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Evaluation o fData: Job-specific incidence and prevalence rates can be calculated using a variety of case definitions. Information on the severity and frequency of symptoms should be used in determining which problems should be given the highest priority. The definitions and formulas for calculation ofincidence and prevalence are included in the section on Passive Surveillance. When evidence from passive surveillance orjob analysis suggests an increase in work-related musculoskeletal disorders or a preponderance ofergonomic stressors; b. When new workers are hired, they should complete a symptom questionnaire prior to beginning work. Active surveillance programs are generally more costly to conduct than passive surveillance; b. The effect ofrepeatedly asking the same questions over an extended period, as in yearly or periodic health interviews, has not been determined. The program should also prevent aggravation of musculoskeletal disorders that could occur in workers due to non-occupational activities. The specific goals of medical management are the elimination or reduction of symptoms and functional impairment, and a return to work in a manner consistent with protecting the health of the worker. Accordingly, medical management policies that encourage workers to report symptoms early and employers to send their symptomatic worker for prompt medical evaluation and treatment may reduce the long-term severity and disability from these work-related musculoskeletal disorders. In addition, these policies create the conditions for an effective health surveillance system. Because the scientific studies suggest that early intervention may be more effective than late intervention, and since, in general, the cost of care generally increases as these disorders become severe and chronic, medical management protocols should be directed at both mild and severe disorders. The evaluation and treatment approaches for early, mild or intermittent disorders are generally simple and can be provided by many different types of health care providers. General Principles of Medical Management Several principles should underlie the development of either voluntary or mandated medical management protocols. The clinical course ofmost work-related musculoskeletal disorders can be divided into three phases: acute (less than one month from the onset), subacute (one to three months), and chronic (greater than 3 months). Chronic disorders that are severe enough to prevent return to work are associated with a poor prognosis. In an attempt to alter this poor prognosis, a number ofcomprehensive rehabilitation programs have been developed. There is limited evidence that these programs may be partially successful in returning injured workers to employment [Feuerstein 1992]. Health Care Provider Any health care provider with training in work-related musculoskeletal disorders who is licensed and/or registered and practicing within the scope of their license and/or registration could develop a medical management protocol. However, the concepts of primary and secondary prevention should be incorporated in the training ofthe health care providers. Training and education should be strongly encouraged that address the causes ofwork-related musculoskeletal disorders, appropriate methods of clinical evaluations, identification ofjob hazards by workplace inspection, review ofwrittenjob description or videotape recording ofwork processes, and the benefits ofearly evaluation should be strongly encouraged. Job Evaluations Job evaluations are predictive to some extent ofrisk of developing work-related musculoskeletal disorders. As discussed earlier, the overall epidemiological, biomechanical, and psychophysical laboratory studies support the basic hypothesis that physical job factors such as force, repetition, and awkward posture are associated with elevated rates ofsymptoms and disorders. A reasonable extension of this body of scientific studies is that workers with work-related musculoskeletal disorders are at higher risk ifthey continue to be exposed once the condition develops. Rehabilitative Medical Management As stated earlier, evidence exists to support early intervention and treatment of work related musculoskeletal disorders in order to decrease the cost, severity, and days of disability. The following recommendations are not meant to substitute for sound medical practice. Standards ofmedical care change over time; therefore, it is the responsibility ofthe treating health care provider to render care consistent with current clinical practice. Early Reporting All workers should receive training regarding the signs and symptoms of work related musculoskeletal disorders and be encouraged to report such symptoms to their employer. Such reporting allows for prompt evaluation, and, if necessary, treatment ofthe symptoms. Early treatment ofmany medical conditions, including musculoskeletal disorders has been shown to reduce their severity, duration of treatment, and ultimate disability [Flowerdew and Bode 1942; Thompson et al. Workers must not be subject to reprisal or discrimination based on such reporting. Employers should also address any financial or other disincentives that discourage workers from reporting their symptoms. The symptomatic area can be rested by: (1) Reducing or eliminating worker exposure to biomechanical stressors (forceful exertions, repetitive activities, extreme or prolonged static postures, vibration, direct trauma). The principles of restricted duty and temporaryjob transfer are to reduce or eliminate the total amount of time a worker is exposed to ergonomic stressors [Lederman and Calabrese 1986; McKenzie et al. The ergonomic risk factors and the muscle-tendon groups required to perform thosejobs should be listed. Treatment for Soft-Tissue Inflammation (1) Cold Therapy Although no clinical trials have been performed on the effectiveness of cold therapy on the affected area, most clinicians consider this useful to reduce the swelling and inflammation associated with tendon-related disorders [Thorson and Szabo 1989; Chipman et al. Cold therapy has effects on the local circulatory system (vasoconstriction) [Olson and Stravino 1972; Thorsson et al. This reduced supply and demand for blood results in reduced effusion, edema, and swelling. In addition to pain reduction from the reduced swelling, cold therapy reduces the nerve conduction from pain receptors [Kaplan and Tanner 1989]. Most clinicians consider physical and occupational therapy a valuable adjunct for treatment through its use of stretching and strengthening programs [Thorson and Szabo 1989; Chipman et al. If the symptoms do not improve within the expected time frames, referral to an appropriate specialist is indicated. The expected time frame for resolution of symptoms depends on the type, duration, and severity of the condition, in addition to the underlying health ofthe weaker. Precise time intervals for follow-up evaluation, referral, improvement, and recovery cannot be stated in this submission. These algorithms are not meant to dictate medical practice, but to provide guidance to practicing occupational health nurses. This applies not only to those employees directly at risk, but also to those whosejob responsibilities may influence the ergonomic risks ofothers. It is, therefore, essential that all risk-related individuals be equipped with the necessary knowledge, skills and incentives to effectively support and participate in the ergonomics management program. Indeed, the absence ofthis training may itselfbe viewed as a risk factor, affecting the well-being of the individual worker and the functioning ofthe organization [Blackburn and Sage 1992]. Training, when used as part of an overall ergonomics management program, has been shown to effectively enhance worker awareness of ergonomic risks [Liker et al. It must also be emphasized that even the most effective training program does not insure that skills and practices learned in the training environment will be enacted and sustained in the workplace. This may include, in addition to employees direcdy at risk, supervisors, managers, engineers, purchasing agents, and safety and health committee members whose job responsibilities are related to risk recognition and control. Baseline training at both levels should be provided to all employees during the implementation phase of the ergonomics management program, or at the time of hire for new employees. Identifying Training Needs a) General Awareness Training A number of general awareness courses regarding the nature and control of ergonomic hazards are currently available through federal. The content ofthis training will be dictated by the findings of the worksite and health surveillance activities. Nevertheless, at a minimum, the training should enable the employees to demonstrate an understanding of the: 1) Specific tasks or operations associated with theirjobs which pose ergonomic risks (results ofworksite analysis) 2) Proper use of tools, devices, and equipment provided to control identified risks 3) Proper engineering, work practice, and administrative controls available to reduce identified risks 4) Procedures for recommendingjob redesign or control strategies for reducing risk 56 3. Identifying Training Objectives Following a determination of the training needs, performance objectives should be specified. The objectives should describe exactly what the trainee should know and be able to do following training [Gagne and Briggs 1979] and specify the conditions under which these behaviors should be performed [Smith and Delahaye 1987; Komaki et al. Because of the variability of ergonomic hazards and related controls across job operations and worksites, training objectives will be situationally specific.

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Trichotillomania should not be diagnosed when hair removal is performed solely for cosmetic reasons. Some individuals may bite rather than pull hair; again, this does not qualify for a diagnosis of trichotillomania. The description of body-focused repetitive behavior disorder in other specified obsessive-compulsive and related disorder excludes individuals who meet diagnostic criteria for trichotillomania. In neurodevelopmental disorders, hair pulling may meet the definition of stereotypies. Individuals with a psychotic disorder may remove hair in response to a delusion or hallucination. Trichotillomania is not diagnosed if the hair pulling or hair loss is attributable to another medical condition. Comorbidity Trichotillomania is often accompanied by other mental disorders, most commonly major depressive disorder and excoriation (skin-picking) disorder. The skin picking is not attributable to the physiological effects of a substance. The skin picking is not better explained by symptoms of another mental disorder. The most commonly picked sites are the face, arms, and hands, but many individuals pick from multiple body sites. Individuals may pick at healthy skin, at minor skin irregularities, at lesions such as pimples or calluses, or at scabs from previous picking. Most individuals pick with their fingernails, although many use tweezers, pins, or other objects. In addition to skin picking, there may be skin rubbing, squeezing, lancing, and biting. Individuals with excoriation disorder often spend significant amounts of time on their picking behavior, sometimes several hours per day, and such skin picking may endure for months or years. Individuals with excoriation disorder have made repeated attempts to decrease or stop skin picking (Criterion B). Associated Features Supporting Diagnosis Skin picking may be accompanied by a range of behaviors or rihials involving skin or scabs. Thus, individuals may search for a particular kind of scab to pull, and they may examine, play with, or mouth or swallow the skin after it has been pulled. Prevaience In the general population, the lifetime prevalence for excoriation disorder in adults is 1. For some individuals, the disorder may come and go for weeks, months, or years at a time. Diagnostic iVlaricers Most individuals with excoriation disorder admit to skin picking; therefore, dermato pathological diagnosis is rarely required. The majority of individuals with this condition spend at least 1 hour per day picking, thinking about picking, and resisting urges to pick. Many individuals report avoiding social or entertainment events as well as going out in public. For example, individuals with the neurogenetic condition Prader-Willi syndrome may have early onset of skin picking, and their symptoms may meet criteria for stereotypic movement disorder. Excoriation disorder is not diagnosed if the skin lesion is primarily attributable to deceptive behaviors in factitious disorder. Excoriation disorder is not diagnosed if the skin picking is primarily attributable to the intention to harm oneself that is characteristic of nonsuicidal self-injury. Excoriation disorder is not diagnosed if the skin picking is primarily attributable to another medical condition. For example, scabies is a dermatolog ical condition invariably associated with severe itching and scratching. For example, acne may lead to some scratching and picking, which may also be associated with comorbid excoriation disorder. The differentiation between these two clirucal situations (acne with some scratching and picking vs. Substance/Medication-Induced Obsessive-Compulsive and Related Disorder Diagnostic Criteria A. The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a medication. Note: this diagnosis should be made in addition to a diagnosis of substance intoxication or substance withdrawal only when the symptoms in Criterion A predominate in the clinical picture and are sufficiently severe to warrant clinical attention.

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Delusional disorder can be diagnosed only if the total duration of all mood episodes remains brief relative to the total duration of the delusional disturbance. Duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning. The disturbance is not better explained by major depressive or bipolar disorder with psychotic features or another psychotic disorder such as schizophrenia or catatonia, and is not attributable to the physiological effects of a substance. The disturbance is not better explained by a depressive or bipolar disorder with psychotic features, by schizoaffective disorder, or by schizophrenia and is not attributable to the physiological effects of a substance. There appears to be an increased risk of suicidal behavior, particularly during the acute episode. Prevaience In the United States, brief psychotic disorder may account for 9% of cases of first-onset psychosis. Psychotic disturbances that meet Criteria A and C, but not Criterion B, for brief psychotic disorder. By definition, a diagnosis of brief psychotic disorder requires a full remission of all symptoms and an eventual full return to the premorbid level of functioning within 1 month of the onset of the disturbance. Functionai Consequences of Brief Psycliotic Disorder Despite high rates of relapse, for most individuals, outcome is excellent in terms of social functioning and symptomatology. A variety of medical disorders can manifest with psychotic symptoms of short duration. The diagnosis of brief psychotic disorder cannot be made if the psychotic symptoms are better explained by a mood episode. Careful attention should be given to the possibility that a recurrent disorder. When malingering involves apparently psychotic symptoms, there is usually evidence that the illness is being feigned for an understandable goal. In certain individuals with personality disorders, psychosocial stressors may precipitate brief periods of psychotic symptoms. If psychotic symptoms persist for at least 1 day, an additional diagnosis of brief psychotic disorder may be appropriate. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). Specify if: With good prognostic features: this specifier requires the presence of at least two of the following features: onset of prominent psychotic symptoms within 4 weeks of the first noticeable change in usual behavior or functioning; confusion or perplexity: good premorbid social and occupational functioning; and absence of blunted or flat affect. Without good prognostic features: this specifier is applied if two or more of the above features have not been present. Each of these symptoms may be rated for its current severity (most severe in the last 7 days) on a 5-point scale ranging from 0 (not present) to 4 (present and severe). Another distinguishing feature of schizophreniform disorder is the lack of a criterion requiring impaired social and occupational functioning. There are multiple brain regions where neuroimaging, neuropa thological, and neurophysiological research has indicated abnormalities, but none are diagnostic. Prevaience Incidence of schizophreniform disorder across sociocultural settings is likely similar to that observed in schizophrenia. In developing countries, the incidence may be higher, especially for the specifier 'with good prognostic features"; in some of these settings schizophreniform disorder may be as common as schizophrenia. Deveiopment and Course the development of schizophreniform disorder is similar to that of schizophrenia. The majority of the remaining two-thirds of individuals will eventually receive a diagnosis of schizophrenia or schizoaffective disorder. Relatives of individuals with schizophreniform disorder have an increased risk for schizophrenia. Functionai Consequences of Sciiizophreniform Disorder For the majority of individuals with schizophreniform disorder who eventually receive a diagnosis of schizophrenia or schizoaffective disorder, the functional consequences are similar to the consequences of those disorders. Most individuals experience dysfunction in several areas of daily functioning, such as school or work, interpersonal relationships, and self-care.

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Prevalence the prevalence of male hypoactive sexual desire disorder varies depending on country of origin and method of assessment. Approximately 6% of younger men (ages 18-24 years) and 41% of older men (ages 66-74 years) have problems with sexual desire. However, a persistent lack of interest in sex, lasting 6months or more, affects only a small proportion of men ages 16-44 (1. There is a requirement that low desire persist for approximately 6months or more; thus, short-term changes in sexual desire should not be diagnosed as male hypoactive sexual desire disorder. Like women, men identify a variety of triggers for their sexual desire, and they describe a wide range of reasons that they choose to engage in sexual activity. Although erotic visual cues may be more potent elicitors of desire in younger men, the potency of sexual cues may decrease with age and must be considered when evaluating men for hypoactive sexual desire disorder. Culture-R elated Diagnostic issues There is marked variability in prevalence rates of low desire across cultures, ranging from 12. Just as there are higher rates of low desire among East Asian subgroups of women, men of East Asian ancestry also have higher rates of low desire. G ender-Related Diagnostic Issues In contrast to the classification of sexual disorders in women, desire and arousal disorders have been retained as separate constructs in men. If the lack of desire is better explained by another mental disorder, then a diagnosis of male hypoactive sexual desire disorder would not be made. If the low/absent desire and deficient/absent erotic thoughts or fantasies are better explained by the effects of another medical condition. If interpersonal or significant contextual factors, such as severe relationship distress or other significant stressors, are associated with the loss of desire in the man, then a diagnosis of male hypoactive sexual desire disorder would not be made. The presence of another sexual dysfunction does not rule out a diagnosis of male hypoactive sexual desire disorder; there is some evidence that up to one-half of men with low sexual desire also have erectile difficulties, and slightly fewer may also have early ejaculation difficulties. Comorbidity Depression and other mental disorders, as well as endocrinological factors, are often co morbid with male hypoactive sexual desire disorder. The symptom in Criterion A causes clinically significant distress in the individual. Specify whether; Lifelong: the disturbance has been present since the individual became sexually active. Acquired: the disturbance began after a period of relatively normal sexual function. Specify whether: Generalized: Not limited to certain types of stimulation, situations, or partners. Specify current severity: iUlild: Ejaculation occurring within approximately 30 seconds to 1 minute of vaginal penetration. Severe: Ejaculation occurring prior to sexual activity, at the start of sexual activity, or within approximately 15 seconds of vaginal penetration. Estimated and measured intravaginal ejaculatory latencies are highly correlated as long as the ejaculatory latency is of short duration; therefore, self-reported estimates of ejaculatory latency are sufficient for diagnostic pufioses. A 60-second intravaginal ejaculatory latency time is an appropriate cutoff for the diagnosis of lifelong premature (early) ejaculation in heterosexual men. The durational definition may apply to males of varying sexual orientations, since ejaculatory latencies appear to be similar across men of different sexual orientations and across different sexual activities. Associated Features Supporting Diagnosis Many males with premature (early) ejaculation complain of a sense of lack of control over ejaculation and report apprehension about their anticipated inability to delay ejaculation on future sexual encounters. The following factors may be relevant in the evaluation of any sexual dysfunction: 1) partner factors. Prevaience Estimates of the prevalence of premature (early) ejaculation vary widely depending on the definition utilized. Internationally, more than 20%-30% of men ages 18-70 years report concern about how rapidly they ejaculate. Some men may experience premature (early) ejaculation during their initial sexual encounters but gain ejaculatory control over time. In contrast, some men develop the disorder after a period of having a normal ejaculatory latency, known as acquired premature (early) ejaculation. There is far less known about acquired premature (early) ejaculation than about lifelong premahire (early) ejaculation. Reversal of medical conditions such as hyperthyroidism and prostatitis appears to restore ejaculatory latencies to baseline values. Age and relationship length have been found to be negatively associated with prevalence of premature (early) ejaculation. Premature (early) ejaculation may be associated with dopamine transporter gene polymorphism or serotonin transporter gene polymorphism. Thyroid disease, prostatitis, and drug withdrawal are associated with acquired premature (early) ejaculation. C uiture-R elated Diagnostic issues Perception of what constitutes a normal ejaculatory latency is different in many cultures. Gender-Reiated Diagnostic Issues Premature (early) ejaculation is a sexual disorder in males.

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Some important points about development the information in this resource provides a brief overview of typically developing children. Except where there are obvious signs, you would need to see a child a number of times to establish that there is something wrong. Premature babies, or those with low birth weights, or a chemical dependency, will generally take longer to reach developmental milestones. The indicators of trauma listed in this guide should not have no choice given their age and vulnerability, and become judgements about the particular child or family in more chronic and extreme circumstances, they made in isolation from others who know the child will show a complex trauma response. It is critical system will become activated and switch on to the to have a good working knowledge of this growing freeze/fght/fight response. Immediately the body is evidence base so that we can be more helpful to fooded with a biochemical response which includes families and child focused. These children require calm, patient, more demanding of an already overwhelmed parent. It is normal for parents to feelings, that are often unspeakable; or cognitive, i. Case practice needs to be child centred the classic and usually most destructive attempts to and family sensitive. Adolescents will often stay up all night to avoid the nightmares and sleep in the safety of the daylight. This is an Australian services to Western Australian individuals, children website, launched in 2006, on the basics of raising and their families. Telephone services healthdirect Australia (24 hour) 1800 022 222 Family Helpline (08) 9223 1100 or 1800 643 000 Monaghan, C. Jim Greenman and Anne Stonehouse, 1996, Prime Bibliography Times: a Handbook for Excellence in Infant and Raising Children Network raisingchildren. Unauthorised reproduction and other uses comprised in the copyright are prohibited without permission. It will also help service providers and organizations to work from a trauma-informed perspective and develop trauma-informed relationships that cultivate safety, trust and compassion. Traumatic events happen to all people at all ages and across all socio-economic strata in our society. These events can cause terror, intense fear, horror, helplessness and physical stress reactions. Instead, some traumatic events are profound experiences that can change the way children, adolescents and adults see themselves and the world. Psychological trauma is a major public health issue affecting the health of people, families and communities across Canada. Given the enormous infuence that trauma has on health outcomes, it is important that every health care and human services provider has a basic understanding of trauma, can recognize the symptoms of trauma, and appreciates the role they play in supporting recovery. Health care, human services and, most importantly, the people who receive these services beneft from trauma informed approaches. From the time the trauma occurs, people can experience the effects in all stages of their life and in their day to day activities parenting, working, socializing, attending appointments and interpersonal relationships. It should be noted that most people who experience traumatic events do not go on to develop symptoms of Post-Traumatic Stress Disorder. However, for many people, poor mental and physical health, depression and anxiety can become the greater challenge. People who have experienced trauma are at risk of being re-traumatized in every social service and health care setting. The lack of knowledge and understanding about the impact of trauma can get in the way of services providing the most effective care and intervention. When retraumatization happens, the system has failed the individual who has experienced trauma, and this can leave them feeling misunderstood, unsupported and even blamed. This can be prevented with basic knowledge and by considering trauma-informed language and practices. Accidents, natural disasters, wars, family conficts, sexual exploitation, child abuse and neglect, and harmful social conditions are inescapable. This toolkit will explore these issues and identify how health care and social services can become trauma-informed, set policies, and encourage interactions with clients that facilitate healing and growth. Recent research has revealed that psychological emotional trauma can result from such common occurrences as an auto accident, sudden job loss, relationship loss, a humiliating or deeply disappointing circumstance, the discovery of a life threatening illness or disabling condition, or other similar situations. Traumatizing events can take a serious emotional toll on those involved, even if the event did not cause physical damage. Regardless of its source, trauma contains three common elements: fi It was unexpected. Those who feel supported after the event (through family, friends, spiritual connections, etc. It is at this point that negative coping behaviours may start and may continue until a person decides to face the diffcult emotions that surround the traumatic experience. Instead, traumatic events are profound experiences that can shape the way a person sees themselves, others and the world. Because the traumatic experience was so terrible, it is normal for people to block the experience from their memory, or try to avoid any reminders of the trauma; this is how they survive. The trauma becomes the organizing principle from which the person lives their life always trying to cope with and/or avoid the impact of the trauma. This lack of processing of the trauma means that it is ever-present for the individual, and they feel as if the trauma happened yesterday when it could have been months or many years since.

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Specify course if full criteria for a mood episode are not currently met: in partial remission (p. During the mood episode(s), the requisite number of symptoms must be present most of the day, nearly every day, and represent a noticeable change from usual behavior and functioning. A hypomanie episode that causes significant impairment would likely qualify for the diagnosis of manic episode and, therefore, for a lifetime diagnosis of bipolar I disorder. Instead, the impairment results from the major depressive episodes or from a persistent pattern of unpredictable mood changes and fluctuating, unreliable interpersonal or occupational functioning. Depressive symptoms co-occurring with a hypomanie episode or hypomanie symptoms co-occurring with a depressive episode are common in individuals with bipolar fi disorder and are overrepresented in females, particularly hypomania with mixed features. There may be heightened levels of creativity in some individuals with a bipolar disorder. However, that relationship may be nonlinear; that is, greater lifetime creative accomplishments have been associated with milder forms of bipolar disorder, and higher creativity has been found in unaffected family members. Many individuals experience several episodes of major depression prior to the first recognized hypomanie episode. Patterns of illness and comorbidity, however, seem to differ by gender, with females being more likely than males to report hypomania with mixed depressive features and a rapid-cycling course. Childbirth may be a specific trigger for a hypomanie episode, which can occur in 10%-20% of females in nonelinieal populations and most typically in the early postpartum period. Distinguishing hypomania from the elated mood and reduced sleep that normally accompany the birth of a child may be challenging. Prolonged unemployment in individuals with bipolar disorder is associated with more episodes of depression, older age, increased rates of current panic disorder, and lifetime history of alcohol use disorder. Other helpful considerations include the accompanying symptoms, previous course, and family history. Anxiety disorders need to be considered in the differential diagnosis and may frequently be present as co-occurring disorders. A diagnosis of a personality disorder should not be made during an untreated mood episode unless the lifetime history supports the presence of a personality disorder. These commonly co-occurring disorders do not seem to follow a course of illness that is truly independent from that of the bipolar disorder, but rather have strong associations with mood states. For example, anxiety and eating disorders tend to associate most with depressive symptoms, and substance use disorders are moderately associated with manic symptoms. During the above 2-year period (1 year in children and adolescents), the hypomanie and depressive periods have been present for at least half the time and the individual has not been without the symptoms for more than 2 months at a time. The diagnosis of cyclothymic disorder is made only if the criteria for a major depressive, manic, or hypomanie episode have never been met (Criterion C). In the general population, cyclothymic disorder is apparently equally common in males and females. In clinical settings, females with cyclothymic disorder may be more likely to present for treatment than males. Deveiopment and Course Cyclothymic disorder usually begins in adolescence or early adult life and is sometimes considered to reflect a temperamental predisposition to other disorders in this chapter. Cyclotiiymic disorder may be more common in the first-degree biological relatives of individuals witiK bipolar I disorder than in the general population. Differentiai Diagnosis Bipolar and related disorder due to another medical condition and depressive disorder due to another medical condition. The diagnosis of bipolar and related disorder due to another medical condition or depressive disorder due to another medical condition is made when the mood disturbance is judged to be attributable to the physiological effect of a specific, usually chronic medical condition. This determination is based on the history, physical examination, or laboratory findings. The frequent mood swings in these disorders that are suggestive of cyclothymic disorder usually resolve following cessation of substance/medication use. Both disorders may resemble cyclothymic disorder by virtue of the frequent marked shifts in mood. Borderline personality disorder is associated with marked shifts in mood that may suggest cyclothymic disorder. Most children with cyclothymic disorder treated in outpatient psychiatric settings have comorbid mental conditions; they are more likely than other pediatric patients with mental disorders to have comorbid attention-deficit/hyperactivity disorder. A prominent and persistent disturbance in mood that predominates inthe clinical picture and is characterized by elevated, expansive, or irritable mood, with or without depressed mood, or markedly diminished interest or pleasure in all, or almost all, activities.

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The symptom or deficit is not better explained by another medical or mental disorder. Sensory symptoms include altered, reduced, or absent skin sensation, vision, or hearing. Although the diagnosis requires that the symptom is not explained by neurological disease, it should not be made simply because results from investigations are normal or because the symptom is "bizarre. Internal inconsistency at examination is one way to demonstrate incompatibility. On this test, a unilateral tremor may be identified as functional if the tremor changes when the individual is distracted away from it. It is important to note that the diagnosis of conversion disorder should be based on the overall clinical picture and not on a single clinical finding. Associated Features Supporting Diagnosis A number of associated features can support the diagnosis of conversion disorder. Onset may be associated with stress or trauma, either psychological or physical in nature. However, while assessment for stress and trauma is important, the diagnosis should not be withheld if none is found. The diagnosis of conversion disorder does not require the judgment that the symptoms are not intentionally produced. Prevalence Transient conversion symptoms are common, but the precise prevalence of the disorder is unknown. This is partly because the diagnosis usually requires assessment in secondary care, where it is found in approximately 5% of referrals to neurology clinics. The incidence of individual persistent conversion symptoms is estimated to be 2-5/100,000 per year. The onset of non-epileptic attacks peaks in the third decade, and motor symptoms have their peak onset in the fourth decade. Maladaptive personality traits, the presence of comorbid physical disease, and the receipt of disability benefits may be negative prognostic factors. Culture-R elated Diagnostic Issues Changes resembling conversion (and dissociative) symptoms are common in certain culturally sanctioned rituals. Gender-Related Diagnostic Issues Conversion disorder is two to three times more common in females. Functional Consequences of Conversion Disorder Individuals with conversion symptoms may have substantial disability. Differential Diagnosis If another mental disorder better explains the symptoms, that diagnosis should be made. However the diagnosis of conversion disorder may be made in the presence of another mental disorder. The main differential diagnosis is neurological disease that might better explain the symptoms. After a thorough neurological assessment, an unexpected neurological disease cause for the symptoms is rarely found at follow up. Most of the somatic symptoms encountered in somatic symptom disorder cannot be demonstrated to be clearly incompatible with pathophysiology. The excessive thoughts, feelings, and behaviors characterizing somatic symptom disorder are often absent in conversion disorder. If both conversion disorder and a dissociative disorder are present, both diagnoses should be made. Depressive disorders are also differentiated by the presence of core depressive symptoms. Comorbidity Anxiety disorders, especially panic disorder, and depressive disorders commonly co-occur with conversion disorder. Personality disorders are more common in individuals with conversion disorder than in the general population. Psychological Factors Affecting Other Medical Conditions Diagnostic Criteria 316 (F54) A. Psychological or behavioral factors adversely affect the medical condition in one of the following ways: 1. The factors have influenced the course of the medical condition as shown by a close temporal association between the psychological factors and the development or exacerbation of, or delayed recovery from, the medical condition. The factors constitute additional well-established health risks for the individual. The factors influence the underlying pathophysiology, precipitating or exacerbating symptoms or necessitating medical attention. These factors can adversely affect the medical condition by influencing its course or treatment, by constituting an additional well-established health risk factor, or by influencing the underlying pathophysiology to precipitate or exacerbate symptoms or to necessitate medical attention.


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