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By C. Jose. Louisiana State University at Alexandria. 2018.

Often generic 10mg lipitor with mastercard cholesterol levels 30 year old woman, the process of talking about formerly un- voiced concerns in therapy is healing in and of itself proven 5mg lipitor cholesterol oysters. But in some cases, decreasing the isolation of the patient and couple from each other, from their extended family and community, and from their health care providers is not sufficient. This may be an indication of an emotional complication arising from unresolved issues that antedate the illness. It is probably al- ways true that a person’s reaction to an external stressor like an illness is colored, at least in some degree, by one’s history and particular vulnerabil- ities, and by the history of the present relationship. Even though she knew it wasn’t his fault, Emily couldn’t help being furious with Charles for having seizures. The referring neurologist and her nurse commented on Emily’s lack of support when they made the referral. In recent years, Charles’s epilepsy had grown increasingly unresponsive to medication, and he was now having several grand mal seizures a week. He was also limited in his ability to care for their young children, since he could neither carry them for fear of dropping them were he to have a sudden seizure, nor could he be left alone with them lest a seizure render him unconscious or impaired for a period of Managing Emotional Reactivity in Couples Facing Illness 263 time. Cooking, climbing, working with power tools, or using sharp imple- ments were likewise off limits. But in addition to her exhaustion and anxiety, she was furious with Charles for not being able to work or help out more with the demands of family life. He struggled to do all he could between seizures to maintain the household, but his efforts seemed, if anything, to only increase her anger and disgust. Emily’s re- sponse to her husband was puzzling and distressing at first, until she shared her history. Her father was alcoholic and abusive of their mother, although not to the children. Her mother had become severely depressed and anxious, and largely unable to function around the house. From an early age, Emily had found that taking the role of housekeeper and caretaker of the younger children had lessened her mother’s depression and given Emily some sense of safety and value in an otherwise bleak situation. Because chronic illness can have such a profound impact on the life of the patient and his or her family, it is easy to forget that emotional factors un- related to the illness can have an equally profound impact on how the cou- ple manages the illness and the changes it requires. In the case of Charles and Emily, it was clear that the emotional reactions to the situation were being fueled by factors external to the illness and the stress and isolation it brings. It is not always so clear, however, how emotional reactivity is con- tributing to the difficulties couples face in dealing with illness. The term emotional reactivity refers to the tendency to get caught up in emotional reactions, which then drive behavior, in contrast to being able to be aware of when one’s responses are out of proportion to the situation and limit the extent to which these responses drive behavior. Indications that emotional reactivity is complicating adjustment to ill- ness include reactions that appear especially intrusive and out of proportion to the situation, problems that do not respond to the couples’ usual coping strategies, or conflicts or concerns that have a sticky quality—that repeat endlessly and with a level of anxiety or intensity that is not easily calmed or soothed, even temporarily. When these signs are present, it is helpful to ex- plore what else might be going on internally that is driving the response, in addition to the real challenges presented by the illness. STEP 3: REDIRECT ATTENTION FROM THE OUTER REALITY OF THE ILLNESS TO THE INNER RESPONSE AND MEANING OF THE ILLNESS Having determined which areas of concern are most likely to be colored by emotional reactivity, it can then be useful to explore the underlying mean- ings associated with those areas of concern. The goal is to begin to clarify 264 SPECIAL ISSUES FACED BY COUPLES the sources of the emotional reactivity. The first step in the process is to highlight the emotions or reactions that are elicited by the particular cir- cumstance or conflict. As a first approach, each member of the couple can be asked why he or she imagines he or she is having such a reaction: To the healthy spouse: "Of course this illness is devastating, but do you have any idea about the reasons for the depth of your frustration about your hus- band’s illness? Having begun this process in the previous step, each individual is now asked to further describe his or her reactions. In the process of description, the speakers elaborate on their internal processes. The therapist responds empathically, underlining the emotions or attitudes hinted at in the speaker’s statement and asking ques- tions to help the speaker continue to elaborate, subtly directing attention to his or her inner experience. As this process continues, the focus shifts from the external difficulty to the speaker’s reaction to it.

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This intrusion breaks down the immune system and throws it into disarray lipitor 20mg low price increased cholesterol definition, opening the door to AIDS and to the de- generative diseases that are literally exploding these days: cancer buy lipitor 40mg online ldl cholesterol level definition, multiple sclerosis, rheumatism, diabetes, insulin-dependencies, and 11 all the auto-immune diseases. Thus, the Horus Cult is happy to produce fake certificates for the vaccine against tetanus. And Tabitha’s Place, by refusing a surgical op- eration for a new-born baby under the pretext of respecting divine will, had no qualms about condemning to death a young child who was born with a cardiac malformation. Patamedicine, Magic, and the Third Way Between belief in divine healing and confidence in a completely mechanistic scientific process, patamedicine represents a third way that is basically a primitive belief in magic. Absolute confidence in God or in a doctor removes the patient from any active role in deciding how to deal with his condition, as his illness evolves. By contrast, patamedi- cal magic gives the patient back an active part in the process of his healing. W hile magic may originally have meant the practices of the sacer- dotal caste of the Medes, who were followers of pseudo-sciences such as astrology or hermetic medicine, the word gradually has taken on a broader meaning to encompass beliefs and practices that have little to do with the rites of organized worship and that presuppose a belief in 11 supernatural forces immanent in nature. For this reason, patamedicine always presupposes the belief in a principle that "animates" the human being and that explains the "inexplicable" aspects of physiology. Energy, in Chinese medicine, or white holes in the memory of water, all derive from this basic approach. They calibrate their responses to health questions and propose to the patient techniques that gradually move away from the scientific ap- 211 Healing or Stealing? Some ethnologists, like Frazer, saw magic as a form of prescience, for this practice includes references to determinism. Frazer described two principles in magical belief, two principles that agree with certain laws of the association of ideas and that are found in patamedicine — even if they may not be overtly stated. The principle of similarity says that the similar calls the similar, like goes to like. Thus, every practice that has been observed as being si- multaneous to an effect is considered to be an inductive principle — and reproducing the practice is expected to generate the same effect. The principle of contiguity, the second principle, states that things that once were in contact continue to act upon each other even after the contact has ceased. Thus, in magic, a photograph is an extension of the being that was photographed, and magic that is practiced on the photo will have its effect upon the individual. It is all the harder to criticize since it seems to respect the scientific laws of causality. But to accept the principle of similarity as flawless scientific reasoning means maintaining confusion between an action and the sign of an action. In the same vein, when a person recov- ers after such and such technique has been applied, that is not absolute proof that the technique was valid. Only verification of the chain of cause and effect is proof of the authenticity of the phenomenon ob- served, even if the phenomenon is repeated several times. The fact that the sun reaches the zenith at midday and the fact that everyone’s watches and clocks point to the numeral 12 are not part of a chain of cause and effect on each other — even though the coincidence seems to hold true universally. And so it is not, as the homeopaths claim, because qui- 212 The Foundations of Patamedicine nine creates malaria-like symptoms in healthy people that quinine has a beneficial effect on those who already exhibit the symptoms of malaria. The principle of similarity is a magic virtuality, and is not consistent with scientific thought. The principle of contiguity is widespread in the world of patamedi- cine, from tele-therapy to the various diagnostic techniques that rely on photographs, or the Kirlian effect. In astrology, predictive numerology and the techniques of morphopsychology (which are sinisterly reminis- cent of the Third Reich’s Institute of Anthropology) all reflect this principle. A given astrological sign, a given birth number, a given physical characteristic is supposed to be either the generating principle (astrology) or an identifying sign (numerology, or a physical sign in morphopsychology) of the psychological nature of the individual and of his destiny. Contrary to religion, which grants almighty power to the divine, magic thought allows us to keep some partial power over matter, and in fact over the phenomena of health and healing; it is based on a form of determinism and rests on the belief in the existence of supernatural, suprahuman, but non-divine forces. Magic thought shares with scientific thought a certainty about the course of predetermined sequences of events. W hile prayer may be intended to secure divine intervention in the processes of mystical heal- ing, in the practice of magic this intervention is not necessary. The magical action is supposed to secure the desired effect on its own, and for this reason magic and science have the same goal: to gain control over how things turn out. Medical magic and medicine share one thing: the certainty of taking some action against the disease.

A very popular recent book on the subject is Love generic lipitor 20 mg overnight delivery cholesterol levels without fasting, Medicine discount lipitor 10 mg otc cholesterol levels requiring statins, and Miracles by the Yale surgeon Bernie Siegel (New York: Harper & Row, 1986). Siegel began his career as a surgeon, became aware of the social and psychological dimensions of cancer and began to work with patients accordingly. His book is highly inspirational and, because of its popularity, has introduced many people to the idea that the mind can be mobilized to combat cancer. Siegel’s work, however, because of its lack of psychologic and physiologic specificity. He does not present a theoretical model of how emotions play a role in the cause and cure of cancer and where his work fits into that model. Lacking that it is unlikely that his work will have much impact on the traditional medical research community. This is a pity for there is a great need for more precise definition of what social and psychological factors are contributing to what illnesses and how. Acknowledging the important role of the emotions in health and illness, medicine must reexamine its concepts of disease causation. The attempt to bridge that mysterious gap between emotion and physiology will require the best minds in experimental medicine and the kind of interest and commitment that medicine now accords to such things as genetic research or the chemotherapy of cancer. But we won’t get those people and that kind of commitment if 160 Healing Back Pain we put “the power of love” into a medical context without carefully studying its specific psychological and physiologic effects. If that isn’t done, how do we distinguish between Bernie Siegel, Norman Vincent Peale and Mary Baker Eddy? These considerations aside, doctors like Siegel, Simonton, Pelletier and Locke (and a number of others I have not mentioned) are pioneers, and what they have to teach is of enormous importance to the future of medicine. THE IMMUNE SYSTEM AND INFECTIOUS DISEASES Here again, there is a long history of awareness that the emotions have something to do with our susceptibility to or ability to fight off infection, but none of it is generally accepted by medical doctors and rarely applied in everyday practice. Frequent colds and genitourinary infections are among the most common but it is likely that psychological factors play a role in all infectious processes. As with cancer, it is the efficiency of the immune system to do its job of eradicating the infectious agent that is at issue. Stressful emotions can reduce that effectiveness and allow the infection to flourish but there is ample anecdotal evidence that people have the capacity to enhance immunologic efficiency by improving their emotional states or employing other techniques, as the following story illustrates. The cover article of the Washington Post Health Journal for January 1985 was a piece written by Sally Squires titled “The Mind Fights Back. Having been previously exposed to the virus, she developed the usual positive immune reaction, a bump about one-half inch in diameter, which then disappeared in a few days. To confirm that an immune reaction was going on a blood test was done that demonstrated that her white blood cells were actively fighting the infection. After repeating the procedure twice with the same reaction she was instructed to try to stop the body’s normal reaction, which she did in her daily meditation, and for three weeks in a row the bump got smaller and smaller. Then she was asked to stop interfering with the normal immune reaction and with the last three injections of the virus she got the usual bump again. Here was a clear demonstration of how the mind can alter a bodily reaction if it is taught how to do it. The doctors involved in the study were so impressed with the results that they repeated the entire experiment nine months later and got the same results. It was a striking demonstration of the so-called power of the mind, in this case over the working of the immune system. The treatment of TMS describes a similar phenomenon, in which acquired knowledge has the ability to interfere with an undesirable physical reaction, the pain of TMS. THE OVERACTIVE IMMUNE SYSTEM— ALLERGY Though the idea is controversial, it is my view, based on experience with patients who have had both TMS and allergic rhinitis (hay fever), that some of the common allergies of adult life are equivalents of TMS, that is, they are brought on by emotional factors. People invariably say when this is discussed, “Oh, but hay fever is caused by things like pollens, dust and molds; how can you say it’s 162 Healing Back Pain due to tension? The immune systems of the latter have become overactive under the influence of tension, the repressed feelings we have been talking about. This has been demonstrated, not occasionally, but repeatedly in TMS patients who have been told in the course of their learning experience that hay fever is a TMS equivalent and can be eliminated in the same way that TMS can. He took to heart what he had heard and, miracle, experienced no hay fever that season. For years I have been allergic to whatever it is that cats exude (we used to call it dander but now we’re told it may be something in their saliva which dries on their meticulously licked fur and then floats into the air). If I walk into a house and don’t know that a cat lives there, my eyes begin to itch.

D espite this pioneering work order 10 mg lipitor otc cholesterol test vap, few clinicians on either side of the Atlantic urged that trials of clinical outcom e should be adopted lipitor 40 mg for sale cholesterol levels european, although the principles of num erically based experim ental design were enunciated in the 1920s by the geneticist Ronald Fisher. The field only started to m ake a m ajor im pact on clinical practice after the Second W orld W ar following the sem inal work of Sir Austin Bradford H ill and the British epidem iologists who followed him , notably Richard D oll and Archie Cochrane. But although the idea of evidence based m edicine is not new, m odern disciples like D avid Sackett and his colleagues are doing a great service to clinical practice, not just by popularising the idea but by bringing hom e to clinicians the notion that it is not a dry academ ic subject but m ore a way of thinking that should perm eate every aspect of m edical practice. W hile m uch of it is based on m egatrials and m eta-analyses, it should also be used to influence alm ost everything that a doctor does. After all, the m edical profession has been brainwashed for years by exam iners in m edical schools and Royal Colleges to believe that there is only one way of exam ining a patient. Our bedside rituals could do with as m uch critical evaluation as our operations and drug regim es; the sam e goes for alm ost every aspect of doctoring. As clinical practice becom es busier and tim e for reading and reflection becom es even m ore precious, the ability effectively to peruse the m edical literature and, in the future, to becom e fam iliar with a knowledge of best practice from m odern com m unication system s will be essential skills for doctors. In this lively book,Trisha G reenhalgh provides an excellent approach to how to m ake best use of m edical literature and the benefits of evidence based m edicine. It x FOREW ORD should have equal appeal for first-year m edical students and grey- haired consultants and deserves to be read widely. W ith increasing years, the privilege of being invited to write a foreword to a book by one’s ex-students becom es less of a rarity. Trisha G reenhalgh was the kind of m edical student who never let her teachers get away with a loose thought and this inquiring attitude seem s to have flowered over the years; this is a splendid and tim ely book and I wish it all the success it deserves. After all, the concept of evidence based m edicine is nothing m ore than the state of m ind that every clinical teacher hopes to develop in their students; D r G reenhalgh’s sceptical but constructive approach to m edical literature suggests that such a happy outcom e is possible at least once in the lifetim e of a professor of m edicine. Professor Sir D avid W eatherall xi In N ovem ber 1995, m y friend Ruth H olland, book reviews editor of the British Medical Journal, suggested that I write a book to dem ystify the im portant but often inaccessible subject of evidence based m edicine. She provided invaluable com m ents on earlier drafts of the m anuscript but was tragically killed in a train crash on 8th August 1996. A handful of academ ics (including m e) were enthusiastic and had already begun running "training the trainers" courses to dissem inate what we saw as a highly logical and system atic approach to clinical practice. Others – certainly the m ajority of clinicians – were convinced that this was a passing fad that was of lim ited im portance and would never catch on. First, students on m y own courses were asking for a sim ple introduction to the principles presented in what was then known as "D ave Sackett’s big red book" (Sackett D L, H aynes RB, G uyatt G H , Tugwell P. London: Little, Brown, 1991) – an outstanding and inspirational volum e that was already in its fourth reprint, but which som e novices apparently found a hard read. Second, it was clear to m e that m any of the critics of evidence based m edicine didn’t really understand what they were dism issing and that until they did, serious debate on the political, ideological, and pedagogical place of evidence based m edicine as a discipline could not begin. I am of course delighted that How to read a paper has becom e a standard reader in m any m edical and nursing schools and has so far been translated into French, G erm an, Italian, Polish, Japanese, and Russian. I am also delighted that what was so recently a fringe subject in academ ia has been well and truly m ainstream ed in clinical service in the U K. For exam ple, it is now a contractual requirem ent for all doctors, nurses, and pharm acists to practise (and for m anagers to m anage) according to best research evidence. In the three and a half years since the first edition of this book was published, evidence based m edicine has becom e a growth industry. D ave Sackett’s big red book and Trisha G reenhalgh’s little blue book have been joined by som e 200 other textbooks and 1500 journal articles offering different angles on the 12 topics covered xiii H OW TO READ A PAPER briefly in the chapters which follow. M y biggest task in preparing this second edition has been to update and extend the reference lists to reflect the wide range of excellent m aterial now available to those who wish to go beyond the basics. N evertheless, there is clearly still room on the bookshelves for a no-frills introductory text so I have generally resisted the tem ptation to go into greater depth in these pages. Trisha G reenhalgh xiv Preface to the first edition: Do you need to read this book? This book is intended for anyone, whether m edically qualified or not, who wishes to find their way into the m edical literature, assess the scientific validity and practical relevance of the articles they find, and, where appropriate, put the results into practice. M any of the descriptions given by cynics of what evidence based m edicine is (the glorification of things that can be m easured without regard for the usefulness or accuracy of what is m easured; the uncritical acceptance of published num erical data; the preparation of all-encom passing guidelines by self-appointed "experts" who are out of touch with real m edicine; the debasem ent of clinical freedom through the im position of rigid and dogm atic clinical protocols; and the overreliance on sim plistic, inappropriate, and often incorrect econom ic analyses) are actually criticism s of what the evidence based m edicine m ovem ent is fighting against, rather than of what it represents. D o not, however, think of m e as an evangelist for the gospel according to evidence based m edicine. I believe that the science of finding, evaluating and im plem enting the results of m edical research can, and often does, m ake patient care m ore objective, m ore logical, and m ore cost effective.

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