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By F. Faesul. Southwestern University. 2019.

To be certain your generator is set correctly it would be best to observe the output on an oscilloscope discount sildenafil 50 mg with visa. Discussion: Persons using a Syncrometer might have already tried putting a small insect on one of the plates discount sildenafil 100mg amex. Even the tiniest ant placed in a glass bottle or plastic baggy will resonate the circuit buy discount sildenafil 25mg online. Obviously the living thing is affecting the circuit differently before and after death. To find its frequency you must add another frequency that will reinforce or interfere with the frequency already on the plate. Start testing well above the suspected range taking big steps downward until you reach a resonant frequency. Method: Find the broadcast range of each one separately and then together on the plate. Lesson Twenty Two Purpose: To see if different living things interfere with each other when put on the plate together. Method: Find the lower and upper end of the broadcast range of two different living things, such as a fly and a beetle or 2 kinds of flies or beetles. Choose more primitive life forms which have lower frequency bandwidths to stay within your limit. Method: You do not need to put yourself on the plate, since you are already there by being in the circuit at the handhold. However, if you are measuring someone else, they can simply touch the plate with a finger. Younger or healthier humans start emitting at a lower fre- quency and sometimes end at a higher frequency. I hope this challenges you to accomplish a health improvement reflected in an even broader bandwidth for yourself. Lesson Twenty Four Purpose: To find the effect of a variety of things on the lower end of your spectrum, such as body temperature, eating, time of day, rainy weather, feeling sick. Notice that you may not change for weeks at a time, then suddenly see a shrinking of your bandwidth. If this is positive go on a mold free diet—watching carefully for mold in your white blood cells. Even after removing the mold from your diet, so that no molds appear in your white blood cells, notice that your bandwidth does not recover. Method: Search for the bottom of the resonant frequency band as in the previous lesson. Note the bandwidth also depends on the accuracy of your particular frequency generator. This lets you determine whether the next illness is new or a recurrence of this one. Any that are back must have come from an internal source not reached by the zapper current, like from the bowel or an abscess. Lesson Twenty Eight Purpose: To observe the action of a positive offset frequency on a very small animal. Method: Place the small animal in a plastic container like a cottage cheese carton. Place them inside the milk glass or cottage cheese carton, across from each other. They should be gone (but the food is not safe to eat due to the metal released from the teaspoons). Per- haps water supplies as well as foods and medicines could be sterilized this way. If you do decide to explore this possibility, remember not to put metals in your mouth or food. Experiment with new combinations to create different flavorful fruit and vegetable juices. Consider the luxury of preparing gourmet juices which satisfy your own individual palate instead of the mass-produced, polluted varieties sold at grocery stores. All honey and maple syrup should have vitamin C added to it as soon as it arrives from the supermarket. Fresh Tomato Juice Simmer for ½ hour: 12 medium-sized raw, ripe tomatoes, ½ cup water, 1 slice onion, 2 ribs celery with leaves, ½ bay leaf, 3 sprigs parsley. Mix the pulp with an equal amount of clover honey and use as topping (kept in freezer) for homemade ice cream (below), pancakes, or yogurt. Maple Milk Shake For each milk shake, blend or shake together: 1 glass of milk and 2 tablespoons maple syrup. C-Milk Milk can absorb a surprising amount of vitamin C powder without curdling or changing its flavor. Many variations are possible: other fruit concentrates, made in the blender, can be used along with some lemon juice; for example, 2 blended whole apples (peeled), blended pineapple, orange or grapefruit. If you have heart disease, high blood pressure, or edema, use potassium bicarbonate instead. Ask your doctor what an ac- ceptable amount of sodium or potassium bicarbonate is. I would suggest limiting yourself to one glass of soda pop a day, even if you do not have heart disease. Another Note: the citric acid kills bacteria, while the car- bonation brings relief. Squeeze 1 slice of lemon and 1 whole orange into an 8 ounce bottle that has a tight lid. Food Recipes Despite the presence of aflatoxins, benzopyrenes, and sol- vents in many foods, it is possible to have a delicious and safe diet. Help yourself to lots of butter, whipping cream, whole milk, avocados, and olive oil. Remember, when you are recovering from a major illness it is essential not to diet to lose weight. Change brands every time you shop to prevent the same pollutants from building up in your body. Be sure to drink plenty of plain water from your cold faucet throughout the day, especially if it is difficult for you to drink it with your meals. Never drink water that has been run through a water softener or copper plumbing or has traveled through a long plastic hose. To further improve flavor and to dechlorinate attach a small faucet filter made of carbon only. Because commercial cold cereals are very convenient, but have solvents, here are two replacements. If you would like to add nuts to your granola recipes, rinse them in cold tap water first, to which vitamin C powder has been added (¼ tsp. This will probably be the most heavenly peanut butter your mouth has ever experienced.

A person can forget to take a tablet buy sildenafil 100mg lowest price, but drug delivery from an implant is largely independent of patient input trusted 100 mg sildenafil. Some implantable systems involve periodical refilling cheap sildenafil 25mg overnight delivery, but despite this factor the patient has less involvement in delivering the required medication. This bypassing effect is particularly of benefit to drugs which are either absorbed poorly or easily inactivated in the gastrointestinal tract and/or the liver before systemic distribution. From a regulatory perspective, it is regarded as a new drug product and can extend the market protection of the drug for an additional 5 years (for a new drug entity) or 3 years (for existing drugs). This requires the appropriate surgical personnel, and may be traumatic, time-consuming, cause some scar formation at the site of implantation and, in a very small portion of patients, may result in surgery- related complications. Although a biodegradable polymeric implant does not require surgical retrieval, its continuing biodegradation makes it difficult to terminate drug delivery, or to maintain the correct dose at the end of its lifetime. Therefore, most systems have a limited loading capacity, so that often only quite potent drugs, such as hormones, may be suitable for delivery by implantable devices. If a new biomaterial is proposed to fabricate an implant, its safety and biocompatibility must be thoroughly evaluated to secure the approval of regulatory authorities. These issues can attribute to significant delay in the development, marketing and cost of a new implant. Adverse effects may be caused by: • The intact polymer: this may be due to the chemical reactivity of end or side groups in a polymer, organometallics used as polymerization initiators, or extractable polymeric fragments. In the case of a bioerodible poly(vinylpyrrolidone), the accumulation of the dissolved polymer in the liver raises a longterm toxicity issue. If the surface of an implant has an affinity towards specific chemicals, an abnormal boundary layer will develop. The subsequent intra-layer rearrangement or reactions with other species then trigger tissue reactions. The defence reactions of the host tissue often lead to encapsulation of an 77 implant by layers of fibrous tissues. Since the encapsulation frequently impedes drug release, in vitro drug release data may not permit the prediction of in vivo drug release patterns. High local drug concentrations at the site of implantation over extended periods of time can also cause severe local irritation or adverse tissue reactions. The performance and response of the host toward an implanted material is indicated in terms of biocompatibility. Major initial evaluation tests used to assess the biocompatibility of an implant are listed in Table 4. These tests include: • observation of the implant/tissue interactions at the site of implantation; Table 4. The choice of whether to select a reservoir-type, or a matrix-type, implantable system depends on a number of factors, including: • the drug’s physicochemical properties; • the desired drug release rate; • desired delivery duration; • availability of a manufacturing facility. For example, it is generally easier to fabricate a matrix-type implant than a reservoir system, so this may determine the selection of a matrix system. However, if drug release is the overriding concern, a reservoir system may be chosen in preference to a matrix system. This is because reservoir systems can provide zero- order controlled release, whereas drug release generally decreases with time if a matrix system is used. They vary in molecular weight, filler content, R and R, and1 2 1 2 the type of reactive silicone ligands for cross-linking. Variations in these parameters permit the synthesis of a wide range of material types such as fluids, foams, soft and solid elastomers (Figure 4. These copolymers have the advantages of: • Ease of fabrication: the copolymers are thermoplastic in nature, thus an implantable device is easily fabricated by extrusion, film casting or injection molding. As the ethylene domain is crystalline, an increase in the content of ethylene unit affects the crystallinity and the solubility parameter of the copolymer. Other polymeric materials commonly used as non-porous, rate-controlling membranes are given in Table 4. The penetration of a solvent, usually water, into a polymeric implant initiates drug release via a diffusion process. Diffusion of drug molecules through non-porous polymer membranes depends on the size of the drug molecules and the spaces available between the polymeric chains. Even through the space between the polymer chains may be smaller than the size of the drug molecules, drug can still diffuse through the polymer chains due to the continuous movement of polymer chains by Brownian motion. For transport through the membrane, there are three barriers to be circumvented (Figure 4. The drug molecules in the reservoir compartment initially partition into the membrane, then diffuse through it, and finally partition into the implantation site. C −C where Cr and C denote the drug concentrations in the reservoirr i i and at the site of implantation respectively. The release rate of a drug from different polymeric membranes can be compared from the corresponding P values. This is the familiar form1 of a first-order rate equation and indicates that the rate of diffusion is proportional to drug concentration. However, in this system, the drug reservoir consists of either: • solid drug particles, or • a suspension of solid drug particles in a dispersion medium so that the concentration of drug (C ) in the system always remainsr constant, so that Equation 4. Thus the release rate of a drug from this type of implantable device is constant during the entire time that the implant remains in the body. Microporous membranes can be prepared by making hydrophobic polymer membranes in the presence of water-soluble materials such as poly(ethylene glycol), which can be subsequently removed from the polymer matrix by dissolving in aqueous solution. Cellulose esters, loosely cross-linked hydrogels and other polymers given in Table 4. In microporous reservoir systems, drug molecules are released by diffusion through the micropores, which are usually filled with either water or oil (e. Solvent-loading of a porous membrane device is achieved simply by immersing the device in the solvent. When this technique presents some difficulty, the implantable device is placed inside a pressure vessel and pressure is then applied to facilitate the filling of the solvent into pores. The selection of a solvent is obviously of paramount importance, since it affects drug permeability and solubility. In this system, the pathway of drug transport is no longer straight, but tortuous. The porosity ε of the membrane and the tortuosity τ of the pathway must therefore also be considered. As for the non-porous reservoir device, in the microporous system, both: • the surface area of the membrane and • the drug concentration in the reservoir compartment remain unchanged, thus “M t” kinetics is again demonstrated and zero-order controlled release is attained (Figure 4. The capsules are surgically implanted subdermally, in a fan-like pattern, in the mid- portion of the upper arm. The implant releases levonorgestrel continuously at the rate of 30 µg/day (the same daily dose provided by the oral uptake of the progestin-only minipill) over a 5-year period. After the capsules are removed, patients are promptly returned to normal fertility. The implant is surgically placed in the vitreous cavity of the eye and delivers therapeutic levels of ganciclovir for up to 32 weeks.

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Rectal prolapse must be distin- guished from hemorrhoids because it is safe to band a hemorrhoid but not a prolapsed rectum order discount sildenafil. Hemorrhoidal tissues are part of the normal anatomy of the distal rectum and anal canal cheap sildenafil 100 mg mastercard. The disease state of “hemorrhoids” exists when the internal complex becomes chronically engorged or the tissue pro- lapses into the anal canal as the result of laxity of the surrounding con- nective tissue and dilatation of the veins trusted 50mg sildenafil. External hemorrhoids may thrombose, leading to acute onset of severe perianal pain. Internal hemorrhoids may have two main pathophysiologic mecha- nisms seen in two distinct but not exclusive groups: older women and younger men. Internal hemorrhoids originate above the dentate line and are lined with insensate rectal columnar and transitional mucosa. In older women, the pathophysiologic mechanism may be related to earlier pregnancy or chronic straining, which leads to vascular engorgement and dilatation, resulting in stretching and disruption of the supporting connective tissue surrounding the vascular channels. Another suggested pathologic mechanism, and the one that may be more important in younger men, is that of increased resting pressures within the anal canal, leading to decreased venous return. Internal hemorrhoids typically do not cause pain but rather bright-red bleed- ing per rectum, mucous discharge, and a sense of rectal fullness or discomfort. External hemorrhoids may develop an acute intravascular thrombus, which is associated with acute onset of extreme perianal pain. Perianal Complaints 475 Grade 1 Rubber banding Internal Repeat as Infrared coagulation Failed needed Determine Grade 2 Sclerotherapy severity Diet changes Failed Initial assessment • History Grade 3 Consider nonsurgical • Exam therapy Failed Surgery • Classification Grade 4 Surgery Thrombectomy, if thrombosed External Improve hygiene Failed Surgery Topical agents Special circumstances • Pregnancy • Inflammatory bowel disease Algorithm 26. Repeated episodes of dilatation and thrombosis may lead to enlargement of the overlying skin, which is seen as a skin tag on physical exam. As in Case 2, the acutely throm- bosed external hemorrhoid is seen as a purplish, edematous, tense sub- cutaneous perianal mass that is quite tender. The complications of internal or external hemorrhoids are the indi- cations for medical or surgical intervention: bleeding, pain, necrosis, mucous discharge, moisture, and, rarely, perianal sepsis. Internal hemorrhoids that fail to respond to medical management may be treated with elastic band ligation, scle- rosis, photocoagulation, cryosurgery, excisional hemorrhoidectomy, and many other local techniques that induce scarring and fixation of the hemorrhoids to the underlying tissues. The acutely thrombosed external hemorrhoid may be treated with excision of the hemorrhoid or clot evacuation if the patient presents within 48 hours of onset of symptoms. If the patient presents more than 48 hours after onset of symptoms, conservation management with warm sitz baths, high-fiber diet, stool softeners, and reassurance is advised. Pilonidal Disease Patients with pilonidal disease may present with small midline pits or an abscess(es) off the midline near the coccyx or sacrum. The workup is limited to a physical exam unless one suspects Crohn’s disease; then 476 S. The differential diag- nosis includes abscess/fistulous disease of the anus, hidradenitis sup- purativa, furuncle, and actinomycosis. For those who fail to heal after 3 months or develop a chronic draining sinus, definitive therapy is recommended. The preferred method is to excise the pilonidal disease and primarily close the defect with rota- tional flaps over closed suction drainage. Neoplasms Historically, the anal canal has been defined as the region above the dentate line, and the anal margin has been defined as the area below the dentate line. Squamous cell tumors of the anal margin are well dif- ferentiated, keratinizing tumors that behave similarly to squamous cell tumors of the skin elsewhere. Tumors of the anal canal are aggressive, high-grade tumors with significant risk for metastasis. Tumors of the Anal Margin Squamous Cell Carcinoma Patients frequently complain of a lump, bleeding, itching, pain, or tenesmus (complaints common to most lesions of this region). Typi- cally, the lesions are large, are centrally ulcerated with rolled everted Table 26. Perianal Complaints 477 edges, and have been present for more than 2 years before detection. All chronic or nonhealing ulcers of the perineum should be biopsied to rule out squamous cell carcinoma. Tumors of the Anal Canal Epidermoid Carcinoma Generally, there is a long history of minor perianal complaints such as bleeding, itching, or perianal discomfort. Early lesions that are small, mobile, confined to the submucosa, and well differentiated may be treated with local excision. Radiation therapy or chemora- diotherapy is the preferred treatment option for larger lesions of the anal canal. Summary Patients with perianal problems often are referred with a diagnosis of hemorrhoids. The sometimes life-threatening causes of perianal complaints require attention to history and a thorough physical examination. While hemorrhoidal disease often can be treated expectantly or by local therapies, improperly treated infectious and malignant causes of such complaints often result in devastating consequences. Chemoradiotherapy versus radiotherapy alone for anal cancer: a retrospective comparison. Lateral internal sphincterotomy remains the treatment of choice for anal fissures that fail conservative therapy [letter; comment]. To be able to discuss the differential diagnosis of inguinal pain and the diagnosis and management of groin masses and hernias. To develop an understanding of the anatomy, loca- tion, and treatment of different types of hernias; this includes the frequency, indications, surgi- cal options, and normal postoperative course for inguinal, femoral, and umbilical hernia repairs. To understand the definition and clarification of the clinical significance of incarcerated, strangu- lated, reducible, and Richter’s hernias. To develop an awareness of the urgency of surgi- cal referral, the urgency of treating some hernias. To develop an understanding of the differential diagnosis of an abdominal wall apparent hernia or mass, including adenopathy, desmoid tumors, rectus sheath hematoma, true hernia, and neoplasm. Cases Case 1 A 74-year-old woman has noted an intermittent small lump in the right groin for 8 months. This has seemed to go away when she lies down, but it is present when she showers in the morning. This morning she felt awful, had a lemon-sized tender right groin mass, and had nausea and some diarrhea. Chandler gurgles heard in the abdomen, and a slightly pink, skin-covered, very tender lump was present in the right groin. Case 2 A male college student, age 20, presents with a 4-year history of inter- mittent soft mass in his groin and a large lump in the right side of the scrotum, which is now uncomfortable. He does not notice any groin mass on awakening, but he becomes aware of the groin and scrotal masses later in the morning, toward noon. Definitions A hernia is present when an object goes through an opening and is now in any unexpected location.

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Time 02/1998 spent on writing tasks in minutes remained the same between groups (6 discount sildenafil 25 mg fast delivery. For dispensings of targeted medications considered inappropriate buy sildenafil, there was also a significant reduction with the use of the alerting system (1 buy sildenafil 75mg overnight delivery. The study was stopped primarily due to 2 false-positive alert types: Misidentificatio n of medications as contraindicated in pregnancy by the pharmacy information system and misidentificatio n of pregnancy related to delayed transfer of diagnosis information. Study Start: There were no 03/2004 significant Study End: differences in 09/2006 time (in days) from alert to lab test (2. During the intervention period, the rate for computerized group was higher than the control (36% vs. Rate of compliance with insulin dose advice was higher in period 2 than 1, and then decreased significantly in period 3 (56% vs. During the intervention period the rate for computerized group was higher than the control (64% vs. Total adherence was higher with diagnoses for which an antibiotic was not indicated (84. However Study Start: the vaccination 00/1995 rate for the Study End: same time 07/2001 period for tetanus vaccine was 100% vs. Physicians in the intervention group prescribed vancomycin for 36% fewer days than physicians in the control group (26. The number of days of vancomycin per course of treatment was also lower for the physicians in the intervention group, mean of 1. Design: Cross- spreadsheets sectional indicated a N = 1,941 relative risk prescriptions reduction of Implementation: 42% (20% vs. We found no evidence of a decrease in use of nonpreferred agents for nonelderly patients. There was an upward, though non­ significant trend in the use of preferred agents in elderly patients following the intervention (p = 0. When test (for alert that was alert was for an triggered for a missing abnormal laboratory test) laboratory value, percentage of times medication order triggered but was not completed increased from 5. The largest effect was noticed when the alert was triggered for a missing laboratory test, the percentage of times the provider ordered the rule-associated laboratory test increased from 43. The rate of discontinuation of inappropriate drugs per 1,000 was not different: 67. There Study End: was no 00/0000 statistically significant difference between the intervention and control group in the proportion of patients who had increases in therapy (28. N = 2,484 patient paper users For the visits computer Implementation: users, 07/1996 compliance Study Start: rates steadily 10/1995 increased year Study End: 2 to year 3 to 01/1998 year 4 (38. The results demonstrated close to 100% compliance with charting of cumulative dose of isotretinoin, pregnancy testing, liver function and lipid profile tests. The results sustained for more than 2 years from January 2005 to June 2007 [no analysis given past 1 year]. Study 2: Variability in standard deviation dosages across medications reduced by 11% following implementation of the dosage guidance application (p <0. Standard deviation of frequency of administration reduced by 30% post- implementation (p <0. The proportion of medications that were potentially inappropriate was also reduced, from 5. Secondary Outcome: When analyzed as a percentage of all medications prescribed by physician subjects, the proportion of medications that were potentially inappropriate was significantly reduced, from 5. There were significantly greater reductions in March 2005 for psychiatrists who had higher percentages of their caseloads on two or more concurrent antipsychotics in January 2004. The overall percentage of patients on 2 or more antipsychotics dropped significantly (54% vs. This decrease in rate was not statistically different from the rate observed in the first period (p = 0. The differences are maintained when hospital teaching status and ownership and number of beds are taken into account. Therefore, the 00/0000 mean time required to review an order was Study Start: 06/2002 increased by 5. Study End: 06/2006 system Turnaround time between drug ordering and administration decreased from 90 minutes to 11 minutes, no stats given. Clinicians who received pharmacists patients * The total rate the prompts had a higher rate of intervening Implementation: of pharmacist with patients overall (1. When the prompts were stopped the rate of aspirin interventions fell to pre-prompt levels. The administrations in Academic benefit was related to a reduction 92 patients associated with errors of wrong Implementation: administration time. The rate of Implementation: pharmacist interventions declined 06/2003 significantly after implementation (3. Total 00/0000 pharmacy time taken on study ward Study End: increased after implementation (1h 8min 00/0000 vs. Turnaround time Study Start: based, between drug ordering and administration 02/2002 Academic decreased from 90 minuets to 11 minutes, Study End: no stats given. Only Study End: minor errors were reduced with the 12/2002 system C-124 Evidence Table 4. The proportion of time Study Start: nurses spent on direct care activities 02/2005 unrelated to medication administration Study End: remained statistically unchanged (20. The overall administration transcription error incidence of medication doses directly Implementation: (2ndary outcome) observed to be administered either early 04/2005 or late decreased from 16. The Implementation: actual and scheduled mean time deviation between actual and 00/0000 administration times*, scheduled administration times did not Study Start: change significantly postimplementation 05/1997 (130 minutes vs. Overall, administration mistakes, 09/2004 pharmacy problems and prescribing Study End: problems accounted for 74% of all 04/2006 variances observed. In addition, after System therapy (days)*, the average duration of therapy was N = 87 patients Integrated Combination- decreased from 10. Combination­ 00/0000 system, Pharmacy escalation rate*, Mean Antimicrobial de-escalation rates were not Study Start: duration of statistically improved upon (67% vs. The average duration of Study End: Antimicrobial therapy therapy was decreased from 12. There was a large effect for Study Start: treatment; treatment of pneumococcal vaccination (12. Study End: warfarin, aspirin or adherence was significantly improved for 06/1996 ticlopidine; treatment of 13 standards (53. There were non significant Implementation: perioperative changes in the proportion of patients 00/0000 antibiotics, proportion of receiving perioperative antibiotics (64% Study Start: patients receiving vs. Supplementation of Mg at 00/0000 hypomagnesemia 1 hour was significantly improved, but not Study Start: treatment guidelines ­ at 24 hrs. Supplementation of K was not 02/2001 synchronous alerts*, improved at 1 or 24 hrs. Synchronous Study End: compliance with alerts resulted in improved compliance at 03/2002 hypokalemia and 1 hr and 24 hrs for bot K and Mg hypomagnesemia supplementation (p <0. The results showed that overall Implementation: positive trends were minimally more 00/0000 prominent in the intervention arm (59.

Bill reluctantly puts a substantial part of his savings into buoying the business discount 75 mg sildenafil visa. Then the stock market tanks and Bill sees that his hard-won gains have virtually evapo- rated buy sildenafil cheap. At the age of 50 order sildenafil visa, he sees that he’s not likely to find something that pays what he used to get from the family business. Instead of looking at ways to develop new skills or options, he sits hopelessly watching the stock market on television for many hours every day. Bill, formerly confident and self-assured, feels insecure, worried, and obsessed about his financial status. Bill had a very good reason to form that assumption, and like most agitating assumptions, Bill’s schema contains some truth — you can never know with certainty what the future will bring. However, as with all agitating assump- tions, the problem lies in the fact that Bill underestimates his ability to adapt and cope. Therefore, he now spends his days engaged in unproductive obsessing rather than changing his goals and lifestyle while developing new skills or possibilities. For every Council has compared travel on buses, planes, 100 million miles driven, there is less than one trains, and cars. In fact, many people who read our books are therapists or counselors who have skills and tools that keep them on an even keel most of the time. Suddenly, a thug stormed in, demanding that everyone lie on the floor, face down, and hand over their money and jewelry. When she found herself waking up from nightmares, she knew the vulnerability assump- tion was creating trouble and that she needed to do something about it. These strategies included gradually returning to the scene of the crime, talking about the crime, and relaxation. By the way, it’s now almost ten years later and she still goes to the same hair salon. Anxious schemas may begin when you’re quite young — perhaps only 4 or 5 years old — or they may emerge much later in life. Challenging Those Nasty Assumptions: Running a Cost/Benefit Analysis After taking our quiz and finding out about anxious schemas in the previous sections, you now have a better idea about which ones may be giving you trouble. Pretend you just took an eye test and found out that you suffer from severe nearsightedness. You’re about to get a prescription for seeing through your problematic assumptions. Maybe you believe that you have profited from your perfectionism and that Chapter 7: Busting Up Your Agitating Assumptions 109 it has helped you accomplish more in your life. Therefore, you need to take a cold, hard look at the costs as well as any pos- sible benefits of perfectionism. Only if the costs outweigh the benefits does it make sense to do something about your perfectionism. After looking at the examples in the next five sections, see the “Challenging your own anxious schemas” section for directions on how to conduct a cost/benefit analysis for your personal problematic anxious schemas. Analyzing perfection Knowing which problematic anxious schemas lurk in your mind is the first step toward change. The story about Prudence shows you someone who has the perfection schema and how she finds the motivation to change her assumption through a cost/benefit analysis. Her closet is full of power suits; she wears her perfectionism like a badge of honor. Prudence works out to maintain her trim figure and manages to attend all the right social events. Too busy for a family of her own, she dotes on her 9-year-old niece and gives her lavish presents on holidays. Prudence is shocked when her doctor tells her that her blood pressure has gone out of control. She believes that her high income is due to her relentless standards and that she can’t let up in the slightest way. Prudence has little hope of changing her anxious schema of perfection if she doesn’t face it head on. Her doctor suggests that she see a counselor, who tells her to run a cost/benefit analysis of her perfection assumption. A cost/benefit analysis starts with listing every imaginable benefit of an agi- tating assumption. Filling out the benefits in her cost/benefit analysis is easy for her, but what about the costs? Prudence will probably have to expend much more effort to complete the costs, and she may even have to ask other people for ideas. Now, review in Table 7-3 what she writes after she works at the task and consults others. Table 7-3 Cost/Benefit Analysis of Prudence’s Perfectionism Schema: Part 2 Benefits Costs My income is higher because of my I don’t have much time for fun. Chapter 7: Busting Up Your Agitating Assumptions 111 Benefits Costs Actually, I think my focus on work has kept me from finding a mean- ingful relationship. The cost/benefit analysis helps you to know whether you really want to chal- lenge your agitating assumptions. The final step is to examine carefully whether you would lose all the benefits by chang- ing the assumption. For example, Prudence attributes her high income to her dedication and long work hours. Perhaps she’s partly right, but would her income evaporate if she worked just a little less? Most likely, if she worked less, her income might drop a bit, but with less anxiety, she might increase her efficiency enough to make up the difference. If she were less irritable, she would be able to retain her secretarial staff and gain efficiency there too. And would Prudence actually start making more mistakes if she relaxed her standards? With respect to her niece, Prudence isn’t really getting the benefit that she thinks she is, because she’s not around enough to serve as an effective role model. So you see, many times the perceived benefits of an assumption evaporate upon close inspection. A little bit of anxiety seems to improve perfor- anxiety interferes with the ability to recall previ- mance and reduce mistakes. Some anxiety ously learned information, and mistakes multi- channels attention and effort to the task at hand. That’s why people with perfection schemas Without anxiety, people don’t take tasks seri- often have severe test anxiety. However, when material, but their anxiety causes them to forget perfectionism reaches extreme levels, so does what they have previously learned.