Empirical Literature on Asthma Care

Empirical Literature on Asthma Care This brief critically considers the empirical literature on asthma care. Emphasis is on UK studies although research from the USA (and other countries) is also considered. It is argued that both environmental and genetic factors are implicated in asthma onset, based on epidemiological evidence. Deficits in care provision persist: these gaps in care may be attributable to a wide range of modifiable factors, including unsatisfactory health professional (GP, nurses) input, limited use of care plans, and patient unawareness. Overall, however, conclusive inferences about asthma care provision are hampered by: A preponderance of retrospective/correlational studies, and a paucity of randomised control trials, which demonstrate causality; A paucity of research on particular gaps in asthma care; Failure to account for third-variable moderator effects. The Office for National Statistics (2004) publishes comprehensive statistics on asthma-related mortality, morbidity, treatment, and care, collapsed by demographic categories. Data is collected from the General Practice Research Database (GPRD). Issues addressed include mortality, prevalence, time trends, patients consulting general practice, incidence of acute asthma, and hospital inpatient admissions. Research suggests that health care providers often fail to agree on the precise criteria for diagnosing asthma, whether mild or severe (e.g. Buford, 2005). Severe asthma is often defined based on pulmonary function measurements, such as forced expiratory volume in 1 second, and hospitalisation. However, neither of these indicators reliably predicts asthma severity (Eisner et al, 2005). Eisner et al (2005) evaluated the efficacy of a method for identifying a cohort of adults with severe asthma based on recent admissions to an intensive care unit (ICU) for asthma. Four hundred adults with severe asthma enrolled at seventeen Northern Carolina hospitals were surveyed. A control group of patients hospitalised without ICU unit admission was also recruited. The study examined whether admission to an ICU unit is in itself a reliable indicator of asthma severity. Asthma patients with a recent ICU admission generated higher asthma scores (based on the frequency of current asthma symptoms, use of steroids and other medications, and history of hospitalisations/intubations), and poorer quality of life, were more likely to have been hospitalised, visited an asthma specialist in the previous twelve months, been in an asthma-related emergency department, and received inhaled corticosteroids in the past year. Data analysis controlled key background variables (e.g. demographic factors), increasing confidence in the reliability of the findings. However, this study was based on quasi-experimental design and hence may be confounded by sampling bias. Trends in annual rates of primary care consultations, mortality, and hospital visits/admissions were monitored for children under 5 years and 5-14 year olds. For children aged For 5-14 year olds, weekly general practice visits rose in the early 1990s (circa 70/100,000 in 1990), showed a fluctuating pattern through the mid 1990s, but has declined steadily since 1997 (about 50/100,000 by 2000). The number of patients treated annually for asthma has risen slowly but steadily, although this increase seemed to level out by the mid/late1990s. Both mortality rates have dropped steadily since the early 1990s, from about 14 million in 1990 to circa 2 million by 2000. Annual hospital admissions has also fallen steadily, from just under 30/10,000 in 1990 to about 15/10,000 by 2000. These patterns suggest an increase in self-management (e.g. action plans) that obviates the need to visit a general practice, and that asthma care overall is having the desired effect on mortality. The prevalence of wheezing and asthma in children has generally increased during the last 40 years. Although there is a paucity of reliable national statistics, data is available from specific parts of the UK, notably Leicester, Sheffield, and Aberdeen (see Figure 1). The prevalence of wheezing increased from 12% (1990) to 26% (1998) in Leicester, and from 17% (1991) to 19% (1999) in Sheffield. The prevalence of asthma showed a similar pattern in both cities, rising from 11% (1990) to 18% (1998) in Leicester, and from 18% (1991) to 30% (1999) in Sheffield. Wheezing incidence rates for Aberdeen increased from 10% (1964), to 20% (1989), 25% (1994), and 28% (1991). Data from national birth cohorts suggests a sharp increase in the average weekly GP consultations for hay fever/allergic rhinitis from 1991 to 1992. The rates rose from circa 13/100,000 (0-4 year olds) and 40/100,000 (5-14 years olds) in 1991 to about 25/100,000 (0-4 year olds) and 76/100,000 (5-14 year olds) as 1992 approached. Trends subsequently dropped off slightly but then started to show an increase again around 1998. By the year 2000 the figures were roughly 20/100,000 (0-4 year olds), and 56/100,000 (5-14 year olds). Data from a nationally representative sample of schools across the country suggests that the prevalence of asthma was fairly even across different regions. However, Data for England suggests a higher prevalence outside big cities. The greatest proportions of wheezing was found in the South West, while the highest proportion of asthma cases was found in East Anglia and Oxford (see Figure 2). In a recent Annual Report, Asthma UK (2003/2004) noted that one child in 10 has asthma and a child is admitted to hospital every 18 minutes due to an asthma attack. Over 600 copies of Asthma in the Under Fives are downloaded from the UK Asthma website monthly and on average every classroom in the UK has at least 3 children with asthma. The impact of acute asthma can be debilitating. Around 5.2 million people in Britain are presently being treated for asthma, and asthma prevention/care costs the NHS on average almost  £900 (i.e.  £889) million per year. GPs across the country treat over 14,000 new episodes of asthma each week, and UK Asthma met almost 25,000 requests for health promotion documents and other materials. About 40% of workers who have asthma find that working actually exacerbates their asthma, and 1 in 5 asthmatic people feel excluded from areas of the workplace in which people smoke. Over 12.7 million working days in the UK are lost as a result of asthma, and it is estimated that the annual cost of asthma to the economy is  £2.3 billion. Asthma UK also states that 82% of people who are asthmatic find that passive smoking triggers their asthma, and 19% of people with asthma indicate that their medical condition makes it difficult for them to play with children in their family. One in 3 children has had their routine daily activities disrupted due to asthma and 39% of asthmatic people are badly affected by traffic fumes (which stop them exercising). About 500,000 people have asthma that is very difficult to control. In 2003/2004 over 90 researchers worked on Asthma UK-funded projects and, Asthma UK spent  £2.5 million on asthma-related research. The group funded/is funding 63 research projects. These statistics paint a rather bleak picture of asthma prevalence, incidence, and the effects on people’s lives. Numerous epidemiological studies have been published that address the etiology of asthma in population groups (International Archives of Allergy Immunology, 2000; Kitch et al, 2000; Schweigert et al, 2000; Tan, 2001; Court et al, 2002; Smyth, 2002; Weissman, 2002; Tan et al, 2003; Wenzel, 2003; Gibson Powell, 2004; Barnes, 2005; Pinto Almeida, 2005). Barnes (2005) considered evidence on the role of genetic factors in resistance to atopic asthma, Studies which focus on the role of genetic factors in resistance to tropical/parasitic diseases (e.g. malaria) overlap with genetic associations found for asthma. It was concluded that genetic factors might be implicated in the development of allergic illnesses. Pregnancy is thought to increase the probability of asthma attacks in about 4% of all pregnant women. Beckmann (2006) assessed eighteen pregnant women with asthma. The study was based on a longitudinal design. Participants were recruited from local prenatal clinics and private enterprises, and enrolled during the first trimester. Patients kept a daily log recording peak expiratory flow data until delivery. Three peak-flow assessments were recorded after which the best value was entered into the log. Asthma was diagnosed by a health professional. Participants were also required to record asthma symptoms, exacerbations, medications, and cigarette use. To increase participation, subjects were reminded by telephone to complete their log. Data analysis showed that peak expiratory flow (PEF) was variable as a function of particular trimesters. Peak air flow was highest during the second trimester, with a statistically reliable difference between the second and third trimester. Unfortunately, the small sample size limits the generalisability of the findings. However, the study was based on a longitudinal design, allowing tentative causal inferences. Schweigert et al (2000) reviewed the literature on the role of industrial enzymes in occupational asthma and allergy. Enzymes used by detergent manufacturing companies (e.g. amylases, cellulases) are toxicologically benign, with mild irritation effects on the body. However, these enzymes do affected asthma and allergy. Thus, the industry is required to adhere to exposure guidelines for these enzymes. Kitch et al (2000) considered literature on the histopathology of late onset of asthma (i.e. onset in adulthood), and whether allergic exposure and sensitivity have the same impact on asthma development in adulthood as they do in children. Epidemiological studies suggest that the prevalence of asthma in older adults aged 65years or more is between 4% and 8%. The illness appears to be more common in women, especially those with a long history of smoking, and with respiratory symptoms (e.g. cough, wheeze, shortness of breath). Asthma in adulthood often developed before the age of 40, with maximum incidence occurring around early childhood. Beyond the age of 20 years the incidence of asthma tends to remain stable through young, middle-aged, and older adulthood. Death rates in adults are generally lower than figures for children; â€Å"Mortality rates attributable to asthma among those aged between 55 and 59 years of age and 60 and 64 years of age were 2.8 and 4.2 respectively, per 100,000 people, the highest rates among all age groups† (p.387). However, as adults get older asthma is less and less likely to be identified as the main cause of death due to the increased incidence of other pathology. Epidemiological research in Japan highlights a link with air pollution (International Archives of Allergy Immunology, 2000). The prevalence of asthma among kindergarten and elementary school children has increased steadily since the early 1960s, rising from 0.5-1.2% between 1960 and 1969, to 1.2-4.5% (1970-1979), 1.7%-6.8% (1980-1989), and 3.9-8.2% (1990 onwards). By contrast, data indicates little or no change in asthma prevalence amongst adults. Figures range from 1.2% in 1950-1959 to 1.2-4.0% (1960-1969), 0.9-5.0% (1970-1979), 0.5-3.1% (1980-1989) the 1960s to 1.6-2.9% (1990 onwards) (see Figure 3). Asthma in Japanese children is more common amongst boys than girls although this gender difference has diminished noticeably since the 1960s. Asthma usually appears in infancy or early in childhood but has been known to begin across all age groups. Inherited (genetic) dispositions to allergies have been implicated in the onset of asthma. There is normally a strong correlation between asthma onset and a family history of asthma. Overall, asthma-related mortality in Japan has decreased since the mid 1990s. Delays in seeking treatment and rapid exacerbation of symptoms have been strongly implicated in asthma mortality. Unfortunately, this article offers little information about the designs of studies reviewed. Inferences regarding the possible causes of asthma morbidity and mortality may be inconclusive if much of the evidence is derived from cohort studies, rather than case control studies that more effectively eliminate alternative causes. The premenstrual period in women has been implicated in asthma exacerbation. Tan (2001) reviews epidemiological literature suggesting that female sex-steroid hormones may be significant in understanding the premenstrual-asthma link, albeit the available evidence is tenuous. The luteal phase of the menstrual cycle is associated with airway inflammation and hyper-responsiveness, and hence may explain asthma exacerbation during the premenstrual phase. However, this increase in asthma severity can still be treated effectively using the normal drugs. Studies suggest that premenstrual asthma affects the rate of hospital admissions – the majority of adults admitted are women, indicating that hormonal factors play an important role. Other evidence suggested that emergency presentations increased before ovulation. It is suggested that oral contraceptive pills or gonadotrophin releasing hormone analogues may be especially effective treatments. However, premenstrual asthma was rarely associated with serious mortality. Unfortunately, most of the studies reviewed were retrospective and questionnaire based, and hence subject to response bias. There was a paucity of randomised control trials, or pseudo experiments that may permit causal inferences. Court et al (2002) considered the distinction between atopic (extrinsic) asthma, common in younger people, and non-atopic (intrinsic) asthma, found mostly in older groups. Additionally, they also considered whether identification of asthma cases in epidemiological research should be based on a doctor’s diagnosis or self-reported asthma symptoms. Nearly 25,000 people in England were surveyed. Data was collected regarding whether participants had experienced wheezing in the past 12 months and/or had been diagnosed as asthmatic by a doctor. People with atopic asthma were more likely to have experienced wheeze and been diagnosed as asthmatic in the past, compared with the non-atopic group. Logistic regression analysis showed that gender, social class, smoking status, living in an urban/rural area, and house dust mice (HDM), were all risk factors for the presence of wheeze both with (age not significant) and without (urban/rural area not significant) a diagnosis of asthma. Wheeze/asthma was more prevalent in women, younger people, lower social classes, previous/current smoking, living in an urban area, and greater HDM IgE levels. Smoking status, social class, and age were all risk factors for wheeze in both atopic and non-atopic cases. Gender was also a risk factor for atopic subjects, and urban living for non-atopics. Other research has considered the epidemiology of severe or ‘refractory’ asthma, which is rather less well understood compared with milder forms of asthma. Wenzel (2003) reviews evidence indicating that severe asthma (defined as asthmatics requiring continuous high-dose inhaled corticosteroids or oral corticosteroids for over half of the preceding year) may account for circa ≠¤ 5% of asthma cases. Data from a large Australian-based study, which has followed a large cohort of asthmatics for over three decades, implicates childhood pulmonary problems with reduced lung function in adulthood. Data suggests that over two-thirds of severe asthmatics were afflicted with asthma in childhood. Other risk factors implicated include genetic mutations (in the IL-4 gene and IL-4 receptor), and environmental factors (e.g. allergen, tobacco exposure, house dust mite, cockroach and alternaria exposures), respiratory infections (e.g. pathogens like chlamydia), obesity, gastroesophageal reflux disease, increased body mass index, lack of adherence to corticosteroid regimes, and poor physiological response to medication. Physiological factors are also implicated, notably structural changes in airway reactivity, inflammation of the peripheral regions of the lungs. Steroids are the main form of treatment. Tan et al (2003) demonstrated the role of respiratory infection in patients with severe (i.e. near fatal) asthma, acute exacerbations, or chronic obstructive pulmonary illness (COPD). Participants had all been diagnosed as asthmatic by a physician and were undergoing treatment. All showed evidence of forced expiratory volume in 1 second (FEV1) increase of 200mL. COPD patients were suffering from chronic cough and dyspnea, with a predicted FEV1% 50%, with no ÃŽ ²-agonist reversibility. Near fatal cases were patients undergoing ventilatory support in the intensive care unit of a hospital (National University Hospital and Alexandria Hospital, Singapore) as a result of a severe exacerbation. Acute asthma subjects were characterised by non-improvement following administration of ÃŽ ²-agonists, and/or severe exacerbation judging from clinical/blood data. Analysis showed that near-fatal cases were the least likely to have the influenza A + influenza B virus, but the most prone to have adenovirus and picornavirus, compared with the other two groups (see Figure 4). This suggests that viral infection may be a risk factor for severe asthma. However, due to sampling size/bias (n= 68), and failure to control for key background variables (e.g. asthma history, smoking history, prior medication use, and outpatient spirometry), the findings can be considered tentative. Smyth (2002) reviewed epidemiological studies on asthma in the UK, and worldwide. The number of new asthma cases seen by GPs has increased noticeably since the mid 1970s. Nevertheless, asthma incidence has tended to decrease since the early 1990s, consistent with data from the Office for National Statistics (2004). By the year 2000 circa 60-70, 40-50, 20-25 new cases (per 100,000 of a given age group) were reported amongst, respectively, preschool children, 5-14 year olds, and people older than 15 years. Significant ethnic differences have been reported, with high asthma prevalence in Afro-Caribbean children. Since 1962, the number of preschool children hospitalised for asthma rose steadily, then peaked in the late 80s and early 90s, and has begun to decline since. The hospitalisation rates in 1989 were 90/10,000 (preschool children), 30/10,000 (5-14 year olds), and 10/10,000 (15 years or older). By comparison the rates for 1999 were 60/10,000, 20/10,000, and 10/10,000 respectively ( see Figure 5). The British Thoracic Society identifies specific benchmarks or ‘best practice’ which health professionals are required to meet when caring for asthma patients (BTS, 2004). These recommendations are mostly based on scientific evidence from RCTs, epidemiological studies (cohort and case-control), meta-analytic reviews, and other good quality research. The recommendations related specifically to the following topics: Diagnosis and assessment in children and adults (e.g. key symptoms, recording criteria which justified diagnosis of asthma); Pharmacological management (e.g. use of drugs [inhaled steroids, ÃŽ ²2 agonist] to control symptoms, prevent exacerbation, eliminating side effects, employing a ‘stepwise’ protocol for treatment); Use of inhaler devices (technique and training for patients, agonist delivery, inhaled steroids, CFC vs. HFA propellant inhalers, suggestions on prescribing devices); Non-pharmacological management (e.g. breast feeding and modified milk formulae for primary prevention, and allergen avoidance for secondary prevention, alternative medicines); Management of acute asthma (initial assessment, clinical features, chest x-rays, oxygen, steroid treatment, referral to intensive care) Asthma in pregnancy (drug therapy, management during labour, drug treatment in breastfeeding mothers); Organisation and delivery of care (e.g. access to primary care delivered by trained clinicians, regular reviews of people with asthma, audit tools for monitoring patient care after diagnosis); Patient education (e.g. action plans, self-management, compliance with treatment regimes). Overall, despite these guidelines, recent research suggests that patients’ treatment needs are not being met. For example, Hyland and Elisabeth (2004) report data on the unmet needs of patients. Focus groups were organised between parents, patients, and clinicians. Patients and parents reported various needs that weren’t been met including frequent exacerbations, and a preference for less complex drug regimens (i.e. with fewer drugs). Many individuals had worries regarding treatment and experienced asthma symptoms 3 or more days per week. As Levy (2004) suggests, there is a need for health professionals to address these concerns, especially in relation to the BTS guidelines. Levy, a GP and Research Fellow in Community Health, identified current deficiencies in the care of asthma victims. These comprised: Higher than expected exacerbations (42/1000 patients per year); Under-diagnosis: more patients presenting for treatment with uncontrollable asthma, who had not been diagnosed previously; Deficiencies in treatment uptake: many patients fail to collect their prescriptions; Many patients with symptoms delay presenting for treatment, until their medical situation becomes critical; Health care professionals are failing to assess patients objectively (PEF, oximetry), both pre- and post-treatment; Failure to adhere to national guidelines for the care of acute asthma (e.g. not enough oral steroids and ÃŽ ²-agonists are prescribed for patients presenting with asthma attacks. Considerable variations across GPs, NHS Trusts, clinics, and other sources of care provision: patient follow-up appointments range from a few days to six months, in direct violation of standards set by the British Thoracic Society (BTS, 2004). Levy suggests various strategies for improving asthma care including diagnosis criteria (e.g. â€Å"any patient with recurring or respiratory symptoms [cough, wheeze, or shortness of breath], or who has been prescribed anti-asthma treatment should be considered to have asthma† (p.44)), use of computerised templates, having systems or triggers in place for recalling patients (e.g. patients requesting more medication, or who have been seen out of hours), introducing more effective protocols for monitoring and informing asthma patients (e.g. using a checklist to ascertain various key information on patients status, such as effects of asthma on patients life, recent exacerbations), providing written self-management plans (e.g. how to detect uncontrolled asthma, using PFM charts), and having an agreed procedure for managing acute asthma attacks (e.g. selecting a low threshold for using oral steroids). Currently there is a lack of research testing the value of these recommendations on asthma health outcomes. However various strategies are continually being implemented in various parts of the country to improve the quality of asthma care. For example, Holt (2004) describes the effects of implementing the RAISE initiative, launched by the National Respiratory Training Centre, in a primary care setting. This scheme is designed to raise awareness of existing variations in standards of care, improve standards of care through education, support, and feedback, increase awareness and understanding of respiratory disease, use asthma as platform to demonstrate the value of shared experiences across different agencies/professionals, and augment the profile of primary care settings as the main source of asthma care and innovation. The RAISE led to various improvements, such as: The use of ‘active’ and ‘inactive’ asthma registers, to distinguish patients who currently have asthma symptoms from those who don’t. Introduction of computerised templates to improve accuracy and reliability of data recording during consultations (e.g. progressing sequentially from assessment of symptoms, to peak flow, inhaler, and advice stages). Use of symptom questionnaires (e.g. handed out with repeat prescriptions) that help patients with well-managed asthma decide whether they can opt for a telephone consultation, rather than taking the trouble to visit the practice for a face-to-face consultation. Haggerty (2005) identifies several factors paramount to effective care and management of asthma in UK patients. These comprise adequate patient education about the nature of asthma (e.g. number of asthma episodes, use of quick relief medicines, long term symptoms, restrictions on daily activities, and emergency visits), use of asthma action plans, and customised treatment plans (to achieve early control), and addressing patients own concerns and perception. Treatment for asthma is usually in the form of regular inhaled corticosteroids (ICS), oral corticosteroids (OCS), and ÃŽ ² agonists. These treatments are usually administered by a health professional when symptoms manifest and/or become severe. However, since asthma can often exacerbate rapidly, before an individual can seek medical help, it is vital that asthma patients receive the necessary care from health professionals, and also self-management skills. GPs and nurses play a critical role. Griffiths et al (2004) conducted a randomised control trial to assess the effect of a specialist nurse intervention on the frequency of unscheduled asthma care in an inner city multiethnic clinic in London. The role of specialist nurses in asthma care has been uncertain. Interventions in which specialist nurses educate patients about asthma, after hospital attendance with acute asthma, were shown to have inconsistent effects on unscheduled care. However, outreach initiatives to educate medical staff had shown no effect. Thus, an intervention was designed that combined patient education with educational outreach for doctors and practice nurses. It was suspected that such an integrated approach would benefit ethnic minority groups, especially given their higher hospital admission rates and reduced access to care during asthma exacerbation. The key research question was whether specialist nurses could improve health outcomes in ethnic minority groups. Outcome variables were the percentage of patients receiving unscheduled treatment for acute asthma during a 12 month period, and time to first unscheduled attendance with acute asthma. The study was based on 44 practices in two east London boroughs. Participants comprised over 300 patients (aged 6 to 60) who were admitted to or attending the hospital, or the out of hours GP service with acute asthma. Half the sample were classified as South Asians, 34% were Caucasian, while 16% were Caucasian. The intervention was based on a liaison model. Practices were assigned to either a treatment or control condition. Practices randomised to the treatment condition ran a nurse led clinic involving liaison with GPs and practice nurses, incorporating education, raising the profile of guidelines for the management of acute asthma, and providing on-going clinical support. In practice these practices received two one-hour visits from a specialist nurse who discussed guidelines for managing patients with acute asthma. Discussions were based on relevant empirical evidence. A computer template was provided to elicit patient information on various treatment issues, such as inhaler technique and peak expiratory flow, and offer self-management advice. By contrast, control practices received a visit promoting standard asthma care guidelines. Data analysis showed that the intervention lengthened the time to first attendance (median 194 days for intervention practices, and 126 days for control practices), and also reduced the proportion of patients presenting with acute asthma (58% treatment practices versus 68% in control practices (see Figure 6). These effects were not moderated by individual differences in ethnicity, albeit Caucasians seemed to benefit more from the intervention compared with minority ethnic groups. O’Connor (2006) noted that asthma care in the UK remains below the required standards. The majority of the 69,000 hospital admissions and circa 1400 deaths annually are attributable to poor patient adherence to treatment regimens. Nurses, it is argued, play an important role in promoting adherence. Additionally, use of a new inhaled corticosteroids – circlesonide – may also help increase adherence. Circlesonide is much easier to use than more established asthma drugs (e.g. it has a once-daily dosing). Evidence is reviewed suggesting that peak expiratory flow remains stable when patients are given circlesonide compared with a placebo. Tsuyuki et al (2005) assessed the quality of asthma care delivered by community-based GPs in Alberta, Canada. They reviewed clinical charts for over 3000 patients from 45 primary care GPs. Of this number 20% had ever visited an emergency department or hospital, 25% had evidence that a spirometry had been performed, 55% showed no evidence of having received any asthma education, 68% were prescribed an inhaled corticosteroid within the past 6 months, while a very small minority (2%) had received a written action plan. Figure 6 shows percentage of participants receiving medication. Sixty-eight percent were prescribed an inhaled corticosteroid, 11% were given an oral corticosteroid, and 80% received a short acting ÃŽ ²-agonist, while 8% were prescribed a long acting ÃŽ ²-agonist. Participants with an emergency room/hospital event were (marginally) more likely to be prescribed medication (no group differences in use of short acting ÃŽ ²-agonists). Regarding pulmonary testing, 25% had evidence of a pulmonary function test (not peak flow), 46% had peak flow monitored, 34% showed no evidence of pulmonary function tests, while 26% had an x-ray. Again individuals with an emergency room/hospital event were more likely to be tested (see Figure 7). Data about education received by patients was also evaluated. Twenty-two percent received information about environmental triggers, 20% on inhaler use, 10% on how to perform a home PEF test, 2% on written action plans, while 55% received no education at all. Those with an emergency room/hospital event were more likely to receive education. Receiving asthma education, use of spirometry, and prescription of inhaled corticosteroids, were all predicted by number of asthma-related clinic visits (4 or more) and having an emergency room/hospital event. Additionally, asthma education was predicted by cormorbidities, and absence of documentation regarding asthma triggers, while use of spirometry was predicted by being a non-smoker, and symptoms or triggers. Finally, use of inhaled steroids was predicted by symptoms. Overall, this study highlights numerous gaps in the care provided by GPs, partly echoing criticisms of GPs in the UK (Levy, 2004). For example, Levy (2004) cited ‘under

Freud and Psychodynamic Theory :: Papers

Freud and Psychodynamic Theory Freud was born on May 6, 1856, in the Moravian town of Freiberg, then a part of the Austro-Hungarian Empire, today a part of Czechoslovakia. He was born into a family full of enough complexity and confusion to give him significant material for his ruminations on the individual mind and its connections with others. His mother, Amalia, an assertive, good-looking woman, was twenty years younger than her husband Jacob. She was his third wife; he was forty at Freud's birth. Freud's siblings were two half-brothers, grown-up, a constant reminder of the oddity of his position. His own confusions, hatreds, love and desires from this period appear to have had significant impact on his later work on development. Components Of Personality Id As the baby emerges from the womb into the reality of life, he wants only to eat, drink, urinate, defecate, be warm, and gain sexual pleasure. These urges are the demands of the id, the most primitive motivational force. In pursuit of these ends, the id demands immediate gratification: it is ruled by the pleasure principle, demanding satisfaction now, regardless of circumstances and possible undesirable effects. If a young child was ruled entirely by his id, he would steal and eat a piece of chocolate from a store regardless of the menacing owner watching above him or even his parents scolding beside him. The id will not stand for a delay in gratification. For some urges, such as urination, this is easily satisfied. However, if the urge is not immediately discharaged, the id will form a memory of the end of the motivation: the thirsty infant will form an image of the mother's breast. This act of wish-fulfillment satisfies the id's desire for the moment, though obviously it does not reduce the tension of the unfulfilled urge. Ego The eventual understanding that immediate gratification is usually impossible (and often unwise) comes with the formation of the ego, which is ruled by the reality principle. The ego acts as a go-between

As I Lay Dying 9

May 10, 2010 013 Child Relations In the book â€Å"As I lay Dying† by William Faulkner the character that is dying name is Addie Bundren, the mother of five children. She was also the wife of no good Anse Bundren. Anse is lazy, selfish, no good farmer, who can hardly be called a farmer because he does almost none of the work himself. Out of an act of lust Addie and Anse married and ended up giving birth to Cash and Darl soon after. After the birth of her two sons Addie was bent on not having any more children. The birth of Cash confirms her feeling that words are irrelevant and that only physical experience has reality and significance. Through the act of giving birth she becomes part of the endless cycle of creation and destruction, discovering that for the first time her aloneness had been violated and then made whole again by the violation† (Vickey 54). Anse wanted as many children as possible so that he would have as many hands a possible to work for him, but Addie w as determined to have no more. This made their marriage very rocky and lead to Addie requesting to be buried with her blood relatives in town. In this time period this was hard because of the lack of transportation that they had as well as a lack of money. Her determination to not have any more children was brought to an end because she had an affair with Whittfield, which lead to the birth of Jewel. Anse did not know of this affair so he thought that jewel was his child. Addie decided to make it up to Anse by giving him two more children. â€Å"She consciously and deliberately gives Anse Dewey Dell to negative Jewel and Vardaman to replace him† (Vickey 55). Among the five children that she had Addie treated them all in a different way. Addie especially treated Cash, Darl, and Dewey Dell very differently. The relationship between Cash and Addie is magnificent for many reasons. Out of the five children that Addie had she liked Cash’s personality the most. Cash is the oldest of the five children. In addition to being the oldest, Cash is also a man of very few spoken words. He can be considered a very simple character compared to the others of the novel. For example, in his first narrative excerpt from As I Lay Dying Cash speaks in list form. {draw:custom-shape} This is one of the most simplistic forms of communication known. As a skilled carpenter, Cash, went and built his mothers coffin, especially to her liking in front of the window in which she was slowly dying. Cash and Addie had a relationship based off very few spoken words. â€Å"Her blissful union with Cash exist beyond body language: Cash did not need to say it [love] to me nor I to him† (Clarke 38). Clarke is explaining in this passage how there are no words needed in the relationship between Addie and Cash. As Cash built his mothers coffin, for each piece that he completed he held up for her approval. â€Å"She’s just watching Cash yonder† (Faulkner 9). This shows how Addie was continuously looking out the window to check on Cash’s progress on her coffin. Cash is extremely determined to complete the coffin. â€Å"With Cash all day long right under the window, hammering and sawing at that——â€Å"(Faulkner 19). This is proof of their strong relationship because he spends all his time doing this strenuous task. â€Å"Work is Cash’s way of communicating with Addie, his means of getting and holding her attention, and thereby assuring that unspoken understanding that has always existed between them†(Bleikasten 179). Bleikasten is showing that Cash rarely speaks unless it is through his actions such as building the coffin. Although Addie and Cash did have a very good relationship, Cash still needed something to help him cope with the death of his mother. For him this would be his carpentry skills. â€Å"The carpentering itself is an activity in which Cash can immerse himself sufficiently to insulate himself from the harsh reality of his mother’s imminent death† (Powers 56). This is simply saying that Cash is using carpentry to replace his mother after her death. The work of mourning begins before death has actually occurred† (Bleikasten 178). The mourning begins early because Cash already has a strong feeling that his mother is about to pass on so he begins to work on her coffin. â€Å"The building of the coffin should become for Cash the object of a manic counter investment. If he cannot be the jewel, he can at the very least be the jewler, the maker of the perfect shrine in which the mother’s precious body is preserved. In nailing Addie into the coffin, Cash encloses himself with her, burying his desire and pain† (Bleikasten 179). Cash making the most perfect coffin possible is his special way of mourning and the completion of the coffin with his mother’s body in he is enclosing his pain. â€Å"The infant loved by his mother grows to be a man of deeds; and Addie, in the absence of Jewel, calls out to him at the moment of her death—and he continues that relationship in his silent agony on the wagon†(Williams 117). Addie and Dewey Dell did not have the best relationship but at the same time did not have the worse possible relationship. Addie felt indifferently towards Dewey Dell, meaning that she didn’t particularly care what happened with her. She didn’t really care because Dewey Dell was only meant to negate Jewel because it was her illegitimate child that Anse did not know of. Addie purposely gave Anse Dewey Dell and Vardaman to make up for the birth of Jewel. Dewey Dell clearly did not have the strongest relationship with her mother though. â€Å"Dewey Dell is not so clearly disturbed by her mother’s death, yet her activity with the fan at Addie’s bedside may be seen as similar in protective function to Cash’s carpentry†(56 Powers). Dewey Dell too had something to substitute for her mother’s death. Dewey Dell, terribly preoccupied by the bud of life within herself- the result of going to the woods, the ‘secret shade,’ with Lafe- can scarcely attend to Addie’s death†(Powers 56). Dewey Dell quickly became pregnant after an agreement that she had with Lafe. Lafe manipulated the agreement and found a loop hole and ended up picking cotton into her basket. As she lost her virginity under the secret shade and realizes soon after that she is pregnant â€Å"Dewey Dell admits that ‘the process of coming unalone is terrible’† (Williams 105). It quickly became clear that â€Å"Dewey Dell has no need to replace the mother figuratively, for she replicates the mother in her own pregnancy† (Clarke 41). This shows that Addie and Dewey Dell really did not have a close relationship because even through her pregnancy she should have been attending to her mother’s needs as she left this world. Further more as they took the casket into town, Dewey Dell’s intent to go to town was so that she could try to find some abortion medicine, because like her mother she did not necessarily want her first child at that point in time. So the daughter goes through the same experiences as her mother: in pregnancy Dewey Dell discovers as Addie did her destiny as begetter, and like her mother she is snatched from aloneness only to be thrown back to it†(Bleikasten 180). Although Addie and Dewey Dell have many similarities when it comes to their pregnancies they are also different. â€Å"Unlike Addie, she is determined, if possible, to effect their separation. Thus, she will not name her condition even to her self because to do so would be to transfer her pregnancy from her private world of awareness to the public world of fact† (Vickery 61). Darl and Addie on the other hand had the worst possible relationship ever. This was proven several times throughout the novel As I Lay Dying by William Faulkner. Darl had said â€Å"I cannot love my mother because I have no mother† (Faulkner 95). This shows exactly how they have a bad relationship, but it is not just a one way street, Addie in turns hates Darl also. â€Å"Addie claims to have been tricked by a word in Darl’s conception; she says that my revenge would be that he would never know I was taking revenge. And when Darl was born I asked Anse to promise to take me back to Jefferson when I died† (Williams 115). This is the beginning of the dislike on Addie’s behalf because she did not want another child to begin with, so she intended on getting revenge on Anse. â€Å"He too must finally cast the son most like him (Darl, the one that folks say is queer, lazy, pottering about the place no better than Anse, the one who most resembles his father looking out over the land†¦with eyes [that] look like pieces of burnt out cinder†(Williams 115). In this passage Williams describes why Addie actually hates Darl. She hates Darl because she hates Anse with a passion, and Darl acts just like Anse in the sense that he is lazy like his father. Because Addie accepts the fact that she and Anse live in different worlds, her second child, Darl, comes as the ultimate and unforgivable outrage† (Vickey 54). Since Darl receives no love from his mother he makes it his duty to terrorize everyone else in the Bundren family minus Anse. â€Å"Never having had a mother, Darl is more surely poss essed by her than any of his brothers. Darl’s eyes, as Dewey Dell describe them, are full of the land dug out of his skull and the holes filled with distance beyond the land†(Bleikasten 188). Darl is known for his abilities to communicate without words, â€Å"at times, a kind of nonlinguistic â€Å"feminine† intuition† (Clarke 35). Using this ability he continuously terrorized Dewey Dell because he was the only one whom knew of her pregnancy in the Bundren house hold. In one of Dewey Dell’s narratives she said â€Å"He said he knew without words like he told me that ma is going to die without words, and I knew he knew because if he had said he knew with words I would not have believed that he had been there and saw us† (27). What Dewey Dell is explaining is that Darl speaks to her without words and knows of all things that are happening and only the most important things Darl says with no words, such as the death of their mother. Darl also takes it upon himself to confuse his youngest brother Vardaman even more than he already is. For example, Vardaman says â€Å"My mother is a fish† (84). This shows how confused Vardaman really is. The conversation that Darl and Vardaman had concerning Vardaman’s mother being a fish and the horse being Jewel’s mother really left Vardaman confused. As if this little part was not confusing enough for the five year old, Darl then confesses that he does not have a mother. â€Å"I haven’t got ere one, Darl said, Because if I had one it was. And if it is was, it can’t be is. Can it† (101)? This conversation leaves Vardaman in a world of confusion. He now starts to doubt if Darl and Jewel are really his brothers. â€Å"Darl, who seems to float through a world of words, passing into peoples minds and crossing vast spaces at will† (Clarke 46). Darl was able to make everyone miserable because he had no substitute for his mother’s death unlike everyone else in the family. Vardaman had the fish to replace their mother, while Dewey Dell had her pregnancy to occupy her mom, Jewel had his horse, and Cash had his carpentry to replace the emptiness left by their mother’s death. Darl had no substitute â€Å"because he never had a mother to replace† (Clarke 46). Darl said this several times throughout the novel in many variations. For example, â€Å"I can not love my mother because I have no mother† (95). There is a reason why Darl feels this way and Addie in turn hates Darl also. Darl’s feeling that he is not a part of his mother is more than just an expression of sibling rivalry. Addie’s rejection of him is absolute; it is the most terrible thing she does. † The rejection by his own mother makes Darl feels that he has no mother especially as a support system. In turn Addie rejects him because he is just like his father Anse of whom she despises as said previously. As a resulting factor â€Å"for Darl, the constant e xception, the journey is a continual nuisance, and he wants only to see his mother- distinctly dead- buried and out of the way†(Powers 61). Darl is constantly suffering emotionally throughout his life due to the absence of his mother, and continues to be affected by his lack of motherly guidance once Addie actually passes away. â€Å"His brothers, as we have seen, all end up some how displacing their grief and replacing Addie: Jewel with a horse, Vardaman with a fish, Cash with a coffin. But Darl’s mother is literally irreplaceable† (Bleikasten 188). Darl’s mother is irreplaceable because all his life he never had one because he was despised by Addie. In conclusion Addie Bundren had very different relationships with her children. After her death all her children had different ways of coping with her loss also. The relationship with Addie varied greatly from her children Cash, Dewey Dell, and Darl. Cash, her oldest child, she had a great relationship with. They loved and understood one another through the minimum use of words possible. Often times they communicated through body gestures and other types of movement. To substitute the emptiness in Cash’s heart due to the death of his mother, he focused on carpentry. Cash hand built Addie’s coffin to her approval as she looked beyond the window as she lay there dying. Addie and Dewey Dell had a relationship in which they felt indifferently about one another. They basically coexisted within the same house hold. Addie brought Dewey Dell into the world with a purpose: to â€Å"negative† Jewel because he was Addie’s illegitimate son. Dewey Dell also had a replacement for her mother after her death. At the time of Addie’s death, Dewey Dell is pregnant with her first child. This pregnancy takes the focus that Addie would have had on Addie and redirects towards an illegitimate child of her own because she is not married. And then there was Darl. Addie and Darl had the worst relationship possible between a mother and a son. They hated each other. Addie despised Darl because he was just like her husband Anse of whom she also despised. Darl also was her second child who she really did not want to have at all. This was the point in which she vowed to seek revenge upon Anse and made Darl an outcast. As for Darl, he hated Addie because she never mothered him his whole life, which left him broken emotionally causing him to terrorize the rest of his siblings especially his younger ones. Darl did not have a substitute for the death of his mother. In Darl’s eyes he had no mother so the mourning of her would be pointless for him. Work Cited Bleikasten, Andre. _The Ink of Melancholy_. Requiem for a Mother. Indiana University Press, Bloomington. 1990 Faulkner, William. As I Lay Dying. New York: Vintage, 1990. Powers, Lyall H. Faulkner’s Yoknapatawpha Comedy. : The University Of Michigan Press. Ann Arbor. Vickey, Olga W. The Novels of William Faulkner: A Critical Interpretation. Baton Rouge: Louisiana State University Press, 1959. Print Williams, David. _Faulkner’s Women: the Myth and the Muse_. University of Toronto Press. 1977.

Thanks to Second Amendment, You Have the Right to Bear Arms

Thanks to Second Amendment, You Have the Right to Bear Arms The second amendment of the constitution offers US citizens the right to keep and bear arms. This was basically done in order to provide citizens with a way to protect themselves from physical harm or danger. But since a lot of instances of misuse of this power have resulted in the injury or death of people, this issue has always been under hot debate. There are people who believe that the right to bear arms should be revoked in order to protect innocent lives. Still, there are others who feel that the intent of this provision is basically otherwise to protect these lives. So, the two groups are always at loggerheads over this highly debatable issue. It is true that the right to bear arms has been misused by individuals, which has resulted in loss of lives. But if we consider it deeply, there are a number of other situations where a similar dilemma exists. For instance, take the matter of issuing driving licenses. There have been instances where careless drivers have caused serious injuries or death of innocent people. But that doesn’t mean that we should revoke the drive licenses for all people and prevent cars from plying on the road. Yes, some of them can and do cause serious damage to others because of their negligence. But the solution to the problem is not abolishing driving all together. Likewise, although a few eccentric people have misused the right to bear arms and caused damaged to others, the provision to bear arms is still an important right for an individual. Robbing someone’s rights due to another person’s misuse of the law may not be the right thing to do.