cognitive behaviouraltherapy

FIND A SOLUTION AT Academic Writers Bay

The key principles ofcognitive behaviouraltherapyCognitive behavioural therapy (CBT) explores the links between thoughts, emotions and behaviour. It is a directive, time-limited, structured approach used to treat a variety of mental health disorders. It aims toalleviate distress by helping patients to develop more adaptive cognitions andbehaviours. It is the most widely researched and empirically supportedpsychotherapeutic method. This strong evidence base is reflected in clinicalguidelines, which recommend it as a treatment for many common mentalhealth disorders.The GP curriculum and cognitive behavioural therapyCBT is listed as a treatment in the knowledge base of clinical example 3.10: Care of people with mentalhealth problems. The GP should be able to:. Understand the range of psychological therapies available including CBT. Understand specific interventions and guidelines for individual conditions using, where appropriate, best practiceas described in the Scottish Intercollegiate Guidelines Network or National Institute for Health and CareExcellence (NICE) guidelinesWhat is CBT?…………………………………………………..CBT is based on the cognitive model of mental illness,initially developed by Beck (1964). In its simplest form,the cognitive model ‘hypothesises that people’s emotionsand behaviours are influenced by their perceptions ofevents. It is not a situation in and of itself that determineswhat people feel but rather the way in which they construe a situation’ (Beck, 1964). In other words, how peoplefeel is determined by the way in which they interpret situations rather than by the situations per se. For example,depressed patients are considered to be excessively negative in their interpretations of events (Beck, 1976).Fundamental to the cognitive model is the way in whichcognition (the way we think about things and the contentof these thoughts) is conceptualised. Beck (1976) outlined three levels of cognition:1. Core beliefs2. Dysfunctional assumptions3. Negative automatic thoughtsCore beliefs, or schemas, are deeply held beliefs aboutself, others and the world. Core beliefs are generallylearned early in life and are influenced by childhoodexperiences and seen as absolute. The cognitive triadof negative core beliefs, as depicted in Fig. 1, captureshow they relate to:1. The self, e.g. ‘I’m useless’2. The world/others, e.g. ‘the world is unfair’3. The future, e.g. ‘things will never work out for me’Dysfunctional assumptions are rigid, conditional ‘rules forliving’ that people adopt. These may be unrealistic andtherefore maladaptive. For example, one may live by therule that ‘It’s better not to try than to risk failing’.Negative automatic thoughts (NATs) are thoughts thatare involuntarily activated in certain situations. In depression, NATs typically centre on themes of negativity, lowself-esteem and uselessness. For example, when facing atask, a NAT may be ‘I’m going to fail’. In anxiety………………………………………………………………………………! The Author(s) 2013. Reprints and permissions:sagepub.co.uk/journalsPermissions.nav579…………………..InnovAiT, 6(9), 579–585 DOI: 10.1177/1755738012471029…………………………………………………………………………………………………………………………………………………………………………………disorders, automatic thoughts often include overestimations of risk and underestimations of ability to cope.In CBT, the ‘cognitive model’ is used as a framework inwhich to understand a person’s mental distress or presenting problem. The process of placing an individual’sidiosyncratic experiences within a cognitive behaviouralframework is known as ‘formulation’. A formulation is ‘Ahypothesis about the causes, precipitants and maintaininginfluences of a person’s problems’ (Eels, 1997). The formulation is intended to make sense of the individual’sexperience and aid the mutual understanding of the individual’s difficulties.Formulations can be developed using different formats,exemplified by different ways of formulating depression.Beck et al. (1979) created a longitudinal formulation ofdepression. Within this formulation, early experiences(e.g. rejection by parents) contribute to the developmentof core beliefs, which lead to the development of dysfunctional assumptions (e.g. ‘Unless I am loved I amworthless’), which are later activated following a criticalincident (e.g. loss), leading to NATs and the symptoms ofdepression. Formulations can also be cross-sectional. Forexample, The ‘hot-cross bun model’ (Greenberger andPadesky, 1995), shown in Fig. 2, emphasises how anindividual’s thoughts, feelings, behaviour and physicalsymptoms interact.What are the keyelements of CBT?…………………………………………………..CBT ultimately aims to teach patients to be their owntherapist, by helping them to understand their currentways of thinking and behaving, and by equipping themwith the tools to change their maladaptive cognitive andbehavioural patterns. The key elements of CBT may begrouped into those that help foster an environment ofcollaborative empiricism and those that support the structured, problem-orientated focus of CBT.Collaborative empiricism (Wright, 2006) is based upon theestablishment of a collaborative therapeutic relationship inwhich the therapist and patient work together as a team toidentify maladaptive cognitions and behaviour, test theirvalidity, and make revisions if needed. A principal goal ofthis collaborative process is to help patients effectivelydefine problems and gain skills in managing these problems. CBT also relies on the non-specific elements of thetherapeutic relationship, such as rapport, genuineness,understanding and empathy. Initially, to aid the collaborative relationship, the therapist explains the rationale of thecognitive behavioural model and illustrates the descriptionusing examples from the patient’s own experience.The focus of CBT is problem-oriented, with an emphasison the present. Unlike some of the other talking treatments, it focuses on ‘here and now’ problems and difficulties. Instead of focusing on the causes of distress orsymptoms in the past, it looks for ways to improve apatient’s current state of mind. CBT involves mutuallyagreed goal setting. Goals should be ‘SMART’, i.e. specific, measurable, achievable, realistic and time-limited.For example, a goal for a patient with obsessive compulsive disorder may be to reduce the time spent washingtheir hands from 5 hours per day to 1 hour per day bythe end of 3 weeks of therapy. The therapist helps thepatient to prioritise goals by breaking down a problemand creating a hierarchy of smaller goals to achieve. CBTsessions are structured to increase the efficiency of……………………………………………………………………………………………………………………………………………………………………………………………………………………….Figure 2. The hot-cross bun model of CBT formulation.From an idea attributed to Greenberger and Padesky(1995).Reproduced from Scott, A. Cognitive behavioural therapyand young people: an introduction. Journal of Family HealthCare (2009) 19(3), 80–82. With permission from PavilionPublishing and Media.Figure 1. The cognitive triad of negative core beliefs.From Beck (1976).580………………….……………………………………………………………………………………………………………………………………………………………………………………………………treatment, improve learning and focus therapeutic effortson specific problems and potential solutions. Sessionsbegin with an agenda-setting process in which the therapist assists the patient in selecting items which can leadto productive therapeutic work in that particular session.Furthermore, homework assignments are used to extendthe patient’s efforts beyond the confines of the treatmentsession and to reinforce learning of CBT concepts.CBT is a structured and time-limited treatment. For noncomorbid anxiety or depression, a course of CBT typically lasts 5–20 sessions. If axis II disorders are present,which are personality disorders or intellectual disabilities,treatment may need to be extended due to the lifelong,pervasive pattern of these disorders and slower changethat has been observed with CBT.What techniques areused in CBT?…………………………………………………..CBT aims to change how a person thinks (‘cognitive’) andwhat they do (‘behaviour’). CBT therefore uses both cognitive and behavioural techniques. The specific interventions chosen depend on the individual’s formulation.Cognitive techniquesA key cognitive concept in CBT is ‘guided discovery’(Padesky, 1993). This is a therapeutic stance whichinvolves trying to understand the patient’s view of thingsand help them expand their thinking to become aware oftheir underlying assumptions, and discover alternativeperspectives and solutions for themselves. An aspect ofguided discovery is Socratic questioning, which is amethod of questioning based on the way in whichSocrates (c. 400 BC) helped his students to reach a conclusion without directly telling them. Padesky (1993)explained that Socratic questions should draw the patient’sattention to something outside of their current focus.Therapists use questions to probe a patient’s assumptions,question the reasons and evidence for their beliefs, highlight other perspectives and probe implications. For example, ‘What else could we assume?’, ‘What do you thinkcauses . . .?’, ‘What alternative ways of looking at this arethere?’ and ‘Why is . . . important?’. Guided discovery iscentral to the interventions aimed at each level ofcognition.To target maladaptive core beliefs, the patient can beasked to keep a positive data log (Padesky, 1994), inwhich the patient keeps a daily log of all observationsthat are consistent with a new, more adaptive schema(e.g. ‘I am useful to people’). Core beliefs are the leastaccessible level of cognition and so are tackled later intherapy than dysfunctional assumptions and negativeautomatic thoughts.To target dysfunctional assumptions, the patient can beasked to provide evidence that supports/does not support their assumptions. The mixed evidence can helpremould the rules to make them more ‘elastic’ andaccurate.Thought records are used to make a patient aware oftheir NATs, distinguish thoughts from facts, and seehow they impact upon their mood. They encourage theconsideration of alternative thoughts and the resultingchange in emotion. These are used to challenge NATs.Filling out a seven-column thought record (Greenbergerand Padesky, 1995) involves detailing the situation,mood, the NAT, evidence for this NAT, evidence againstthis NAT, the development of an alternative rationalresponse, and a rerating of mood.Behavioural techniquesActivity scheduling and graded task assignment aim toenhance functioning and systematically increase pleasurable or productive experiences. Activity scheduling is usedto plan each day in advance. The therapist and patientwork to reduce the mass of tasks to a manageable list,which removes the need for repeated decision making.The graded task assignments create manageable steps tohelp overcome procrastination and anxiety-provoking situations. These techniques involve obtaining a baseline ofactivities during a day or week, rating activities on thedegree of mastery and/or pleasure, and then collaboratively designing changes that will reactivate the patient,stimulate a greater sense of enjoyment in life, or changepatterns of isolation or procrastination. These techniqueshelp patients re-establish daily routines, increase pleasurable activities and deal with problems and difficult issuesby increasing problem solving.Behavioural experiments are mainly used with anxietybased mental health disorders. The technique allows aperson to test out their catastrophic predictions (e.g. ‘If Ileave the house, something terrible will happen’).Concurrently, behavioural experiments also help patientsto learn to tolerate anxiety. The patient makes a prediction before completing a task (e.g. walking to the shop)and then records whether that prediction came true.Over time, the patient will thereby be re-evaluatingtheir catastrophic thoughts, by developing helpful evidence against their predictions. The therapist workswith the client to develop hierarchical tasks, startingfrom lowest anxiety-provoking task going up to highanxiety-provoking tasks.Behavioural experiments are also used to help patientsgather evidence against the use of ‘safety behaviours’(Salkovskis, 1996), which are avoidance and escapebehaviours. Within the cognitive model, safety behaviours reinforce anxiety as they make disconfirmation ofdysfunctional assumptions and negative automatic beliefsimpossible. For example, if a patient avoids going onpublic transport because they believe something terrible……………………………………………………………………………………………………………………………………………………………………………………………………………………….581………………….InnovAiT……………………………………………………………………………………………………………………………………………………………………………………will happen, they will believe that avoiding public transport ‘saves’ them from this perceived threat. A behavioural experiment would allow the patient to gatherevidence to discount the predictions that somethingterrible will happen and that the safety behaviour ofavoidance is necessary to remain safe.Progressive relaxation training and breathing exercisesmay be used to reduce levels of autonomic arousal relatedto anxiety. These techniques may be used to help managepanic attacks or other symptoms of anxiety disorders.Is there evidence thatCBT is effective?…………………………………………………..CBT has proven to be an effective treatment for manypsychiatric conditions. In a meta-analytic review of controlled trials, Lynch et al. (2010) found CBT to be an effective intervention in the treatment of major depression.Butler et al. (2006) conducted a comprehensive reviewof 16 meta-analyses comparing CBT to no-treatment,wait list and placebo conditions. The authors found CBTto be an effective treatment for adult and adolescent bipolar disorder, generalised anxiety disorder, panic disorderwith or without agoraphobia, social phobia, post traumaticstress disorder, and childhood depressive and anxiety disorders. However, there is evidence from Scott et al. (2006)that CBT for bipolar disorder may be less effective thantreatment as usual in people who have suffered more than12 episodes. CBT fulfils the criteria for a ‘well-established’empirically supported therapy, as its efficacy has beenestablished in two or more carefully designed methodologically reliable randomised controlled trials (Meyer andScott, 2008).What are theadvantages of usingCBT?…………………………………………………..Long-term outcomeCBT has been shown to have an enduring positive effectfor patients. In a randomised trial, Dobson et al. (2008)found that depressed patients who had previously beentreated with anti-depressant medication (ADM) had agreater chance of relapse through 1 year follow-up thanpatients who had previously received CBT. In fact, priorCBT had an enduring effect (in terms of prevention ofrelapse and recurrence during the follow-up period) thatwas at least as strong as continuing patients on ADM.Cost-effectivenessIn a randomised trial of CBT and ADM, Dobson et al.(2008) found that, although CBT was more expensive toprovide initially, the cumulative cost of continued medications proved to be more expensive by the end of thefirst year of follow-up. Furthermore, mindfulness-basedCBT is a particularly cost-effective approach, because it isdelivered in a group format.When should Irecommend CBT?…………………………………………………..CBT is a main treatment option for commonmental health disorders. NICE (2011) recommendsCBT for all depressive and anxiety disorders, as shownin Box 1.Improving access to psychologicaltherapiesIn 2007 the UK Government announced a large-scaleinitiative for Improving Access to Psychological………………………………………………………………………………………………………………………………………………………………………………………………………………………Box 1. Summary of recommendations forcommon mental health disorders.CBT is recommended in the following cases:Depression. Mild to moderate: individual facilitated self-helpbased on the principles of CBT and computerisedCBT. Moderate to severe: CBT in combination withADM
.
Relapse prevention: individual CBT and mindfulness-based cognitive therapy (for those who have
had three or more episodes)Generalised anxiety disorder. When there is marked functional impairment. When there has been no response to a low-intensity interventionPanic disorder
.
For moderate to severe cases (with or withoutagoraphobia)
Obsessive compulsive disorder. Mild to moderate: individual CBT with exposureand response prevention (ERP) (using self-helpmaterials or over the phone) or group CBT. Moderate to severe functional impairment, andwhen there is significant co-morbidity: CBT(including ERP). Severe impairment: CBT combined with ADMPost traumatic stress disorder. All cases including mild to moderate cases:trauma-focused CBT.Source: NICE (2011).582………………….……………………………………………………………………………………………………………………………………………………………………………………………………Therapies (IAPT) for depression and anxiety disorderswithin the English NHS. The IAPT programme supportsfrontline NHS in the implementation of NICE guidelinesfor depression and anxiety, of which CBT is a key recommendation. By March 2011, 3660 new cognitivebehavioural therapy workers had been trained (thoughnot necessarily as clinical psychologists) to work on theIAPT programme. High-intensity therapists are trained inCBT to treat moderate to severe depression and anxiety.Psychological well-being practitioners are trained in cognitive behavioural approaches (guided self-help; psychoeducational groups) to treat mild to moderate depressionand anxiety (www.iapt.nhs.uk).In 2012, a total of 142 of the 151 Primary Care Trusts inEngland provided a service from this programme in atleast part of their area and just over 50% of the adultpopulation had access to these services. However,IAPT services vary significantly across the UK. Detailsof local service provision can be found at www.iapt.nhs.uk/servicesCan CBT be used inprimary care?…………………………………………………..Most people with psychological problems are managed inprimary care. There is some evidence that CBT can beeffectively adapted and utilised in such settings. For example, Edinger and Sampson (2003) found that a speciallyabbreviated two-session course of CBT for insomnia, delivered by a beginner-level clinical psychologist, reducedsubjective sleep disturbance and insomnia symptoms inprimary care patients to a greater extent than genericsleep hygiene suggestions. Additionally, Proudfoot et al.(2004) found computer-delivered CBT (a package called‘Beating the Blues’) to be an effective treatment for anxietyand/or depression in general practice.Studies have investigated how best to equip GPs with CBTskills to use in primary care. Heatley et al. (2005) found thattraining and clinical supervision in CBT for panic disordersincreased GPs’ use of CBT techniques and ability to assessand manage the disorders. Nonetheless, a remaining question is how to most (time- and cost-) effectively equipalready heavily burdened GPs with additional CBT skills.Given the proven effectiveness of CBT, this is a worthwhileendeavour.What CBT resources canI recommend topatients?…………………………………………………..There are various online resources and books basedon CBT principles, which can be accessed directlyby patients. A selection of CBT resources is shownin Box 2.Key points. The cognitive model hypothesises that people’semotions and behaviours are influenced by theirperceptions of events. Cognition is split into three levels: core beliefs,dysfunctional assumptions and NATs. Formulation is the process by which an individual’sexperiences are placed within a cognitive behavioural framework. CBT is time-limited, problem-oriented andcollaborative. CBT involves both cognitive techniques, such asguided discovery and Socratic questioning, andbehavioural techniques, such as activity scheduling and behavioural experiments. The effectiveness of CBT for many psychiatric conditions is supported by meta-analytic and systematic reviews……………………………………………………………………………………………………………………………………………………………………………………………………………………….Box 2. Online resources and books based onCBT principles.Online resourcesFor depression
www.beatingtheblues.co.ukanu.edu.au/welcome
and
www.moodgym.
For panic and phobiaswww.fearfighter.com (free access can only be prescribed by a doctor in England and Wales)‘Living life to the full’: www.llttf.com (self-help lifeskills training based on CBT)www.moodjuice.scot.nhs.uk/ (for a variety of emotional problems)BooksManage Your mood: How to use BehavioralActivation Techniques to Overcome Depression. ByVeale and Wilson (2007); Published by Robinson:London.The ‘Overcoming’ series: Published by Constable andRobinson, this is a series of self-help books which usethe theories and concepts of CBT to help peopleovercome many common problems. Titles include:Overcoming Social Anxiety and Shyness,Overcoming Depression and Overcoming Low SelfEsteem.Manage Your Mind: The Mental Fitness Guide,second edition. By Butler and Hope (2007).Published by Oxford University Press.583………………….InnovAiT……………………………………………………………………………………………………………………………………………………………………………………References and further information. Beck, A. T. (1976). Cognitive Therapy and theEmotional Disorders. New York: Penguin. Beck, A. T., Rush, J., Shaw, B., & Emery, G. (1979).Cognitive Therapy of Depression. New York:Guildford Press. Beck, J. S. (1964). Cognitive Therapy: Basics andBeyond. New York: Guildford Press
. British
Association
forhas
Counselling
and
Psychotherapies.
How
IAPT
evolved?
Retrieved from www.bacp.co.uk/iapt/how.php. Butler, A., Chapman, J., Foreman, E., & Beck, A. T.(2006). The empirical status of cognitive-behavioraltherapy: a review of meta-analyses. ClinicalPsychology Review, 26, 17–31. doi:10.1016/j.cpr.2005.07.003. Clark, D., Beck, A. T., & Alford, B. (1999).Scientific Foundations of Cognitive Theory andTherapy of Depression. New York: John Wiley. Dimidjian, S., Hollon, S., Dobson, K., Schmaling,K., Kohlenberg, R., Addis, M., . . . Jacobson, N.(2006). Randomized trial of behavioral activation,cognitive therapy, and antidepressant medicationin the acute treatment of adults with major depression. Journal of Consulting and Clinical Psychology,74, 658–670. doi: 10.1037/0022-006X.74.4.658. Dobson, K. (1989). A meta-analysis of the efficacyof cognitive therapy for depression. Journal ofConsulting and Clinical Psychology, 57, 414–419.doi: 10.1037/0022-006X.57.3.414. Dobson, K., Hollon, S., Dimidjian, S., Schmaling,K., Kohlenberg, R., Gallop, R., . . . Jacobson, N.(2008). Randomized trial of behavioral activation,cognitive therapy, and antidepressant medicationin the prevention of relapse and recurrence inmajor depression. Journal of Consulting andClinical Psychology, 76, 468–477. doi: 10.1037/0022-006X.76.3.468. Edinger, J. & Sampson, W. (2003). A primary care‘friendly’ cognitive behavioral insomnia therapy.SLEEP, 26, 177–182. Retrieved from www.journalsleep.org/Articles/260209.pdf. Eels, T. (1997). Handbook of Psychotherapy CaseFormulation. New York: Guilford Press. Fennell, M. (1999). Overcoming Low Self-Esteem:A Self-Help Guide Using Cognitive-BehaviouralTechniques. London: Constable Robinson. Greenberger, D., & Padesky, C. (1995). Mind OverMood: A Cognitive Therapy Treatment Manual forClients. New York: Guilford Press. Hayes, S., Strosahl, K., & Wilson, K. (1999).Acceptance and Commitment Therapy: AnExperiential Approach to Behavior Change. NewYork: Guilford Press. Heatley, C., Ricketts, T., & Forrest, J. (2005). Traininggeneral practitioners in cognitive-behavioural therapyfor panic disorder: randomized-controlled trial.Journal of Mental Health, 14, 73–82. doi:10.1080/09638230500047877. Lynch, D., Laws, K., and McKenna, P. (2010).Cognitive behavioural therapy for major psychiatricdisorder: Does it really work? A meta-analyticreview of well-controlled trials. PsychologicalMedicine, 40, 9–24. doi: 10.1017/S003329170900590X. Linehan, M. (1993). Cognitive-BehavioralTreatment of Borderline Personality Disorder.New York: Guilford Press. Meyer, T., & Scott, J. (2008). Cognitive behaviouraltherapy for mood disorders. Behavioural andCognitive Psychotherapy, 36, 685–693. doi:10.1017/S1352465808004761. NICE (2011). CG123: Common Mental HealthDisorders: Identification and Pathways to Care.Retrieved from: www.nice.org.uk/nicemedia/live/13476/54520/54520.pdf. Padesky, C. (1993). Socratic questioning: changingminds or guiding discovery? Keynote addressdelivered at European Association for Behaviouraland Cognitive Psychotherapies Conference,London.. Padesky, C. (1994). Schema change processes in
cognitive
therapy.
Clinical267–278.
Psychology
and
Psychotherapy,cpp.5640010502
1,
doi:
10.1002/
. Proudfoot, J., Ryden, C., Everitt, B., Shapiro, D.,Goldberg, D., Mann, A., . . . Gray, J. (2004).
Clinical
efficacy
of
computerised
cognitive
behavioural therapy for anxiety and depression inprimary care: randomised controlled trial. BritishJournal of Psychiatry, 85, 46–54. doi: 10.1192/bjp.185.1.46. RCGP. Clinical example 3.10: Care of people withmental health problems. Retrieved fromwww.rcgp.org.uk/gp-training-and-exams//media/Files/GP-training-and-exams/Curriculum-2012/RCGP-Curriculum-3-10-Mental-HealthProblems.ashx. Royal College of Psychiatrists (2012) Description ofCBT. Retrieved from www.rcpsych.ac.uk/mentalhealthinfoforall/treatments/cbt.aspx. Salkovskis, P. (1996). Trends in Cognitive andBehavioural Therapies. Chichester: John Wiley. Scott, A. (2009). Cognitive behavioural therapyand young people: an introduction. Journal ofFamily Health Care, 19(3), 80–82. Scott, J., Paykel, E., Morriss, R., Bentall, R.,Kinderman, P., Johnson, T., . . . Hayhurst, H.(2006). Cognitive-behavioural therapy for severeand recurrent bipolar disorders: randomised controlled trial. British Journal of Psychiatry, 188,313–320. doi: 10.1192/bjp.188.4.313. Teasdale, J., Segal, Z., & Williams, J. (1995). Howdoes cognitive therapy prevent relapse and whyshould attentional control (mindfulness) traininghelp? Behaviour Research and Therapy, 33,25–39. doi: 10.1016/0005-7967(94)E0011-7. Teasdale, J., Segal, Z., Williams, J., Ridgeway, V.,Soulsby, J., & Lau, M. (2000). Prevention of………………………………………………………………………………………………………………………………………………………………………………………………………………………584………………….……………………………………………………………………………………………………………………………………………………………………………………………………relapse/recurrence in major depression by mindfulness-based cognitive therapy. Journal ofConsulting and Clinical Psychology, 68, 615–623.doi: 10.1037/0022-006X.68.4.615. Wright, J. (2006). Cognitive behavior therapy:basic principles and recent advances. Focus 4,173–178. Retrieved from http://focus.psychiatryonline.org/data/Journals/FOCUS/2634/173.pdfMiss Kristina FennKing’s College, University of LondonEmail: [email protected]Dr Majella ByrneClinical Psychologist, Outreach and Support in South London (OASIS) and Institute of Psychiatry,King’s College, University of LondonDOI: 10.1177/1755738013497646…………………………………………………………………………………………………………………………………………AKT question relating to central retinalvein occlusionSingle Best Answer QuestionAn 82-year-old woman attends your morning surgerycomplaining of acute, unilateral loss of vision that hasdeveloped overnight. She denies a headache, but doessmoke and has a history of hypertension.On examination her corrected visual acuity is 6/60 andthere is no evidence of an afferent pupillary defect.Fundoscopy reveals the following appearance.Sue Ford/Science Photo LibraryWhat is the SINGLE MOST likely diagnosis in thispatient? Select ONE option only.A. Branch retinal artery occlusionB. Branch retinal vein occlusionC. Central retinal artery occlusionD. Central retinal vein occlusionE. Diabetic retinopathyAnswer DOI: 10.1177/1755738013497647Dr Ranbir RajputGP, Craigmillar Medical Group, Edinburgh……………………………………………………………………………………………. …………………….585………………….InnovAiT……………………………………………………………………………………………………………………………………………………………………………………

Order from Academic Writers Bay
Best Custom Essay Writing Services

QUALITY: 100% ORIGINAL PAPERNO PLAGIARISM – CUSTOM PAPER