Amyotrophic Lateral Sclerosis Essay -- Medical Health Medicine Essays

Amyotrophic Lateral Sclerosis Amyotrophic Lateral Sclerosis is an insidiously developing, adult-onset, progressive anterior horn cell degeneration with associated degeneration of descending motor pathways. Despite increasing clinical and research interest, its cause remains obscure. Although many theories as to its cause have been proposed, no intervention has yet been shown to modify biologically determined motor system degeneration. There is no clear cut neuropathological diagnosis for Amyotrophic Lateral Sclerosis (ALS). Instead, clinicians must rely on both the topographic distribution of the neuronal loss and the finding of some characteristic cytological changes. The precise pattern of these changes, however, varies to some extent, depending on whether the disease is of the classical sporadic type, one of the less common familial types, or the Chamorro form in Guam (1). The primary feature of ALS is anterior horn neuronal cell degeneration and loss. The pathologic features of this process include shrinkage and pyknosis of the large spinal motor neurons (with consequent prominence of lipofuscin), the presence of ghost cells, neuronophagia, and gliosis (2). There is a massive loss of Betz cells and other pyramidal cells from the precentral cortex. Along with the loss of cortical cells, the corticospinal tracts are preferentially depleted of large myelinated fibers (3). Corticospinal tract involvement is most readily observed in the anterior and lateral columns of the spinal cord, particularly caudally. Degeneration of the spinocerebellar tracts may be seen. The posterior columns are affected (but not always) as well (4). Cell loss can be difficult to judge in the brainstem nuclei. Associated findings such as i... ...lerosis. Neurology, 1987; 37:529-532. 4. Williams, D. B., Windebank, A. J. Motor neuron disease (amyotrophic lateral sclerosis). Mayo Clin. Proc., 1991; 66(1): 54-92. 5. Swash, M., Schwartz. Staging motor neurone disease: single fiber EMG studies of asymmetry, progression and compensatory reinnervation. In Research Progress in Motor Neurone Disease, 1984; 123-140. 6. Hirano, A., et. al. Fine structural observations of neurofilamentous changes in amyotrophic lateral sclerosis. J. Neuropathol. Exp. Neurol., 1984; 43:461-470. 7. Kurland, L. T., Mulder, D. W. Epidemiologic investigations of amyotrophic lateral sclerosis. Neurology, 1989; 5:182-196. 8. Barron, K. D., Rodichok, L. D. Cancer and disorders of motor neurons. Adv. Neurol., 1982; 36:267-272. 9. Kurtzke, J. F. Risk factors in amyotrophic lateral sclerosis. Adv. Neurol., 1991; 56:245-70.

Comparison Of 1984 By George Orwell To The Actual 1984 Essay -- Compar

Comparison Of 1984 By George Orwell To The Actual 1984 Since the onset of the United States, Americans have always viewed the future in two ways; one, as the perfect society with a perfect government, or two, as a communistic hell where free will no longer exists and no one is happy. The novel 1984 by George Orwell is a combination of both theories. On the "bad" side, a communist state exists which is enforced with surveillance technology and loyal patriots. On the "good" side, however, everyone in the society who was born after the hostile takeover, which converted the once democratic government into a communist government, isn't angry about their life, nor do they wish to change any aspect of their life. For the few infidels who exist, it is a maddening existence, of constant work and brainwashing. George Orwell's novel was definitely different from the actual 1984, but how different were they? They were different in 3 ways: government, society, and thought.1984 starts out with a so called "traitor to the party," Winston Smith, walking through the streets nervously observing the video cameras that are watching his every move. He makes his way into his apartment and produces a journal from his coat pocket. He thinks that even this simple act of attempting to keep track of time and history could get him vaporized. This scene portrays the strong grip the government has on its patrons. A person either obeys them, or is killed, or put into a forced labor camp. After Winston starts an illegal affair with a younger woman he gets careless and "the party" finds out that he has committed what they call "thought crimes". A thought crime is the intent to do something illegal but not actually doing it. In Winston's world a thought crime is just as severe as a physical crime. They arrest him and his girlfriend and torture them until they realize what they did was wrong and that they love "the party" and will never do anything to hurt it again.The two governmental systems were different in a very major way. The actual government of England in 1984 was a democracy. This democracy's foundation was made up of a parliament and a prime minister. Most other nations of the time had the same set up. In Orwell's novel an oligarchic state existed. Airstrip One, which is the area we call England, was home to Winston and the central government of Oceania (a large natio... ...omething without actually doing it. In Oceania a "thought crime" is just as bad as a physical crime.The penalty for such an offense is that you are taken to the "Ministry of Love", but not killed. You are now brainwashed until you love the "Party." O'brien, an inner party member, justifies this by stating that all great nations of the past fell because they killed all people who didn't like them. The "Party" will never fall because they don't create martyrs. All people they eliminate love the "Party" when they are finally killed. For example: Winston is captured and brought to the "Ministry of Love," he then is brainwashed and released to society when he truly liked the "Party." Once he lived in the community for a while longer he is shot in the back of the head. The trains of thought, government, and society of the year 1984 versus George Orwell's 1984 are clearly different. After looking at the differences I stated, the reason why most people who have read the book feel sorry f or Winston should be more apparent than ever. The creation of books with story lines like 1984 help to shape our opinions of how the world should be, and make our views stronger than they have ever been.

Information and communication technologies Essay

Even though the ICT sector is itself worth between 6-8% of the EU’s GDP in the last few years, ICTs are much more important than that figure suggests, as they are central for the current situation and development of much more spheres of contemporary society as a whole and of national economies in Europe in particular. Today ICTs play a crucial role in: improving competitiveness throughout the economy in the face of globalisation, by boosting innovation, creativity and efficiency; – scientific and technological development in various areas (including medicine and physics); – modernising sectors as diverse as education, security, energy and transport, and making Europe’s public sector more efficient; – tackling social challenges and improving quality of life and meeting the challenge of an ageing society. The EU policy framework for the information society and media – i2010- also promotes a European Information Society for all citizens[2]. Actions implemented under this i2010 priority aim to ensure that the benefits of the information society can be enjoyed by everyone (e-Inclusion). Areas of eInclusion policy, as defined in i2010, are: ageing, eAccessibility, broadband gap (overcoming the so called â€Å"digital divide†), inclusive eGovernment, digital literacy and culture. Actions under this priority also aim to encourage provision of better public services (eGovernment and eHealth). Here are the main spheres where ICTs have even bigger potential and are expected to develop in the short run: – Growth and Competitiveness ICT is a driver for productivity. The gains from ICT stem directly from investment in ICT, a fast growing and innovative ICT sector, and indirectly from improvements in business processes through wider use of these technologies across the economy. According to a study[3], the overall contribution to labour productivity growth from ICT investments and from technical progress in the production of ICT goods and services accounted for about 40% of EU labour productivity growth over the second half of the 1990s, compared with 60% in the US. The ICT sector, as a whole, performs fairly well in comparison with the US in terms of size (10% of GDP in the US against 8% in the EU, and also in productivity and employment creation), but less so in terms of contribution to R&D (in the US, ICT account for 30% of R&D). However, in these developments the EU has suffered from lower and delayed investments in ICT and, possibly, a less efficient use of ICT. Using Information and Communication Technologies can also further be used to manage finite natural resources and energy consumption much more efficiently, so that improving environmental protection without holding back economic development[4]. – Convergence More and more, convergence of technologies, infrastructure and applications is developing to provide consumers with an access to a great diversity of attractive services and rich media and content on a wide range of devices. Availability of content and services is becoming critical as the market moves to a phase where value-added services and content are key to revenue growth. The policy focus for 2010 will probably be the creation of a favourable environment that stimulates the competitive deployment of new converging services. – Broadband networks EU countries are global leader in high-speed internet. The number of fixed broadband internet connections in the EU keeps growing: 14 million more in 2008, reaching over 114 million in total. Denmark and the Netherlands are world leaders in broadband, with take up over 35% of population. They lead, along with Sweden, Finland, the UK, Luxembourg, Belgium, Germany and France, the US, which was at 25% in July 2008. This has produced a critical mass and there is already evidence that markets for high-quality content and service development are taking off. Furthermore, new developments in wireless broadband have made spectrum availability crucial to new services and applications, and the efficient management of spectrum key to further broadband developments. Finally, the enhancement of interoperability and security are essential to and increase consumers’ choice and facilitate take-up. In the beginning of 2009 1 billion euro has been earmarked by the European Commission to help rural areas[5] get online, bring new jobs and help businesses grow. Competitiveness, job creation and protection, sustainable development, spatial balance and fighting the digital divide are the main goals that the broadband internet access could achieve. – Contents and information society services Convergence is creating a promising range of opportunities for the development of content and information society services making the most of ICT. The challenge for the single information space is to create the appropriate environment that will meet both business and consumer expectations while promoting the European content industry. This requires a competitive environment, where interoperability allows cross-platform competition and usage. This also requires a clear European regulatory framework with respect to content regulation and a secure environment for the distribution of digital content. Ensuring consumer acceptance pass by offering access to a great variety of flexible content and services adapted to user needs. Improving security and privacy as well as minor protection and media literacy are needed to allow European citizens to benefit fully from these content and services. – Innovation and research In order Europe to catch-up with the levels of productivity growth of other regions of the world, it should strengthen innovation and concentrate these efforts in those sectors, like the ICT, where the value added is the highest. A pre-requisite is to increase investment in research: at present the EU devotes only 18% of research expenditure to ICT whereas the leading OECD countries allocate more than 30%[6]. In absolute amounts, Europe’s investment in ICT research is only two thirds of that of Japan and one third of that seen in the USA. Research and development is making technology simpler to use, more available and affordable; providing new ICT-based solutions that are trusted, reliable, and adaptable to users’ contexts and preferences. However, research alone is not sufficient as it needs be consolidated by organisational innovation. ICT must be widely adopted and supported by adequate reorganisation of business processes and by a skilled workforce. Businesses in the EU are increasingly adopting advanced ICT and are engaging in on-line transactions but are lagging behind in the adoption of integrated business applications (particularly the European small and medium enterprises). – Skills and work The development of the ICT sector and the wide-spread diffusion and use of ICT in the economy and in the society bring opportunities for new employment and more creative and fulfilling jobs. Changing needs for ICT and e-Business skills (e-Skills) in the future heavily depend on innovation and the introduction of new technologies. The greatest challenge is to assess forward-looking innovations and understand what new skills will be needed, to be able to anticipate and manage changes and be effective, quick and efficient in creating new, innovative jobs. – e-Business Though nearly all enterprises are connected to the internet, a large section of the business community is only beginning to exploit the potential of ICT. E-commerce is expected to continue to grow rapidly. More efforts are needed to improve business processes in European enterprises and fully integrate ICT providing new opportunities to reduce their costs and improve performance. Factors which will contribute to increase e-Business include promotion of take-up of e-business solutions and best practices security, addressing privacy and security concerns, availability of content and new services, increase automation of business processes, acceptance of payment for content and services, e-invoicing and e-procurement. Public services Public services are at the heart of the European social model, playing a key role in growth, innovation and cohesion. There is increasing evidence that a better exploitation of ICT through combined improvement of facilities, working processes and skills can significantly enhance public service’s organisation provision. However, the potential remains unfulfilled due to technical, legal or organisational obstacles. For example, government services are widely available online but the demand is not sufficient and efficiency gains from back-office reorganisation are still largely underexploited. Specific challenges relate to friendly user-centric services, back-office streamlining, interoperability of key infrastructures and facilities, identity management, or privacy and trust. – e-Inclusion Increasing impact of ICT on social inclusion and participation creates new opportunities. Significant progress on ICT penetration across all EU regions and socio-demographic groups helps to decrease disparities. However, some specific challenges concern accessibility of ICT equipment and user-friendly interfaces, digital literacy or improved confidence and support for ICT use. Some important concerns are â€Å"design for all† of ICT equipment; human mediation and support for e-services; intuitive use of affordable value-added e-content and services accessible; and efficient solutions for threats to privacy, security and harmful content threats. – Quality of life and environment ICT have a direct impact on the environment but also indirect social and economic consequences as a result of its application. ICT positive impact on the environment includes environmental modelling (forecasting), the miniaturisation of devices (which reduces the resources needed for manufacture and distribution), micro/nano technology and embedded systems which improve disaster management, and reduce the environmental impact of farming and fishing. ICT also enables a less resource-intensive production, thereby reducing the environmental impact of economic activities. – e-Work contributes to environmental sustainability as travelling to work is reduced. Innovative transport planning systems can ease traffic congestion and optimise transport capacity. ICT can also contribute to quality of life by delivering more efficient and more effective public services and goods to individuals which in turn can improve their life chances. ICT support for comprehensive life-long learning policies (through e-learning, digital competence actions) can enable all individuals to adapt and keep the pace with the continuous social, economic and technological changes. – Climate and energy policy The combined climate and energy policy is central at the EU’s political programme. Its aism are to bring about alternative ways of running our daily lives so that Europe can continue to create growth and jobs while leading the global effort to tackle climate change and energy efficiency. Europe faces three main challenges in this field – tackling climate change, guaranteeing secure, sustainable and competitive energy, and making the European economy a model for sustainable development in the 21st century[7]. The resolve of the European Council[8] to transform Europe into a low-carbon, high energy efficiency economy means that the continued growth of the European economy, essential to achieve full employment and inclusion, needs to be decoupled from energy consumption. The current trends are unsustainable. Indeed, if nothing were to change, final energy consumption in the EU is predicted to increase up to 25% by 2012, with a substantial rise in greenhouse gas emissions. ICTs have an important role to play in reducing the energy intensity and increasing the energy efficiency of the economy, in other words, in reducing emissions and contributing to sustainable growth. In addition to that, ICTs will not only improve energy efficiency and combat climate change but will also stimulate the development of a large leading-edge market for ICT enabled energy-efficiency technologies that can foster the competitiveness of European industry and create new business opportunities.

Case Analysis of Mdd, Gad, and Substance Use

Case Analysis of Comorbid Major Depressive Disorder, Generalized Anxiety Disorder, and Substance Abuse Nicole Gapp University of Minnesota School of Nursing Case Analysis of Comorbid Major Depressive Disorder, Generalized Anxiety Disorder, and Substance Abuse Major Depressive Disorder (MDD) is a mood disorder with symptoms that greatly affect the life of the individual. MDD could in fact be called a public health crisis, as it is projected that it will soon overtake heart diseases as the major worldwide health concern (Boyd, 2008).Diagnostic criteria for MDD are depressed mood or loss of interest or pleasure in nearly all activities, present for at least 2 weeks. Findings and behaviors associated with MDD are disruption of sleep, suicidal ideation, feelings of worthlessness and hopelessness, and fatigue and loss of energy. MDD is also associated with a high impairment in occupational, social, and physical functioning, causing as much disability and distress as chronic medical disorde rs (United States Department of Health and Human Services, 1999).MDD has been shown to be associated with increased medical illnesses. MDD can make everyday living a challenge, as research shows that depressive symptoms are associated with impaired everyday problem-solving ability directly and indirectly mediated through learning and memory, and reasoning (Yen, Rebok, Gallo, Jones, & Tennstedt, 2011). It is important for MDD to be identified and treated early on, as MDD that is not treated appropriately results in recurrent depressive episodes, with each successive episode increasing in severity.As MDD is highly associated with suicidal ideation and suicide, it is imperative that MDD be treated to ensure patient safety. Risk factors for MDD are a prior episode of depression, lack of social support, lack of coping abilities, medical comorbidity, substance use, and presence of life and environmental stressors. In addition, major depression may follow adverse or traumatic life events, especially those that involve the loss of an important human relationship or role in life. Social isolation, deprivation, and financial deprivation are also risk factors (APA, 2002).Genetics play a role in the development of MDD, and deficiency or dysregulation of neurotransmitters are also thought to play a part in its etiology. Psychological theories of MDD hypothesize that an early lack of love and warmth may be involved with the development of depressive symptoms, while developmental and family theorists have proposed that parental loss, emotionally inadequate parenting styles, or maladaptive patterns in family interaction may contribute to the etiology of MDD.Women are twice as likely as men to be diagnosed with MDD, though it is believed that the incidence in men is under-diagnosed. Prevalence rates are unrelated to race (Boyd, 2008). Nursing responses to MDD should involve interventions to treat symptoms within the biologic domain, such as changes in appetite, weight, sleep, or energy, as well as symptoms within the psychological domain, such as changes in mood and affect, thought content, suicidal behavior, and cognition and memory. Many types of interventions are used to treat the varied effects and symptoms of MDD.Pharmacologic interventions, such as selective serotonin reuptake inhibitors, tricylic antidepressants, monoamine oxidase inhibitors, and other classes of antidepressants may be used to decrease or manage depressive symptoms. Medication should be continued for at least six months to a year after complete remission of depressive symptoms. Lifestyle patterns, such as good sleep hygiene, activity and exercise, and adequate intake of well-balanced meals should also be encouraged, as these patterns help the client move toward a healthy daily routine that supports remission or recovery.Psychotherapy, such as cognitive therapy, behavior therapy, and interpersonal therapy, has been shown to be effective in individuals with MDD, and a combination of psychotherapy and pharmacotherapy is recommended for patients with severe or recurrent MDD as a strategy to prevent relapse (Boyd, 2008). In addition, electroconvulsive therapy has been shown to be an effective treatment for MDD, especially severe MDD that has not responded to medications. Major depression frequently occurs in conjunction with ther psychiatric disorders, such as anxiety or substance use disorders, which can also affect antidepressant responsiveness. In such cases, the co-occurring mental health problem should be treated in addition to major depression (President and Fellows of Harvard College, 2011). The patient described in this case analysis has comorbid diagnoses of generalized anxiety disorder and substance abuse. Generalized Anxiety Disorder is a psychiatric disorder characterized by excessive worry and anxiety with an insidious onset.The anxiety of GAD persists for at least six months, with excessive anxiety and worry occurring for more days than not, and for some individuals, persisting daily. Risk factors for GAD are thought to be unresolved conflicts, cognitive misinterpretations, and multiple stressful life events (Boyd, 2008)). Few studies have examined the genetic basis of GAD, but it is thought to be moderately heritable. In clinical settings, the incidence of GAD is equally distributed in women and men. However, in wider studies GAD is twice as common in women.In no studies has the prevalence of GAD been related to race (Boyd, 2008). Patients with GAD often have associated depressive symptoms, and MDD is a common comorbid disorder. For this reason, there has been debate surrounding whether GAD is a separate disorder than MDD, or if GAD symptoms are part of the course of MDD. However, research shows that many patients with GAD do not present with a distinct MDD symptom profile. This does not support the hypothesis that co-morbidity between MDD and GAD is artificially inflated because of the similar symptom criteria required by th e current diagnostic system.Instead, MDE and GAD may be thought of as two distinct diagnostic entities that frequently co-occur because of a shared underlying trait (Sunderland, Mewton, Slade & Baillie, 2010). Current diagnostic criteria state that GAD exists when the excessive worry does not occur exclusively during a mood disorder, psychotic disorder, or pervasive developmental disorder. For example, a patient who experiences persistent excessive anxiety but has minimal or no depressive symptoms would be diagnosed with GAD (Boyd, 2008). However, research has shown that the presence of a comorbid anxiety disorder may make MDD harder to resolve or manage.One particular study comparing individuals with MDD and individuals with MDD and a comorbid anxiety disorder showed that after adjusting for the severity of depression, those in the anxious depression group had significantly younger onset age, had been suffering from depression for a longer period, were more likely to experience a r ecurrence, and obtained lower scores on a scale assessing quality of life. The anxious depression group was also characterized by a significantly higher proportion of individuals reporting significant suicidal ideation and previous suicide attempts (Seo, Jung, Kim, T. , Kim, J. Lee, Kim, J. & Jun, 2011). Patients with GAD are often highly somatic, with many complaints of physical symptoms. One study concluded that painful physical symptoms in patients with GAD are twice as prevalent as in the control group, which consisted of individuals with neither GAD nor MDD. The presence of comorbid MDD was associated with a significantly higher prevalence of painful physical symptoms. Painful physical symptoms were significantly associated with functioning and health status impairment both in GAD alone and in GAD and comorbid MDD compared with controls (Romera, Fernandez, Perez, Montejo, Caballero, F. Caballero, L. , Arbesu & Gilaberte, 2010). In addition, those with GAD also often experience poor sleep habits, irritability, and poor concentration. Patients with GAD often feel frustrated, demoralized, and hopeless. They often feel restless and on edge and experience clinically significant distress or impairment of functioning resulting from anxiety, worry, or physical symptoms. GAD has a significant negative impact on work functioning, although smaller than the effect of MDD (Plaisier, Beekman, de Graaf, Smit, van Dyck & Penninx, 2010).Interventions addressing symptoms of the biologic domain include eliminating caffeine, diet pills, amphetamines, ginseng, and ma huang, which have all been shown to be anxiety-producing substances (Boyd, 2008). In addition, good sleep hygiene should be promoted, as a common symptom of GAD is sleep disturbances. The nurse should teach the patient breathing control and progressive muscle relaxation as calming techniques, help the patient identify other positive coping strategies, and educate the patient on time management.Pharmacological int erventions, such as the use of benzodiazepines, certain antidepressants, and other non-benzodiazepine anxiolytics may be effective in reducing anxiety. Roughly 75% of those with GAD have at least one additional current or lifetime psychiatric diagnosis, with MDD being one of the more common comorbidities. Alcoholism is also a significant problem associated with GAD. Patients may use alcohol, anxiolytics or barbiturates to relieve anxiety, and this may lead to abuse and dependency. Such is the case of the patient described in the case analysis, who also has a substance-related disorder.The DSM-IV-TR defines substance abuse as a maladaptive pattern of substance use leading to clinically significant impairment or distress. This impairment may be manifested by recurrent use, resulting in failure to fulfill major role obligations at work or home, recurrent use in situations that are physically hazardous, recurrent substance related legal problems, or continued use despite feeling persist ent or recurrent effects of the substance. To constitute substance abuse, three or more of these manifestations must be present within a 12-month period.In general, men consume more alcohol and abuse drugs more than women, though women are more likely to abuse prescription medication. Substance abuse and dependency are not correlated so much with gender as with an early age of initiation of substance use (Boyd, 2008). Comorbid mental disorders occur often with substance dependence and abuse. For some, comorbid mental disorders are byproducts of long-term substance abuse. Other people have mental conditions that predispose them to substance abuse, with substance abuse becoming a comorbid problem as they use drugs and/or alcohol to self-medicate existing mental illnesses.There is a well-documented association between depression and alcohol abuse and dependence which cannot be explained solely by the random overlapping of these two conditions. A systematic review of 35 studies estimate d the prevalence of current alcohol problems in depressed patients to be 16%, as compared to 7% in the general population. The three most commonly described causal hypotheses for this comorbidity are as follows: 1) an independent depressive episode (e. g. he self-medication theory), 2) alcohol induced depressive symptoms and 3) the existence of shared biological and environmental factors that predispose persons to both (Cohn, Epstein, McCrady, Jensen, HunterReel, Green & Drapkin, 2011). In addition, men with at least four heavy drinking occasions were found to be 2. 6 times as likely to be classified as being depressed as men who drank heavily less than four times in the previous 28  days (Levola, Holopainen & Aalto, 2011). Specific substances that have been abused by the patient who is the subject of this analysis are alcohol, cocaine, heroin, and the prescription drugs oxycodone and Valium.At the time of admission, the patient was no longer regularly using drugs or alcohol, but his history of substance abuse, including overdose, is extensive. Thus, although the patient is already withdrawn from drugs and alcohol, his long-term substance use has significant physical and mental consequences. The depression of the central nervous system by alcohol causes relaxed inhibitions, heightened emotions, mood swings, and cognitive impairments such as reduced concentration and attention, and impaired judgment and memory. In particular, this patient engages in periodic binge drinking, drinking up to 15 drinks in one evening.This alcohol use would result in several days of intoxication, which were interspersed with periods of sobriety. The amount of alcohol consumed in an episode of binge drinking can cause severely impaired motor function and coordination difficulties, emotional lability, stupor, disorientation, and in extreme cases, even coma, respiratory failure, or death. Long-term abuse of alcohol can adversely affect all body systems, and research has shown a conne ction between alcohol dependence and increased risk for diabetes mellitus, gastrointestinal problems, hypertension, liver disease, and stroke (Smith & Book, 2010).Cocaine users typically report that cocaine enhances their feelings of well-being and reduces their anxiety. However, long-term cocaine use leads to increased anxiety. Severe anxiety, restlessness, and agitation are all symptoms or cocaine withdrawal. Withdrawal causes intense depression, craving, and drug seeking behavior that may last for weeks (Boyd, 2008). Valium, a benzodiazepine, is a prescription drug that this patient abused. Patients who abuse benzodiazepines often feel hyperactive or anxious after using them.Often, patients who abuse these drugs combine them with alcohol, putting the patient at risk of coma or death. Symptoms during benzodiazepine withdrawal include anxiety rebound, such as tension, agitation, tremulousness and insomnia, as well as symptoms of autonomic rebound, sensory excitement, motor excitati on, and cognitive excitation, such as nightmares and hallucinations (Boyd, 2008). Opiates are powerful drugs that can quickly trigger addiction when used improperly. Heroin is an opiate that was abused by this patient.Heroin is the most abused and most rapidly acting of all opiates. It can be injected intravenously, and such was the method of delivery for this patient. Heroin produces profound degrees of tolerance and physical dependence. Withdrawal from opiates should be tapered, and if abruptly withdrawn from someone dependent on them, severe physical symptoms may occur, along with nervousness, restlessness and irritability (Boyd, 2008). In addition to heroin use, the patient attempted to commit suicide by overdosing on oxycodone, a prescription opiate.Overcoming substance abuse and preventing relapse can be especially difficult as denial is common in substance abusing patients. Denial is defined as the patient’s inability to accept his loss of control over substance use, o r to accept the consequences associated with the substance use (Boyd, 2008). Because many patients find it difficult or impossible to believe they have a serious problem with drugs and alcohol, many do not seek treatment, or stop treatment prematurely. Motivation is a key predictor of whether individuals will change their substance abuse behavior.Several effective modalities are used effectively to treat addiction, such as 12-step programs, social skills groups, psychoeducational groups, group therapy, and individual and family therapies. Depending on the individual, different treatment techniques will be more or less helpful. History of Present Illness The patient is a 58-year-old Caucasian male who was participating in a partial hospitalization program (PHP) at Hennepin County Medical Center (HCMC) for the treatment of severe major depressive disorder. He has been involved in PHP since his last discharge from the HCMC psychiatric inpatient unit in early March.The patient was coope rative with treatment and medication compliant. He was put on a 72-hour hold after becoming angry and hostile during the PHP group and threatening to hang himself that evening when he got home from PHP. He eventually committed himself voluntarily to the HCMC psychiatric inpatient unit. Upon introduction, the patient appears to be clean, casually dressed, and of normal weight. He is alert and oriented. His attention, cognition, and abstract reasoning are intact, and his thought content is appropriate and organized.In conversation, he is pleasant and cooperative, exhibiting a stable mood and a slightly blunted affect. The patient will talk to staff members but interacts minimally with peers and does not attend groups unless encouraged by staff. The patient has a normal gait but moves quite slowly. In addition it appears that his thought processes are slowed, as he is slow to respond during conversation and seems to have difficulty finding the words to express what he wants to say. The patient appears to have intact recall, short-term, and long-term memory.He appears to be an adequate historian though he exhibits poor judgment due to his depressive and anxious symptoms, as evidenced by his extensive history of drug and alcohol abuse and dependency. The patient has psychiatric diagnoses of severe and recurrent major depressive disorder, generalized anxiety disorder, and polysubstance abuse. The patient has been suffering from MDD with chronic suicidal ideation since age 15. His first suicide attempt was at age 15, and he began abusing drugs and alcohol at approximately the same time.His extensive history of substance abuse includes use of alcohol, cocaine, and IV heroin. His alcohol abuse as a teenager led to a DWI charge. He has participated in mental health outpatient treatment and has undergone chemical dependency treatment numerous times. He completed high school without apparent difficulty. The patient seems to be of average intelligence, though his IQ is not listed in the record. He does not have a history of violent or sexual crime. He has a history of five suicide attempts. He began smoking as a teenager and currently smokes one pack of cigarettes per day.In 1983, the patient married and remained so until his wife died 25 years later, in 2008. He had no children. According to the patient, he was happily married, and he called his relationship with his wife â€Å"the best thing that has ever and will ever happen to me. † While he was married, he got completely clean from drugs and alcohol, remaining drug free and sober for 12 years. Though he struggled with episodes of depression and suicidal ideation, he was able to manage his symptoms with medication and mental health outpatient treatment. Most of my problems faded into the background,† said the patient. During this time, he and his wife bought a condo, and the patient was employed as a janitor and handyman, working at the Minneapolis-Saint Paul airport. He remained at this job for over a decade and was promoted to the position of supervisor. He had, as he said â€Å"everything I ever wanted. † In 2007, his wife became very ill and eventually died in 2008 after complications from a surgery intended to prolong her life. The patient reports that as his wife got sicker, he became increasingly depressed.Unlike in the previous 12 years, medication and outpatient treatment did not seem to manage his symptoms. In addition, he started experiencing extreme and persistent anxiety, feeling â€Å"like I was always one second away from a panic attack. † He was diagnosed with generalized anxiety disorder and was prescribed benzodiazepines to manage this condition. As his wife got sicker, he slowly began to self medicate with alcohol and admitted to â€Å"popping an extra pill† occasionally to decrease his anxiety.When his wife died, the patient became so depressed and anxious that he was unable to concentrate at work. He had to give up his job as a supervisor, and said, â€Å"I couldn’t even manage myself, how was I supposed to handle anyone else. † As his depression and anxiety got worse, he turned increasingly to alcohol and drugs. He reported binge drinking, consuming up to 20 drinks in one evening. He would remain intoxicated for several days, and would switch to using drugs as the alcohol cleared his system. He reported being either drunk, high, or both almost every day.Although he used cocaine and heroine, which were the drugs he used as a teenager, he also became dependent on prescription benzodiazepines to manage his increasingly severe anxiety. The increase in anxiety may be explained by his cocaine use, which, though it reduces anxiety while high, causes increased anxiety with long term use. Additionally, though proper use of benzodiazepines decreases anxiety, benzodiazepine abuse or dependency results in increased anxiety levels. When his request for more prescription benzodiazepines was denie d due to drug seeking behavior, he gained possession of Valium illegally and continued abusing them.He was arrested for illegal Valium possession in 2009, and received two DWIs between 2008 and 2011. His medical record notes that he has a history of antisocial behavior, though it does not expand on this statement beyond the mention of his previous arrests. With no income coming in and increasing amounts of money used to fuel his drug and alcohol addiction, he lost his condo and all of his savings and was living at the Salvation Army homeless shelter by June 2008. His depression grew in severity as the major life losses piled up and his substance dependency problem worsened.In 2008, he lost consciousness due to heroin intoxication. In August of that year, the patient overdosed on oxycodone, intending to kill himself. He was brought to HCMC, and for the past several years has experienced being in and out of the psychiatric inpatient. In 2010, he moved from the homeless shelter to Alte rnative Homes in Minneapolis. Following his latest psychiatric hospitalization in March, he began the partial hospitalization program at HCMC. Upon discharge from the current hospitalization, he will be returning o Alternative Homes and participating again in the PHP program. A common finding associated with a diagnosis of either MDD, GAD, or substance abuse is the presence of sleep disturbances. Such is the case with the patient described. These sleep disturbances may present themselves as difficulty falling asleep, trouble maintaining sleep, or waking up too early (National Insititute of Health, 2005). This patient currently experiences insomnia, getting only 3-4 hours of sleep per night. Reportedly, this insomnia has been a chronic issue.The insomnia the patient experience sets him up for a negative cycle. Because of his depression and anxiety, it is difficult for the patient to sleep. This lack of sleep, in turn, exacerbates his anxiety and depressive symptoms. As his symptoms p rogress in severity, he turns to substances to self medicate. The use of substances results in a worsening of his insomnia. Thus, finding a way for the patient to get adequate sleep is important. He has tried a variety of medications to promote sleep, but none have been effective.He can no longer be prescribed many of the medications for insomnia because of his history of abuse and overdose using prescription drugs. Thus, the options available to him for sleep promotion lie in the realm of sleep hygiene promotion. The patient might also consider participating in a sleep study, as this may reveal additional factors that prevent him from getting the sleep he needs. In addition to his mental illnesses, the patient also has significant medical problems. He has been diagnosed with hypertension, hepatitis C, diabetes mellitus, osteoarthritis of the left shoulder, and acid reflux.Research shows that diabetes mellitus, gastrointestinal problems, hypertension, liver disease are correlated wi th substance abuse (Moffitt, Caspi, Harrington, Milne, Melchior, Goldberg & Poulton, 2010). Indeed, the patient’s hepatitis C is a direct consequence from his use of street drugs. Interestingly, multiple studies have revealed that not only are depressive symptoms a risk factor for the development of type 2 diabetes, but they have also been shown to contribute to hyperglycemia, diabetic complications, functional disability and mortality among diabetic patients (Moffitt et al. 2010). Also, as previously discussed, patients with GAD and MDD report more painful physical symptoms than the general population, and the patient’s osteoarthritis pain could well be exacerbated by the presence of these psychiatric conditions. Thus, it is possible that with improved management of his psychiatric conditions, his medical problems may improve as well. Family and Social History The patient’s social and family history is somewhat lacking. The patient was adopted at a young age.He has three non-biological brothers and he reports that he is estranged from all of them, and is not willing to contact them until he has â€Å"my life back together. † In addition, both of his adoptive parents are dead. The patient was not keen on discussing his adoptive family or his childhood and adolescence, but stated that this adoptive family â€Å"were good people, and tried hard to give me everything I needed. † He denies any history of physical, emotional, or sexual abuse. According to the social history, there is no history of mental illness in his adoptive family.This does not mean that environmental or social factors play no role in the etiology of his mental illness, but that these factors may be less obvious. Information on the patient’s biological mother and family history is unavailable. The patient was given up for adoption at birth, and remained a ward of the state, living in various foster homes, until he was adopted at age 3. As the patient wa s given up for adoption and adopted at such a young age, he has he has no recollection of his biological family or his time in the foster care system.Any instances of abuse, neglect, or trauma in his early years are thus unknown. Because there is no available family history, it is impossible to know if any of the patient’s first-degree relatives suffered from mental illnesses, or if the biological mother used drugs or alcohol during her pregnancy. This lack of information is unfortunate, as it is impossible to conjecture whether, or to what degree, the patient’s mental disorders have a basis in genetics or in disturbed fetal development.Because MDD, GAD, and substance abuse have all been shown to have a moderate to high degree, of heritability, it is very plausible that mood, anxiety, or substance related disorders were present in his biological family. The patient seems to have very limited social support, as he is estranged from his adoptive siblings and has no commu nication with his biological family. The patient also has a history of limited social interactions and close friendships. He reports that he has felt disconnected from others for as long as he remembers, and that he had few close friendships throughout his childhood, adolescence, and adulthood.In addition, the patient reports that most of the relationships that he would call the closest have been with people who have substance abuse problems, as he spent â€Å"years and years running with the wrong crowd. † The basis of most of these relationships was a shared interest in drug and alcohol use, and he does not think that these friends would be of any support to him in pursuing and maintaining recovery. During the time that he was sober, he states that his wife was â€Å"the only friend I really needed† and as a result, he did not form many close friendships with his peers.He states that he currently has no supportive relationships. Furthermore, he has little desire to f orm such relationships. Application of Developmental Theories Viewing the patient and his family and social history through the lens of attachment theory provides a possible framework for viewing the patient’s development of mental illnesses. Attachment theory, a biologically based framework first proposed by John Bowlby in the mid 1950s, is the theoretical approach used to describe the importance of stable and secure relationships of all infants, especially those in foster care (Bruskas, 2010).This theoretical approach reasons that infants and children have a need to belong and to experience secure relationships with a small number of consistent â€Å"preferred† primary caregivers in order to successfully develop into normal healthy adults who can actively and emotionally participate in social life (Boyd, 2008). In particular, a child should receive the continuous care of this single most important attachment figure for approximately the first two years of life.If the attachment figure is broken or disrupted during the critical two year period the child will suffer irreversible long-term consequences of this deprivation, which might include delinquency, reduced intelligence, increased aggression, depression, and affectionless psychopathy–an inabilityto show affection or concern for others. Research, such as the Adverse Childhood Experiences Study, correlates untreated childhood adversity with an increased risk toward poor developmental health and other major diseases seen later in life such as cardiac disease, depression, and even premature death (Felitti & Anda, 2010).Studies reveal that infants in foster care are among the most vulnerable because of their complex and immense brain development, and the importance of attaining developmental milestones. The onset of brain development begins soon after conception and will continue to mature well into adulthood, but the most abundant and dramatic time of growth is during the first few years of life, specifically within the first three years. The primary and most important developmental milestone for any infant is to establish a relationship, especially one with a primary caregiver.This period presents sensitive â€Å"windows of opportunity† for the development of particular parts of brain structure and circuitry influenced and dependent on social experiences for optimal brain development (Bruskas, 2010). The majority of children entering foster care are infants, and the impact of not addressing mental health needs of preverbal children can have deleterious effects (National Research Council Committee on Integrating the Science of Early Childhood Development, 2000).Although an infant may not be able to articulate losses because of their preverbal age, they nonetheless experience grief and loss, and for many, these experiences will be forever embedded in their memory (Felitti & Anda, 2010). Moreover, the consequences of unresolved losses have a much more devastati ng affect in infancy than adulthood because of the potentially permanent psychological impact on the developing brain of an infant or child (Bruskas, 2010).Infants and children in foster care who are not afforded supportive primary caregivers to help them develop an internal ability to regulate their own will continue to use whatever coping methods they can. Under stress-provoking adversities such as abuse, neglect, and relationship disruptions, children’s coping strategies to manage such circumstances may present as hostility, frustration, and anxiety with underlying feelings of fear, abandonment, and powerlessness (Bruskas, 2010).The relationships infants and children develop while in foster care are crucial; relationships characterized by trust and commitment help an infant or child become more resilient toward the challenges and obstacles that all humans face in life; conversely, a lack of such relationships in life can result in long-term dysfunction socially and physica lly. Attachments and â€Å"templates† of the world are significantly developed by the time a child reaches a year old (Bruskas, 2010).Efforts to address behavioral problems later in life may prove to be more difficult and costly as brain structure becomes permanent and behavior becomes more difficult to change. Due to the patient’s experience of foster care as an infant and toddler, it is likely that he was unable to form a secure attachment with a primary caregiver. Although this disruption in attachment is not the sole contributor to his problems with depression, anxiety, and substance abuse, it is very possible that the chaotic structure of his early years play a large role in the development of these conditions.Applying the concepts of Erikson’s model of psychosocial development allow for a greater understanding of the patient’s current state. Because of the disruption of relationships early in life, the patient may not ever have resolved the developm ental conflict of basic trust vs. mistrust, which is often resolved in infancy. This may be one reason behind his feeling of disconnectedness from others. According to Erikson, this inability to resolve this developmental conflict results in a decreased sense of drive and hope. It is also likely that the patient was able to resolve the developmental conflict of autonomy vs. hame and doubt, which is often resolved in toddlerhood (Boyd, 2008). This may explain the patient’s reliance on his wife as the sole supportive relationship in his life, as well as his fast descent into previous behaviors after his wife’s death. As the patient was never able to develop a sense of autonomy, it seems that he became extremely emotionally dependent on his wife. Because of this relationship, he was able to progress at his job and maintain his recovery. However, with the death of his wife, he was brought back to the conflict of autonomy vs. shame and doubt.Really, it was through the prese nce of his wife that he was able to take initiative, be industrious, and have an intimate relationship, all of which are successful outcomes of developmental conflicts. The marriage provided him with hope, purpose, a sense of devotion and fidelity, as well as affiliation and love. In short, it seems that his wife was his mental and emotional anchor. The recurrence of symptoms of his mental disorders after the loss of the anchor of his life threw him back into the early developmental conflicts that he was unable to resolve due to his unstable childhood.According to Erikson, in order for the patient to move forward from his regressed state he must tackle and resolve the conflicts of trust vs. mistrust, autonomy vs. shame and doubt, initiative vs. guilt, industry vs. inferiority, identity vs. role diffusion, and intimacy vs. , isolation to reach the adulthood stage of generativity vs. stagnation. Ultimately, with the resolution of all these conflict, the patient will reach a mature sta te in which he is able to attain ego integrity instead of falling into despair. Patient Prognosis and Treatment RecommendationsIt is important to remember that the patient was seeking help and trying to recover prior to his most recent hospitalization. He was enrolled in and regularly attending the partial hospitalization program. In addition, he was no longer abusing drugs or alcohol. PHP staff report that he had been medication compliant, cooperative, and was motivated to change. The patient’s recent hospitalization was precipitated by a change in drug dose and type. He reported that it was only after the medication change that the suicidal ideation intensified.Thus, an important goal for this patient is to find the drug types and dosages that will successfully manage his depression and anxiety. However, because the patient has such an extensive history of addiction, primary care providers are hesitant to prescribe large dosages of often highly addictive medications. This h esitation is especially understandable given the patients past abuse of prescription drugs, including an overdose with the intent to commit suicide. However, the types and dosages of the drugs he is currently receiving are not enough to manage his symptoms.The severity of the patient’s depression and anxiety necessitates the use of powerful antidepressants and anxiolytics, but his past substance abuse and dependency make the prescription of these drugs a last resort. Appropriate pharmacotherapy is also complicated by the fact that this patient has tried various classes and types of drugs to manage his symptoms, but no drug therapy has been effective enough to prevent the periodic recurrences of major episodes of depression and anxiety.To manage his depression, the patient has tried typical and atypical antipsychotics, anticonvulsants, tricyclic antidepressants, monoamine oxidase inhibitors, and selective serotonin reuptake inhibitors, as well as other classes of antidepressan ts, such as Serotonin Norepinephrine Reuptake inhibitors, Norepinephrine Dopamine Reuptake Inhibitors, Alpha-2 Antagonists, and Serotonin-2 Antagonist/Reuptake Inhibitors. Although the apparent failure of all these drugs to manage his depression might cause one to suspect that he is exhibiting purely drug seeking behaviors, the depressive symptoms he xperiences impair and affect him so severely that a denial of the reality of these symptoms would be unsafe and unethical. Electroconvulsive therapy has been recommended to treat his depression, but the patient has refused to undergo this treatment modality. The patient’s anxiety is more easily managed than his depression, and benzodiazepines have proven effective. However, his past abuse of benzodiazepines make his primary care providers reluctant to give them to him, and they have prescribed non-benzodiazepines, such as Buspar and Zolpidem, instead.Unfortunately, these medications have not been effective in controlling the pati ent’s anxiety. As a result, the patient has been asking repeatedly for benzodiazepines, while promising that he will use them responsibly. Ultimately, for the patient to achieve effective maintenance of his comorbid mental disorders, he must be able to take medications as prescribed. Due to his history of substance abuse and his still unstable depression and anxiety, it is unlikely that the patient will be able to take his medications as prescribed.It is recommended that a staff member have control of his drugs while he is attending the PHP, and that once discharged, a home health nurse be sent to administer his medication. This would reduce the potential for abuse. In addition, the use of coping mechanisms besides substance abuse may help the patient adhere to the prescribed drug regimen, as well as decrease his depression and anxiety. Coping skills the patient has identified as helpful are watching television and spending some quiet time alone.However, interaction with othe rs should also be encouraged, as too much time spent alone will only reinforce depressive symptoms of isolation. An increase in the quantity and quality of sleep will also aid the patient in his recovery, as sleep deprivation is positively correlated with depressive symptoms and anxiety levels. The patient’s prognosis is one of cautious hopefulness. Though the patient has experienced severe recurrences of MDD, GAD, and substance abuse in recent years, the patient had maintained a long period of sobriety prior to this, during which he was happy, productive, and high functioning.The patient’s ability to achieve remission from his mental illnesses during his marriage to his wife shows that investing in a supportive relationship is an important and powerful coping skill for this patient. Thus, if the patient is able to form and maintain new supportive relationships, his chance of recovery will improve substantially. It is also important to remember that he was doing very w ell until his wife died. According to the Holmes and Rahe Index, the death of a spouse is the number one most stressful event that occurs in the life of an individual (Perry & Potter, 2009).It is not an exaggeration to say that with his wife’s death, life as he knew it ended. Many people experience periods of long and severe depression following the death of a loved one. For this patient, his descent into depression, combined with the resurgence of his anxiety sent his life into a complete tailspin. Under the severe stress of not only his wife’s death but also his inability to keep working, he returned to his former coping mechanisms of drug and alcohol abuse.These habits detracted him from working through the grief of his wife’s death, and furthermore caused him to lose his house and his savings, thus increasing his depression and anxiety, thus perpetuating the substance abuse. Now that the patient has withdrawn from drugs and alcohol and is in a safe environme nt, he can continue his grief work. As a result, his depression may begin to subside, and he may be able to get closer to his previous level of functioning. DSM-IV-TR Axis I: Major Depressive Disorder, Generalized Anxiety Disorder, Polysubstance Abuse Axis II: Cluster B traitsAxis III: Hypertension, Hepatitis C, Diabetes Mellitus, Type 2, Osteoarthritis of the left shoulder, Acid Reflux, Bilateral hearing loss Axis IV: Chronic mental illnesses, chronic medical conditions, death of spouse, family estrangement, lack of social support, unemployment, financial insecurity, acute hospitalization, Axis V: 35 (current), 75 (potential) Patient Goals: †¢ I want to find medications that will help my depression and anxiety †¢ I want to keep from abusing my medications †¢ I want my grief over my wife’s death to get better †¢ I want to take one day at a time †¢ I want to feel less alone †¢ I want to get better sleepNursing Goal: Patient will be safe during hos pital stay. Interventions: †¢ Assess for suicidal ideation every shift. †¢ Perform rounds every 15 minutes to ensure patient safety. †¢ Ensure that the patient has no access to potentially harmful objects and/or substances. †¢ Observe, record, and report any changes in mood or behavior that may signify increasing suicide risk and document results of regular surveillance checks. Nursing Goal: Patient will seek help in dealing with grief-associated problems. Interventions: †¢ Develop a trusting relationship with the client by using empathetic therapeutic communication (Eakes, Burke & Hainsworth, 1998). Educate the client that grief resolution is not a sequential process and that the positive outcome of grief resolution is the integration of the deceased into the ongoing life of the griever (Matthews & Marwit, 2004). †¢ Identify available community resources, including grief counselors and community or Web-based bereavement groups. †¢ Focus on enhanci ng coping skills to alleviate life problems and distressing symptoms such as anxiety and depression. Nursing Goal: Patient will practice social and communication skills needed to interact with others. Interventions: †¢ Discuss causes of perceived or actual isolation. Assess the patient’s ability and/or inability to meet physical, psychosocial, spiritual, and financial needs and how unmet needs further challenge the ability to be socially integrated. †¢ Use active listening skills to establish trust one on one and then gradually introduce the patient to others. †¢ Provide positive reinforcement when the patient seeks out others. †¢ Encourage the client to be involved in meaningful social relationships and support personal attributes (Gulick, 2001). Nursing Goal: Patient will use effective coping strategies instead of abusing drugs and alcohol.Interventions: †¢ Assist the client to set realistic goals and identify personal skills and knowledge. †¢ Use verbal and nonverbal therapeutic communication approaches including empathy, active listening, and confrontation to encourage the client to express emotions such as sadness, guilt, and anger, verbalize fears and concerns, and set goals. †¢ Offer instruction regarding alternative coping strategies (Christie & Moore, 2005). †¢ Encourage use of spiritual resources as desired. Nursing Goal: Patient will identify actions that can be taken to improve quality of sleep.Interventions: †¢ Obtain a sleep-wake history, including history of sleep problems, changes in sleep with present illness, and use of medications and stimulants. †¢ Encourage the patient to develop a bedtime ritual that includes quiet activities such as reading, television, or crafts. †¢ Encourage the patient to use soothing music to facilitate sleep (Lai & Good, 2005). †¢ Teach the patient sleep hygiene guidelines for improving sleep habits (ie. go to bed only when sleepy, avoid afternoon an d evening naps, use the bed only for sleeping, get up at the same time every morning). Use relaxation techniques to decrease anxiety before going to sleep. †¢ Refer to a sleep center if interventions are ineffective. Analysis of Interaction Before interacting with the patient, I read the patient’s medical record and notes. I paid particular attention to ways the patient said he learned best, which for my patient was one on one conversation. Prior to approaching the client, I asked myself if I had any beliefs, biases, or limitations that would affect my interaction with the patient or prevent the formation of a therapeutic relationship.In order to set the tone of a professional therapeutic relationship, I introduced myself to the client, saying that I was a student nurse and shaking his hand. I made some small talk with him about such topics as sports and the patient’s hobbies in order to show interest in the patient and develop rapport. During this conversation, t he patient grew more visibly at ease. His face became less taut, his answers became longer and less forced, and he moved from an erect posture so a somewhat more relaxed position in his chair. The patient spoke slowly and eemed to have difficult finding the words he wanted to use. Such a speech pattern is characteristic of depression, one of the patient’s psychiatric diagnoses. This first conversation was punctuated with the start of morning group. After morning group, I gave the patient some space, as I did not want him to feel overwhelmed or threatened by my questions. About a half hour later, I asked the patient if we could continue the conversation we were having that morning, and he agreed without hesitation. In this second interaction, I began with a few open-ended questions about how group had been.I then started asking the patient some more questions about his readmission into the hospital and precipitating events. I asked open-ended question, and often responded to h is answers by asking further open-ended questions. For example, after asking the patient if he was having suicidal thoughts, he responded that he did not want to hurt himself right now. I replied with the open-ended question, â€Å"So are you feeling safe? † using reflection to redirect the idea back to the patient and allow him to explore whether or not he felt safe.I focused on actively listening to the patient, following the patient’s lead and sometimes asking clarifying questions. Because of the patient’s slower rate of response, I employed the use of silence to allow him to gather his thoughts and proceed at his own pace. As the patient told me more about recent events in his life, including the death of his wife, the loss of his job and his descent into substance abuse, he began to look away more and more. This decrease in eye contact might be the result of the patient feeling ashamed, embarrassed, or guilty about his feelings and behaviors.In order to mai ntain connection with the patient and assure him of my nonjudgmental view of his situation, I used empathy and restatement, saying, â€Å"It sounds as though you have had a very difficult past couple of years. † Upon saying this, the patient looked up, maintained eye contact, and agreed. He then began to expand on his current feeling of hopelessness, saying, â€Å"I wonder if life is worth living, and sometimes I just want to go to sleep and not wake up. † As he explored and expanded on his feelings I alternated between using silence and validating what he said.The silence allowed him to express intense feelings without interruption, while statements of restatement and interpretation, such as â€Å" It sounds like you have been feeling pretty hopeless,† demonstrated empathy and a nonjudgmental attitude toward what the client was feeling. At one point, the patient put his head in his hands, saying â€Å"I had so much going for me, and after my wife died, everyth ing went to pot. † I felt that in this moment, what the client needed was neither a cheery reassurance that things would get better, nor dispensation of advice, but rather a person to understand and acknowledge his current misery.I replied that sometimes life gets you down, and sometimes when it rains it pours, and it’s ok to be sad about that. The patient seemed appreciative of the acknowledgment of his pain and the justification of his sadness. I sat silently with him for 2-3 minutes, as I felt it was important for him to feel, sit with, and process these emotions for a short period of time. During these periods of silence, I continued to lean forward slightly, as I had done throughout the interaction, to show that I was still interested and engaged despite the lack of verbalization.Because I had acknowledged the patient’s hardships and thereby connected with him, I felt that I was in a good position to explore with him goals he had for the future, and ideas th at could help him reach these goals. I made sure to approach this topic not by giving advice or suggestions, but by asking him open-ended questions about what things made him feel less sad or anxious and what things he wanted to work on during his stay. These open ended questions elicited the response of his goals for the future, and his verbalization that he needed to find better coping mechanisms, because his old ones didn’t seem to work.He also stated that he knew he needed to â€Å"continue grieving my wife, because the drugs and alcohol kept me from doing that. † I thought that this realization of substance abuse as inhibitory to his grief process was very insightful, and told him so. He made a small smiling expression and responded that he wanted to â€Å"get back on the straight and narrow† and take his medications â€Å"the way I’m supposed to—no more, no less. † The patient’s elucidation of his goals and his insight into help ful and hindering coping devices was a very positive outcome of this therapeutic conversation.The patient seemed less burdened after the opportunity to talk about his recent losses in life, and more hopeful after verbalizing his goals and ways to meet them. References Ackley, B. J. & Ladwig, G. B. (2008). Nursing Diagnosis Handbook (7th ed. ). St. Louis, Missouri: MOSBY Elsevier. American Psychological Association. (2002). Boyd, M. A. (2008). Psychiatric nursing: contemporary practice (4th ed. ). New York: Lippincott Williams & Wilkins. Bruskas, D. (2010). Developmental health of infants and children subsequent to foster care.Journal of Child and Adolescent Psychiatric Nursing, 23(4), 231-241. doi:http://dx. doi. org/10. 1111/j. 1744-6171. 2010. 00249. x Christie, W. & Moore, C. (2005). The impact of humor on patients with cancer. Clinical Journal of Oncology Nursing, 9(2), 211-218. Cohn, A. M. , Epstein, E. E. , McCrady, B. S. , Jensen, N. , HunterReel, D. , Green, K. E. , & Drapki n, M. L. (2011). Pretreatment clinical and risk correlates of substance use disorder patients with primary depression. Journal of Studies on Alcohol and Drugs, 72(1), 151-157. Eakes, G. G. , Burke, M. L. & Hainsworth, M. A. 1998). Middle-range theory of chronic sorrow. Image Journal Nursing Scholar, 30, 179. Felitti, V. J. & Anda, R. F. (2010). The Relationship of Adverse Childhood Experiences to Adult Medical Disease, Psychiatric Disorders, and Sexual Behavior: Implications for Healthcare. Cambridge University Press. Gulick, E. (2001). Emotional distress and activities of daily living functioning in persons with multiple sclerosis. Nursing Resolutions, 50(3), 147-154. Lai, H. L. & Good, M. (2005). Music improves sleep quality in older adults. Journal of Advanced Nursing, 49(3), 234-244.Lawrence, A. E. , Liverant, G. I. , Rosellini, A. J. , & Brown, T. A. (2009). Generalized anxiety disorder within the course of major depressive disorder: Examining the utility of theDSM-IV hierarchy rule. Depression and Anxiety, 26(10), 909-916. Levola, J. , Holopainen, A. , & Aalto, M. (2011). Depression and heavy drinking occasions: A cross-sectional general population study. Addictive Behaviors, 36(4), 375-380. doi:http://dx. doi. org/10. 1016/j. addbeh. 2010. 12. 015 Matthews, L. & Marwit, S. (2004). Complicated grief and the trend toward cognitive-behavioral therapy.Death Studies, 28, 849-863. Moffitt, T. E. , Caspi, A. , Harrington, H. , Milne, B. , Melchior, M. , Goldberg, D. , & Poulton, R. (2010). Generalized anxiety disorder and depression: Childhood risk factors in a birth cohort followed to age 32 years. Diagnostic issues in depression and generalized anxiety disorder: Refining the research agenda for DSM-V (pp. 217-239). Washington, DC, US: American Psychiatric Association; US. National Institute of Health. (2005). National Research Council Committee on Integrating the Science of Early Childhood Development. (2000). Perry, A. G. , Potter, P.A. (2009). Fundamentals of Nursing (7th ed. ). St. Louis, Missouri: MOSBY Elsevier. Plaisier, I. , Beekman, A. T. F. , de Graaf, R. , Smit, J. H. , van Dyck, R. , & Penninx, B. W. J. H. (2010). Work functioning in persons with depressive and anxiety disorders: The role of specific psychopathological characteristics. Journal of Affective Disorders, 125(1-3), 198-206. doi:http://dx. doi. org/10. 1016/j. jad. 2010. 01. 072 President and Fellows of Harvard College. (2011). Harvard Mental Health Letter. Harvard Health Publications. Retrieved from http://www. health. harvard. du Romera, I. , FernandezPerez, S. , Montejo, A. L. , Caballero, F. , Caballero, L. , Arbesu, J. A. , . . . Gilaberte, I. (2010). Generalized anxiety disorder, with or without co-morbid major depressive disorder, in primary care: Prevalence of painful somatic symptoms, functioning and health status. Journal of Affective Disorders, 127(1-3), 160-168. doi:http://dx. doi. org/10. 1016/j. jad. 2010. 05. 009 Seo, H. , Jung, Y. , Kim, T. , Kim, J. , Lee, M. , Kim, J. , . . . Jun, T. (2011). Distinctive clinical characteristics and suicidal tendencies of patients with anxious depression.Journal of Nervous and Mental Disease, 199(1), 42-48. doi:http://dx. doi. org/10. 1097/NMD. 0b013e3182043b60 Smith, J. P. , & Book, S. W. (2010). Comorbidity of generalized anxiety disorder and alcohol use disorders among individuals seeking outpatient substance abuse treatment. Addictive Behaviors, 35(1), 42-45. doi:http://dx. doi. org/10. 1016/j. addbeh. 2009. 07. 002 Sunderland, M. , Mewton, L. , Slade, T. , & Baillie, A. J. (2010). Investigating differential symptom profiles in major depressive episode with and without generalized anxiety disorder: True co-morbidity or symptom similarity?Psychological Medicine: A Journal of Research in Psychiatry and the Allied Sciences, 40(7), 1113-1123. doi:http://dx. doi. org/10. 1017/S0033291709991590 United States Department of Health and Human Services. (1999). Yen, Y. , Rebok, G. W. , Gallo, J. J. , Jones, R. N. , & Tennstedt, S. L. (2011). Depressive symptoms impair everyday problem-solving ability through cognitive abilities in late life. The American Journal of Geriatric Psychiatry, 19(2), 142-150. doi:http://dx. doi. org/10. 1097/JGP. 0b013e3181e89894 Case

Critique of the Ramayana Modern Prose Translation Essay

In a just world, Mr. R. K. Narayan’s estate would be responsible for reimbursing seventeen-fifty, plus applicable taxes, to all those who purchased the Penguin Classics 2006 publication of his book, The Ramayana: A Shortened Modern Prose Version of the Indian Epic. Stated clearly on the back of the cover is the promise that R. K. Narayan â€Å"recounts [The Ramayana] with the narrative flair of a master novelist’’. The back cover lied. Narayan’s re-telling condenses the epic poem so much to the point of nearly listing a series of events. No matter the inspiration, Narayan’s The Ramayana is still a story, and should therefore be able to stand on it’s own as a captivating tale—with further literary research or expansion being used to enhance it’s appeal, not explain it. Arguably, the ‘narrative flair’ of this re-telling is little more expressive than unsolicited summaries found on the Internet, and without further literary aide or instruction, does not stand as a solid piece of literature. What is worse, is that instead of allowing a greater breadth of readers to relate and experience tale of the Ramayana, new readers are alienated by it’s convoluted atmosphere. While the task is grand, Narayan’s translation is not listed as an aide to a larger, more in-depth version; it is still a novel and as such needs to be able to stand strong in its own right when evaluated alone. People who have no prior knowledge of the original Sanskrit story, and who have not been raised with the Hindu epic as a part of their life, should be able to pick up this book, read it, and—regardless of how far the tale may go in global history—be able to enjoy one hundred and fifty one pages of literature, without having any prior knowledge, or requiring further research. Having more knowledge, and doing more research on the original epic tale should increase what readers are able to receive from the book, but it should not be necessary in order to understand it. As it stands, without knowing the original tale, new readers are left with very little literary flow and a patchy depiction of what is supposed to be a lush world. At one point, while Bharatha and Rama argue as to who should be the rightful king, their entire episode is related with: â€Å" The argument went on at a highly academic and philosophical level, the entire assembly watching with respect. (Narayan 60) That assertion does not express a deep academic and philosophical argument, but rather states that one was occurring; the reader doesn’t get to experience what transpired between the brothers, or garner any emotion from it. It goes on to almost quite literally depict the event with a he-said/he-said monotony: So be it; if I have the authority—then I confer it on you as the ruler,† said Bharatha at one stage. â€Å"On my command as the ruler, if you desire to think so, you shall be the King. † It went on thus. Rama went on repeating that there could be no word higher than that of a father; no conduct other than obedience to it. Throughout he referred to Kaikeyi in the gentlest terms and always as â€Å"mother†. (Narayan 61) The listed manner in which the plot is unfolded by Narayan’s re-telling is barely more narrative as a piece of literature than an excerpt from that of the free online encyclopedia Wikipedia: Bharatha refuses to profit from his mother’s wicked scheming and visits Rama in the forest. He requests Rama to return and rule. But Rama, determined to carry out his father’s orders to the letter, refuses to return before the period of exile. However, Bharatha carries Rama’s sandals, and keeps them on the throne, while he rules as Rama’s regent. (Wikipedia Contributors) There is very little more efficiency or flair in Narayan’s telling, and in fact, Wikipedia depicts the stages of the long tale with better clarity; if the prose is not going to be linguistically lush and evocative, it may as well be clear (Wikipedia is not only clear, but free of charge as well). It is of course not a simple task to undertake translating an epic poem from a rhythmic language, into prose with a language devoid of the same musicality. However, to the novice reader of The Ramayana, they would not know the difficulty of the task, and thus—however harsh it may seem— should not be a factor in the reviewing of the story as it stands alone. Narayan was by no means an incapable writer, and as winner of numerous awards and accolades—not the least of which being multiple nominations for the Nobel Prize in Literature (Rajnish Wattas), he does not need defending that he has great ability as a writer, yet the bottom line remain that when it is stripped of further discussion, research, and introductions, The Ramayana: A Shortened Modern Prose Version of the Indian Epic just does not stand on it’s own as captivating modern prose. With nearly each new episode of the tale, Narayan prefaces the action with even more listed information, take for example the introduction to the chapter of Vali: The characters in the drama that follows are Vali, Sugreeva, Hanuman, and Rama. The action takes place in the mountainous forest regions of Kiskinda, a kingdom ruled and inhabited by monkeys. In the Ramayana, the articipants are not only human beings, but many others from God’s creation, intelligent, cultured and with their own achievements of spirit as well as physique: Jambavan was a bear, Jatayu was an eagle, Lakshmana—Rama’s brother—was himself a human incarnation of the Great Serpent Adisesha in whose coils Vishnu rested. (Narayan 90) Again, the story is told by listing statements of what is going on. As with the landscape, and even the characters themselves, nothing is depicted in the story-writing of the prose, but stated, as if the entire epic was a news article being reported by Narayan, as opposed to a vivid history with grand escapades and extreme characters. By translating an epic tale from poetic verse into shortened modern prose, the objective is ultimately to enable a broader audience to relate to and appreciate a classic tale. Poetry is a secluded literary world that does not have the mass appeal that modern prose does; yet Narayan’s re-telling is too constrained and overwhelmed by the amount of story condensed into it. By trying to constrain the length of the story to allow for more readers to get through it, Narayan’s ‘master narrative flair’ seems lost, and the epic tale is a heavy list of events that merely occur on the page.

Introduction to Psychological Testing Essay

Psychological tests are common tools used by schools, hospitals, companies, and other institutions in order to assess the personality of a particular person. Such tests apprise individuals of their personalities, including their behaviors and what they are capable of doing. The history of personality assessment is very long. It might be possible that assessing personality had been of existence since the time a man tried to assess the personality of a stranger for the first time. However, formally assessing personality first became popular in the beginning and the end of World War II. The first tests were paper-and-pencil group tests which consisted of multiple choice and true-or-false questions administered to a large group (Kaplan, et al, 2005). What is a Test? According to the Merriam-Webster dictionary, a test is a critical evaluation or observation. It is also a procedure wherein a statement is being submitted and subjected for acceptance or rejection. Basically, it is a procedure. As related to psychology, it is used to measure skill, intelligence, capacities, or aptitudes of an individual or a group (Test, n. d. ). Categories of Psychological Testing See more: how to write an academic introduction Basically, there are two categories of psychological tests. According to a book entitled, â€Å"Psychological Testing: A practical Introduction†, the two categories are Normal Personality Traits, and Clinical Instruments (Hogan, 2007). The similarities between these two categories involve the nature of the test items and the response formats. Both tests use simple statements as test items, as well as response items. Basically, these items can easily be answered by a simple response such as yes or no. The second similarity is that these categories are subcategorized into comprehensive instruments and specific domain instruments. The aim of the comprehensive clinical instruments is to survey all potential areas of difficulty. In order to do so, these tests produce numerous scores. The specific domain instruments however, focus in only one particular area such as depression, anxiety, or eating disorders. These tests produce only one type of score or a few number of closely related scores. Both normal personality traits and clinical instruments also involve similar strategies for development such as criterion-keying and both have the same stand on faking and responses. Aside from similarities, the two categories of psychological tests also have a number of differences. Firstly, normal personality traits focus on the normal range of personality while clinical instruments focus on the psychopathological aspects or some psychological difficulty. Most of the time, clinical instruments are administered individually, while normal personality traits are administered in a group setting. Clinical instruments are commonly used for diagnosis, treatment, and follow-up evaluation. Normal personality traits such as the NEO PI-R do not have that kind of characteristic (Hogan, 2007). Reliability and Validity Reliability of a psychological test means that the results should be consistent. If a person, for example, takes a test, the result of that specific test should be consistent for a considerable period of time. If in any way the result of a test is not the same with an already proven reliable test for a particular person, then that test is not reliable. Thus, reliability is proven with the use of a coefficient correlation between the test scores of the first testing and the second testing. The correlation coefficient (r) is a numerical summary of the relationship indicated in a bivariate distribution. This is computed by defining first the formula for r and computing its raw score (Hogan, 2007). The coefficient for a perfect reliability is +1. 0 while a coefficient of 0. 0 means no reliability. Reliability can also be determined by comparing two psychological measures (McCurley, et al. , 2005). The difference of reliability from validity is that validity is determined whether a particular test is appropriate for the condition to be measured. It is important that an intelligence test should measure and intelligence and a personality test measure personality. The American Psychological Association issued a book entitled, â€Å"Educational and Psychological Tests and Manuals† in order to help practitioners in the field of testing determine the validity of a certain test (McCurley, et al. , 2005). It should be noted that it would be inappropriate to refer to the validity of a test in itself. Rather, what should be referred to be the interpretation of the scores, whether it fits the particular purpose. A test may be suitable for a particular condition, but not to another. The question should be asked is if the interpretation of scores of a test fully addressed the level of the condition. Also, validity is not a matter of degree, as according to Hogan. It is necessary that what should be known is the extent of the validity for a particular condition, since some tests may have no validity at all (Hogan, 2007). Reliability and validity have their own significance in psychological testing. Reliability makes sure that tests are consistent and can be used universally to a large number of population. It also makes comparing test results easier since these are standardized and their relationships are already proven appropriate. A test may have reliability without having validity. However, both are essential in determining accurately every individual’s psychological condition. Validity requires that the test is truly measures the entity it intends to measure. It is difficult to determine validity (McCurley, et al. , 2005). However, it is important that each test accurately measures what it intends to measure. Validity and reliability are interdependent in establishhing a trully effective psychological test.

Amy Chua Analysis Essay

Reader: Parents from the Western World, who are also readers of The Wall Street Journal. Language: Well written text, with an extensive vocabulary. It is written to some extent with formal jargon. Circumstances: The writer’s home. She lives with her daughters and husband. There is a flashback into Chua’s childhood as well. Intention: She is trying to clarify the differences between Chinese parents and Western parents, along with making us understand the Chinese parents’ mindset and approach. 2) â€Å"Why Chinese Mothers Are Superior† is an article written by Amy Chua. Chua is a professor at Yale, she is the mother of two daughters and she is married to a â€Å"western† man. They live in the USA, but what makes her different is her upbringing. She is from a Chinese family. Throughout her upbringing she has been raised by Chinese methods. Currently being an adult and a parent herself, she has written an article in which she supports and simultaneously explains the significance of Chinese parents. Throughout the text she uses the three modes of appeal. She starts out by using ethos: â€Å"Amy Chua is a professor at Yale Law School, USA.† and â€Å"Well, I can tell them, because I’ve done it.† By pointing out her job, education and being a Chinese parent herself in the introduction, she lets the readers know that she is a reliable source. Then (line 41-43) she uses pathos, and tries to make Western parents feel ashamed of their parenting ha bits. In addition to that, with displaying â€Å"†¦western kids are more likely to participate in sports teams.† she thinks that it is easier for Western parents to let their kids play sports, instead of spending time with them. Chua uses logos, but pathos as well in (line 50-53). Any person can relate to her statement, and bit by bit persuades the reader to understand her parenting approach. In the following passage (line 54-59) she creates and strengthens her ethos by using a harsh metaphor, and in that way exposes the reader to the way she was raised. In the passage (line 65-69) she creates pathos by using contrasts as a topological feature; Chua makes the reader aware of how honest and real Chinese parents are to their kids in contrast to Western parents. â€Å"In other words, Western parents are concerned about their children’s psyches. Chinese parents aren’t. They assume strength, not fragility, and as a result they behave very differently.† Chua proves this statement with the following passages (line 78-92), where she creates logos by using comparisons as a topological feature, and antithesis as a linguistic feature. Later in the text (line 99-105) she uses pathos, but the whole passage backfires on Chua, because of Chinese parentsà ¢â‚¬â„¢ very overwhelming and disturbing view on parenting. Afterwards (line 125-137) she creates pathos by being mean towards her daughter, and her behavior makes Chua distant from the reader. Subsequent (line 156-165) she straightens up the situation by creating pathos again. â€Å"After the rain, the rainbow appears†, this time she describes her daughter’s success and happiness as a result of the hard working days. At last in the final passage (line 176-181) she concludes her article by creating pathos. By doing that she makes the reader feel, as the writer has achieved her goal of making Western readers understand Chinese parenting. But also lets the reader know, even though Chinese and Western are very different types of parents, there are in spite of everything some resemblances. From line 75-77 Chua uses antithesis to explain what some of the differences are between the Chinese and Western parents and how their mindsets are the total opposite. In line 90 she uses the phrase â€Å"†¦ hair – tearing explosion.† By using a metaphor, she makes it clear to the reader, how horrible the parents’ reaction is going to be. In line 121, once again she uses a metaphor â€Å"†¦ drilling each of her hands.† Her intention with this is to exaggerate how long and hard they worked on her daughter’s piano skills. In line 91 she says: â€Å"†¦ maybe hundreds of practice tests†. In this example the hyperbole is used in order to demonstrate the reader how much time the Chinese mother will dedicate to her daughter’s grade.