Pinky And The Brain Episodes

PTSD and Child Sexual Abuse

INTRODUCTION

posttraumatic stress disorder meets the psychological manifestations, immediate or delayed, which can follow exposure to high-level stressors and thus reflects the effects of these stressors in the lives of people.
Detailed studies of the responses observed in extreme situations (natural disasters, wars) have provided important evidence about the consequences of participation in these events.
not yet know a lot of parameters that define the stress traumatic, or clinical course and treatment, but it is essential to explore the interaction between biological, psychological and social aspects of the victim and the characteristics of the traumatic event.
This has been studied in adults than in children, these have been difficult to assess symptoms such as amnesia and numbness, and flashbacks were not found.
In the new DSM-IV, is included as a traumatic event in children, inappropriate sexual experiences for their stage of development, without being accompanied by threats, violence or injury.

DEFINITION OF STRESS POST-TRAUMATIC

Diagnostic criteria

The person has experienced a traumatic event which was attended by the following two items :

1. Events leading death or the threat of death, serious injury or threat to physical integrity
2. The response of the person involved intense fear, helplessness or horror. Note in young children can be expressed by disorganized or agitated behavior.

The traumatic event is persistently re-experiences at least one of the following ways:

1. unpleasant memories, recurrent and
2. invasive and recurring unpleasant dreams about the event
3. sudden behaviors or feelings as if the traumatic event from happening again (flashbacks).
4. intense psychological distress at exposure to internal or external signals that symbolize or resemble an aspect of the traumatic event.
5. physiological reactivity when exposed to these signals.

Persistent avoidance of stimuli associated with the trauma and numbing of general response level, indicated by the presence of at least three of the following phenomena:

1. Efforts to avoid these thoughts.
2. Efforts to avoid activities or places that arouse recollections of the trauma
3. Inability to recall some aspects of the trauma
4. marked decline of interest or participation in activities.
5. feeling of detachment or estrangement from others.
6. restricted range of affect.
7. Sensation of shortened future.

Persistent symptoms of increased arousal (arousal).

1. or difficulty maintaining sleep
2. Irritability or outbursts of anger.
3. Difficulty concentrating.
4. Hypervigilance.
5. exaggerated startle response.

The duration of the disorder is more than a month.

The disorder causes significant distress or impairment in social functioning .
Specify other:

• Acute: duration of symptoms less than three months
• Chronic: duration is three months or more.

Specify other:

• delayed start: if the onset of symptoms occurred at least six months after the stressor.

KEY ASPECTS IN THE STUDY CHILD SEXUAL ABUSE

definition of child sexual abuse

called child sexual abuse is the involvement of a child or adolescent (under 18 years old) in sexual activities that are not yet fully understood, to which it has no capacity to consent or that violate social taboos of family roles.

Prevalence of child sexual abuse

exact prevalence is unknown but is estimated between 6 and 62% in women and 3 and 31% in men. In Spain it is around 22.5% in women and 15.2% in men, using the 16 years age limit.

Characteristics of abused child's family.

No differences were found in As to socioeconomic status, but as negative factors that have proved relevant and add to the traumatic experience are:
in which there has been domestic abuse, families are described as entangled or chaotic
and common factors that experience has been within or outside the family are: low levels of cohesion, poor personal growth stimulation of children, with little encouragement of independent thought, moral and ethical development and leisure activities; little organization in terms of responsibilities mutual activities and family rules.
study in detail the familial risk factors for sexual abuse as well as it is a difficult task to design treatments and prevention programs.

mediate the effects of child sexual abuse

negative factors related to abuse characteristics

1. The type of sexual behavior, the more intimate carries a greater impact.
2. The relationship with the abusante, here is reflected as the most important variable, the existence of a good emotional relationship between the victim and the aggressor, rather than whether it has been in the family.
3. The use of coercion, has a weak but significant, and there are no neglect the importance of more subtle psychological tricks or he have received awards and benefits, which can increase the feeling of guilt on the victim.
4. The duration and frequency of abuse, given that every abuse of the victim is a test of learning.
5. The child's age, there is no clear relationship between age and gives the victim further trauma.
6. Breaking the silence without support, since this is an extremely stressful time, so the adult should not only try to resolve the conflict, but seek professional help.
7. not forget that the child may have contracted a sexually transmitted disease sex, AIDS or becoming pregnant, being therefore appropriate medical examination, which is essential not blame the victim.

negative factors associated with family characteristics and child
The effects of sexual abuse can be difficult to distinguish from the consequences of emotional abuse, physical or experience of a dysfunctional family.
The characteristics of the child before the abuse, are also important. Personal problems that predate the abuse can be triggered or exacerbated by it. Also consider the responsibility of the child and his family attributed to abuse. This last factor, together with support, has a special significance because, unlike others, can be modified by treatment.

Factors that protect against the negative effects of abuse
are associated with resistance to adversity: the presence of a mother's warm, it being believed or supported, have a high IQ, ability to solve problems, not make biased attributions, hope, fantasy and good self-esteem emerge as strong predictors of adjustment in adulthood.

effects of child sexual abuse

Short-term effects
To increase experimental control of these studies is be taken into account: that children usually do not report what happened to them, some lack the language skills and that in cases of incest on the whole episode is usually not sudden.
This effect has been studied using standardized questionnaires are completed by parents, teachers, social workers and the children themselves.
-effects has been observed that these children show antisocial behavior, aggression, fear, ambivalence toward both parents, anxiety, phobias, sleep problems, nightmares, alarm reactions, hypervigilance, withdrawal from normal activities, nervousness and poor cognitive development . It has also been observed more frequently in boys than girls, physical complaints, regressive behavior and self-destructive behavior, while girls may appear enuresis and encopresis. In addition to those other symptoms such as compulsive, hyperactive, withdrawn, guilt, mood swings, suicidal thoughts, fatigue, loss of appetite, change in eating habits, distrust and school problems.
Despite being very different symptoms, many authors agree that present: onset of sexual misconduct, public masturbation, sex require adults or other children or inappropriate sexual play. In addition to dissociative symptoms understood as avoidance responses.
Some authors have found that after an experience of child sexual abuse, increased social competence and greater sympathy for girls, to strangers, which has been interpreted as an adaptation to an abnormal situation has been termed inescapable this form of pseudo-sophistication interaction.
The variety of reactions makes it difficult to detect the existence of sexual abuse at home. Then as indicators arise: the presence of physical signs of shock or penetration (anal or vaginal) that can be accompanied by pain. And appearance in the child afraid of men or their families, loss of sphincter control, changes in hygiene. Of particular relevance last appearance of sympathy toward strangers or the presence of sexual misconduct for his age that can be observed in games, verbal expressions, drawings or compulsive masturbation. In adolescents will have to show special attention to the fleeing from home, to the intake of alcohol or other drugs.

term effects
not found a direct relationship between child sexual abuse and a single disease in adulthood. The most frequently studied, depression, anxiety, eating disorders, sexual, dissociative and certainly stress disorder disorder.
Given the wide range of problems that may have a person who has been abused should not be overlooked in the evaluation of any patient, the possibility that these events have occurred in its infancy, but be careful not to create false memories.

Explanatory models of the effects of child sexual abuse

To explain the rise of the conditioned response in the absence of a new traumatic experience.

1. Two Factor Theory of Mower .- The neutral stimuli present in the abusive situation (smells, clothing, place, thoughts) are conditioned to fear and anxiety that occur during the same (EI) and generalize to other stimuli.
2. associative Other possibilities would be:
• Subsequent changes in the value of unconditional stimulus
• brief contact with the conditional status (Flashbacks)
3. The learned helplessness model of Seligman
4. social learning principles .- In this sense, modeling, instructions, reinforcement and punishment inadequate and forge a code determined unintended consequences for behavior.
5. The conceptualization of Foa and Kozak .- in it together proposals on the stimuli and responses, with proposals of meaning or interpretation of danger, forming a node or fear structure, conceived as a program to perform the escape or avoidance response. And according to this model, the traumatic event breaks the basic security concept and the world becomes less predictable.
6. traumatic learning model or cognitive-behavioral model Hoier. For these emotional responses would learn by classical conditioning, whereas negative reinforcement account for the acquisition and maintenance of avoidance responses.

During the establishment of this learning, the child form rules, which can regulate behavior. Therefore argue that the rules are among the answers important to the abuse and are essential to explain the response pattern that appears in the long term. And to them we should direct the evaluation to design the treatment.

ASSESSMENT OF THE EFFECTS OF CHILD SEXUAL ABUSE

Initial assessment

The first priority is to ensure that neither he nor his siblings or other children at risk of further abuse or consequences of having spoken . Sometimes the child will have to find another home, and others that will be the offender. Suffice it to say that the longer children are away from home more difficult it will reunite again. As will be better leave the adult.
The therapist must be prepared to initiate legal action (21/87 Law on Adoption and foster care).
Then you have to assess their current world, if the child receives the necessary support of the family, we must banish the belief that abuse only happens in special environments (poverty, overcrowding) and the mentally ill abusantes with serious diseases. Guilt, jealousy, fear of losing emotional and economic support, fear of making mistakes in reporting or poor family relationships can stoke doubts to believe the child, in which case parents should start their own therapy.
At the same time to study other family needs can be met and that other stressors are also present.
must be known as was the abuse and all mediating factors previously mentioned, this information may be obtained from adults with the child we can communicate either verbally or through drawings, games or the use of anatomical dolls.
Assessment should be idiographic, targeting both the child and family and should collect information from different people and situations.

Instruments for assessing general aspects

have to study the consequences, avoidance responses, beliefs and responsibilities about the abuse. Also the list of child behavior (Achenback) Depression Inventory for Children (Kovacs) and the State Anxiety Inventory-Trait for children (Spielberg), may also be used.

Tools for assessing specific aspects

The scale of impact of traumatic events in children (CITES-R) (Wolfe) consists of 11 subscales across four dimensions: posttraumatic stress syndrome (intrusive thoughts, avoidance and sexual anxiety), social reactions (negative reactions to others, social support), attributions about the abuse (guilt, control, vulnerability, dangerous world) and eroticism.
relations between stimuli and conditioned responses, unconditional and active and controlling variables must be examined very carefully, because these are crucial to detect patterns of response and all related stimuli. The stimuli can be private or come from external, the latter of various modalities (olfactory, thermal). To identify relevant conditioned stimuli are: sexual issues, body, small details (a pubic hair) and the dates and places where they had the experience also nightmares can be used to detect anxiogenic stimuli.
Finally do not forget to evaluate the positive aspects of child and family, to teach them to recognize and then empower them.

Evaluation during the treatment phase

This should continue throughout the operation, which will allow flexibility in the operation, outline the functional analysis, knowing the course and impact of the intervention and identify at what point should end.
As the records will be subjective, we can use the little smiley faces, angry, sad or normal)

TREATMENT OF THE EFFECTS OF CHILD SEXUAL ABUSE

key action areas are

The therapeutic relationship
2. Intervention on anxiety-related problems
3. Discussions focused on the abuse and the child's understanding of what happened
Sex Education Prevention of future abuses

The therapeutic relationship

This relationship should promote: respect, trust, unity and mutual feelings of empathy.
As always no complaint is to have suffered sexual abuse, if this is the case, the therapist must know how to react, without judging and without embarrassment to show it. Finally it
to be open and willing to seek a sex therapist, at least at the beginning of treatment, to facilitate the intervention. Intervention

emotional processing

For patients diagnosed with PTSD, behavioral techniques have led to exposure of the subject to stimuli (gradual or abrupt (systematic desensitization, flooding, negative practice) in imagination or in vivo, participatory modeling), the control of physiological arousal (eg relaxation, coping skills instruction, stress inoculation) and the proper handling of contingencies; to what has joined a training aimed at changing the perception of coping effectiveness (assertiveness training, cognitive restructuring).
With the smallest of the game can be incorporated into the chosen techniques, with the highest a good strategy is to speak, write or write about what concerns them, using diaries, biographies, letters. The therapist must constantly helping your child not to feel overwhelmed by the intensity of memories or feelings, not to exceed their coping capabilities.
may remember experiences appear fragmented, a good technique to bring them together is the use of imagination tour. Through the evocation of images of the trauma and the exploration of its meaning can rearrange the content.
There are times when it is convenient to provide the patient with the necessary skills to deal with intrusive memories and dissociative, they are to teach them to concentrate on the here and now, describing the immediate environment, touching nearby objects, or talking to someone . Another possibility is to teach and perform in conduct incompatible distractors.
There is considerable controversy with the use of techniques of flooding. Kilpatrick has said that a problem of this intervention is to focus only on reducing anxiety to the exclusion of other symptoms, but decreases anxiety get a major therapeutic achievement as this is accompanied by a decrease in negative irrational cognitions. The Foa and Kozak model explains how an activation of fear memories in the absence of situations involving risk, changes the meaning of memory. In addition, once anxiety has been reduced it is possible to start another type of training specific to the deficiencies that prevail.
Fear and anxiety need to neutralize the stimuli that cause, then it is important to expose all of the traumatic stimulus and the feelings caused by them. As since the start of treatment is impossible to know all these peculiarities treatment may be timely but not progressive. Intervention

fears related to going to bed
is one of the fears that often appear in the abuse, for this we must take the necessary measures for the environment is safe, remove all the details that help to elicit or maintain anxiety and distribute objects that help the child to have control over their environment (eg night lamp if you wake up, posters favorites).
Parents and caregivers need to train them to extinguish the fear of inappropriate behavior.
At the time of going to sleep is to institute a reassuring ritual (bath warm glass of milk), both to go to bed as if startled awake at night. If anxiety starts to go to bed is necessary for the child to engage in conduct incompatible at the time it begins to have anxiety, without waiting for increased anxiety. Regarding
nightmares may have a role to decrease the anxiety that prolonged or intense exposure to the feared stimuli appearing in them to reduce the physiological responses associated with them. Waking up in the middle of a nightmare just to exposure and may explain its recurrence. Then it should give the child the option to count or draw their dreams and transform their content so that it loses its ability terrifying. Has also been used systematic desensitization coupled with training in self-control and implosive therapy. Intervention

other emotions
emotional reactions such as anger, grief and sadness are common in abused children. The child must learn to recognize their intensity, naming them and learn how emotions are legitimate and permissible, but no contingent relation with the environment, ie not change any aspect of your situation. The fear to express them is an aspect that should be taken into account by the therapist.
The search for the events that trigger these emotions, is a step of deconditioning of abuse-related stimuli. Intervention

beliefs and rules (reference)

abusante is possible that, to win the boy and his silence has been distilling arguments that undermine their self-esteem and happiness, also the potential gains (gifts) and duration of abuse can generate ideas of guilt. The goal is for desculpabilizar the child and has to understand to prevent future abuses, which aspects of their behavior may be harmful.
The internal attributions, specific and unstable enable more adaptive coping responses, they help to foster a sense of control.
must also explain the behavior of the aggressor with the 4 points made by Finkelhor (adult interest in sex with children, ability to overcome internal inhibitions, lack of external control and withdrawal of the child's resistance.)
Avoid explanations of abuse as a form of love misunderstood or submit to abusante as a patient and increases the vulnerability of children in the future.
abuse is more traumatic when there was an affectionate relationship with the abusante. For what should be taught to discriminate on who can be trusted without extreme generalizations, for it is the ideal therapeutic relationship itself.
Cognitive training must be accompanied by acquisition of social skills, communication and assertiveness, to promote positive relationships with others and integration into the social networking environment.
Social relations are also favored the creation of a positive personal image and not stigmatized.
is appropriate to revise and influence children's academic performance, difficulties in concentrating and fatigue characteristic of PTSD, they may be hindering their academic performance. Then you need to improve by studying their feelings of efficacy and achievement. Sex education



Its objectives are: Provide

1. proper sex information to the child's age
2. Correct distorted ideas about sexuality.
3. clarify and establish social values.
4. Training in managing their own feelings.
5. inhibitions promote internal and external controls appropriate behavior
6. make the development of healthy sexual expression and not traumatic. Foster
7. contraceptive use and prevent sexually transmitted diseases, AIDS, unwanted pregnancies. This point should not ignore in adolescents.

develop a positive image, which fits the idea that the body is important and worth protecting, give the best results that impact on the already battered self-perception of vulnerability of training typical of social groups.

Intervention for secondary prevention of child sexual abuse

The primary and secondary prevention teaches children to recognize the aggression before it is carried out and react, but secondary prevention, as opposed to primary may be held in the school or by parents, results in a therapeutic environment, and taking great care not to trigger unwanted emotional responses.
As important points of training include: Teaching

1. the child to trust their feelings about touch.
2. When a touch makes them feel bad, they should say no, run, defend, or speak to a trusted adult.
3. Abuse can come from an acquaintance or a stranger.
4. should not keep secrets that make you feel bad.
5. There are many adults who can help.
6. abuse is never child's fault.

properly designing the program, the therapist should know the risk factors and vulnerability of children, affection, uncovered, isolation, lack of ability to sense danger or to respond.
The low correlation between what we know must be done and what is done in a given situation is encouraging the workhorse of preventive programs. Transform
programs eminently practical and not theoretical, in which there is an opportunity to shape and develop appropriate behavior will be important future contributions.
In any case he had gone through a prevention program, it places the child in a situation of complete absence of risk, and are the adults responsible for their welfare and the society itself which must ensure that these misdeeds are not repeated. Intervention



family whenever possible, should be to involve parents in the treatment, making them co-therapists, intervention can be performed continuously and natural.
Parents must show the child's verbal and nonverbal support him, not push him to talk and normalizing daily life. It is inappropriate to ask the child to forget or overcome what happened. They must also be trained in proper methods of childrearing and education, to recognize and record specific behaviors, the appropriate use of reinforcement and development of guidelines on privacy, sexuality and family boundaries. Using operant techniques (observation, contingency management and stimulus control).
Where necessary, we can advise parents perform their own therapy. Still a controversy today whether to treat or not, as goal of treatment, family reunification.
The abused child's siblings, and especially those who have been abused by a family member must not be forgotten in the intervention. CONCLUSIONS



The assessment should involve more people and situations related to the child, and must pass a general examination and extensive, detailed analysis of particular problems.
treatment, but must address the specific problems of each child, in general, will aim emotional processing of the traumatic event, not forgetting to make a proper sex education and prevent future abuses. When possible, involve the family in treatment will be an important therapeutic aid.

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G Wagner Cartoonmaxine

Behavioral Treatment of Smoking

INTRODUCTION: THE USE OF SNUFF AND HEALTH

the damages that smoking on the health aspects are better known and is, in developed countries, the first problem likely public health prevention.
snuff consumption damages the respiratory system contributes to the onset of cardiovascular problems and has been associated with the presence of some cancers may be said, therefore, that smoking reduces life expectancy.
There are more than 400 substances in cigarette smoke, including some pharmacologically active antigenic, cytotoxic, mutagenic and carcinogenic.
The snuff is a cardiovascular risk factor of first order, increasing the occurrence of arteriosclerosis and morbidity and mortality from coronary heart disease, peripheral arterial disease and cerebrovascular disease. During pregnancy has negative effects on the health of pregnant women and endangers the health of your child.
The mortality attributable to consumption of snuff has risen, yet the problem remains more or less chronic, favored among others by economic and business benefits.
data on the consumption of snuff in Spain indicate that 36 100 people over age 15 are consumers of snuff, and the distribution by sex shows that are smokers to 51.5 per 100 for males and 21, 4 per 100 women.

DETERMINANTS OF SMOKING BEHAVIOR

The acquisition of the smoking habit is the result of a complex process of ontogenetic development. The evolutionary history of smoking appears to produce step by step through a series of steps that have unique characteristics.

Factors affecting learning of smoking

Explain why people start smoking is a key issue for the design of preventive activities. Lichtenstein (1982) mentioned how the social endorsement, curiosity, the role of defiance, the anticipation of the role of adult social pressure, the modeling of parents and peers and advertising are the factors in the natural history of behavior smoking, explain the onset smoking.
Peer pressure is probably one of the first movers to experimentation with snuff, and are partners, peers, who exert the pressure that would lead to try a cigarette
Another factor to consider is the drug aspect. Nicotine is an alkaloid that is classified as a drug and produce some reactions that smokers perceive as beneficial, weight regulation, regulation of mood and cognitive performance improvement, addictive and acts as a reinforcer of behavior. Is capable of producing dependence, which can be inferred from the introduction of the withdrawal, due to the lack of drugs, and tolerance, which manifests itself in the need to increase the doses for the desired effects.
Thus, once the consumption, physiological determinants, effects of nicotine, they start to play an important role in the automation of smoking behavior
Knowing why individuals begin smoking can design preventive action, but not find the hints on how to act so that people will abandon the habit is already established.

economic and social determinants in the habit of smoking

Within the group of environmental factors include the socioeconomic aspects surrounding the product, and availability, as well as social permissiveness.
The influence of advertising, its capacity as a stimulus to the response to smoke, and the cognitive effect is present snuff consumption while ignoring the harmful consequences associated with smoking

physiological and psychological determinants in maintaining smoking behavior

Overall, the effects of nicotine as an addictive substance, and the immediate consequences of consumption (pleasure on the one hand and the completion of the withdrawal symptoms and other) performance enhancers.
Smokers of low nicotine cigarettes do not consume less nicotine than smoking other cigarettes, but simply smoke more.
People who stop smoking continue, often feeling the desire to use snuff (craving), and often fall in consumption after a long time since that nicotine was no longer present in your body. Therefore, it needs to resort to these factors both biological and other psychological and social
Can I smoke in a wide variety of situations and while doing almost any other activity. The many contexts in which smoking go on to become discriminative stimuli for smoking behavior, in whose presence the behavior occurs and is rewarding.
Also, there have been studies concluding that people smoke as a coping strategy against stress. Therefore
thousands of repetitions of behavior, more than 50,000 a year for a person who smokes 20 cigarettes a day (Sarafin, 1990), in all situations, determine the broad generalization of this behavior, which is to be set up as a well established and persistent habit.

ASSESSMENT OF SMOKING BEHAVIOR

Interview with smoking

The smokers' behavioral interview aims to collect information relevant to the description of the circumstances in which smoking behavior occurs, for the development of hypotheses about antecedent and consequent conditions maintaining the habit and knowledge of resources and coping skills of clients.
Structured interviews for the evaluation of smokers often gather information concerning: a) social and family context of the client; b) the circumstances that led to the establishment of the habit and to those of previous quit attempts; c) the topographical aspects of smoking behavior, d) the current reasons for exposing himself to a treatment program, and e) to expectations for this treatment. Also some motivational aspects, such as discomfort caused by the use of cigarettes or expectations of the benefits go to treatment, are in the interview a suitable framework for evaluation.
appropriate that the information obtained through the interviews are contrasted with more interviews with the subject, interviews with their relatives and / or other information gathering techniques. Using



self-reports constitute the most used in this context.
addition to the frequency of the motor response of smoking, self-registration may include observation of other categories of response and situational conditions consistent background or behavior, in practice, you should not include more than six categories, being a good start with the simple strategy observing the occurrence of behavior, and include then, progressively, all other categories of interest.
Among the most common systems used was the notation on a role of the observed variables, but also offered to smokers have different mechanical and electronic devices. When using paper and pencil procedures should employ a self-registration form that provides a comfortable and easy use by smokers.
A particularly important aspect is the reactive effects produced by self-observation on smoking behavior. This may adversely affect the accuracy of the data. Basically, reactive effects of self-reports tend to include, with large differences between individuals, increased motivation for treatment, but could constitute a limitation of self-registering as a measure favors a positive response to the intervention.

Questionnaires and scales to evaluaci6n of smokers

Two objectives:

1. diagnostic classification of subjects, and assessment
2. variables considered as predictors of treatment efficacy. Such measures its utility based on the possibility of interindividual comparisons.

One of the variables traditionally has been evaluated in programs to quit smoking is nicotine dependence. The instrument most popular and widely used by clinicians and researchers. Tolerance Questionnaire Fagerstrom nicotine.
Within the same approach that seeks the classification of smokers, but from different theoretical perspectives have been developed other questionnaires and scales as the motivation questionnaire smoking (Tomkins, 1966) and the scale of pros and "cons" of smoking (DiClemente).
As predictors of success in the treatment of smokers, have been used for the past decade self-efficacy scales, from which to highlight the scale of trust in situations smoking (Condiotte and Lichtenstein, 1981).
Other questionnaires to measure personality variables have also been used relatively often, to evaluate the characteristics of smokers in this sense, the dimension of Locus of Control (LOC), presenting, in general, subjects more internal, more likely to remain abstinent than external subjects. Physiological measures



The priority objective confirmation of abstinence and / or a finding that will produce a decrease in the frequency of smoking.
Thiocyanate is a good measure of smoking, the average life of this product in biological fluids is between 10 and 14 days and slowly eliminated, mainly through the urine.
Cotinine, with a half life in the body about 20 hours to be observed in blood or plasma, which due to the invasiveness of the procedures to be very useful, now attempts are underway to assess cotinine in saliva, what is expected in the near future to increase its use.
nicotine assessment was carried out taking into account their presence in blood, saliva and urine, using sophisticated laboratory procedures. These circumstances, together with its short life, have resulted in a measure has not been much used in smoking cessation programs.
Evaluation carbon monoxide (CO) in exhaled air, which is a simple and noninvasive estimation of carboxyhemoglobin (COHb), besides being cheap and not require specialized personnel, the criterion used for the estimation of smoking behavior present 5 to 10 parts per million of carbon monoxide.

TREATMENT OF SMOKING

types of interventions for smoking cessation

They fall into four main sections: social interventions, procedures, self-help interventions in community and / or labor and clinical interventions.

Interventions social / institutional and self-help procedures
social interventions are characterized mainly by:

1. be directed to collective
2. the use of social media and
3. assume that the repeated calls to abandon of snuff will mean that the subjects change their attitudes and stop smoking. It is considered that the information on the harmful aspects of the use of snuff can motivate smokers to change their habit, but does not take into account the possibility of offering concrete help ..

Self-help procedures, while the oldest approach and one of the most promising. Probably a large number of smokers give up the habit without professional help, if he had specific strategies that enable you to do this, the design and development of materials to help people to eliminate smoking from their codes of conduct, should be an interesting challenge for researchers and therapists. Within the procedures
self-help manuals are the most attention has been given to date, typically include information about the risks of smoking and the benefits of its abandonment, as well as concrete suggestions on how to quit.
The advantages of this procedure

1. The cost-effectiveness: cost;
2. The accessibility of the therapeutic device, and
3. seems that self-help procedures favor the maintenance of the achievements producing a lower relapse rate.

addition, the materials have the potential to be used in media community and workplace, and in the clinical setting
as classic material, we can mention the manual Break the Smoking Habit (Pomerleau, 1977), recently published in Spain under the entitled "How to Quit Smoking: an invaluable aid to permanently delete cigarettes in an easy and safe" (Pomerleau, 1992).
reported abstinence rates are highly variable between 0 and 74 100.
seems likely that, due to its easy application and distribution, the use of self-help procedures increase in the future.

Interventions in labor and community frameworks
Within the community health model referred to individuals as responsible for maintaining and improving their health and as stewards of their health. Programs to quit snuff can be considered as activities to promote health and its validity will depend, in addition to the effectiveness and usefulness, adherence to the program.
In this sense we can consider the workplace and the rules of conduct can be adapted to deter and control the behavior of smoking, both health and economic reasons. The employment framework maximizes efficiency in terms of convenience, time, accessibility, control, and monitoring of the subject, which is an invitation to health institutions to intervene in this way.
One example of intervention in the workplace the Smoke Free multicomponent program of Dawley (1982), consists of three phases

1. control;
2. deterrence and cessation
3. snuff. Dawley also

and Fassler (1988) developed another program in the workplace smoking cessation, consisting of a 90-minute session, preceded by a campaign of deterrence, in which participants signed a contract with a commitment to not smoking at six months, when they would receive a financial incentive from the company, at six months, only 33 100 (3 of 9 participants) were still not smoking.
competitions to quit smoking or remain abstinent a given time, is a procedure widely used in community media and / or labor. This usually includes the use of leaflets and cash rewards or other rewards.
radio, television and newspapers have also been used, diffusers as well as prevention campaigns and social assistance / institutional. This author concludes that the results of these programs are very difficult to assess, by suggesting that although the approach is promising, these programs should be viewed with caution until studies appear to solve, or alleviate to a large extent, the methodological shortcomings

Treatment by the medical model
In the clinical setting, and from the medical model addresses the issue by emphasizing mainly on the physiological aspect of nicotine dependence, proposed as methods of intervention, mainly, the council doctor and prescription of nicotine replacement in order to avoid withdrawal symptoms. E1
medical advice is based on the medical consultation. It, therefore, to convince the health problems that the consumption of snuff and should refrain from smoking in front of patients.
Several studies have shown how the council and the doctor's warning about the dangers associated with the use of snuff effective. Especially in subjects with respiratory, cardiovascular and pregnant women. As for the general population, using the simple medical alert, we have obtained rates of abstinence, years of between 3 per 100 and 13 100.
Within the medical model of treatment of tobacco has historically emphasized pharmacological intervention, it usually includes both prescription nicotine replacement in the form of gum or nicotine patches, as anxiolytic or activating substance, in the latter case because many people mention, among the reasons to keep smoking, that will snuff them relaxing or active.
Today, this line of treatment is largely abandoned in the field of medical interventions, having been relieved by the interest aroused by the use of nicotinic receptor agonists, nicotine substitutes, chewing gum and patches.
Prescription gum and nicotine patches is subject to some controversy. Yet we must consider that the cost-effectiveness can not recommend the use of nicotine gum over other effective behavioral procedures.
As an alternative to these approaches are psychological tools, with mixed results regarding its effectiveness, we found that behavioral intervention is, in general, which has been more effective for the cessation of snuff consumption. Main

psychological strategies for smoking cessation


General techniques Although you can consider that all smoking cessation programs established, at least implicitly, a contract between the smoker and the therapist, some treatments employ this strategy as the key therapeutic technique, sometimes as a facilitator of adherence or maintaining abstinence, as a motivating factor, as, for example, the use of monetary incentives has also been used
systematic desensitization to strengthen responses incompatible with smoking, building approach, in which smoking behavior is often associated with anxiety and if they desensitize subjects to the stimuli that precede smoking, then this behavior will decrease. Other researchers suggest that relaxation may be conditioned as an alternative response to smoking.
aversive techniques underlying its effectiveness in three types of assumptions:

1. that when the behavior occurs with a frequency and / or a high enough intensity, reinforcing aspects of it disappear and become aversive;
2. that when the conduct creates highly aversive consequences likely to take place decreases, and when
3. aversion occurs because of intrinsic negative consequences to one's response to smoke, the intensity of the aversion is higher and their maintenance and generalization are more likely.

In this sense, the electric shock contingent on the occurrence of the response to smoke or when they feel the urge to smoke in the laboratory was difficult to produce the desired generalization. Except for the Schick program, with positive results using electric shocks of medium intensity, though. Lichtenstein and Danaher (1976) have suggested that the effectiveness of this program was due to the strong motivation generated by the clever use of social pressure and other processes not specific to the treatment.
covert sensitization, in this case, the aversive consequences of it are imaginary, the smoker must play on your imagination in an appropriate manner, conduct and consequences agreed in advance. Basically, after a period of training in the use of imagination, the subject is asked to imagine getting ready to smoke and then imagine that feeling unpleasant sensations such as dizziness, nausea, etc. Also requested that once rejected this imaginary cigarette, have the unpleasant sensations will disappear and be replaced by images that make you feel better and better in general, the effectiveness of the technique, have found very poor results today technique is rarely used, although, as part of a multicomponent program. E1
satiation procedure is instructing the subjects to increase, doubling and even tripling their normal consumption of cigarettes for a week. It is assumed that as the subjects themselves are forced to dislike smoking, cigarette rewarding properties will be phased out, being replaced by other negative properties. Specific techniques


The technique of rapid smoking, smoking cigarettes is your favorite brand, making a breath every five or six seconds for fifteen minutes, one hour sessions with a break between runs of five minutes, during which discusses the negative aspects of the experience and suggests negative cognitions respect to smoking behavior. Another way is to apply the technique in a single trial, which is usually between 20 and 25 minutes, when the smoker does not want to follow the great discomfort it causes. Rapid smoking sessions are held daily at the beginning of treatment and then will gradually spacing. Treatment usually lasts two or three weeks, and subjects tend to quit after the sixth session.
One aspect often given when speaking of the rapid smoking technique is the risk that your application can have on the smoker's health, taking into account the excessive intake of nicotine, carboxyhemoglobin level, possible changes in electrocardiographic etc. that may attach to the application of the technique. However, revisions of these risks appear to indicate that they affect the health of the subject. While it is recommended that treatment subjects older than 40 years.
The technique of retaining the smoke is a better alternative for smokers who accepted the rapid smoking technique, and their results are similar to those achieved with it. Is that the subject hold the smoke of his cigarette in his mouth for 30 seconds while still breathing normally through your nose, after this test rests for 30 seconds and then repeat up to six times the same procedure. In each trial, while the subject is the smoke Mouth says he must concentrate on the unpleasant sensations of the experience. Just as in the case of rapid smoking technique, this strategy is more effective in multi-component programs.
technique gradual reduction of tar and nicotine intake by changing brands is to consume cigarettes containing lower and lower nicotine and tar, forming a more acceptable alternative, he directs his attention to both the highly pharmacological factors associated with the consumption of snuff, as psychological factors of habit. The technique combines, often, weekly change of cigarette brands with lower and lower nicotine content (usually reductions of 30 per 100 in the first week, 60 100 second and 90 for 100 reduction on consumption in the baseline, in the third week) with daily consumption self-registration and representation weekly chart.
recent addition to the treatment of smokers with a new specific technique: the physiological feedback of carbon monoxide (CO). Generally, the technique has been used in a comprehensive program that also used other techniques of treatment, and offered to smokers weekly information on the levels of CO in exhaled air by providing a motivating effect for treatment.
It can be concluded in a general way, that both general and specific techniques, applied in isolation can be considered insufficient.

multicomponent programs for the treatment of smokers

Today, we tend to apply effective methods, but not aversive.
Some ingredients in these programs so that successful treatment seems to be: an intervention method acceptable to smokers, therapists conducting the treatment and maintaining a well-planned strategies, depending on the specific needs exist. In a general, multicomponent programs are presented in three interlinked phases:

1. preparation
3. neglect and maintenance.

Thus, in the first phase, preparation, try to increase motivation and commitment on the part of smokers. To do this, are used, among other procedures, contingency contract and monetary deposits, the latter being recovered for clients over the treatment sessions and follow-up. In this phase the subjects become aware of their own behavior and its consequences through self-reports, the graphical representation of consumption, etc., And also are provided with training in subjects self-control techniques, such as stimulus control, stress management, relaxation, alternative behaviors to smoking, etc. In the second phase, that of abandonment, is often incorporated into the program one of the following techniques: rapid smoking, hold the smoke, gradually reducing tar and nicotine intake, satiation, covert sensitization, contract with a fixed date of abandonment, etc.. in order to facilitate the decision to quit. Finally, in the maintenance phase of withdrawal, which the subject comes and abstinence, are scheduled meetings at which former smokers are trained in skills to cope with high-risk situations, and provides social support, preventing possible relapse.
However, today it is considered that more is not always better, because a too complex treatment package may cause the opposite effect and the smoker may find it very difficult to follow
Due to the complexity of smoking behavior and individual differences among smokers, multicomponent programs are essential when a simple method has not proved sufficient to accommodate the full range of problems and smoking.

abrupt cessation versus gradual reduction in consumption

seems that quitting with immediate cessation is a procedure that can be offered to smokers who have willingly and who have been assessed to have skills to cope with withdrawal.
However, smokers often do not meet these conditions of high motivation and / or lack the skills required to meet the withdrawal, in these cases it seems the time has come to quitting smoking in a gradual way, through the gradual reduction cigarette consumption
This approach often raises the problem that customers can reduce the amount of cigarettes smoked, but this reduction is as a result of personal effort that the effect of a real weakening of the links without occur to reach a genuine process of addiction.
With the intention to solve the mentioned problems, Buceta and Thomas (1983) developed a multicomponent intervention program phasing. This program was intended at first to weaken the links between the history, behavior and reinforcing consequences smokers and training skills to combat withdrawal symptoms to nicotine in a second phase, when consumption was reduced sufficiently and the patient was evaluated and mastered the skills that had been trained, they proceeded to cessation. With very encouraging results,

conclusions about the psychological treatment for smoking cessation

Multicomponent programs may increase the utility of intervention programs.
aversive techniques are being disregarded in favor of others such as stimulus control, behavioral contracts, the gradual reduction of nicotine, etc.
Increasingly frequent use of objective tests to evaluate the smoking abstinence.
multicomponent programs can and should still be improved.
seems proven techniques multicomponent programs are aimed, on the one hand, increased motivation, increased perception of self-efficacy to smoking cessation and, finally, the maintenance of abstinence. The
interventional procedures should take into account the following assumptions:

1. smoking behavior is a learned habit, strongly consolidated.
2. smoking behavior occurs in specific situations, as determined by the antecedent conditions and consequences of behavior, which implies the need for a precise functional analysis of behavior.
3. smoking behavior can be eliminated when:
1. weakens the link between antecedent stimuli;
2. eliminating the reinforcing nature of smoking behavior, and
3. amending relevant thoughts and beliefs that support the provision the smoker to smoking behavior.
4. Smoking causes physiological effects in the body, such as nicotine dependence and tolerance, so stop abruptly in the consumption of snuff, you can receive the withdrawal of nicotine (APA, 1988). The gradual reduction in consumption can mitigate this problem.
5. However, smoke a few cigarettes can be highly reinforcing
6. seems appropriate to start with a gradual reduction process, but without allowing them to dilate over time periods of low consumption of cigarettes
7. Overlooking increase the likelihood of success, it seems appropriate to draw "Trial periods so that the smoker was successful in the attempt and strengthened their confidence.
8. intervention on smoking behavior requires the active participation of clients from the outset.
9. The provision of information regarding their progress (for example, CO in exhaled air), may contribute to increased motivation.

APPROACH OF A PSYCHOLOGICAL INTERVENTION PROGRAM FOR THE CESSATION OF SMOKING BEHAVIOR

intervention is developed in four phases:

1. Introduction to treatment and establishment of the line basis of cigarette smoking
2. Decomposition of smoking by weakening the links ERC, and training of smokers in various coping skills;
3. tests cessation and abstinence, and
4. Maintenance of abstinence.

First phase of treatment: Introduction and data collection

be developed over the first two sessions
Objectives:

• Presentation of the program.
• setting expectations.
• Establishing the baseline, is a measurement of CO

Activities:

• Explanation of the objectives of the intervention. Description
• standards of the program.
• active Understanding Your Customer.
• Basic explanation of the mechanisms that maintain smoking behavior (antecedents-behavior-consequences).
• Training in the use of self-reports, with them set the frequency of smoking, in order to describe the behavior topographically and to clarify the factors that shape the background conditions and the degree of pleasure felt as a result of each cigarette consumption. Preparation
• lists of pros and cons of quitting smoking with the patient and their families

Phase II: Decomposition of smoking

During this phase aims at the decomposition of smoking by weakening of ties stimulus-behavior-consequences.

Objectives:

• Functional analysis of smoking behavior.

should address the following elements:

• background stimuli used for the implementation of stimulus control techniques.
• rewarding consequences.
• stimulus-behavior-consequences rewarding.
• Cognitions relevant through the information reflected in lists of pros and cons of smoking
• deficits and resources including behavioral deficits and weakening family support links

ERC (stimulus-behavior-consequence). Strategies for the weakening
:

• stimulus control. Is not to demonstrate, on a voluntary basis, smoking behavior in situations in which the set of stimuli the elicitaría, carrying out other alternative behaviors. Reduction
• reinforcing nature of smoking behavior. Delay
• cigarette smoking behavior. Ask
• brush your teeth.
• Remove ashtrays from your home and keep only one
• Prevention
response
• Begin the session by the client view of a pack of cigarettes. Turn
• some cigarettes during the session, and let you eat. Training
• alternative responses. Exercised to reject offer of cigarettes. Changing

related cognitions smoking. Identification and discussion of thoughts and beliefs relevant
Strategies:

• Cognitive restructuring: training is intended for smokers, on the one hand, to make them aware of your inner dialogue at the time that have to smoke a cigarette and the other to change their automatic thoughts and internal verbalizations. An important aspect of this procedure is to include elements of cognition, which provide a pleasant consequence of these thoughts (save money, my spouse will feel proud of myself, my children will model a parent showing their value health), so as to eliminate, as far as possible the anxiety associated with prohibiting self-instruction.
• self-instruction training.
• training and acquisition of coping skills. Situations and symptoms that will probably appear at the time of complete cessation and during abstinence: hold com.

Strategies:

• relaxation training to reduce anxiety, irritability, stress and difficulty concentrating (muscle relaxation).
• social skills training. Facilitate assertive behavior by role playing exercises in which patients receive offers and have to be rejected. Maintenance

motivation for treatment.

Information
• CO in exhaled air.
• daily charts.
• Anticipating the benefits of quitting.
• contingency contracts between client and therapist. To facilitate adherence and as a motivating factor for carrying out treatment activities.

In short, it is that smokers, in addition to not leave and keep going, learn all the skills necessary for your particular case, without applying a general treatment package to all customers. in all cases

Third phase: Evidence of cessation and abstinence.

When he has acquired some control over the smoking behavior. It is important to note that this is only a test, in order to check how are facing difficulties in principle a person is faced with a long history of smoking, when you begin to live without smoking.
Objectives:

• periodic abstinence test.
• Top of continuous abstinence.

Activities: Negotiating

• timing and duration of trial periods. The first test will last between 1 and 3 days or less, and proceed to implement new over longer periods of time up to 7 days without smoking.
• difficulties and test prevention strategies to control them.
• analysis of the difficulties encountered during periods of abstinence and seeking solutions. Strengthening
• achievements during periods of abstinence.

Fourth stage: maintenance of abstinence

Objectives:

• stay quit. Avoid
• chronicity of possible relapse.

Activities: Anticipation

• risk situations more likely to smoke.
• test strategies for controlling high-risk situations.
• Anticipating consequences of living without smoking. Withdrawal symptoms, weight gain and possible occurrence of thoughts that invite smoking and downplay the negative.
• Application of previously learned skills.

After this stage, although no more meetings are set with the client, can be very beneficial for the maintenance of abstinence to be tracked through regular telephone contacts, in which any doubts are resolved is anticipate situations of risk and strengthen the customer to remain abstinent.

EFFECTIVENESS OF PSYCHOLOGICAL TREATMENT FOR SMOKING CESSATION

Effectiveness of psychological techniques in the treatment of smokers

technique rapid smoking, cessation rates of between 6 per 100 and 40 100 in 6 studies conducted
year follow-up retention technique of smoke, of 11.11 per 100 at one year, well below the abstinence rate of 30 per 100 for the twelve months, obtained when the technique of holding the smoke was applied by the gradual reduction, which seems to suggest again, the desirability of placing this technique in intervention programs with other strategies .
gradual reduction, in these studies (abstinence rates ranged from 7 per 100 and 46 100 in the treatments with one year follow up.

Effectiveness multicomponent programs

had the best results are obtained. Most studies on the effectiveness of multicomponent programs have attempted to compare a particular treatment package with other packages that differed only in a single element, without any significant differences that have supported the specific efficacy of a particular strategy
Within the body of research in which aversive techniques have been used as elements of multicomponent programs, abstinence rates achieved at the end of treatment were 75 per 100 for the group subjected to satiation, 50 per 100 for which was applied rapid smoking technique and 75 per 100 for subjects treated with the combination of satiation and rapid smoking. At follow-up, 67 100 of the total group of subjects at the end of treatment and 47 per 100 at six months remained smoke-free.
In Spain, as a motivational strategy asked participants to make a deposit of 20,000 pesetas, which would be returned as remain in the program at different times. Was used as an objective criterion for withdrawal nicotine in urine analysis, and specific program strategies were: self-reports, the graphical representation of consumption, a fixed date of abandonment, stimulus control, relaxation, rapid smoking technique, contingency management, covert aversion and cognitive control. The abstinence rate at end of treatment was 60 100.
The combination of aversive techniques and procedures of self seems to be very useful for the treatment of smokers. Aversive procedures have proved effective in achieving short-term abstinence, but its use has, in addition to the difficulties already mentioned in a previous section, an inherent limitation when applied to the extinction of high occurrence of such behavior as the behavior of smoking. And, when you have not anticipated the availability of alternative responses by the subjects, cessation efforts in consumption, obtained only temporary success (Schwartz, 1987), which justifies that complement other techniques for future maintenance of abstinence.
With the aim of evaluating the personal training for relapse prevention. 587 subjects were randomly assigned to one of the following three conditions follow: 1) skills training (41.3% abstinence), 2) discussion with social support (34.1%), and 3) no treatment (33, 3%). Data from this study seems to conclude that the program works best when adapted to the needs of each smoker
As already noted, gradual reduction of tar and nicotine intake has been the backbone of many programs multicomponent The results at the end of treatment showed an abstinence rate of 66.66 per 100 in the group with gradual reduction of tar and nicotine intake and 12 month follow up, abstinence rates were of 45.83 per 100 in the group which used only a gradual reduction.

Some data on the effectiveness of the proposed program

At the end of the program, 84 100 were abstinent, in the monitoring carried out at six months, 53 100 subjects remained abstinent.
More recently, analyze he difference between the reduction of weekly consumption by a fixed pattern, compared to the treatment activities that were aimed at the decomposition of habit and showed superior efficacy of this treatment compared with that came through a gradual reduction indiscriminately.
In the same study also hypothesized that if the feedback of CO in exhaled air was a useful treatment, the results showed that among subjects who received feedback of CO were produced abstinence rates significantly higher at end of treatment.
Finally, it is remarkable that those subjects who received similar treatment we have proposed in this chapter, focused on the reduction due to the decomposition of habit and coping skills training, and also received feedback from CO, had the highest scores in all measures of efficacy variables.
may be considered relevant to all subjects in the different treatments, but failed to stop consumption, somehow also benefited from the program, since they had a significantly reduced number of cigarettes smoked.

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The cold strikes again, but it makes me lose the desire to model;). Here 's the result of a lazy afternoon, new plastilustración.
Nothing makes me lose the Desires of working. This one is the result of an idle evening, a new clay illustration.

2001 Volvo S40 Blown Head Gasket Repair

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In love, hand painted stone
Size / Dimensions: 17 x 19 x 4 cm Weight

: / Weight: 1'800 kg
acquired by a private collector / Acquired by a private collector