By X. Gamal. Edward Waters College. 2019.

Centrally acting mus- cle relaxants depress neuron activity in the spinal cord or in the brain buy himcolin 30gm with visa. They are used to treat acute spasms from muscle trauma buy discount himcolin, but are less effective for treating spasms caused by chronic neurological disorders order 30 gm himcolin with visa. These drugs decrease pain purchase himcolin canada, increase range of motion and have a sedative effect on the patient. Centrally acting muscle relaxants should not be taken concurrently with central nervous system depressants such as barbiturates, narcotics, and alcohol. Diazepam (Valium) and Baclofen (Lioresal) These are used to treat acute spasms from muscle trauma and for treating spasms caused by chronic neurologic disorders. Peripherally acting muscle relax- ants depress neuron activity at the skeletal muscles and have a minimal effect on the central nervous system. These are most effective for spasticity or muscle contractions caused by chronic neurologic disorders. This is also used to treat malignant hypertension which is an allergic reaction to anesthesia. Patients experience fatigue and muscle weakness—particularly in respiratory muscles, facial muscles, and muscles in the extremities. They have drooping eye- lids (ptosis) and difficulty in chewing and swallowing and their respiratory mus- cles become paralyzed which leads to respiratory arrest. They include ambenonium (Mytelase), edrophonium Cl (Tensilon), Neostigmine bromide (Prostigmin), and Pyridostigmine bromide (Mestinon). Multiple lesions of the myelin sheath that surround the nerve fibers occur that are called plaque. At times patients don’t experience symptoms and other times symptoms can become severe and debilitating. Interferonß-1B (betaseron) and interferonß-1a (avonex) These are used to reduce the frequency and severity of relapses. Copolymer 1 This drug is in clinical trials and appears to decrease the disease’s activity. Copaxone (glatiramer acetate injection) This drug reduces new brain lesions and the frequency of relapses in people with relapsing-remitting multiple sclerosis. Part of the patient’s brain that controls thought, memory, and language becomes impaired. Alzheimer’s disease affects 5% of people between 65 and 74 years of age and half of those older than 85 years. Although the cause of Alzheimer’s disease remains unknown, investigators have discovered Alzheimer’s patients have abnormal clumps of amyloid plaques and tangled bundles of fibers called neurofibrillary tangles in parts of their brain. Amyloid plaques, neurofibrillary tangles, and decreased chemical levels impair thinking and memory by disrupting these messages and causing nerve cells to die. Eventually, the patient loses mental capacity and the ability to carry out daily activities. Although there isn’t a treatment that stops Alzheimer’s disease, there are medications that provide some relief to patients who are in the early and middle stages of the disease. Tacrine (Cognex), donepezil (Aricept), rivastigmine (Exelon), and galantamine (Reminyl) These drugs prevent some symptoms from becoming worse for a limited time. Tranquilizers, mood elevators, and sedatives These can help control behavioral symptoms such as sleeplessness, agitation, wandering, anxiety, and depression. Effects of Cholinergic and Anticholinergic Drugs Body Tissue Cholinergic Response Anticholinergic Response Cardiovascular* Decreases heart rate, lowers blood Increases heart rate with pressure due to vasodilation, large doses. Eye+ Increases papillary constriction, Dilates pupils of the eye or miosis (pupil becomes smaller), (mydriasis) and paralyzes and increases accommodation ciliary muscle (cycloplegia), (flattening or thickening of eye causing a decrease in lens for distant or near vision). Glandular* Increases salivation, perspiration, Decreases salivation, and tears sweating, and bronchial secretions. Bronchi (lung)* Stimulates bronchial smooth Dilates the bronchi and muscle contraction and increases decreases bronchial bronchial secretions. Striated muscle+ Increases neuromuscular Decreases tremors and transmission and maintains rigidity of muscles. Central nervous system Drowsiness, disorientation, and hallucination can result from large doses. Seventy-five percent of persons with seizures had their first seizure before 18 years of age. These include grand mal (tonic-clonic), petit mal (absence), and psychomotor seizures. Hydantoins (phenytoin, mephenytoin, ethotoin) These treat grand mal (tonic-clonic) seizures and psychomotor seizures. Barbiturates (Phenobarbital, mephobarbital, primidone) These are used for treating grand mal and acute episodes or status epilepticus; meningitis, toxic reactions, and eclampsia Succinimides (ethosuximide) These are used to treat absence seizures and may be used in combination with other anticonvulsants. Oxazolidones (trimethadione) This is used to treat petit mal seizures and may be used in combination with other drugs or singly for treating refractory petit mal seizures. Benzodiazepines (diazepam, clonazepam) These are effective in controlling petit mal seizures. Carbamazepine This is effective in treating refractory seizure disorders that have not responded to other anticonvulsant therapies. It is also used to control grand mal and partial seizures and a combination of these seizures. Valproate (valproic acid) This is used to treat petit mal, grand mal, and mixed types of seizures. It can suppress the sodium influx by binding to the sodium channel pro- longing the channel’s inactivation and preventing neurons from firing. Antipsychotics Psychosis is a disorder that is characterized by a number of symptoms. These include difficulty processing information and reaching a conclusion; experienc- ing delusions or hallucinations; being incoherent or in a catatonic state; or demonstrating aggressive violent behavior. Schizophrenia is a chronic psychotic disorder where patients exhibit either positive or negative symptoms. Positive symptoms are exaggeration of normal function such as agitation, incoherent speech, hallucination, delusion, and paranoia. Negative symptoms are characterized by a decrease or loss of motiva- tion or function such as social withdrawal, poor selfcare, and a decrease in the content of speech. Psychosis is caused by an imbalance in the neurotransmitter dopamine in the brain. Antipsychotic medication, also known as dopamine antagonists, block the D2 dopamine receptors in the brain thereby reducing the psychotic symptoms. A number of antipsychotic medications block the chemoreceptor trigger zone and vomiting (emetic) center of the brain. Although blocking dopamine improves the patient’s thought processes and behavior, it can cause side effects. These include symptoms of Parkinsonism (see Parkinsonism previously dis- cussed in this chapter). Patients who undergo long-term treatment for psychosis using antipsychotic medications also might be prescribed drugs to treat the symptoms of Parkinsonism. The typical category of antipsychotic med- ication is further subdivided into phenothiazines and nonphenothiazines. Phenothiazines block norepinephrine causing sedative and hypotensive effects early in treatment. Nonphenothiazines include butyrophenone haloperidol (Haldol) whose phar- macologics are similar to phenothiazines as it alters the effects of dopamine by blocking the dopamine receptor sites. Included in this group are prochlorperazine (Compazine), fluphenazine (Prolixin), perphenazine (Trilafon), and trifluoperazine (Stelazine). These have replaced sedatives that were traditionally used because they have fewer and less potent side effects, especially if an overdose of the medication is given to the patient. Anxiolytics are prescribed when the patient’s anxiety reaches a level where the patient becomes disabled and is unable to perform normal activities. Anxiolytics have a sedative-hypnotic effect on the patient, but not an antipsychotic effect. Primary anxiety is not caused by a medical condition or drug use but may be sit- uational. Anxiolytics are usually not administered for secondary anxiety unless the sec- ondary cause is severe or untreatable.

If these side effects become persistent or interfere with activities of daily living buy himcolin, the client should report them to the physician purchase himcolin canada. To do so might pro- duce withdrawal symptoms discount 30 gm himcolin otc, such as nausea himcolin 30gm with visa, vertigo, insomnia, headache, malaise, nightmares, and a return of the symptoms for which the medication was prescribed. Smoking increases the metabolism of tricyclics, requiring an adjust- ment in dosage to achieve the therapeutic effect. Many medications contain substances that, in combination with antidepressant medication, could precipitate a life-threatening hyperten- sive crisis. If the erection persists longer than 1 hour, seek emergency department treat- ment. Taking bupropion in divided doses will decrease the risk of seizures and other adverse effects. These drugs are believed to readily cross the placental barrier; if so, the fetus could experience adverse effects of the drug. Inform the physician immediately if pregnancy occurs, is suspected, or is planned. Refer to written materials furnished by health care providers for safe self-administration. Serum levels should be taken twice weekly at the initiation of therapy and until therapeutic level has been achieved. Serum levels should be monitored in uncomplicated cases during maintenance therapy every 1 to 2 months. Clonazepam ● Contraindicated in hypersensitivity, acute narrow-angle glaucoma, liver disease, lactation. Oxcarbazepine ● Contraindicated in hypersensitivity (cross-sensitivity with carbamazepine may occur), lactation. Decreased effects oforal contraceptives, digoxin, lithium, riseridone,and valproic acid. Maximum dose: 1000 mg/day in children 12 to 15 years; 1200 mg/day in patients >15 years. May increase weekly to achieve optimal clinical response admin- istered 3 or 4 times a day. Dosage may be adjusted in 200 mg daily increments to achieve optimal clinical response. May increase dose in increments of 200 mg/day depending on response, tolerability, and plasma concentrations. Some Mood-Stabilizing Drugs ● 455 patients may require up to 4 mg/day, in which case the dose may be increased in increments of 0. Titrate rapidly to desired clinical effect or trough plasma levels of 50 to 125 mcg/mL. If valproic acid is also being taken, the initial dose should be 25 mg every other day for 2 weeks, then 25 mg once daily for next 2 weeks; then increase by 25 to 50 mg/day every 1 to 2 weeks to maintenance dose of 50 to 200 mg twice a day. Titration may be continued until desired results have been achieved (range is 900 to 1800 mg/day in 3 divided doses). Gradually increase by 25 to 50 mg weekly up to 200 to 400 mg/day in 2 divided doses (200 to 400 mg/day in 2 divided doses for partial seizures and 400 mg/day in 2 divided doses for primary generalized tonic/ clonic seizures). Conversion to monotherapy: 300 mg twice daily; may be increased by 600 mg/day at weekly intervals, whereas other antiepileptic drugs are tapered over 3 to 6 weeks; dose of oxcarbazepine should be increased up to 2400 mg/day over a period of 2 to 4 weeks. Initiation of monotherapy: 300 mg twice daily, increase by 300 mg/day every third day, up to 1200 mg/day. Children 2 to 16 years: (adjunctive therapy): 4 to 5 mg/kg twice daily (up to 600 mg/day), increased over 2 weeks to achieve 900 mg/day in patients 20 to 29 kg, 1200 mg/day in patients 29. In patients <20 kg, initial dose of 16 to 20 mg/kg/day may be used, not to exceed 60 mg/kg/day. Conversion to monotherapy: 8 to 10 mg/kg/day given twice daily; may be increased by 10 mg/kg/day at weekly inter- vals, whereas other antiepileptic drugs are tapered over 3 to 6 weeks; dose of oxcarbazepine should be increased up to 600 to 900 mg/day in patient ≤20 kg, 900 to 1200 mg/ day in patients 25 to 30 kg, 900 to 1500 mg/day in patients 35 to 40 kg, 1200 to 1500 mg/day in patients 45 kg, 1200 to 1800 mg/day in patients 50 to 55 kg, 1200 to 2100 mg/day in patients 60 to 65 kg, and 1500 to 2100 mg/day in patients 70 kg. Contraindications and Precautions Contraindicated in: • Hypersensitivity • Severe left ventric- ular dysfunction • Heart block • Hypotension • Cardiogenic shock • Congestive heart failure • Patients with atrial flutter or atrial fibrillation and an accessory bypass tract Use Cautiously in: • Liver or renal disease • Cardiomyopa- thy • Intracranial pressure • Elderly patients • Pregnancy and lactation (safety not established) Adverse Reactions and Side Effects ● Drowsiness ● Dizziness ● Headache ● Hypotension ● Bradycardia ● Nausea ● Constipation Interactions ● Effects of verapamil are increased with concomitant use of amiodarone, beta-blockers, cimetidine, ranitidine, and grapefruit juice. Contraindications and Precautions Olanzapine ● Contraindicated in hypersensitivity; lactation. Orally disin- tegrating tablets only: Phenylketonuria (orally disintegrating tablets contain aspartame). Mood-Stabilizing Drugs ● 461 Aripiprazole ● Contraindicated in hypersensitivity; lactation. Chlorpromazine ● Contraindicated in hypersensitivity (cross-sensitivity with other phenothiazines may occur); narrow-angle glaucoma; bone marrow depression; severe liver or cardiovascular dis- ease; concurrent pimozide use. Increased fl u o x e t i n e , p a r- hypotension with oxetine, or other antihypertensives. Quetiapine Cimetidine; keto- Phenytoin, Decreased effects of conazole, itracon- thioridazine levodopa and dopamine azole, fluconazole, agonists. Risperidone Clozapine, fluoxetine, Carbamazepine Decreased effects of paroxetine, or levodopa and dopamine ritonavir agonists. Adjust dosage according to efficacy and tolerability to within a range of 6 to 12 olanzapine/25 to 50 fluoxetine. Dosage increases should not be made before 2 weeks, the time required to achieve steady state. Increase by 20 to 50 mg every 3 to 4 days until effective dose is reached, usually 200 to 400 mg/ day. Increase gradually over several days (up to 400 mg every 4 to 6 hours in severe cases). May increase dose at 24-hour intervals in increments of 1 to 2 mg/day to a recommended dose of 4 to 8 mg/day. Adjust dose on the basis of toleration and efficacy within the range of 40 to 80 mg twice/day. The safety of doses above 10 mg twice daily has not been evaluated in clinical trials. The safety of doses above 10 mg twice daily has not been evaluated in clinical trials. Risk for self-directed or other-directed violence related to unresolved anger turned inward on the self or outward on the environment. Risk for activity intolerance related to side effects of drowsiness and dizziness. Drowsiness, dizziness, headache * Ensure that client does not participate in activities that require alertness, or operate dangerous machinery. Some physicians prescribe a small dose of beta-blocker pro- pranolol to counteract this effect. Hypotension; arrhythmias; pulse irregularities * Monitor vital signs two or three times a day. Drowsiness; dizziness * Ensure that client does not operate dangerous machin- ery or participate in activities that require alertness. Blood dyscrasias * Ensure that client understands the importance of regular blood tests while receiving anticonvulsant therapy. Prolonged bleeding time (with valproic acid) * Ensure that platelet counts and bleed time are deter- mined before initiation of therapy with valproic acid. Risk of severe rash (with lamotrigine) * Ensure that client is informed that he or she must report evidence of skin rash to physician immediately. Decreased efficacy of oral contraceptives (with topiramate) * Ensure that client is aware of decreased efficacy of oral contraceptives with concomitant use. Drowsiness; dizziness * Ensure that client does not operate dangerous machin- ery or participate in activities that require alertness. Hypotension; bradycardia * Take vital signs just before initiation of therapy and before daily administration of the medication. Constipation * Encourage increased fluid (if not contraindicated) and fiber in the diet. Drowsiness; dizziness * Ensure that client does not operate dangerous machin- ery or participate in activities that require alertness. Dry mouth; constipation * Provide sugarless candy or gum, ice, and frequent sips of water. Provide foods high in fiber; encourage physical activity and fluid if not contraindicated. Observe for the appear- ance of symptoms of polydipsia, polyuria, polyphagia, and weakness at any time during therapy.

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Staff from other areas in direct contact with patients should be encouraged to either change into unit clothing discount himcolin online master card, or remove jackets and coats worn outside the unit (before washing their hands) cheap generic himcolin uk. Critical illness necessitates contact with many staff 30gm himcolin sale, but unnecessary staff should be discouraged from visiting order himcolin 30 gm with amex, and movement of staff between beds minimised. Conflicts with educational Infection control 133 needs (particularly in teaching hospitals) need to be evaluated against risks to patients. Communication and teamwork between different multidisciplinary team members, including microbiologists and infection control teams, can proactively minimise infection risk; multidisciplinary audit should identify unit-specific issues; action research may develop solutions. Inadequate staffing (quantity and quality) increases cross-infection (Hanson & Elston 1990). Many invasive procedures and treatments are unavoidable with critical illness, but each may introduce infection into immunocompromised patients. Nurses can usefully question whether some may be avoided: alternative routes for drugs may be possible (e. Central vein cannulae remain the major cause of nosocomial septicaemia (Randolph 1998), and so should be replaced whenever practical. Unused cannulae (peripheral or central) create unnecessary risks and should be removed. Despite extensive research, time limits for replacing invasive equipment vary between equipment type, insertion site and researchers. Hospitals and units often provide evidence-based guidelines for replacement times, and manufacturers should state recommended times; staff extending manufacturers’ times should consider their legal liability (see Chapter 45). Insertion dates of all invasive equipment should be recorded so that they can be changed promptly. Improving gut perfusion with dopamine (McClelland 1993b) has proved disappointing; dobutamine may be more effective (Levy et al. Measuring intramucosal pH (pHi) indicates sepsis and mortality (Lavery & Clapham 1993), although benefits remain controversial. Enteral nutrition (see Chapter 9) remains the most effective way to enhance gut defences and reduce translocation of gut bacteria. Intensive care nursing 134 Isolation can halve nosocomial infection rates (Hanson & Elston 1990), but increase psychological stress (see Chapter 3) and delay discharge, thus exposing patients to prolonged risk of nosocomial infection (Teare & Barrett 1997). Staff screening has recently generated heated debate in the British Medical Journal, Lessing et al. Specimen analysis incurs costs and usually requires medical approval; however vigilance by nurses often identifies signs of potential infection. Treating infection The antibiotic era has witnessed many microorganism mutations, creating resistance to successive generations of (increasingly expensive and toxic) antibiotics. Drug companies face escalating investment costs for products increasingly difficult to market, and potentially soon obsolete; Gould (1994b) reports that one-half of drug companies are stopping or seriously reducing antibiotic production. The Chief Medical Officer for Scotland has predicted that by 2020 healthcare will run out of antibiotics (cited by Amyes & Thomson 1995). Such statements may appear sensationalist, but they emphasise the need to reorientate from relying on drugs to preventing and controlling infection. Antibiotics remain useful adjuncts to treatment, but will probably become progressively less effective. The inappropriate use of antibiotics has created more pathogenic, resistant organisms (Parke & Burden 1998), and so unnecessary use is actively discouraged (House of Lords Select Committee on Science and Technology 1998). Early onset pneumonia (from aspiration during trauma) is usually antibiotic- sensitive, but late onset pneumonia (ventilator-associated pneumonia) is usually resistant (Rello et al. Monoclonal antibodies are cloned and genetically engineered human Blymphocytes (Eburn 1993). Heat Moisture Exchangers) should be changed according to manufacturers’ instructions (normally daily); catheter mounts should be changed at the same time as humidifiers Infection control 135 ■ invasive techniques and disconnection of intravenous lines should, when possible, avoid times of dust disturbance (e. Antibiotics and other medical treatments can reduce morbidity and mortality, but preventing infection is humanly (and usually financially) preferable. Hygiene is helped by adequate and appropriate facilities, including sufficient washbasins, aprons and unit guidelines and protocols. All multidisciplinary team members should be actively involved in making decisions, but nurses have an especially valuable role in coordinating and controlling each patient’s environment. Problems from infection are likely to escalate; continuing vigilance and care can minimise infection risks and the spread of microorganisms. Further reading Articles on infection control frequently appear in specialist and general journals. Taylor’s (1978) classic article on handwashing is recommended; issues for nursing practice regularly appear in many general nursing journals. She was transferred from elderly care facilities with rapidly deteriorating respiratory function, copious mucopurulent sputum and atelectasis. Catherine’s previous respiratory tract infections had been treated with oral Amoxycillin (beta lactam class of antibiotics). Issues related to infection control are included in end-of-chapter scenarios in chapters 39 and 40. Chapter 16 Ethics Introduction The value of ethics for healthcare has been increasingly recognised: critical care often adds greater focus and poignancy to ethical dilemmas. Ethics raises questions rather than provides answers; dilemmas have more than one solution. Each person has values; some are formed or shared with peer groups, others are individual. Different values may cause conflict (for example, the care versus cure debate of Chapter 1). Active questioning enables evaluation of beliefs underpinning practice, helping nurses to understand others’ perspectives, but solutions necessarily remain individual. Increasing public expectations (and litigation) of healthcare, and changes within nursing (increased autonomy, responsibility and accountability) are reflected by greater emphasis on ethics in nursing education. A high public and media profile makes intensive care nursing a much-scrutinized area. This chapter provides a basis both for practice and for the remainder of this book; professional development can usefully be extended through discussion with colleagues and further study. This chapter describes the four main ethical principles identified by Beauchamp and Childress (1994): ■ autonomy ■ non-maleficence ■ beneficence ■ justice and the three main ethical theories identified by Rumbold (1993): ■ duty-based ■ goal-based ■ rights-based Other authors may give different arrangements, wording or additional theories and principles. Ethical principles provide a framework with which to work through dilemmas, identifying what is harmful, what is good and what is just. Decisions may differ between individuals because individual morals (values and beliefs) influence decision-making Intensive care nursing 138 processes. Ethical theories identify different sets of beliefs; understanding our own and others’ sets of beliefs (values) helps towards the understanding of differences. Some examples presented in this chapter include legal and professional perspectives; unlike ethics, these expectations can be enforced, and so nurses should consider their individual professional (and legal) accountability. Ethics are guides to decision-making, and decisions are influenced by sources such as ■ religion ■ law ■ society (and social values) ■ peers ■ individual values If growth from novice to expert entails moving from following rules to initiation (Benner 1984), understanding sources of ‘intuitive’ decisions can substantiate accountable evidence-based practice. The literal translation of both is ‘norm’ (Greek ethos, Latin mores), but they have different connotations. Many staff are uncomfortable with applying economics to healthcare, but while decisions should never be made solely on economic grounds, finance cannot be ignored where resources remain finite. Intensive care nursing relies on technology to support and monitor physiological function. Breathing and heartbeat can be replaced by technology (causing redefinition of death as absence of brainstem function), but intervention may prolong dying rather than prolong life: Rachels (1986) draws a distinction between living and the physical process of being alive. Technology may be used inappropriately; no treatment, intervention or observation should become ‘routine’. This much-used term is value-laden: what one person considers acceptable quality, another may not (e. Values vary between the extremes of preserving life at all costs, and always letting ‘nature’ take its course. Ethical principles Autonomy Beauchamp and Childress (1994) suggest that each ethical principle is part of a continuum. Autonomy, the first principle, is usually interpreted as ‘self-rule’—that is, making an informed free choice.

Berlyne’s work on curiosity and in- formation seeking; George Kelly’s theory of personal Psychologist Aaron Beck developed the cognitive constructs purchase cheap himcolin line, and investigations by Herman Witkin purchase genuine himcolin, Riley therapy concept in the 1960s buy himcolin mastercard. The treatment is based on Gardner order himcolin on line amex, and George Klein on individual perceptual and the principle that maladaptive behavior (ineffective, self- cognitive styles. In- The emergence of cybernetics and computer science stead of reacting to the reality of a situation, an individ- have been central to contemporary advances in cognitive ual automatically reacts to his or her own distorted view- psychology, including computer simulation of cognitive point of the situation. Cognitive therapy focuses on processes for research purposes and the creation of infor- changing these thought patterns (also known as cognitive mation-processing models. Herbert Simon and Allen distortions), by examining the rationality and validity of Newell created the first computer simulation of human the assumptions behind them. This process is termed thought, called Logic Theorist, at Carnegie-Mellon Uni- cognitive restructuring. Other major contributions in this Cognitive therapy is a treatment option for a number area include D. It is also tures of behavioral modification into the traditional cog- frequently prescribed as an adjunct, or complementary, nitive restructuring approach. In cognitive-behavioral therapy for patients suffering from back pain, cancer, therapy, the therapist works with the patient to identify rheumatoid arthritis, and other chronic pain conditions. Patients may have certain fundamental core beliefs, known as schemas, which are flawed, and are having a Cognitive therapy is usually administered in an out- negative impact on the patient’s behavior and function- patient setting (clinic or doctor’s office) by a therapist ing. For example, a patient suffering from depression trained or certified in cognitive therapy techniques. Ther- may develop a social phobia because he/she is convinced apy may be in either individual or group sessions, and he/she is uninteresting and impossible to love. A cogni- the course of treatment is short compared to traditional tive-behavioral therapist would test this assumption by psychotherapy (often 12 sessions or less). Therapists asking the patient to name family and friends that care are psychologists (Ph. The therapist asks the patient to defend behavioral techniques such as conditioning (the use of his or her thoughts and beliefs. If the patient cannot positive and/or negative reinforcements to encourage de- produce objective evidence supporting his or her as- sired behavior) and systematic desensitization (gradual sumptions, the invalidity, or faulty nature, is exposed. The patient is asked to imagine a ly reintroduce the patient to social situations. When the patient Preparation is confronted with a similar situation again, the re- Cognitive therapy may not be appropriate for all pa- hearsed behavior will be drawn on to deal with it. The therapist and patient then review lationship is critical to successful treatment. Individuals the journal together to discover maladaptive thought interested in cognitive therapy should schedule a consul- patterns and how these thoughts impact behavior. The consultation session is similar to an in- reinforce insights made in therapy, the therapist may terview session, and it allows both patient and therapist to ask the patient to do homework assignments. During the consultation, the may include note-taking during the session, journaling therapist gathers information to make an initial assess- (see above), review of an audiotape of the patient ses- ment of the patient and to recommend both direction and sion, or reading books or articles appropriate to the goals for treatment. They may also be more behaviorally focused, learn about the therapist’s professional credentials, applying a newly learned strategy or coping mecha- his/her approach to treatment, and other relevant issues. The intake interview is typically performed by a psychiatric nurse, counselor, or social worker, either face-to-face or over the phone. It is used to gather a brief background on treatment history and make a preliminary evaluation of the patient before assigning them to a therapist. Typical results Because cognitive therapy is employed for such a broad spectrum of illnesses, and is often used in con- junction with medications and other treatment interven- tions, it is difficult to measure overall success rates for the therapy. Cognitive and cognitive behavior treatments have been among those therapies not likely to be evaluat- ed, however, and efficacy is well-documented for some symptoms and problems. Some studies have shown that cognitive therapy can reduce relapse rates in depression and in schizophrenia, particularly in those patients who respond only margin- ally to antidepressant medication. It has been suggested that this is because cognitive therapy focuses on chang- ing the thoughts and associated behavior underlying these disorders rather than just relieving the distressing symptoms associated with them. The integrative power of cognitive throughout the world and how they cope with war, therapy. Mind over mood: chiatry and medical humanities at Harvard University a cognitive therapy treatment manual for clients. Further Information Coles was born in 1929 in Boston to parents who Beck Institute For Cognitive Therapy And Research. During advanced training in psychoanalysis in New Orleans, Coles reached a turning point. Deeply Robert Martin Coles moved by the sight of a young black girl being heckled 1929- by white segregationists, in 1960 Coles began his exami- American psychiatrist and author. Instead, I became a ‘field worker,’ learning to talk with children going through their everyday lives amid substantial social and educational stress. He inherited condition which affects more men than women, has also volunteered as a tutor in a school for underprivi- has two varieties: monochromats lack all cone receptors leged children. Besides Children in Crisis, Coles’s and cannot see any color; dichromats lack either red- prominent books include The Moral Life of Children, green or blue-yellow cone receptors and cannot perceive The Political Life of Children, The Spiritual Life of Chil- hues in those respective ranges. The Mind’s Fate: A Psychiatrist Looks at His wavelength in order to see it normally. Coma An abnormal state of profound unconsciousness accompanied by the absence of all voluntary be- Color vision havior and most reflexes. A coma may be induced by a severe neurological in- Color vision is a function of the brain’s ability to jury—either temporary or permanent—or by other phys- interpret the complex way in which light is reflected off ical trauma. What the human eye sees as color even the most intense stimuli, although he or she may is not a quality of an object itself, nor a quality of the show some automatic movements in response to pain. Specific conditions that Each of three types of light receptors called cones, lo- produce comas include cerebral hemorrhage; blood clots cated in the retina of the eye, recognizes certain ranges of in the brain; failure of oxygen supply to the brain; tu- wavelengths of light as blue, green, or red. From the cones, mors; intracranial infections that cause meningitis or en- color signals pass via neurons along the visual pathway cephalitis; poisoning, especially by carbon monoxide or where they are mixed and matched to create the percep- sedatives; concussion; and disorders involving elec- tion of the full spectrum of 5 million colors in the world. Comas may also be caused by metabolic abnor- Because each person’s neurons are unique, each of malities that impair the functioning of the brain through us sees color somewhat differently. In general, treatment of a Further Reading coma involves avoiding further damage to the brain by Herman, Judith Lewis. New York: Basic maintaining the patient’s respiratory and cardiac func- Books, 1992. Combat neurosis The preferred term to describe mental disturbances related to the stress of military combat; also known by such alternative terms as combat fatigue syn- Communication skills and drome, shell shock, operational or battle fatigue, disorders combat exhaustion, and war neurosis. The skills needed to use language (spoken, written, signed, or otherwise communicated) to interact Combat neurosis describes any personality distur- with others, and problems related to the develop- bance that represents a response to the stress of war. Symptoms of the Language employs symbols—words, gestures, or disturbance may appear during the battle itself, or may spoken sounds—to represent objects and ideas. Children first acquire the skills to receive commu- known then according to the American Psychiatric As- nications, that is, listening to and understanding what sociation as “gross stress reaction. Next, plied to personality disturbances resulting from catastro- they will begin experimenting with expressing them- phes other than war as well. Speaking will attention from both the general public and the medical begin as repetitive syllables, followed by words, phrases, community has focused on the combat neuroses experi- and sentences. Later, children will acquire the skills of enced by those who fought during the Vietnam and Per- reading and writing, the written forms of communica- sian Gulf Wars. Although milestones are discussed for the develop- are triggered by war or combat; rather, in most cases, the ment of these skills of communication, many children disturbance begins with feelings of mild anxiety. Parents should refrain from attaching too signs are typically increased irritability and problems with much significance to either deviation from the average. As the disturbance progresses, symptoms in- When a child’s deviation from the average milestones of clude depression, bereavement-type reactions (character- development cause the parents concern, they may con- ized as guilt over having survived when others did not), tact a pediatrician or other professional for advice. The in- Spoken language problems are referred to by a num- ability to concentrate and loss of memory are also com- ber of labels, including language delay, language dis- mon. Emotional indifference, withdrawal, lack of atten- ability, or a specific type of language disability. In gener- tion to personal hygiene and appearance, and self-endan- al, experts distinguish between those people who seem to gering behaviors are also possible signs of combat neuro- be slow in developing spoken language (language delay) sis. Individuals suffering from combat neurosis often react and those who seem to have difficulty achieving a mile- to these symptoms by abusing alcohol or drugs. Language Combat neuroses can be a severe mental disorder disorders include stuttering; articulation disorders, such and the potential success of treatment varies consider- as substituting one sound for another (tandy for candy), ably.

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