basic receptor function • Ligand: General term for a molecule (peptidic, A basic principle of pharmacology is that a drug chemical, ionic or synthetic), which binds at a recep- must exert an effect on one or more of the cell’s tor site. Binding is generally, but not exclusively, reversible (competitive) and Firstly, the ligand molecule must come into contact attenuates the effect of an agonist.

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Short ciliary nerves contain parasympa- thetic impulses from ciliary ganglion (Chapter 17) buy cheap cleocin gel 20gm. Continues as external nasal nerve supplying cutaneous sensation to anterior aspect and tip of nose discount 20 gm cleocin gel visa. The nerve impulses pass thus: cornea, nasociliary nerve, Va, principal sensory nucleus of V, brain stem interneurons,facial motor nucleus,VII,orbicularis oculi muscle. This may lead to displacement of the The ophthalmic nerve (Va) 55 orbital contents causing proptosis and squint, and sensory loss over the anterior nasal skin. The isolated area of palate and lip in these cases are supplied by Va through its external nasal branch which enters from above. In a unilateral cleft, Vb of one side is able to innervate the area in an asymmetric fashion. Some of its branches transmit postganglionic parasympathetic fibres from the pterygo- palatine ganglion which pass to the lacrimal, nasal and palatine glands (see Section 17. The maxillary nerve (Vb) 57 Trigeminal ganglion Foramen rotundum Zygomatic nerve with Pons parasympathetic fibres to lacrimal gland Infraorbital nerve Nasal, palatine and Pterygoid canal, pterygopalatine superior alveolar ganglion (parasympathetic fibres branches distributed with Vb as shown) Cutaneous distribution Zygomaticotemporal Zygomaticofacial Vb Infraorbital Fig. Infraorbital nerve – infraorbital skin, upper lip Passes anteriorly between orbit and maxillary antrum in infraor- bital groove. Two small cutaneous branches penetrate zygoma: zygomaticofacial and zygomaticotem- poral. Conveys postganglionic parasympathetic fibres from pterygo- palatine ganglion to lacrimal gland (see Chapter 17). Branches also convey postganglionic parasympathetic fibres from pterygopala- tine ganglion to nasal glands (see Chapter 17). Superior alveolar (dental) nerves Branches of infraorbital and palatine nerves pass directly through maxilla to maxillary teeth, gums and sinus. Branches also convey postganglionic parasympathetic fibres from pterygopalatine ganglion to minor saliv- ary glands in the palatal mucosa (see Chapter 17). Pharyngeal branch Passes posteriorly to contribute to sensory supply of nasopharynx.

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Both partners indi- cated that they were committed to their relationship and to working on their current difficulties generic cleocin gel 20 gm otc. They had grown to accept each other’s differ- ences and truly liked each other best 20 gm cleocin gel, although humor and light moments had become infrequent in recent years. José stated that family was first and foremost for him, and he was uncomfortable knowing that Indira placed equal priority on her career. Neither had any major secrets relating to out- side relationships, finances, past history, or any disorder that could inter- fere with improving their relationship. At the end of the third session, I presented the following to Indira and José: • Developmentally, their relationship began with excitement and inten- sity and progressed well during times of low stress. Cognitive Behavioral Couple Therapy 131 • Their implicit expectation was that their earlier free and easy style would carry them through times that demanded greater planning, clearer communication, negotiation skills, and free time for themselves as a couple. As the stress increased, so did their sense of not getting what they needed from the relationship. Although each had success- fully individuated from their respective family of origin, the pressure for Indira to be a traditional homemaker and for José to assert himself as head of the household, and their overloaded schedules weighed on them and resulted in some guilt, repression of feelings, and isolation from other dual-career couples. COGNITIVE-BEHAVIORAL FORMULATION Based on the problems presented by this couple, an exploration of cognitive elements was essential. Unspoken assumptions and expectations were re- sulting in dysfunctional interactions and resentment, and I could not as- sume that acceptance and commitment levels were adequate at their current stage of development. They were also deficient in their knowledge and practice of communication, problem solving, and behavior exchange. Thus, activation of more satisfying behaviors appeared to be contingent upon cognitive intervention, and both areas were emphasized in the treatment plan presented to the couple. INTERVENTION Contracting During the fourth session, I proposed the following to Indira and José in the form of a written contract based on my assessment: 1. Weekly conjoint sessions of 75 minutes, initially for six more weeks followed by a mutual evaluation of progress and an option for renewal 2. The partners’ perceptions of their early relationship and style of re- lating and their expectations for dealing with children, home, work, and family b.

By L. Tom. Pikeville College. 2017.

The relationship each member of the couple has with his or her own cul- tural background may shed light on the impasses that illness has created for them buy cleocin gel 20gm otc. For example cheap 20 gm cleocin gel with visa, a couple who has moved to the United States from an- other country five years ago may be experiencing different rates of assimila- tion, which in turn leaves them speaking a different language from each other (Landau-Stanton, 1982). In such a context, the development of a seri- ous illness in one spouse may cause a smoldering resentment to burst into open conflict as they struggle with their now-different expectations for management of the illness. These differences, in turn, may bring up compli- cated feelings relating to immigration and the dilemma of assimilation to the new culture versus maintenance of traditional values. Unresolved fam- ily of origin issues may serve to further intensify the struggle with cultural transition. For example, if one partner has significant guilt about leaving family in the home country, significant unresolved and unexpressed guilt about betrayal of family and cultural loyalties may function as a source of emotional reactivity in their current conflict over management of illness (McDaniel, Harkness, & Epstein, 2001). BOWEN THEORY AND CULTURE Western culture places particular stress on the individual over the group, on self-assertion over self-sacrifice, nonconformity over conformity, intel- lect over affect, novelty over tradition, youth over age, and doing over being. Many other cultures, especially those with collectivist traditions, emphasize the opposite of each of these polarities. Bowen theory has been criticized from a feminist perspective for valuing thinking and devaluing feeling, and emphasizing the differentiation side of the differentiation- togetherness pole in emotional functioning (Bograd, 1988; Lerner, 1985; Luepnitz, 1988). Cautions regarding Bowen theory and its implementation have also been offered from a cultural perspective for similar reasons. For example, Managing Emotional Reactivity in Couples Facing Illness 269 Tamura and Lau (1992), note that "the preferred direction of change for Japanese families in therapy is toward a process of integration—how a person can be effectively integrated into the given system—rather than a process of differentiation. This discussion of differentiation from the perspective of Japanese culture illustrates that the interpretation of healthy relatedness is heavily influenced by cultural values. As therapists, it is important to be mindful of our own cultural biases and the cultural values of the couples with whom we work, just as it is important to be aware of our own areas of reac- tivity as we help couples address theirs. SUMMARY From a holistic approach, all couples therapy should include a careful analysis of the impact of health concerns on relational functioning, and vice versa.

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Antibodies to nerve growth factor • Loss of tonic inhibition generated by these systems (NGF) suppress this redistribution of CGRP as well contributes to the increased responsiveness and as pain-related behaviours and abnormal responsive- enlargement of receptive fields of neurones in pain ness of wide dynamic range neurones buy 20gm cleocin gel visa. Patients Patients Referred sensations to a de-afferented region generic 20 gm cleocin gel mastercard, after The importance of neuronal spontaneous and evoked stimulation in a reference zone at or above the level of hyperactivity for central pain has been confirmed in a lesion, suggest a re-organization of the CNS. At cord level, spinal cord injury (SCI) Functional magnetic resonance imaging (MRI) has patients with central pain have significantly more demonstrated co-activation of non-adjacent cortical sensory hypersensitivity at-level than pain-free SCI representations after contact in a reference zone of a patients. High levels of cortical re-organization projecting to the cortex after spontaneous activity and evoked hyperactivity during a central injury. Central nerve lesions are also related C-fibre electrical stimulation are recorded in the to re-organization in the thalamus. Receptive and NERVE DAMAGE AND RELATIONSHIP TO NEUROPATHIC PAIN 47 projected field dissociation is observed, with receptive Further reading fields located on the border zone and projected fields referred to anaesthetic body areas. Peripheral and central Key points hyperexcitability: differential signs and symptoms in per- sistent pain. Lambert Pain serves a vital biological defensive function, often • Selectivity: The ability of a ligand to be selective associated with other psychological and central dis- (i. It is a physiological condition, which is • Stereoselectivity: The selectivity of a receptor for a detected by refined receptors within the damaged body particular stereoisomer of a ligand. It has two components: the motivational- • Co-localization: Similar anatomical distribution affective (emotional) component and the sensory- patterns (e. Nociception is the term applied • Down- and upregulation: Decrease or increase in to perception of nociceptor activation by noxious stim- levels of expression of cellular components. For example, Gq-protein- cology and then some of the more important and coupled receptors activate the enzyme phospholipase unusual receptors in the ‘pain pathway’. General terminology Some of the terms used in receptor pharmacology are described below: Basic receptor function • Ligand: General term for a molecule (peptidic, A basic principle of pharmacology is that a drug chemical, ionic or synthetic), which binds at a recep- must exert an effect on one or more of the cell’s tor site. Binding is generally, but not exclusively, reversible (competitive) and Firstly, the ligand molecule must come into contact attenuates the effect of an agonist.

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Short ciliary nerves contain parasympa- thetic impulses from ciliary ganglion (Chapter 17) buy cheap cleocin gel 20gm. Continues as external nasal nerve supplying cutaneous sensation to anterior aspect and tip of nose discount 20 gm cleocin gel visa. The nerve impulses pass thus: cornea, nasociliary nerve, Va, principal sensory nucleus of V, brain stem interneurons,facial motor nucleus,VII,orbicularis oculi muscle. This may lead to displacement of the The ophthalmic nerve (Va) 55 orbital contents causing proptosis and squint, and sensory loss over the anterior nasal skin. The isolated area of palate and lip in these cases are supplied by Va through its external nasal branch which enters from above. In a unilateral cleft, Vb of one side is able to innervate the area in an asymmetric fashion. Some of its branches transmit postganglionic parasympathetic fibres from the pterygo- palatine ganglion which pass to the lacrimal, nasal and palatine glands (see Section 17. The maxillary nerve (Vb) 57 Trigeminal ganglion Foramen rotundum Zygomatic nerve with Pons parasympathetic fibres to lacrimal gland Infraorbital nerve Nasal, palatine and Pterygoid canal, pterygopalatine superior alveolar ganglion (parasympathetic fibres branches distributed with Vb as shown) Cutaneous distribution Zygomaticotemporal Zygomaticofacial Vb Infraorbital Fig. Infraorbital nerve – infraorbital skin, upper lip Passes anteriorly between orbit and maxillary antrum in infraor- bital groove. Two small cutaneous branches penetrate zygoma: zygomaticofacial and zygomaticotem- poral. Conveys postganglionic parasympathetic fibres from pterygo- palatine ganglion to lacrimal gland (see Chapter 17). Branches also convey postganglionic parasympathetic fibres from pterygopala- tine ganglion to nasal glands (see Chapter 17). Superior alveolar (dental) nerves Branches of infraorbital and palatine nerves pass directly through maxilla to maxillary teeth, gums and sinus. Branches also convey postganglionic parasympathetic fibres from pterygopalatine ganglion to minor saliv- ary glands in the palatal mucosa (see Chapter 17). Pharyngeal branch Passes posteriorly to contribute to sensory supply of nasopharynx.

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Both partners indi- cated that they were committed to their relationship and to working on their current difficulties generic cleocin gel 20 gm otc. They had grown to accept each other’s differ- ences and truly liked each other best 20 gm cleocin gel, although humor and light moments had become infrequent in recent years. José stated that family was first and foremost for him, and he was uncomfortable knowing that Indira placed equal priority on her career. Neither had any major secrets relating to out- side relationships, finances, past history, or any disorder that could inter- fere with improving their relationship. At the end of the third session, I presented the following to Indira and José: • Developmentally, their relationship began with excitement and inten- sity and progressed well during times of low stress. Cognitive Behavioral Couple Therapy 131 • Their implicit expectation was that their earlier free and easy style would carry them through times that demanded greater planning, clearer communication, negotiation skills, and free time for themselves as a couple. As the stress increased, so did their sense of not getting what they needed from the relationship. Although each had success- fully individuated from their respective family of origin, the pressure for Indira to be a traditional homemaker and for José to assert himself as head of the household, and their overloaded schedules weighed on them and resulted in some guilt, repression of feelings, and isolation from other dual-career couples. COGNITIVE-BEHAVIORAL FORMULATION Based on the problems presented by this couple, an exploration of cognitive elements was essential. Unspoken assumptions and expectations were re- sulting in dysfunctional interactions and resentment, and I could not as- sume that acceptance and commitment levels were adequate at their current stage of development. They were also deficient in their knowledge and practice of communication, problem solving, and behavior exchange. Thus, activation of more satisfying behaviors appeared to be contingent upon cognitive intervention, and both areas were emphasized in the treatment plan presented to the couple. INTERVENTION Contracting During the fourth session, I proposed the following to Indira and José in the form of a written contract based on my assessment: 1. Weekly conjoint sessions of 75 minutes, initially for six more weeks followed by a mutual evaluation of progress and an option for renewal 2. The partners’ perceptions of their early relationship and style of re- lating and their expectations for dealing with children, home, work, and family b.