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Chapter 3 - Part A Nervous System Conditions. Introduction Chronic Degenerative Disorders Infectious Disorders Psychiatric Disorders. Chapter 3 - Part A Nervous System Conditions: Introduction. Function:

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Chapter 3 part a nervous system conditions l.jpg
Chapter 3 - Part ANervous System Conditions

  • Introduction

  • Chronic Degenerative Disorders

  • Infectious Disorders

  • Psychiatric Disorders


Chapter 3 part a nervous system conditions introduction l.jpg
Chapter 3 - Part ANervous System Conditions: Introduction

  • Function:

    • Nerves are bundles of fibers that carry messages to and from the CNS (motor vs. sensory)

  • Structure:

    • Each neuron has a dendrite, cell body, and axon

    • Sensory neurons have long dendrites, cell bodies just outside the spine (dorsal root ganglia), short axons

    • Motor neurons have tiny dendrites, cell bodies in spinal cord; long axons to muscles or glands

    • Interneurons in spinal cord allow quick response to stimuli (reflex arc) (Fig. 3.1)


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Chapter 3 - Part ANervous System: Introduction, cont.

  • Long fibers in PNS have two layers:

    • Myelin (speeds transmission, insulates; also present in CNS)

    • Neurilemma (allows for regeneration; not present in CNS) (Fig. 3.2)

  • General neurologic problems:

    • Damage to peripheral nerves (good prognosis)

    • CNS damage (poorer prognosis, but maybe not as bleak as generally considered)

    • Psychiatric disorders


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Chronic Degenerative Disorders

  • Alzheimer’s Disease

  • Amyotrophic Lateral Sclerosis

  • Multiple Sclerosis

  • Parkinson’s Disease

  • Peripheral Neuropathy

  • Tremor


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Alzheimer’s Disease

  • Progressive degeneration of the brain, leading to memory loss, personality changes, and death

  • Incidence:

    • Affects 5% of the U.S. population (4.5 million);

    • 50% of people over 85 years old;

    • Estimated 16 million people by 2050


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Alzheimer’s Disease, cont.

  • Features:

    • Plaques: sticky deposits of beta amyloid trigger an inflammatory response

    • Neurofibrillary tangles: tau proteins degenerate, causing neurons to collapse and move out of relationship to each other

    • Low neurotransmitters: as neurons degenerate, less neurotransmitters are produced; fewer synapses are functional

    • Genetics: Some people are genetically predisposed, especially to the development of plaques


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Alzheimer’s Disease, cont.

  • Signs and symptoms (7 phases):

    1. No impairment

    2. Very mild decline (“pre Alzheimer’s”)

    3. Mild dementia (some memory and word loss)

    4. Moderate dementia (loss of some skills; social withdrawal)

    5. Moderately severe dementia (assistance is needed for complex tasks)

    6. Severe dementia (profound memory loss, personality changes, disorientation, loss of bladder/bowel control)

    7. Very severe dementia (loss of language, muscle control)


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Alzheimer’s Disease, cont.

  • Diagnosis:

    • Not definitive until death

    • Mental tests, ruling out other causes

  • Differential diagnosis:

    • Vascular dementia

    • Stroke/TIA

    • Parkinson’s

    • Other


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Alzheimer’s Disease, cont.

  • Treatment:

    • Some drugs can slow progress, if caught early

  • Massage?

    • Touch is calming influence, even in advanced stages

    • Beware of other accumulated disorders, inability to communicate verbally

    • See Figs. 3.3a, 3.3b


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Amyotrophic Lateral Sclerosis

  • Progressive destruction of motor neurons in CNS and PNS

    • Lou Gehrig’s disease

  • Incidence:

    • 4,000 to 5,000 diagnoses per year,

    • Mostly 40–70 years old

  • Three types:

    • Sporadic (most common)

    • Familial

    • Mariana Island type


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Amyotrophic Lateral Sclerosis, cont.

  • Etiology (current theories):

    • Neural tangles and plaque (like Alzheimer’s, but only on motor neurons)

    • Glutamate accumulates and kills postsynaptic neurons

    • Free radical damage (especially for familial ALS)


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Amyotrophic Lateral Sclerosis, cont.

  • Signs and symptoms:

    • Stiffness, loss of coordination, usually starts distally and progresses toward the core

    • May become painful as muscles atrophy and the skeleton collapses

    • No impact on intellect

  • Diagnosis:

    • Rule out other similar presentations; no specific test


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Amyotrophic Lateral Sclerosis, cont.

  • Treatment:

    • Palliative

    • Some drugs may limit glutamate, prolong function

  • Prognosis:

    • Death within 2–10 years from pneumonia or renal infection

    • Some survive for decades (Stephen Hawking)


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Amyotrophic Lateral Sclerosis, cont.

  • Massage?

    • This is a motor dysfunction; sensation stays intact

    • Massage may help with pain related to degeneration

    • Work with health care team


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Multiple Sclerosis

  • Inflammation, degeneration of myelin sheath in CNS

  • Incidence:

    • Most common in people who live far from the equator;

    • Whites more than other groups

    • Women more than men (2:1) in youth; more or less equal among older;

    • Approximately 350,000 people in United States have MS;

    • Approximately 9,000 diagnoses per year


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Multiple Sclerosis, cont.

  • Myelin in CNS is attacked and replaced with scar tissue

  • Electrical insulation is lost; electrical impulses short-circuit

  • Probably autoimmune

    • Flare and remission

    • Inflammation damages myelin, and ultimately the nerve tissue as well


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Multiple Sclerosis, cont.

  • Signs and symptoms:

    • Weakness

    • Spasm

    • Changes in sensation (paresthesia, reduced sensation, numbness)

    • Optic neuritis

    • Urologic dysfunction

    • Sexual dysfunction

    • Difficulty walking

    • Loss of cognitive function

    • Depression

    • Lhermitte’s sign (electrical sensation when neck is in flexion)

    • Digestive disturbance

    • Fatigue


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Multiple Sclerosis, cont.

  • Progression:

    • Relapse/remitting (flare/remission)

    • Primary progressive (steady decline in function)

    • Benign MS (1 flare only)

    • Malignant MS (rapidly progressive)


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Multiple Sclerosis, cont.

  • Diagnosis:

    • Diagnostic criteria:

      • Objective evidence of at least two episodes

      • Episodes of flare are separated by at least one month and by location of affected function

      • No other explanation for symptoms can be found

    • Differential diagnosis is a long process; can take years


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Multiple Sclerosis, cont.

  • Treatment:

    • Symptomatic

    • Steroids, immune suppressants

    • Exercise, physical therapy for maintenance

  • Massage?

    • Most appropriate when in remission

    • MS patients have poor tolerance for rapid changes in temperature; avoid heat and cold (warm and cool are better)

    • Watch for accurate sensation; be conservative in numb areas


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Parkinson’s Disease

  • “Shaking palsy”: degeneration of motor center in brain

  • Incidence:

    • 1%–2% of people over 50; men more than women (3:2); 500,000 in United States; 50,000 diagnoses/year

  • Anatomy review:

    • Basal ganglia is one motor center deep in brain

      • Basal ganglia cells need dopamine

      • Dopamine is manufactured by nearby substantia nigra (“black stuff”)


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Parkinson’s Disease, cont.

  • Etiology:

    • Substantia nigra dies off; insufficient dopamine to basal ganglia; loss of motor function

    • Causes:

      • Mostly unknown

      • Environmental exposures?

      • Pugilistic parkinsonism (repeated head trauma)

      • Premature death of substantia nigra cells


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Parkinson’s Disease, cont.

  • Signs and symptoms (Fig. 3.4):

    • Primary:

      • Nonspecific pain, fatigue

      • Resting tremor

      • Bradykinesia (difficulty initiating movement)

      • Rigidity (especially of trunk flexors, facial muscles)

      • Poor postural reflexes


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Parkinson’s Disease, cont.

  • Signs and symptoms:

    • Secondary:

      • Shuffling gait (festinating gait: loss of center of gravity)

      • Changes in speech

      • Changes in handwriting (“micrographia”)

      • Sleep disorders

      • Depression

      • Mental degeneration (unclear whether part of disease, or part of medication side effects)


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Parkinson’s Disease, cont.

  • Treatment:

    • Supplementing dopamine is problematic

      • Blood-brain barrier

      • Resistance

      • Different activity in different places in the brain

    • Deep brain stimulation

    • Surgery to alter thalamus, other structures

    • Physical, speech, occupational therapy


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Parkinson’s Disease, cont.

  • Massage?

    • May be appropriate, helpful with muscle stiffness and quality of life issues

      • Clients have trouble with tables

      • Elderly clients may have other conditions as well

      • Rigidity is safer for massage than spasticity


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Peripheral Neuropathy

  • A complication of other pathologic conditions leading to peripheral nerve damage

    • Mononeuropathy/polyneuropathy

  • Possible causes:

    • Alcoholism

    • Vitamin deficiency

    • Toxic exposure

    • HIV/AIDS

    • Lupus

    • Scleroderma

    • Rheumatoid arthritis

    • Mechanical pressure related to carpal tunnel syndrome, disc disease, thoracic outlet syndrome, etc…


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Peripheral Neuropathy, cont.

  • Signs and symptoms:

    • Usually slow onset, often in hands or feet

    • Hypersensitivity, often followed by numbness

    • Motor neuron damage can lead to specific muscle weakness

  • Treatment:

    • Depends on cause

      • Pain relievers, topical applications, TENS units, biofeedback, acupuncture, relaxation techniques, massage…


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Peripheral Neuropathy, cont.

  • Massage?

    • Depends on cause, client

      • Numbness is always a caution!

      • May exacerbate or soothe hypersensitivity


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Tremor

  • Rhythmic oscillation of antagonistic muscles in a fixed plane

  • Classes of tremor

    • Resting tremor

    • Postural tremor (occurs when holding a limb up against gravity: arm in flexion)

    • Kinetic tremor (occurs in large muscle groups for general movement)

    • Activity-specific (occurs in hands for fine-motor control)

    • Psychogenic (disappears when patient is distracted)


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Tremor, cont.

  • Further classifications:

    • Physiologic (worse with stress, fear, etc.)

    • Pathologic (idiopathic or related to underlying disorder)

  • Types of tremor:

    • Essential tremor (most common diagnosis)

      • Slowly progressive, usually appears around age 45

    • Huntington’s disease

      • Hereditary degeneration of neural tissue

    • Parkinson’s disease

      • Degeneration of substantia nigra and loss of basal ganglia

    • Others

      • More rare causes for tremor


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Tremor, cont.

  • Treatment:

    • Depends on cause; can include…

      • Dopamine precursors, Botox, beta blockers, anti-seizure medications…

      • Surgery at globus pallidus or thalamus

  • Massage?

    • Often useful, but should be diagnosed for cause

    • Work with health care team for best results


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Infectious Disorders

  • Encephalitis

  • Herpes Zoster

  • Meningitis

  • Polio, Postpolio Syndrome


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Encephalitis

  • CNS infection, usually viral

  • Used to be endemic to certain areas; now many are worldwide

  • Incidence:

    • Relatively rare, even with West Nile Virus: <5,000 infections/year


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Encephalitis, cont.

  • Etiology:

    • Usually vector-borne (mosquitoes, some ticks)

    • Viral attack on brain, sometimes spinal cord

    • Infants, elderly, immune-suppressed are most vulnerable

  • Signs and symptoms:

    • Mild to life-threatening

    • Fever, headache, irritability, stupor, coma; can cause personality and memory changes


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Encephalitis, cont.

  • Treatment:

    • “Supportive therapy”: antivirals and good care

  • Massage?

    • Fever, especially with headache, contraindicates massage

    • Clients with a history of encephalitis may be safe; get information about any permanent loss of function


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West Nile Virus

  • August, 1999: 6 people in Queens, NY go to the hospital with high fever and headache

  • In nearby boroughs, birds were dying and horses were getting sick

  • At end of season, 56 cases of WNV were confirmed among humans; 7 deaths (all people older than 68 years)

  • 2002: 4,000+ confirmed cases; 284 deaths

    • Most develop flu-like symptoms; 1:150 develop neurologic symptoms


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Herpes Zoster

  • Viral attack on sensory dendrites in skin

    • Also called “shingles”

  • Incidence: Approximately 300,000 /year

  • Etiology:

    • Causative agent is Varicella zoster (same as chicken pox)

    • Member of the herpes family; never fully expelled

    • Virus is dormant in dorsal root ganglia until a drop in immune function; then it resurfaces as shingles along the affected dermatome

      • Triggers include stress, age, immune suppression, or other infections


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Herpes Zoster, cont.

  • Signs and symptoms:

    • Painful blisters on a red base

    • Unilateral on affected dermatome

      • Trunk and buttocks are most frequent (Fig. 3.5)

      • Can affect the face through trigeminal nerve

  • Complications:

    • Secondary bacterial infection of blisters

    • Damage to trigeminal nerve: Ramsey-Hunt syndrome

    • Postherpetic neuralgia


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Herpes Zoster, cont.

  • Treatment:

    • Antiviral medication, topical anesthetics, anti-inflammatories, painkillers

  • Massage?

    • Active shingles is extremely painful!

    • Communicability is an issue if the massage therapist has no history of chicken pox or chicken pox vaccine

    • During recovery, be guided by tolerance of the client


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Meningitis

  • Inflammation of meninges (pia and arachnoid)

  • Incidence:

    • Mostly children < 5 years old;

    • About 300 deaths/year;

    • Very young, very old, and immune suppressed are most vulnerable

  • Can be bacterial or viral

    • Bacterial: Streptococcus pneumoniae or Neisseria meningitides; more severe infections with a high risk of permanent damage; responsive to antibiotics

    • Viral: many agents, including herpes simplex; lower risk of long-term damage


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Meningitis, cont.

  • Signs and symptoms:

    • High fever and chills

    • Deep red or purple rash

    • Extreme headache

    • Aversion to bright light

    • Stiff, painful neck

    • More extreme:

      • Drowsiness, slurred speech, nausea, vomiting, delirium, convulsions, coma


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Meningitis, cont.

  • Diagnosis:

    • Spinal tap (important to know the causative agent!)

  • Treatment:

    • Antibiotics for bacterial infection; supportive therapy for viral; prognosis is generally good

  • Communicability:

    • Mucous secretions (like cold or flu)

    • Not every exposed person develops symptoms (1:1000)


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Meningitis, cont.

  • Prevention:

    • Vaccine against Haemophilus influenzae (bacterial causative agent)

    • Vaccines against meningococci recommended for travelers

  • Massage?

    • Not appropriate during acute infection

    • Afterward, get information about permanent damage, if any


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Polio, Postpolio Syndrome

  • Polio: viral attack on motor neurons in spinal cord

    • Also called infantile paralysis

  • Postpolio Syndrome (PPS): progressive muscular weakness that may develop years or decades after polio infection

  • Incidence:

    • 300,000 polio survivors in the United States;

    • Approximately 25% have symptoms of PPS (overlap with arthritis and other orthopedic problems)


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Polio, Post Polio Syndrome, cont.

  • Polio etiology:

    • Virus enters through mouth, goes through GI tract and ends up in spinal cord

    • 1:100 people exposed develop symptoms

    • Practically extinct in the wild, especially in Western hemisphere

    • Affected motor neurons degenerate, leading to specific muscle weakness

      • Other motor nerves serving muscles in same groups may compensate (Fig. 3.6)

    • Usually in lumbar spine, can affect diaphragm, heart


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Polio, Post Polio Syndrome, cont.

  • Postpolio syndrome etiology:

    • Not a resurgence of original infection

    • Cumulative wear and tear leads to progressive muscle weakness later in life

  • Postpolio syndrome symptoms:

    • Sudden onset of new pattern of weakness, fatigue

    • Sleep, breathing, other difficulties

    • Cycles of degeneration and recovery


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Polio, Post Polio Syndrome, cont.

  • Treatment:

    • Motor dysfunction (not sensory): hydrotherapy and massage are safe and effective

    • Adjustments to supportive tools (crutches, braces, etc.)

    • Careful exercise to avoid over-stressing motor neurons and damaged muscles


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Polio, Post Polio Syndrome, cont.

  • Prevention:

    • Two effective vaccines

      • Need to be administered fully to avoid outbreaks of cultured virus

    • Polio survivors need to exercise carefully, emphasizing uninvolved muscles

  • Massage?

    • Because sensation is intact, massage is safe and appropriate

    • Work to improve nutrition, efficiency, function of damaged muscles


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Psychiatric Disorders

  • Attention Deficit Hyperactivity Disorder

  • Anxiety Disorders

  • Chemical Dependency

  • Depression

  • Eating Disorders


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Attention Deficit Hyperactivity Disorder

  • Neurobiochemical disorder leading to…

    • Inattentiveness

    • Hyperactivity

    • Poor impulse control

  • Incidence:

    • Estimates: 3%–5% of school-age children

    • Statistics vary widely; underdiagnosed among some groups, overdiagnosed among others

    • Boys diagnosed 3:1 over girls

      • Girls tend to manifest with withdrawal, not hyperactivity

    • Up to 4% adults have ADHD

      • Coping skills may be better developed

      • Often raising children with ADHD as well


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    Attention Deficit Hyperactivity Disorder, cont.

    • Etiology:

      • Largely unknown

      • Dopamine, noradrenaline pathways are disrupted

      • Genetic predisposition

      • Maternal exposures during pregnancy

    • Signs and symptoms:

      • Any combination of…

        • Inattentiveness

        • Hyperactivity

        • Impulsivity


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    Attention Deficit Hyperactivity Disorder, cont.

    • Diagnosis:

      • By observation in different settings

      • Determining what is ADHD vs. other problems vs. age-appropriate behavior

    • Differential diagnosis:

      • Depression, anxiety disorders, sleep disorders, learning disability, fetal alcohol syndrome, etc…

    • Coexisting conditions:

      • Oppositional defiant disorder, depression, anxiety disorders


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    Attention Deficit Hyperactivity Disorder, cont.

    • Complications:

      • People with untreated ADHD have a higher than normal risk of…

        • Poor self esteem, poor school performance, difficulty maintaining relationships and jobs…

        • Substance abuse

        • Other addictive behaviors

        • Motor vehicle accidents


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    Attention Deficit Hyperactivity Disorder, cont.

    • Treatment:

      • Psychostimulants

        • methylphenidates or dextroamphetamines

        • norepinephrine reuptake inhibitor

      • Learning coping skills along with medications

    • Massage?

      • No particular risks

      • May help to improve behavior in children

      • May have to adapt technique for client’s tolerance


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    Anxiety Disorders

    • Irrational fears, sometimes connected to behaviors that attempt to control them

    • Incidence:

      • Estimates up to 19 million people

      • Often cannot hold job, lowest socioeconomic standing

    • Basic etiology:

      • “Am I safe?” “Probably not.”


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    Anxiety Disorders, cont.

    • Stimuli are interpreted as threatening

      • Hypervigilance, sympathetic state

      • Affects limbic system (for memory), basal ganglia (movement control); frontal lobe (judgment, decision-making)

      • Neurotransmitters involved:

        • Norepinephrine, GABA, serotonin


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    Anxiety Disorders, cont.

    • Signs and symptoms: types of anxiety disorders (5 out of dozens)

      • General anxiety disorder (GAD)

        • Chronic worry, anticipation of disaster

        • 4 million people, women >men, 2:1

      • Panic disorder

        • Sudden onset of sympathetic reaction (pounding heart, dry mouth, hyperventilation, feeling of impending doom); lasts several minutes to hours

        • 2.4 million people, women >men, 2:1

        • Complicated by fear of having an episode, leading to agoraphobia

        • Treated most successfully before agoraphobia develops


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    Anxiety Disorders, cont.

    • Posttraumatic stress disorder (PTSD)

      • 5.2 million in United States, mostly men

      • AKA “shell shock”

      • Persistent, visceral memories of an ordeal—as a participant or a witness; leads to hypervigilance

      • Can spontaneously resolve, or be a lifelong issue

    • Obsessive–compulsive disorder (OCD)

      • Unwelcome thoughts (obsessions) and efforts to control them (compulsions)

      • 3.3 million people; men = women

      • Obsessions usually around contamination, sexuality, or violence

      • Compulsions include handwashing, checking locks, etc., avoiding touching people, counting, and creating symmetry


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    Anxiety Disorders, cont.

    • Phobias: social and specific:

      • Social phobia (social anxiety disorder):

        • Fear of being judged, embarrassed

        • 5.3 million people

        • Men more likely to seek treatment

      • Specific phobia:

        • Intense, irrational fear of something not inherently dangerous (closed spaces, open spaces, bridges, elevators, feathers, the number 13…)

        • 6.3 million people


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    Anxiety Disorders, cont.

    • Treatment:

      • Depends on disorder

        • Medication plus therapy

        • Antidepressants, anti-anxieties, beta blockers

    • Massage?

      • Various relaxation techniques are recommended; massage can be appropriate too

      • Client must perceive it to be safe and nurturing

        • This may mean altering the way the work is conducted


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    Chemical Dependency

    • Use, abuse, dependence (addiction)

      • Use: using a substance to change mood or physical experience

      • Abuse: use of a substance in a way that is potentially harmful to user or people close by; use interferes with normal function; user’s behavior is unacceptable to others; use continues, in spite of repeated problems it incurs

      • Dependence:progressive tolerance; physical addiction develops (withdrawal symptoms)


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    Chemical Dependency, cont.

    • Incidence:

      • 19.5 million over 12 years of age use illicit drugs/year

      • 14 million abuse alcohol

    • Etiology of chemical dependency:

      • Most stimulants slow dopamine reuptake

      • Postsynaptic neurons can become desensitized: takes more drug for same effect

    • Etiology of alcoholism:

      • Depresses CNS, but loss of inhibitions can feel like stimulant

      • Brain chemistry ultimately changes so that it cannot function well without alcohol


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    Chemical Dependency, cont.

    • Risk factors:

      • Genetic predisposition

      • Other mental illness (depression, anxiety disorders)

      • Environmental factors (peer pressure, availability)

      • Age

      • Medical history (addiction to sleeping pills, anti-anxieties, painkillers…)


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    Chemical Dependency, cont.

    • Types of addiction:

      • Psychological: Using feels good!

      • Physical: Not using feels like I’m going to die!

        • Need to avoid withdrawal symptoms

    • No delineation between legal and illegal substances: caffeine and nicotine can create the same patterns as crack

    • The higher the tolerance, the harder to break the addiction


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    Chemical Dependency, cont.

    • Signs and symptoms (4 main):

      • Persistent craving

      • Unable to voluntarily control use

      • Increasing tolerance

      • Withdrawal symptoms

      • Others:

        • Increasing time is invested in use and recovery; responsibilities are neglected; user lives in denial


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    Chemical Dependency, cont.

    • Complications (chemical dependency):

      • Vary, depending on substance

        • Paranoia, coma, convulsions, death

        • Increased spread of HIV

        • Accidents (car, boat, industrial)

        • Child abuse and neglect


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    Chemical Dependency, cont.

    • Complications (alcoholism):

      • Digestive system: gastritis, liver damage, ulcers, pancreatitis, increased risk of stomach/esophageal cancer

      • Cardiovascular system: decreased force of heartbeat, arrhythmia; cardiomyopathy; agglutination of red blood cells; (ultimately can interfere with clotting, leading to bleeding)

      • Nervous system: memory loss, slowed reflexes, organic brain syndrome

      • Immune system: suppressed activity, vulnerability to infection

      • Reproductive system: reduced sex drive, fetal alcohol syndrome

      • Others: ½ car fatalities; 40% industrial accidents; 65% adult drownings; 100,000 deaths/year


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    Chemical Dependency, cont.

    • Treatment:

      • Recognize that a problem exists

      • Detoxification (may be treated with other meds)

      • Rehabilitation

        • New coping skills

      • After-care is the most important feature

    • Massage?

      • Can be used to help with withdrawal symptoms

      • Be careful about other conditions that may exist

        • Hepatitis B, C; HIV/AIDS, cirrhosis, etc.

      • Clients who are drunk or high during a session are not good candidates for massage


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    Depression

    • Genetic predisposition + CNS chemical imbalances + triggering event leads to persistent sense of loss and hopelessness

    • Incidence:

      • Estimates of 10%–20% of the U.S. population (not all seek help):

      • 11–19 million people/year


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    Depression, cont.

    • Factors (all overlap each other):

      • Neurotransmitter imbalance

        • Serotonin, norepinephrine, dopamine; too low? Or too high, leading to resistance?

      • Hormonal imbalance

        • Estrogen, progesterone, endorphins, cortisol

      • Hypothalamus-pituitary-adrenal axis (HPA axis)

        • Stress response system between hypothalamus, pituitary, adrenal gland; high CRF levels means more stress responses

      • Atrophy in hippocampus

        • May be related to hypersecretion of cortisol


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    Depression, cont.

    • Causes:

      • Genetics

      • Environmental triggers

      • Personality traits

      • Chronic illness

      • Other

        • Hypothyroidism, chemical dependency, nutritional deficiencies, etc


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    Depression, cont.

    • Signs and symptoms (6 main ones):

      • Persistent sad or empty feeling

      • Less enjoyment from activities

      • Deep sense of guilt or disappointment with self

      • Hopelessness: things will never get better

      • Irritability

      • Change in sleeping habits

      • Others:

        • Poor concentration; weight changes; loss of energy; persistent physical pain (headaches, indigestion); suicidal thoughts or behaviors


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    Depression, cont.

    • Types of depression (5 of many)

      • Major depressive disorder

        • Severe symptoms, 2+ weeks; untreated episodes can last 6–18 months, with 4–6 in a lifetime (10 years of feeling awful!)

      • Dysthymia

        • Less severe symptoms, much longer lasting (months or years)

      • Bipolar disease

        • Aka, manic depression; cycles from mania to depression

      • Seasonal affective disorder

        • Related to lack of sunlight, melatonin

      • Postpartum depression

        • Combination of hormonal swings, unmet expectations, sleep deprivation


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    Depression, cont.

    • Treatment:

      • Antidepressants:

        • SSRIs, MAOIs, tricyclics

          • Can take weeks to take effect, side effects at the beginning

        • Lithium for bipolar

          • “smooth out” mood swings

      • Psychotherapy

      • Other therapies

        • Light therapy for SAD

        • Electroconvulsive therapy

        • St. John’s Wort


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    Depression, cont.

    • Complications:

      • 15% of major depressives successfully commit suicide

      • Correlation to other disorders:

        • Heart attack and other cardiovascular disease

    • Massage?

      • Improved efficiency of HPA axis

      • Sympathetic to parasympathetic state

        • Reduction in cortisol, improvement in serotonin

      • Changes brain activity to more balanced emotional state

      • Risks:

        • Respect medications, doctor’s role in prescribing them

        • Respect appropriate boundaries with emotionally fragile clients


    Eating disorders l.jpg
    Eating Disorders

    • Poor eating habits that ultimately can become life-threatening

      • Anorexia nervosa

      • Bulimia nervosa

      • Compulsive overeating

    • Incidence:

      • Usually girls between adolescence and college (for anorexia and bulimia);

      • Girls > boys by 10:1


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    Eating Disorders, cont.

    • Etiology of anorexia and bulimia:

      • Over-achievers, exerting power and control

      • Serotonin disturbance (?)

      • Can reach the point where it is difficult or impossible to return to healthy eating

    • Etiology of overeating:

      • Touch deprivation

      • Protection (touch abuse survivors)


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    Eating Disorders, cont.

    • Signs and symptoms:

      • Anorexia:

        • Avoid eating in public

        • Distorted self image

        • Restrictive: self-starvation

        • Purge-type: barely sufficient nutrition + behaviors to eliminate it (vomiting, laxatives, excessive exercise)

        • Lanugo


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    Eating Disorders, cont.

    • Signs and symptoms:

      • Bulimia

        • Appear to eat normally; binge in private

        • Binges triggered by stress

        • Followed by purging or exercise

      • Compulsive overeating

        • Public and private eating

        • Not compensated with purging, exercise

        • May have rapid weight gain

        • Long-term problems generally more manageable than with anorexia, bulimia


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    Eating Disorders, cont.

    • Complications:

      • Anorexia:

        • Arrhythmia, bradycardia, hypotension; infertility, osteoporosis; purging can cause colon dysfunction, esophageal damage

      • Bulimia:

        • Erosion of tooth enamel; esophageal ulcers, strictures, rupture; colon dysfunction; electrolyte imbalances

      • Compulsive overeating:

        • Cardiovascular disease, arthritis


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    Eating Disorders, cont.

    • Treatment:

      • Must focus on control issues, not eating

      • Address neurotransmitter imbalances

      • Address overlap with other psychiatric disorders

        • OCD, depression, etc.

    • Massage?

      • Can be a wonderful positive body experience

      • Watch for cardiovascular problems (arrhythmia, etc.)