RELAXATION (CONTINUED)

 Tense-release

2 sessions are devoted to learning this version of progressive relaxation. The procedures are first demonstrated by the trainer and carried out by the trainee to ensure that they have been understood. A debriefing session follows. Participants are instructed to practice twice daily. They are asked to record the level of relaxation achieved using a 0-100 scale where, 0=total relaxation; 100=maximum tension; 50=normal. They are also asked to keep a note of the length of practice time taken to reach the level achieved.

Release only

In this phase of instruction, the tension part of the sequence is eliminated, leaving just the “release” part. As a result, the relaxed state can be achieved in less time than when working with the full sequence; 5-7 mins are suggested instead of the 15 of the tense-release sessions. The session is terminated like the previous one. Homework assignment is twice daily. The trainee is asked to record afterwards the level of relaxation achieved and how long it took to reach it.

Cue-controlled or conditioned relaxation

It is focused on breathing. It begins by asking the trainee to relax himself by employing the release only method of progressive relaxation. Once relaxed, he/she is asked to begin silently to recite the word “relax”, he/she recite it once each time he/she breathes only. Following many repetitions, an association is built up between capable of inducing a measure of relaxation. The word has thus become a cue; the stronger the association, the greater the power of the cue word. Expressed in other terms, a conditioning process has been set up, as a result of which the trainee feels himself relaxed whenever he thinks the word “relax”. Leading with the instructions of “inhale” and relax for 5 breaths, the trainer then asks the participants to continue on his own for a further 5 breathes after a few minutes rest, the full sequence is repeated. As the proficiency increases, the command “inhale” can be dropped and the word “relax” is used on its own. Participants must be warned against over-breathing, i.e. allowing the breathing to become deeper or more rapid.

Differential relaxation

In this stage we apply the skills previously learned. This technique focuses on controlling the levels of muscle tension while the individual is engaged in some activity. Although some tension is needed in order to carry out the task, the level is often greater than is necessary and may need to be reduced. There may be unnecessary tension in the muscles not directly engaged in the task. Since an ability to recognize muscle tension at its varying levels is essential for developing this skill, differential relaxation is presented after the individual has been trained in progressive relaxation. 2 sessions of tuition are indicated, one dealing with sitting and the other with standing activities (both sessions begin with a revision of cue-controlled relaxation).

Rapid relaxation

This component is designed to reduce still further the time it takes to become relaxed; it also gives the trainee opportunity to practice in everyday situations. The trainee’s environment is arranged so that a regularly used appliance acts as a cue to relax. For example, the wristwatch or phone is marked with colored dot which reminds the individual to relax whenever he/she sees it. Every time he/she looks at his/her watch or makes a telephone call he is reminded to release tension. Each time the dot is seen, the following is done: “take a slow breath, think relax, then exhale. Repeat this twice, scan the body for unnecessary tensions and release them.”

Application training

Applying relaxation skills to situations of potential stress is the subject of this phase. The trainee is provided with a range of opportunities in which to use the technique he has learned. Anxiety provoking situations should however be presented at a level of challenge which the trainee can cope with. As a preliminary, the individual could visualize himself successfully coping in the stress-provoking situation before exposing himself to the same event in real life.

Note- the above descriptions are only suggestions, the therapist can adopt according to the need of the patient.

RELAXATION

Relaxation is “a state of consciousness characterised by feelings of peace, and release from tension, anxiety and fear”.

The 3 aims of relaxation:

·        A preventive measure, to protect body organs from necessary wear and tear and in particular the organs involved in stress-related disease

·        A treatment, to help relieve stress in conditions such as essential hypertension, tension headache, insomnia, asthma, immune deficiency, panic and many others. Relaxation strategies may help to make the body’s innate healing mechanism more available.

·        A coping skill, to calm the mind and allow thinking to become clearer and more effective. Stress can impair people mentally, relaxation can help to restore clarity of thought. It has been found that positive information in memory becomes more accessible when a person is relaxed.

Deep relaxation:

1.   Procedures which induce an effect of large magnitude

2.   Carried out in a calm environment

3.   With the trainee lying down

4.   Examples- progressive relaxation and autogenic training.

Brief relaxation:

1.   Produces immediate effects

2.   Can be used when individual is face with stressful events

3.   The object here is the rapid release of excess tension

PROGRESSIVE RELAXATION

Edmund Jacobson, a pioneer in this field; his works lays the foundation of both the tense-release and passive approaches. Arising out of electromyography (EMG), he was able to demonstrate that thinking was related to muscle state and that mental images, particularly those associated with movement were accompanied by small but detectable levels of activity in the muscles concerned. Just as a calm mind would be reflected in a tension-free body, so Jacobson proposed a relaxation musculature would be accompanied by the quieting of thoughts and the reduction of sympathetic activity, notions that would have relevance in the treatment of anxiety and associated conditions. Muscle activity is accompanied by sensations so faint that we do not normally notice them. To promote awareness of tension, Jacobson emphasized the need to concentrate on those sensations, cultivating what he called “learned awareness”. Once tension had been recognized, it would be easier to release it.

Introducing the method- points to be included in psycho-education/ rationale for relaxation

·        resting enables body energy to be used more efficiently

·        it helps protect us from illness

·        by creating and releasing tension you will learn: to tune into subtle feelings in the muscles and to recognize different levels of tension and to release that tension

·        muscles that are unnecessarily tense reflect their tension in the mind. If that muscle tension can be released, you will feel mentally calmer.

·        Your internal organs will also benefit (pulse rate and Blood pressure will be lowered while you are relaxing)

·        It is not possible to learn it in 1 lesson; the more you practise, the more proficient you become.

APPLIED RELAXATION

The methods described previously are concerned with the induction of deep relaxation. Their purpose is to equip the individual with routines to be performed in the privacy. These methods are useful for unwinding after a stressful day, but may not however, provide strategies for coping with stress as it occurs. Goldfried (1971) recognized the extent of the gulf between relaxation in the therapeutic environment and relaxation in the stressful situation, focused expressly on the issues of the application of the skills. He emphasized the need for a portable and shortened form of progressive relaxation, a form that could use as a general coping skill in everyday life. In doing so, he gave the individual a new role, defining him as an active agent in his treatment rather than a passive client. The approach was called “training in self-control” because it implied active mastery of anxiety by the individual himself. The method consists of 6 components, in each of which a particular aspect of relaxation is taught:

1.   Tense-release technique

2.   Release only technique

3.   Cue-controlled (conditioned) relaxation

4.   Differential relaxation

5.   Rapid relaxation

6.   Application training

 

 

SYMPTOMS RELATED TO MOOD

1.      Alexithymia- inability or difficulty in describing or being aware of one’s emotions or moods. The elaboration of fantasies associated with depression, substance abuse and post traumatic stress disorder (PTSD).

2.      Anaclitic- depending on others (relating to or characterized by a strong emotional dependence on another or others). Especially seen as the infant on the mother. Anaclitic depression in children results from an absence of mothering.

3.      Anhedonia- loss of interest in, and withdrawal from all regular and pleasurable activities. Often associated with depression.

4.      Apathy- dulled emotional tone associated with detachment or in-difference. It is observed in certain types of schizophrenia and depression.

5.      Bereavement- feeling of grief or desolation, especially at the death or loss of a loved one.

6.      Blunted effect- disturbance of affect manifested by a severe reduction in the intensity of externalized feeling tone. As outlined by Eugen Bleuler, it is one of the fundamental symptoms of schizophrenia.

7.      Constricted affect- reduction in the intensity of feeling tone that is less severe than that of blunted affect.

8.      Dysphoria- feeling of unpleasantness or discomfort, a mood of general dissatisfaction and restlessness (occurs in depression and anxiety).

9.      Emotional lability- excessive emotional responsiveness characterized by unstable and rapidly changing emotions.

10.   Euphoria- exaggerated feeling of well being that is inappropriate to real events. Can occur with drugs such as opiates, amphetamines and alcohol.

11.   Euthymia- normal range of mood, implying absence of depressed or elevated mood.

12.   Exaltation- feeling of intense elation and grandeur.

13.   Excited- agitated, purposeless motor activity uninfluenced by external stimuli.

14.   Expansive mood- expression of feelings without restraint, frequently with an overestimation of their significance or importance. It is seen in mania and grandiose delusional disorder.

15.   Flat effect- absence or near absence of any signs of affective expression.

16.   Free floating anxiety- severe, pervasive, generalised anxiety that is not attached to any particular idea, object or event.

17.   Hyperpragia- excessive thinking and mental activity. Generally associated with manic episodes of bipolar 1 disorder.

18.   Hypomania- mood abnormality with the qualitative characteristics of mania, but somewhat less intense (seen in cyclothymic disorder).

MOTOR OR MOVEMENT RELATED SYMPTOMS

1.      Abulia- reduced impulse to act and to think which is associated with indifference about consequences of action. Occurs as a result of neurological deficit, depression and schizophrenia.

2.      Adiadochokinesia- inability to perform rapid alternating movements. Occurs with neurological deficit and cerebellar lesions.

3.      Adynamia- weakness and fatigability, characteristic of neurasthenia and depression.

4.      Agitation- severe anxiety associated with motor restlessness.

5.      Akathisia- subjective feeling of motor restlessness manifested by a compelling need to be in constant movement. May be seen as an extrapyramidal adverse effect of antipsychotic medication. May be mistaken for psychotic agitation.

6.      Akinesia- lack of physical movement, as in extreme immobility of catatonic schizophrenia. It can also occur as an extrapyramidal effect of antipsychotic medication.

7.      Akinetic Mutism or Coma Vigil- absence of voluntary motor movement or speech in a patient who is apparently alert (as evidenced by eye movement). It is seen in psychotic depression and catatonic states.

8.      Apraxia- inability to perform a voluntary purposeful motor activity. It cannot be explained by paralysis or other motor or sensory impairment.

9.      Constructional Apraxia- patient cannot draw a 2 or 3 dimensional form (inability to copy a drawing).

10.   Astasia Abasia- inability to stand or walk in a normal manner, even though normal leg movements can be performed in a sitting or lying down position. It is seen in conversion disorder.

11.   Ataxia- lack of coordination, physical or mental. In neurology, refers to loss of muscular co-ordination. In psychiatry, the term intra-psychic ataxia refers to lack of co-ordination between feelings and thoughts. It is seen in schizophrenia and in severe OCD.

12.   Atonia- lack of muscle tone.

13.   Bradykinesia- slowness of motor activity, with a decrease in normal spontaneous movement.

14.   Catalepsy or Waxy flexibility or Cerea Flexibilitas- condition in which person maintains the body position into which they are placed. It is observed in severe cases of catatonic schizophrenia.

15.   Cataplexy- temporary sudden loss of muscle tone, causing weakness and immobilization. It can be precipitated by a variety of emotional states and is often followed by sleep. It is commonly seen in narcolepsy.

16.   Catatonic excitement- excited, uncontrolled motor activity seen in catatonic schizophrenia. Patients in catatonic state may suddenly erupt into an excited state and may be violent.

17.   Catatonic Posturing- voluntary assumption of an inappropriate or bizarre posture, generally maintained for long periods of time (may switch unexpectedly with catatonic excitement).

18.   Catatonic rigidity- fixed and sustained motoric position that is resistant to change.

19.   Catatonic stupor- stupor in which patients ordinarily are well aware of their surroundings.

20.   Chorea- movement disorder characterized by random and involuntary quick, jerky, purposeless movements. It is seen in Huntington’s disease.

21.   Command Automatism- condition associated with catalepsy in which suggestions are followed automatically.

22.   Cycloplegia- paralysis of the muscles of accommodation in the eye. It is observed at times, as an automatic adverse effect (anti-cholinergic effect) of antipsychotic or antidepressant medication.

23.   Dyskinesia- difficulty in performing movements. It is seen in extrapyramidal disorders.

24.   Dystonia- extrapyramidal motor disturbance consisting of slow, sustained contractions of the axial or appendicular musculature. One movement often predominates, leading to relatively sustained postural deviations. Acute dystonic reactions (facial grimacing and torticollis) are occasionally seen with the invitation of antipsychotic drug therapy.

25.   Hypoactivity or hypokinesis- decreased motor and cognitive activity, as in psychomotor retardation. Visible slowing of thought, speech and movement.

26.   Mannerism- ingrained, habitual involuntary movement.

27.   Muscle rigidity- state in which the muscles remain immovable. It is seen in schizophrenia.

28.   Mydriasis- dilation of the pupil. Sometimes occurs as an autonomic (anticholinergic) or atropine like adverse effect of some antipsychotic and antidepressant drugs.

29.   Overactivity- abnormality in motor behaviour that can manifest itself as psychomotor agitation, hyperactivity (hyperkinesis), tics, sleepwalking or compulsions.

30.   Paresis- weakness or partial paralysis of organic origin.

31.   Posturing or Catatonia- strange, fixed and bizarre bodily positions held by a patient for an extended time.

32.   Psychomotor Agitation- physical and mental over activity that is usually non-productive and is associated with a feeling of inner turmoil, as seen in agitated depression.

33.   Stupor- state of decreased reactivity to stimuli and less than full awareness of one’s surroundings; as a disturbance of consciousness, it indicates a condition of partial coma or semi-coma. In psychiatry, used synonymously with mutism and does not necessarily imply a disturbance of consciousness. In catatonic stupor, patients are ordinarily aware of their surroundings.

34.   Tic disorders- predominantly psychogenic disorders characterized by involuntary, spasmodic, stereotyped movement of small groups of muscles. It is seen most predominantly in moments of stress or anxiety, rarely as a result of organic disease.

35.   Tremor- rhythmical alteration in movement, which is usually faster than one beat a second. It typically decreases during periods of relaxation and sleep and increase during periods of anger and increased tension.

36.   Ideomotor Apraxia- often called IMA, is a neurological disorder characterized by the inability to correctly imitate hand gestures and voluntarily mime tool use, e.g.- pretend to brush one’s hair.

37.   Lesh- Nyhan Syndrome- impaired kidney function, acute gouty arthritis and self mutilating behaviours such as lip and finger biting and/or head banging. Additional symptoms include involuntary muscle movements, and neurological impairment.

38.   Stereotypy- repetitive, abnormal frequent, non-goal directed movements.

39.   Grimacing- an ugly, twisted expression on a person’s face, typically expressing disgust, pain or wry amusement.

SIGNS AND SYMPTOMS RELATED TO SPEECH AND LANGUAGE

1.    Acataphasia- Disordered speech in which statements are incorrectly formulated. Patients may express themselves with words that sound like the ones intended, but not appropriate to the thoughts or they may use totally inappropriate expression.

2.    Aculalia- nonsense speech associated with marked impairment of comprehension. Occurs in mania, schizophrenia and neurological deficit.

3.    Alogia- inability to speak because of a mental deficiency or an episode of dementia.

4.    Aphasia- any disturbance in the comprehension or expression of language caused by a brain lesion.

5.    Asyndesia- disorder of language in which the patient combines unconnected ideas and images. It is commonly seen in schizophrenia.

6.    Bradylalia- abnormally slow speech. Commonly seen in depression.

7.    Circumstantiality- disturbance in the associative thought and speech processes in which a patient digresses into unnecessary details and inappropriate thoughts before communicating the central idea. It is commonly observed in schizophrenia, obsessional disturbances and certain cases of dementia.

8.    Clang association- association or speech directed by the sound of a word rather than its meaning. The words have no logical connection. Punning and rhyming may dominate the verbal behaviour. It is seen most frequently in schizophrenia and mania.

9.    Cluttering- disturbance of fluency involving an abnormally rapid rate and erratic rhythm of speech that impedes unintelligibly. The affected individual is usually unaware of the communicative impairment.

10.  Copralalia- involuntary use of vulgar or obscene language. Observed in some cases of schizophrenia and Tourette’s syndrome.

11.  Cryptolalia- a private spoken language.

12.  Cryptographia- a private written language.

13.  Dysphasia- (Reception dysphasia) -difficulty in comprehending oral language. (Expressive Dysphasia)-difficulty in trying to express verbal language.

14.  Dysprosody- loss of normal speech prosody. It is commonly seen in depression.

15.  Echolalia- psychopathological repeating of words or phrases of one person by the other, tends to be repetitive and persistent. It is seen in certain kinds of schizophrenia, particularly the catatonic types.

16.  Expressive aphasia or Broca’s Aphasia or Motor Aphasia or non-fluent aphasia- disturbance of speech in which understanding remains but ability to speak is grossly impaired, halting, laborious, inaccurate speech. People with this condition may know exactly what they want to say and understand what they hear others say, but they cannot control the actual production of their own words. Speech is halting and words are often mispronounced such as saying “cot” instead of “clock” or “non” instead of “nine”.

17.  Expressive dysphasia- difficulty in expressing verbal language, the ability to understand language in intact.

18.  Fluent aphasia or Wernicke’s aphasia or sensory aphasia or receptive aphasia- aphasia characterized by inability to understand the spoken word. Fluent but incoherent speech is present. A person with Wernicke’s aphasia would be able to speak fluently and pronounce words correctly, but the words would be the wrong one entirely. For example, “now get me some milk out of the air conditioner, woman!”

19.  Global aphasia- combination of grossly non-fluent aphasia and severe fluent aphasia.

20.  Glossolalia, it is also called “speaking in tongue”- unintelligible jargon that has meaning to the speaker but not to the listener. Commonly seen in schizophrenia.

21.  Holophrastic- using a single word to express a combination of ideas. It is seen in schizophrenia.

22.  Jargon aphasia- aphasia in which words produced are neologistic; that is nonsense words created by the patient.

23.  Metonymy- speech disturbance common in schizophrenia in which the affected persons use a word or phrase that is related to the proper one but is not the one ordinarily used. For example, the patient speaks of consuming a menu rather than a meal, or refers to losing the piece of string of the conversation, rather than the thread of the conversation.

24.  Mutism- organic or functional absence of faculty of speech.

25.  Neologism- new word or phrase whose derivation cannot be understood, often seen in schizophrenia. It has also been used to mean a word that has been incorrectly constructed but whose origins are nonetheless understandable ( e.g., head-shoe to mean hat), but such constructions are more properly referred to as word approximations)

26.  Nominal aphasia or Anomia or Amnestic aphasia- aphasia characterized by difficulty in giving the correct name of an object.

27.  Poverty of speech or Laconia speech- condition characterized by a reduction in the quality of spontaneous speech. Replies to questions are brief and unelaborated, and little or no unprompted additional information is provided. It commonly occurs in schizophrenia, major depression and organic mental disorders.

28.  Lethologica- momentary forgetting of a name or proper noun.

29.  Poverty of speech content- speech that is adequate in amount, but conveys little information because of vagueness, emptiness or stereotyped phrases.

30.  Pressured speech- increase in the amount of spontaneous speech, rapid, loud, accelerated speech, as occurs in mania, schizophrenia and cognitive disorders.

31.  Receptive aphasia- organic loss of ability to comprehend the meaning of words, fluid and spontaneous but incoherent and nonsensical speech.

32.  Receptive dysphasia- difficulty in comprehending oral language, the impairment involves comprehension and production of language.

33.  Paraphasia- abnormal speech in which one word is substituted for another, the irrelevant word generally resembling the required one in form, meaning or phonetic composition. The inappropriate word may be a legitimate one used incorrectly, such as “clover” instead of hand, or a bizarre nonsense expression such as “treen” instead of “train”.

34.  Stereotypy- continuous mechanical repetition of speech or physical activities. It is observed in catatonic schizophrenia.

35.  Stuttering- frequent repetition or prolongation of a sound or syllable, leading to markedly impaired speech fluency.

36.  Syntactical aphasia- aphasia characterized by difficulty in understanding spoken speech. Associated with gross disorder of thought and expression.

37.  Tangentiality- oblique, digressive or even irrelevant manner of speech in which the central idea is not communicated.

38.  Verbigeration or Cataphasia- meaningless and stereotyped repetition of words or phrases as seen in schizophrenia.

39.  Word salad or incoherence- incoherent, essentially incomprehensible, mixture of words and phrases commonly seen in far advanced cases of schizophrenia.

40.  Dysarthria- difficulty in articulation, the motor activity of shaping phonated sounds into speech, not in word finding or in grammar.

41.  Dyslalia- faulty articulation caused by structural abnormalities of the organs required for articulation or impaired hearing.

42.  Logorrhoea or Tachylogia or Verbomania or Volubility- copious, pressured, coherent speech, uncontrollable, excessive talking. It is observed in manic episodes of bipolar disorder.

43.  Hypergraphia- writing style that are unusual, excessive and preoccupied with selected themes.