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In contrast they use more emotion focused coping if the problem is perceived as being out of their control (Lazarus and Folkman 1987) generic 100mg extra super cialis fast delivery. Available resources: Coping is influenced by external resources such as time cheap extra super cialis 100mg fast delivery, money trusted extra super cialis 100 mg, education proven extra super cialis 100 mg, children, family and education (Terry 1994). Poor resources may make people feel that the stressor is less controllable by them resulting in a tendency not to use problem focused coping. Measuring coping The different styles of coping have been operationalized in several measures which have described a range of specific coping strategies. The most commonly used measures are the Ways of Coping checklist (Folkman and Lazarus 1988) and Cope (Carver et al. The coping strategies described by these measures include the following: s Active coping (e. Some of these strategies are clearly problem focused coping such as active coping and planning. For example, positive reframing involves thinking about the problem in a different way as a means to alter the emotional response to it. Some strategies can also be considered approach coping such as using emotional support and planning whereas others reflect a more avoidance coping style such as denial and substance use. Therefore effective coping can be classified as that which reduces the stressor and minimizes the negative outcomes. In addition, recent research has shifted the emphasis away from just the absence of illness towards positive outcomes. Much research has addressed the impact of coping on the physiological and self-report dimensions of the stress response. Coping and the stress illness link: Some research indicates that coping styles may moderate the association between stress and illness. For some studies the outcome vari- able has been more psychological in its emphasis and has taken the form of well-being, psychological distress or adjustment. For example, Kneebone and Martin (2003) critic- ally reviewed the research exploring coping in carers of persons with dementia. They examined both cross-sectional and longitudinal studies and concluded that problem- solving and acceptance styles of coping seemed to be more effective at reducing stress and distress. In a similar vein, research exploring coping with rheumatoid arthritis sug- gests that active and problem-solving coping are associated with better outcomes whereas passive avoidant coping is associated with poorer outcomes (Manne and Zautra 1992; Young 1992; Newman et al. Similarly, research exploring stress and psoriasis shows that avoidant coping is least useful (e. For example, Holahan and Moos (1986) examined the relationship between the use of avoidance coping, stress and symptoms such as stomach-ache and headaches. The results after one year showed that of those who had experienced stress, those who used avoidance coping had more symptoms than those who use more approach coping strategies. Coping and positive outcomes: Over recent years there has been an increasing recognition that stressful events such as life events and illness may not only result in negative outcomes but may also lead to some positive changes in people lives. This phenomenon has been given a range of names including stress related growth (Park et al. This finds reflection in Taylor’s cognitive adaptation theory (Taylor 1983) and is in line with a new movement called ‘positive psychology’ (Seligman and Csikszentmihalyi 2000). Although a new field of study, research indicates that coping processes which involve finding meaning in the stressful event, positive reappraisal and problem focused coping are more associated with positive outcomes (Folkman and Moskowitz 2000). Coping is considered to moderate the stress/illness link and to impact upon the extent of the stressor. Much research has involved the description of the kinds of coping styles and strategies used by people and some studies suggest that some styles might be more effective than others. Initially, it was defined according to the number of friends that were available to the individual. However, this has been developed to include not only the number of friends supplying social support, but the satisfaction with this support (Sarason et al. Wills (1985) has defined several types of social support: s esteem support, whereby other people increase one’s own self-esteem; s informational support, whereby other people are available to offer advice; s social companionship, which involves support through activities; s instrumental support, which involves physical help. The term ‘social support’ is generally used to refer to the perceived comfort, caring, esteem or help one individual receives from others (e. A number of studies have examined whether social support influences the health status of the individual.

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Subjects were asked not to eat or drink for a length of time discount 100mg extra super cialis with mastercard, and were divided into two groups purchase extra super cialis 100 mg free shipping. Group one were offered money if they managed to abstain from eating and drinking cheap extra super cialis 100 mg with mastercard, providing these subjects with good justification for their behaviour buy 100mg extra super cialis visa. Group two were simply asked not to eat or drink for a length of time, but were given no reason or no incentive, and therefore had no justification. Having good justification for their behaviour, group one were not in a state of dissonance; they were able to justify not eating and still maintain a sense of being rational and in control. Group two had no justification for their behaviour and were therefore in a state of high dissonance, as they were performing a behaviour for very little reason. Therefore in order to resolve this dissonance it was argued that group two needed to find a justification for their behaviour. At the end of the period of abstinence all subjects were allowed to eat and drink as much as they wished. The results showed that group two (those in high dissonance) ate and drank less when free food was available to them than group one (those in low dissonance). The subjects in group two, being in a state of high dissonance, needed to find a justification for their behaviour and justified their behaviour by believing ‘I didn’t eat because I was not hungry’. The subjects in group one, being in a state of low dissonance, had no need to find a justification for their behaviour as they had a good justification ‘I didn’t eat because I was paid not to’. The results of this study have been used to suggest that high dissonance influenced the subject’s physiological state, and the physiological state changed in order to resolve the problem of dissonance. Research has also examined the effects of justification on placebo-induced pain reduction. Half of the subjects were offered money to take part in the study, and half were offered no money. Totman argued that because one group were offered an incentive to carry out the study and to experience the pain they had a high justification for their behaviour, they therefore had high justification and were in a state of low dissonance. The other group, however, were offered no money and therefore had low justification for subjecting themselves to a painful situation; they therefore had low justification and were in a state of high dissonance. Totman argued that this group needed to find some kind of justification to resolve this state of dissonance. If the drug worked, Totman argued that this would provide them with justification for subjecting themselves to the experiment and for choosing to take the drug. The results showed that the group in a state of high dissonance experienced less pain following the placebo than the group in low dissonance. Totman argued that this suggests that being in a state of low justification activated the individual’s unconscious regulating mechanisms, which caused physiological changes to reduce the pain, providing the group with justification for their behaviour, which therefore eradicated their state of dissonance. An example of Totman’s theory The following example illustrates the relationship between justification, the need to see oneself as rational and in control, and the problem of dissonance between these two factors. Visiting Lourdes in order to improve one’s health status involves a degree of invest- ment in that behaviour in terms of time, money, etc. If the visit to Lourdes has no effect, then the behaviour begins to appear irrational and unjustified. If the individual can provide justification for their behaviour, for example ‘I was paid to go to Lourdes’, then they will experience low dissonance. If, however, the individual can find no justification for their visit to Lourdes and therefore believes ‘I chose to do it and it didn’t work’, they remain in a state of high dissonance. Dissonance is an uncomfortable state to be in and the individual is motivated to remove this state. Therefore, according to cognitive dissonance theory, dissonance can be resolved by the placebo having an effect on the individual’s health status by activating unconscious regulating mechanisms. Support for cognitive dissonance theory The following factors provide support and evidence for cognitive dissonance theory: s The theory can explain all placebo effects, not just pain. This helps to explain those reported instances where the individual does not appear to expect to get better. This can explain some of the proposed effects of treatment characteristics, individual characteristics and therapist characteristics.

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It also decreases the sensitivity of the visceral nerves that carry impulses from the gut to the emetic centre discount extra super cialis 100mg free shipping. In an Pharmacokinetics attempt to reduce side effects and increase efficacy extra super cialis 100 mg cheap, a number Metoclopramide is well absorbed orally and is also given by of analogues extra super cialis 100 mg overnight delivery, including nabilone discount extra super cialis 100 mg overnight delivery, have been synthesized. There is some evidence that opioid pathways Glucocorticosteroids are not suitable for maintenance treatment are involved in these actions. Benzodiazepines given before treatment with cytotox- pository or enema preparations are as effective as systemic ics reduce vomiting, although whether this is a specific anti- steroids. Drugs currently available in this group are sulfasalazine, mesalazine, balsalazide and olsalazine. Although usually well tolerated, and Crohn’s disease include kinins and prostaglandins. The the adverse effects of sulfasalazine are nausea, vomiting, latter stimulate adenylyl cyclase, which induces active ion epigastric discomfort, headache and rashes (including toxic secretion and thus diarrhoea. All of the adverse effects associated with thromboxane A2 and prostacyclin by the gut increases during sulphonamides can occur with sulfasalazine, and they are disease activity, but not during remission. Toxic effects on red cells lates influence the synthesis and metabolism of these are common (70% of cases) and in some cases lead to haemoly- eicosanoids, and influence the course of disease activity. Temporary oligospermia with life-saving) and other non-specific treatment, glucocorticos- decreased sperm motility and infertility occurs in up to 70% of teroids, aminosalicylates and immunosuppressive drugs are males who are treated for over three years. Prednisolone and hydrocorti- ate sulfasalazine and in men who wish to remain fertile. Topical therapy in the form of a rectal drip, foam or enema of Key points hydrocortisone or prednisolone is very effective in milder Aminosalicylates and blood dyscrasias attacks of ulcerative colitis and Crohn’s colitis; some systemic • Any patient who is receiving aminosalicylates must be absorption may occur. Prednisolone is preferred to hydrocortisone as it has less min- • If there is suspicion of blood dyscrasia, stop aminosalicylates. Also, it is important to remember that many drugs is activated in the intestine of patients with inflammatory can cause constipation (Table 34. This forms the rationale for the use of immuno- In general, patients with constipation present in two ways: suppressive agents in the group of patients who do not respond to therapy with aminosalicylates or glucocorticos- 1. General indications for their use include patients who may be due to decreased colon motility or to dyschezia, or have been on steroids for more than six months despite efforts to a combination of both. It is usually sufficient to reassure to taper them off, those who have frequent relapses, those with the patient and to instruct them in the importance of re- chronic continuous disease activity and those with Crohn’s establishing a regular bowel habit. Patients with ulcerative colitis combined with an increased fluid intake and increased may benefit from a short course of ciclosporin (unlicensed bulk in the diet. Patients with unresponsive or chronically active alternative, non-absorbed bulk substances such as inflammatory bowel disease may benefit from azathioprine or methylcellulose, ispaghula or sterculia are helpful. The mercaptopurine, or (in the case of Crohn’s disease) once- other laxatives described below should only be tried if weekly methotrexate (these are all unlicensed indications). Loaded colon or faecal impaction – sometimes it is nerosis factor (see Chapters 16 and 26) is licensed for the necessary to evacuate the bowel before it is possible to management of severe active Crohn’s disease and moderate to start re-education, particularly in the elderly or those who severe ulcerative colitis in patients whose condition has not are ill. In these cases, a laxative such as senna combined responded adequately to treatment with a glucocorticosteroid with glycerol suppositories is appropriate. Infliximab is also licensed for the management of refractory fistulating Crohn’s disease. It is usually given for a month, but no Iron preparations longer than three months because of concerns about develop- ing peripheral neuropathy. Antimotility drugs such as codeine and loperamide (see below) and antispasmodic drugs may precipitate paralytic ileus and megacolon in active ulcerative colitis; treatment of the inflammation is more logical. There is now a greater know- ledge of intestinal pathophysiology, and of outstanding import- Key points ance is the finding that the fibre content of the diet has a marked regulatory action on gut transit time and motility and Inflammatory bowel disease on defecation performance. Magnesium sulphate (Epsom salts) and other magnesium salts are useful where rapid bowel evacuation is required. Plant fibre Macrogols are inert polymers of ethylene glycol which Plant fibre is the portion of the walls of plant cells that resists sequester fluid in the bowel; giving fluid with macrogols may digestion in the intestine. The main effect of increasing the reduce the dehydrating effect sometimes seen with osmotic amount of fibre in the diet is to increase the bulk of the stools laxatives. It does not increase the Lactulose is a disaccharide which passes through the small effective caloric content of the diet, as it is not digested or intestine unchanged, but in the colon is broken down by absorbed. This By increasing the bulk of the intestinal contents, fibre slowly produces a laxative effect after two to three days.

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