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A 29-year-old woman with a previous diagnosis of bipolar disorder is hospitalized during an acute manic episode gastritis diet ginger buy generic lansoprazole 30mg. She is elated gastritis diet vegetarian safe lansoprazole 30mg, sexually provocative gastritis symptoms in elderly lansoprazole 15mg online, and speaks very fast gastritis diet under 1000 buy lansoprazole 15mg online, jumping from one subject to another. She tells the nurses that she has been chosen by God to be “the second virgin Mary. After appropriate tests are obtained to the patient in the previous vignette, lithium treatment is started. Within what time interval does this medication come to steady state with regular administrationfi A 25-year-old woman with schizophrenia is started on an antipsychotic medication to control her symptoms. While her hallucinations decrease on the medication, she notes that she feels as if her “skin is crawling” and her legs “want to move by themselves. For which of the following comorbid medical conditions would this medication be contraindicated for this patientfi Which of the following hormones is most commonly used in the adjuvant treatment of depressionfi A 32-year-old woman is prescribed nortriptyline for her first episode of major depression. The initial dose is 25 mg at bedtime, gradually increased over the next week to 50 mg at bedtime. Two days after the dosage increase, the woman develops urinary retention, blurred vision, and severe constipation. Her blood level is 280 ng/mL (recommended therapeutic window is 50 to 150 ng/mL) 12 hours after the last dose. The patient takes carbamazepine 200 mg three times a day to treat trigeminal neuralgia. The patient has taken 800 mg of ibuprofen for headaches every day for the past week. A patient with refractory schizophrenia has been almost free of active psychotic symptoms and has been functioning considerably better since he was placed on clozapine 500 mg/day, but he has experienced two episodes of grand mal seizure. A patient reports that she has become depressed with the onset of winter every year for the past 6 years. A 19-year-old girl is taken hostage with other bystanders during an armed robbery. She is freed by police intervention after 10 hours of captivity, but only after she has witnessed the shooting death of two of her captors. She startles at every noise and experiences acute anxiety whenever she is reminded of the robbery. Which of the following medications would most likely help decrease this patient’s hyperarousalfi A 72-year-old man with a long history of recurrent psychotic depression is hospitalized during a relapse. He has prostatic hypertrophy, coronary heart disease, and recurrent orthostatic hypotension. Which of the following is the most appropriate antipsychotic medication for this patientfi A 47-year-old businessman who has taken paroxetine 40 mg/day for 6 months for depression leaves for a 2-week business trip overseas and forgets his medication at home. Since his depression has been in full remission for at least 3 months, he decides to stop the treatment without talking with his psychiatrist. The benzodiazepines’ action depends on their interaction with which of the following receptorsfi She states that she has been carefully avoiding high-tyramine foods as she was told, but she admits that a friend gave her two tablets of a cold medication shortly before her symptoms started. If the woman’s symptoms from the vignette above were caused by a dietary indiscretion, which of the following foods would be the most probable cause of her symptomsfi A 28-year-old woman is embarrassed by her peculiar tendency to collapse on the floor whenever she feels strong emotion. His blood pressure is 150/95 mm Hg, his pulse is 110 beats/min, and his temperature is 38. Which of the following medications can be effective in treating the condition from the vignette abovefi Which of the following adverse effects is most commonly associated with this drugfi Which of the following serum level ranges is the target for lithium use in acute maniafi Thickening of mitral valve cusps 264 Psychiatry Questions 481 to 484 For each patient’s symptoms, select the most likely diagnosis. A 35-year-old painter is very frustrated by a fine tremor of her hands that worsens when she works and causes her to smudge her paintings. She was started on a medication several months ago after she had begun to believe that she was the “next Picasso. An 18-year-old male is admitted to a locked psychiatric unit after he assaulted his father. He is convinced that his family members have been replaced with malevolent aliens and hears several voices that comment on his actions and call him demeaning names. Two days after initiating treatment, he develops a painful spasm of the neck muscles and his eyes are forced into an upward gaze. At that time, he was noted to have hallucinations of two men commenting on his behavior and delusions that God was going to punish him for not finishing college. Once started on medications, the hallucinations and delusions lessened, though he remained socially isolative and apathetic. After 35 years on the same medication, he has a coarse, pill-rolling tremor that worsens at rest and improves during voluntary movements. A 45-year-old woman with schizoaffective disorder has received neuroleptic medications, antidepressants, and mood stabilizers for at least 20 years. Other facial muscles, her trunk, and extremities are not affected, and her tongue does not dart in and out of her mouth when she is asked to protrude it. They are metabolized by the hepatic cytochrome P450 oxidase system, and can therefore increase the circulating levels of many psychotropic drugs which are metabolized the same way. Also every 6 months, patients should have the signs and symptoms of both hyperand hypothyroidism reviewed with them, to double check that they are not experiencing any of the symptoms. The tricyclic drugs include imipramine, desipramine, amitriptyline, and nortriptyline. Tricyclic antidepressants have different side effect profiles, with each blocking cholinergic, adrenergic, and histaminic receptors to different degrees. For example, there is less anticholinergic activity with desipramine than with imipramine, and nortriptyline is less likely to cause orthostatic hypotension than amitriptyline. However, all tricyclics are at least somewhat anticholinergic and sedating, and thus should not be used 265 266 Psychiatry as a first-line treatment for major depression in the elderly. Its efficacy is thought to be related to its effects on inhibition of serotonin reuptake. With an uncomplicated agranulocytosis (no signs of infection), the patient should be placed in protective isolation, the clozapine should be discontinued, and a bone marrow specimen may need to be gotten to see if progenitor cells are being suppressed. In more extreme cases, such as this one, the emergency use of dialysis is indicated. Ramelteon reduces time to sleep Psychopharmacology and Somatic Therapies Answers 267 onset, and to a lesser extent, increases the amount of time spent in sleep. There has been no evidence found of rebound insomnia or withdrawal effects from this drug. Flumazenil can be used in the emergency room setting to counteract the effects of benzodiazepine overdose. Disulfiram is used as an aversive treatment to maintain sobriety in those with alcohol dependence, and acamprosate is also used to improve treatment outcomes in those with alcoholism, though the exact treatment mechanism is not known. The typical neuroleptics (eg, haloperidol and chlorpromazine) are particularly prone to causing these side effects.

Most regimens are patient-friendly with low pill burden and few dietary restrictions gastritis symptoms right side purchase lansoprazole 15mg with mastercard. Although complete eradication of the infection cannot be achieved gastritis neck pain cheap 30mg lansoprazole free shipping, sustained inhibition of viral replication results in partial and often substantial reconstitution of the immune system in most patients gastritis chronic diet order 15 mg lansoprazole free shipping, greatly reducing the risk of clinical disease progression gastritis diet òâ order lansoprazole 15 mg mastercard. Some medicines are so similar or have synergistic toxic effects and so should not be combined. Adequate viral suppression for most patients on therapy is defined as a reduction in viral load to undetectable levels. Nowadays, clinicians have considerable reservations about treating asymptomatic immunocompetent cases, because of the risk of adverse effects to medication, the challenge of long-term adherence and development of virus resistance. During the initiation of therapy and when adjustments are made to the regimen used, applicants should be assessed as temporarily unfit. Further assessment should then be made for side effects that are likely to be disabling after treatment is stable for a period of months, before any decision on certification is made. There is considerable variability in the occurrence of adverse effects between medicines and between individuals. Noteworthy is the occurrence of a lipodystrophy syndrome, characterized by a “buffalo hump” fat distribution, in 50 per cent of the cases. This syndrome is associated with aeromedical risk factors, such as hypertriglyceridaemia, hypercholesterolaemia, insulin resistance, and Type 2 diabetes mellitus. The data presented by the collaboration is limited by its broad categories (although recent updates on their original publication have improved this). The populations used in these studies are predominantly Western European, Israeli and Australian and so caution may be required when applying the data to pilots from other regions. In addition the socio-economic level of pilots and air traffic controllers may differ from that of the study populations. Regular evaluation of cockpit performance may be considered in lieu of this or to enhance assessment in asymptomatic, stable applicants with very low risk of progression. Further co-infection testing will be required where clinically indicated and those with new positive tests may require specialist evaluation prior to further certificatory assessment. However, some applicants may be fit and remain so for a prolonged period, and it is to assist in the identification of such individuals that the information in this chapter is written. As a rule, immune-compromised people should not receive vaccines based on live-attenuated organisms, such as measles and yellow fever. Include assessment of primitive reflexes (because of their association with cognitive decline). The figures are summated to reach a score that allows a prediction of risk of progression during the next 12 months. Unacceptable medications include enfuvirtide, zalcitabine, indinavir and stavudine. Particular attention needs to be given to the toxicity and side-effect profile of such medications. Those commencing or modifying efavirenz treatment require a psychiatric and neurological examination at initial certification or within six months after initiating therapy. Reviews should take account of any over-the-counter medications and alternative therapies being taken. Impaired performance will require further neuropsychological assessment to be compared with baseline testing, and any deficits will require that the pilot is declared temporarily unfit. Neuropsychological assessment should be undertaken if there are any clinical concerns about cognitive impairment. Further co-infection testing should be undertaken where clinically indicated and those with new positive tests must be deferred for further evaluation. If an applicant develops new symptoms and/or fails to achieve the nominal levels listed above he must be declared temporarily unfit and referred to the Licensing Authority. The names of pharmaca and other substances mentioned in this chapter are primarily based on North American nomenclature. Aircraft accidents have occurred as a result of pilot incapacitation related to disease and/or medication. Illnesses that interfere with safe aircraft operations may be only minor problems in other occupational settings. The common cold, minor gastroenteritis, headaches, mild vertigo, and otitis media, while not precluding work in an office, may pose significant hazards to the pilot, especially if flying in instrument meteorological conditions or congested airspace. What is “minor” to an administrator may be a “major” problem for the on-duty pilot. Accordingly, one must not only be concerned with the effects of disease on flying ability but also with the possible effect of the medicines utilized to treat the illness in question. Self-medication with “over-the-counter” medicines such as analgesics and anti-histamines should be discouraged, and licence holders should be advised to consult their medical examiner before taking any medicine that may have detrimental effects on performance. The medical examiner should avoid recommending medicines that are new to market; it is better to wait until a medicine is well established and any side effects recognized. With all kinds of medicines, a period of grounding is necessary when starting a new medicine to avoid a possible idiosyncratic reaction while flying. As different medicines are available in different States, as the generic and trade names of medicines may vary from one State to another, as medicines may be licensed for different purposes in different States, and as local health care practices may vary widely and be dependent on the prevalence of particular diseases, each Licensing Authority should issue guidance on pharmacotherapy for its medical examiners. The term “problematic use” is defined in Annex 1 as follows: the use of one or more psychoactive substances by aviation personnel in a way that: a) constitutes a direct hazard to the user or endangers the lives, health or welfare of others; and/or b) causes or worsens an occupational, social, mental or physical problem or disorder. In some cultures, traditional medicine is the first choice of treatment for many medical conditions. The medical examiner should be aware of this, as the pilot may not volunteer such information, considering herbal medicines and other “over-the-counter” preparations as safe and harmless in spite of the fact that they may have significant side effects in the context of aviation. The possible flight safety impact of preventive medication is a consideration particularly encountered in tropical operations. All considerations of medication as applied to a flight crew member must be in compliance with the provisions of Annex 1. Its purpose is to aid in the implementation of the provisions of Annex 1 in a manner to achieve international uniformity in the safest disposition of pilots undergoing pharmacotherapy. Knowledge of the operational aspects and working conditions pertaining to the pilot is essential in making decisions concerning medication. If the disorder to be treated does not per se preclude aviation operations, then questions b) and c) become important. It is reasonable to approach the problem of medication in the pilot by considering the problem from the aspect of undesirable. The value of an alert mind and clear thought processes needs no discussion or defence. The same principle applies to the air traffic controller whose role in flight safety is also of high importance. Individual variation can be quite wide with respect to the metabolism of depressants, so any rule of conduct must be very conservative. It is for this reason that in general a 24-hour period is suggested prior to resumption of flight duties after administration of a central nervous system depressant. It is certainly true that short-term hypnotics exist that can be used and still allow the pilot to return to duty after a much shorter period, for example, 12 hours or less after ingestion of the sedative. Under well-supervised operational conditions, it may be safer for a pilot to occasionally use a short-acting hypnotic between transmeridian long-haul flight segments to assure adequate sleep during rest periods, than to operate without adequate sleep. Self-medication should be discouraged, and particular attention should be paid to this when operations include stop-overs at destinations where sedatives are more readily available than at home base. Stimulation of the sympathetic (thoraco-lumbar, sympatho-adrenal, or adrenergic) portion of the autonomic system can induce tachycardia, increased cardiac output, mydriasis, lessened fatigue, raised blood sugar levels, rise in body temperature, peripheral vasoconstrictions, and a general response to overcome stress. Predominance of one of these two autonomic systems can be achieved by either direct stimulation of the system in question or inhibition of the other. Examples of the more commonly used sympathomimetic pharmaca are ephedrine, adrenaline, amphetamine and isoproterenol. While such effects are usually not severe, especially in certain modern preparations, their usage by active licence holders should be controlled. Some examples of pharmaca of this type are belladonna (which contains the anticholinergics hyoscyamine and atropine) and atropine itself. Some examples of pharmaca in this class are bethanechol, methacholine and pilocarpine. In some cases one might observe tachycardia and hyperventilation, seemingly effects of sympathetic stimulation rather than depression.

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It is mild gastritis symptoms treatment purchase lansoprazole 15mg, therefore gastritis diet of the stars generic 30mg lansoprazole, probably more appropriate for the chief medical officer of the Licensing Authority to gastritis diet 6 pack discount 30 mg lansoprazole visa be the ‘accountable executive’ responsible for national aeromedical safety gastritis symptoms light headed cheap 30 mg lansoprazole free shipping. Collection and Analysis of Aeromedical Data Just as the senior executives of a company need accurate information (concerning costs, profit, marketing, personnel, etc. Such data can be obtained from three main sources: in-flight medical events; medical events that occur between flights, but which would have been of importance had they occurred in flight; and medical conditions discovered by the medical examiner during a routine medical examination. The chief medical officer is responsible for using this aeromedical data, along with relevant information from the wider medical literature, to devise and implement appropriate aeromedical policies. In-flight medical events: When considering what data might be useful to monitor aeromedical safety, a good starting point would be to include in-flight aeromedical events that affect the flight crew. However, while accurate information concerning in-flight medical events is of potential benefit to companies and States alike, there remain some significant challenges in obtaining such data: a) a minor event may not be obvious to the passengers or cabin crew and there may be a temptation not to report it if only the flight crew are aware of the event; b) the flight crew involved may fear adverse repercussions from the employer, or regulator; c) the paperwork regarding such an event may be onerous; d) confidentiality issues may be a concern; or e) the initial report will almost always be made by crewmembers with little or no medical training. A recent comparison between in-flight medical events in the United States and the United Kingdom demonstrated that, in the United Kingdom, relatively minor pilot-related in-flight medical events were reported to the Licensing Authority at a rate approximately 40 times greater (55:1. While it is possible that this observation reflects an actual difference between U. A regular analysis of in-flight events by individual States and a comparison of reporting systems in different States would be of value in helping to better understand why such differences exist. Efforts to gather and analyze in-flight medical events may also be hampered by the lack of a single, widely accepted, classification system. For example, incapacitation from smoke or fumes may be reasonably regarded as medically related, but there is usually little connection between such events and the fitness of the pilot, as determined by the medical examiner. In addition, classification of events may need to be undertaken with less than full (medical) information, which introduces an element of error and subjectivity. Ideally, in order to maximize benefit from the analysis of in-flight aeromedical events, categorization should be undertaken by an individual who understands both the aviation environment, and aviation medicine. Medical events that occur between flights: On average, professional pilots spend between 5 and 10% of their time in the air, so noting events that occur between flights would greatly increase the size and utility of any database of medical events that affect pilots. An analysis of the medical conditions that come to light between routine examinations would be particularly useful. Some States require significant medical events to be reported to the regulatory authority after a certain time period, which provides the basis of a useful database for medical conditions that may appear, or deteriorate, between routine examinations. Further, as a medical history is required at each routine medical examination, it should be possible to obtain data on such events, which could be analyzed. Information from routine medical examinations: There are two types of information available from routine examinations: information from the medical history, and findings from the examination (mental and physical, including any investigations. The aero medical literature contains few studies that have attempted to investigate the relationship between those medical conditions that are identified during the routine periodic medical examination and I-1-22 Manual of Civil Aviation Medicine those that cause in-flight medical events. The results of one such study (6) suggested that the conditions most likely to result in in-flight medical events were usually first observed during the period between routine examinations — they were not discovered during the periodic examination by a medical examiner. If this is the case, it would seem important that the Licensing Authority ensures that the license holder knows what action to take when such an event occurs so that flight safety is not eroded, and that the medical examiner and Licensing Authority are informed of the necessary information. Reporting of Medical Conditions Reporting of in-flight incidents involving operational errors may create a fear of adverse repercussions. An analogy can be made with medical events, both in flight and on the ground as a license holder may withhold information if he believes his career may be adversely affected should he report a medical condition. However, systems which encourage reporting of events of safety relevance generate information that can be used to enhance safety. It is reasonable to assume that if medical conditions of license holders are made known to the medical department of a Licensing Authority, a potential exists to improve safety. To this end, a regulatory authority should have, as part of its regulatory regime, a fair, transparent, and consistent system, developed in consultation with the license holder’s representative bodies. Such a system should be based as much as possible on evidence of aeromedical risk and action in individual cases should be proportionate to the individual risk. Such an approach might include, as a formally stated goal, perhaps included in the mission statement of a regulatory authority’s medical department, the aim of returning license holders to operational status whenever possible. Experience shows that this is often mentioned as a desirable goal in aviation medicine circles, but rarely stated formally. Conclusions Despite the growth and acceptance of evidence-based practice throughout most fields of medicine, we still find ourselves routinely using the lowest level of evidence (expert opinion, unsupported by a systematic review) for regulatory aeromedical decisions. Such decisions are often not based on the explicit acceptance of any particular level of aeromedical risk. Without guidelines concerning acceptable risk levels, and with reliance on expert opinion for individual aeromedical decisions, consistent decision making is impeded, and comparisons between States are more difficult. A cornerstone of a successful future for regulatory aviation medicine is consistent decision making by Licensing Authorities using high-level evidence. Such an approach, if applied by different regulatory authorities, would assist global harmonization of medical fitness requirements. To promote these aims, several aspects of the aeromedical process should be reviewed and improved, such as: 1. The periodicity and content of periodic medical examinations should be adjusted to better reflect the medical demographics of applicants and the safety relevance of their medical conditions. For example, an increased emphasis on alcohol, drugs, and mental health may be warranted for younger pilots while it would be appropriate to give greater consideration to cardiovascular disease as pilots age. Few licensing authorities collect medical examination data in a format that is easily amenable to analysis and there is a lack of data concerning conditions of aeromedical significance that are discovered during routine medical examinations. Of those that do, it is rare that the reports are assessed in a systematic manner. Support for better reporting through the development of an appropriate culture by companies and regulatory authorities. A more supportive approach to license holders who develop medical problems should improve the reliability of data on which aeromedical policies are based by encouraging reporting of medical conditions. Annex 6 – operation of aircraft, to the convention on international civil aviation, Amendment 30, November 2006. Annex 11 – air traffi c services, to the convention on international civil aviation, Amendment 45, November 2007. Annex 14 – aerodromes, to the convention on international civil aviation, Amendment 8, November 2006. In-flight medical incapacitation and impairment of United States airline pilots: 1993 to 1998. In-flight incapacitation in United Kingdom public transport operations: incidence and causes 1990-1999 [Abstract]. Aerospace Medical Association 73rd Annual Scientifi c Meeting; Montreal, Canada; May 2002. The predictive value of periodic medical examinations of commercial pilots [Abstract]. Aerospace Medical Association 73rd Annual Scientific Meeting; Montreal, Canada; May 2002. Aeromedical regulation of aviators using selective serotonin reuptake inhibitors for depressive disorders. Of necessity, many decisions relating to the evaluation of medical fitness must be left to the judgement of the individual medical examiner. The evaluation must, therefore, be based on a medical examination conducted throughout in accordance with the highest standards of medical practice. In such cases due regard must be given to the privileges granted by the licence applied for or held by the applicant for the Medical Assessment, and the conditions under which the licence holder is going to exercise those privileges in carrying out assigned duties. This guidance material also contains a discussion of the terms “likely” and “significant” as used in the context of the medical provisions in Chapter 6. The important non-medical factors which should be taken into consideration in such cases are the age and experience of the applicant, the privileges of the particular licence or rating applied for or held, and the environmental conditions in which these are to be exercised: 6. The applicant shall be made aware of the necessity for giving a statement that is as complete and accurate as the applicant’s knowledge permits, and any false statement shall be dealt with in accordance with 1. The medical requirements of Annex 1 are not concerned with social considerations or medical conditions of importance for employment. Nevertheless, on initial issue of a Medical Assessment, it would be poor medical practice to encourage an applicant to pursue flight training if the minimum requirements of Annex 1 are barely met, especially in cases where further deterioration might be expected or is likely to occur. Likewise, it would be poor practice to disregard the preventive aspects of the regulatory examination for renewal.

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If neglect occurs early and signs of the disorder appear gastritis or morning sickness trusted lansoprazole 15mg, clinical features of the disorder are moderately stable over time gastritis diet mayo clinic discount 30mg lansoprazole otc, particularly if conditions of neglect persist gastritis chest pain buy lansoprazole 15mg on-line. Indiscriminate social behavior and lack of reticence with un­ familiar adults in toddlerhood are accompanied by attention-seeking behaviors in pre­ schoolers atrophische gastritis definition generic 30mg lansoprazole overnight delivery. When the disorder persists into middle childhood, clinical features manifest as verbal and physical overfamiliarity as well as inauthentic expression of emotions. Peer relationships are most affected in adolescence, with both indiscriminate behavior and conflicts appar­ ent. Disinhibited social engagement disorder has been described from the second year of life through adolescence. There are some differences in manifestations of the disorder from early childhood through adolescence. At the youngest ages, across many cultures, children show reticence when interacting with strangers. Young children with the disorder fail to show reticence to approach, engage with, and even accompany adults. In preschool children, verbal and social intrusiveness appear most prominent, often accompanied by attention-seeking behavior. Verbal and physical overfamiliarity continue through middle childhood, accompanied by inauthentic expressions of emotion. Relative to healthy adolescents, adolescents with the disorder have more "superficial" peer relationships and more peer conflicts. Serious social neglect is a diagnostic requirement for disinhibited social engagement disorder and is also the only known risk factor for the disorder. Neurobiological vul­ nerability may differentiate neglected children who do and do not develop the disorder. However, no clear link with any specific neurobiological factors has been established. The disorder has not been identified in children who experience social neglect only after age 2 years. Prognosis is only modestly associated with quality of the caregiving environment following serious neglect. In many cases, the disorder persists, even in children whose caregiving environment becomes markedly improved. Caregiving quality seems to moderate the course of disinhibited so­ cial engagement disorder. Nevertheless, even after placement in normative caregiving environments, some children show persistent signs of the disorder, at least through ado­ lescence. Comorbidity Limited research has examined the issue of disorders comorbid with disinhibited social engagement disorder. Conditions associated with neglect, including cognitive delays, language delays, and stereotypies, may co-occur with disinhibited social engagement dis­ order. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: 1. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s). Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). Marked physiological reactions to internal or external cues that symbolize or re­ semble an aspect of the traumatic event(s). Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following: 1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feel­ ings about or closely associated with the traumatic event(s). Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: 1. Inability to remember an important aspect of the traumatic event(s) (typically due to dis­ sociative amnesia and not to other factors such as head injury, alcohol, or drugs). Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others. Marked alterations in arousal and reactivity associated with the traumatic event(s), be­ ginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: 1. Irritable behavior and angry outbursts (with little or no provocation) typically ex­ pressed as verbal or physical aggression toward people or objects. Specify whether: With dissociative symptoms: the individual’s symptoms meet the criteria for post­ traumatic stress disorder, and in addition, in response to the stressor, the individual ex­ periences persistent or recurrent symptoms of either of the following: 1. Dereaiization: Persistent or recurrent experiences of unreality of surroundings. Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance. In children 6 years and younger, exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: 1. Witnessing, in person, the event(s) as it occurred to others, especially primary care­ givers. Note: Witnessing does not include events that are witnessed only in electronic me­ dia, television, movies, or pictures. Note: Spontaneous and intrusive memories may not necessarily appear distress­ ing and may be expressed as play reenactment. Note: It may not be possible to ascertain that the frightening content is related to the traumatic event. One (or more) of the following symptoms, representing either persistent avoidance of stimuli associated with the traumatic event(s) or negative alterations in cognitions and mood associated with the traumatic event(s), must be present, beginning after the event(s) or worsening after the event(s): Persistent Avoidance of Stimuli 1. Avoidance of or efforts to avoid activities, places, or physical reminders that arouse recollections of the traumatic event(s). Avoidance of or efforts to avoid people, conversations, or interpersonal situations that arouse recollections of the traumatic event(s). Markedly diminished interest or participation in significant activities, including con­ striction of play. Alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: 1. Irritable behavior and angry outbursts (with little or no provocation) typically ex­ pressed as verbal or physical aggression toward people or objects (including ex­ treme temper tantrums). The disturbance causes clinically significant distress or impairment in relationships with parents, siblings, peers, or other caregivers or with school behavior. Specify whether: With dissociative symptoms: the individual’s symptoms meet the criteria for post­ traumatic stress disorder, and the individual experiences persistent or recurrent symp­ toms of either of the following: 1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body. Derealization: Persistent or recurrent experiences of unreality of surroundings. 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).

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