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He also pioneered the use of encounter groups buy imipramine 25 mg with amex, adapting the sensitivity training (T-group) methods de- The third necessary component of a therapist’s atti- veloped by Kurt Lewin (1890-1947) and other re- tude is empathy (“accurate empathetic understanding”) generic imipramine 75mg visa. The therapist tries to appreciate the client’s situation While client-centered therapy is considered one of from the client’s point of view, showing an emotional the major therapeutic approaches, along with psychoana- understanding of and sensitivity to the client’s feelings lytic and cognitive-behavioral therapy, Rogers’s influ- throughout the therapy session. In other systems of ther- ence is felt in schools of therapy other than his own, and apy, empathy with the client would be considered a pre- the concepts and methods he developed are drawn on in liminary step enabling the therapeutic work to proceed, an eclectic fashion by many different types of counselors but in client-centered therapy, it actually constitutes a and therapists. A primary way of conveying this empathy is by active listening that Further Reading shows careful and perceptive attention to what the client Rogers, Carl. Boston: Houghton Mifflin, centered therapists employ a special method called re- 1961. This technique shows that the therapist is listening carefully and accurately and gives clients an added opportunity to examine their own thoughts and feelings as they hear them repeated by an- other person. Generally, clients respond by elaborating Clinical psychology further on the thoughts they have just expressed. The application of psychological principles to diag- Two primary goals of client-centered therapy are in- nosing and treating persons with emotional and creased self-esteem and greater openness to experience. Some of the related changes that it seeks to foster in clients include increased correspondence between the Clinical psychologists apply research findings in the client’s idealized and actual selves; better self-under- fields of mental and physical health to explain dysfunc- standing; decreases in defensiveness, guilt, and insecuri- tional behavior in terms of normal processes. Most psychologists earn a mental retardation, marital and family issues, criminal Ph. The clinical psy- four- to six-year program offered by a university psy- chologist may also address less serious problems of ad- chology department. The course of study includes a justment similar to those encountered by the counseling broad overview of the field (including courses in such psychologist. A number of clinical psychologists are in private prac- A new training program for psychologists was de- tice, either alone or in group practice with other mental veloped and introduced at the University of Illinois, health professionals. Others may practice in a variety of which offered the first Psychology Doctorate (Psy. This degree program is geared exclusively toward university medical schools, social work departments, the training of clinicians rather than researchers. It centers for the mentally and physically handicapped, stresses course work in applied methods of assessment prisons, state institutions and hospitals, juvenile courts, and intervention and eliminates the dissertation require- and probation offices. The term “clinical psychol- Individuals consult clinical psychologists for treat- ogy” itself was first used at the end of the nineteenth ment when their behaviors or attitudes are harmful to century in connection with the testing of mentally retard- themselves or others. The discipline methods are employed by psychologists, depending on soon expanded with the growing interest in the applica- the setting in which they work and their theoretical ori- tion of assessment techniques to the general population entation. The major types of therapy include psychody- following Robert Yerkes’s revision of the Stanford Binet namic therapies, based on uncovering unconscious Intelligence scales in 1915, creating a widely used point processes and motivations, of which the most well scale for the measurement of human mental ability. Assessment counter between equals, abandoning the traditional doc- may be used to compare an individual with others in a tor-patient relationship; and behavior-oriented therapies reliable way using standardized norms; determine the geared toward helping clients see their problems as type and circumstances of symptomatic behaviors; un- learned behaviors that can be modified without looking derstand how a person functions in a given area (cogni- for unconscious motivations or hidden meanings. These tion, social skills, emotion); or match a patient to a par- therapies, derived from the work of Ivan Pavlov and ticular diagnostic category for further treatment. Skinner, include methods such as behavior modi- While the clinical psychologist does not specialize in fication and cognitive-behavior therapy, which may be research, the two disciplines often overlap. With their var- used to alter not only overt behavior but also the thought ied experiences, clinicians are qualified to participate in re- patterns that drive it. Clinical psychologists overlap in what these professionals do, there are also routinely contribute to the training of mental health profes- specific distinctions between them. As of 1996, clinical sionals and those in other areas of health care, serving on psychologists cannot prescribe drugs to treat psychologi- the faculties of universities and independent institutes of cal disorders, and must work in conjunction with a psy- psychology, where they teach courses, supervise chiatrist or other M. They also carry out administrative appointments way for prescription privileges for psychologists. The which call for them to assist in the planning and implemen- clinical psychologist has extensive training in research tation of health care services and are represented in inter- methods and in techniques for diagnosing, treating, and national groups such as the World Health Organization. Seeing Both Sides: Classic Controversies Most cliques are fairly complex and have a mixture in Abnormal Psychology. Even if a group exerts posi- tive peer pressure, it may also be exerting negative peer pressure by being exclusive on the basis of race, class, religion, sexual orientation, or ethnicity. Cliques A group of people who identify with each other Further Reading and interact frequently. Lockers, Lunch Lines, Chemistry, and people who interact with each other more intensively Cliques. It is used to describe an adolescent social group that excludes others on the basis of superficial differences, exercising greater than average amount of peer pressure upon its mem- Cocaine bers. The numerous terms teenagers use to describe themselves and others—such as jocks, druggies, popu- See Drugs/Drug abuse lars, brains, nerds, normals, rappers, preps, stoners, rock- ers, punks (punx), freaks (phreaks), and skaters—exem- plify both levels of meaning in the word “clique. A term used to describe a person who is intimately A clique consists of a particular group of people involved with a person who is abusing or addicted within a particular location. Joining cliques, having the desire to person involved with the dependent person in any inti- join a particular clique, and being excluded from cliques mate way (spouse, lover, child, sibling, etc. The definition of the term has been expand- Joining cliques helps children to develop, identify, and ed to include anyone showing an extreme degree of cer- regulate social interaction. Generally children begin to tain personality traits: denial, silent or even cheerful tol- be more aware of differences and form cliques in late el- erance of unreasonable behavior from others, rigid loyal- ementary school, between the ages of 8 and 10 years old.

Adverse effects • Patients with dihydropyridine dehydrogenase deficiency These include the following: (enzyme activity 5% of normal) have an increased risk of severe mucositis/haematologic suppression order 75mg imipramine overnight delivery. It is effect- Drug interactions ive as part of combination therapy for acute leukaemias imipramine 75mg without a prescription. This is Mechanism of action important because allopurinol pretreatment is used to reduce Cytotoxic actions of anthracyclines lead to apoptosis, and the risk of acute uric acid nephropathy due to rapid tumour include: lysis syndrome in patients with leukaemia. Uses Doxorubicin is a red antibiotic produced by Streptomyces Anthracycline cardiotoxicity peucetius. It is the most widely used drug of the anthracycline • Acute: this occurs shortly after administration, with the group, with proven activity in acute leukaemia, lymphomas, development of various dysrhythmias that are occasionally sarcomas and a wide range of carcinomas. It is The camptothecins are active against a broad range of tumours, determined by the cumulative dose. They are cardiomyopathy include prior mediastinal irradiation, age given intravenously. Agents to protect against anthracycline cardiomyopathy Mechanism of action and allow dose intensification are under investigation. Hepatic extrac- tion is high, with 40% appearing in the bile (as unchanged Pharmacokinetics drug and metabolites, e. Topotecan is hydrolysed by disease, particularly if accompanied by hyperbilirubinaemia. Despite their close structural A component of the cytotoxic action of anthracyclines (e. Etoposide and teniposide, synthetic derivatives of omas and the initial treatment of acute lymphoblastic podophyllotoxin (which is extracted from the American man- leukaemia. Vinblastine is a component of the cytotoxic combin- drake or May apple, and is topically effective against warts), ations used to treat testicular cancer and Hodgkin’s disease. Uses Mechanism of action Etoposide is one of the most active drugs against small-cell Vinca alkaloids bind to β-tubulin, a protein that forms the micro- lung cancer and is used in combination therapy. It is also used tubules which are essential for the formation of the mitotic spin- to treat lymphomas, testicular and trophoblastic tumours. They prevent β-tubulin polymerizing with α-tubulin and Mechanism of action thus inhibit mitosis. Key points Adverse effects Practical ‘do’s and don’ts’ of cytotoxic therapy These include the following: • Patients should have recovered fully from the toxic • nausea and vomiting; effects of the previous cycles of cytotoxic therapy • alopecia; before starting the next treatment cycle. Pharmacokinetics • Haematopoietic growth factors (for myelosuppression) Etoposide is given by intravenous injection or orally (50% reduce the duration of the nadir neutropenia, but bioavailability). They are classified Pharmacokinetics into tyrosine kinases, serine-threonine kinases and tyrosine- Paclitaxel is poorly absorbed orally and requires intravenous serine-threonine kinases. It is administered orally on a daily molecules or cellular processes on or within the malignant basis. In the non- Adverse effects ligand-binding domain of these receptors, there is a tyrosine These include the following: kinase which phosphorylates the receptor. Adverse effects Pharmacokinetics These include the following: Oral absorption is very good with almost 100% bioavailabilty. The kinetics do not change with chronic dosing and • hepatitis; little drug appears unchanged in the urine. It is active to metabolites with little or no tyrosine kinase inhibiting activity. Sorafenib increases median survival by approximately 12 months in patients with advanced refractory renal cell cancer. The development of mono- kinases, including platelet-derived growth factor receptor and clonal antibodies against specific antigens (targets) has been vascular endothelial growth factor receptor. Less fre- mouse antibodies have a short half-life and induce human quently, neutropenia, thrombocytopenia and decreases in left anti-mouse antibody immune response, they are usually ventricular ejection fraction have been noted. Trastuzumab, one of the first agents demonstrated to have clinical benefit in cancer therapy, Bortezomib is the first member of this class. All are tive inhibitor of the proteolytic function of the chymotrypsin- administered intravenously. Proteasome inhibition affects a number of cellular functions, but a major effect is to disable IκB degradation. Adverse effects include thrombocyto- Mechanism of action penia, fatigue, peripheral neuropathy, neutropenia, gastro- This monoclonal antibody binds tightly to the Her-2/Neu intestinal disturbances. Many tumour cells overexpress histone deacetylase enzymes Adverse effects which deacetylate histones. Vorinostat inhibits these enzymes, These include the following: blocking the transcription of genes involved in cell cycle pro- gression. It undergoes • infusion reactions involving fever, chills, nausea, hepatic glucuronidation and oxidation. Plasma opportunistic fungoides and T-cell t1/2 12 days, dose-dependent kinetics infections, lymphoma pancytopenia Bevacizumab Colorectal and? They often alleviate symptoms over a long period and they do not cause bone mar- row suppression.

Counterfactual Thinking In addition to influencing our judgments about ourselves and others imipramine 25 mg lowest price, the ease with which we can retrieve potential experiences from memory can have an important effect on our own emotions discount imipramine 50mg with visa. If we can easily imagine an outcome that is better than what actually happened, then we may experience sadness and disappointment; on the other hand, if we can easily imagine that a result might have been worse than what actually happened, we may be more likely to experience happiness and satisfaction. The tendency to think about and experience events according to “what might have been‖ is known ascounterfactual thinking (Kahneman & Miller, 1986; Roese, [26] 2005). Imagine, for instance, that you were participating in an important contest, and you won the silver (second-place) medal. Certainly you would be happy that you won the silver medal, but wouldn‘t you also be thinking about what might have happened if you had been just a little bit better—you might have won the gold medal! If you were thinking about the counterfactuals (the “what might have beens‖) perhaps the idea of not getting any medal at all would have been highly accessible; you‘d be happy that you got the medal that you did get, rather than coming in fourth. They videotaped the athletes both as they learned that they had won a silver or a bronze medal and again as they were awarded the medal. Then the researchers showed these videos, without any sound, to raters who did not know which medal which athlete had won. In a follow-up study, raters watched interviews with many of these same athletes as they talked about their performance. The raters indicated what we would expect on the basis of counterfactual thinking—the silver medalists talked about their disappointments in having finished second rather than first, whereas the bronze medalists focused on how happy they were to have finished third rather than fourth. I really wanted to make it home when I got near the end of my journey; I would have been extremely disappointed if the car broke down only a few miles from my home. Perhaps you have noticed that once you get close to finishing something, you feel like you really need to get it done. Jurors who were asked to award monetary damages to others who had been in an accident offered them substantially more in compensation if they barely avoided injury than they offered if the accident seemed inevitable (Miller, Turnbull, & McFarland, [29] 1988). Psychology in Everyday Life: Cognitive Biases in the Real World Perhaps you are thinking that the kinds of errors that we have been talking about don‘t seem that important. After all, who really cares if we think there are more words that begin with the letter ―R‖ than there actually are, or if bronze medal winners are happier than the silver medalists? But it turns out that what seem to be relatively small cognitive biases on the surface can have profound consequences for people. Why would so many people continue to purchase lottery tickets, buy risky investments in the stock market, or gamble their money in casinos when the likelihood of them ever winning is so low? One possibility is that they are victims of salience; they focus their attention on the salient likelihood of a big win, forgetting that the base rate of the event occurring is very low. The belief in astrology, which all scientific evidence suggests is not accurate, is probably driven in part by the salience of the occasions when the predictions are correct. People may also take more care to prepare for unlikely events than for more likely ones, because the unlikely ones are more salient. For instance, people may think that they are more likely to die from a terrorist attack or a homicide than they are from diabetes, stroke, or tuberculosis. And people are frequently more afraid of flying than driving, although the likelihood of dying in a car crash is hundreds of times greater than dying in a plane crash (more than 50,000 people are killed on U. Because people don‘t accurately calibrate their behaviors to match the true potential risks (e. Salience and accessibility also color how we perceive our social worlds, which may have a big influence on our behavior. For instance, people who watch a lot of violent television shows also view the world as more dangerous [31] (Doob & Macdonald, 1979), probably because violence becomes more cognitively accessible for them. We also [32] unfairly overestimate our contribution to joint projects (Ross & Sicoly, 1979), perhaps in part because our own contributions are highly accessible, whereas the contributions of others are much less so. Even people who should know better, and who need to know better, are subject to cognitive biases. Economists, stock traders, managers, lawyers, and even doctors make the same kinds of mistakes in their professional activities that [33] people make in their everyday lives (Gilovich, Griffin, & Kahneman, 2002). Just like us, these people are victims of overconfidence, heuristics, and other biases. Furthermore, every year thousands of individuals, such as Ronald Cotton, are charged with and often convicted of crimes based largely on eyewitness evidence. When eyewitnesses testify in courtrooms regarding their memories of a crime, they often are completely sure that they are identifying the right person. But the most common cause of [34] innocent people being falsely convicted is erroneous eyewitness testimony (Wells, Wright, & Bradfield, 1999). Although cognitive biases are common, they are not impossible to control, and psychologists and other scientists are working to help people make better decisions. One possibility is to provide people with better feedback about their Attributed to Charles Stangor Saylor. Weather forecasters, for instance, learn to be quite accurate in their judgments because they have clear feedback about the accuracy of their predictions.

The onset of these effects takes tubular secretion may increase systemic drug exposure buy imipramine 50 mg otc. It is used as chronic oral therapy cell cytotoxicity buy cheap imipramine 25 mg, thereby increasing viral elimination. Oral administration twice daily is well feron concentrations needed to produce antiviral effects are tolerated in hepatitis B patients and the most common adverse lower than those required for their antiproliferative effects. Pharmacokinetics • Ganciclovir and foscarnet are best given intravenously, Most clinical experience has been gained with interferon-α, poorly or not absorbed orally, both are renally excreted. Following subcutaneous admin- yields 60% bioavailable ganciclovir with oral dosing. She was being treated with pimozide for her psychosis and combined glargine insulin with short-acting insulins at meal times. She was started on itraconazole, 100mg daily, and after a few days her oropharyngeal symptoms were improving. Her electrolyte and magnesium concentrations measured immediately on admission were normal. Question What is the likely cause of this patient’s life-threatening dysrhythmia and how could this have been avoided? Answer In this case, the recent prescription of itraconazole and the serious cardiac event while the patient was on this drug are temporally linked. Other common drugs whose concen- trations increase (with an attendant increase in their toxicity) if prescribed concurrently with azoles (which should be avoided) are listed in Table 45. Newer systemic antifun- • Neuraminidase inhibitors produce viral aggregation at gal agents: pharmacokinetics, safety and efficacy. Oral azole drugs as systemic antifungal • Interferon-alfa plus ribavirin is effective against chronic therapy. Journal of Clinical • Resistant hepatitis B or C: use lamivudine or adefovir Virology 2004; 30: 115–33. Not all patients tolerate triple ther- apy due to toxicity, and alternate double therapy may be used. At currently recommended doses, it • If there is drug treatment failure or resistance, change occurs in only 1–2% of patients; at least two and preferably all three drugs being used. The are used in combinations and are available as combined major metabolite (80%) is the glucuronide and approximately products, e. Tenofovir is well tolerated with few adverse These are numerous and clinically important; the following effects (mainly flatulence). Occasional cases of renal failure and list is not comprehensive: Fanconi syndrome have been reported, so it should be used with caution in patients with pre-existing renal dysfunction. Uncommon Well absorbed; t1/2 of Intracellular triphosphate has 3-thiacytidine) gastro-intestinal upsets, 3–6h. Resistance is only be used in combination therapy due to the rapid devel- a problem and leads to cross-resistance between protease opment of viral resistance. Thus they act as • lipodystrophy; competitive inhibitors of the viral protease and inhibit matu- • arthralgia, myalgia; ration of viral particles to form an infectious virion. These include the following: Pharmacokinetics • nausea, vomiting and abdominal pain; • fatigue; Efavirenz is well absorbed. Combining two Drug interactions agents from this group is called ‘boosted protease inhibitor’ therapy, e. The same principle applies if saquinavir/ This leads to reduced clearance and increased toxicity of low-dose ritonavir or amprenavir/low-dose ritonavir are a number of drugs often causing severe adverse effects combined. It is a 36 amino acid peptide analogue of part of the trans- novel entry inhibitors e. This reduces the number of patients who require These include: mechanical ventilation and improves survival. Initial treatment is intravenous; if the patient • flu-like syndrome; improves after five to seven days, oral therapy may be substi- • eosinophilia; tuted for the remainder of the course. Treatment may have to be discontinued in 20–55% of cases Enfuvirtide is well absorbed after subcutaneous administra- because of side effects and one of the alternative therapies listed tion and is distributed in the plasma volume, with 98% bound below substituted. The major oral co-trimoxazole (one double strength tablet two or three route of clearance is unknown. Use Intravenous route adverse effects include: This combination is the first-line therapy for cerebral and tis- sue toxoplasmosis. Pyrimethamine is given as an oral loading • hypotension and acidosis (due to cardiotoxicity) if given dose followed by a maintenance dose, together with sulfadi- too rapidly; azine. Treatment is continued for at least four to six weeks • dizziness and syncope; after clinical and neurological resolution, and for up to six • hypoglycaemia due to toxicity to the pancreatic β-cells, months thereafter. Folinic acid is given prophylactically to producing hyperinsulinaemia; reduce drug-induced bone marrow suppression. Sulfadiazine acts as a competitive inhibitor of dihydropteroate (folate) synthase (competing with p-aminobenzoic acid) in folate Pharmacokinetics synthesis. Pyrimethamine is a competitive inhibitor of dihydro- folate reductase, which converts dihydrofolate to tetrahydrofo- Pentamidine is administered parenterally. Together they sequentially block the first two major steps in and it is redistributed from plasma by tissue binding.