Jeffrey A Brinker, M.D.
- Professor of Medicine
- Joint Appointment in Radiology and Radiological Science
There are different approaches regarding resuscitation of the hypothermic arrest patient best buy prothiaden. The state of Alaska’s 2014 guidance on management of hypothermic patients in cardiac arrest advises that defibrillation should be attempted once buy prothiaden 75 mg cheap, followed by 2 minutes of chest compressions 75mg prothiaden with mastercard, then rhythm and pulse checks i. If defibrillation is unsuccessful and the patient’s core temperature is fl 30°C (86°F), do not make further attempts at defibrillation until the core temperature has increased to greater than 30°C (86°F) ii. An alternate strategy, per the Wilderness Medical Society’s accidental hypothermia guideline, suggests that if the patient’s core temperature is below 30°C (86°F), attempt defibrillation once, then wait until the patient has been rewarmed at least 1° 2°C or to 30°C (86°F) before attempting additional shocks. It is noted that the likelihood of successful defibrillation increases with every one-degree increase in temperature d. If defibrillation is unsuccessful and the patient’s core temperature is greater than 30°C (86°F), follow guidelines for normothermic patients. Manage the airway per standard care in cardiac arrest victims [see Cardiac Arrest guideline] a. In the absence of advanced airways, ventilate the patient at the same rate as a normothermic patient b. If the patient has an advanced airway, ventilate at half the rate recommended for a normothermic patient to prevent hyperventilation. Patients with severe hypothermia and arrest may benefit from resuscitation even after prolonged downtime, and survival with intact neurologic function has been observed even after prolonged resuscitation Patients should not be considered deceased until rewarming has been attempted 9. If a hypothermic patient clearly suffered cardiac arrest and subsequently became hypothermic afterward with prolonged down time between arrest and rescue, there is no rationale for initiating resuscitation and warming the patient Pertinent Assessment Findings 1. Measure of patients who received treatment to correct their hypoglycemia o Trauma-01: Pain assessment of injured patients. Recognizing that pain is undertreated in injured patients, it is important to assess whether a patient is experiencing pain 303 References 1. Wilderness Medical Society guidelines for the prevention and treatment of frostbite. Wilderness Medical Society practice guidelines for the prevention and treatment of frostbite: 2014 update. Pennsylvania Statewide Advanced Life Support Protocols: Hypothermia/cold injury/frostbite. Rhode Island Statewide Emergency Medical Services Protocols: Cold exposure – frostbite. Wilderness Medical Society practice guidelines for the out-of-hospital evaluation and treatment of accidental hypothermia: 2014 update. Transport all patients suffering from drowning for hospital evaluation Patient Presentation Inclusion Criteria Patients suffering from drowning or drowning events independent of presence or absence of symptoms. History should include circumstances leading to the submersion, details of mechanism of injury, time under water, and water temperature (if available) 3. History, mechanism of injury and exam should include consideration of possible c-spine injury if evaluation suggests injury to the cervical spine, manage c-spine 5. Assess for other associated injury such as injury to the head or dive-related emergency Treatment and Interventions 1. Practice the safest water rescue technique possible, given circumstances on scene b. If there is a delay to accessing shore or a rescue boat, initiate in-water basic life support consisting of ventilation only 2. If mechanism or history suggest cervical spine injury, manage c-spine, per the Spinal Care guideline 306 5. If O2 saturations are less than 92%, administer oxygen as appropriate with a target of achieving 94-98% saturation. If the victim was involved in underwater diving and uncertainty exists regarding the most appropriate therapy, consider contacting direct medical oversight and discussing need for hyperbaric treatment. The World Health Organization definition of drowning is “the process of experiencing respiratory impairment from submersion/immersion in liquid” 2. Immersion refers to situations in which the patient’s body is in water but the patient’s airway remains out of the water 4. Risk factors for drowning include male gender, age fl less than 14 yo, alcohol use, lack of supervision, and risky behavior 5. Rescue efforts should be coordinated between all responding agencies to ensure patient is rapidly accessed and removed from the water 6. Initiation of in-water ventilations may increase survival – In-water chest compressions are futile 7. The European Resuscitation Council recommends 5 initial breaths be provided to the drowning victim a. The initial ventilations may be more difficult to achieve as water in the airways may impede alveolar expansion b. After the initial 5 breaths and 30 compressions, the standard ratio of 2 breaths to 30 compressions may be resumed 307 8. Active efforts to expel water from the airway (by abdominal thrusts or other means) should be avoided as they delay resuscitative efforts and increase the potential for vomiting and aspiration 9. Long-standing teaching has suggested that rescuers should always assume c-spine injury in victims of drowning a. The 2010 American Heart Association update on special circumstances in cardiac arrest notes that routine c-spine precautions in all victims of drowning is likely unnecessary unless the mechanism or injury, history, or physical exam suggests a cervical spine injury b. Mechanisms of injury highly suggestive of cervical spine injury include diving, water skiing, surfing or watercraft accidents 10. Uncertainty exists regarding survival in cold water drowning, however, recent literature suggests the following: a. If water temperature is less than 43°F (6°C) and the patient is submerged with evidence of cardiac arrest: i. Survival is possible for submersion time less than 90 minutes and resuscitative efforts should be initiated ii.
The very best way to best purchase for prothiaden test out this anxious thought is to 75mg prothiaden overnight delivery collect information on it while you are in the classroom buy prothiaden master card. We all learn so much more from our own experiences than we do from listening to teachers or even therapists for that matter. In fact homework exercises such as this have been shown to be one of the most important ingredients for reducing anxiety. Not only does it give you an opportunity to test the anxious thinking, but it also provides an opportunity for you to directly work on the anxiety. Would you like to work together on constructing an exercise that would test out this anxious thoughtfl Statement of Threat Appraisal and Its Alternative Assuming collaboration has been established with the client, the next step is to state the threat appraisal and its alternative. The therapist and client then come up with an alternative interpretation that is clearly distinct and more plausible than the anxious thought or belief (see previous section on generating alternatives). The alternative is recorded on the form and the client is asked to provide a belief rating at the conclusion of the behavioral experiment. The two belief ratings will provide an indication of whether the behavioral experiment has led to a shift in belief from a threat-related interpretation to the alternative perspective. In our case illustration, Jodie’s threat interpretation was “If I feel nervous in class everyone will notice me and think I don’t belong in university. Besides they are too busy listening to the lecture, talking to the person beside them, sleeping, or daydreaming to take the time to notice me. Planning the Experiment Devising a good behavioral experiment will probably take at least 10–15 minutes of therapy time. It is important to write out suffcient details of how the experiment should be conducted so it is clear to the client what is to be done at a certain time and in a particular location. The experiment must involve an activity that provides a clear test between the anxious and alternative interpretation. It is important that the exercise is planned out collaboratively with the client and there is agreement that the experiment is a relevant test of the anxious thought. There is little sense in pursuing an empirical hypothesis-testing exercise that the client doubts has relevance or has little intention of carrying out. Assuming a mutually agreed-upon relevant exercise, the therapist should write down specifc instructions for completing the experiment in the left-hand column of the Empirical Hypothesis-Testing Form. Make sure the purpose of the experiment is clear, that a time and place for the experiment has been identifed, and that resources needed to carry out the exercise have been determined. The therapist can ask a client “What do you think might discourage or even prevent you from carrying out this exercisefl It is important that something constructive is gained from the experiment regardless of the outcome. Finally all doubts, fears, and other concerns expressed by the client must be addressed and any potential medical complications should be assessed by the client’s physician. She was asked to arrive at the lecture hall at 8:55 and to sit at least three seats in from the aisle in a middle row. Ten minutes into the lecture she agreed to write down anything she noticed in Cognitive Interventions for Anxiety 215 other students that indicated they were looking directly at her. Fifteen minutes into the lecture she would take three to four deep breaths and observe whether anyone noticed what she was doing. Twenty minutes into the lecture she would try to make her body shake ever so slightly for a few seconds and observe whether anyone noticed. The therapist and client practiced each of the elements of the experiment: how to record student reactions and what behavior would constitute a direct look, how to deep breath, and how to shake ever so slightly. Jodie agreed that this was a “doable exercise” and that it would be a good test of how much she is noticed in class. Hypothesis Statement Under item 3 on the Empirical Hypothesis-Testing Form (Appendix 6. The hypothesis would directly refect the anxious thought or belief stated in item 1. The therapist can ask, “Based on your anxious thought [state item #1 here], what do think will happen when you do this exercisefl Record the Actual Experiment and Outcome Clients should record how they conducted the experiment and its outcome as soon after completing the exercise as possible. A short description of what was done and its outcome can be written in the center and right columns on the Empirical HypothesisTesting Form. Often individuals do not conduct an experiment exactly as planned so a description of what was actually done is important in evaluating the success of the exercise. However, the actual outcome reported by the client is even more important when following up on the effects of the behavioral experiment. It is the client’s perceived outcome that will provide the necessary information for determining whether the exercise had an effect on anxious thoughts and feelings. Thus the outcome recorded on the form becomes a main focus of therapy when reviewing the assigned homework. Consolidation Phase the success of a behavioral experiment in large part depends on how effectively the therapist reviews the outcome of the exercise at the following session. Based on information recorded on the Empirical Hypothesis-Testing Form, the therapist uses a combination of active listening and probing questions to determine how the exercise was implemented and the client’s evaluation of the outcome. When discussing the experiment it is particularly important to evaluate the outcome in light of the previously stated hypothesis, or predicted outcome. If there was a discrepancy, what does this indicate about the relation between threat appraisals and anxietyfl When reviewing the outcome of a behavioral experiment, the therapist is drawing the client’s attention to the anxiety-provoking properties of heightened threat and vulnerability interpretations, and the anxiety-reducing effects of the alternative perspective. The goal is to reinforce the cognitive conceptualization of anxiety and to promote the idea that cognitive change is a critical component of anxiety reduction.
The physician treating a patient with mulwhereas gabapentin as adjunctive therapy produced a much tiple handicaps must appreciate this potential unwanted higher rate of negative behavior prothiaden 75mg online, especially in patients with effect discount 75 mg prothiaden mastercard. Bone health safe prothiaden 75 mg, contracture formation, etam, oxcarbazepine, zonisamide, and vigabatrin have proweight regulation, gastrointestinal disturbances, gynecologic duced, at least in case reports, aberrant behavior in persons concerns, and drug interactions affect not only the treatment with behavioral comorbidity, including those with mental of epilepsy but also medications prescribed for other comorretardation (38). Careful changes in behavior may often be the only sign of significant titration and monotherapy are recommended whenever possiabnormality in this group. Increased acting out and belligerence may appear as part of the “brightening” the treatment of the multihandicapped child or adult with process that can occur with conversion to newer, less sedative epilepsy must be tailored to the individual patient. Thus, changes in therapy should be made slowly with assessment of all comorbid conditions must be part of the careful clinical monitoring (38). New-onset seizures or (36,46–48), as an excessive drug burden complicates the seizures that have changed in type or intensity warrant a comassessment of efficacy and tolerability. The comoroccur in an individual patient, long-term studies suggest that bid treatment and the epilepsy treatment will each affect the polypharmacy can be reduced successfully, especially when a other. In one study of 244 mentally retarded patients Understanding the difficulties in diagnosis and treatment of with epilepsy who were followed up for 10 years, monotherindividuals with multiple handicaps and the inter-relationship apy could be increased in 36. Identification of the epilepsy syndrome may also aid in Definition, Classification and Systems of Support. Diagnostic and Statistical Manual of Therapy for the multihandicapped individual comprises Mental Disorders. Diagnostic and Statistical Manual of educational, vocational, and psychological (49–51). Static long-term follow-up and links with electrical status epilepticus during sleep Encephalopathies of Infancy and Childhood. Initiating and discontinuing antiepileptic drugs in patients with multiple handicaps and epilepsy. In: Devinsky E, Westbrook American Academy of Neurology and the Child Neurology Society. Removal of sedative-hypnotic antiepileptic ders after infantile spasms: a population based study nested in a cohort drugs from the regimen of patients with intractable epilepsy. Notably, the incidence (new cases) of epilepsy is signifidetected a higher rate. Some retrospective studies have indicantly higher in this population than in any other (2,3). Accordingly, the incidence of seizures after stroke Netherlands and Finland (5,6). It is suspected that Currently, there is a debate within the medical community those persons with Alzheimer’s disease who experience brief regarding the precise definition of epilepsy (7). Until recently, periods of increased confusion may be having unrecognized it has been accepted that persons should not be diagnosed partial complex seizures. Most problematic, though, is that in with epilepsy until an individual experienced two or more a large number of cases the precise cause cannot be deterseizures. However, in light of current diagnostic tools, brain mined and the etiology is termed cryptogenic (crypt hidden; pathologies can be more readily identified. This is of particular Because most seizures in the elderly are caused by a focal area importance to the geriatrician due to the fact that many perof damage to the brain, the most common seizure types are sons within this age group suffering from seizures possess an localization related. Complex partial seizures are the most comidentifiable brain pathology that corresponds with a known mon seizure type, accounting for nearly 40% of all seizures in risk for future seizures. Both simple and complex may spread and develop into generalized tonic–clonic seizures. In a prospecsuch as cardiac insufficiency, metabolic conditions, convulsive tive study of 1897 patients suffering from stroke, seizures syncope (micturation syncope, cough syncope), be eliminated occurred in 168 (8. Of the 265 persons within the study who suffered a event was an epileptic seizure. Of the Evaluation after a single seizure must therefore be compre1632 persons within the study who suffered an ischemic hensive. Thus, those who sufevents of the previous day or days, in order to identify any fered a hemorrhagic stroke had an increased risk for a seizure precipitating or predisposing factors that may have led to the 458 Chapter 37: Epilepsy in the Elderly 459 onset. Osteoporosis and bone fractures are many natural products designed to simulate weight loss or commonly seen in the elderly population and thus an elderly improve memory may have proconvulsant properties. Large prospective studies in women and abuse of drugs is not absent in the elderly, and a drug screen men have associated use of both phenytoin and gabapentin should be considered. Not well studied is the possibrain tumor, and encephalomalacia, should be performed. Thus, broad statements about these persons may not be relevant to each individual patient. Detection of interictal patterns can this group into the young-old (65 to 74 years of age), the confirm the presence of physiologically abnormal brain, middle-old or old (75 to 84 years of age), and the old-old solidifying the diagnosis of an epileptic as opposed to a (85 years of age). However, because these persons develop nonepileptic seizure; additionally, these patterns can also health issues at different times, further subdivisions, such as provide information on the severity of the epilepsy. Persons who experience periodic lateralized epileptiform also been proposed (Table 37. Thus, studies should be designed to address specific 21,551 studied persons was 83. Also seen as significantly problematic is the selection of an this distribution is similar to the data provided by the U. Of the residents in increased susceptibility to adverse effects, use of other medicathe Garrard et al. Of these epilepsy/seizure disorder as it relates to advancing age in the persons, 20,558 (1. A similar pattern Phenytoin was used as monotherapy by almost 70% of the was reported from a study in Italy (25). Levetiracetam was not available at the time of the 10,318); while the second represented a follow-up cohort (n survey.
Lorazepam generic 75mg prothiaden amex, diazepam prothiaden 75 mg online, and midazolam are the most frequently used benzodiazepines in the prehospital setting iii order prothiaden 75 mg otc. In the scenario of an acetylcholinesterase inhibitor agent exposure, the administration of diazepam or midazolam is preferable due to their more rapid onset of action iv. Benzodiazepines may be provided in multi-dose or single-dose vials, pre-filled syringes, or auto-injectors v. A commercially available kit of nerve agent/organophosphate antidote autoinjectors. A Mark I kit consists of one auto-injector containing 2 milligrams of atropine and a second auto-injector containing 600 milligrams of pralidoxime chloride. A commercially available auto-injector of nerve agent/organophosphate antidote ii. An auto-injector of nerve agent/organophosphate antidote that is typically in military supplies ii. Atropine in extremely large, and potentially multiple, doses is the antidote for an acetylcholinesterase inhibitor agent poisoning b. Atropine should be administered immediately followed by repeated doses until the patient’s secretions resolve 236 c. There is some emerging evidence that, for midazolam, the intranasal route of administration may be preferable to the intramuscular route. However, intramuscular absorption may be more clinically efficacious than the intranasal route in the presence of significant rhinorrhea f. The patient should be emergently transported to the closest appropriate medical facility as directed by direct medical oversight 3. Recommended Doses (see dosing tables below) the medication dosing tables that are provided below are based upon the severity of the clinical signs and symptoms exhibited by the patient. For organophosphate or severe acetylcholinesterase inhibitor agent exposure, the required dose of atropine necessary to dry secretions and improve the respiratory status is likely to exceed 20 mg. Atropine should be administered rapidly and repeatedly until the patient’s clinical symptoms diminish. Atropine must be given until the acetylcholinesterase inhibitor agent has been metabolized. Since the antidotes in the Mark I kit are in two separate vials, the atropine autoinjector in the kit can be administered to the patient in the event that Atro-Pen or generic atropine auto-injectors are not available and/or intravenous atropine is not an immediate option c. Due to the fact that Duodote auto-injectors contain pralidoxime chloride, they should not be used for additional dosing of atropine beyond the recommended administered dose of pralidoxime chloride d. All of the medications below can be administered intravenously in the same doses cited for the intramuscular route. However, due to the rapidity of onset of signs, symptoms, and potential death from acetylcholinesterase inhibitor agents, intramuscular administration is highly recommended to eliminate the inherent delay associated with establishing intravenous access. Clinical response to treatment is demonstrated by the drying of secretion and the easing of respiratory effort 3. Initiation of and ongoing treatment should not be based upon heart rate or pupillary response 4. Pediatrics: an overdose of pralidoxime chloride may cause profound neuromuscular weakness and subsequent respiratory depression ii. Adults: Especially for the geriatric victim, excessive doses of pralidoxime chloride may cause severe systolic and diastolic hypertension, neuromuscular weakness, headache, tachycardia, and visual impairment iii. If an auto-injector is administered, a dose calculation prior to administration is not necessary b. For atropine, additional auto-injectors should be administered until secretions diminish. Atro-Pen auto-injectors are commercially available in a 1 mg auto-injector (blue) and a 2 mg auto-injector (green). A pralidoxime chloride 600 mg auto-injector may be administered to an infant that weighs greater than 12 kg Notes/Educational Pearls Key Considerations 1. The clinical effects are caused by the inhibition of the enzyme acetylcholinesterase which allows excess acetylcholine to accumulate in the nervous system b. The excess accumulated acetylcholine causes hyperactivity in muscles, glands, and nerves 2. Revision Date September 8, 2017 243 Radiation Exposure Aliases None noted Patient Care Goals 1. Prioritize identification and treatment of immediately life-threatening medical conditions and traumatic injuries above any radiation-associated injury 2. Reduce risk for contamination of personnel while caring for patients potentially or known to be contaminated with radioactive material Patient Presentation Inclusion Criteria 1. Patients who have been acutely exposed to ionizing radiation from accidental environmental release of a radioactive source 2. Patients who have been acutely exposed to ionizing radiation from a non-accidental environmental release of a radioactive source 3. Patients who have been contaminated with material emitting ionizing radiation Exclusion Criteria 1. Patients exposed to normal doses of ionizing radiation from medical imaging studies 2. Patients exposed to normal doses of ionizing radiation from therapeutic medical procedures Patient Management Assessment 1. Identification and treatment of life-threatening injuries and medical problems takes priority over decontamination 2. Do not eat or drink any food or beverages while caring for patients with radiation injuries until screening completed for contamination and appropriate decontamination if needed 4. Provide appropriate condition-specific care for any immediately life-threatening injuries or medical problems Treatment and Interventions 1. Consider a primary medical cause or exposure to possible chemical agents unless indicators for a large whole body radiation dose (greater than 20Gy), such as rapid onset of vomiting, are present 244 b.
A difference in susceptibility in humans that is likely to buy online prothiaden be in part genetically determined is one between men and women discount generic prothiaden canada. Sex Differences Feminist opinion notwithstanding discount prothiaden 75mg with visa, it is very commonly believed that there are some differences in susceptibility to fear as between men and women. At the same time it is clear that in this regard there is much overlap between any population of women and a comparable population of men. Culture, moreover, can either magnify such potential differences as there may be, for example by sanctioning the expression of fear by members of one sex but not by those of the other, or else try to reduce them. Evidence from four sources supports the idea of a difference in susceptibility between the sexes: In the experiments with nursery-school children, carried out by Jersild & Holmes (1935a) and described in Chapter 7, -187a higher percentage of the girls were afraid than of the boys. The situations in which the difference was most marked were going into the dark passage and approaching the two animals, snake and dog. In these three situations the percentages of boys who showed fear were respectively 36, 40, and 46. In interviews of mothers of children aged six to twelve years Lapouse & Monk (1959) found that the proportion of girls reported as being afraid of strangers and animals, notably snakes, was higher than that of boys. In two other studies in which children of about the same age were interviewed, girls reported more situations as feared than did boys (Jersild, Markey & Jersild 1933; Croake 1969). In epidemiological studies of psychiatric casualties women are reported to suffer from anxiety states about twice as frequently as men (Leightonet al. A difference in the opposite direction -that females tend to show less fear than do males -seems not to have been reported. In most races of man, as in other species of groundliving primates, males are larger and stronger than females (Cole 1963). While males bear the brunt of defence against predators, as well as attacking them when necessary, females protect young and, unless prevented from doing so, are more likely to retire from dangerous situations than to grapple with them. It would be strange were such long-standing differences between the sexes in respect of body structure and social role not to be reflected in complementary differences in behavioural bias. Minimal Brain Damage In Chapter 16 of the first volume an account is given of a longitudinal study of twenty-nine pairs of boys (Ucko 1965), which shows that children who at birth are noted to be suffering from asphyxia are much more sensitive to environmental change than are matched controls. When the family went on holiday -188or changed house, boys who had suffered from asphyxia were more likely to be upset than were the controls. The same was true when a member of the family -father, mother, or sibling -was absent for a time. These differences were apparent during each of the first three years of life (though not significantly so during the third). A comparable difference was seen when some of the children started nursery school. Soon after his fifth birthday every child started infant school, making this the only event that was common to them all (though of course they went to many different schools). On a three-point scale (reduced from five points), the children distribute as shown below: Asphyxiated Controls at birth Enjoyed school from the start or at least accepted it 8 17 Mild apprehension and protest disappearing within one week 8 10 Mild apprehension or 13 2 148 Asphyxiated Controls at birth marked disturbance lasting more than a week Totals 29 29 Childhood Autism the behaviour of an autistic child shows a complete absence of attachment together with many indications of chronic fear. Tinbergen & Tinbergen (1972), adopting an ethological approach, suggest that the underlying condition may be one of chronic and pervasive fear, which cannot be allayed by contact with an attachment figure because the child also fears humans. If this is so, the syndrome could be conceived as resulting from a persistently lowered threshold to fear-arousing stimuli combined with delayed development of and/or inhibition of attachment. Causal factors might then include any of -189the following: (a) genetic factors, (b) brain damage, (c) inappropriate mothering. Clancy & McBride (1969) describe a treatment programme based on this type of theory. Blindness Nagera & Colonna (1965) report that blind children are apt to be more than usually afraid of such common fear-arousing situations as animals, mechanical noises, thunder and wind, and to live in a state of permanent alertness. A principal reason for this is probably that, being blind, they are likely to be out of contact with their attachment figure far more often than are sighted children, and thus often to be effectively alone when something frightening occurs. Their tendencies on some occasions to remain rigidly immobile and, on others, to seek very close bodily contact with an adult are in keeping with this explanation. Great difficulties arise for such children after a brief separation because a blind child cannot track his mother visually and keep close to her as a sighted child commonly does on such occasions. Fraiberg (1971) describes the very acute reaction of a blind boy of fourteen months after his mother had been absent for three days, during which he had been cared for by various friends and relations. Only when his mother held him was there any respite; and then he would crawl relentlessly all over her. Because the screaming was so distressing to mother it was suggested she give him pots and pans to bang together instead. Fraiberg describes also another blind child, a little older, who was cared for by familiar grandparents while mother had a new baby. When reunited with his mother he was markedly ambivalent at first but responded quickly when she, an affectionate mother, gave him plenty of cuddling. The main reason for the far more acute reaction in the younger child is likely to have been that his mother was a disturbed woman whose mothering was erratic both before 149 and after her absence; another factor may have been that he was cared for by several different people while she was away. In regard to a susceptibility to respond fearfully, there are certain developmental trends sufficiently buffered to environmental variation to be seen in a huge majority of individuals. For example, as related in Chapter 7, all descriptive studies agree that, whereas during the first two years of life a child is broadening the range of situations he fears -to include especially strangeness, animals, darkness, and separation -from his fifth birthday onwards, and often before, he is likely to become steadily more discriminating in what he fears and more confident and competent in dealing with situations that would formerly have frightened him. Because change towards greater discrimination and confidence represents the norm, we start by considering the nature of the experiences and processes likely to be responsible for it. Subsequently we consider experiences and processes that have an opposite effect, for example, those that interfere with the usual tendency for susceptibility to diminish, or even enhance the susceptibility, and others that have the effect of increasing the range of situations feared.
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