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By: William A. Weiss, MD, PhD

  • Professor, Neurology UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA

Specify if: With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the event (although the onset and expression of some symptoms may be immediate) best tretiva 10mg. In some individuals cheap tretiva 10mg on-line, fear-based re experiencing purchase tretiva 10mg with mastercard, emotional buy tretiva 5mg line, and behavioral symptoms may predominate. In others, anhe donic or dysphoric mood states and negative cognitions may be most distressing. In some other individuals, arousal and reactive-externalizing symptoms are prominent, while in others, dissociative symptoms predominate. The directly experienced traumatic events in Criterion A include, but are not limited to, exposure to war as a combatant or civilian, threatened or actual physical assault. For children, sexually violent events may include developmentally inappropriate sexual experiences without physical violence or injury. A life-threatening illness or debilitating medical condition is not neces­ sarily considered a traumatic event. Medical incidents that qualify as traumatic events in­ volve sudden, catastrophic events. Indirect exposure through learning about an event is limited to experiences affecting close relatives or friends and experiences that are violent or acciden­ tal. Such events include violent per­ sonal assault, suicide, serious accident, and serious injury. The disorder may be especially severe or long-lasting when the stressor is interpersonal and intentional. Commonly, the individual has recurrent, involuntary, and intrusive recollections of the event (Criterion Bl). The emphasis is on recurrent memories of the event that usually include sensory, emotional, or physiological behavioral components. A common reexperiencing symptom is distressing dreams that replay the event itself or that are representative or thematically related to the major threats involved in the traumatic event (Criterion B2). The individual may experience dissociative states that last from a few seconds to several hours or even days, during which components of the event are relived and the individual behaves as if the event were occurring at that mo­ ment (Criterion B3). Such events occur on a continuum from brief visual or other sensory intrusions about part of the traumatic event without loss of reality orientation, to complete loss of awareness of present surroundings. These episodes, often referred to as "flash­ backs," are typically brief but can be associated with prolonged distress and heightened arousal. For young children, reenactment of events related to trauma may appear in play or in dissociative states. Intense psychological distress (Criterion B4) or physiological re­ activity (Criterion B5) often occurs when the individual is exposed to triggering events that resemble or symbolize an aspect of the traumatic event. The individual commonly makes deliberate efforts to avoid thoughts, memories, feelings, or talking about the traumatic event. Negative alterations in cognitions or mood associated with the event begin or worsen after exposure to the event. These negative alterations can take various forms, including an inability to remember an important aspect of the traumatic event; such amnesia is typically due to dissociative amnesia and is not due to head injury, alcohol, or drugs (Criterion Dl). The individual may experience markedly diminished interest or participation in previously enjoyed activities (Criterion D5), feeling detached or es­ tranged from other people (Criterion D6), or a persistent inability to feel positive emotions (especially happiness, joy, satisfaction, or emotions associated with intimacy, tenderness, and sexuality) (Criterion D7). They may also engage in reckless or self­ destructive behavior such as dangerous driving, excessive alcohol or drug use, or self injurious or suicidal behavior (Criterion E2). Problems with sleep onset and maintenance are common and may be associated with nightmares and safety concerns or with generalized elevated arousal that interferes with adequate sleep (Criterion E6). Some individuals also experience persistent dissociative symptoms of de­ tachment from their bodies (depersonalization) or the world around them (derealization); this is reflected in the 'with dissociative symptoms" specifier. Associated Features Supporting Diagnosis Developmental regression, such as loss of language in young children, may occur. Lower estimates are seen in Europe and most Asian, African, and Latin American countries, clustering around 0. Highest rates (ranging from one-third to more than one half of those exposed) are found among survivors of rape, military combat and captivity, and ethnically or politically motivated internment and genocide. Latinos, African Americans, and American Indians, and lower rates have been reported among Asian Americans, after ad­ justment for traumatic exposure and demographic variables. Symptoms usually begin within the first 3 months after the trauma, although there may be a delay of months, or even years, before criteria for the diagnosis are met. Duration of the symptoms also varies, with complete recovery within 3 months occurring in approximately one-half of adults, while some individuals remain symptomatic for longer than 12 months and sometimes for more than 50 years. Symptom recurrence and intensification may occur in response to reminders of the original trauma, ongoing life stressors, or newly experienced traumatic events. Young children may report new onset of frightening dreams without content specific to the traumatic event. Before age 6 years (see criteria for preschool subtype), young children are more likely to ex­ press reexperiencing symptoms through play that refers directly or symbolically to the trauma. They may not manifest fearful reactions at the time of the exposure or during reex­ periencing. Parents may report a wide range of emotional or behavioral changes in young children. Avoidant behavior may be associated with restricted play or exploratory behavior in young children; reduced par­ ticipation in new activities in school-age children; or reluctance to pursue developmental op­ portunities in adolescents. Adolescents may harbor beliefs of being changed in ways that make them socially undesirable and estrange them from peers. Irritable or aggressive behavior in children and adoles­ cents can interfere with peer relationships and school behavior. Reckless behavior may lead to accidental injury to self or others, thrill-seeking, or high-risk behaviors. In older individuals, the disorder is associated with negative health perceptions, primary care utilization, and suicidal ideation.

Fight or flight tends to buy discount tretiva 10mg be a male response cheap 5mg tretiva with amex, while dissociation tends to purchase tretiva 10 mg without prescription be a female response tretiva 5mg without prescription. However, if an initial active response characterized by crying is unsuccessful, infants and young children of both genders tend to use dissociative responses. This tends to protect the young child, who is incapable of effective fighting and effective flight. As the male child grows older, in conjunction with other variables also, he may shift from dissociation to fight or flight, and it is not uncommon for children to use a combination of both types of defensive responses (Perry et al, 1995). It is presumed that structural changes in the brain are intimately linked to biochemical processes that occur, and that brain structure and function are altered as a result of trauma exposure, especially of a chronic nature. Practically, the affected parts of the brain are linked to critical functions for each individual. These include recognition and response to danger, interpretation of stimuli, self-regulation, memory formation, attention and ability to acquire information, processing of emotional information, control of impulses, planning, and learning from experience. Especially prominent at a biochemical level in the brain’s fight or flight response to trauma is the release of chemicals known as catecholamines, which include adrenaline and noradrenaline. Catecholamines are responsible for a variety of emergency bodily responses, including highly focused attention, increased heart rate and blood pressure, sweating, and increased energy availability in skeletal muscles. These responses create a state of hyperarousal and enable the person to focus on the danger and react actively, either in self-defense (“fight”) or by removing oneself from the danger (“flight”). The immediate catecholamine release in the fight or flight response is adaptive, and promotes survival of the individual and the species. For most people, this emergency response shuts down shortly after the danger has passed. The person once again calms down and is able to attend to the wide range of events occurring at the time and afterwards. In contrast, people exposed to severe and chronic trauma often are unable to “shut down” their emergency response system (Yehuda and Davidson, pp. As a result, they remain in a hyperaroused state, which interferes with their internal comfort level, their ability to complete daily tasks, and their capacity to listen, reason, take in information, and learn new skills. A variation of chronic hyperarousal involves the person able to shut down, while remaining highly vulnerable to reactivation of the internal emergency system – even in response to stimuli that others would not experience as threatening. Thus, a common consequence of severe fight or flight reactions to trauma, in both children and adults, is that a short-term, protective response (release of catecholamines) becomes chronic and, even in the absence of objective danger, a barrier to effective functioning. The dissociation responses form a continuum, depending on the severity of the trauma and the circumstances of the child. Initially, there is release of catecholamines as with the fight or flight response, but then a different neurobiological process occurs. With dissociation, there is an increase in vagal tone, which decreases blood pressure and heart rate despite the increased catecholamines (Perry et al, 1995). As other neurobiological processes are activated, the manifestations of early dissociation occur – for example, decreased movement, compliance, avoidance, numbing, and restrictive affect. It has been proposed that these responses may help “camouflage” the child and enable the child to organize and figure out how to respond, thereby promoting survival (Perry et al, 1995). Cortisol, a glucocorticoid produced by the adrenal gland in response to stimulation by the pituitary gland, is critical to the adaptation of the organism to stress and serves to activate the emergency response. It is hypothesized that the low level of cortisol might be associated with the impaired shut down. In contrast, some studies of traumatized children have shown elevated cortisol levels (van der Kolk, p. It is likely that some people may be at greater risk than others due in part to their biological profile prior to trauma exposure (Bryant, pp. In addition, the biological processes that occur after trauma exposure follow a changing course (Bryant, p. Regardless of the details of the neurobiological processes, it is essential that clinicians, educators, and other child-serving professionals appreciate that the symptoms and behaviors demonstrated by traumatized children, for the most part, reflect physiological and experiential responses that are not intentional in nature. This is of considerable practical relevance, because those working with these children “have a tendency to deal with their frustration by retaliating in ways that often uncannily repeat the child’s earlier trauma” (van der Kolk, p. The Contribution of James Garbarino – “Lost Boys” James Garbarino, who has studied youth violence and adaptation to maltreatment for many years, addresses some of the consequences of trauma, particularly for males, not reflected in the diagnostic nomenclature but of extreme importance in understanding and working effectively with these youth (1995). In Lost Boys: How Our Sons Turn Violent and How We Can Save Them, he refers to what he calls the ten “facts of life” for violent males subjected to trauma (pp. In what follows, Garbarino’s “facts” are listed and underlined, followed by brief editorial comment or elaboration underneath: 1. Child becomes hypersensitive to arousal in the face of a (perceived) threat, with response to threat involving emotional disconnection or aggressive acting out. Apparent disinterest can be misleading: the child may appear emotionless, “when in fact (he is) actually filled with intense emotions,” and may explode, “when pushed too far. Traumatized kids need a calming and soothing environment to increase the level at which they are functioning. Without a future orientation, there is little motivation to try, and a tendency to take unnecessary risks and place oneself and others in harm’s way. Traumatized youth tend to develop “juvenile vigilantism,” lacking trust in the adult’s ability to ensure safety and feeling the need to “take matters into their own hands,” They can only let go of this when they feel safe and protected, and experience adults as fair and trustworthy. This orientation is difficult to change, and requires the promotion of spiritual values and a positive identity. Since “feeling like a nobody is intolerable,” it follows that “even a negative definition of self is better than nothing at all. Therefore, there is need for respect and saving face, to avoid humiliation and additional shame. Thus, it is important to understand and begin from the point of view of the child, in non-judgmental manner, as “the first step in moral reeducation. With needs so great and overwhelming, many of these children also have not developed empathy.

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Every day I tried a diferent these ideas together by providing an way to buy tretiva 5 mg with visa go to generic tretiva 5mg overnight delivery and from school effective tretiva 5mg. I was able to generic 5mg tretiva free shipping do public and private K-12 schools across better at school because I had better the United States. Kids can a must-read for the school counselor, improve their grades, like I did, and school psychologist, or school social get along with their teachers. How series of group sessions designed to run ever, a substantial minority continue to “bell to bell” during one class period. Trauma exposure can tion with Los Angeles Unifed School lead to a variety of problems, including District school-based social workers, alterations in mood and behavior and ensuring that it is feasible and acceptable loss of social and academic functioning in the school environment. This second edition to sists at least one month following trauma the original 2003 manual retains all of the exposure and includes the following core content of the program and updates four kinds of symptoms, according to it with lessons learned through training the Diagnostic and Statistical Manual of and implementation. Though focused about child abuse and domestic primarily on students with moderate violence is also increasing. However, such students can infuence later adult mental and may require concurrent individ physical health (Felitti et al. Training in the use of this interventions for at-risk students, and manual is strongly encouraged. For tertiary interventions for those in more information, including detailed need of services (see Reinbergs and implementation materials, see Following training, secondary or tertiary intervention, implementation support is also very depending on the level of need of important, including coaching and the students included. Thoughts, develop more-balanced and helpful feelings, and behavior are seen as thoughts. For example, the thought that or problematic thoughts that are something is dangerous will heighten getting in their way. What we • Teach students to decide on a plan Stress think of action and carry out their desired Trauma plan. Research shows that thinking is disturbed after an extreme trauma or experience with violence. Two gen eral themes can begin to dominate thinking: xvi • the world is dangerous, I am not clif. The longer • I can’t deal with this, I’ll never be they stay, the more calm and com the same, I am falling apart. This example shows how our bodies naturally these two ideas or “themes” in adjust to new situations, as long as thinking can begin to interfere with nothing bad happens to arouse the daily life. Through train or talking about their trauma in ing, students can usually fnd a more the safety of the group, gradually adaptive, less distressing way of look decreasing their anxiety. A common example is to process it, the easier it will be to blaming themselves for what hap do so, and the less these thoughts pened and therefore feeling guilty or and anxiety will interfere with their ashamed. The goal is for students on recognizing and challenging mal to feel that although a terrible thing adaptive thinking, they are able to happened to them, it cannot hurt consider these ideas more fully and them now. As students are gradually able related to the traumatic experience to approach and endure these situa by using a process called habituation. At other times, particular for screening students or for partici students are exposed to personal pation in groups. Whatever the source of trauma, some preparation is needed prior to implementing How do you select students a trauma-focused program. It is important to address common We recommend using a screening concerns at this stage, such as how instrument in the general school privacy, suspicions about child population to identify students in abuse, and missed class time will be need of this program. Since children’s responses An alternative to screening stu on self-report measures are not dents in the general population always valid, we suggest that you is to request referrals from school follow the screening process with a counselors, teachers, or caregivers personal interview with the student, who are aware of a traumatic expo during which a clinician can review sure. If the Once students are identifed for par entire school is afected by a disaster ticipation, form groups of six to eight or violence, it is possible that many students who are near in age to one more would beneft from this kind another. One common victim relationships or relationship strategy for screening is to begin with tensions that may create a difcult one grade level or certain class group environment. This way, you do not • Sessions last about 45 minutes and are designed to be delivered xix weekly. Use the school calendar to ize group engagement, good behav fnd a block of ten to 12 weeks that ior, and homework completion. In addition, or through a schedule that varies materials are listed at the beginning the meeting so that students don’t of each session. In addition, if you plan to transportation and safety issues are use some kind of behavioral incentive worked out. Ensure that you will have protected How do parents/guardians/ time during the groups and will caregivers get involvedfi In both sessions, dents to come to the group, such as caregivers are taught about the sending call slips or passes ahead material the students will learn and of time, sending runners to gather also directly learn the core elements students, or setting up a buddy of the material. If there is more How do you promote good than one clinician or group in the behavior in groupsfi However, it can be a good idea to use one, even with the best scheduling, it particularly for younger groups or can be difcult to draw caregivers in in groups that include students with for these meetings. We suggest unable to join, you can do outreach you use your favorite strategy for by phone to convey some of the key behavioral reinforcement to incentiv information. However, it can be difcult toms settle down naturally before to decide which trauma to focus on bringing them into the program. It is okay to switch the focus to whichever trauma is the How do I take care most difcult, but be careful to con sider whether the student might be of myselffi

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These in­ dividuals may show worse performance in unstructured work or school situations buy tretiva 10mg fast delivery. Individuals with borderline personality disorder display impulsivity in at least two areas that are potentially self-damaging (Criterion 4) purchase tretiva 10 mg. They may gamble discount 10 mg tretiva with amex, spend money irrespon­ sibly purchase 10 mg tretiva otc, binge eat, abuse substances, engage in unsafe sex, or drive recklessly. Individuals with this disorder display recurrent suicidal behavior, gestures, or threats, or self-mutilat­ ing behavior (Criterion 5). Completed suicide occurs in 8%-10% of such individuals, and self-mutilative acts. Recurrent suicidality is often the reason that these individuals present for help. These self-destructive acts are usually precipitated by threats of separation or rejection or by expectations that the individual assumes increased responsibility. Individuals with borderline personality disorder may display affective instability that is due to a marked reactivity of mood. The basic dysphoric mood of those with borderline personality disorder is often disrupted by periods of anger, panic, or despair and is rarely relieved by periods of well-being or satis­ faction. Individuals with borderline personality disorder may be troubled by chronic feel­ ings of emptiness (Criterion 7). Individuals with this disorder frequently express inappropriate, intense anger or have dif­ ficulty controlling their anger (Criterion 8). The anger is often elicited when a caregiver or lover is seen as neglectful, withholding, uncaring, or abandoning. Such expressions of anger are often followed by shame and guilt and contribute to the feeling they have of being evil. During periods of extreme stress, transient paranoid ideation or dissociative symptoms. These episodes occur most frequently in re­ sponse to a real or imagined abandonment. Associated Features Supporting Diagnosis Individuals with borderline personality disorder may have a pattern of undermining themselves at the moment a goal is about to be realized. Premature death from suicide may occur in individu­ als with this disorder, especially in those with co-occurring depressive disorders or sub­ stance use disorders. Physical handicaps may result from self-inflicted abuse behaviors or failed suicide attempts. Recurrent job losses, interrupted education, and separation or di­ vorce are common. Physical and sexual abuse, neglect, hostile conflict, and early parental loss are more common in the childhood histories of those with borderline personality dis­ order. Common co-occurring disorders include depressive and bipolar disorders, sub­ stance use disorders, eating disorders (notably bulimia nervosa), posttraumatic stress disorder, and attention-deficit/hyperactivity disorder. Borderline personahty disorder also frequently co-occurs with the other personality disorders. Prevalence the median population prevalence of borderline personality disorder is estimated to be 1. The prevalence of borderline personality disorder is about 6% in primary care settings, about 10% among individuals seen in outpatient mental health clinics, and about 20% among psychiatric inpatients. The prevalence of borderline personality disorder may decrease in older age groups. Development and Course There is considerable variability in the course of borderline personahty disorder. The most common pattern is one of chronic instability in early adulthood, with episodes of serious affective and impulsive dyscontrol and high levels of use of health and mental health re­ sources. The impairment from the disorder and the risk of suicide are greatest in the young-adult years and gradually wane with advancing age. Although the tendency to­ ward intense emotions, impulsivity, and intensity in relationships is often lifelong, indi­ viduals who engage in therapeutic intervention often show improvement beginning sometime during the first year. During their 30s and 40s, the majority of individuals with this disorder attain greater stability in their relationships and vocational functioning. Fol­ low-up studies of individuals identified through outpatient mental health clinics indicate that after about 10 years, as many as half of the individuals no longer have a pattern of be­ havior that meets full criteria for borderline personality disorder. Borderline personality disorder is about five times more common among first-degree biological relatives of those with the disorder than in the gen­ eral population. There is also an increased familial risk for substance use disorders, anti­ social personality disorder, and depressive or bipolar disorders. C ulture-Related Diagnostic Issues the pattern of behavior seen in borderline personality disorder has been identified in many settings around the world. Adolescents and young adults with identity problems (especially when accompanied by substance use) may transiently display behaviors that misleadingly give the impression of borderline personality disorder. Such situations are characterized by emotional instability, "existential" dilemmas, uncertainty, anxiety-provoking choices, con­ flicts about sexual orientation, and competing social pressures to decide on careers. Gender-Related Diagnostic issues Borderline personality disorder is diagnosed predominantly (about 75%) in females. Borderline personality disorder often co-occurs with depressive or bipolar disorders, and when criteria for both are met, both may be diagnosed. Because the cross-sectional presentation of borderline personality disorder can be mimicked by an episode of depressive or bipolar disorder, the clinician should avoid giving an addi­ tional diagnosis of borderline personality disorder based only on cross-sectional presenta­ tion without having documented that the pattern of behavior had an early onset and a long­ standing course. Other personality disorders may be confused with border­ line personality disorder because they have certain features in common. It is therefore im­ portant to distinguish among these disorders based on differences in their characteristic features.

Foods rich in potassium include bananas purchase tretiva 5mg mastercard, potatoes order 10 mg tretiva amex, avocados purchase tretiva 10 mg with mastercard, apricots safe 10 mg tretiva, dried fruits, spinach, mushrooms, skim milk products, cocoa drinks and whole grain products. Excessive washing of vegetables and cooking with too much liquid reduces the potassium content of foods. Here, too, supplementation with nutritional preparations should occur only after consulting the treating physician. Zinc, because of its wide range of functions in a variety of biological processes in the human body, is one of the most important trace elements. On the one hand, there is in creased loss due to intestinal bleeding, diarrhea, fistulae and chronic inflammation; on the other, zinc intake may be reduced due to inadequate dietary consumption and/ or malabsorption in the bowel associated with an albu min deficiency. For example, diarrhea refractory to treatment may 18 the informed patient often be due to zinc deficiency; zinc is lost to a great extent with the stool. Zinc deficiency is more frequently encountered in patients with Crohn’s disease than in those with ulcerative colitis. Foods rich in zinc include beef, pork, poultry, eggs, milk, cheese, oys ters, grain sprouts, poppy seeds, sunflower seeds, liver, wheat, oats, Brazil nuts, cashews and cocoa. This is due to the fact that there are both organic and inor ganic zinc compounds. In addition, it is important that the zinc preparation be taken on an empty stomach at least one hour before the next meal. Special care should always be exercised when multivitamin and min eral preparations are combined with other preparations with the goal of dietary supplementation. A first requirement, however, is to determine the degree to which the bowel can tolerate the presence of food, which depends on the extent and severity of the inflam mation and patient’s other symptoms. During mild in flammatory flares or during remission (the phase in which the inflammation subsides), it may be sufficient to eat according to the guidelines of a light full diet (see chap ter 5. Juices (especially made from citrus fruits), car bonated beverages, and strong coffee and tea are usu ally less well tolerated. This solution contains sodium, potassium, chlo ride, citrate, bicarbonate and glucose in amounts best suited for fluid replacement. In very severe inflammatory flares, patients may require to be maintained on parenteral nutrition for several weeks. It is useful to begin with easily digested foods high in carbohydrates, such as zwieback, oat or rice meal and low-fat broths. During this period, patients should still avoid raw produce, including lettuce and uncooked fruit. If patients continue to tolerate the dietary progression, they can be advanced to a “light full diet”, always con sidering patients’ individual nutritional intolerances, such as lactose intolerance. The food choices permitted according to light full diet are especially suitable in cases in which there remains uncertainty about what foods can be eaten. As the patient becomes increasingly free of symptoms, remaining restrictions can be reduced, while still being guided by individual tolerances. Symptoms may, however, be triggered by in dividual intolerances: Experience has shown that per sons with digestive disorders tend to react with bloating, diarrhea and pain to coarsely milled grains and nuts and products made from them, as well as vegetables of the cabbage family, legumes, fatty and fried foods, fruits with hard peels (plums, gooseberries etc. Products made for diabetics containing a large amount of fructose may make diarrhea worse. In particular, so-called soluble fiber (contained in large amounts in fruit, vegetables, potatoes and whole grain products) binds water, thus helping to thicken the stool and reduce the frequency of bowel movements. In testinal bacteria break down these substances into short chain fatty acids, which serve the intestinal mucosal membrane as a direct energy substrate and contribute to maintaining healthy bowel function. Any undesired weight loss is a warning sign for malnutrition and should be investigated by your physician! Many patients would prefer to reduce or even stop med ication during symptom-free phases. This is important in preventing the overgrowth of pathogenic (disease-causing) microbes (table 5). Although our understanding of the effects of prebiotics in the bowel is increasing, results of clinical studies have not yet shown clear and significant advantages in terms of health promotion associated with the use of prebiot ics. Probiotics are living microorganisms that, when ingest ed into the human body, produce health-promoting ef fects beyond their basic nutritional and physiological ef fects. In order to be classified as a probiotic, a microor ganism must fulfill defined criteria. Whether a combination of different microbes is superior to a single probiotic agent cannot be answered definitively at this time. The data on preventing occurrence of inflammation in the pouch (pouchitis) are also interesting. Several clinical studies have confirmed the efficacy of a probiotic mix Table 6: Effects of probiotics 30 the informed patient ture (lactobacilli, bifidobacteria, Streptococcus ther mophilus) in pouchitis. In these studies, both the devel opment of pouchitis and disease recurrence were re duced in comparison with patients receiving placebo. Cur rently, there is increased marketing of foods enriched with pre and/or probiotics. Preliminary studies point to certain eating habits in patients with ulcerative colitis that may indicate a potential correlation with disease ac tivity, namely, a possibly longer duration of the symptom free interval in patients whose diet contains smaller amounts of sulfur-containing substances. The currently state of knowledge is inadequate to make a general recommen dation in this regard.

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