By O. Marcus. Texas Tech University.
Undergraduates are often expected to produce research projects as part of their assessment order 100mg silagra with amex, and academic staﬀ and research teams carry out research to develop and test theories and to explore new areas generic silagra 50 mg fast delivery. Such research often feeds directly into practice discount 100 mg silagra with visa, with intervention programmes aiming to change the factors identiﬁed by research discount silagra 100mg on line. This book aims to provide a com- prehensive introduction to the main topics of health psychology. In addition, how these theories can be turned into practice will also be described. This book is now supported by a comprehen- sive website which includes teaching supports such as lectures and assessments. Health psychology focuses on the indirect pathway between psychology and health which emphasizes the role that beliefs and behaviours play in health and illness. The contents of the ﬁrst half of this book reﬂect this emphasis and illustrate how diﬀerent sets of beliefs relate to behaviours and how both these factors are associated with illness. Chapter 2 examines changes in the causes of death over the twentieth century and why this shift suggests an increasing role for beliefs and behaviours. The chapter then assesses theories of health beliefs and the models that have been developed to describe beliefs and predict behaviour. Chapter 3 examines beliefs individuals have about illness and Chapter 4 examines health professionals’ health beliefs in the context of doctor– patient communication. Chapters 5– 9 examine health-related behaviours and illustrate many of the theories and constructs which have been applied to speciﬁc behaviours. Chapter 5 describes theories of addictive behaviours and the factors that predict smoking and alcohol con- sumption. Chapter 6 examines theories of eating behaviour drawing upon develop- mental models, cognitive theories and the role of weight concern. Chapter 9 examines screening as a health behaviour and assesses the psychological factors that relate to whether or not someone attends for a health check and the psychological consequences of screening programmes. Health psychology also focuses on the direct pathway between psychology and health and this is the focus for the second half of the book. Chapter 10 examines research on stress in terms of its deﬁnition and measurement and Chapter 11 assesses the links between stress and illness via changes in both physiology and behaviour and the role of moderating variables. Chapter 12 focuses on pain and evaluates the psycho- logical factors in exacerbating pain perception and explores how psychological interven- tions can be used to reduce pain and encourage pain acceptance. Chapter 13 speciﬁcally examines the interrelationships between beliefs, behaviour and health using the example of placebo eﬀects. Chapter 16 explores the problems with measuring health status and the issues surrounding the measurement of quality of life. Finally, Chapter 17 examines some of the assumptions within health psychology that are described throughout the book. My thanks again go to my psychology and medical students and to my colleagues over the years for their comments and feedback. For this edition I am particularly grateful to Derek Johnston and Amanda Williams for pointing me in the right direction, to David Armstrong for conversation and cooking, to Cecilia Clementi for help with all the new references and for Harry and Ellie for being wonderful and for going to bed on time. Take advantage of the study tools oﬀered to reinforce the material you have read in the text, and to develop your knowledge of Health Psychology in a fun and eﬀective way. Study Skills Open University Press publishes guides to study, research and exam skills, to help under- graduate and postgraduate students through their university studies. Get a £2 discount oﬀ these titles by entering the promotional code app when ordering online at www. The chapter highlights differences between health psychology and the biomedical model and examines the kinds of questions asked by health psychologists. Then the possible future of health psychology in terms of both clinical health psychology and becoming a professional health psychologist is discussed. Finally, this chapter outlines the aims of the textbook and describes how the book is structured. This chapter covers: ➧ The background to health psychology ➧ What is the biomedical model? Darwin’s thesis, The Origin of Species, was published in 1856 and described the theory of evolution. This revolutionary theory identiﬁed a place for Man within Nature and suggested that we were part of nature, that we developed from nature and that we were biological beings. This was in accord with the biomedical model of medicine, which studied Man in the same way that other members of the natural world had been studied in earlier years. This model described human beings as having a biological identity in common with all other biological beings. The biomedical model of medicine can be understood in terms of its answers to the following questions: s What causes illness? According to the biomedical model of medicine, diseases either come from outside the body, invade the body and cause physical changes within the body, or originate as internal involuntary physical changes. Such diseases may be caused by several factors such as chemical imbalances, bacteria, viruses and genetic predisposition. Because illness is seen as arising from biological changes beyond their control, individuals are not seen as responsible for their illness. The biomedical model regards treatment in terms of vaccination, surgery, chemotherapy and radiotherapy, all of which aim to change the physical state of the body. Within the biomedical model, health and illness are seen as qualitatively diﬀerent – you are either healthy or ill, there is no continuum between the two. According to the biomedical model of medicine, the mind and body function independently of each other. From this perspective, the mind is incapable of inﬂuencing physical matter and the mind and body are deﬁned as separate entities. The mind is seen as abstract and relating to feelings and thoughts, and the body is seen in terms of physical matter such as skin, muscles, bones, brain and organs. Changes in the physical matter are regarded as independent of changes in state of mind. Within traditional biomedicine, illness may have psychological consequences, but not psychological causes. These developments have included the emergence of psychosomatic medicine, behavioural health, behavioural medicine and, most recently, health psychology. These diﬀerent areas of study illustrate an increasing role for psychology in health and a changing model of the relationship between the mind and body. Psychosomatic medicine The earliest challenge to the biomedical model was psychosomatic medicine. This was developed at the beginning of the twentieth century in response to Freud’s analysis of the relationship between the mind and physical illness. At the turn of the century, Freud described a condition called ‘hysterical paralysis’, whereby patients presented with paralysed limbs with no obvious physical cause and in a pattern that did not reﬂect the organization of nerves. Freud argued that this condition was an indication of the individual’s state of mind and that repressed experiences and feelings were expressed in terms of a physical problem. This explanation indicated an interaction between mind and body and suggested that psychological factors may not only be consequences of illness but may contribute to its cause. Behavioural health Behavioural health again challenged the biomedical assumptions of a separation of mind and body. Behavioural health was described as being concerned with the main- tenance of health and prevention of illness in currently healthy individuals through the use of educational inputs to change behaviour and lifestyle. The role of behaviour in determining the individual’s health status indicates an integration of the mind and body. Behavioural medicine A further discipline that challenged the biomedical model of health was behavioural medicine, which has been described by Schwartz and Weiss (1977) as being an amalgam of elements from the behavioural science disciplines (psychology, sociology, health edu- cation) and which focuses on health care, treatment and illness prevention. Behavioural medicine was also described by Pomerleau and Brady (1979) as consisting of methods derived from the experimental analysis of behaviour, such as behaviour therapy and behaviour modiﬁcation, and involved in the evaluation, treatment and prevention of physical disease or physiological dysfunction (e. Behavioural medicine therefore included psychology in the study of health and departed from traditional biomedical views of health by not only focusing on treatment, but also focusing on prevention and intervention. In addition, behavioural medicine challenged the traditional separation of the mind and the body. Health psychology Health psychology is probably the most recent development in this process of including psychology into an understanding of health. It was described by Matarazzo as the aggregate of the speciﬁc educational, scientiﬁc and professional contribution of the discipline of psychology to the promotion and maintenance of health, the promotion and treatment of illness and related dysfunction. Health psychology can be understood in terms of the same questions that were asked of the biomedical model: s What causes illness? Health psychology suggests that human beings should be seen as complex systems and that illness is caused by a multitude of factors and not by a single causal factor. Health psychology therefore attempts to move away from a simple linear model of health and claims that illness can be caused by a combination of biological (e. This approach reﬂects the biopsychosocial model of health and illness, which was developed by Engel (1977, 1980) and is illustrated in Figure 1. The biopsychosocial model represented an attempt to integrate the psychological (the ‘psycho’) and the environmental (the ‘social’) into the traditional biomedical (the ‘bio’) model of health as follows: (1) The bio contributing factors included genetics, viruses, bacteria and structural defects. Because illness is regarded as a result of a combination of factors, the individual is no longer simply seen as a passive victim. For example, the recognition of a role for behaviour in the cause of illness means that the individual may be held responsible for their health and illness. According to health psychology, the whole person should be treated, not just the physical changes that have taken place. This can take the form of behaviour change, encouraging changes in beliefs and coping strategies and compliance with medical recommendations. Because the whole person is treated, not just their physical illness, the patient is therefore in part responsible for their treatment. This may take the form of responsibility to take medication, responsibility to change beliefs and behaviour. From this perspective, health and illness are not qualitatively diﬀerent, but exist on a continuum. Rather than being either healthy or ill, individuals progress along this continuum from healthiness to illness and back again. The twentieth century has seen a challenge to the traditional separation of mind and body suggested by a dualistic model of health and illness, with an increasing focus on an interaction between the mind and the body. This shift in perspective is reﬂected in the development of a holistic or a whole person approach to health. However, although this represents a departure from the traditional medical perspective, in that these two entities are seen as inﬂuencing each other, they are still categorized as separate – the existence of two diﬀerent terms (the mind/the body) suggests a degree of separation and ‘interaction’ can only occur between distinct structures. Health psychology regards psycho- logical factors not only as possible consequences of illness but as contributing to its aetiology. Health Psychologists considers both a direct and indirect association between psychology and health. The direct pathway is reﬂected in the physiological literature and is illustrated by research exploring the impact of stress on illnesses such as coronary heart disease and cancer.
Long-term Goal Client will verbalize and demonstrate behaviors that indicate self-satisfaction with assigned gender discount 100 mg silagra with amex, ability to interact with others purchase silagra 100mg overnight delivery, and a sense of self as a worthwhile person buy 50mg silagra amex. Encourage the child to engage in activities in which he or she is likely to achieve success cheap silagra 100mg overnight delivery. Help the child to focus on aspects of his or her life for which positive feelings exist. Discourage rumination about situations that are perceived as failures or over Sexual and Gender Identity Disorders ● 217 which the client has no control. Help the client identify behaviors or aspects of life he or she would like to change. Having some control over his or her life may decrease feelings of powerlessness and increase feelings of self-worth. Offer to be available for support to the child when he or she is feeling rejected by peers. Having an available support per- son who does not judge the child’s behavior and who provides unconditional acceptance assists the child to progress toward acceptance of self as a worthwhile person. Client verbalizes self-satisfaction about accomplishments and demonstrates behaviors that reﬂect self-worth. A third category of eating disorder, binge eating disorder, is also being considered by the American Psychiatric Association. Anorexia Nervosa Deﬁned Anorexia nervosa is a clinical syndrome in which the person has a morbid fear of obesity. It is characterized by the individual’s gross distortion of body image, preoccupation with food, and refusal to eat. Reports “not being hungry,” although it is thought that the actual feelings of hunger do not cease until late in the disorder. Prepares enormous amounts of food for friends and family members but refuses to eat any of it. Amenorrhea is common, often appearing even before notice- able weight loss has occurred. May engage in the binge-and-purge syndrome from time to time (see following section on bulimia nervosa). Bulimia Nervosa Deﬁned Bulimia nervosa is an eating disorder (commonly called “the binge-and-purge syndrome”) characterized by extreme over- eating, followed by self-induced vomiting and abuse of laxatives and diuretics. The disorder occurs predominantly in females and begins in adolescence or early adult life. Binges are usually solitary and secret, and the individual may consume thousands of calories in one episode. After the binge has begun, there is often a feeling of loss of control or inability to stop eating. Following the binge, the individual engages in inappropriate compensatory measures to avoid gaining weight (e. Eating binges may be viewed as pleasurable but are followed by intense self-criticism and depressed mood. Individuals with bulimia are usually within normal weight range, some a few pounds underweight, some a few pounds overweight. Obsession with body image and appearance is a predominant feature of this disorder. Individuals with bulimia display undue concern with sexual attractiveness and how they will appear to others. Excessive vomiting may lead to problems with dehydration and electrolyte imbalance. Genetics: A hereditary predisposition to eating disorders has been hypothesized on the basis of family histories and an apparent association with other disorders for which the likelihood of genetic inﬂuences exist. Neuroendocrine Abnormalities: Some speculation has occurred regarding a primary hypothalamic dysfunction in anorexia nervosa. Studies consistent with this theory have revealed elevated cerebrospinal ﬂuid cortisol levels and a possible impairment of dopaminergic regulation in individuals with anorexia (Halmi, 2008). Neurochemical Inﬂuences: Neurochemical inﬂuences in bulimia may be associated with the neurotransmitters serotonin and norepinephrine. Some studies have found high levels of endogenous opioids in the spinal ﬂuid of cli- ents with anorexia, promoting the speculation that these chemicals may contribute to denial of hunger (Sadock & Sadock, 2007). Some of these individuals have been shown to gain weight when given naloxone, an opioid antagonist. Psychodynamic Theory: The psychodynamic theory sug- gests that behaviors associated with eating disorders reﬂect a developmental arrest in the very early years of childhood caused by disturbances in mother-infant interactions. The tasks of trust, autonomy, and separation-individuation go unfulﬁlled, and the individual remains in the depen- dent position. The problem is compounded when the mother responds to the child’s physical and emotional needs with food. Manifestations include a disturbance in body identity and a distortion in body image. When events occur that threaten the vulner- able ego, feelings emerge of lack of control over one’s body (self). Behaviors associated with food and eating provide feelings of control over one’s life. Family Dynamics: This theory proposes that the issue of control becomes the overriding factor in the family of the individual with an eating disorder. These families often consist of a passive father, a domineering mother, and an overly dependent child. A high value is placed on perfec- tionism in this family, and the child feels he or she must satisfy these standards. Parental criticism promotes an increase in obsessive and perfectionistic behavior on the Eating Disorders ● 221 part of the child, who continues to seek love, approval, and recognition. In adolescence, these distorted eating patterns may represent a rebellion against the parents, viewed by the child as a means of gaining and remaining in control. The symptoms are often triggered by a stressor that the adolescent perceives as a loss of con- trol in some aspect of his or her life. These guidelines, which were released by the National Heart, Lung, and Blood Institute in July 1998, markedly increased the number of Americans considered to be overweight. Obesity is known to contribute to a number of health prob- lems, including hyperlipidemia, diabetes mellitus, osteoarthritis, and increased workload on the heart and lungs. Genetics: Genetics have been implicated in the develop- ment of obesity in that 80% of offspring of two obese parents are obese (Halmi, 2008). This hypothesis has also been supported by studies of twins reared by normal and overweight parents. Physical Factors: Overeating and/or obesity has also been associated with lesions in the appetite and satiety centers of the hypothalamus, hypothyroidism, decreased insulin production in diabetes mellitus, and increased cortisone production in Cushing’s disease. Lifestyle Factors: On a more basic level, obesity can be viewed as the ingestion of a greater number of calories than are expended. Weight gain occurs when caloric in- take exceeds caloric output in terms of basal metabolism and physical activity. Psychoanalytical Theory: This theory suggests that obe- sity is the result of unresolved dependency needs, with the individual being ﬁxed in the oral stage of psychosex- ual development. The symptoms of obesity are viewed as depressive equivalents, attempts to regain “lost” or frus- trated nurturance and care. Common Nursing Diagnoses and Interventions for Anorexia and Bulimia (Interventions are applicable to various health-care settings, such as inpatient and partial hospitalization, community outpatient clinic, home health, and private practice. Possible Etiologies (“related to”) [Refusal to eat] [Ingestion of large amounts of food, followed by self-induced vomiting] [Abuse of laxatives, diuretics, and/or diet pills] [Physical exertion in excess of energy produced through caloric intake] Deﬁning Characteristics (“evidenced by”) [Loss of 15% of expected body weight (anorexia nervosa)] Pale mucous membranes Poor muscle tone Excessive loss of hair [or increased growth of hair on body (lanugo)] [Amenorrhea] [Poor skin turgor] [Electrolyte imbalances] [Hypothermia] [Bradycardia] [Hypotension] [Cardiac irregularities] [Edema] Eating Disorders ● 223 Goals/Objectives Short-term Goal Client will gain lbs per week (amount to be established by client, nurse, and dietitian). Long-term Goal By discharge from treatment, client will exhibit no signs or symptoms of malnutrition. If client is unable or unwilling to maintain adequate oral in- take, physician may order a liquid diet to be administered via nasogastric tube. Nursing care of the individual receiving tube feedings should be administered according to established hospital procedures. The client’s physical safety is a nursing priority, and without adequate nutrition, a life-threatening situation exists. In collaboration with dietitian, determine number of cal- ories required to provide adequate nutrition and realistic (according to body structure and height) weight gain. Explain to client details of behavior modiﬁcation program as outlined by physician. Explain beneﬁts of compliance with prandial routine and consequences for noncompliance. Behavior modiﬁcation bases privileges granted or restricted directly on weight gain and loss. Without a time limit, meals can become lengthy, drawn-out sessions, providing client with attention based on food and eating. This time may be used by client to discard food stashed from tray or to engage in self-induced vomiting. Client may need to be accompanied to bathroom if self- induced vomiting is suspected. Client care, privileges, and restrictions will be based on accurate daily weights. Do, however, offer support and positive reinforcement for obvious improvements in eating behav- iors. Client must understand that if, because of poor oral intake, nutritional status does not improve, tube feedings will be ini- tiated to ensure client’s safety. Staff must be consistent and ﬁrm with this action, using a matter-of-fact, nonpunitive ap- proach regarding the tube insertion and subsequent feedings. As nutritional status improves and eating habits are estab- lished, begin to explore with client the feelings associated with his or her extreme fear of gaining weight. Vital signs, blood pressure, and laboratory serum studies are within normal limits. Possible Etiologies (“related to”) [Decreased ﬂuid intake] [Abnormal ﬂuid loss caused by self-induced vomiting] [Excessive use of laxatives or enemas] [Excessive use of diuretics] [Electrolyte or acid-base imbalance brought about by malnour- ished condition or self-induced vomiting] Deﬁning Characteristics (“evidenced by”) Decreased urine output [Output greater than intake] Increased urine concentration Elevated hematocrit Decreased blood pressure Increased pulse rate Increased body temperature Eating Disorders ● 225 Dry skin Decreased skin turgor Weakness Change in mental state Dry mucous membranes Goals/Objectives Short-term Goal Client will drink 125 mL of ﬂuid each hour during waking hours. Long-term Goal By discharge from treatment, client will exhibit no signs or symptoms of dehydration (as evidenced by quantity of urinary output sufﬁcient to individual client; normal speciﬁc gravity; vital signs within normal limits; moist, pink mucous membranes; good skin turgor; and immediate capillary reﬁll). Client should be observed for at least 1 hour following meals and may need to be accompanied to the bathroom if self- induced vomiting is suspected. Encourage frequent oral care to moisten mucous membranes, reducing discomfort from dry mouth, and to decrease bacte- rial count, minimizing risk of tissue infection. Help client identify true feelings and fears that contribute to maladaptive eating behaviors. Client’s vital signs, blood pressure, and laboratory serum studies are within normal limits. No abnormalities of skin turgor and dryness of skin and oral mucous membranes are evident. Client verbalizes knowledge regarding consequences of ﬂuid loss due to self-induced vomiting and importance of adequate ﬂuid intake.
On the other hand buy 100 mg silagra with mastercard, if you religiously take your dogs on a leisurely walk every morning for 45 minutes cheap silagra 50mg without a prescription, that probably won’t do the trick — you need to pick up your pace because anything done leisurely just doesn’t cut it discount silagra 100mg mastercard. Therefore discount silagra 100 mg with amex, an exercise program that works for one person may not work for another. The following instructions and checklist in Worksheet 10-3 are designed to help you choose exercise that will work into your life. Read through Worksheet 10-3, checking off all the exercise ideas that could conceiv- ably become part of your routine. Include comments on how you think you can work these activities into your daily life. Chapter 10: Lifting Mood Through Exercise 153 Worksheet 10-3 Exercise Checklist ❑ Get up 15 minutes early each day and take a brisk walk — take the dogs if you have any! And hopefully you’ve found a few types of exercise that just may ﬁt into your life and have tried them out. Your intentions may be good, but what happens when your ini- tial enthusiasm and commitment to do something positive for yourself fade? Fighting de-motivating thoughts The problem with ﬁnding and maintaining motivation to exercise lies in distorted, de-motivating thinking (see Chapters 5, 6, and 7 for more on distorted thinking). De-motivating thinking keeps you from taking action and puts you in a defeatist frame of mind, where you’re doomed to fail. The following example gives you an idea of how you can give de-motivating thoughts the one-two punch. She rushes off every morning to drop her kids at day care and tries to ﬁt in her errands during a 45-minute lunch break. When her doctor suggests she begin exercising to improve her mood and health, Janine laughs and says, “You’ve got to be kidding; I don’t have an extra second in my day. Worksheet 10-5 shows what she comes up with, and Worksheet 10-6 has her reﬂections on the exercise. For example, rather than saying, “You’re the best person in the whole world,” consider narrowing it down and saying, “I love the way you play with the baby. For example, you may make a note in your calendar or put sticky notes in various places around the house. Get into the habit of handing out genuine compliments to everyone, not just your partner. Doing so will improve your popularity by making people notice you, and it may even get you a raise! Some people dismiss compliments by saying, “Oh, you don’t mean that,” or “That isn’t really true. People dismiss compliments not because they don’t want to hear them but because they have trouble accepting them. After you spend a couple of weeks increasing the compliments you give your partner, reﬂect on any changes in your relationship (see Worksheet 15-5). Self-Blame Reality Scramblers relationships, and effects of, 207–208 body signals. Hachette Livre’s policy is to use papers that are natural, renewable and recyclable products and made from wood grown in sustainable forests. The logging and manufacturing processes are expected to conform to the environmental regulations of the country of origin. Whilst the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. In particular, (but without limiting the generality of the preceding disclaimer) every effort has been made to check drug dosages; however it is still possible that errors have been missed. Furthermore, dosage schedules are constantly being revised and new side-effects recognized. For these reasons the reader is strongly urged to consult the drug companies’ printed instructions before administering any of the drugs recommended in this book. He considered a text in clinical pharmacology suitable for his undergraduate and postgradu- ate students to be an important part of the programme he developed in his department at Guy’s Hospital Medical School, London. In other words, he helped to change a ‘non-subject’ into one of the most important areas of study for medical students. He was also aware of the need for a high quality textbook in clinical pharmacology that could also be used by nurses, phar- macists, pharmacology science students and doctors preparing for higher qualifications. It is interesting to follow in all the editions of the book, for example, how the treatment of tumours has progressed. It was about the time of the first edition that Trounce set up the first oncology clinic at Guy’s Hospital in which he investigated the value of combined radiation and chemotherapy and drug cocktails in the treatment of lymphomas. John Trounce was pleased to see his textbook (and his subject) in the expert hands of Professor Ritter and his colleagues. Clinicians of all specialties pre- scribe drugs on a daily basis, and this is both one of the most useful but also one of the most dangerous activities of our professional lives. Understanding the principles of clinical pharma- cology is the basis of safe and effective therapeutic practice, which is why this subject forms an increasingly important part of the medical curriculum. This textbook is addressed primarily to medical students and junior doctors of all special- ties, but also to other professionals who increasingly prescribe medicines (including pharma- cists, nurses and some other allied professionals). Clinical pharmacology is a fast moving subject and the present edition has been completely revised and updated. It differs from the fourth edition in that it concentrates exclusively on aspects that students should know and understand, rather than including a lot of reference material. Another feature has been to include many new illustrations to aid in grasping mechanisms and principles. The first section deals with general principles including pharmacodynamics, pharmaco- kinetics and the various factors that modify drug disposition and drug interaction. Drug metabolism is approached from a practical viewpoint, with discussion of the exciting new concept of personalized medicine. Adverse drug reactions and the use of drugs at the extremes of age and in pregnancy are covered, and the introduction of new drugs is discussed from the viewpoint of students who will see many new treatments introduced during their professional careers. Many patients use herbal or other alternative medicines and there is a new chapter on this important topic. There is a chap- ter on gene and cell-based therapies, which are just beginning to enter clinical practice. The remaining sections of the book deal comprehensively with major systems (nervous, musculo- skeletal, cardiovascular, respiratory, alimentary, renal, endocrine, blood, skin and eye) and with multi-system issues including treatment of infections, malignancies, immune disease, addiction and poisoning. Their expertise in many specialist areas has enabled us to emphasize those factors most relevant. For their input into this edition and/or the previ- ous edition we are, in particular, grateful to Professor Roy Spector, Professor Alan Richens, Dr Anne Dornhorst, Dr Michael Isaac, Dr Terry Gibson, Dr Paul Glue, Dr Mark Kinirons, Dr Jonathan Barker, Dr Patricia McElhatton, Dr Robin Stott, Mr David Calver, Dr Jas Gill, Dr Bev Holt, Dr Zahid Khan, Dr Beverley Hunt, Dr Piotr Bajorek, Miss Susanna Gilmour- White, Dr Mark Edwards, Dr Michael Marsh, Mrs Joanna Tempowski. We would also like to thank Dr Peter Lloyd and Dr John Beadle for their assistance with figures. Similar People consult a doctor to find out what (if anything) is wrong considerations apply in other disease areas. If they are well, they may nevertheless want to know judgements based on risk/benefit ratio permeate all fields of how future problems can be prevented. Drugs are the physician’s prime therapeutic tools, nosis, treatment may consist of reassurance, surgery or other and just as a misplaced scalpel can spell disaster, so can a interventions. Sometimes contact with the ical defence societies, but perhaps as important is the morbid- doctor is initiated because of a public health measure (e. Consequently, doctors of nearly all special- How are prescribing errors to be minimized? By combining ties use drugs extensively, and need to understand the scien- a general knowledge of the pathogenesis of the disease to be tific basis on which therapeutic use is founded. Thousands of potent drugs have since been induced injury, list eight basic duties of prescribers: introduced, and pharmaceutical chemists continue to discover new and better drugs. Medical students with due regard to the likely risk/benefit ratio, available and doctors in training therefore need to learn something alternatives, and the patient’s needs, susceptibilities and of the principles of therapeutics, in order to prepare them- preferences; selves to adapt to such change. Such formularies have the questioning the patient (and sometimes family, neighbours, advantage of encouraging consistency, and once a decision other physicians, etc. What prescription tablets, medicines, has been made with input from local consultant prescribers drops, contraceptives, creams, suppositories or pessaries are they are usually well accepted. What over-the-counter remedies are being used including herbal or ‘alternative’ therapies? Has the patient experienced any problems with anaes- The scientific basis of drug action is provided by the discipline thesia? It entails the study of the interaction of The prescriber must be both meticulous and humble, espe- drugs with their receptors, the transduction (second messen- cially when dealing with an unfamiliar drug. Checking ger) systems to which these are linked and the changes that contraindications, special precautions and doses in a formu- they bring about in cells, organs and the whole organism. The use of drugs in society is encom- Great Britain 2007) is the minimum requirement. The proposed passed by pharmacoepidemiology and pharmacoeconomics – plan is discussed with the patient, including alternatives, both highly politicized disciplines! Modern methods of molecu- intended and be happy with the means proposed to achieve lar and cell biology permit expression of human genes, includ- these ends. Much of the ‘art’ of medicine lies in the ability of preclinical pharmacology and toxicology. Generic Basic pharmacologists often use isolated preparations, names should generally be used (exceptions are mentioned where the concentration of drug in the organ bath is controlled later in the book), together with dose, frequency and duration precisely. Such preparations may be stable for minutes to of treatment, and paper prescriptions signed. In therapeutics, drugs are administered to the whole print the prescriber’s name, address and telephone number to organism by a route that is as convenient and safe as possible facilitate communication from the pharmacist should a query (usually by mouth), for days if not years. The processes of absorption, distribution, metabolism and elim- Historically, formularies listed the components of mixtures ination (what the body does to the drug) determine the drug prescribed until around 1950. The perceived need for hospital concentration–time relationships in plasma and at the recep- formularies disappeared transiently when such mixtures tors. Pharmacokinetic modelling is crucial in drug development to plan a rational therapeutic A general practitioner reviews the medication of an 86-year-old woman with hypertension and multi-infarct regime, and understanding pharmacokinetics is also import- dementia, who is living in a nursing home. Her family used ant for prescribers individualizing therapy for a particular to visit daily, but she no longer recognizes them, and needs patient. Pharmacokinetic principles are described in Chapter 3 help with dressing, washing and feeding. Genetic influences on bendroflumethiazide, atenolol, atorvastatin, aspirin, haloperi- pharmacodynamics and pharmacokinetics (pharmacogenet- dol, imipramine, lactulose and senna. On examination, she smells of urine and has several bruises on her head, but ics) are discussed in Chapter 14 and effects of disease are otherwise seems well cared for. She is calm, but looks pale addressed in Chapter 7, and the use of drugs in pregnancy and bewildered, and has a pulse of 48 beats/min regular, and at extremes of age is discussed in Chapters 9–11. The only way to ensure that a drug with promising Her rectum is loaded with hard stool.