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London: National Institute for chotherapy in subjects with chronic blood pressure medication micardis purchase 20 mg nifedipine with amex, treatment-resistant posttrauHealth and Clinical Excellence blood pressure chart to keep track nifedipine 30 mg overnight delivery. J National Institute for Health and Clinical Excellence (2011) Generalised Psychopharmacol 25: 439–452 blood pressure chart 15 year old purchase nifedipine 30mg online. Manchester: National Institute absence of harmful effects or drug dependency after 3 pulse pressure heart 30 mg nifedipine amex,4-methylfor Health and Clinical Excellence. J Clin Psychiatry 73: 1179– as adjunctive therapy for irritable aggression in posttraumatic stress 1186. A revised (second) consensus statement from the British Association Mukherjee S, Sullivan G, Perry D, et al. Manchester: National Institute for Health and for enhancing response to cognitive-behavior therapy for panic disClinical Excellence. Int Clin Psychopharmacol 27: posttraumatic stress disorder and posttraumatic stress disorder symp142–150. Am J Rickwood D and Bradford S (2012) the role of self-help in the treatPsychiatry 162: 1320–1327. Neuropsychiatr Dis Treat 7: 621– panic disorder and comorbid major depression A naturalistic study. Royal College of Psychiatrists (2007) Use of Licensed Medicines for Brit Med J 318: 593–596. Aust N Z J in the long-term treatment of social anxiety disorder: the 12to Psychiatry 43: 36–44. Curr care; comparative diagnostic accuracy of the Four-Dimensional Opin Psychiatry 21: 37–42. Stud trolled trial of aerobic exercise in combination with paroxetine in the Health Technol Inform 144: 223–229. Read each phrase and decide if it is “Not True or Hardly Ever True” or “Somewhat True or Sometimes True” or “Very True or Often True” for you. Then for each sentence, fill in one circle that corresponds to the response that seems to describe you for the last 3 months. When I get frightened, I feel like things are not real o o o I have nightmares about something bad happening to my par16. When I get frightened, I feel dizzy o o o I feel nervous when I am with other children or adults and I have 39. I am shy o o o *For children ages 8 to 11, it is recommended that the clinician explain all questions, or have the child answer the questionnaire sitting with an adult in case they have any questions. Read each statement carefully and decide if it is “Not True or Hardly Ever True” or “Somewhat True or Sometimes True” or “Very True or Often True” for your child. Then for each statement, fill in one circle that corresponds to the response that seems to describe your child for the last 3 months. My child gets stomachaches at school o o o When my child gets frightened, he/she feels like he/she is going 12. When he/she gets frightened, he/she feels like things are not real o o o My child has nightmares about something bad happening to his/her 16. My child is afraid of having anxiety (or panic) attacks o o o My child worries that something bad might happen to his/her 31. When my child gets frightened, he/she feels dizzy o o o My child feels nervous when he/she is with other children or adults 39. Mitchell Scientia Professor and Head of the School of Psychiatry University of New South Wales December 2012 Contents Funding and Acknowledgements. The authors also wish to thank Natalia Yee whom contributed to the screening of the articles for inclusion and all the experts and organisations who responded to our request for grey or unpublished literature. The authors declare that they have no conflict of interest relevant to this report. It includes within its scope systematic literature reviews, narrative literature reviews and meta-analyses and excludes primary research articles. In order to achieve consensus, any disagreement about a study’s inclusion at any stage was referred to a third researcher for consideration. Of the 144 included reviews, 21 were meta-analyses, 46 were systematic reviews and 77 were non-systematic narrative reviews. The contribution of work in the development of depression and anxiety disorders 4. These include psychosocial risk factors, organisational change, employment status, exposure to workplace trauma and job dissatisfaction. There is preliminary evidence, backed up by a sound theoretical underpinning that strategies which increase employee control may result in positive psychological outcomes. There is also preliminary evidence that interventions which aim to increase employees’ level of physical activity may reduce depressive and anxiety symptoms, although the impact of such interventions on sickness absence levels and work performance in unknown. There was some suggestion that other simpler interventions, such as relaxation and meditation techniques, may have some positive effects, but the impact of these appeared to be less than cognitive behavioural techniques. However, to date there is very little good quality evidence supporting its effectiveness and the relative benefits of different forms of counselling remains unknown. How work protects against, and contributes to the recovery from, depression and anxiety disorders 4. Employees report that good quality work increases feeling of personal wellbeing, facilitates peer interactions and provides access to economic resources. Research gaps and future research priorities As a result of this meta-review, we have identified a number of key research priorities which need to be addressed: 5. Such interventions should be built around evidence-based interventions such as the cognitive behavioural therapies and could be directed at individual workers, managers or the organisation. Chapter 1 – Introduction One of the most dramatic ways in which mental illness leads to social exclusion, financial disadvantage and impaired wellbeing is via its impact on occupational function (Henderson, Harvey et al. In recent decades, mental disorders have replaced musculoskeletal disorders as the leading cause of sickness absence and long term work incapacity in most developed countries (Moncrieff and Pomerleau 2000; Shiels, Gabbay et al. As a result, mental illness is one of the main contributors to the global prevalence of disability (Vos, Flaxman et al. The majority of mental illness difficulties seen in the workforce are attributed to the most common psychiatric disorders, specifically depression and anxiety, which while highly prevalent are usually treatable (Lelliott, Tulloch et al. Within Australia, the cost of workers’ compensation claims for stress-related mental disorders is estimated at $200 million per annum (National Occupational Health and Safety Commission 2003). However, compensation claims and sickness absence form only part of the economic costs associated with depression and anxiety disorders. There is mounting evidence that mental illness is also associated with high levels of presenteeism, a situation where an employee is symptomatic and underperforming, but nevertheless goes to work (Stewart, Ricci et al. Economic analyses from both Europe and the United States suggest that for depression, presenteeism is more common than absenteeism, meaning the overallfinancial cost of presenteeism is between two and four times the cost of absenteeism (Stewart, Ricci et al. The importance of the relationship between work and mental health extends well beyond the economic consequences. Mental illness has a notable influence upon every stage of an individual’s occupational trajectory. In one study, fifty percent of employers reported they would “never” or “rarely” employ someone they knew had a psychiatric disorder (Manning and White 1995). Individuals with mental illness who manage to secure work are more likely to be employed in low status or poorly remunerated jobs, or employed in roles which do not adequately match their skills or level of education (Stuart 2006). These findings demonstrate that stigmatisation and fear of disclosure remain significant barriers that individuals with mental illness are likely to encounter when attempting to enter or return to the workplace (Brohan, Henderson et al. However, there are a number of important reasons why individuals pursue work in the face of such challenges and why promoting work amongst those with mental illness is important. First, work is central to self-identity and the way an individual is viewed by society, provides a daily structure and a sense of purpose. Second, those without work are often financially dependent upon family members or social services and are subsequently prevented from playing an active role in society. Third, being in work appears to be associated with greater mental wellbeing, with a lower prevalence of depression and lower incidence of suicide (Claussen, Bjorndal et al. Finally, the adverse economic and health effects of unemployment are felt not only by the individuals who are not working, but also by their children (Reinhardt Pedersen and Madsen 2002). Together these findings indicate that for most individuals, the mental and physical health benefits of work outweigh any risks (Waddel and Burton 2006). The apparent increase in mental health issues among the working population over recent decades is likely to be the result of a combination of interconnected sociological, psychological and economic factors. One possibility is that some aspects of the modern work environment are ‘toxic’ to workers’ mental health and have contributed to a significant increase in the prevalence rates of mental illness. However, there is substantial research evidence to suggest that the prevalence of mental illness has not increased in the general population over the previous decade (Goldney, Fisher et al.


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Laparoscopic cholecystectomy is associated with less pain heart attack vegas cheap nifedipine 30 mg visa, shorter hospital stay arrhythmia of the stomach buy nifedipine 30mg with mastercard, faster return to blood pressure medication and grapefruit 20mg nifedipine activities of daily living and less abdominal scarring than open surgery blood pressure chart 3 year old buy nifedipine 20mg low price, and it is therefore the treatment of choice in symptomatic gallstone disease. In addition, the laparoscopic approach is amenable to use in the day case setting with appropriate patient selection, improved operative techniques and 16 postoperative control of pain, nausea and vomiting. The mortality rate for a low risk patient undergoing laparoscopic cholecystectomy is <1%; operative risks usually arise from comorbid disease. Other complications of cholecystectomy include bile leak treated conservatively (0. Studies have reported that biliary colic remained in only 8% to 9% of patients, in contrast to non-colicky pain in 18% to 32%. It has been suggested that persistent functional gastrointestinal disorder (characterised by abnormal motility, sensation and perception of gut processes) causes post-cholecystectomy symptoms, especially in 20 those who are operated on for atypical symptoms. Between 10% and 18% of patients undergoing surgery for symptomatic gallstones 21 will also have stones in their common bile duct (choledocholithiasis). However, it is unclear if such thresholds are being used, or how consistently they are being applied. This procedure may be coded as the principal procedure or as a secondary procedure. For consistency and completeness, data is reported to include the principal and secondary procedures (that is ‘all procedures’) with all data presented on this basis. Any variation in practice may be explained by differing catchment sizes or the availability of a particular surgical service, hospital size or specialisation. The number of elective cholecystectomies undertaken in the publicly-funded healthcare system increased by 19. The length of time a patient must wait to be reviewed varies according to the referral pathway and the individual hospital and consultant to which a patient is referred. Of note, delays in access to routine radiological services from primary care have also been noted. Where access is available, public patients were noted to have an average waiting period of 27 14 weeks (range one day to 42 weeks, depending on geographical location). The protocol specifies that patients should be treated based on clinical urgency, with urgent referrals seen and treated first. This had randomised just 75 patients, and the review authors regarded it as being at high risk of bias. The authors concluded that – the results of this trial notwithstanding (the trial had favoured early laparoscopic cholecystectomy) – further 38 trials were needed prior to a making any firm recommendations. In this instance, seven trials met the inclusion criteria, with data from six included for meta-analysis (244 patients in each group). No significant differences were seen in relation to primary outcomes: 39 mortality, bile duct injury, other serious adverse events, and quality of life. Although much of this guidance lay outside the scope of this present work, a number of relevant points were made regarding patients who present with right upper quadrant pain. Most patients who are medically fit will be offered an elective laparoscopic cholecystectomy (within six weeks ideally) after one severe attack of biliary colic as the likelihood of symptomatic recurrence is high. Of note, the guideline also recommended that those with acute cholecystitis should have a cholecystectomy, either electively following conservative management in the first instance (ideally about six weeks after the acute episode), or with an early 16 Health Technology Assessment of Scheduled Procedures: Gallstone disease – draft for consultation Health Information and Quality Authority cholecystectomy during the first admission, particularly if the pain is of less than five 32 days’ duration. It went on to suggest that the presence of gallstones without abdominal symptoms is not an indication for cholecystectomy unless the patient is immunosuppressed or there is a predisposition for malignancy (for example, the gallbladder wall is calcified or there is a family history of gallbladder cancer). The guideline noted that once a patient with gallstones becomes symptomatic, elective cholecystectomy is indicated. It did note that although there is no single accepted scoring system to predict the presence of stones in the common bile duct (choledocholithiasis), by using factors such as age, liver test results, and ultrasound findings, patients can generally be categorised into low (<10%), intermediate (10%-50%), and high (>50%) probability of having stones in the common bile duct (Appendix 1. The guideline’s treatment algorithm was based on the premise that all patients with symptoms require some form of operative intervention, with that intervention dependent upon the likelihood or otherwise of a stone being present in the common bile duct. In addition, these patients are at risk of serious complications including pancreatitis, cholecystitis and biliary obstruction; over a 10-year period such complications can be expected to occur in 2%-3% of patients with initially silent gallbladder stones and hence cholecystectomy should be offered to all patients with symptomatic gallstones, with the exception of those in whom surgical risk is considered prohibitive. Similarly, in relation to patients with symptomatic common bile duct stones, the consequences are often serious and can include pain, partial or complete biliary obstruction, cholangitis, hepatic abscesses or pancreatitis. Based on these risks, the guideline recommends that wherever patients have symptoms, and investigation suggests ductal stones, extraction should be performed if possible. This report concluded that secondary prevention in the form of prophylactic cholecystectomy for people with asymptomatic gallstones could not be recommended. The guideline did outline a number of exceptions to this rule, however, and these are included in Appendix 1. Similarly, a review by Duncan and Riall, published in 2012, highlighted a number of instances in which those with asymptomatic gallstones should be 40 considered for cholecystectomy (Appendix 1. However, the thresholds that were previously developed by these trusts are likely to represent ongoing practice at a local level while new commissioning guides are being established. For illustrative purposes, the findings of a number of related studies are outlined below. Over this time, 114 patients were admitted for the treatment of confirmed gallstone-related diseases; only 40 patients (35. Delay in referral of symptomatic patients had substantial cost implications; more than half of the patients (11/21 [52. A total of 156 patients underwent cholecystectomy, after a mean duration of 12 months on the waiting list. Reasons for emergency admission included pancreatitis (one), cholangitis (three), choledocholithiasis (seven), cholecystitis (seven), and exacerbation of symptoms (10). The median waiting time for cholecystectomy was 130 days (1 to 1,481 days) (mean 188 days). In other words laparoscopic cholecystectomy within three days of index admission dominates (is less costly and as, or more efficacious) than the alternatives of delayed surgery during the same or a future admission. After three days, surgery during the same admission 47 conferred little advantage over elective admission at a later date. Note the remaining diagnosis-related groups accounted for five or fewer of the procedures each. This patient pathway should be managed by the secondary care team (including gastroenterology, general surgery and interventional radiology services, as appropriate). Where symptoms are suggestive of gallstone disease, all patients should have timely access to necessary radiological investigations via primary care services. Referral of patients for review in secondary care should be considered for patients with known gallstone disease (incidentally picked up through radiological investigation for other reasons), that present to primary care with any of the following features, even if asymptomatic: fi suspicion of stones in the common bile duct fi asymptomatic gallstones, but deranged liver function tests fi gallbladder polyps reported on ultrasound – if greater than or equal to [fi] 1cm in size or if demonstrating growth on annual surveillance ultrasound fi patients with a ‘porcelain gallbladder’ (calcification of gallbladder wall) – because of the association with malignancy fi patients who are due to undergo organ transplantation fi patients with insulin-dependent diabetes. Where surgery is indicated, it should be made available at a time when the patient is most likely to derive maximum potential benefit, with due consideration given to their associated risk factors and risk of disease progression. In this case, this pertains to the majority of patients with asymptomatic gallstones. Therefore, the thresholds developed here aim to provide primary care practitioners, surgeons and other clinicians involved in the care of these patients with a template upon which decision making can be standardised. As noted in section 1, obesity has been identified as a key risk factor for the development of gallstone disease. While the evidence regarding resource utilisation and post-operative outcomes may be equivocal at present, the likely continued increased demand within the obese population places an onus on the healthcare system to develop thresholds that will aid in defining which patients are suitable candidates for surgery. The reasons for the regional and local variation are currently unclear and therefore an analysis of the underlying causative factors would be useful in identifying how existing resources might be better utilised. While efficiencies have also been achieved in terms of length of stay and the total number of procedures undertaken, it is likely that waiting lists for surgical intervention will remain substantial. It is thus suggested that one mechanism through which this referral threshold might be implemented would be through its integration in the form of a standardised referral form into this project. As with all thresholds, it is imperative that there are opportunities for appeal mechanisms to ensure good governance. The correlation between ultrasonography and histology in the search for gallstones. Gall stones and mortality: a study of all gall stone related deaths in a single health district. Oral contraceptives, pregnancy, and endogenous oestrogen in gall stone disease-a case-control study. Contemporary outcomes of ambulatory laparoscopic cholecystectomy in a major teaching hospital. Early versus delayed laparoscopic cholecystectomy for people with acute cholecystitis. Referral pathways of patients with gallstones: a potential source of financial waste in the U.

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Appropriateness/Congruence of Affect or Mood and Behavior (by degree) the following groupings are sequenced by degree of increasing appropriateness/ congruence blood pressure medication grapefruit juice cheap nifedipine 30 mg fast delivery. Inappropriate heart attack enrique generic nifedipine 20 mg otc, incongruent blood pressure chart hypertension generic nifedipine 20 mg without prescription, inconsistency of reported/observed feelings and those expected in the circumstances described blood pressure under 80 buy generic nifedipine 30 mg on line. Indifferent to problems, foated over his/her real problems and limitations, la belle indifference, showed no/very minimal/much less than expected affect when discussing experiences that would normally be accompanied by intense feelings, treated own intense experiences too lightly. Affect variable but unpredictable from the topic of conversation, modulations/shifts inconsistent and unrelated to content or affective signifcance of statements. A range of emotions/feelings, appropriate emotions for the ideational content and circumstances, emotional reactions relevant to the thought content and situation, emotions seemed appropriate during the interview/examination, although depressed he was able to smile at the comic elements of his history. Emotions highly appropriate to/congruent with situation and thought content/ subject of discussion, face refects emotions reported, all thoughts colored by emotional state. Or are episodes repetitive, recurrent, irregular, cyclothymic, cyclical, seasonal, annual, anniversary reactionsfi Hostility/Verbal Hostility (by degree) irritated temperamental hostile furious annoyed whining provoked enraged disgruntled piqued embittered incensed cranky “pissed off” exasperated choleric miffed “burned up” indignant displeased “bugged” simmering threatens “snippy” smoldering seething shouts “bothered” ill-tempered infuriated yells restive bad-tempered bristled bellicose insults combative grudging irascible swears assaultive resentful abrasive curses violent sarcastic chronically angry foul-mouthed complaining pugnacious Violence/Aggressive Behaviors See Sections 12. Autonomic Nervous System/Somatic Hyperactivity/Overarousal Facets pallor or fushing Shortness Of Breath dizziness clamminess heart palpitations diffculty breathing vertigo sweaty palms racing heartbeat/ chest pain/tightness room spinning cold sweats/chills tachycardia choking/smothering light-headedness excessive perspiration fast and deep faintness sweaty forehead diarrhea respiration syncope dry mouth urgent urination air hunger “wobbly” stomach hyperventilation “wobbly knees” piloerection/ “butterfies” sneezing “goose bumps” stomach churned yawning overall weakness queasiness sighing unsteadiness hot fashes nausea dry heaves tingling paresthesias “lump in throat” numbness Fight-or-fight response/arousal: Any of the above, plus more acute hearing, spleen contracts, peripheral blood vessels dilate, bronchioles widen, pupils dilate, more coagulates and lymphocytes in blood, adrenaline secreted, stomach acid production decreases, loss of bladder/ anal sphincter control, decreased salivation, etc. Emotional/Affective Symptoms and Disorders 135 Behavioral Facets Motor Tension Agitation, trembling, tightness, twitching, fdgets, feeling shaky, tremulous, body swaying, rigid posture, stiff neck/back/muscles, muscle aches, sits on edge of chair, inhibited movements, restlessness, easy fatigability. Vigilance and Scanning Easily startled, jumpy, oversensitive to stimuli, overreactive. Lessened concentration, erratic, mind goes blank, unable to proceed, unable to function, immobilized, freezes. Baffed, confused, jumbled thoughts, blurred thoughts, perplexed, lessened concentration, unable to recall/indecisive, forgetful, preoccupied, many errors, diminished initiative/productivity/creativity. Depersonalization, derealization, preoccupied with bodily sensations, “futtery,” “quavery. No depth of feeling when recounting events, erratic, guardedness, rigidity, confuses self, selfinduced pressures, jumps from one subject/topic to another, low frustration tolerance, low stress tolerance, low tolerance for ambiguity. For a Child: Fears of animals, ghosts, demons, “the bogeyman,” darkness, getting lost, parental illness/disability/death/loss, punishment, being embarrassed/humiliated, separation anxiety. The cardinal features are chronic mood instability and at least one major depressive episode with at least one episode of hypomania (but not full mania, as in Bipolar I). Eating Appetite/hunger increase or decrease, anorexia, fewer/more frequent meals, fasting, selective hungers, “comfort foods,” binges, weight increase/decrease. Energy Anergic, lowered energy, slowed down, listless, sluggish, “needs to be pushed to get things done,” “everything is an effort,” easy fatigue, tired, feels “run down,” mopes, muddles through, weakened, lethargic, deenergized, torpid, lassitude, “can’t shake off the blues,” “can’t get out of bed,” energy is just adequate for life’s tasks, inability to cope with routine responsibilities, weary, drained, exhausted. Lessened/no interest, indifferent, passive, “I’d like to but it is too much trouble,” “I can take it or leave it,” “My partner wants to but I don’t care. Substance Use Overuse of prescription and over-the-counter medications (analgesics, laxatives, sleeping aids, vitamins), alcohol, caffeine, stimulant drugs. Dissipated, worn, drained, “a shell of a person,” haphazard self-care, self-neglect. Emotional/Affective Symptoms and Disorders 139 Summary Statements All appetites are muted. Slowed, ruminative, mulls over, indecisive, decreased concentration, trouble mobilizing thoughts, abulia. Confused, perplexed, “I’m not mentally here,” worsened memory, spotty memory, vague, unclear. Dichotomous thinking: Oversimplifying; black or white, good or bad, right or wrong, all or nothing. Magnifcation or minimization: Loss of proportion; exaggerating or minimizing the importance of an event. Overgeneralizing: Basing a general conclusion on too few data or one incident; jumping to conclusions, “always” or “never. Selective abstraction: Attending to only the negative aspect(s) of a situation and ignoring the other (positive) ones; mental flter; selective attention; disqualifying the positive. Telescoping of time and options so that a single, fnal, negative outcome is seen as inevitable. Client’s attributions are negative, stable/unstable, global/specifc/situational, internal/external. She/he dwelled on past failures, lost opportunities, what could never be, roads not taken, etc. Social Facets Interpersonal reclusive avoidant envious irritable strained inaccessible distances resentful low frustration relationships asocial self-absorbed argumentative tolerance dependent withdraws bitter passive barricades self low social feels scorned demanding unassertive away interest feels abandoned crabby isolates subdued easily irritated wary hermit-like painfully shy easily annoyed distrustful secludes separates from life/others petulant suspicious only watches self-righteous less interactive Support-Seeking See also Section 9. Emotional/Affective Symptoms and Disorders 141 Other Facets of Depression Bear the following possibilities in mind: Is client depressed because forced into dependency by disability/losses/injuryfi Does client interpret deaths as desertions, yet is simply alone because she/he has outlived othersfi Depression in Children (5–15 years) u Note: Children under 7 are usually unable to characterize internal mood states. Most symptoms are similar in children and adults, but some listed below are slightly different or in addition to adult ones. Scales for depression in children include the Children’s Depression Inventory (Kovacs, 1992) for ages 7–17 years, and the Children’s Depression Rating Scale—Revised for ages 6–12 years. Cognitions: Catastrophizing, assumption of personal responsibility for negative outcomes. Lack of interest in playing/favorite activities, isolation, agitation, despair, hypersensibility, insecurity, boredom, temper tantrums, fugues, feelings of inferiority, nihilistic thoughts, suicidal impulses, obsessive thoughts, loneliness. School problems: Learning diffculties, school refusal/“phobia,” dyslexia, concentration diffculties. Vegetative symptoms: Fatigue, anergia, sleep disorders/terrors, appetite changes (very common at different ages), weeping, abdominal pains, alopecia aureata, tics, eczema, allergies, anorexia, bulimia. Other: Fears of parents’ dying, clinging, isolation in room, aggression, substance abuse. Grief/Bereavement Normal Grief Distress, sorrow, anguish, despair, heartache, pain, woe, suffering, affiction, troubles. Easily made/becomes tearful, slowed thinking and responding with long latencies of response, stares into space. Kubler-Ross (1969) identifed fve stages of the normal reaction to loss: denial, anger, bargaining, depression, and acceptance. Unresolved/Morbid/Pathological Grief Partial denial of death, absence of grieving, pathological identifcation, hypochondriasis, chronic depression, bitterness, chronic grieving, avoidance of cues to the deceased, isolation, reattachment. Decreased immune system functioning, increased use of drugs and alcohol, depression, over-/ misuse of medical care for grief. Guilty, responsible, guilt proneness, mortifed, self-condemning, self-reproaching, has a punitive superego, transgressed superego boundaries, unacceptable impulses, fears of annihilation. Embarrassed, humiliated, disgraced, reproached, depreciated, devalued, humbled, wishes to disappear/become invisible, avoids disclosure of faws, hides inadequacies. Ashamed, feels inferior, fears rejection/abandonment, fails to attain goal/measure up. Guiltless, cold, hardened, cynical, unrepentant, conscienceless, shameless, unscrupulous, parasitic, incorrigible, predatory. Distinctions between Shame and Guilt the following distinctions are adapted by permission from Potter-Effron (1989). Central trait Shame Guilt Failure Of being, of meeting goals, of Of doing, of moral self. Involvement of self Total self-image involvement: Partial self-image involvement: “How could I have done thatfi Primary defenses Desire to hide (withdrawal), Obsessive thinking, paranoid, denial, perfectionism, intellectualization, seeking grandiosity, shamelessness. Positive functions Awareness of limits of human Sublimation, moral behavior, condition, discovery of initiative, reparation. Assessment Tests have been developed by Mosher (1988), Tangney and Dearing (2002), Harder and Greenwald (1999), O’Connor et al.

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