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In fact generic 17.5 mg nicotinell quit smoking 27 days, the new Guidance goes so far as to eliminate separate review of “qualified” health care claims based on its conclusion that the standard is essentially the same as for any health care claim purchase generic nicotinell canada quit smoking injection. According to Berkeley Wellness order nicotinell pills in toronto quit smoking calculator, there have been numerous reports of dietary supplements containing much less, or much more, than what’s listed on the labels. Not surprisingly, manufacturers fought against measures that would increase costs. In particular, the provision to test finished products was dropped in the final rule. Ingredients can still have side effects and unknown long-term effects, interact with drugs and be dangerous if you have certain medical conditions. Unlike labels on drugs, those on supplements still need not list any precautions, contraindications or possible interactions -- another reason for this outline. We must never relax our vigilance in reaching out to protect the stigmatized, marginalized people who, abandoned by lack of government funding of both institutional and community-based treatment, roam our streets and sleep under our bridges. But we must do more to help the broader group of people who want to make their lives better and need basic scientific information about alternatives. Development of Balanced Information: It is in the interest of persons with mental health and substance use conditions that research and education be dedicated to investigating and disseminating reliable scientific information concerning behavioral health medications and other treatments, services and supports. All mood stabilizers treat mania and hypomania, and some have been found to be effective in treating depression as well. Other mood stabilizers currently used were originally developed to treat seizure disorders, such as epilepsy, and are thus called anticonvulsants. Acute episodes of mania result in psychosis in as many as two-thirds of those with this disorder. They are also often used to decrease symptoms of mania until mood stabilizers such as those listed above can take full effect. Anti-anxiety drugs in a class called benzodiazepines are sometimes used to gain rapid control of manic symptoms so that mood stabilizers have time to take effect. These medications are primarily used to produce sedation, induce sleep, relieve anxiety and muscle spasms, and prevent seizures. People who regularly focus on the positive in their lives are less upset by painful memories. People who consistently help others experience less depression, greater calm and fewer pains. Not getting enough rest increases risks of weight gain, accidents, reduced memory and heart problems. Eating healthy food and regular meals can increase your energy, lower the risk of developing certain diseases and influence your mood. People who can tackle problems or get support in a tough situation tend to feel less depressed. The Evidence The concrete steps suggested by the website are not based on guesses, fads or advice from grandma (though she probably got a lot right). They represent hundreds of research studies with thousands of participants, cited on the website. This research shows that there are several evidence based approaches to help individuals handle stressful situations effectively and protect their wellbeing. No matter how stressful your situation, you can take steps to promote your well-being. It helps you focus at work, overcome obstacles, get along with the people around you and even fight off illness. It has been used for several years outside the United States to treat cerebrovascular disorders (those that affect the blood in the brain), including stroke, and has been studied for use in cognitive impairment and dementia. A recent well-designed Italian study confirms its effectiveness in treating vascular dementia. The many years of use have caused an evolution in dosage, method of administration, and selection criteria. Choline is incorporated into the membrane phospholipid structure, improves mitochondrial metabolism and synthesis of phospholipids and elevates norepinephrine, dopamine, and serotonin. The evidence of benefit from global impression was stronger, but is still 3 limited by the duration of the studies. Seven of the included studies observed the subjects for a period between 20 to 30 days, one study was of 6 weeks duration, four studies used periods extending over 2 and 3 months, one study observed continuous administration over 3 months and one study was prolonged, with 12 months of observation. The studies were heterogeneous in dose, modalities of administration, inclusion criteria for subjects and outcome measures. Results were reported for the domains of attention, memory testing, behavioral rating scales, global clinical impression and tolerability. The main outcomes were an improvement in Mini-Mental State Examination, Activities of Daily Living, and Instrumental Activities of Daily Living scores in the study group compared with the control group. Thus, Brown and Gerbarg recommend, "more long-term studies, particularly for vascular 5 cognitive impairment, vascular dementia, and age-related memory decline. Leading researchers (Lake and Spiegel) posit a therapeutic effect in other kinds of depression as well, but the studies are not yet adequate to fully credit this suggestion. Chromium is a widely used nutritional supplement marketed for a wide range of applications. Chromium is sold as a single-ingredient supplement as well as in combination formulas, particularly those marketed for weight loss and performance enhancement. Clinical studies have focused on chromium picolinate, but chromium is sold in many forms. A compound such as chromium that exerts a normalizing effect on insulin sensitivity and appetite while having antidepressant activity may be a promising therapeutic option in people with atypical depression, a subtype of depression typically associated with overeating and weight gain. The available evidence suggests that chromium supplementation can be used as a monotherapy [for depression and other mood 1 disorders] or as an adjunct therapy with conventional antidepressants. Ten persons received chromium picolinate (initial dose of 400 mcg per day, increased to 600 mcg per day after 2 weeks) and 5 persons received placebo for 8 weeks. As a result, the level of these drugs may be increased in the blood and may cause increased effects or adverse reactions. This concern seems more theoretical than real, at least with the use that has been made of chromium in clinical practice. Brown and Gerbarg and Iovieno have not observed any such interactions in extensive experience with chromium picolinate. The Natural Standard makes no reference to clinical evidence, and Brown and Gerbarg have never observed such an interaction. The Natural Standard urges caution to people with compromised immune systems, while acknowledging that, “the evidence thus far has not been conclusive. The principal side effects cited by the Natural Standard are stomach discomfort, nausea and vomiting. The Natural Standard says only that “it is possible” that chromium may lower blood sugar, and this concern is only relevant if the person is taking diabetes medicine. The Natural Standard details less likely side effects, including adverse effects on the heart, blood, kidneys, or liver, and cognitive, perceptual and motor effects.

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Oral charcoal may also inactivate any coma effective 35 mg nicotinell quit smoking support groups, samples of blood purchase nicotinell 35mg mastercard quit smoking quebec, urine and (when available) gastric oral antidote (e cheap nicotinell express quit smoking 10 weeks. Subsequent toxicological screen- The use of repeated doses of activated charcoal may be ing may be necessary if the cause of the coma does not become indicated after ingestion of sustained-release medications or apparent or recovery does not occur. Avoidable morbidity is drugs with a relatively small volume of distribution, and pro- more commonly due to a missed diagnosis, such as head longed elimination half-life (e. Metal salts, alcohols and sol- Syrup of ipecacuanha is no longer recommended in the man- vents are not adsorbed by activated charcoal. Whole bowel irrigation using non-absorbable polyethylene Gastric aspiration and lavage should only be performed if glycol solution may be useful when large amounts of sus- the patient presents within one hour of ingestion of a poten- tained-release preparations, iron or lithium tablets or packets tially fatal overdose. It should only be performed by experienced personnel with efficient suction apparatus close at hand (see Table 54. Gastric lavage is usually Patients are generally managed with intensive supportive contraindicated following ingestion of corrosives and acids, therapy whilst the drug is eliminated naturally by the body. Haemodialysis Salicylates, methanol, ethylene Plasma electrolytes and acid-base balance should be meas- glycol, lithium, phenobarbital ured. Hypotension is the most common cardiovascular com- Charcoal haemoperfusion Barbiturates, theophylline, plication of poisoning. This is usually due to peripheral disopyramide vasodilatation, but may be secondary to myocardial depres- ‘Gastro-intestinal dialysis’ Salicylates, theophylline, quinine, sion following, for example, α-blocker, tricyclic antidepressant via multiple-dose most anticonvulsants, digoxin or dextropropoxyphine poisoning. If dysrhythmias occur any hypoxia or hypokalaemia should be corrected, but anti-dysrhythmic drugs should only be adminis- Haemodialysis and, much less commonly, charcoal haemo- tered in life-threatening situations. Since the underlying cardiac perfusion are sometimes used to enhance drug elimination. In addition, exchange resuscitation whilst the toxic drug is excreted is indicated. Repeated oral doses of activated Naloxone is a pure opioid antagonist with no intrinsic agonist charcoal may enhance the elimination of a drug by ‘gastro- activity (Chapter 25). Several drugs are eliminated in the bile and drugs, including morphine, diamorphine, pethidine, dextro- then reabsorbed in the small intestine. When injected intravenously, interrupt this enterohepatic circulation by adsorbing drug in naloxone acts within two minutes and its elimination half-life is the gut lumen, thereby preventing reabsorption and enhancing approximately one hour. Naloxone can precipitate withdrawal reac- However, it is extremely safe unless aspiration occurs. This is not a contraindication, but it is diuresis is hazardous, especially in the elderly, and is no longer wise to ensure that patients are appropriately restrained if this recommended. However, it is not usually necessary, may be harmful This over-the-counter mild analgesic is commonly taken in and is almost never recommended. Dimercaprol Penicillamine concentration should be obtained urgently and related to the Opioids Naloxone graph shown in Figure 54. A more precise treatment graph is printed in the Digoxin Digoxin-specific fab antibody British National Formulary (it is unreliable for staggered over- fragments doses). If doubt exists concerning the time of ingestion it is better to err on the side of caution and give the antidote. For serious paracetamol overdoses seen greater than 24 hours after ingestion, advice should be sought from poisons or liver specialists. The patient is usually asymptomatic that the infusion be stopped and an antihistamine adminis- at the time of presentation, but may complain of nausea and tered parenterally. Right hypochondrial pain and anorexia may precede acetylcysteine may be restarted at a lower infusion rate. If a potentially toxic overdose is suspected, the stomach phenytoin, carbamazepine) and chronic alcoholics are at a should be emptied if within one hour of ingestion. The anti- higher risk of hepatic necrosis following paracetamol over- dote should be administered and blood taken for determina- dose. The decision to stop or continue 24 hours after the overdose, significant hepatic or renal dam- the antidote can be made at a later time. If the patient reaches 600–800mg/L and in elderly adults and children with levels in the hospital alive they may be conscious, confused, aggressive or range 450–750mg/L in deep coma. It may be useful in remote areas where there will be should be limited to correction of any metabolic abnormalities, a delay in reaching hospital or when acetylcysteine is con- especially hypokalaemia, hypoxia and acidosis. Some centres recommend prophylactic bicarbonate and but in contrast to paracetamol overdose usually look and feel ill, potassium to keep the pH in the range of 7. If resistant ventricular tachy- renal function, blood glucose (hypoglycaemia is particularly cardia occurs, intravenous magnesium or overdrive pacing common in children) and plasma salicylate concentration. If ventricular tachycardia results in patient is usually dehydrated and requires intravenous fluids. Convulsions should be stomach washout is performed, if within one hour of ingestion. Blood gases and arterial pH normally reveal a mixed metabolic acidosis and respiratory alkalosis. The metabolic acidosis is due to uncoupling of in place of tricyclic antidepressants has reduced the mortality oxidative phosphorylation and consequent lactic acidosis. Nausea and be delayed and the plasma salicylate concentration can increase diarrhoea are common. Depending on the salicylate with venlafaxine (which blocks noradrenaline, as well as concentration (see Table 54. Oral activated charcoal is recommended following the hazardous, especially in the elderly. It is usually the dextropropoxyphene that causes death from Supplemental intravenous potassium may cause dangerous overdose with this mixture of dextropropoxyphene and para- hyperkalaemia if renal function is impaired, so frequent moni- cetamol. The patient may present with coma, hypoventilation toring of serum electrolytes is essential. The cardiac toxicity includes a negative centration reaches 800–1000mg/L, haemodialysis is likely to inotropic effect and dysrhythmias. Haemodialysis may also be life-saving at lower resuscitation and intravenous naloxone are indicated. The salicylate concentrations if the patient’s metabolic and clinical plasma paracetamol concentration should be measured and condition deteriorates. Whilst overdose Diagnosis of acute self-poisoning in comatose patients from other paracetamol–opioid compounds (e. The immediate man- Note: Acute overdose may mimic signs of brainstem death, yet the patient may recover if adequate supportive care is agement consists of removal from exposure and administration provided. There is evidence that hyperbaric oxygen speeds in an undiagnosed comatose patient. Most commonly, tablets were • Vertigo, 50% prescribed to the parents and left insecure in the household • Alteration in consciousness, 30% or handbag. Non-drug substances that cause significant poisoning in children include antifreeze, cleaning liquids and pesticides. Although most patients take overdoses as This is one mode of non-accidental injury of children.

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Although there were organiza- industry is now faced with a shortage of registered tional differences 35 mg nicotinell quit smoking 4 weeks pregnant, results showed a high correlation nurses buy genuine nicotinell quit smoking 84 days ago. According to statistics provided by the of caring attributes among the various settings purchase on line nicotinell quit smoking government programs. Department of Interviews conducted with nurses indicated a con- Health and Human Services (2000), over the next cern that their “ability to be caring was in jeopardy. These nurses felt that the practice these studies did not merge economic concepts into of caring was being seriously threatened by the nursing research or theory. As the nursing practice economic pressure associated with health-care environment has continued to change, new re- changes. Foa (1971), an ex- Narrative examples of the attribute, exchanging change theorist, designed an economic theory that commodity values, were “making caring tangible” and “patient care is a commodity (economic good could bridge the gap between economic and or value). In this model, noneco- gotiating the politics were “the nurse administrator nomic resources (love, status, and information) is a system coordinator, nurses are the system and were correlated with economic resources (money, know what impinges on them,” and “nurses are po- goods, and services). The philosophical framework of quality care is located in the reciprocal actions of the economic dimension of bureaucratic caring has the interpersonal nurse-patient relationship served in part as the basis for this type of needed (Hoggard-Green, 1995). Turkel (1997) interviewed nurses, ethnographic approach to study nurse-patient in- patients, and administrators from the for-profit teractions in the critical care environment. The sector to examine the process involved in the devel- subsequent theme generated among all categories opment of the nurse-patient relationship as an of interaction was the nurse-patient relationship. This research was conducted a qualitative study, Price (1993) examined the as managed care penetration was having an enor- meaning of quality nursing care from the perspec- mous impact on the current health-care delivery tive of parents of hospitalized children. The basic ing as a result of health-care reform and managed care, nurses are finding themselves in a period of transition, moving from traditional in-patient hos- The basic social process of the nurse- pital practice to community-based practice. In a re- patient relationship as an economic re- search study conducted by Turkel, Tappen, and Hall source was struggling to find a balance, (1999), the development of a positive nurse-patient which referred to sustaining the caring relationship was shown to be seen as a reward for ideal in a new reality controlled by costs. The research’s long-term goal qualitative interviews were accomplished in not- is to establish caring as an economic interpersonal for-profit and military sectors of the health-care resource. The purpose of this research was to through empirical nursing research, that hospitals continue the study of the nurse-patient relation- with a higher organizational caring score have in- ship as an economic interpersonal resource. Findings from this study identified that the nurse- patient relationship was both outcome and process. Categories, which emerged during data analysis, Economic/Political Implications included relationships, caring, and costs. The formal nomic dimension of bureaucratic caring can be theory of relational caring complexity illustrated used to guide administrative practice within that the caring relationship between the nurse, the health-care organizations. As a dimension of her patient, and the administrator is complex and research, Turkel (1997) interviewed eight top-level cocreative, is both process and outcome, and is hospital and corporate-level administrators to gain a function of a set of economic variables and a an understanding of how they viewed the experi- set of nurse-patient relational caring variables. Economic variables are depicted as time, technical, Administrators were chosen to be interviewed be- and organizational resources. Nurse-patient rela- cause they make the ultimate decision on how to al- tional caring variables are caring, relationships, and locate scarce human and economic resources education (Turkel & Ray, 2000). One administrator (1999) developed and tested a professional and shared the following with the researcher: patient questionnaire designed to measure organi- zational caring. The Organizational Caring ques- Lying in a bed like that, people feel vulnerable and are vulnerable, and they want to know that someone is tionnaire is a 26-item professional and an 18-item there for them and will share with them what’s going patient questionnaire designed from qualitative on. I hear [patients research (Ray & Turkel, 1995, 1997, 1999) and vali- say] that my nurse cared, she listened, and she kept dated and established as reliable through quantita- me informed. The three positive comments I receive from patients have to do subscales are caring, trust, and economics. What comes back to me questionnaire has been distributed in five different is they cared about me, they took time to talk to me, hospitals to over 500 participants. Given this, professional nursing practice remains in the forefront of organizational profit- must embrace and illuminate the caring philosophy. The issue of time constraints Staff nurses describe the essence of nursing as and inadequate staffing has been identified as prob- the caring relationship between nurse and patient lematic. However, nurses are practicing hindrance to forming a caring nurse-patient rela- in an environment where the economics and costs tionship. This points out the need for administra- of health care permeate discussions and clinical de- tors to restructure the organization so that the cisions. The focus on costs is not a transient re- maximum of nursing time is focused on direct sponse to shrinking reimbursement; instead, it has nurse-patient interactions. Hospital administrators become the catalyst for change within corporate desire high levels of quality care and see financial health-care organizations. With a system goal of decreasing administrators must maintain adequate staffing ra- length of stay and increasing staffing ratios, nurses tios in order to allow time for nurses to be with need to establish trust and initiate a relationship their patients. As this In the research conducted by Turkel and Ray relationship is being established, nurses need to (2000, 2001, 2003), administrator participants con- focus on being, knowing, and doing all at once firmed the above but also discussed the concomi- (Turkel, 1997) and being there from a patient per- tant need for maintaining care and quality. For the nurses, this means completing a challenge facing administrators in a managed care task while simultaneously engaging with a patient. Ray (1989) asserted that this the patient as a person in all his or her complexity can be accomplished if administrators consider and then identifying the needs for professional both the tangible and intangible benefits of services nursing as they arise. Changes that incorporated the human caring di- Administrators need to recognize caring as a mension and the critical nature that human rela- value-added interaction. From this point of view, tionships play in hospital organizations were the benefits of the interaction outweigh the expense identified by Ray over two decades ago. Caring can be viewed as an described the problems associated with economic “opportunity cost” or the cost of doing it right. This changes in health care and the negative impact eco- concept is applicable to contemporary health-care nomics would have on nurse caring. If people don’t come back to a Current research (Turkel & Ray, 2000, 2001, hospital (because of poor care), “you’ve lost an 2003) on the economics of the nurse-patient rela- opportunity. The re- The economic and political dimensions of bureau- searchers recommend that administrators recog- cratic caring can be used to guide practice. Now is nize and respect the contributions nursing could the time for professional nurses to become proac- make in developing hospital organizations as polit- tive and use theory-based practice to shape their ically moral, caring organizations. Strategies for cratic Caring as a middle-range holographic rebuilding the loss of trust in order to transform practice theory. Administrators need outside of nursing will continue to make the to focus on rebuilding in order to create a better political and economic decisions concerning working environment for the nursing staff. Having an in-depth tered nurses view the rebuilding of trust as the key knowledge of the economics of health care component to the recruitment and retention of will allow nurses to challenge and change the nursing staff. A new theory-based model can be created for nursing practice that supports human caring in relation to the organiza- tion’s economic and political values. The political and economic dimensions of bu- The foundation for professional caring is the reaucratic caring serve as a philosophical/ blending of the humanistic and empirical as- theoretical framework to guide both contem- pects of care. In today’s environment, the porary and futuristic research and theory- nurse needs to integrate caring, knowledge, based nursing practice. Given political and eco- nomic constraints, the art of caring cannot occur in isolation from meeting the physical needs of patients. When caring is defined Having an in-depth knowledge of the solely as science or as art, it is not adequate to economics of health care will allow nurses reflect the reality of current practice.

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The ability of a person charged with a crime to un- Another assessment test is the Competency Assessment derstand the nature and purpose of the criminal proceedings discount 52.5mg nicotinell visa quit smoking symptom timeline. It consists of a detailed face-to-face interview about various aspects of competent function- ing order nicotinell amex quit smoking support groups, including an appreciation of the charges and an un- Defendants in a criminal trial must have the ability derstanding of the various roles of the judge cheap 17.5 mg nicotinell otc quit smoking calculator, witnesses, (i. This requirement is a long- Research has shown that when competency evalua- standing and fundamental principle of criminal law. Its tions occur, most (70%) of the defendants who are as- purpose is to ensure that defendants can participate sessed are judged competent. The requirement incompetent tend to have been charged with more seri- refers to the defendant’s competence at the time of the ous crimes, compared to defendants in general. They trial, rather than their psychological state at the time of also are likely to have a history of psychosis, to have a the alleged offense. Rationality is a key issue in compe- serious current mental disorder, and to be poorly educat- tency determinations. Once a defendant is judged to be competent, the legal usually lack the ability to understand, communicate, or proceedings are resumed and a trial takes place. Otherwise the United States, where individual rigor and competition defendant is returned to an institution until competency appear to be nationalistic qualities Americans cherish can be restored. If competency cannot be restored within a capitalist-driven society thrives because of the spirited reasonable period of time (e. Ac- being the serial bomber who built homemade bombs that cording to Sigmund Freud, humans are born screaming killed three people and injured many others between for attention and full of organic drives for fulfillment in 1978 and 1995. Initially, according to this view, we com- the proceedings because of a dispute with his lawyers pete for the attention of our parents—seeking to attract it about his defense. His request to represent himself and either from siblings or from the other parent. Thereafter, an attempted suicide provoked concerns about his com- we are at the mercy of a battle between our base impuls- petence. In her report to the court, ever, that this view of the role of competition in human the psychiatrist said that Kaczynski was not suffering behavior may be incorrect. Thomas Hobbes (1588- from any mental defect that could prevent him from un- 1679), one of the great philosophers of the seventeenth derstanding the nature of the charges, or from assisting century, is perhaps best remembered for his characteriza- his lawyers in mounting a defense. On the other hand, tion of the “natural world,” that is, the world before the she noted that he was suffering from paranoid schizo- imposition of the will of humanity, as being “nasty, phrenia. The that those species best able to adapt to and master the nat- Unabomber case provides a good illustration of a situa- ural environment in which they live will survive, has tion in which a psychological disorder did not necessar- suggested to many that the struggle for survival is an in- ily harm the defendant’s ability to participate meaning- herent human trait which determines a person’s success. Darwin’s theory has even been summarized as “survival of the fittest”—a phrase Darwin himself never used—fur- Timothy Moore ther highlighting competition’s role in success. As it has often been pointed out, however, there is nothing in the concept of natural selection that suggests that competition Further Reading Wrightsman, L. Darwin asserted in The Origin of Species that the strug- gles he was describing should be viewed as metaphors and could easily include dependence and cooperation. Many studies have been conducted to test the impor- tance placed on competition as opposed to other values, Competition such as cooperation—by various cultures, and generally An adaptive strategy that pits one person’s interests conclude that Americans uniquely praise competition as against another’s. In 1937, the world- renowned anthropologist Margaret Mead published Co- Psychologists have long been in disagreement as to operation and Competition among Primitive Peoples, whether competition is a learned or a genetic component based on her studies of several societies that did not prize of human behavior. Perhaps what first comes to mind competition, and, in fact, seemed at times to place a nega- when thinking of competition is athletics. One such society was the Zuni Indians of mistake, however, not to recognize the effect competition Arizona, and they, Mead found, valued cooperation far has in the areas of academics, work, and many other more than competition. Psychologists disagree as to whether competition is a learned or genetic component of human behavior. Natural concepts are often learned through the use Conditioned responses develop in a process called of prototypes, highly typical examples of a category— acquisition, in which the natural or unconditioned stimu- like the robin cited above. Some re- concept learning is through the trial-and-error method of sponses develop more quickly than others; similarly, testing hypotheses. The nature of certain item is an instance of a particular concept; they the conditioned response depends on the circumstances then learn more about the concept when they see in which acquisition occurs. This People learn simple concepts more readily than process is called “delayed conditioning” because the un- complex ones. For example, the easiest concept to learn conditioned stimulus is delayed relative to the condi- is one with only a single defining feature. The response is weaker if the condi- est is one with multiple features, all of which must be tioned and unconditioned stimuli begin together, and be- present in every case, known as the conjunctive concept. For example, the concept square is defined by four conditioned response resembles the unconditioned re- sides and four 90-degree angles. People also learn response is not identical to the unconditioned response concepts more easily when they are given positive rather and may be very different. An animal usually produces a conditioned response to stimuli that resemble the conditioned stimulus, a Further Reading process called stimulus generalization. Studies in Cognitive Growth: A Collabora- a complementary tendency not to respond to anything tion at the Center for Cognitive Studies. Piaget’s Theory of Intel- nation of generalization and discrimination leads to ap- lectual Development. The Growth of Logical In classical conditioning, a stimulus leads to a Thinking from Childhood to Adolescence. In Ivan Pavlov’s experimentations with classical Chicago: University of Chicago Press, 1991. After the powder and the sound had co-occurred a few times, the dog salivated when the sound occurred, even when the meat powder was not ad- Conditioned response ministered. Although most research in classical condi- In classical conditioning, behavior that is learned tioning has involved reflexive behaviors that are typical- in response to a particular stimulus. The effects of the condi- Reflexive behaviors occur when an animal encoun- tioned stimulus can vary widely in different circum- ters a stimulus that naturally leads to a reflex. For example, if the unconditioned stimulus is ple, a loud noise generates a fright response. If an initial- more intense, the conditioned stimulus will have a ly neutral stimulus is paired with the noise, that neutral greater effect. On the other hand, if the conditioned stim- or conditioned stimulus produces a fright response. Further, if an animal has associated a particu- lar conditioned stimulus with a certain unconditioned stimulus and a new conditioned stimulus is presented, the animal will typically not develop a response to the new conditioned stimulus. The conditioned stimulus seems to exert its effect by providing information to the animal. If the animal has al- ready gained information through an initial conditioned stimulus, the second one will not be very useful. Similar- ly, if the potential conditioned stimulus does not always occur with the unconditioned stimulus, the information provided by the conditioned stimulus is less useful to the animal. If the conditioned stimulus occurs without the unconditioned stimulus, extinction will occur; that is, the conditioned stimulus will no longer have an effect. The reflex can be conditioned more easily the second time around if the two are again paired. Sometimes, after extinction has taken place, the conditioned stimulus will produce the reflexive behavior without the uncondi- tioned stimulus, a process called spontaneous recovery.