СИНДРОМ ХРОНИЧЕСКОЙ БОЛИ-CHRONIC PAIN SYNDROME

Parents regard head-banging in young children as one of the more distressing behaviours in childhood. The sight of their toddler repeatedly banging his head against the cot or on the floor, often with a force so violent that it seems inevitable that a serious injury will be sustained, causes intense concern in most parents. Yet this is a behaviour that is relatively common, occurring in 10%-15% of young children, with boys outnumbering girls by a ratio of 3 to 1, and there are virtually never any serious consequences. The peak age for head-banging is from about 6 months to 3 years, and the vast majority of children outgrow it, in the same way that they outgrow other rhythmic, repetitive, self-stimulatory behaviours (body-rocking, thumb-sucking).

Cause

It is not known why some children engage in head-banging. Nor is it clear why it is more common in boys than girls. Like other rhythmic, self-stimulatory behaviours, it seems to soothe and comfort young children at a particular developmental age and then becomes unnecessary as the child matures and his repertoire of coping behaviours expands. It seems to be a response to stress or discomfort, although usually no distress is discernible to the parents. It may increase in frequency and duration during periods of insecurity or stress such as separation or illness.

Head-banging, along with other repetitive behaviours such as body-rocking, is seen more frequently in certain groups of children, such as those with mental retardation, autism, those who are blind, and often in institutionalised youngsters. Again, the reason for this increased frequency is not clear. The persistence of head-banging may be associated with underlying psychological or emotional problems.

Clinical features

The usual picture is of a baby, or particularly a toddler, repeatedly hitting his forehead against the headboard of the cot or bed, or against the mattress, the floor, or even against the wall. Often it occurs at bedtime, but it may happen at any time of the day. The duration varies from a few minutes to up to an hour or even more. Although it appears that considerable force is being used and it seems to the parents that the child must surely sustain an injury, it does not seem to bother the child at all. In fact the opposite is true — the child appears to enjoy it.

Frequently there will be a bruise, welt, callus or even an abrasion on the child’s forehead. Very rarely will the child’s actions result in any bleeding, and he never suffers any serious injury from the head-banging.

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Here were some of the recommendations in this area.

1. Your spouse should be introduced to all of your friends at least once. Each of us needs distance and our own chance to be free and be a «non-spouse» once in a while, but super marital sex depends on total disclosure. Make sure your spouse knows everybody you know.

2. Never, but never, criticize your spouse to someone else or in front of someone else. Marriage is for intimacy, and that includes the dignity of both sexual and problem-solving privacy. One angry wife stated, «Unless you want to have sex with me in public, don’t try to screw me in front of our friends.» Take your spouse with you when out with your friends sometimes. There is no rule that all groups must match up gender for gender, couple for couple. Maybe your spouse could become a different type of friend to you by seeing your friends and relating to them in different settings. This was the idea behind the «managed-a-trois» assignment discussed earlier.

3 If you are putting more effort into your friendships and into your interactions outside of marriage, stop and ask why. Your primary energy, including your emotional and physical presentation of yourself, should be for the marriage.

4. When your spouse is available, take advantage of it. Time is always a problem, so talking on the phone or spending time with friends while your spouse «waits» can cause subtle and sometimes not so subtle messages of lack of concern or feelings for your partner. Try to schedule most of your calling and visiting when your spouse is not available or when you have mutually planned some time for other friends.

5. You do not have to be inseparable. Go to some couples’ parties without your spouse when this seems convenient. One reason for friends is that they provide variety, different points of view and feelings. If one or the other of you feels that you are going to a dinner or party reluctantly or as a favor, discuss the possibility of going alone. Your host or hostess will probably be shocked at first, and rumors of your impending divorce will start immediately. You know better, and that is what really matters. Show off. Show them that your super marriage is strong enough to allow for independence.

I have described six of the «dirty dozen» problems that can affect super marital sex. You and your partner have reviewed each issue together and come up with some of your own plans for dealing with these problem areas. Dealing with loss, parenting, parenting your parents, working and loving, finances, and working others in and out of your marriage are strong challenges in themselves, so take a break here before going over the last six problems. Stand up and hug. If you have some time, have some super sex. You’ve earned it.

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We need to stop and realise that there have been other times in our life when we have made major changes. Although these changes were external, we still feared change because we did not really know what lay ahead. We may have felt this fear when we started work, went to university, got married or had children. That fear is the same as we are feeling now. If we can remember those other occasions we will see this fear is not unique. We have felt it before. Back then, we went ahead and did what we had to do, still feeling unsure, still feeling the fear, the aloneness and isolation. This time, although the changes are internal, the fear is no different.

All we know at this stage is that we are walking into unknown territory and it can seem easier to stop where we are, despite our unresolved difficulties. What we don’t know is that the unknown territory is that of the self. As the ‘disordered’ self breaks down it can mean the birth of our real self.

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If you decide there is a certain procedure you will not allow under any circumstances, make sure that you tell your surgeon so very clearly, both orally and in writing. Read the consent form that you are asked to sign prior to your operation very carefully. On most forms you are expected to agree not only to the operation, but also to ‘further alternative operative measure as may, in the opinion of the surgeon performing the operation, be found necessary during the course of such operation.’ Do not sign this form as it stands — write in the procedure that you will not permit. Sign your addition in the presence of a witness, as well as signing at the bottom of the form.

Alternatively, if you wish to ensure that only the operation you have agreed to and nothing else is done, you would also have to make this very clear to your surgeon beforehand. Tell him or her directly. In addition, cross out the disclaimer on your written consent form, write ‘only’ next to the name of the operation, and sign this as well as signing at the bottom of the form. In this way you will be giving consent only to the operation that is named on the form. If a technical name is written on the form, ask for it to be explained fully. You could even cross it out and write a description in your own words of the operation you are agreeing to if you want to be quite sure that your wishes are clearly understood.

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Ordinary tap water with a teaspoon of salt added to each half litre (1 pint) and stored in the refrigerator can be applied on gauze to the burned areas. Local applications of soothing creams can also help. These often contain small amounts of local anaesthetic.

If blisters form, this indicates the burn is deeper and it is classed as second degree. If the blisters are small they can be left but, if large, they are better broken and the fluid drained.

Do not just prick the blisters with a needle — this lets the fluid out but infection in. Clean a pair of scissors by soaking in a disinfectant (boiling blunts them), then cut away the skin overlying the blister so there is no overhang left. This isn’t painful. The raw surface can be dried by gentle pressure with sterile gauze and a drying lotion like mercur-ochrome applied.

If the blisters are large and extensive, it is better to seek medical advice.

The chronic effects of the sun are more dangerous. Repeated exposure to UV light, over many years, leads to premature ageing of the skin.

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Complete prolapse of the uterus outside the vagina is called procidentia. This may make it difficult for the woman to move about and the uterus is subject to irritation and inflammation.

When the bladder falls back into the vagina, it distorts the normal anatomy where the urethra, or tube which carries the urine to the outside, leaves the bladder.

This leads to problems with passing urine. It may be difficult to completely empty the bladder and so small quantities are passed frequently.

The commonest symptom, however, is stress incontinence. When the woman strains by coughing, laughing, sneezing or lifting, the urine may involuntarily come away.

A watchspring pessary, which is a flexible rubber ring, can be inserted into the vagina to hold the uterus in place. This sits firmly in the vault or upper part of the vagina and is kept there by pressing on the pubic bone at the front of the pelvis.

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Pores. Finally, there is the myth concerning the pores. Pores are the openings, on the skin surface, of sweat and oil glands and hair follicles. It is these which give the skin its texture and produce variations between all skins, not only those of humans. You will have noticed the difference between call and pig skin; similarly, the difference between young children and adolescents.

It is widely imagined, thanks to media exposure, that the pores open and close and require ‘cleansing’. This is of course complete nonsense. Our pores are completely static, and after adolescence never alter in size or shape, no matter what cosmetic is used. They do not breathe, feed nor require ‘deep cleansing’. Astringents, which usually contain alcohol, may remove excessive oil and make the pores temporarily less obvious. They may also cause irritation of the surrounding skin, so that it swells slightly around the pores, diminishing their apparent size for a very short time. Nothing, however, can change the number or size of ‘enlarged’ pores. Pore size is an individual characteristic which no product or treatment can alter.

It can thus be seen that there are a considerable number of untested and/or misleading claims made in the field of skin care and cosmetics.

It should be borne in mind, with relation to cosmetic advertising, that some cosmetic houses use suggestive advertising techniques alluding to flimsily-conducted experiments reported under the guise of scientific research. To further promote their products they infer that youthfulness and beauty are essential ingredients for a successful life. They imply that without the assistance of their products your skin will be inferior.

The external application of any nutriment, vitamin or other exotic substance will have no effect on the basic nature of a person’s skin. That is, the skin cannot be fed or nourished by any known cosmetic. The realistic person will accept the limitations of cosmetics as well as their benefits. Cosmetics cannot perform miracles. They can add colour to the skin and hair, help conceal minor blemishes, temporarily relieve excessive skin dryness or oiliness and, to an extent, reduce the drying of skin caused by environmental factors. In this way cosmetics help people to look and feel more attractive. But they accomplish this solely through such properties as colour, fragrance, and local physical action. They cannot, to date, rejuvenate or change the basic nature of the skin.

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Хронические боли могут возникнуть в любом месте, т.к. они не связаны с соматическими нарушениями. Наиболее часто проявляются в области головы, спины, живота, крупных суставов, сердца.

В качестве основных симптомов хронического болевого синдрома отмечают:

• Боль присутствует в течение длительного периода времени, может наблюдаться годами, но при этом остается на том же уровне (отсутствие прогрессии)
• Субъективно, боль оценивается больным, как очень сильная
• Во время сна болевые проявления значительно уменьшаются или вовсе отсутствуют и «просыпаются» вместе с пациентом
• Отмечается присутствие психосоциальных факторов в возникновении и развитии основной симптоматики.

Трудности в лечении хронического болевого синдрома заключаются в том, что часто медикаментозное воздействие не приносит никакого облегчения состояния пациента, а если и приносит, то необходимо вместе с обезболивающими препаратами принимать еще дополнительные средства для снижения риска побочных действий. Кроме того, существует привыкание к лекарствам, что ведет к ослаблению их обезболивающего действия или полного его прекращения. Ничего другого, кроме лекарственных препаратов, поддерживающих процедур и нетрадиционных методов лечения, например таких, как иглоукалывание, гомеопатия и др., медицина предложить не может.

Действительно, трудно лечить заболевание, которое есть только в ощущениях пациента, при помощи медикаментов или других внешних воздействий. Для этих целей лучше всего подходит такой способ, который будет помогать именно изменению ощущений больного и поможет восстановить нормальную работу его нервной системы. Методы психотерапии и обучение саморегуляции – позволяют сделать именно это. В Центре лечения психосоматических заболеваний ApertaVia предлагается комплексный подход в работе с хроническим болевым синдромом. Грамотный психологический подход, индивидуально подобранные процедуры, благоприятная атмосфера, созданная в санаторных условиях (выезд в санаторий – обязательное условие для достижения максимального эффекта!) – все это способствует восстановлению хорошего самочувствия и обретению радости жизни без боли.

Подробнее о синдроме хронической боли на сайте психотерапевтического центра санаторного типа ApertaVia.

Technological developments in the area have led to a number of different machines now being available for directly or indirectly measuring body fatness. Some of these are extremely expensive and would not be used in the normal day-to-day counseling situation. Others are now becoming more portable and more accessible and provide at least an opportunity for adding to other measures. The current range of machines include: underwater weighing, bio-impedance analysis, etc.

Underwater, hydrostatic weighing, or densiometry as it is sometimes called, has been the ‘gold standard’ of fat measurement for many years. This is carried out by immersing the subject totally in water and corrrecting for air trapped in the lungs. The person’s weight in air and their weight underwater are then calculated to determine body density, body volume and body fat percentage. The fatter a person is, the heavier he or she weighs in air and the lighter he or she weighs in water. Because it requires a lot of equipment and delicate measuring techniques, underwater weighing is generally reserved for research purposes or for measuring body fat changes in elite athletes. Validity is high, as is the reliability and sensitivity of the measure. The practicality of this measure, however, limits it to research and teaching facilities, with little prospect for use in the practical counselling situation.

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Unlike hypothyroidism, hyperthyroidism is usually a condition of older children and is more probable in girls in the 12-14 age group, but it may affect any age.

Symptoms may develop rapidly. Entire body functions are speeded up, and the child tends to be nervous and irritable, fidgets and cannot sit still for long. The skin tends to be warm and clammy, the skin flushed, and in some cases the eyes appear prominent. Often the heart seems to race. The child may often feel weak and look thin, despite a good appetite. There may be a substantial rate of growth, probably above average. In adolescent girls, menstrual periods may start late or may be absent. Any symptoms of this nature need medical attention. The doctor will arrange suitable tests to help diagnosis.

Treatment

Treatment will depend on the extent of the disorder and the age of the child. In some cases, medical treatment with the use of tablets aimed at reducing thyroid activity will be adequate. In other instances, surgery may be necessary. It is a case of a special form of treatment being worked out for each patient. With proper care, the outcome is usually good.

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The other name for mumps is epidemic parotitis. (Don’t you enjoy these gobbledegook names that doctors use? It makes even the simplest problem seem difficult. That’s probably why they use them!)

Mumps is a common infectious disease, rarely seen in persons under the age of three, but rife after that. It can occur at virtually any age, from young to old, but children are the usual victims. It is caused by a virus, and usually attacks the parotid gland. This is a large organ that sits in front of and below the ears. It produces saliva, and for some unknown reason the virus simply loves having an affair with it. Also, various other glands under the jaw (the submaxilliary salivary gland) may also become involved.

It is not as highly infectious as some of the other childhood disorders, such as measles and chicken pox, and is usually spread via contamination of toys and articles shared with others. A person may infect another from two days before the appearance of the glandular swelling, until it has subsided completely. The glands are not always affected. It takes 12-24 days for the germ to incubate and produce symptoms.

During the prodromal period (the days immediately before the glands are noticeably involved), there is usually a fever, a feeling of being unwell, and probably pains about the ear when eating and swallowing. The skin may feel sensitive and tingly.

Suddenly the salivary glands become affected. They swell, become tender to touch, and this is aggravated by any movement of the jaw, such as eating, talking, swallowing food or fluid. The fever may reach 40°C (104°F) or it may be only mild. There may be headaches, aches and pains and a general feeling of misery and being off-colour.

The most serious complication is the onset of a severe headache, stiffness of the neck or back muscles, vomiting, lethargy, and a further increase in temperature which may reach 41.1°C (106°F).

This may indicate meningeal irritation—meaning the virus has attacked the lining of the brain.

Another important and fairly serious complication is when the virus moves to the testes in males or the ovaries in females. This may cause swelling and pain in the scrotum or lower pelvic regions. In fact, it may prolong the illness and cause a great deal of discomfort. The main hazard is that this may reduce fertility in later life; and cases of subsequent sterility, whilst not common, have often been reported. Occasionally the pancreas (a gland in the abdomen which produces insulin), the kidneys and the ears may be attacked and can produce serious symptoms. But these complications, in the total picture, are not common.

Treatment

There is no specific antibiotic—as with most other viral infections—that will cut short the attack. Ideally, the treatment is bed for a few days, until the temperature has fallen and the child feels improved. Once again, most children are good barometers and will want to get up and start moving about as soon as they feel a little better. Isolation is often suggested until swelling of the salivary glands has subsided, for the virus is transmissible to others.

Plenty of fluids are advised, for they require little effort apart from swallowing and do not unduly exercise the jaws. Water, water-based drinks and fruit juices are all good. Any food may be served, but those requiring little chewing are best. Softly boiled and poached eggs, mashed vegetables, stewed fruit, broth and soup, custards, ice-cream, jellies and soft toast are all suitable. There is no restriction on food to be served to the patient.

Pain and fever may be reduced by giving analgesics and antipyretics. Paracetamol elixir for children aged under six is suitable; and for those over six years, paracetamol or aspirin tablets may be given. Dosage is usually written on the label.

Warm applications such as compresses may give relief if the swollen areas of the face are sore. Warm, salty-water mouth rinses may give a feeling of freshness, and improve the outlook.

Most patients recover with few, if any, problems. Even those with gonadal involvement usually recover. If there are any symptoms that appear odd, or that are not responding to simple home remedies fairly promptly, call the doctor for further advice on management. This is especially important if any of the symptoms indicating complications develop, particularly high fevers, headaches, neck stiffness, lower abdominal pain or testicular pain. These are the main problem areas.

A vaccine is available for children to prevent mumps. This may be given at the age of 12 months, and consists of one single injection. In time, it may be available as a combined mumps-measles vaccine. Its use is not widespread at present, for some doctors do not think mumps is serious enough to warrant routine immunization, but this attitude is now rapidly altering. In 1981 the National Health and Medical Research Council recommended routine immunization of children against mumps.

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