COGNITIVE-BEHAVIORAL THERAPY FOR BDD: WHAT’S THE EVIDENCE THAT CBT WORKS?

In the 1980s a few clinician-researchers (e.g., Isaac Marks in England) published papers in scientific journals that illustrated the effectiveness of CBT for several patients with BDD. These clinical reports spurred other researchers to conduct more scientifically rigorous studies of CBT. In these studies, larger numbers of patients were evaluated, and they were assessed with standard rating scales.
CBT is the only type of therapy that has been systematically studied in BDD. Available research studies indicate that CBT substantially improves BDD symptoms in a majority of people. Most of these studies, which are summarized in Table 17 below, used a combination of cognitive and behavioral techniques. Research hasn’t been published which teases apart which components of CBT are most effective. Nor have studies compared CBT to other forms of therapy, so it hasn’t been proven that CBT is more effective than other types of therapy. Nonetheless, clinical impressions suggest that this is probably the case. Studies have demonstrated that CBT is more effective than certain other therapies in disorders with similarities to BDD, such as OCD and social phobia.
The first two studies, which were “controlled” studies, are the most scientifically rigorous studies done so far. In these studies, patients who received CBT were compared to patients on a waiting list who received no treatment. The no treatment condition controls for changes in BDD that might occur simply with the passage of time or for other reasons. Another advantage of these two studies is that patients were randomly assigned to these two treatment conditions, which minimizes differences in the patients in each group that might affect treatment outcome. The other studies shown in the table were “case series,” in which a series of patients was treated with CBT (without comparison to another condition, such as a waiting list).
*287\204\8*

COGNITIVE-BEHAVIORAL THERAPY FOR BDD: WHAT’S THE EVIDENCE THAT CBT WORKS?In the 1980s a few clinician-researchers (e.g., Isaac Marks in England) published papers in scientific journals that illustrated the effectiveness of CBT for several patients with BDD. These clinical reports spurred other researchers to conduct more scientifically rigorous studies of CBT. In these studies, larger numbers of patients were evaluated, and they were assessed with standard rating scales.CBT is the only type of therapy that has been systematically studied in BDD. Available research studies indicate that CBT substantially improves BDD symptoms in a majority of people. Most of these studies, which are summarized in Table 17 below, used a combination of cognitive and behavioral techniques. Research hasn’t been published which teases apart which components of CBT are most effective. Nor have studies compared CBT to other forms of therapy, so it hasn’t been proven that CBT is more effective than other types of therapy. Nonetheless, clinical impressions suggest that this is probably the case. Studies have demonstrated that CBT is more effective than certain other therapies in disorders with similarities to BDD, such as OCD and social phobia.The first two studies, which were “controlled” studies, are the most scientifically rigorous studies done so far. In these studies, patients who received CBT were compared to patients on a waiting list who received no treatment. The no treatment condition controls for changes in BDD that might occur simply with the passage of time or for other reasons. Another advantage of these two studies is that patients were randomly assigned to these two treatment conditions, which minimizes differences in the patients in each group that might affect treatment outcome. The other studies shown in the table were “case series,” in which a series of patients was treated with CBT (without comparison to another condition, such as a waiting list).*287\204\8*

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LIVING WITH RHEUMATOID ARTHRITIS: QUESTIONS ABOUT PREGNANCY AND CHILDBIRTH

Deciding whether or not to have children is a momentous decision for everyone. It is natural to have concerns about the health of a potential child, and most people think about this before or during pregnancy. Women of childbearing age who have RA will have specific questions about how their illness might affect their body and their unborn child.
Can I Become Pregnant?
Fertility is generally not affected by RA. During severe flare-ups, however, fertility may be temporarily lower in some individuals. But you should not count on this as a method of birth control since it is not a fail-proof method.
How Will Pregnancy Affect My RA?
More than 75 percent of women see improvement in their RA during pregnancy. After delivery most of them find that their arthritis returns to its pre-pregnancy level.
How Will My RA Affect My Unborn Child?
The health of the fetus and newborn infant does not appear to be affected adversely by RA, although this question has not been studied adequately for us to state unequivocally that this is so.
We do know that certain arthritis medications can compromise your baby’s health. If you are considering getting pregnant or if you are sexually active and are not using birth control, you must discuss your medications with your physician. To be cleared completely out of your body, several arthritis medications need to be discontinued months or weeks before conception takes place.
Will My Child Have RA?
We do not know exactly what triggers the development of RA. It is true that a person who has a close family member with RA or another autoimmune condition has a higher likelihood of developing RA than the general population. We do not feel that the small increased risk of passing on RA should influence a person’s decision about childbearing. The vast majority of children born to a parent with RA do not develop the condition.
Can I Care for My Baby?
This is perhaps the most difficult question. Caring for a baby requires a great deal of energy and stamina on the part of the caregiver. Performing frequent diaper changes and carrying around an extra 10 to 20 pounds can put a serious strain on tender joints. Feedings at two o’clock in the morning fatigue even healthy parents. And, as we have discussed, joint stress, fatigue, and exhaustion can make arthritis and its symptoms worse.
You and your partner need to discuss these issues honestly with each other. You both need to be committed to creating and carrying out a plan that will allow the person with RA to get adequate rest. Putting aside extra funds for child care assistance is an excellent idea. Using disposable diapers will help so that you don’t have to fuss with diaper pins and wringing out soiled diapers. You may want to invest in a carrier for holding the infant and get advice from an occupational therapist about how you can carry the baby while putting the least amount of stress on your joints. Plan ahead, and make certain that your plans include the toddler years.
*125/209/5*

LIVING WITH RHEUMATOID ARTHRITIS: QUESTIONS ABOUT PREGNANCY AND CHILDBIRTHDeciding whether or not to have children is a momentous decision for everyone. It is natural to have concerns about the health of a potential child, and most people think about this before or during pregnancy. Women of childbearing age who have RA will have specific questions about how their illness might affect their body and their unborn child.
Can I Become Pregnant?Fertility is generally not affected by RA. During severe flare-ups, however, fertility may be temporarily lower in some individuals. But you should not count on this as a method of birth control since it is not a fail-proof method.
How Will Pregnancy Affect My RA?More than 75 percent of women see improvement in their RA during pregnancy. After delivery most of them find that their arthritis returns to its pre-pregnancy level.
How Will My RA Affect My Unborn Child? The health of the fetus and newborn infant does not appear to be affected adversely by RA, although this question has not been studied adequately for us to state unequivocally that this is so.We do know that certain arthritis medications can compromise your baby’s health. If you are considering getting pregnant or if you are sexually active and are not using birth control, you must discuss your medications with your physician. To be cleared completely out of your body, several arthritis medications need to be discontinued months or weeks before conception takes place.
Will My Child Have RA?We do not know exactly what triggers the development of RA. It is true that a person who has a close family member with RA or another autoimmune condition has a higher likelihood of developing RA than the general population. We do not feel that the small increased risk of passing on RA should influence a person’s decision about childbearing. The vast majority of children born to a parent with RA do not develop the condition.
Can I Care for My Baby?This is perhaps the most difficult question. Caring for a baby requires a great deal of energy and stamina on the part of the caregiver. Performing frequent diaper changes and carrying around an extra 10 to 20 pounds can put a serious strain on tender joints. Feedings at two o’clock in the morning fatigue even healthy parents. And, as we have discussed, joint stress, fatigue, and exhaustion can make arthritis and its symptoms worse.You and your partner need to discuss these issues honestly with each other. You both need to be committed to creating and carrying out a plan that will allow the person with RA to get adequate rest. Putting aside extra funds for child care assistance is an excellent idea. Using disposable diapers will help so that you don’t have to fuss with diaper pins and wringing out soiled diapers. You may want to invest in a carrier for holding the infant and get advice from an occupational therapist about how you can carry the baby while putting the least amount of stress on your joints. Plan ahead, and make certain that your plans include the toddler years.*125/209/5*

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SYPHILIS – ANTIBIOTIC TREATMENT 2

Cardiovascular syphilis and neurosyphilis

Prednisolone 20 mg twice daily for two days prior to commencement of penicillin is recommended for patients with cardiovascular or neurosyphilis.

Aqueous procaine penicillin G 1.5 g daily intramuscularly with probenecid 500 mg four times daily by mouth for 21 days may be used for patients with cardiovascular syphilis and for patients with neurosyphilis managed as outpatients.

For patients with neurosyphilis treated as inpatients, intravenous benzylpenicillin G 4 g at four hourly intervals with probenecid 500 mg four times daily by mouth for 10 days may be used.

Asymptomatic patients with positive CSF findings should be treated as having neurosyphilis.

Patients with neurosyphilis should be referred for specialist advice. Benzathine penicillin should not be used for the treatment of neurosyphilis because an adequate level of penicillin in the CSF is not achieved. However, if the CSF examination is negative, benzathine penicillin G 1.8 g intramuscularly at 7 day intervals for 3 doses may be used for the treatment of cardiovascular or gummatous disease in patients unable to comply with daily injections.
*67/56/1*
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SYPHILIS – ANTIBIOTIC TREATMENT

Parenteral penicillin is the drug of choice. Alternative antibiotics should only be used where there is a history of penicillin sensitivity.

Early syphilis

Aqueous procaine penicillin G 1.5 g daily intramuscularly for a minimum of 10 days;

Benzathine penicillin G 1.8 g intramuscularly in a single dose for patients unable to comply with daily injections, preferably repeated 7 days later.

Late latent syphilis

Aqueous procaine penicillin G 1.5 g daily intramuscularly for 15 days; OR

Benzathine penicillin 1.8 g intramuscularly at 7 day intervals for 3 doses for patients unable to comply with daily injections.

Benign gummatous syphilis

Aqueous procaine penicillin G 1.5 g daily intramuscularly for 21 days; OR

Benzathine penicillin G 1.8 g intramuscularly at 7 day intervals for 3 doses for patients unable to comply with daily injections. This should never be used in late syphilis unless the CSF is negative.
*66/56/1*
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SYPHILIS – MANAGEMENT

In a patient with a local genital lesion thought to be syphilitic, treatment of syphilis should be withheld until dark ground examination is completed. Treatment for coexistent gonorrhoea or NGU should not be delayed but a non-treponemicidal drug such as spectinomycin or trimethoprim-sulphamethoxazole should be used.

The patient should be told the diagnosis, the natural history of syphilis and the need for compliance with treatment and for regular follow up with clinical examination and repeat serological tests.

The cooperation of the patient in the following up of known contacts should be sought at an early stage.

Notification of cases of syphilis is required in all States and Territories although the name and address of a patient is not required unless the patient defaults.

The patient should avoid sexual intercourse until all lesions have healed and until the antibiotic course is complete.
*65/56/1*

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SYPHILIS – FALSE POSITIVE REAGIN TESTS MAY BE TRANSIENT OR PERSISTENT; CEREBROSPINAL FLUID (CSF) EXAMINATION

The causes of biological false positive reagin (non-treponemal) tests are:

Acute (persisting less than 6 months): acute viral febrile illness (e.g. infectious mononucleosis, viral pneumonia, hepatitis); and pregnancy.

Chronic (persisting six months or more): intravenous drug abuse; autoimmune disease — positive serology may predate the disease (e.g. disseminated lupus erythematosis, rheumatoid arthritis, thyroiditis); malaria; and lepromatous leprosy.

The diagnosis of congenital syphilis is mainly dependent on serology.

Negative serology in the presence of Tpallidum infection may occur in: very early infection; and immunodeficiency following HIV infectioa CSF examination includes white cell count, total protein and VDRL or RPR. Raised lymphocyte count, raised total protein and positive reagin test in the CSF is indicative of neurosyphilis. CSF examination is indicated: where there are symptoms or signs of CNS disease in the presence of positive serological tests for syphilis;

before retreating a patient who has had relapse, treatment failure or reinfection after any form of treatment; in any patient who has been treated with non-penicillin regimens; where late or latent syphilis has been discovered and the period of latency cannot be determined or is in excess of 2 years; or before treatment with benzathine penicillin except in early disease.
*64/56/1*

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SYPHILIS – SYPHILIS AND HIV INFECTION 2

Dark ground examination

Spirochaetes can be demonstrated by microscopic examination of smears from early lesions using dark ground or fluorescent antibody techniques. Antibiotics or antiseptics should not be used until satisfactory examination has been completed. Dark ground examination is not suitable for oral lesions.

Serology

Serological tests provide indirect evidence of infection. The non-specific reagin tests, namely the Venereal Disease Research Laboratory test (VDRL) and the Rapid Plasma Reagin test (RPR), are reactive in 50 to 75% of cases of primary syphilis and in most cases of secondary syphilis. The reagin tests are inexpensive and capable of automation. They are generally used for screening. Treponemal tests, including the Fluorescent Treponemal Antibody test (FTA-ABS) and the Treponema pallidum Haemagglutination Assay (TPHA), are more specific than the reagin tests (see table 2). In early syphilis, the FTA-ABS usually becomes positive first followed by the reagin tests and then TPHA. The reagin tests usually become negative within 3 to 6 months of effective treament. Treponemal tests may remain positive for years. False positive FTA-ABS tests have been reported in association with herpes infection.
*63/56/1*

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CLINICAL STAGES; SYPHILIS AND HIV INFECTION; DIAGNOSIS AND INVESTIGATION

The diagnosis of syphilis depends on a detailed history, careful clinical examination and specific investigations. Underlying these is the need to THINK of the possibility of syphilis. It is also important to investigate patients with syphilis for concurrent STDs.

Syphilis is classified clinically into early or late stages  which relate to infectivity and are the basis of treatment regimens.

HIV and syphilis are commonly associated. In patients with AIDS and syphilis, standard regimens for syphilis are not always curative. Seronegative syphilis has been reported in patients with HIV infection. Lymphadenopathy in a patient with HIV infection may be due to coexisting secondary syphilis.
*62/56/1*

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