Behavioural Science Week 5 - Drug Abuse To Comp/alt Med

Front 1

What is the scope of the problem of drug abuse? i.e. epidimiology of it?

Back 1

- 15-20% lifetime risk of abuse/dependence in men and less in women.

-Abuse of drugs can:
--Cause wide range of psychiatric symptoms
--Contribute to problems in workplace
--Contribute to fatal accidents and injuries
--Exacerbate almost all major madical problems

Front 2

What is the percentage that is dependent on?
1. Alcohol
2. Cocaine
3. Marijuana

Back 2

1. 12%
2. 16%
3. 9%

Front 3

Define:
1. Intoxication
2. Withdrawl
3. Tolerance

Back 3

1. Intoxication - Substance-Specific syndrome of maladaptive behavioral or psychological changes due to CNS effects

2. Withdrawl - Substance-Specific syndrome due to cessation or reduction in use that has been heay and prolonged.

3. Tolerance - need for increased amounts of desired effects or diminished effects with same amount.

Front 4

What is substance ABUSE?

Back 4

Maladaptive patter of use leading to impairment or distress. as manifested by one (or more) of the following, occuring within a 12-month period:

1. Failure to fulfill role obligations
2. Use in hazardous Situation
3. Recurrent legal problems
4. Use despite social/interpersonal problems caused/exacerbated by the drug

It is when the drug takes a HOLD of you:
H - Hazardous Situations
O - Obligations unfulfilled
L - Legal Problems
D - Difficulties w/interpersonal relationships

Front 5

What is Substance Dependence?

Back 5

Maladaptive pattern of use leading to impairment or distress, as manifested by three (or more) of following, occuring within a 12-month period:

1. Tolerance
2. Withdrawl
3. Use in larger amounts or over longer period than intended
4. Unsuccessful efforts or persistant desire to cut down or control use.
5. Grat deal of time spent on activities to obtain, use, or recover from effects
6. Give up or reduce important social, occupational, or recreational activities.
7. Continued use despite knowledge of having a persistent or recurring physical or psychological problem caused by substance.

Front 6

Acronym for Substance Dependence:

Back 6

"WE are unable TO CUT our using"

1. Withdral Symptoms
2. Exessive using (progressivly increasing amounts)
3. Tolereance
4. Occupational/Social abondonment (in order to use)
5. Continued use despite physical/psychological consequences
6. Uncontrolled use
7. Time increasingly occupeied by using

Front 7

Define the Course Specifiers for drug dependence/abuse?

Back 7

- Early Full Remission - no criteria met for dependence or abuse for 1 to 12 months.

- Early Partial Remission - one or more criteria met for dependence or abuse for 1 to 12 months but full criteria for dependence not met.

- Sustained Full Remission - No criteria met for dependence or abuse for > 12 months.

- Sustained Partial Remission - one of more criteria met for dependence or abuse for > 12 months but full criteria for dependence not met.

Front 8

Neural Mechanisms: Dysregulation of neural transmission as a basis of chemical dependence. Neurotransmitters in the MFB disrupted...

For ..
1. Dopamine
2. Serotonin
3. Endorphins
4. GABA
5. Glutamate
6. Acetylcholine

Back 8

1. affected by cocaine, amphetamine, alcohol
2. alcohol, LSD
3. alcohol, opioids, nicotine
4. alcohol, benzadiazapines
5. alcahol
6. alcahol, nicotine

* Alcahol affects all neurotransmitters.

Front 9

Describe the dysregulation/what could it be due to?

Back 9

Dysregulation could be due to too much or too little nerotransmitters produced, abnormal breakdown (degradation) of neurotransmitter or abnormal receptor function

Dopamine centers (reinforce behavior necessary for species survival - eating and sexual activity) -- get overwhelmed by Dopamine triggers by drugs

Front 10

Describe Marijuana:

Back 10

- Fat soluble, persists in body for 7 - 10 days.
- 1-15% THC in a joint
- 400 other compounds, some carcinogens
- Reduced Glucose uptake
---------------------------
Subjective Effects -> Euphoria, Anxiety, Social Withdrawl, Perceptual Changes - touch, taste, smell, Slowed time sensation, Decreased Libido

Objective Effects - Increased HR and appetite, Conjunctival Reddening, Dry Mouth, Short-Term memory impairment, Impaired motor coordination, Impaired Judgment

-----

@ high doses -> Hallucinations, Delusions, Disrupted, Anxiety/Panic, Decreased Intraocular Pressure

Chronic Effects -> Broncitis, Asthma, Cancer, Amotivational Syndrome

Pattern of Use: Mostly adolescents and young adults 18-30, mostly males, but now in all segments of society. Survey (NIDA 2002) of use in last month: 8th grade - 8%, 10th grade - 18% and 12 grade - 21%.

Medical Use:
- Decrease intraocular pressure in glucoma patients
- Appetite Stimulant in anorexia and AIDS patients
- Supress Nausea & Vometing induced by cancer treatment (radiation/chemo), also treatment of AIDS, MS
- Decrease immune response of body to reject organ transplants

Front 11

Describe Hallucinogens:

Back 11

May modify serotonin action, increase responsivity of brain stem of sensory input, affect perceptual control systems

Flashblacks- hallucinogen persisting perception disorder following cessation, recognized as drug effct

12 hours of "trip" 2-3 days of acute psychotic episode.

Subjective Effects - perceptual changes, synesthesias, Depresonalization, Illusions, Hallucinations, Paranoid Ideation, Psychotic Insight, Impaired Judgment, Time Distortions.

Objective Effects: Mydriasis (dilation of pupils), Increase in BP, HR, sweating, Hand tremor, incoordination, Blurred Vision

Pattern of Use: Educational Transmission. Upper/Mid Class 18-34 y.o.

Front 12

Describe Cocain:

Back 12

- Can be introduced into body in any way
- Sibjective "rush" for 20-30 min
- Rapidly Metabolized, 50% eliminated in 1 hr
- Paranoid Delusions with high dose, chronic use.

Subjective Effects: Euphoria, Hyperactive, Hypervigilant, Supress Fatigue, Apetite, Increased Sociability, Impaired Judgment, Difficulty Concentrating, Hallucinations

Objective Effects: Increased HR, BP, Arrhythmias, Vasoconstriction (risk of stroke & MI), Dilated Pupils, Nausea/Vomiting

Withdrawl - Dysphoric mood with fatigue, vivid & unpleasant dreams, insomnia/hypersomnia, increased appetite, psychomotor agitation/retardation

Pattern of use:
- Powder - male, white, 30-34
- Crack - male, black, 30-34
- use in evening continously for several hrs
- increased incidence and prevalence

Medical use:
-Dialated Pupils (topical)
- Anesthesia (topical and nerve block)
- Decreased Bleeding

Front 13

Describe Amphetamines:

Back 13

Effects:
- increased energy/activations, hypervigilance
- increased HR, BP, sweating
- Dilated Pupils
- Evidence of weight loss
- Euphoria/Decreased Fear
- High Lasts 8-24 hrs
- 50% removed in 12 hrs, UA+1-3 days.

Patterns of use:
-Cyclic- use for several weeks, several days, sleeplesness, crash for several days, reactive depression, start cycle over.
-use in mornings, then every 2-4 hrs.
Used in narcolepsy and short-term died control; no longer used for ADHD

Front 14

Describe Sedative-Hypnotics:

Back 14

-Effects: Innapropriate sexual/agressive behavior
-Impaired Judgment
-Impaired attention and memory consolidation
- Slurred speech, incoordination, ataxic gait, nystagmus
-Stupor or Coma

Withdrawl Symptoms: Autonomic Hyperactivity, Hand Tremor, Insomnia, Nausea/Vomiting, Agitation, Anxiety, Seizures, Death

Pattern of Use: Primary iatrogenic, Given for sleep but sleep quality is poor so take more.

Appropriate prescribed use of anti-anxiety drugs is fixed interval rather than PRN (variable interval)

Women more then man (over 25)
Men more then Women (under 25)

Front 15

Describe Narcotics:

Back 15

--opium, morphne, heroin, vicodin...etc--
- Bind at opiate receptors, dulls senses and relieves pain
- has no deteriorating physical effects
- Administrated by various routes.
- Tolerance is infinite if build up gradually with pure drugs
- Withdrawl is rarely life threatening
- Shorter acting narcotics - shorter, intense, withdrawls, longer acting - protracted, less severe withdrawl

Effects:
- used to treat pain, supress cough, alleviate diarrhea, and induce anesthesia
- sense of well-being reduced anxiety
- Drowiness, impraited attention or memory, apathy, lethargy, constricted pupils, constipations, nausea, comiting, and respiratory depression. Not as much loss of motor coordination or slurred speech as with other depressants
- Risk of infection, disease, adulteration, and overdose

Withdrawl Symptoms: Dysphoric Mood, Watery eyes/nose, Yawning, Diarrhea, Insomnia, Fever, Nausea/Vomitting, Chilld Alternating with sweatings, Drug Craving, Muscle/Bone Pain, Dilated Pupils

Pattern of Use:
- Iatrogenic - use initiated in medical treatment, escalate dose, drug-seeking behavior (fradulent precription, doctor shopping)
-Experemental or recreational use - abuse sporadically for months or years. May not become dependent but social, medical and legal consequences of behavior are serious
- Younger age of inital use more likely to progress to dependence

Front 16

Describe Phencyclidine

Back 16

Intoxication - within one hour of use, 2 or more of:
- Vertical or horizontal nystagmus
- Hyppertension or Tachycardia
- Numbness or decreased response to pain
- Ataxia, dysarthria, Muscle Rigidity
- Seizures or Coma
- Hyperacusis
- Bizzare, Violent Behavior

Pattern of Use:
- Smoke Severl Time a day - peak in minutes
- Oral - Peak 1 hour
- Mild intox resolves 8-20 hrs, severe - days
- More in males, minorities, 20-40 y/o

Front 17

Describe Inhalants:

Back 17

Commercial and Volitile Solvents -- Plastic, Cement, Lacquer, Nail polish remover, petroleum products, amyl nitrate.

- Aerosoles - propellants, solvents, hairspray

- CND depressants; tolerance may develop with heave use, but no withdrawl syndrome

- Hydrocarbones excreted by lungs, others are fat-soluble cross BBB
- High Lethaliry
- No Chronic Effects Demonstrated

Acute Effects:
- Incoordination, Diziness, Slurred Speech Ataxia, Nystagmus, Tremor, Blurred Vision
- Euphoria
- Belligerence, Assaultivness
- Depressed Reflexes, Incoordination, Lethargy, Muscle Weakness, Stupor
- Perceptual Distrubances

Pattern of Use:
- Used Recreationaly by poorer pre-teens and teens (10-15 yrs-olds use most; 10:1 male to female)
- Use 1-5 years then go to alcohol when they can afford it
- Kids model after parents use of alcohol
- Also used by those with limited access to other substances (prisoners, isolated military)

Front 18

Physicians and Drug Abuse:
1. What is the most commong cause for premature physician death?
2. What is the prevalence of drug / substance abuse in physicians?

3. How many enter treatment and return to their proffesional positions?

4. What about medical students?

5.Residents?

6. Practicing Physicians?

Back 18

Physician Impairment - can't do their job due to drug/substance abuse or other problems (i.e. health).

Suicide is the most commong cause for premature physician death.

2. 8-12%. RR is greater for anesthesiologists and emergency medicine.

3. 75-85%
4. Found that a 18% med the criteria for alcohol abuse.
5. Most intense training.. higher rates of alcohol abuse, benzos and opiate use compared to peers. Emergency medicine / Psychiatry had highest rates of drug abuse, surgeons, lowest.

6. Same as above.

Medico-Legal Issues:

National Practitioner Database Bank (1990) designed to maintain files on individual physicians concerning actions taken by state licensing boards, hospital medical staff officers, state medical societies as well as malpractice claims.

Front 19

What is the taxonomy of drug-seekers?

Back 19

Professional Patients - Exploit Chronic Medical Conditions for Feign Illness to Secure Drugs.

Pseudo-Addicted Patients - Have been legitimatley prescribed medications for pain managment.

Psychologically Disturbed Patients - May Inflict Extrenal Trauma upon selves or violate own body cavities to create reason for requiring meds.

Front 20

1.How many adults had experiance with alcohol in US?
2.Of those ____ males and ____ females, had adverse life events related to alcohol.

Back 20

1. 90%
2. 60% and 30%

* Most people learn from their mistakes and moderate their drinking*

Front 21

1. ___ Americans abuse alcohol or are dependent.
2. Alcohol dependence is more common in ___ w/ a ratio of ___.
3. Abuse and Dependence progresses more rapidly in_____
4. Are there gender differences in blood alcohol concentration (BAC) ?

Back 21

1. 19 million (1 in 13 adults)
2. Male (Ratio of 5:1)
3. Women
4. Yes

Front 22

What are some of the cultural differences in alcohol abuse?

Back 22

1. Cultural Differences Exist.
2. Alcohol Abuse and Dependence Rates are about equal in Caucasians and African Americans
3. Slightly Higher abuse and dependence rates in Latino Males
4. Very low in Asian populations ( due to adverse physical effects at low doses)

Front 23

What are some problems w/ Alcohol abuse?

Back 23

- The earlier in life one starts drinking, the greater the risk of developing alcohol abuse and/or dependence.
- Health - Related problems associated with drinking include various cancers, brain damage, immune system problems and fetal alcohol syndrome.
- 50% of fatal traffic fatalities involve alcohol.
- Most homicides and suicides involved alchol or drugs.

Check Slides for some numbers..

In purley economic terms, alcohol-related problems cost the American society an estimated $185 billion annually

In hman terms, the cost cannot be calculated!

Front 24

What are the three types of alcohol?

Back 24

- Methyl Alcohol - used in solvents;
- Isopropyl - ' rubbing ' alcohol
- Ethyl [EtOh] - found in beer, wine, distilled spirits and fules.

Front 25

How much constititues one drink?

Back 25

The same amount of alcohol is found:
- one 12-ounce beer
- one 5-ounce glass of wine
- one and 1/2 shot of liqur

Front 26

How much is too much?

Back 26

- Social Drinking - no clinical definition exists
- Moderate Drinking - 2-3 drinks for men / 1-2 drinks for women
- Heavey Drinking - Anything beyond moderate drinking, or drinking every day (includes "binge" drinking).

---------------------------
The terms 'alcoholic' and 'addict' are not clinical terms (but most people know when they see one)

The Diagnostic and Statistical manual o Mental Disorders (DSM-IV) describes the following alcohol-related disorders:
-- Intoxication
-- Withdrawl
-- Abuse
-- Dependence

Front 27

What is Alcohol Intoxication?

Back 27

- Recent injestion of EtOH
- Behavioral / Psychological changes during or shrtly after ingestion (libile mood, poor judgment, inappropriate aggression or sexual behaviour)
- One or more of the following: slurred speech, incoordination, unsteeady gait, stupor, nystagmus, poor attention/memory.
- Not due to a mental disorder

Front 28

Alcohol Withdrawl

Back 28

-Cessation of or significant reduction in alcohol use that has been heavy and prolonged:
- At least 2 of the following:
-- Autonomic Hyperactivity
-- Hand Tremor
-- Insomnia
-- Nausea/Vometting
-- Hallucinations/illusions
-- anxiety/psychomotor agitation
-- grand mal seixures

Front 29

Alcohol Abuse:

Back 29

Maladaptive pattern of alcohol use over a 12 month period resulting in 1 or more:
-- Failure to fulfill major role obligations
-- use in physcially hazardous situtations
-- recurrent social/interpersonal/legal problems
-- continued use despite recurrent social or interpersonal problems caused or exacerbated by alcohol.

Front 30

What is Alcohol Dependence ?

Back 30

Maladaptive pattern of alcohol use over a 12 months period as manifested by 3 or more of the following 7:

- tolerance
- Withdrawl
- Increased amounts of extended durations
- Desire to stop; unsuccessful attempts
- lots of time spent to obtain alcohol
- important activities are abandoned
- alcohol use is continued despite knowledge of the damage it is causing.

Front 31

What is CAGE?

Back 31

-have you ever felt you need to CUT down?
- have people ANNOYED or critisized you about your drinking?
- have you ever felt bad or GUITY about your drinking?
- Have you ever had a drink in the a.m. as an "EYE OPENER" to stedy your nerves or get rid of hangover?

Front 32

Clinicial Aspect of Neurobiology of Alcohol?

Back 32

- EtOH is an irregulary descending CND depressant
- It is classified as a neurotoxin
- It has no real food value, so it is easily absorbed by the stomach and small intestine
- it is hydrophilic (has a strong affinity for and is readily dissolved in water).

- Alcohol is processed (and is known to be broken down) primarily by the liver
- It takes the liver about one hour to break down or detoxify one drink
- Time is required to detoxify larger amounts of alcohol
- You cannot sober up quickly with cold showers, food, coffee, or exercise.

Front 33

Once injested EtOH affects?

Back 33

- The Frontal Lobe, alteraing or impairing:
- Judgment
- Reasoning and Problem-Solving
- Self-Awarness/Self-Monitoring
- Planning, Organization, Sequencing
- Shifting and Dividing attention
- Emotional Control
- Inhibition

Front 34

Continued EtOH consumption does what?

Back 34

Alters or impairs other higher cortical functions:
- narrowing of the visual fields, visual neglect
- comprehension and relevance of incoming information
- encoding (verbal/auditory memory)
-"blackouts"

Front 35

Higher blood alcohol concentration (BAC)affects?

Back 35

Subcortical Functions:
- Cerebellum - causing decreased balance, poor fine motor control
- Brain Stem - decreased arousal and life-sustaining functions (heart rate, respirations).
- Spinal Cord - decreased reaction time and impaired reflexes?

Front 36

What were some early ideas about alcoholism?

Back 36

- Drinking was a choice, therefore the 'drunkard' was a weak, had no will power, sinner, etc.
- Benjamin Rush (1810) wrote about the progressive nature of alcoholism and loss of control. He recommended abstinence
- Temperance movment was followed by Prohibition, During prohibition alcoholism was seen as a cime.

Front 37

What was Jellinek's Disease Model?

Back 37

- Gained acceptance in the 1960s
- Described alcoholism as progressie and fatal.
- Defined stages of disease
- Only some people who were unable to abstain suffered from alcoholism
- Ushered in the begining of scientific examination of the disorder, and the importance of enviornmental, developmental and social factors.

Front 38

What are some of the Genetic Studies?

Back 38

Family Studies - children of alcoholics are 3-4X more likley to develop a disorder compared to children of non-alcoholic controls. COA do not show higher rates of other disorders.

-Concordance rates for identical twins is 58% vs. 28% for fraternal twins

- Children of alcoholic parents are significantly more likely to develop alcohol abuse or dependence, even when raised w/ non-relative surrogates who did not drink.

Front 39

Describe Social Learning and Conditioning:

Back 39

-Families, friends and others in our society at large influence our behavior
-Instrumental learning - a behavior reliably followed by a reinforcer increases the probobility of that behavior occuring in the future.
- Classical Conditioning - Stimuli reliably signaling the arrival of the reinforcer can acquire that ability to elicit behavioral reponses.

UCS (waning BAC) -> UCR (discomfort, irrit)
CS (return home) -> CR (discomfort, irrit)

Front 40

Describe pos/neg reinforcement in social learning and conditioning?

Back 40

Negative Reinforcement: Terminating an aversive stimulus, reducing unpleasent withdrawl effects, may occur with inital use by decreasing unpleasant emotions.
Neg. Reinf. - Relief From Boredom - Delayed

Positive Reinforcemnt (Operant Conditioning) - Pos. Reinf- buzz from drug - immediate Beh. Assoc. with taking drug will increase probobility of euphoria.

Front 41

Describe brain reward mechanisms:

Back 41

-Brain Reward mechnisms involve the dopamine system in frontal-limbic areas (pleasure centers) and serotoning systems.

-Endorphins also produce pleasure and dampen pain

- Drugs can alter brain's normal reward circut and produce reliance on external agents of pain relif

Front 42

Describe the development of Drug Abuse/Dependence?

Back 42

-Exposure to drugs
-Use of drugs begins and is met with positive consequences
-Use continues and possibl increases, tolerance develops without significant negative consequences
-Use continues and increases, significant negative consequences occur
-Use continues in the face of serious consequences, person is unaware of the relationship between drug use and negative consequences.
-Behaviour change is rarely a discrete, single event; patient moves gradually from being uninterested (pre-contemplation stage) to considering a change (contemplation stage) to deciding to make a change.
- Most people find themselves 'recycling' through the stage of change several times ('relapsing') before change becomes truly established.

Front 43

Describe the evolution of quitting:

Back 43

-It is the turning point ('hitting bottom')
-Active Quitting (Action Stage)
-Maintenance (Relapse Prevention)
-Managing Relapses

Front 44

Treatment Approaches --> Minnesota Model

Back 44

Influenced heavily by Jellinek's Disease concept of alcoholism.

Emphasizes group work to help clients understand the nature of their illness and identify defenses.
-Requires clients to accept a diagnostic model
- Recovery is dependent on complete abstinence
-Resistance is seen as a form of denial and is confronted
-Uses Twelve-Step principles

Front 45

Treatment Approaches --> Cognitive Behavioral Techniques

Back 45

-Identifies maladaptive cognitions and behavior patterns
-Prescribes and teaches specific-coping stratagies to replace maladaptive cognitions and behavior patterns. Reinforces acquisition of adaptive, competing responses.
-Uses behavioral techniques such as modeling, role reversal, directed practice, homework, relaxation training.
-Resistance is expected as part of the change process
-Relapse is seen as part of the recovery process.

Front 46

Treatment Approaches --> Motivational Interviewing

Back 46

-Based on the 'stages of change' model
-De-emphesizes diagnostic labels
-Non-confrontational; resistance is met w/ reflection, acceptance facilitates change, awarness of consequences important.
-Objective is to create cognitive dissonance and prepare client to change (support self-efficacy)
-"if you treat an individual as he is, he will stay as he is, but if you treat him as if he were what he ought to be and could be, he will become what he ought to be and could be." -- Goethe
-This approach reduces the assault on self-esteem and improves commitment to change
-Resistance is seen as interperonal behavior influences by therapist's behavior
-Empowers client to make change (emphesizes client's perception of problem, personal choice, etc)
-Relapse is viewed as a single event, not failure
-"Planting a seed"

Front 47

Treatment Approaches --> Medications

Back 47

-Antabuse (Disulfiram)
-Antidepressants, anti-anxiety medications
-Naltrexone,Naloxone (Narcotic Anatgonists)
-Acamprosate (anti-craving)

Pharmacological approaches to treatment should always be coupled with counseling.

Front 48

Treatment Approaches --> Harm Reducton

Back 48

-Origins in Europe, public health principles.
-Developed as an alternative to traditional 'moral model' and 'disease model' of addictions
-Accepts the notion that some people will not be able to stop abusing substance of choice; recognizes abstinence as an ideal outcome, but focuses on reducing harmful consequences vs. reducing use.
-Embraces "bottom up" (addict advocacy) vs. "top up" (authoriterian) approach.
-Promotes "low threshold" access to services
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Read Conclusion in packet
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Front 49

1. Most men and women rate sex as______.
2. Importance of sexuality to quality of life decreases with __________.

Back 49

1. Important in their overall life.
2. Age

Front 50

Sexuality: Therapy as a moral enterprise:

Back 50

- No sexual norms found in nature
-Classifying sexual behaviour is never a scientific judgment
-No correct "philia"

Front 51

Paraphilia: Inanimate Objects

Back 51

Fetishism - fetish object is required or strongly preferred for sexual excitement. [i.e. penties, bra, shoes, boots, balloons]
-- Can also include focus on certain body parts (e.g. feet, hair, ears)
-- Transestic Fetishism - Cross-Dressing (males).

Front 52

Paraphilia: Suffering or Hmilation

Back 52

Masochism - acts (real or stimulated) of being humilated, beaten, bound, or otherwise made to suffer

Sadism - acts (real or stimulated) involving psychological or physical suffering (inc. humiliation) of victim.

Front 53

Paraphilia: Unwilling Partners

Back 53

- Exhibitionism - exposure of one's genitals o an unsuspecting stranger in a public place
- Voyeurism - observing an unsuspecting person who is naked, disrobing or engaging in sexual activity.
- Padophilia - Sexual activity w/ a child (<13); person >16 and at least 5 yr old.
- Frotteurism - touching and rubbing against a non-consenting person

Front 54

Gender Identity Disorder:

Back 54

- Strong and Persisten cross-gender identification
- Persistent discomfort with his or her own sex or a sense of inappropriateness of gender role of that sex.

Front 55

Sexual Addiction:

Back 55

-Not a recognized DSM-IV diagnosis
-One who compulsively seeks out sexual experiances and whose behaviour becomes impaired if unable to gratify sexual impulses.
-May also describe habitual, compulsive, unsatisfactory, foolish, egotistical, self-destructive, inconsiderate, and aggressive sexual behavior.

Front 56

Sexual Dysfunctions:

Back 56

-Individual's sexual response is significantly impaired. Can be occasional, freqent, or permanent.
-"Soft" Definition - what degree of impairment is 'significant' and to whom?
-Sexual Dysfunction rarely applied to same-sex couples or to sexual-stimulation, generally refers to dysfunctions preventing or interfering with coitus [sexual intercourse].

Front 57

During sexual dysfunction diagnosis, what do you look for?

Back 57

- Physical Exam
- Sex History
- Female Sexual History (only for females)

Front 58

In evaluating the female sexual history, what do you look for?

Back 58

- Details on any pain or dyscomfort
- Any previous treatment
- First sexual experiance
- Early learning regardless of sexuality
- History of sexual/domestic/psychological abuse
- Sexually transmitted diseases
- Pregnancies
- History of sexual problems

Relationship quality
- Conflict
- Communcations
Sources of stress and/or anxiety
-Employment
-Elderly parents
-Children

Front 59

There is an increased asociation of marital problems with:

Back 59

- Arousal, Orgasm, Enjoyment Problems.

Front 60

Problems w/ sexual pain are:

Back 60

Dyspareunia: ganital problems associated w/ sexual intercourse.

Vaginismus: involuntery spasm of the musculature of the outer third of the vagina that interferes with sexual intercourse.

Front 61

What are some of the subtypes of sexual dysfunction:

Back 61

Lifelong: Since onset of sexual functioning
Acquired: developes after a period of normal sexual functioning
Generalized: not limited to certain types of stimulation, situations or partners
Situational - limited
Due to pschological factors
Due to medical factors

Front 62

Sexual Dysfunction: Problem of Desire..

Back 62

Sexual Aversion - aversion to and avoidance of sexual contact

Inhibited (hypoactive) sexual desire- deficient sexual fantasies and desires for sexual activity. Judgment of deficiency or absence is made by clinician, taking into account factors that affect sexual functioning, such as age and context of person's life.

Front 63

Sexual Dysfunctions: problems with arousal

Back 63

Female sexual arousal disorder - persistent or recurrent inability to attain or maintain adequate lubrication/swelling response.

Male erectile disorder - persistent or recurrent inability to attain or maintain an adequate erection.

Front 64

Sexaual Dysfunctions: Problems of Orgasm

Back 64

-Female orgasmic disorder - delay or absence of orgams following a normal arousal

-Male orgasmic disorder - same;sexual activity judged by clinician to be adequate in focus, intensity, and duration for person's age.

-Premature Ejaculation - orgasm and ejaculation with minimal stimulation or before person wishes

Front 65

What can be done to help with sexual dysfunctions?

Back 65

-Ignore female/male stereotypes
-Expand options beyond coitus
-Orgasm is not everything
-Change attitutdes, reduce pressure to perform

Front 66

Describe PLISSIT: A graduated Counseling System

Back 66

Permission Giving - letting patients know that sexual concerns are common and that it appropriate to discuss sexual concerns

Limited Information - providing brief education, correcting erroneous notions and expectations.

Specific Suggestions - Providing resources for information, suggestions to improve sexual activity, and information on intervention.

Intensive Therapy - initiating long-term individual therapy and/or referral to a therapist specializing in sexual dysfunction or marital counseling.

-----------------------
P = Permission
LI = Limited Information
SS = Specific Suggestions
IT = Intensive Therapy
-----------------------------

Front 67

How many % of women experiance sexual problems?

Back 67

- 43%

Front 68

How do you treat problems of arousal?

1. Lack of vaginal lubrication 2. Lack of erection

Back 68

1. artificial lubricans, other forms of sexual acitivity, postpone coitus

2. drugs to improve tumescence (erection), reeduction, mechanical devices.

Front 69

How do you treat problems with orgasms?

Back 69

Unsatisfacotry Timing:
- Women can train self to speed up (self-stimulation)
- Man can learn how to slow down (squeeze technique)
- Man accepts difference in timing and helps woman reach orgasm in some non-coital way.

- Absence of orgasm in women
- Mutual pleasuring exercises, sensate focus
- Female superior, side-by side positions
- Self-help manuales and videos
- Pubococygeus muscle exercise
- Use Viabrator

Remember, timing of orgasms is basically a matter of a couple's mutual adjustment.

Non-demanding attitude and full communication of needs, wishes, and fears, along with appropriate exercises, are keys to couple's satisfaction.

Front 70

Interview Skills: Discussing Sexual Function

Back 70

Ideal Setting:
- Private Setting
- No Desk separating patient and physician
- Patient is clothed and comfortable
- Once a conversation has been established
- After review of systems

Physician Body Language
- Relaxed nature
- Practice using sexual terminology
- Proper therapeutic distance
- Active Listening
- Eye contact
- Gesturing with open arms

Front 71

General Conclusions about Sexual Dysfunction...

Back 71

- Patient comfort, physician body language, and the setting are important components of a patient-physcian discussion of sexual function, not MD gender.

- The evaluation and diagnosis of sexual dysfunction should be based on medical, sexual and psychosocial histories.

- Medical devices or pharmaceuticla agent may be used to treat arousal, orgasm, and desire disorders.

- Sex therapy and psychotherapeutic interventions may be necessary in treating sexual dysfunction.

Front 72

What is CAM?

Back 72

Complementary and Alternative Medicine

Complementary: Together With
- Acupuncture to help with pain after surgery
- Tai Chi or Massage with anti-anxiety med

Alternative: In Place Of
- sing garlic to lower blood pressure
- Homeopath instead of regular doctor

Integrative Medicine: Combines treatments from conventional medicine and CAM for which there is some high-quality evidence of safety and effectivness.

Front 73

Why are people using CAM?

Back 73

- Dissatisfaction with health care providers and medical outcomes.
- Side efects of drugs and treatments
- High health costs
- Technology
- Lack of control in their own health care practices
- Time spent with practitioner
- Looking for 'cures'
- Want to use 'natrual' products
- Patient feels empowered
- Focus on spiritually ahd emotional well-being
- Health care provider employs the 3 Ts: touch, talk, time.
- A more culturaly diverse patient population will bring in different/alternative health care practices.

Front 74

Why is it difficult to incorporate CAM into Conventional Medicine ?

Back 74

Medical Model does not focus on prevention or promotion"
- Active Care
- Treat Disease
- Reductionalistic, Mechanistic
- Casulity with linear thinking

This model has done a very good job in extending our lifespan and increasing quality of life (contributing to chronic illness)

Front 75

What are the Foundationl Skills in CAM?

Back 75

-Understanding why patients use CAM
-Learn how to discuss CAM
-Have knowledge base about the varying modalities with the skills and abilities to provide culturally competent care indcluding respect, compassion and dignity.

Front 76

What are some challenges to EBCAM?

Back 76

- Access to the literture
- Types o studies reported
- Lack of standardization of practices and variability between studies
- Different medical system have different classification for disease states
- Control group issues

Front 77

CAM becomes 'legit'?

Back 77

- 1990
Wiki et al v. AMA
- 1991
$2 million dollar in funding to establish NIH office of Alternative Medicine
- 1994
Dietery Supplements health and Education Act

-1995
NIH Office of Dietry Supplements
FDA classifies acupuncture needles as experimental product

-1996
NIH Consensus Conference on Acupuncture

-1997
Fist large trial of CAM therapy, St John's Word for depression

- 1998
National Center for Complementary & Alternative medicine (NCCAM) established
First full scale article in JAMA on herbal medicine
Office of Cancer Complementary and Alternative Medicine (OCCAM) Established

-2001
CAM on PubMed

Front 78

Why are there so few CAM clinical trials?

Back 78

- Drug companies have to do studies to go on the market - supplement companies do not.
- Alternative treatments are often customized for a specific person. Clinical trials try to prove something works for most people.
- Belief systems of some CAM pratitioners do not agree w/ the idea of Western studies, so they do not participate.
- CAM has only recently become 'legit' in the scientific community.

Front 79

What is the Impact of CAM?

Back 79

CDC Report (2004):
- 36% of adults used some form of CAM
- 55% CAM + conventional treatments
- 26% used CAM because a medical professional suggested it
- $30-$47 billion on CAM therapies
- $5 billion on herbal remedies

JAMA (1998)
- 12% of population use herbal medicine.

Front 80

CAM and Physicians?

Back 80

Patients hesistate to reveal use of CAM

Physicians hesitate to communicate about CAM

Therefore:
-Patient-centered communication
-Biopsychosocial approach to patient care.

Front 81

Disease and Conditions that can be treated with CAM?

Back 81

1. Back pain or problem
2. Head or chest cold
3. Neck pain or problems
4. Joing pain or Stiffness
5. Anxiety/Depression
6. Arthritis, gout, loupus, fibromyalgia
7. Stomach or Intestinal Illness
8. Severe headache or migrane

Front 82

Top 5 CAM therapies / Top 10 Supplements:

Back 82

Therapies
1. Natural Products, Dietary Supplements
2. Deep breathing exercises
3. Meditation
4. Chiropractic
5. Yoga

-- Top 10 Supplements --
1. Echinacea
2. Ginseng
3. Ginko Biloba
4. Garlic
5. Glucosamine
6. St. John's Wart
7. Peppermint
8. Fish Oil/Omega 3
9. Ginger
10. Soy

Front 83

What is Alternative medicine?

Back 83

Complete Syste of theory and practice that evolved independtly.

Traditional systems of medicine that are praticed by individual cultures throughout the world.
i.e. Chinese, Ayurvedic.. etc.

Front 84

Describe: Traditional Chinese Medicine

Back 84

- Based on concept of balance qi/chi
- Disease results from disrupted flow, imbalance of yin/yang
- Restoration through herbal and nutritional therapy, exercises, meditation, acupuncture, massage

Front 85

Describe: Ayurvedic Medicine

Back 85

- Place equal emphasis on body, mind and spirit.
- Individual's 'constitution' determines treatment plan
- Treatment may include dietary changes, exercise, yoga, meditation, massage, herbal tonic; controlled breathing, exposure to sunlight.

Front 86

Describe Homeopathy:

Back 86

"Like cures like"
- Small doses, vigorously shaken, are more effective thant standard pharmacologic doses.

Front 87

Describe Neuropathy:

Back 87

- Natural healing power of body
- Non-Invasive
- Uses array of natural interventions from other healing systems
- Nutrition, lifestyle counsseling, dietary supplements, exercise

Front 88

What is Biologically-Based Therapies:

Back 88

- Includes: botanicals, animal-derived extracts, vitamins, minerals, fatty acids, amino acids, proteins, whole diets, and functional foods.

- Dietary Supplements are a sbset of biologically-based practices.

Front 89

What is a supplement?

Back 89

Regulated by FDA
- No requirments for FDA testing
- Manufacturers responsible for ensuring product safety
- Label requirments
- Safety alerts

Front 90

What are some biologically-based supplements?

Back 90

- Echinacea Purpurea
- Gingo Biloba
- Saw Palmetto
- Glucoseamine and Chondroitin
- Fish oils and Omega fatty acids

Front 91

In terms of Energy Therapies, what is:
1. Veritable
2. Putative

Back 91

1. Veritable - energy that can be measured, i.e. sound, visible light, magnetism, MW.
2. Putative - energy that has yet to be measured (biofields)
- Human beings are infused with a sublt form of energy
- Includes qi' (ki in Japanese), doshas, prana, homeopathic resonance, life force, orgone...

Front 92

What are Manipulative and Body-Based Therapies:

Back 92

Structures and system of body, including bones and joints, soft tissues, and circulatory and lymphatic systems
- includes chiropractice manipulation, osetopathy, massage, reflexology, rolfing, Alexander technique, Feldenkrais method..

Front 93

Describe Mind-Body Interventions:

Back 93

- Focuses on interactions among the brain, mind, body, and behavior
- Focuses on ways in which emotional, mental, social, spiritual and behavioral factors can directly affect health.
- Includes relaxation, hypnosis, visual imaery, meditation, yoga, deep breathing, tai chi, biofeedback, group support, creative outlets, prayer and spirituality.

* Look at the last few slides of alternative med packet *

Front 94

For Alternative Medicine, what does it mean to Protect, Permit, Promote and Partner?

Back 94

PROTECT - from dangerous practices or situations

PERMIT - Non-dangerous practices belived in by the patient

PROMOTE - these practices proes safe and effective, esp. in situations where allopathic approached have no desirable intervention avalible

PARTNER - with alternative practitioners

Front 95

In Evaluating Web Sites what do you need to know/be aware of [Alternative Med]?

Back 95

Accuracy - How accurate is this site/information.

Authority - Who created the website?

Bias - Who sponsers the site?

Coverage - is the information complete?

Front 96

Patients report their use of CAM about _____ of the time

Back 96

40%

Front 97

The FDA says that / Claims there must be a label, what should be on that label?

Back 97

-> Must contain a disclaimer stating it is NOT approved my FDA

-> Can't claim curative effect only that it is for a specific organ.. i.e Vitamin A for the heart NOT Vitamine A for Heart Disease.

Front 98

How many people have ever used CAM? How many used it in the last year?

Back 98

1. 75%
2. 36%