By Q. Sugut. University of Houston.

It only took one in- dividual to point out the broken glass shards and the brown border before all were agreeing that the image looked anxious and fearful discount tenormin 25mg line. The client generic tenormin 25 mg online, thrown off guard, attempted to dismiss and minimize the group’s input. However, by stepping back from his defensive position and observing his own art production, he eventually spoke of his fears—without sermoniz- ing, without bravado—just as a person afraid of a community that had not embraced him for numerous years. Yalom (1983) states: One elementary but important goal of the inpatient group is that patients simply learn that talking helps. They learn that unburdening and discussing their problems not only offers immediate relief but also initiates the process of change. To learn, often for the first time, that one’s experience is, after all, human and shared by many others is enormously reassuring and one of the most potent antidotes to a state of devastating isolation. Developing the Language of Metaphor One cannot explore consciousness, or self-awareness, without asking how we arrive at such a state. It is widely believed that the portion of our personality that dictates our thoughts, memories, feelings, impulses, and desires is built upon a sequence of phases. As infants we respond on a pri- 10 Introduction mary level of consciousness, which mainly encompasses sensations, in- stincts, and movement. As adults we become increasingly free to experi- ence memory, language, and symbolization. Regardless of whether you subscribe to a psychosocial model, a psychosexual model, or a model that encom- passes intellectual development, the stages of human life must be solved. It is this personality that grapples with outside pressures, copes with cri- sis, interacts in social situations, and builds memories that can be accessed through the conscious and unconscious. Jay Haley (1976) states, "The psy- chodynamic therapist as well as the behavior therapist is interested in metaphors about the past because of an assumption that past traumas lead to present difficulties" (p.

High- intensity white matter in sarcoid may be indistinguish- able from MS Lyme disease Neuroborreliosis buy 100mg tenormin free shipping. High-signal contrast-enhancing subcortical abnormalities on pro- ton density and T2-weighted images on MRI in the frontal and parietal lobes generic tenormin 100mg on line, the basal ganglia and pons, cranial nerves (facial nerve) Vasculitides Multisystem immune-related vasculitis, with CNS in- volvement in 10–49% of cases, e. May resemble MS clinically and due to a white matter lesion pattern in the brain and spinal cord Neurosyphilis Contrast-enhanced MRI shows patchy enhancement involving the basal ganglia or the middle cerebral artery territories Tuberculosis Single or multiple lesions located in the cerebral hemi- sphere and basal ganglia in adults, and in the cerebel- lum in children. On MRI with gadolinium injection, a hypodense rim may separate the hyperintense center from the peripheral hyperintense edema on T2- weighted images, and T1-weighted images often show nodular enhancement Viral infection Devic’s disease, or neuro- myelitis optica Diffuse sclerosis An acute, rapidly progressing form of MS with bi- (Schilder’s disease) lateral, relatively symmetric and large areas of demy- elination, often involving the centrum semiovale and the occipital lobes; seen usually in childhood, and rarely in those over 40 Myelopathy Acute disseminated Acute monophasic inflammatory demyelination, dis- encephalomyelitis tinguished from MS by its clinical course—a single acute episode including fever and headache. The loca- tions and characteristics of the lesions on the MRI may be indistinguishable from MS Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. The perivascular spaces remain isodense to CSF, whereas lesions are hypodense on the proton density–weighted MRI sequence Lesions associated with High-intensity abnormalities in the centrum semiovale migraine and frontal white matter in young patients under 40. The lesions appear to be a diffuse process, possibly resulting from platelet microemboli or primary neu- ronal damage related to the pathophysiology of mi- graine Multi-infarct dementia, Affects the elderly population, and the predominant leukoareosis, and clinical manifestations are cognitive and behavioral Binswanger’s disease disorders. The MRI shows periventricular white matter and centrum ovale watershed infarcts, similar in ap- pearance to the demyelinating lesions of MS; however, in contrast to the MS lesions, there are no associated lesions in the basal ganglia, brain stem, or occipital horns, and there is sparing of the subcortical U fibers Normal aging In healthy individuals of 52–72 years of age, atrophic periventricular demyelination has been found in 53. Incidental white matter T2 hyperintensities occur frequently in elderly people Metastases and brain Rarely produce lesional patterns quite similar to MS. Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Cerebral Atrophy 147 Cerebellar Atrophy Toxic – Alcohol abuse The most common cause, with the vermis more ex- tensively involved – Long-term drug use! Phenobarbital – Mercury poisoning Hereditary, degenerative – Olivopontocerebellar degeneration – Shy–Drager disease – Friedreich’s ataxia – Hereditary cerebellar atrophy – Louis–Bar syndrome, or ataxia teleangi- ectasia Ischemia E. Over 80% of patients with dementia suffer from a small number of conditions, associated with characteristic types of pathology and different etiologies. Etiology % of dementia cases Alzheimer’s disease 45 Cerebrovascular disease 15 Cortical Lewy body disease 10 Head trauma 3 Parkinson’s disease 3 Motor neuron disease 2 Other 5 AIDS dementia (prion disease) >1 Unknown 15 AIDS: acquired immune deficiency syndrome. Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved.

In the feed- back stage of this directive the family’s spontaneous comments focused on these tangible order 50 mg tenormin with visa, visual purchase tenormin 50 mg without prescription, and clearly noticeable differences. Although these obvious signs engendered a spirited discussion, as I noted in Chapter 6, without illumination of the process the session will not be generalized because the interrelationships will be ignored. For this rea- son, I initiated a commentary on the interaction, which was fraught with conflict, power, and control issues. Of further note is that while the mother was directing her son, he not only abandoned the task when he did not understand her direction but was verbally cruel and judgmental, blaming his difficulty on her inadequacies. Similarly, the father, while giving instructions to Gregory, became frus- trated with Gregory’s questions and responded in a manner that was no- ticeably vague and distancing. In an effort to clarify, confront, and interpret I directed the discussion by asking the family which suggestions the partners had listened to and which ones they ignored. I followed this question by asking all the family members if they had listened the same way today as they generally did. The responses to both questions ranged from indifference and disregard (manifestation of transference by the younger son and father) to self- justification (a sense of cultural obligation on the mother’s part) and re- 281 The Practice of Art Therapy proach toward both his father and brother (defensive functioning by Gre- gory). This came about because the younger son made the brusque comment that if he had been the leader the results would have been better. Consequently, the father unexpectedly decided to give his son his wish, and the children thus became the leaders. Beyond the placement of the paper (which was perfect in both cases), the younger son did not pro- duce an improved response, as he once again became frustrated and sud- denly discarded the project while attempting to describe the vertical and horizontal lines. Equally, the father’s aggravation became increasingly ap- parent as Gregory was describing the diamond shape that connected to the outer lines. Unaccustomed to following another’s direction, his situation worsened by confusion and a lack of understanding, the father reacted by abandoning the effort through a palpable lack of emotional response. In this brief case example, the technique of art therapy allowed each family member to divulge his or her underlying conflicts from a here-and- now perspective as the artwork provided a template for the transference re- 7. In this way, I could explore the familial dynamics from both within and without, while the artwork assisted in developing an ob- serving ego as emotions were not split off but instead clarified through the use of concrete directives, identification of motives, and the process of working through. Additionally, if one believes, as Nichols (1984) has stated, that "family members reveal repressed images of past family relationships in their cur- rent interactions with family members" (p.

If you recall the case review on Dion generic 100mg tenormin with visa, in Chapter 5 discount 25 mg tenormin visa, this technique was illustrated through his rendering of Figure 5. The paired communica- tion drawing can be utilized in a multiplicity of ways and with any number of people. If you are in a group setting, or if the family has an uneven num- ber of participants, one individual can take on the role of leader while the remainder of the group members form a horseshoe with their backs turned away from one another. As with the majority of art therapy directives, the mental health professional is hindered only by a lack of creativity. Thus, you can employ numerous variations on this technique to maximize any number of goals or objectives. Due to this family’s dysfunctional interaction patterns, their invisible loyalties (Boszormenyi-Nagy & Spark, 1973), and regressive coping styles, I opted to determine the teams. As is evident from the completed drawings, the parents—the leaders of this communication-driven exercise—did not accomplish the goal of an exact rendering. The differences begin with the physical direction of the 280 Two’s Company, Three’s a Crowd? In the feed- back stage of this directive the family’s spontaneous comments focused on these tangible, visual, and clearly noticeable differences. Although these obvious signs engendered a spirited discussion, as I noted in Chapter 6, without illumination of the process the session will not be generalized because the interrelationships will be ignored. For this rea- son, I initiated a commentary on the interaction, which was fraught with conflict, power, and control issues. Of further note is that while the mother was directing her son, he not only abandoned the task when he did not understand her direction but was verbally cruel and judgmental, blaming his difficulty on her inadequacies. Similarly, the father, while giving instructions to Gregory, became frus- trated with Gregory’s questions and responded in a manner that was no- ticeably vague and distancing. In an effort to clarify, confront, and interpret I directed the discussion by asking the family which suggestions the partners had listened to and which ones they ignored. I followed this question by asking all the family members if they had listened the same way today as they generally did. The responses to both questions ranged from indifference and disregard (manifestation of transference by the younger son and father) to self- justification (a sense of cultural obligation on the mother’s part) and re- 281 The Practice of Art Therapy proach toward both his father and brother (defensive functioning by Gre- gory).

Outcomes resulted in a sig- High risk could refer to susceptibility to or a specific nificant reduction in the risk of falling discount 100 mg tenormin mastercard, as well as reduc- disease syndrome proven 25 mg tenormin, or it could refer to an individual’s tion in the number of actual risk factors for falling. For example, hazards of hospital- Another study of 530 older individuals (mean age, 77 ization for older adults have been well documented. Bloom Also, the hospital readmission rate for a subset of older References patients is high, especially during the first month after hospital discharge. A study to examine the effectiveness of intensive pre- and posthospital care, the transitional 1. From outcomes research to practice nurses with at-risk older patients, demonstrated disease management: a guide for the perplexed. Disease Management Hand- ments, and were available 24 h per day, 7 days per week, book. A structured teaching and self-management health care costs while maintaining or even improving program for patients receiving oral anticoagulation: a ran- quality of care. Working Group for the Study of deal with large populations and often have the capability Patient Self-Management of Oral Anticoagulation. Commu- or small physician groups to implement and evaluate nity impact of anticoagulation services: rationale and design disease management programs. Comprehensive multidisciplinary programs for as quickly modify or cancel programs, if necessary. Rich MW, Beckham V,Wittenberg C, Leven CL, Freedland grams in the traditional system, this discrepancy will KE, Carney RM. Cline CM, Israelsson BY, Willenheimer RB, Broms K, ating chronic disease management programs, significant Erhardt LR. Cost effective management programme for barriers to success exist even within managed care. Prolonged beneficial effects of a home-based intervention physicians to participate in or support programs, and the on unplanned readmissions and mortality among patients difficulty in measuring any dollar savings. Mittelman MS, Ferris SH, Shulman E, Steinberg G, Levin has programs in both diabetes and congestive heart fail- B. A family intervention to delay nursing home placement ure, which program will be primarily responsible for a of patients with Alzheimer disease.