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Many primary care providers appreciate having identifying Policy statement: Recommendations for preventive pediatric health information flled in on the form about the child care facility mood disorder 29696 wellbutrin sr 150 mg, care mood disorder therapy quality wellbutrin sr 150mg. The health history can serve as an interim health assessment during this grace period mood disorder research articles buy wellbutrin sr 150 mg on-line. The fle for each child should include a health history completed by the parent/guardian at admission depression symptoms diagnosis treatment cheap wellbutrin sr 150 mg without a prescription, preferably with Health data should be presented in a form usable for carestaff involvement. This history should include the following: givers/teachers to help identify any special needs for care. In some emergency; situations, screenings may be performed at the facilities, but c) Chronic diseases/health issues currently under it is always preferable that the child have a medical home treatment; and primary care provider who screens the child and prod) Developmental variations, sensory impairment, vides the information. When clinicians do not fll out forms serious behavior problems or disabilities that may completely enough to assist the caregiver/teacher in underneed consideration in the child care setting; standing the signifcance of health assessment fndings or e) Description of current physical, social, and language the unique characteristics of a child, the caregiver/teacher developmental levels; should obtain parental consent to contact the child’s prif) Current medications, medical treatments and other mary care provider to explain why the information is needed therapeutic interventions; and to request clarifcation. Children with suspected oral problems should see m) Any special equipment that might be needed; a dentist immediately, regardless of age or interval. This information must be obtained and reviewed at measures of visual acuity by four years and audiomadmission by the signifcant caregiver/teacher. This informaetry measures of hearing by fve years of age); and tion may be the only health information on fle for up to the b) Dental exam at one year (or sooner if there are susfrst four weeks following enrollment. Both the child’s name and the name and dose of the fle for each child should include a medication record the medication should be clear. Medications should never maintained on an ongoing basis by designated staff for all be removed from their original container. Serious should include the child’s name, medication, time, medication side-effects might require emergency care. Addose, how to give the medication, and start and end justments or additional medications might help those sympdates when it should be given; toms if the prescribing health professional is made aware of b) Authorization from the prescribing health professional them. Children who do not tolerate medications may vomit for each prescription and non-prescription or spit up the medication. Notation should be made if any of medication; this authorization should also include the medication was retained in those cases. Children may potential side effects and other warnings about the also vigorously refuse medications, and plans to deal with medication (exception: non-prescription sunscreen this should be made (1,2). Healthy futures: Medication original, labeled container with a label that includes administration in early education and child care settings. American the child’s name, date flled, prescribing clinician’s Academy of Pediatrics. Policy statement: Guidance for the administration of effects and other warnings about the medication medication in school. The f) For medications that are to be given or available facility health log should include: to be given for the entire year, a Care Plan should a) Staff and parent/guardian observations of the child’s also be in place (for instance, inhalers for asthma or health status, behavior, and physical condition; epinephrine for possible allergy); b) Response to any treatment provided while the child is g) Side effects. Caregivers/teachers should 391 Chapter 9: Administration Caring for Our Children: National Health and Safety Performance Standards e) Staff observations of changes in and assessments of source of care for the child. An effective way to educate the child’s learning and social activity; parents/guardians on the value of maintaining the child’s def) Documentation of planned communication with velopmental and health information is to have them focus on parents/guardians and a list of participants involved; their own child’s records. Such records should be used as a g) Documentation of parent/guardian participation in mutual education tool by parents/guardians and caregivers/ health education. Parents/guardIndividual fles for all staff members and volunteers, should ians and caregivers/teachers can use these logs in planning be maintained in a central location within the facility and for the child’s needs. On occasion, the child’s primary care should contain the following: provider can use them as an aid in diagnosing health condia) the individual’s name, birth date, address, and tions. Upon parent/guardian 1) Regulations and statutes governing child care; request, designated portions or all of the child’s records 2) Human resource management and procedures; should be copied and released to specifc individuals 3) Health policies and procedures; named and authorized in writing by the parents/guardians to 4) Discipline policy; receive this information. The original records and the written 5) Guidelines for reporting suspected child abuse, requests should be retained by the facility. For centers, the date of the training, the number of hours, the names of staff participants, the Emergency contact information for staff, paid or volunteer is name(s) and qualifcation(s) of the trainer(s), and the content needed in child care in the event that an adult becomes ill or of the training (both orientation and continuing educainjured at the facility. If the state has a training/professional notifcation of responsibilities that might otherwise by overdevelopment registry, the director should provide training looked by the employee. Continuing praisals, Including Immunization education with course credit should be recorded and the Standards 1. When a caregiver/teacher, substitute provider and/or volunteer cares for more than one group of children during their hours worked, daily attendance records will refect the names of the children cared for during each block of time. This standard ensures that the facility knows which children are receiving care at any given time and who is responsible for directly supervising each child. It also aids in the surveillance of child:staff ratios and provides data for program planning. Past attendance records are 393 Chapter 9: Administration Chapter 10 Licensing and Community Action Caring for Our Children: National Health and Safety Performance Standards 3. Licensing can also be known as “permission,” “certifcation,” All phases of regulatory administration should have autho“registration,” or “approval. Licensing must have a statutory basis, because it operations and enforcement of child care regulations and is unknown to the common law. Reports of unlicensed care should be the administration and location of the responsibility. Fifty promptly investigated and illegally operating providers either states have child care regulatory statutes. The laws of some brought into the regulated system or forced to terminate states exempt part-day centers, school-age child care, care offering care. Fines for continuing to provide unlicensed provided by religious organizations, drop-in care, summer care should be substantial enough to serve as an effective camps, or care provided in small or large family child care deterrent. These exclusions and gaps in coverage expose children ritual and lose its safeguarding intent. Licensing and public regulation of early childhood programs: A position statement. In addition, the “Licensing and Public Regulation of Early Childhood Programs” document published by 10. License exempt entation, or setting of an early childhood program inherently early care and education programs: Equal protection and quality protects children from health and safety risks or provides education for every child. Authorization for operation gives states a mechaimplement, and enforce regulations that reduce risks to nism to identify facilities and individuals that are providing children in out-of-home child care (1,2). Regulations must be: Currently, many church run nurseries, nursery schools, a) Understandable to any reasonable citizen; group play centers, and home based programs operate b) Specifc enough that any person knows what is to be incognito in the community because they are not required to done and what is not to be done; notify any centralized agency that they care for children (2). However, the state public research fndings and changes in public views to offer health agency can be an appropriate licensing authority for necessary protection and to avoid unacceptable risk; safeguarding children in some states. Formulating operationally valid home by someone whom the parent has employed, not a standards. The administrative regulation of community care facilities family child care home, should not be licensed as a child with special reference to child care. Class, Professor Emeritus, School of Social Work, University of Southern California. Chapter 10: Licensing/Community 398 Caring for Our Children: National Health and Safety Performance Standards Regulations formulated through a representative citizen prothis advisory board should be linked to the State Early cess should come before the public at well-publicized pubChildhood Advisory Council (see Standard 10. The licensing advisory board should should include many opportunities for public debate and report directly to the agency having administrative authority discussion as well as the ability to provide written input. The interests of the child must Management/Head Start Requirements/Head Start Act/. Formulating valid standards for service, and education departments; institutions of higher licensing. The council should be States should have an offcial child care licensing advisory mandated by law, and should report to the legislature and to body for regulatory and related policy issues. Larger communities should advisory board should: have a network of local councils to advise the state council. Some states have separate groups that advise the health the advisory group should include representatives from the agency, the social service agency, the education agency, the following agencies and groups: licensing agency, the governor, and the legislature (1). Other a) State agencies with regulatory responsibility or an states have some, but not all, of these advisory bodies; interest in child care (human services, public health, each of which has some relevance to child care, but often fre marshal, emergency medical services, education, with a different focus. Manand referral, early childhood education, and early dating the council by law will reduce the likelihood that the childhood professional development; council will be rendered ineffective by changes in political e) Parents/guardians who refect the diversity of the leadership or dissolved when its recommendations are not families that are consumers of licensed child care in agreement with a current administration.
They should keep their attention focused on the catastrophe “and to depression symptoms hallucinations order 150 mg wellbutrin sr amex think about it or imagine it with as much detail and vividness as possible depression test by doctors purchase wellbutrin sr in india. If their mind wonders off the worry topic depression video game wellbutrin sr 150mg without prescription, try to depression symptoms female generic wellbutrin sr 150mg otc pull it back to the worry as quickly as possible. Clients are encouraged to use the catastrophe script to help them focus on the worry. Particular attention should be given to recording the quality of the catastrophe exposure and any anxious thoughts about engaging in the worry exercise. The client should write down challenges to the anxious thoughts that will encourage more repetition of the worry sessions. If worry occurs during some other time of the day, individuals are to postpone the worry until the worry exposure session. This can be accomplished by writing down the worry content on the Worry Self-Monitoring Form B (Appendix 10. It challenges individuals’ maladaptive beliefs about the dangers and uncontrollability of worry and prevents the use of ineffective worry control strategies. Safety Cue Processing Chronic worriers become so focused on threat and uncertainty during the worry process that they often fail to process positive, safe, or benign aspects of a worry situation. Thus the cognitive therapist takes every opportunity while assessing aspects of worry or employing cognitive restructuring to explore the positive or safety aspects of situations. Individuals are encouraged to write down aspects of a worry situation that are positive or safe as a counter to their automatic threat and danger interpretations. The purpose of this intervention is to help individuals develop a more balanced, realistic perspective on the worry. Sometimes there may be one or two primary safety cues associated with the worry, whereas at other times there may be multiple indicators of safety that are evident throughout the worry process. After generating the catastrophic scenario, the cognitive therapist helped Clare think about the possible positive or safety aspects of her cancer worry. Generalized Anxiety Disorder 433 Th er a pisT: Clare, you have suggested one possible outcome of the mammogram, that it is positive indicating that you have cancer. Th er a pisT: That sounds very high but it sounds like you are saying there is a 50% chance the test will be negative. But what if you are overestimating the chance of a positive test result and underestimating the chance of a negative outcomefl This kind of thinking will increase your worry and yet it’s not going to change the outcome of the test. Th er a pisT: Well, one thing would be to very intentionally train yourself to pay closer attention to the positive or safety aspects of this situation. You could begin by getting some information on the real likelihood that the mammogram result will be positive. You could also survey family and friends to see how many have had negative results or false positive results and never had cancer. You could then practice reminding yourself of this information whenever you start to worry about cancer. I’m not saying this will magically reduce your worries, but gradually over time you will get better at thinking about cancer in a more balanced fashion. You can’t change the fact there is always uncertainty about cancer for everyone but you could correct how you think about this uncertainty. Before leaving the issue of safety cue processing, it must be emphasized that the objective of this intervention is to counter the client’s tendency to be overly focused on processing the threatening aspects of situations. The therapist does not try to persuade the client that the worst outcome is unlikely to happen. For example, the therapist can not try to persuade Clare that her mammography results will be negative. Instead Clare is being taught to intentionally process safety cues in order to counter her excessive emphasis on thinking that the test will indicate she has cancer. Obviously safety signal processing can not change the fact that a positive test result is a distinct possibility. The therapist is able to identify the individual’s main metacognitive worry beliefs from the worry induction exercise and from cognitive restructuring of biased threat interpretations. Wells (2006) notes that cognitive restructuring of negative metacognitive beliefs involves questioning the evidence that worry is harmful, questioning how worry could be dangerous, reviewing counterevidence, and learning new information. Wells (2006) suggests that the client can be provided information that worry is not stressful but instead a coping strategy in response to stress. The client could be assigned a homework task of fnding information that worry can directly cause heart attacks. A list of individuals the client knows could be generated with one list for all chronic worriers and the other list of all individuals who suffered a heart attack. Students who are chronic worriers are often convinced that the worry will cause a signifcant decline in their academic performance. Again a survey could be conducted to determine how many engaged versus disengaged students are worriers. An alternative explanation is that many factors determine a student’s level of academic performance and worry can play a small, even insignifcant, part of it. Beliefs about the uncontrollability of worry can be challenged by having clients participate in worry induction exercises, paradoxically increase their level of worry during stressful times, or try to lose complete control of worry (Wells, 2006). The point of these behavioral experiments is to provide evidence that in fact worry is a controlled. Cognitive restructuring of the positive beliefs about worry would follow the same format as described for the negative beliefs. For example, the belief that worries lead to problem solving can be tested by examining how often the individual’s excessive worry led to problem resolution. Wells (2006) suggests a mismatch intervention in which the client is asked to compare his catastrophic worry script against a reality-based script. Another behavioral experiment for the individual who believes worry improves his work performance is to ask the client to purposely increase his level of worry prior to leaving for work on certain days and then to monitor the level of improvement in work productivity. They explain that chronic worriers have a strong reaction to even small amounts of uncertainty that causes them to ask “what if” questions. Robichaud and Dugas note there are only two ways to reduce the role of uncertainty in worry: either reduce uncertainty itself or increase one’s tolerance of uncertainty. It is explained to clients that the former option is unrealistic because uncertainty is an inescapable part of life. In our cognitive therapy approach to worry, changing risk and uncertainty beliefs begins with an explanation of intolerance of uncertainty based on Robichaud and Dugas (2006). Next the therapist collects data on the idiosyncratic uncertainty beliefs associated with the client’s primary worry concerns. The “what if” questions generated during a worry episode will provide insight into the client’s risk aversion and intolerance of uncertainty. The column labeled “Responses to Uncertainty” directly assesses intolerance of uncertainty beliefs and the client’s attempts to reduce or avoid uncertainty. Cognitive restructuring of intolerance of uncertainty beliefs examines evidence that uncertainty can be reduced or eliminated, that living with uncertainty is intolerable, and that one has suffcient control over future events to ensure desired outcomes. Leahy (2005) asks clients to examine the costs and benefts of accepting uncertainty versus striving to eliminate uncertainty associated with worry concerns. One of the most useful interventions for intolerance of uncertainty involves a form of “uncertainty inoculation” in which clients are exposed to ever increasing amounts of uncertainty in their daily experiences (Robichaud & Dugas, 2006). For example, a student worried that she did not understand what she was reading in her anatomy textbook. She also believed that the only solution was to reread and repeatedly study the same material over and over again until she was certain she would never forget it. After engaging in a cognitive restructuring exercise in which the therapist challenged the client’s belief that she could attain certainty in her knowledge of the subject matter, a series of behavioral exercises were introduced in which the client reduced her checking and rereading responses and worked on tolerating increasing amounts of uncertainty about the anatomy material she had just studied. A target was set for what constituted a reasonable study strategy that was not based on eradicating all sense of uncertainty about the outcome of the fnal anatomy exam. Cognitive restructuring and systematic exposure to increasing amounts of uncertainty will lead to better acceptance of the uncertainty associated with primary worry concerns. They frst address the clients’ negative problem orientation by using cognitive restructuring to modify dysfunctional beliefs involving doubts about one’s problem-solving ability, a tendency to view problems as threatening, and pessimism about the outcome of problem solving.
Some qualitative differences in the movements have been suggested but these are less clear-cut10 depression test chemical cheap wellbutrin sr 150mg line. Paroxysmal motor disorders occurring from sleep include not only frontal lobe seizures mood disorder nos 311 cheap wellbutrin sr 150 mg, but also Epilepsia depression definition in psychiatry discount wellbutrin sr 150 mg line. There are benign mood disorder xxy wellbutrin sr 150 mg line, unpleasant or undesirable behavioural or experiential phenomena that occur 2. To a reasonable degree parasomnias, such as sleep-walking in frontal and temporal lobe epilepsies. Though the semiology may vary between members of the same kindred, seizures are stereotyped within 13. Neuroimaging is normal, as may be the inter-ictal with autosomal dominant nocturnal frontal lobe epilepsy. However, these genes are not mutated in the majority of kindreds, suggesting Brain 130, 574–584. A recent large series has analysed 70 patients who underwent a frontal lobectomy between 1995 and 2003. A favourable outcome was defined as complete seizure freedom, allowing for auras and seizures restricted to the first post-operative week. It should be noted that, in addition to patients becoming seizure free, a significant percentage of patients experience an 80% or more reduction in their seizures. Another recently published cohort of frontal lobe surgeries documented 55% seizure freedom rate at seven years after surgery16. Completeness of resection of a visible lesion remains one of the most important predictors of good outcome. Surgery need not be associated with increased neurological or neuropsychological deficit. Corpus callosum section may be of benefit in patients with drop attacks, who are at risk of major injury. This may prevent secondary generalisation, or at least slow seizure spread, with less devastating collapses17. The two lobes serve mainly sensory functions, and the characteristic seizure phenomena are therefore subjective sensations. The incidence of these seizures is not well known, but they are generally considered rare. The pattern of seizures is most commonly focal seizures without impairment of awareness, with occasional secondary generalisation. Focal seizures with impairment of awareness are rare and usually indicate spread of the seizure into the temporal lobe. Seizures with somatosensory symptomatology1-3 Somatosensory seizures may arise from any of the three sensory areas of the parietal lobe, but the post-central gyrus is most commonly involved. Seizures present with contralateral, or rarely ipsilateral, or bilateral sensations. All sensory modalities may be represented, most commonly tingling and numbness, alone or together. There may be prickling, tickling or crawling sensations, or a feeling of electric shock in the affected body part. The arms and the face are the most common sites, but any segment or region may be affected. The paraesthesia may spread in a Jacksonian manner, and when this occurs motor activity in the affected body member follows the sensations in about 50% of cases. Pain is the second most common somatosensory seizure experience, often described as stabbing, intense, torturing, agonising or dull. It may be difficult to distinguish the pain from thermal perception or muscle cramps, which frequently follow the pain. Thermal perceptions are less common than pain or paraesthesia, and rarely occur without other sensory phenomena. A small subgroup of seizures with sexual phenomenology seems to originate in the paracentral lobule where the primary somatosensory area for the genitalia is thought to reside, usually involving the non-dominant hemisphere. The seizures present with a tactile somatosensory aura affecting the genitalia, but the ensuing seizure may exhibit other features of sexual behaviour. A feeling of inability to move is thought to involve the secondary sensory area on the suprasylvian border. Paroxysmal ictal paralysis may spread in a Jacksonian way and be followed by clonic activity in the same body part. Other somatosensory features in epilepsy are body image disturbances, such as feeling of movement or altered posture in a stationary limb, feeling of floating, twisting or even disintegration of a body part. Rarely the eyes are the only affected body part, and in those cases the discharge is thought to involve the rostral occipital cortex. The peripheral suprasylvian border close to the sensory region for the mouth and tongue. Vertiginous sensations are also parts of the extremities and tongue are most commonly affected. Other described disturbances are unilateral thought to originate in the suprasylvian and possibly the occipito-parietal region. Various seizure types asomatognosia where absence of a body part, limb or the hemibody is experienced and sensation may occur in a single patient at different times. The only primary motor seizures from the posterior brain regions are oculotonic and oculoclonic seizures, Parietal onset seizures are great imitators and may, for example, give rise to hypermotoric seizures, that or epileptic nystagmus, originating in the occipito-parietal cortex. Eyelid flutter and rapid blinking are other It is important to note that there is also sensory representation in the posterior insula and in the features of occipital epilepsy, often at the very beginning of seizures. Provoking and associated/accompanying features1 Seizures with visual symptomatology1,3 Partial occipito-parietal seizures may be provoked by various stimuli involving the receptive, interpretive and connective function of the parietal and occipital lobes. The most common precipitating factor Seizures from the occipital lobes and the parieto-occipital junction are characterised by visual phenomena, is photic stimulation, but other well-known inducers are tactile stimulation, reading, drawing, calculation but visual auras may occur in epilepsy affecting any part of the visual pathways. Visual loss, either total or partial, may also occur and is especially common in children. Transient amaurosis as an ictal phenomenon Seizure spread from an occipital or parietal origin may cause a variety of motor activities; some patients may lasts seconds to minutes, but visual loss may also occur as a post-ictal deficit. Amaurosis is usually have different patterns of seizure spread in different seizures, misleadingly suggesting multifocal disease. Post-ictal phenomena associated with parietal and occipital seizures are transient numbness, inability Formed visual hallucinations are experienced fairly often in epilepsy. Pictures of people, animals or to move despite no loss of power in affected limbs and post-ictal blindness. One subtype is epileptic autoscopia, where the subjects between duration and severity of seizures and the duration of the post-ictal neurological deficits. Formed hallucinations are usually numbness and paralysis are usually short lasting, but post-ictal blindness may be prolonged and, brief, and may be associated with slow head and eye turning, with the gaze towards the direction of the in some cases, permanent. In comparison with migraine, that is usually associated with Causes sharp lines and fortification spectra, the visual hallucinations of occipital seizures commonly comprise coloured blobs of light. As a further distinction, the visual aura of migraine usually evolves much more In a large series of patients with parietal lobe epilepsy from the Montreal Neurological Institute6,7, tumours, slowly, over several minutes. Causes include tumours, trauma, malformations (focal cortical dysplasia, periventricular have been located to the non-dominant parietal lobe. The simplest types mainly involve visual illusion heterotopia, band heterotopia and polymicrogyria), ischaemia, mitochondrial disease (with migraine, of spatial interpretation, illumination or colouring of vision, or movement in space. Perceived objects photosensitivity and other neurological manifestations), Sturge-Weber syndrome and coeliac disease with may appear diminished or enlarged (microor macropsia), altered in shape, squeezed or compressed bilateral occipital calcifications. Occipital seizures can occur in hyperglycaemia and pre-eclampsia, and from above, downwards or sideways, vertical and horizontal components may be oblique and lines may occur early in the course of Kuf’s disease or Lafora body disease. Lines may be defective or fragmented, stationary objects seen as moving, or motion appears too epilepsy have been described in childhood and adolescence8–11. More complex forms include inappropriate orientation of objects in benign, and symptomatic occipital epilepsy. The relationship space, like teleopsia, where objects appear both small and at a distance, or enhanced stereoscopic vision, between migraine and occipital epilepsy is complex8. Further, in which near subjects seem very close and more distant objects located very far away. Palinopsia, or epileptic seizures may evolve from an attack of migraine, and vice versa.
With repeated experiences of the intrusive thought depression mentality definition purchase wellbutrin sr 150mg, the orienting mode would be primed to depression definition business order 150mg wellbutrin sr automatically detect occurrences of the obsessive intrusive thought depression symptoms vs anxiety buy wellbutrin sr 150 mg with mastercard. In fact schematic differences will be evident even between individuals who have similar obsessional concerns depression symptoms eyes generic wellbutrin sr 150mg overnight delivery. As discussed below, there is tremendous overlap between these belief Obsessive–Compulsive Disorder 459 table 11. Given this heterogeneity even at the schematic level, it is important that a thorough case conceptualization is conducted in order to understand the nature of each patient’s schematic activation. The activation of these schemas will lead to other automatic processes, the most important being certain cognitive processing errors. An inference is “a plausible proposition about a possible state of affairs, itself arrived at by reasoning but which forms the premise for further deductive/inductive reasoning” (O’Connor, Aardema, & Pelissier, 2005, p. The faulty reasoning processes involved in obsessional states leads to the confusion of an imagined possibility. O’Connor and colleagues identifed a number of inductive reasoning errors that lead to the construction of an idiosyncratic narrative of doubt. These include category errors, confusion of comparable events, selective use of out-of-context facts, reliance on purely imaginary sequences, inverse inference, and distrust of normal perception (see D. This faulty inductive reasoning intensifes a state of doubt and confusion which in turn can elevate the threatening nature of the obsessional concern. Compulsive rituals are a more complex neutralization response that requires considerable elaborative processing and so it is located within the secondary phase of the model. Finally, any automatic thoughts or images that occur during the immediate fear response probably refect the actual obsessional concerns of the individual. A number of key metacognitive appraisals have been implicated in the elaboration and persistence of obsessional thinking (see also Table 11. According to the cognitive model unwanted intrusive thoughts that are appraised in the above manner will result in an exaggerated evaluation of their personal signifcance and potential to cause harm or danger to self or others (Rachman, 2003). This metacognitive elaborative faulty appraisal of the intrusion as a personally signifcant threat is associated with heightened anxiety or distress leading to a sense of urgency to fnd relief from the distress and neutralize the imagined danger. Secondary Appraisals of Control In addition to these primary appraisals of the obsession, D. Clark (2004) proposed that obsession-prone individuals also engage in a secondary appraisal of their ability to cope with or control the obsession. Repeated failures to exert effective control over obsessional thinking will also contribute to an increased evaluation of the signifcance and threatening nature of the obsession as well as a heightened sense of personal vulnerability. Thus both primary appraisals of the obsession and secondary appraisals of one’s control efforts are important elaborative processes that contribute to an escalation in the obsessional state. Neutralization, which often involves covert mental control activities such as reciting a certain phrase to one’s self, is mainly directed at undoing or correcting the perceived negative effects of the obsession (Rachman & Shafran, 1998). Although neutralization efforts may be successful in achieving these aims in the short term, they are nonetheless maladaptive coping strategies that ultimately contribute to an increase in the frequency, salience, and attention given to the obsession (Salkovskis, 1999). Presence of disconfrmation bias—a person erroneously believes the neutralization was responsible for preventing a feared outcome or for reducing anxiety, thus thwarting exposure to any disconfrming evidence (Rachman, 1998, 2003). Heightened attention—based on Wegner’s (1994) ironic process theory, any deliberate effort to control or suppress an unwanted thought will increase automatic attentional search for subsequent reoccurrences of the thought so that the intrusion gains attentional priority. Elevated personal responsibility—the temporary success in dealing with the intrusion will elevate its perceived signifcance and the person’s responsibility in preventing the anticipated threat (Salkovskis, 1989). Excessive control efforts and more ambiguous “stop rules”—repeated brief success in terminating the obsessional concern will lead to even more excessive control efforts and increased diffculty knowing when “enough is enough”. It is beyond the scope of this chapter to present an extensive review of this burgeoning literature but the interested reader is directed to several extended critical reviews that have been published in recent years (see D. Clark, 2004; Frost & Steketee, 2002; Julien, O’Connor, & Aardema, 2007; Rachman et al. Numerous studies have administered either self-report questionnaires or interview checklists and found that the vast majority of nonclinical individuals experience, at least occasionally, unwanted intrusive thoughts, images, or impulses that are similar in content to clinical obsessions. This fnding has been replicated in countries other than those located in North America such as Korea (Lee & Kwon, 2003), Spain (Belloch, Morillo, Lucero, Cabedo, & Carrio, 2004b), Italy (Clark, Radomsky, Sica, & Simos, 2005), and Turkey (Altin, Clark, & Karanci, 2007). There is some preliminary evidence that questionnaires may actually underestimate the frequency of obsession-relevant intrusive thoughts in nonclinical samples when more open-ended interviews are employed (D. Although the continuity between nonclinical and clinical intrusive thought content was recently challenged in a content analysis conducted by Rassin and Muris (2006), there is still considerable empirical support for the universality of obsession-relevant intrusive thoughts. The authors argued that the combination of strong encoding and weak inhibition might perpetuate obsessionality by making vulnerable individuals more responsive to obsessive-like intrusive thoughts and compulsive behaviors. Most of the belief measures have strong correlations with generalized anxiety, worry, and even depression. However, Lee and Kwon (2003) found that importance and control appraisals were more relevant to intrusions that were autogenous in nature (spontaneous occurrence with no identifable trigger), whereas responsibility appraisals were more relevant for reactive intrusions (those evoked by an external stimulus). Overall these studies support the third hypothesis, which posits a close association between how an intrusive thought is appraised. In order to validate the cognitive model, it is important to demonstrate cause-andeffect relations between faulty appraisals and various parameters of unwanted intrusive thoughts or obsessions. However, weaker effects have also been reported, with the main difference attributed to a decrease in responsibility (Lopatka & Rachman, 1995). Although these results are consistent with the cognitive view that faulty appraisals may contribute to the transformation of a normal intrusion into an obsession, there are limitations to this research. There have been inconsistencies across the studies, most of the focus has been on infated responsibility to the exclusion of other appraisal domains, and most fail to control for general distress, which could account for the observed effects (Julien et al. According to the cognitive model, attempts to neutralize or otherwise control the occurrence and distress of obsessional intrusions contribute to the persistence of obsessional thinking. However, reliance on such ineffective response strategies can be reduced with treatment (Abramowitz, Whiteside, Kalsy, & Tolin, 2003a). Studies involving the experimental manipulation of neutralization indicate that it has the same functional characteristics as overt compulsions, as made evident by an immediate decrease in anxiety and perceived threat but a longer term increase in distress and urge to neutralize (Rachman, Shafran, Mitchell, Trant, & Teachman, 1996; Salkovskis, Thorpe, Wahl, Wroe, & Forrester, 2003; Salkovskis, Westbrook, Davis, Jeavons, & Gledhill, 1997). However the studies are inconsistent Obsessive–Compulsive Disorder 467 on the negative consequences of suppression. Suppression of unwanted obsessional intrusions in nonclinical samples has also failed to produce the expected enhancement or resurgence of unwanted thoughts once suppression efforts cease, although suppression may result in more sustained levels of unwanted target thought occurrence in the postsuppression period (Belloch, Morillo, & Gimenez, 2004; Hardy & Brewin, 2005; Purdon, 2001; Purdon & Clark, 2001). In addition failure to completely suppress unwanted target intrusions may have direct or indirect effects on level of distress associated with recurrence of the unwanted mental intrusion (Janeck & Calamari, 1999; Purdon & Clark, 2001; Purdon et al. Whatever the exact processes involved, the overall fndings from the self-report, daily diary, and experimental studies are consistent with Hypothesis 4 that neutralization plays an important role in the persistence of obsessional symptoms with particular effects on the amplifcation of distress and the misinterpretation of intrusions. Recent experimental research on the suppression of unwanted intrusive thoughts in both clinical and nonclinical samples indicates that exaggerated misinterpretation of the signifcance of failed control might be an important contributor to the pathogenesis of obsessions. In an earlier nonclinical thought suppression experiment, exaggerated appraisals of the signifcance of thought control failures was associated with a more negative mood state (Purdon, 2001). Furthermore, individuals who reported a higher need for control exhibited greater thought suppression effort in the experiment. Magee and Teachman (2007) also found that maladaptive attributions of self-blame and importance in controlling thoughts predicted distress and recurrence of unwanted thoughts in a thought suppression experiment. A number of possible vulnerability pathways have been described (see Rachman et al. Salkovskis and colleagues argued that infated responsibility beliefs might constitute an enduring vulnerability for the etiology of obsessions (Salkovskis, Shafran, et al. They speculated that fve different developmental learning pathways could result in the adoption of general infated responsibility assumptions. A preexisting generalized sense of infated responsibility might lead to misinterpretations of certain intrusive thoughts, especially if they are associated with a critical incident of perceived harm (see Shafran, 2005). High cognitive self-consciousness has also been promoted as a possible cognitive vulnerability for obsessions (Janeck et al. Clark (2004) suggested that high trait negative affectivity, an ambivalent self-evaluation, and preexisting metacognitive beliefs about the importance and control of thoughts might constitute a vulnerability for obsessions. Thought intrusions representing failures in these highly valued or sensitive domains of the self. The authors trace the origins of these cognitive-affective representations of self and world to certain developmental and early attachment experiences.
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