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Cross References Altitudinal field defect; Hemianopia; Junctional scotoma muscle relaxant causing jaundice purchase cheapest rumalaya forte and rumalaya forte, Junctional scotoma of Traquair; Macula sparing spasms under left rib discount 30 pills rumalaya forte with amex, Macula splitting; Quadrantanopia; Scotoma; Tilted disc Visual Form Agnosia this name has been given to an unusual and a highly selective visual perceptual deficit back spasms 5 weeks pregnant generic rumalaya forte 30 pills without prescription, characterized by loss of the ability to identify shape and form spasms lower left side order cheap rumalaya forte on-line, although colour and surface detail can still be appreciated muscle spasms zinc generic rumalaya forte 30 pills overnight delivery, but with striking preservation of visuomotor control muscle spasms zyprexa discount rumalaya forte 30 pills free shipping. The pathophysiology is uncertain but may relate to rhythmic contractions of the cricothyroid and rectus abdominis muscles. With the patient standing, the examiner holds the shoulders and gently shakes backwards and forwards, the two sides out of phase. Normally, the passive arm swing induced by this movement will be out of phase with the trunk movements, but in rigidity the limbs and trunk tend to move en bloc. Passive swinging of the wrist or elbow joint may also be performed to assess rigidity. Wasting may also be seen in general medical disorders associated with a profound catabolic state. However, this is not a linear scale; grade 4 often becomes subdivided into 4-, 4, and 4+ (or even 5-) according to the increasing degree of resistance which the examiner must apply to overcome activity. Accepting all these difficulties, it should be acknowledged that the grading of weakness, like all clinical observations, is subject to some degree of observer bias. However, there is no evidence that pure lesions of the pyramidal tracts produce this picture: pyramidotomy in the monkey results in a deficit in fine finger movements, but without weakness. Coexistent wasting suggests that muscle weakness is of lower motor neurone origin, especially if acute, although wasting may occur in long-standing upper motor neurone lesions. Weakness with minimal or no muscle wasting may be non-organic, but may be seen in conditions such as multifocal motor neuropathy with conduction block. Other terms sometimes used for Wernicke-type aphasia are sensory aphasia or posterior aphasia. There may be associated anxiety, with or without agitation and paranoia, and concurrent auditory agnosia. Wernicke placed it in the posterior two-thirds of the superior temporal gyrus and planum temporale (Brodmann area 22), but more recent neuroradiological studies (structural and functional imaging) suggest that this area may be more associated with the generation of paraphasia, whereas more ventral areas of temporal lobe and angular gyrus (Brodmann areas 37, 39, and 40) may be associated with disturbance of comprehension. A correlation exists between the size of the lesion and the extent of the aphasia. A similar clinical picture may occur with infarcts of the head of the left caudate nucleus and left thalamic nuclei. Cross Reference Tremor Winging of the Scapula Winging of the scapula, or scapula alata, is a failure to hold the medial border of the scapula against the rib cage when pushing forward with the hands. Winging of the scapula may be a consequence of weakness of the serratus anterior muscle, usually due to a neuropathy of the long thoracic nerve of Bell, but sometimes as a consequence of brachial plexus injury or cervical root (C7) injury. Weakness of trapezius, particularly the middle trapezius muscle, may also cause winging of the upper part of the scapula, more prominent on abduction of the arm, when the superior angle of the scapula moves farther from the midline. Witzelsucht Witzelsucht, or the joking malady, refers to excessive and inappropriate facetiousness or jocularity, a term coined in the 1890s for one of the personality changes observed following frontal (especially orbitofrontal) lobe injury. These are most commonly seen in the context of untreated hypothyroidism, but have also been recorded in other situations, including treatment with -blockers, diabetes mellitus, and complete heart block. It may coexist with intermittent voluntary effort, collapsing weakness, cocontraction of agonist and antagonist muscles, and inconsistency in clinical examination. Cross Reference Collapsing weakness Wrist Drop Wrist drop describes a hand hanging in flexion due to weakness of wrist extension. When attempting to write, patients may find they are involuntarily gripping the pen harder, and there may also be involuntary movement at the wrist or in the arm. A tremor may also develop, not to be confused with primary writing tremor in which there is no dystonia. There is some neurophysiological evidence that the condition is due to abnormalities within the spinal cord segmental motor programmes and muscle spindle afferent input to them. Excessive or pathological yawning (chasm) is compulsive, repetitive yawning not triggered by physiological stimuli such as fatigue or boredom. Cross References Parkinsonism; Sighing Yips Yips is the name given to a task-specific focal dystonia seen in golfers, especially associated with putting. Abnormal cocontraction in yips-affected but not unaffected golfers: evidence for focal dystonia. Yo-yo-ing is difficult to treat: approaches include dose fractionation, improved drug absorption, or use of dopaminergic agonists with concurrent reduction in levodopa dosage. Cross References Akinesia; Dyskinesia; Hypokinesia - 380 - Z Zeitraffer Phenomenon the zeitraffer phenomenon has sometimes been described as part of the aura of migraine, in which the speed of moving objects appears to increase, even the vehicle in which the patient is driving. Zooagnosia the term zooagnosia has been used to describe a difficulty in recognizing animal faces. In one case, this deficit seemed to persist despite improvement in human face recognition, suggesting the possibility of separate systems for animal and human face recognition; however, the evidence is not compelling. In a patient with developmental prosopagnosia seen by the author, there was no subjective awareness that animals such as dogs might have faces. Nonrecogntion of familiar animals by a farmer: zooagnosia or prosopagnosia for animals. Cross References Agnosia; Prosopagnosia Zoom Effect the zoom effect is a metamorphopsia occurring as a migraine aura in which images increase and decrease in size sequentially. It is often associated with genetic aberrations that may be correlated with disease outcomes. The region involved in our reported translocation, in this case, seems to have an impact on B-cell development and proliferation, disease initiation and poor prognosis. Its association with poor prognosis needs to be confirmed by examining the matched samples from more such cases. While recurring chromosomal rearrangements have been recognized as critical events in leukemogenesis, they often require additional genetic perturbations for a complete disease phenotype. The underlying result of all these alterations driving the disease is the disruption of tumor suppressor genes and arresting hematopoietic development, along with activation of proto-oncogenes and de-regulation of signaling pathways to drive proliferation. Though, mitoxantrone has been shown to be significantly better than idarubicin with marginal improvement in the therapeutic outcomes [12,13]. The patient died following two episodes of cardiac arrest after 18 days of reporting to the hospital. In August 2014 that patient was reported to Indraprastha Apollo Hospital, New Delhi with complaints of severe body pain, itching all over body, hematuria, gum bleeding, epistaxis and fever. The initial diagnosis was on preliminary clinical evaluation; he was diagnosed with generalized lymphadenopathy, severe bony tenderness along with enlargement of the liver and spleen. During his stay in the hospital, he received 2 cycles of chemotherapy comprising cytocristin, methotrexate, leucovorin, and leunase. During his treatment, he developed Pseudomonas aeruginosa and Escherichia coli infections in the blood; later he developed coagulase-negative Staphylococcus infection. Within 3 days he again got admitted with complaints of pyuria and high-grade fever. On the 6th day of the second admission, he developed hemoptysis that he aspirated. He had a cardiac arrest from which he could be revived with prompt efforts, and again a second cardiac arrest developed after 1 hour when he was already shifted to the intensive care unit. Importantly, 97% atypical cells (immature lymphoblast) were detected on differential cell count (Table 1). Table 1 Hematological parameters of the patient at presentation Result Reference Interval 9. Bone marrow biopsy showed areas of myelonecrosis along with marrow spaces almost entirely replaced by blasts. Analysis of 26 metaphases was performed using standard procedures for G-T-G banding. Structural aberrations including translocation between chromosomes 1 and 7 at regions q32 and p22 respectively, an additional derivative of chromosome 2, addition of a material of unknown origin at 4q33, deletion of 6q21 and both missing copies of chromosome 12 are indicated by arrows the same karyotype was observed in all the 26 metaphases. Ethical Consent Int J Med Res Health Sci 2018, 7(9): 107-111 Written informed consent was obtained from the legal guardian of the patient for publication of this case report and accompanying image. Despite bacterial infections being treated adequately and undergoing two cycles of aggressive chemotherapy, the patient suffered two episodes of cardiac arrest and succumbed to the disease. Since the patient died early during the course of treatment, further follow-up or analysis could not be undertaken. This is substantiated by the fact that all the translocation was noted in all the 26 metaphases that were analyzed. Taken together, the regions involved in the reported translocation seem to influence B-cell development and proliferation, disease initiation and poor prognosis. The t (1;7) (q32;p22) translocation may be an ancestral clone as it was noted in all the 26 metaphases involved. Furthermore, the specific t(1;7) (q32;p22) translocation has not been reported earlier for any hematologic malignancy. Also, no prior information is available on the cytogenetic status of the patient, either at initial diagnosis or at any other time during treatment for the next 3 years. No part of this book may be reproduced in any form or by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Library of Congress Cataloging-in-Publication Data A concise review of clinical laboratory science / [edited by] Joel Hubbard. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with recommendations and practice at the time of publication. This is particularly important when the recommended agent is a new or infrequently employed drug. The publishers have made every effort to trace copyright holders for borrowed material. If they have inadvertently overlooked any, they will be pleased to make the necessary arrangements at the first opportunity. In your upcoming role as professionals, remember that your job is important to the medical world as well as to the individual patient. Always be excited about the unlimited opportunities available in your chosen profession and help lead the field of Clinical Laboratory Science well into the 21st century. This review text is a valuable educational tool for both the novice and the experienced clinical laboratory scientist. Practicing clinical laboratory scientists and medical residents will also find this book to be an excellent source for review. This book represents a culmination of the efforts and expertise of the faculty of the Clinical Laboratory Science program at Texas Tech University Health Sciences Center in Lubbock, Texas, and reflects over 100 years of combined medical technology experience. All contributing authors reflect their professional excellence in their contributed chapters, not only as educators, but also as outstanding professionals in their field. I encourage readers to send me feedback on this book at the following email address: joel. Text Format and Features Each chapter presents a concise summary of the most important facts and concepts in that subject area in an outline format. Boxes, tables, and figures throughout distill concepts and make them easier to comprehend. Online menus at the end of each chapter point readers to supplementary Web-based materials. An expanded chapter dealing with laboratory operations (Chapter 11) addresses topics such as management and organizational theory, professionalism, quality assurance, laboratory regulations, and delivery of an educational unit. In addition, a new chapter on molecular pathology (Chapter 10) focuses on molecular laboratory methods and an overview on the testing of genetic diseases. See the inside front cover of this text for more details, including the pass code you will need to gain access to the Web site. Their individual expertise, willingness to present the highest quality of material, and high level of professionalism made the task of producing this text easy. I would also like to thank my wife, Kathy, who patiently listened to my endless rambling about the project. Solutions can be described in terms of the concentration of the components of the solution. A percent solution can be described as: (1) w/w, which is expressed as weight (mass) per 100 units of weight (g/g). Molarity (M) is expressed as moles per liter (mol/L) or millimoles per milliliter (mmol/mL). Normality (N) is expressed as equivalent weight (Eq wt) per liter of volume (Eq/L or mEq/mL). Dilutions are solutions formed by making a less concentrated solution from a concentrated solution. They are stated as a part (concentrate) of the concentrated substance used plus the volume of diluent used. Hydration is the process of adding water molecules to the chemical structure of a compound. Statistics is the science of gathering, analyzing, interpreting, and presenting data. Descriptive statistics are data that can be described by their location and dispersion compared with the average.

Self-reported excessive sleepiness (hypersomnolence) despite a main sleep period lasting at least 7 hours muscle relaxant tablets buy 30pills rumalaya forte overnight delivery, with at least one of the following symptoms: 1 muscle relaxant pediatrics buy rumalaya forte canada. A prolonged main sleep episode of more than 9 hours per day that is nonrestorative muscle relaxant ibuprofen generic rumalaya forte 30 pills overnight delivery. The hypersomnolence is accompanied by significant distress or impairment in cogni tive yawning spasms purchase discount rumalaya forte on-line, social spasms treatment purchase rumalaya forte online pills, occupational muscle relaxant rx discount rumalaya forte 30 pills visa, or other important areas of functioning. The hypersomnolence is not better explained by and does not occur exclusively during the course of another sleep disorder. The hypersomnolence is not attributable to the physiological effects of a substance. Coexisting mental and medical disorders do not adequately explain the predominant complaint of t^ypersomnolence. Specify if: With mental disorder, including substance use disorders With medicai condition With another sleep disorder Coding note: the code 780. Code also the relevant associated mental disorder, medical condition, or other sleep disorder im mediately after the code for hypersomnolence disorder in order to indicate the associ ation. Specify current severity: Specify severity based on degree of difficulty maintaining daytime alertness as manifested by the occurrence of multiple attacks of irresistible sleepiness within any given day occur ring, for example, while sedentary, driving, visiting with friends, or working. Diagnostic Features Hypersomnolence is a broad diagnostic term and includes symptoms of excessive quantity of sleep. Individuals with this disorder fall asleep quickly and have a good sleep efficiency (>90%). They may have difficulty waking up in the morning, sometimes appearing confused, combative, or ataxic. This prolonged impairment of alert ness at the sleep-wake transition is often referred to as sleep inertia. During that period, the individual appears awake, but there is a decline in motor dexterity, behavior may be very inappro priate, and memory deficits, disorientation in time and space, and feelings of grogginess may occur. The persistent need for sleep can lead to automatic behavior (usually of a very routine, low-complexity type) that the individual carries out with little or no subsequent recall. For example, individuals may find themselves having driven several miles from where they thought they were, unaware of the "automatic" driving they did in the preceding minutes. For some individuals with hypersomnolence disorder, the major sleep episode (for most individuals, nocturnal sleep) has a duration of 9 hours or more. However, the sleep is often nonrestorative and is followed by difficulty awakening in the morning. For other individ uals with hypersomnolence disorder, the major sleep episode is of normal nocturnal sleep duration (6-9 hours). In these cases, the excessive sleepiness is characterized by several un intentional daytime naps. These daytime naps tend to be relatively long (often lasting 1 hour or more), are experienced as nonrestorative. Individuals with hypersomnolence have daytime naps nearly everyday regard less of the nocturnal sleep duration. Individuals typically feel sleepiness developing over a period of time, rather than experiencing a sudden sleep "attack. Associated Features Supporting Diagnosis Nonrestorative sleep, automatic behavior, difficulties awakening in the morning, and sleep inertia, although common in hypersomnolence disorder, may also be seen in a variety of conditions, including narcolepsy. Approximately 80% of individuals with hyper somnolence report that their sleep is nonrestorative, and as many have difficulties awak ening in the morning. Prevaience Approximately 5%-10% of individuals who consult in sleep disorders clinics with com plaints of daytime sleepiness are diagnosed as having hypersomnolence disorder. Deveiopment and Course Hypersomnolence disorder has a persistent course, with a progressive evolution in the se verity of symptoms. While many individuals with hypersomnolence are able to reduce their sleep time during working days, weekend and holiday sleep is greatly increased (by up to 3 hours). Awakenings are very difficult and accompanied by sleep inertia episodes in nearly 40% of cases. Hypersomnolence fully manifests in most cases in late adolescence or early adulthood, with a mean age at onset of 17-24 years. Individuals with hypersomnolence disorder are diagnosed, on average, 10-15 years after the appearance of the first symptoms. Hypersomnolence has a progressive onset, with symptoms beginning between ages 15 and 25 years, with a gradual progression over weeks to months. For most individuals, the course is then persistent and stable, unless treatment is initiated. Although hyperactivity may be one of the presenting signs of daytime sleepiness in children, voluntary napping increases with age. Hypersomnolence can be increased temporarily by psychological stress and alcohol use, but they have not been documented as environmental precipitating factors. Viral infections have been reported to have preceded or accompanied hyper somnolence in about 10% of cases. Diagnostic iVlarlcers Nocturnal polysomnography demonstrates a normal to prolonged sleep duration, short sleep latency, and normal to increased sleep continuity. Some individuals with hypersomnolence disorder have increased amounts of slow-wave sleep. The multiple sleep latency test documents sleep tendency, typically indicated by mean sleep latency values of less than 8 minutes. In hypersomnolence disorder, the mean sleep latency is typically less than 10 minutes and frequently 8 minutes or less. Functional Consequences of Hypersomnoience Disorder the low level of alertness that occurs while an individual fights the need for sleep can lead to reduced efficiency, diminished concentration, and poor memory during daytime activ ities. Hypersomnoience can lead to significant distress and dysfunction in work and social relationships. Prolonged nocturnal sleep and difficulty awakening can result in difficulty in meeting morning obligations, such as arriving at work on time. Unintentional daytime sleep episodes can be embarrassing and even dangerous, if, for instance, the individual is driving or operating machinery when the episode occurs. If social or occupational demands lead to shorter nocturnal sleep, daytime symptoms may appear. In hypersomnoience disorder, by contrast, symptoms of excessive sleepiness occur regard less of nocturnal sleep duration. An inadequate amount of nocturnal sleep, or behaviorally induced insufficient sleep syndrome, can produce symptoms of daytime sleepiness very similar to those of hypersomnoience. An average sleep duration of fewer than 7 hours per night strongly suggests inadequate nocturnal sleep, and an average of more than 9-10 hours of sleep per 24-hour period suggests hypersomnoience. Individuals with inadequate noctur nal sleep typically "catch up" with longer sleep durations on days when they are free from social or occupational demands or on vacations. Unlike hypersomnoience, insufficient nocturnal sleep is unlikely to persist unabated for decades. A diagnosis of hypersomno ience disorder should not be made if there is a question regarding the adequacy of noctur nal sleep duration. A diagnostic and therapeutic trial of sleep extension for 10-14 days can often clarify the diagnosis. Hypersomnoience disorder should be distinguished from excessive sleepiness related to insufficient sleep quantity or quality and fatigue. Excessive sleepiness and fatigue are difficult to differentiate and may overlap considerably. Individuals with hypersomnoience and breathingrelated sleep disorders may have similar patterns of excessive sleepiness. Breathing- related sleep disorders are suggested by a history of loud snoring, pauses in breathing during sleep, brain injury, or cardiovascular disease and by the presence of obesity, oro pharyngeal anatomical abnormalities, hypertension, or heart failure on physical examina tion. Polysomnographie studies can confirm the presence of apneic events in breathingrelated sleep disorder (and their absence in hypersomnolence disorder). Circadian rhythm sleep-wake disorders are often characterized by daytime sleepiness. A history of an abnormal sleep-wake schedule (with shifted or irregular hours) is present in individuals with a circadian rhythm sleepwake disorder. Parasomnias rarely produce the prolonged, undisturbed nocturnal sleep or daytime sleepiness characteristic of hypersomnolence disorder. Hypersomnolence disorder must be distinguished from mental disorders that include hypersomnolence as an essential or associated feature. In particular, complaints of daytime sleepiness may occur in a major depressive episode, with atypical fea tures, and in the depressed phase of bipolar disorder. Assessment for other mental disorders is essential before a diagnosis of hypersomnolence disorder is considered. A diagnosis of hyper somnolence disorder can be made in the presence of another current or past mental disorder. Comorbidity H)ersomnolence can be associated with depressive disorders, bipolar disorders (during a depressive episode), and major depressive disorder, with seasonal pattern. Many individu als with hypersomnolence disorder have symptoms of depression that may meet criteria for a depressive disorder. This presentation may be related to the psychosocial consequences of persistent increased sleep need. Individuals with hyper somnolence disorder are also at risk for substance-related disorders, particularly related to self-medication with stimulants. This general lack of specificity may contribute to very heterogeneous profiles among indi viduals whose symptoms meet the same diagnostic criteria for hypersomnolence disorder. Recurrent periods of an irrepressible need to sleep, lapsing into sleep, or napping oc curring within the same day. These must have been occurring at least three times per week over the past 3 months. Episodes of cataplexy, defined as either (a) or (b), occurring at least a few times per month: a. In individuals with long-standing disease, brief (seconds to minutes) episodes of sudden bilateral loss of muscle tone with maintained consciousness that are precipitated by laughter or joking. In children or in individuals within 6 months of onset, spontaneous grimaces or jaw-opening episodes with tongue thrusting or a global hypotonia, without any obvious emotional triggers. Moderate: Cataplexy once daily or every few days, disturbed nocturnal sleep, and need for multiple naps daily. Severe: Drug-resistant cataplexy with multiple attacks daily, nearly constant sleepi ness, and disturbed noctumal sleep. Subtypes In narcolepsy without cataplexy but with hypocretin deficiency, unclear 'cataplexy-like" symptoms may be reported. Seizures, falls of other origin, and conversion disorder (functional neurological symptom disorder) should be excluded. In other cases, the destruction of hypocretin neurons may be secondary to trauma or hypothalamic surgery. Diagnostic Features the essential features of sleepiness in narcolepsy are recurrent daytime naps or lapses into sleep. Sleepiness typically occurs daily but must occur at a minimum three times a week for at least 3 months (Criterion A). Narcolepsy generally produces cataplexy, which most commonly presents as brief episodes (seconds to minutes) of sudden, bilateral loss of mus cle tone precipitated by emotions, typically laughing and joking. Muscles affected may include those of the neck, jaw, arms, legs, or whole body, resulting in head bobbing, jaw dropping, or complete falls. To meet Criterion Bl(a), cataplexy must be triggered by laughter or joking and must occur at least a few times per month when the condition is untreated or in the past. Cataplexy should not be confused with 'weakness" occurring in the context of athletic activities (physiological) or exclusively after unusual emotional triggers such as stress or anxiety (suggesting possible psychopathology). Episodes lasting hours or days, or those not triggered by emotions, are unlikely to be cataplexy, nor is rolling on the floor while laugh ing hysterically. In children close to onset, genuine cataplexy can be atypical, affecting primarily the face, causing grimaces or jaw opening with tongue thrusting ("cataplectic faces"). Alter natively, cataplexy may present as low-grade continuous hypotonia, yielding a wobbling walk. Criterion Bl(b) can be met in children or in individuals within 6months of a rapid onset. Narcolepsy-cataplexy nearly always results from the loss of hypothalamic hypocretin (orexin)-producing cells, causing hypocretin deficiency (less than or equal to one-third of control values, or 110 pg/mL in most laboratories). These tests must be performed after the individual has stopped all psychotropic medications, following 2 weeks of adequate sleep time (as documented with sleep diaries, actigraphy). Associated Features Supporting Diagnosis When sleepiness is severe, automatic behaviors may occur, with the individual continuing his or her activities in a semi-automatic, hazelike fashion without memory or conscious ness. Approximately 20%-60% of individuals experience vivid hypnagogic hallucinations before or upon falling asleep or hypnopompic hallucinations just after awakening. These hallucinations are distinct from the less vivid, nonhallucinatory dreamlike mentation at sleep onset that occurs in normal sleepers. Approximately 20%-60% of indi viduals experience sleep paralysis upon falling asleep or awakening, leaving them awake but unable to move or speak. However, many normal sleepers also report sleep paralysis, especially with stress or sleep deprivation. Nocturnal sleep disruption with frequent long or short awakenings is common and can be disabling. Individuals may appear sleepy or fall asleep in the waiting area or during clinical ex amination.

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Cluster B includes antisocial spasms multiple sclerosis purchase rumalaya forte once a day, borderline muscle relaxant uses generic 30pills rumalaya forte free shipping, histri onic zoloft spasms discount 30 pills rumalaya forte amex, and narcissistic personality disorders muscle relaxants yellow 30pills rumalaya forte visa. Cluster C includes avoidant muscle relaxant for tmj discount rumalaya forte amex, dependent spasms mouth purchase rumalaya forte 30 pills fast delivery, and obsessivecompulsive personality disorders. It should be noted that this clustering system, although useful in some research and ed ucational situations, has serious limitations and has not been consistently validated. Moreover, individuals frequently present with co-occurring personality disorders from different clusters. Data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions suggest that approximately 15% of U. Dimensional Models for Personality Disorders the diagnostic approach used in this manual represents the categorical perspective that personality disorders are qualitatively distinct clinical syndromes. An alternative to the categorical approach is the dimensional perspective that personality disorders represent maladaptive variants of personality traits that merge imperceptibly into normality and into one another. The alternative di mensional models have much in common and together appear to cover the important ar eas of personality dysfunction. Their integration, clinical utility, and relationship with the personality disorder diagnostic categories and various aspects of personality dysfunction are under active investigation. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. The enduring pattern leads to clinically significant distress or impairment in social, oc cupational, or other important areas of functioning. The pattern is stable and cf long duration, and Its onset can be traced back at least to adolescence or early adulthood. The enduring pattern is not better explained as a manifestation or consequence of an other mental disorder. The enduring pattern is not attributable to the physiological effects of a substance. Diagnostic Features Personality traits are enduring patterns of perceiving, relating to , and thinking about the en vironment and oneself that are exhibited in a wide range of social and personal contexts. Only when personality traits are inflexible and maladaptive and cause significant func tional impairment or subjective distress do they constitute personality disorders. This enduring pattern is inflexible and pervasive across a broad range of personal and social situations (Criterion B) and leads to clinically significant dis tress or impairment in social, occupational, or other important areas of functioning (Crite rion C). The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood (Criterion D). The pattern is not better explained as a manifestation or consequence of another mental disorder (Criterion E) and is not attribut able to the physiological effects of a substance. Specific diagnostic criteria are also provided for each of the personality disorders included in this chapter. The personality traits that define these disorders must also be distin guished from characteristics that emerge in response to specific situational stressors or more transient mental states. The clinician should assess the stability of personality traits over time and across different situations. Although a single interview with the individual is sometimes sufficient for making the diagnosis, it is often necessary to conduct more than one inter view and to space these over time. Assessment can also be complicated by the fact that the characteristics that define a personality disorder may not be considered problematic by the individual. To help overcome this difficulty, sup plementary information from other informants may be helpful. Deveiopment and Course the features of a personality disorder usually become recognizable during adolescence or early adult life. By definition, a personality disorder is an enduring pattern of thinking, feeling, and behaving that is relatively stable over time. Some types of personality disorder (notably, antisocial and borderline personality disorders) tend to become less evident or to remit with age, whereas this appears to be less true for some other types. It should be recognized that the traits of a per sonality disorder that appear in childhood will often not persist unchanged into adult life. For a personality disorder to be diagnosed in an individual younger than 18 years, the fea tures must have been present for at least 1 year. The one exception to this is antisocial per- sonality disorder, which cannot be diagnosed in individuals younger than 18 years. Al though, by definition, a personality disorder requires an onset no later than early adulthood, individuals may not come to clinical attention until relatively late in life. A per sonality disorder may be exacerbated following the loss of significant supporting persons. However, the devel opment of a change in personality in middle adulthood or later life warrants a thorough evaluation to determine the possible presence of a personality change due to another med ical condition or an unrecognized substance use disorder. Although these differences in prevalence probably reflect real gender differences in the presence of such patterns, clinicians must be cautious not to overdiagnose or underdiagnose certain personality disorders in females or in males because of social stereotypes about typical gender roles and behaviors. Many of the specific criteria for the per sonality disorders describe features. It may be particularly difficult (and not particularly useful) to distinguish personality disorders from persistent mental disorders such as per sistent depressive disorder that have an early onset and an enduring, relatively stable course. Some personality disorders may have a "spectrum" relationship to other mental disorders. Personality disorders must be distinguished from personality traits that do not reach the threshold for a personality disorder. Personality traits are diagnosed as a personality disorder only when they are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective distress. For the three personality disorders that may be related to the psy chotic disorders. When personality changes emerge and persist after an individual has been exposed to extreme stress, a diagnosis of posttraumatic stress disorder should be considered. When an individual has a substance use disorder, it is impor tant not to make a personality disorder diagnosis based solely on behaviors that are con sequences of substance intoxication or withdrawal or that are associated with activities in the service of sustaining substance use. When enduring changes in per sonality arise as a result of the physiological effects of another medical condition. Cluster A Personality Disorders Paranoid Personality Disorder Diagnostic Criteria 301. A pervasive distrust and suspiciousness of others such that their nfiotives are inter preted as malevolent, beginning by early adulthood and present in a variety of con texts, as indicated by four (or more) of the following: 1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her. Perceives attacks on his or her character or reputation that are not apparent to oth ers and is quick to react angrily or to counterattack. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder and is not attributable to the physiological effects of another medical condition. Note: If criteria are met prior to the onset of schizophrenia, add "premorbid," i. Individuals with this disorder assume that other people will exploit, harm, or deceive them, even if no evidence exists to support this expectation (Criterion Al). They suspect on the basis of little or no evidence that others are plotting against them and may attack them suddenly, at any time and without reason. They often feel that they have been deeply and irreversibly injured by another person or persons even when there is no objective evidence for this. They are preoccupied with unjustified doubts about the loyalty or trustworthiness of their friends and associates, whose actions are minutely scrutinized for evidence of hos tile intentions (Criterion A2). Any perceived deviation from trustworthiness or loyalty serves to support their underlying assumptions. They are so amazed when a friend or as sociate shows loyalty that they cannot trust or believe it. If they get into trouble, they ex pect that friends and associates will either attack or ignore them. Individuals with paranoid personality disorder are reluctant to confide in or become close to others because they fear that the information they share will be used against them (Criterion A3). For example, an individual with this disor der may misinterpret an honest mistake by a store clerk as a deliberate attempt to short change, or view a casual humorous remark by a co-worker as a serious character attack. They may view an offer of help as a criticism that they are not doing well enough on their own. Individuals with this disorder persistently bear grudges and are unwilling to forgive the insults, injuries, or slights that they think they have received (Criterion A5). Minor slights arouse major hostility, and the hostile feelings persist for a long time. Because they are constantly vigilant to the harmful intentions of others, they very often feel that their character or reputation has been attacked or that they have been slighted in some other way. They are quick to counterattack and react with anger to perceived insults (Criterion A6). Individuals with this disorder may be pathologically jealous, often suspecting that their spouse or sexual partner is unfaithful without any adequate justification (Criterion A7). They may gather trivial and circumstantial "evidence" to support their jealous beliefs. They want to maintain complete control of intimate relationships to avoid being betrayed and may constantly question and challenge the whereabouts, actions, intentions, and fi delity of their spouse or partner. Paranoid personality disorder should not be diagnosed if the pattern of behavior oc curs exclusively during the course of schizophrenia, a bipolar disorder or depressive dis order with psychotic features, or another psychotic disorder, or if it is attributable to the physiological effects of a neurological. Associated Features Supporting Diagnosis Individuals with paranoid personality disorder are generally difficult to get along with and often have problems with close relationships. Their excessive suspiciousness and hos tility may be expressed in overt argumentativeness, in recurrent complaining, or by quiet, apparently hostile aloofness. Because they are hypervigilant for potential threats, they may act in a guarded, secretive, or devious manner and appear to be "cold" and lacking in tender feelings. Although they may appear to be objective, rational, and unemotional, they more often display a labile range of affect, with hostile, stubborn, and sarcastic expressions predominating. Their combative and suspicious nature may elicit a hostile response in others, which then serves to confirm their original expectations. Because individuals with paranoid personality disorder lack trust in others, they have an excessive need to be self-sufficient and a strong sense of autonomy. They are often rigid, critical of oth ers, and unable to collaborate, although they have great difficulty accepting criticism them selves. Because of their quickness to counterattack in response to the threats they perceive around them, they may be litigious and frequently become involved in legal disputes. Individuals with this disorder seek to confirm their preconceived negative notions regarding people or situations they encounter, attributing malevolent motivations to others that are projections of their own fears. They may exhibit thinly hidden, unrealistic grandiose fantasies, are often attuned to issues of power and rank, and tend to develop negative stereotypes of others, particularly those from population groups distinct from their own. Attracted by simplistic formulations of the world, they are often wary of ambiguous situations. They may be perceived as "fanatics" and form tightly knit "cults" or groups with others who share their paranoid belief systems. Particularly in response to stress, individuals with this disorder may experience very brief psychotic episodes (lasting minutes to hours). In some instances, paranoid personal ity disorder may appear as the premorbid antecedent of delusional disorder or schizo phrenia. Individuals with paranoid personality disorder may develop major depressive disorder and may be at increased risk for agoraphobia and obsessive-compulsive dis order. The most common co occurring personality disorders appear to be schizotypal, schizoid, narcissistic, avoidant, and borderline. Development and Course Paranoid personality disorder may be first apparent in childhood and adolescence with solitariness, poor peer relationships, social anxiety, underachievement in school, hyper sensitivity, peculiar thoughts and language, and idiosyncratic fantasies. In clinical samples, this disorder appears to be more commonly diagnosed in males. There is some evidence for an increased prevalence of par anoid personality disorder in relatives of probands with schizophrenia and for a more spe cific familial relationship with delusional disorder, persecutory type. Culture-Related Diagnostic Issues Some behaviors that are influenced by sociocultural contexts or specific life circumstances may be erroneously labeled paranoid and may even be reinforced by the process of clinical evaluation. Members of minority groups, immigrants, political and economic refugees, or individuals of different ethnic backgrounds may display guarded or defensive behaviors because of unfamiliarity. These behaviors can, in turn, generate anger and frustration in those who deal with these indi viduals, thus setting up a vicious cycle of mutual mistrust, which should not be confused with paranoid personality disorder. Some ethnic groups also display culturally related be haviors that can be misinterpreted as paranoid. Paranoid personality disorder can be distinguished from delusional disorder, persecutory type; schizophrenia; and a bipolar or depressive disorder with psychotic features because these disorders are all characterized by a period of persistent psychotic symptoms. For an additional diagnosis of paranoid personality disorder to be given, the personality disorder must have been present before the onset of psychotic symptoms and must persist when the psychotic symptoms are in remission. Paranoid personality disorder must be distinguished from personality change due to another medical condition, in which the traits that emerge are attributable to the direct effects of another medical condi tion on the central nervous system. Paranoid personality disorder must be distinguished from symptoms that may develop in association with persistent substance use. The disorder must also be distin guished from paranoid traits associated with the development of physical handicaps. Other personality disorders may be confused with paranoid personality disorder because they have certain features in common.

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Cultural explanations or perceived causes are labels muscle spasms youtube order cheap rumalaya forte line, attributions muscle relaxer 93 purchase rumalaya forte 30 pills on-line, or features of an explanatory model that indicate culturally recog nized meaning or etiology for symptoms muscle relaxant kidney stones purchase rumalaya forte 30pills without prescription, illness muscle relaxant 2265 purchase discount rumalaya forte, or distress quad spasms after squats cheap rumalaya forte online master card. These three concepts-syndromes muscle relaxant juice rumalaya forte 30pills for sale, idioms, and explanations-are more relevant to clinical practice than the older formulation culture-bound syndrome. Specifically, the term culture-bound syndrome ignores the fact that clinically important cultural differences often involve explanations or experience of distress rather than culturally distinctive configura tions of symptoms. Furthermore, the term culture-bound overemphasizes the local partic ularity and limited distribution of cultural concepts of distress. Across groups there remain culturally patterned differ ences in symptoms, ways of talking about distress, and locally perceived causes, which are in turn associated with coping strategies and patterns of help seeking. Cultural concepts arise from local folk or professional diagnostic systems for mental and emotional distress, and they may also reflect the influence of biomedical concepts. For example, an individual with acute grief or a social predicament may use the same idiom of distress or display the same cultural syndrome as another individual with more severe psychopathology. A familiar example may be the concept of "depression," which may be used to describe a syndrome. To obtain useful clinical information: Cultural variations in symptoms and attribu tions may be associated with particular features of risk, resilience, and outcome. To improve clinical rapport and engagement: "Speaking the language of the patient," both linguistically and in terms of his or her dominant concepts and metaphors, can re sult in greater communication and satisfaction, facilitate treatment negotiation, and lead to higher retention and adherence. To improve therapeutic efficacy: Culture influences the psychological mechanisms of disorder, which need to be understood and addressed to improve clinical efficacy. For example, culturally specific catastrophic cognitions can contribute to symptom escala tion into panic attacks. To guide clinical research: Locally perceived connections between cultural concepts may help identify patterns of comorbidity and underlying biological substrates. To clarify the cultural epidemiology: Cultural concepts of distress are not endorsed uniformly by everyone in a given culture. Distinguishing syndromes, idioms, and ex planations provides an approach for studying the distribution of cultural features of ill ness across settings and regions, and over time. It also suggests questions about cultural determinants of risk, course, and outcome in clinical and community settings to en hance the evidence base of cultural research. Once the disorder is diagnosed, the cultural terms and explanations should be included in case for mulations; they may help clarify symptoms and etiological attributions that could other wise be confusing. For example, the typical patient meeting criteria for a specific personality disorder fre quently also meets criteria for other personality disorders. Similarly, other specified or un specified personality disorder is often the correct (but mostly uninformative) diagnosis, in the sense that patients do not tend to present with patterns of symptoms that correspond with one and only one personality disorder. The specific personality disorder diagnoses that may be derived from this model include antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal personality dis orders. ThG current approach General Criteria for Personality Disorder General Criteria for Personality Disorder the essential features of a personality disorder are A. A diagnosis of a personality disorder requires two determinations: 1) an assessment of the level of impairment in personality functioning, w^hich is needed for Criterion A, and 2) an evaluation of pathological personality traits, which is required for Criterion B. Criterion A: Levei of Personaiity Functioning Disturbances in self and interpersonal functioning constitute the core of personality psy chopathology and in this alternative diagnostic model they are evaluated on a continuum. Self functioning involves identity and self-direction; interpersonal functioning involves empathy and intimacy (see Table 1). Identity: Experience of oneself as unique, with clear boundaries between self and others; sta bility of self-esteem and accuracy of self-appraisal; capacity for, and ability to regulate, a range of emotional experience. Self-direction: Pursuit of coherent and meaningful short-term and life goals; utilization of constructive and prosocial internal standards of behavior; ability to self-reflect productively. Intim acy: Depth and duration of connection with others; desire and capacity for closeness; mutuality of regard reflected in interpersonal behavior. Impairment in personality functioning predicts the presence of a personality disorder, and the severity of impairment predicts whether an individual has more than one person ality disorder or one of the more typically severe personality disorders. A moderate level of impairment in personality functioning is required for the diagnosis of a personality dis order; this threshold is based on empirical evidence that the moderate level of impairment maximizes the ability of clinicians to accurately and efficiently identify personality disor der pathology. Criterion B: Pathoiogicai Personaiity Traits Pathological personality traits are organized into five broad domains: Negative Affectivity. Within the five broad trait domains are 25 specific trait facets that were developed initially from a review of existing trait models and subsequently through iterative research with samples of persons who sought mental health services. Criteria C and D: Pervasiveness and Stability Impairments in personality functioning and pathological personality traits are relatively per vasive across a range of personal and social contexts, as personality is defined as a pattern of perceiving, relating to , and thinking about the environment and oneself. The term relatively reflects the fact that all except the most extremely pathological personalities show some de gree of adaptability. The pattern in personality disorders is maladaptive and relatively inflex ible, which leads to disabilities in social, occupational, or other important pursuits, as individuals are unable to modify their thinking or behavior, even in the face of evidence that their approach is not working. Personality traits-the dispositions to behave or feel in certain ways-are more stable than the symptomatic expressions of these dispositions, but personality traits can also change. Criteria E, F, and G: Alternative Explanations for Personality Pathology (Differential Diagnosis) On some occasions, what appears to be a personality disorder may be better explained by another mental disorder, the effects of a substance or another medical condition, or a nor mal developmental stage. When another mental disorder is present, the diagnosis of a personality disorder is not made, if the manifestations of the personality disorder clearly are an ex pression of the other mental disorder. On the other hand, personality disorders can be accurately diagnosed in the presence of another mental disorder, such as major de pressive disorder, and patients with other mental disorders should be assessed for comorbid personality disorders because personality disorders often impact the course of other mental disorders. Therefore, it is always appropriate to assess personality functioning and pathological personality traits to provide a context for other psychopathology. All personality disorders also meet criteria C through G of the General Criteria for Personality Disorder. Antisocial Personality Disorder Typical features of antisocial personality disorder are a failure to conform to lawful and ethical behavior, and an egocentric, callous lack of concern for others, accompanied by de ceitfulness, irresponsibility, manipulativeness, and/or risk taking. Characteristic difficul ties are apparent in identity, self-direction, empathy, and/or intimacy, as described below, along with specific maladaptive traits in the domains of Antagonism and Disinhibition. Identity: Egocentrism; self-esteem derived from personal gain, power, or pleasure. Self-direction: Goal setting based on personal gratification; absence of prosocial internal standards, associated with failure to conform to lawful or culturally norma tive ethical behavior. Empathy: Lack of concern for feelings, needs, or suffering of others; lack of re morse after hurting or mistreating another. Intimacy: Incapacity for mutually intimate relationships, as exploitation is a primary means of relating to others, including by deceit and coercion; use of dominance or intimidation to control others. Deceitfulness (an aspect of Antagonism): Dishonesty and fraudulence; misrepre sentation of self; embellishment or fabrication when relating events. Hostility (an aspect of Antagonism): Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults; mean, nasty, or vengeful behavior. Impulsivity (an aspect of Disinhibition): Acting on the spur of the moment in re sponse to immediate stimuli; acting on a momentary basis without a plan or consid eration of outcomes; difficulty establishing and following plans. Irresponsibility (an aspect of Disinhibition); Disregard for-and failure to honorfinancial ^nd other obligations or commitments; lack of respect for-and lack of fol low-through on-agreements and promises. A distinct variant often termed psychopathy (or "primary" psychopathy) is marked by a lack of anxiety or fear and by a bold inteersonal style that may mask mal adaptive behaviors. This psychopathic variant is characterized by low levels of anxiousness (Negative Affectivity domain) and withdrawal (Detachment do main) and high levels of attention seeking (Antagonism domain). High attention seeking and low withdrawal capture the social potency (assertive/dominant) component of psy chopathy, whereas low anxiousness captures the stress immunity (emotional stability/re silience) component. In addition to psychopathic features, trait and personality functioning specifiers may be used to record other personality features that may be present in antisocial personality dis order but are not required for the diagnosis. Furthermore, although moderate or greater impair ment in personality functioning is required for the diagnosis of antisocial personality disor der (Criterion A), the level of personality functioning can also be specified. Avoidant Personality Disorder Typical features of avoidant personality disorder are avoidance of social situations and in hibition in interpersonal relationships related to feelings of ineptitude and inadequacy, anxious preoccupation with negative evaluation and rejection, and fears of ridicule or em barrassment. Characteristic difficulties are apparent in identity, self-direction, empathy, and/or intimacy, as described below, along with specific maladaptive traits in the do mains of Negative Affectivity and Detachment. Moderate or greater impairment in personality functioning, manifest by characteristic difficulties in two or more of the following four areas: 1. Identity: Low self-esteem associated with self-appraisal as socially inept, person ally unappealing, or inferior; excessive feelings of shame. Self-direction: Unrealistic standards for behavior associated with reluctance to pursue goals, take personal risks, or engage in new activities involving inteersonal contact. Intimacy: Reluctance to get involved with people unless being certain of being liked: diminished mutuality within intimate relationships because of fear of being shamed or ridiculed. Three or more of the following four pathological personality traits, one of which must be (1) Anxiousness: 1. Anxiousness (an aspect of Negative Affectivity): Intense feelings of nervous ness, tenseness, or panic, often in reaction to social situations: worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of embarrass ment. Withdrawal (an aspect of Detachment); Reticence in social situations; avoidance of social contacts and activity; lack of initiation of social contact. Intimacy avoidance (an aspect of Detachment); Avoidance of close or romantic relationships, interpersonal attachments, and intimate sexual relationships. Considerable heterogeneity in the form of additional personality traits is found among individuals diagnosed with avoidant personality disorder. Trait and level of personality functioning specifiers can be used to record additional personality features that may be present in avoidant personality disorder. Furthermore, although moderate or greater impairment in personality functioning is required for the diagnosis of avoidant personality disorder (Cri terion A), the level of personality functioning also can be specified. Borderline Personality Disorder Typical features of borderline personality disorder are instability of self-image, personal goals, interpersonal relationships, and affects, accompanied by impulsivity, risk taking, and/or hostility. Characteristic difficulties are apparent in identity, self-direction, empa thy, and/or intimacy, as described below, along with specific maladaptive traits in the do main of Negative Affectivity, and also Antagonism and/or Disinhibition. Identity: Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress. Empathy: Compromised ability to recognize the feelings and needs of others asso ciated with inteersonal hypersensitivity. Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anxious preoccupation with real or imagined abandonment; close relationships often viewed in extremes of idealization and devaluation and alternat ing between overinvolvement and withdrawal. Four or more of the following seven pathological personality traits, at least one of which must be (5) Impulsivity, (6) Risk taking, or (7) Hostility: 1. Emotional lability (an aspect of Negative Affectivity): Unstable emotional expe riences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances. Anxiousness (an aspect of Negative Affectivity): Intense feelings of nervous ness, tenseness, or panic, often in reaction to interpersonal stresses; worry about the negative effects of past unpleasant experiences and future negative possibili- 3. Separation insecurity (an aspect of Negative Affectivity): Fears of rejection by- and/or separation from-significant others, associated with fears of excessive de pendency and complete loss of autonomy. Depressivity (an aspect of Negative Affectivity): Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feelings of inferior self-worth; thoughts of sui cide and suicidal behavior. Impulsivity (an aspect of Disiniiibition): Acting on the spur of the moment in re sponse to immediate stimuli; acting on a momentary basis without a plan or consid eration of outcomes; difficulty establishing or following plans; a sense of urgency and self-harming behavior under emotional distress. Hostility (an aspect of Antagonism): Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults. Trait and level of personality functioning specifiers may be used to record ad ditional personality features that may be present in borderline personality disorder but are not required for the diagnosis. Furthermore, although moderate or greater impairment in personality functioning is required for the diagnosis of borderline personality disorder (Criterion A), the level of personality functioning can also be specified. Narcissistic Personaiity Disorder Typical features of narcissistic personality disorder are variable and vulnerable self-esteem, with attempts at regulation through attention and approval seeking, and either overt or covert grandiosity. Characteristic difficulties are apparent in identity, self-direction, em pathy, and/or intimacy, as described below, along with specific maladaptive traits in the domain of Antagonism. Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following four areas: 1. Identity: Excessive reference to others for self-definition and self-esteem regula tion; exaggerated self-appraisal inflated or deflated, or vacillating between extremes; emotional regulation mirrors fluctuations in self-esteem. Self-direction: Goal setting based on gaining approval from others; personal stan dards unreasonably high in order to see oneself as exceptional, or too low based on a sense of entitlement; often unaware of own motivations. Empathy: Impaired ability to recognize or identify with the feelings and needs of others; excessively attuned to reactions of others, but only if perceived as relevant to self; over- or underestimate of own effect on others. Grandiosity (an aspect of Antagonism); Feelings of entitlement, either overt or co vert; self-centeredness; firmly holding to the belief that one is better than others; condescension toward others. Attention seeldng (an aspect of Antagonism): Excessive attempts to attract and be the focus of the attention of others; admiration seeking. Trait and personality functioning specifiers may be used to record additional personality features that may be present in narcissistic personality disorder but are not re quired for the diagnosis. Furtiiermore, although moderate or greater impairment in personality functioning is required for the diagnosis of narcissistic personality disorder (Criterion A), the level of personality functioning can also be specified. Obsessive-Compulsive Personaiity Disorder Typical features of obsessive-compulsive personality disorder are difficulties in establish ing and sustaining close relationships, associated with rigid perfectionism, inflexibility, and restricted emotional expression. Characteristic difficulties are apparent in identity, self-direction, empathy, and/or intimacy, as described below, along v^ith specific mal adaptive traits in the domains of Negative Affectivity and/or Detachment. Identity: Sense of self derived predominantly from work or productivity; constricted experience and expression of strong emotions. Self-direction: Difficulty completing tasks and realizing goals, associated with rigid and unreasonably high and inflexible internal standards of behavior; overly consci entious and moralistic attitudes.

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