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Michael Timothy Smith, M.A., Ph.D.

• Director, Division of Behavioral Medicine, Department of Psychiatry, Johns Hopkins Bayview
• Professor of Psychiatry and Behavioral Sciences

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0017164/michael-smith

The principle of unconditional positive regard has become a foundation of psychological therapy; therapists who use it in their practice are more effective than those who [12] do not (Prochaska & Norcross allergy medicine children under 6 buy clarinex online now, 2007; Yalom allergy shots upset stomach order clarinex master card, 1995) allergy medicine cat dander discount clarinex. Today the positive psychology movement argues for many of these ideas allergy treatment natural supplements discount clarinex 5mg mastercard, and research has documented the extent to which thinking positively and openly has important positive consequences for our relationships allergy research group cheap clarinex express, our life satisfaction allergy symptoms vision buy generic clarinex pills, and our psychological and [13] physical health (Seligman & Csikszentmihalyi, 2000). Research Focus: Self-Discrepancies, Anxiety, and Depression [14] Tory Higgins and his colleagues (Higgins, Bond, Klein, & Strauman, 1986; Strauman & Higgins, 1988) have studied how different aspects of the self-concept relate to personality characteristics. These researchers focused on the types of emotional distress that we might experience as a result of how we are currently evaluating our self concept. Higgins proposes that the emotions we experience are determined both by our perceptions of how well our own behaviors meet up to the standards and goals we have provided ourselves (our internal standards) and by our perceptions of how others think about us (our external standards). Furthermore, Higgins argues that different types of self-discrepancies lead to different types of negative emotions. The participants listed 10 thoughts that they thought described the kind of person they actually are; this is the actual self-concept. Then, participants also listed 10 thoughts that they thought described the type of person they would ideally like to be? (the ideal self-concept) as well as 10 thoughts describing the way that someone else?for instance, a parent?thinks they ought to be? (the ought self-concept). Those with low self-concept discrepancies were those who listed similar traits on all three lists. Their ideal, ought, and actual self-concepts were all pretty similar and so they were not considered to be vulnerable to threats to their self-concept. The other half of the participants, those with high self-concept discrepancies, were those for whom the traits listed on the ideal and ought lists were very different from those listed on the actual self list. Then, at a later research session, Higgins first asked people to express their current emotions, including those related to sadness and anxiety. Participants in the ideal self-discrepancy priming condition were asked to think about and discuss their own and their parents? hopes and goals for them. Participants in the ought self-priming condition listed their own and their parents? beliefs concerning their duty and obligations. For high self-concept discrepancy participants, however, priming the ideal self-concept increased their sadness and dejection, whereas priming the ought self-concept increased their anxiety and agitation. These results are consistent with the idea that discrepancies between the ideal and the actual self lead us to experience sadness, dissatisfaction, and other depression-related emotions, whereas discrepancies between the actual and ought self are more likely to lead to fear, worry, tension, and other anxiety-related emotions. For participants with low self-concept discrepancies (right bars), seeing words that related to the self had little influence on emotions. For those with high self-concept discrepancies (left bars), priming the ideal self increased dejection whereas priming the ought self increased agitation. Self-discrepancies and emotional vulnerability: How magnitude, accessibility, and type of discrepancy influence affect. This makes it clear that even though you might not care that much about achieving in school, your failure to do well may still produce negative emotions because you realize that your parents do think it is important. Based on your understanding of psychodynamic theories, how would you analyze your own personality? Are there aspects of the theory that might help you explain your own strengths and weaknesses? Based on your understanding of humanistic theories, how would you try to change your behavior to better meet the underlying motivations of security, acceptance, and self-realization? A new look at defensive projection: Thought suppression, accessibility, and biased person perception. Self-discrepancies as predictors of vulnerability to distinct syndromes of chronic emotional distress. Outline the methods of behavioral genetics studies and the conclusions that we can draw from them about the determinants of personality. Explain how molecular genetics research helps us understand the role of genetics in personality. One question that is exceedingly important for the study of personality concerns the extent to which it is the result of nature or nurture. If nature is more important, then our personalities will form early in our lives and will be difficult to change later. If nurture is more important, however, then our experiences are likely to be particularly important, and we may be able to flexibly alter our personalities over time. In this section we will see that the personality traits of humans and animals are determined in large part by their genetic makeup, and thus it is no surprise that identical twins Paula Bernstein and Elyse Schein turned out to be very similar even though they had been raised separately. A gene is the basic biological unit that transmits characteristics from one generation to the next. These common genetic structures lead members of the same species to be born with a variety of behaviors that come naturally to them and that define the characteristics of the species. These abilities and characteristics are known as instincts?complex inborn patterns [1] of behaviors that help ensure survival and reproduction(Tinbergen, 1951). Birds naturally build nests, dogs are naturally loyal to their human caretakers, and humans instinctively learn to walk and to speak and understand language. Rabbits are naturally fearful, but some are more fearful than others; some dogs are more loyal than others to their caretakers; and some humans learn to speak and write better than others do. Personality is not determined by any single gene, but rather by the actions of many genes working together. Furthermore, even working together, genes are not so powerful that they can control or create our personality. Some genes tend to increase a given characteristic and others work to decrease that same characteristic?the complex relationship among the various genes, as well as a variety of random factors, produces the final outcome. Furthermore, genetic factors always work with environmental factors to create personality. Having a given pattern of genes doesn?t necessarily mean that a particular trait will develop, because some traits might occur only in some environments. For example, a person may have a genetic variant that is known to increase his or her risk for developing emphysema from smoking. Studying Personality Using Behavioral Genetics Perhaps the most direct way to study the role of genetics in personality is to selectively breed animals for the trait of interest. If the selective breeding creates offspring with even stronger traits, then we can assume that the trait has genetic origins. In this manner, scientists have studied the role of genetics in how worms respond to stimuli, how fish develop courtship rituals, how rats differ in play, and how pigs differ in their responses to stress. Although selective breeding studies can be informative, they are clearly not useful for studying humans. For this psychologists rely onbehavioral genetics?a variety of research techniques that scientists use to learn about the genetic and environmental influences on human behavior by comparing the traits of biologically and nonbiologically related family members (Baker, [2] 2010). Behavioral genetics is based on the results of family studies, twin studies, and adoptive studies. The presence of the trait in first-degree relatives (parents, siblings, and children) is compared to the prevalence of the trait in second degree relatives (aunts, uncles, grandchildren, grandparents, and nephews or nieces) and in more distant family members. The scientists then analyze the patterns of the trait in the family members to see the extent to which it is shared by closer and more distant relatives. Although family studies can reveal whether a trait runs in a family, it cannot explain why. Twin studies rely on the fact that identical (or monozygotic) twins have essentially the same set of genes, while fraternal (or dizygotic) twins have, on average, a half-identical set. The idea is that if the twins are raised in the same household, then the twins will be influenced by their environments to an equal degree, and this influence will be pretty much equal for identical and fraternal twins. In other words, if environmental factors are the same, then the only factor that can make identical twins more similar than fraternal twins is their greater genetic similarity. In a twin study, the data from many pairs of twins are collected and the rates of similarity for identical and fraternal pairs are compared. Twin studies divide the influence of nature and nurture into three parts: Heritability. Shared environment determinants are indicated when the correlation coefficients for identical and fraternal twins are greater than zero and also very similar. These correlations indicate that both twins are having experiences in the family that make them alike. Nonshared environment is indicated when identical twins do not have similar traits. These influences refer to experiences that are not accounted for either by heritability or by shared environmental factors. Nonshared environmental factors are the experiences that make individuals within the same family less alike. If a parent treats one child more affectionately than another, and as a consequence this child ends up with higher self-esteem, the parenting in this case is a nonshared environmental factor. In the typical twin study, all three sources of influence are operating simultaneously, and it is possible to determine the relative importance of each type. An adoption study compares biologically related people, including twins, who have been reared either separately or apart. Evidence for genetic influence on a trait is found when children who have been adopted show traits that are more similar to those of their biological parents than to those of their adoptive parents. Evidence for environmental influence is found when the adoptee is more like his or her adoptive parents than the biological parents. The results of family, twin, and adoption studies are combined to get a better idea of the influence of genetics and environment on traits of interest. Genetic and environmental effects on same-sex sexual behavior: A population study of twins in Sweden. Nature, nurture, and cognitive development from 1 to 16 years: A parent-offspring adoption study. This column represents the pure effects of genetics, in the sense that environmental differences have been controlled to be a small as possible. You can also see from the table that, overall, there is more influence of nature than of parents. Identical twins, even when they are raised in separate households by different parents (column 4), turn out to be quite similar in personality, and are more similar than fraternal twins who are raised in separate households (column 5). These results show that genetics has a strong influence on personality, and helps explain why Elyse and Paula were so similar when they finally met. For instance, for sexual orientation the estimates of heritability vary from 18% to 39% of the total across studies, suggesting that 61% to 82% of the total influence is due to environment. You might at first think that parents would have a strong influence on the personalities of their children, but this would be incorrect. Shared environment does influence the personality and behavior of young children, but this influence decreases rapidly as the child grows older. By the time we reach adulthood, the impact of shared environment on our [6] personalities is weak at best (Roberts & DelVecchio, 2000). If parents are not providing the environmental influences on the child, then what is? You can see that these factors?the largely unknown things that happen to us that make us different from other people?often have the largest influence on personality. Studying Personality Using Molecular Genetics In addition to the use of behavioral genetics, our understanding of the role of biology in personality recently has been dramatically increased through the use of molecular genetics, which is the study of which genes are associated with which personality traits (Goldsmith et al. Molecular genetics researchers have also developed new techniques that allow them to find the locations of genes within chromosomes and to identify the effects those genes have when activated or deactivated. One approach that can be used in animals, usually in laboratory mice, is the knockout study. In this approach the researchers use specialized techniques to remove or modify the influence of a [9] gene in a line of knockout? mice (Crusio, Goldowitz, Holmes, & Wolfer, 2009). When these animals are born, they are studied to see whether their behavior differs from a control group of normal animals. Research has found that removing or changing genes in mice can affect their anxiety, aggression, learning, and socialization patterns. Research using molecular genetics has found genes associated with a variety of personality traits including novelty-seeking (Ekelund, Lichtermann, Jarvelin, & Peltonen, [10] [11] 1999), attention-deficit/hyperactivity disorder (Waldman & Gizer, 2006), and smoking [12] behavior (Thorgeirsson et al. Over the past two decades scientists have made substantial progress in understanding the important role of genetics in behavior. Behavioral genetics studies have found that, for most traits, genetics is more important than parental influence. And molecular genetics studies have begun to pinpoint the particular genes that are causing these differences. The results of these studies might lead you to believe that your destiny is determined by your genes, but this would be a mistaken assumption. Over time we will learn even more about the role of genetics, and our conclusions about its influence will likely change. Current research in the area of behavioral genetics is often criticized for making assumptions about how researchers categorize identical and fraternal twins, about whether twins are in fact treated in the same way by their parents, about whether twins are representative of children more generally, and about many other issues. Although these critiques may not change the overall conclusions, it must be kept in mind that these findings are relatively new and will certainly be [13] updated with time (Plomin, 2000). In fact, the major influence on personality is nonshared environmental influences, which include all the things that occur to us that make us unique individuals. These differences include variability in brain structure, nutrition, education, upbringing, and even interactions among the genes themselves. The genetic differences that exist at birth may be either amplified or diminished over time through environmental factors. The brains and bodies of identical twins are not exactly the same, and they become even more different as they grow up. As a result, even genetically identical twins have distinct personalities, resulting in large part from environmental effects. Because these nonshared environmental differences are nonsystematic and largely accidental or random, it will be difficult to ever determine exactly what will happen to a child as he or she grows up.

When errors and mistakes of consequence occur that indicate some corrective action is needed to minimize recurrence allergy symptoms red face order 5mg clarinex visa, knowing the work processing method or performance mode the individual was working in is instructive allergy medicine and adderall buy 5mg clarinex free shipping. All too often allergy san antonio order clarinex 5mg on line, workers involved in skill-based performance who err are scheduled for retraining as a logical solution allergy symptoms lung congestion buy discount clarinex 5mg. But allergy testing for hives purchase cheap clarinex on line, retraining workers to do work that is already basically memorized and automatic allergy symptoms medications generic clarinex 5mg amex, performed with little conscious thought because of the nature of the work, is a waste of time and is an insult to the worker. It is very hard to train a worker not to repeat something he or she did not intend to do in the first place. Observations are used to gather data about the worker behaviors, the job-site conditions, and organizational support that may have been wanting. Inadequate tools, incomplete work packages, scheduling conflicts, poorly written procedures, excessive noise, extreme heat or cold, poor lighting, and so on, may be contributing factors to poor performance. The purpose is to learn of the circumstances surrounding the slip, trip, or lapse and what, if anything, can be changed in the work environment or with the individual to eliminate a similar reoccurrence. The error may have been provoked by fatigue and stress; the worker may have lost sleep worrying about a teenager who left home. Errors that occur when working in rule-based performance may be corrected through retraining. In these instances, understanding requirements and knowing where and under what circumstance those requirements apply is cognitive in nature and must be learned or acquired in some way. Rule based errors can be caught or mitigated by individuals exhibiting a questioning attitude, by calling a time out, or by stopping work when they are unsure. Peer checks can also be used to stop someone from committing a consequential error. An analysis of what went wrong will need to be carried out to formulate a corrective action. Coaching is a pro-active solution to helping individuals eliminate error when working in any performance mode, but is particularly adept for knowledge based performance modes. Mental Models A person handles a complex situation by simplifying the real system into a mental image he/she can remember (such as a simple one-line drawing). A mental model is the structured understanding of knowledge (facts or assumptions) a person has in his or her mind about how 85,86 something works or operates (for example, facility systems). In fact, mental models give humans the ability to detect skill-based slips and lapses. They aid in detecting deviations between desired and undesired system states, such 87 as manually controlling tank water level. Note that all mental models 88 are inaccurate to some extent because of the limitations of human nature. It is important to remember that knowledge-based performance involves problem-solving, and 89 mental models should be considered explicitly when a team works on a problem. Team members should agree with the model they intend to use to diagnose and solve a problem. Assumptions reduce the strain on the mind, allowing a person to think without excessive effort. Consequently, assumptions tend to occur more often when people experience uncertainty, leading to trial-and-error and cause-and-effect problem-solving approaches. Assumptions also occur as an outgrowth of unsafe attitudes and inaccurate mental models. Challenging assumptions is important in improving mental models, solving problems, and optimizing team performance. Also, challenging assumptions helps detect unsafe attitudes and inaccurate mental models. Mental biases, or mental shortcuts, offer the human mind several unconscious methods to create 91 order and simplicity amid uncertainty, reducing mental effort. Personnel should be aware of the potential for error that mental biases and mental shortcuts create during problem-solving and decision-making, such as troubleshooting and diagnostics during emergency operation. More will be said about underlying unconscious assumptions and taken-for-granted beliefs in the opening pages of Chapter 5 on organizational culture. Biases were discussed earlier in this chapter with respect to the limitations of human nature and include the following, among others:? It is an attitude that operational and personnel safety must be protected regardless of current schedule and production pressures. In light of the limitations of human nature, it makes sense to be conservative, especially when a decision potentially affects operational or personnel safety. A systematic, team-based approach is called for so that safety considerations are not compromised. The second principle of human performance states: error-likely situations are predictable, manageable, and preventable. The simple presence of adverse conditions cannot be error-likely unless a specific action is to occur within that set of adverse conditions. Error precursors interfere with successful performance and 93 increase the probability for error. Examples include excessive workload, hurrying, concurrent actions, unclear roles and responsibilities, and vague standards. Examples are unfamiliarity with the task, unsafe attitudes, level of education, lack of knowledge, unpracticed skills, personality, inexperience, health and fitness, poor communication practices, fatigue, and low self-esteem. These include distractions, awkward equipment layout, complex tagout procedures, at-risk norms and values, work group attitudes toward various hazards, work control processes, and temperature, lighting, and noise. Error precursors are, by definition, prerequisite conditions for error and, therefore, exist before an error occurs. If discovered and removed, job-site conditions can be changed to minimize the chance for error. This is more likely if people possess an intolerance for error precursors or error traps. Examples include reporting an improperly marked valve or a malfunctioning gauge in a safety system, taking a broken ladder out of service, immediately cleaning up an oil spill, stopping work until a change can be made to the procedure, calling in a replacement to relieve a worker who has become ill, seeking technical help when unsure, asking for a peer review on engineering calculations, routinely performing safety self-assessments, and so on. These are the more common conditions associated with events triggered by human error. Some organizations distribute a plastic-coated error precursor card to their front line workers to carry with them on the job. Workers refer to these cards during pre-job briefings to help identify precursors related to the upcoming task. A more extensive list of error precursors and error precursor descriptions is provided in Attachments A and B of this chapter. Illness or fatigue; general poor health or injury Work Environment Human Nature 1. Irreversible actions are not necessarily precursors to error, but are often overlooked, leading to preventable events. A human act or task must be either planned or occurring concurrent with error precursors to be considered error-likely. Error??Change new year Precursors:??Repetitive action write several checks??Habit pattern written previous year numerous times during the previous year 2. Error??Confusing displays and controls identical switches both pistol Precursors: grip style??Adjacent within an inch apart both pistol-grip controls very close together??Interruption verifying the status of several annunciator alarms just at the moment to start dilution??Repetitive action done several times during shift while performing system startup 3. Error??Time pressure behind schedule getting equipment on line Precursors:??Departure from routine poor lighting in store room where products were stored??Complacency, mind-set location of fluids on unmarked shelves next to each other??Assumptions containers appear nearly identical Many different factors can affect performance. Considering the number and variety of factors involved with a specific job, many things can change, even with simple, repetitive tasks. When people believe a job is routine, they subconsciously think that nothing can go wrong,? and they expect only success. Then, when something does go wrong, people tend to 95 rationalize the situation away, inhibiting proper response in time to avert the consequences. The design of systems, structures, and components aids in performing the latter through engineered controls such as physical barriers, interlocks, keyed parts, shaped/color-coded controls, automation, and alarms. However, the prevention of or detection of errors also depends on people, either the performer or other people. For example, self-checking and procedures provide individuals with the means of avoiding or detecting mistakes, while peer-checking and three-way communication engage another person. Human performance tools are designed to help people anticipate, prevent, and catch active errors. Human Performance Improvement Handbook Volume 2: Human Performance Tools For Individuals, Work Teams, and Management, is a companion publication to this handbook. Volume 2 provides an explanation of numerous tools that individuals and work teams can employ to reduce errors. The fundamental purpose of human performance tools is to help the worker maintain positive control of a work situation; that is, what is intended to happen is what happens, and that is all that happens. Every person wants to do good work, to be 100 percent accurate, 100 percent complete, and meet 100 percent of the requirements. On occasion, people still err despite how rigorously they use human performance tools. System Changes Although this handbook focuses on what people can do to reduce human error, it is recognized there is another whole dimension associated with error reduction. This involves improvements or changes in the engineered systems so the machines and working conditions better support the human needs, thus reducing human error. The location of instruments and controls on operating control panels, the accessibility and positioning of monitoring equipment, the lighting in passage ways, the sounds of warning alarms, the heights of working surfaces, the distance from communication sources, the number of work a-rounds present, and numerous other conditions can either enhance or hinder human performance. Human error is more likely when tools and equipment, procedures, work processes, or technical support are inadequate. Human factors professionals study and report on adverse engineered and management systems within an organization and recommend modifications or improvements to eliminate these and other conditions. Implementation of such recommendations improves worker perform and reduces human error. Reporting errors and error precursors is an essential behavior needed to acquire feedback from the field about flawed engineered or management systems. Managers and supervisors should encourage workers to report adverse system-related conditions that promote error (error precursors) when ever they are encountered. With input from worker reporting, management can direct needed engineering and system changes. More will be said about how to encourage a reporting culture in Chapter of this handbook. Many references refer to error precursors as behavior-shaping factors or performance-shaping factors. The bolded error 96 precursors are more prevalent and are listed in order of impact. Guidelines for Preventing Human Error in Process Safety, American Institute of Chemical Engineers, 1994. Review of Findings for Human Error Contribution to Risk in Operating Events, 2001. Improving Compliance with Safety Procedures, Reducing Industrial Violations, 1995. The writer was employed by Westinghouse-Hanford as the 200 area training manager at the time of this incident. An internal study of errors across the nuclear industry revealed that 25 percent of errors were skill-based, 60 percent were rule-based, and 15 percent were knowledge-based. Guidelines for Preventing Human Error in Process Safety, American Institute of Chemical Engineers, 1994, pp. From that introduction, the reader will gain an appreciation of the importance of controls in preventing events. The various categories of controls used and their relative dependability will be addressed. Most importantly, the emphasis will be placed on how to identify and eliminate latent organizational conditions in the system that weaken controls by using a variety of available and familiar methods (tools) introduced herein. Depending on the linguistic traditions of various hazardous technological domains, the terms defenses, barriers, controls?, or similar terms may be used. In general, they all connote technological or organizational features specifically designed to protect against hazards. Proper understanding and use of controls are important to understanding and preventing accidents. Controls comprise any human, technical, or organizational features that protect the facility and 2 personnel against hazards. In addition to human error, other hazards include radiation, industrial safety hazards, hazardous chemicals, and various forms of energy, such as electricity and rotating equipment. Controls take the form of containments; physical interlocks; redundant equipment, power sources, and annunciators; personal protective equipment; procedure use; caution tags; and self checking, among others Example of Failed Controls in Industry: Chernobyl the Chernobyl Unit 4 nuclear reactor accident in the Ukraine on April 26, 1986, is a classic example of multiple failed or missing controls?some resulting from design flaws and some from the errors of operators. The schedule that day called for a safety demonstration test to 3-1 Department of Energy Human Performance Handbook Chapter 3 Managing Defenses determine how long the turbines could provide electrical power from residual momentum alone 3 in the event of a power loss. Operators failed in their role as the most important line of protection because they did the following. The station operating procedures strictly prohibited any operations below 20 percent of full power. The operators should have aborted the test completely and returned the reactor to normal power to prevent this, but they did not. That operators could physically disable these safety systems was indeed a flaw in the design of the system. When temperature in the core increased rapidly, giving rise to more boiling and increasing reactivity, an operator attempted a manual scram. Rather than slow down reactivity, insertion of the graphite-tipped control rods caused quite the opposite effect. The reactor vessel head was blown off, and, in a second chemical explosion, the roof of the building was blown off. The presence of a containment structure would have precluded the release of aerosolized fuel and fission products into the environment. Instead, there was a total meltdown of the fuel and fire in the reactor housing burned for 10 days, dispensing radionuclides into the atmosphere.

A great deal of time is spent in activities necessary to obtain phencyclidine allergy fever quality clarinex 5 mg, use the phencyclidine allergy medicine for toddlers under 2 clarinex 5mg on line, or recover from its effects allergy nasal spray buy cheap clarinex line. Recurrent phencyclidine use resulting in a failure to fulfill major role obligations at work allergy treatment europe buy 5 mg clarinex with visa, school anti allergy medicine xyzal buy 5mg clarinex amex, or home allergy kid order clarinex 5 mg mastercard. Continued phencyclidine use despite having persistent or recurrent social or inter? personal problems caused or exacerbated by the effects of the phencyclidine. Important social, occupational, or recreational activities are given up or reduced be? cause of phencyclidine use. Phencyclidine use is continued despite knowledge of having a persistent or recur? rent physical or psychological problem that is likely to have been caused or exac? erbated by the phencyclidine. A need for markedly increased amounts of the phencyclidine to achieve intoxi? cation or desired effect. A markedly diminished effect with continued use of the same amount of the phencyclidine. Note: Withdrawal symptoms and signs are not established for phencyclidines, and so this criterion does not apply. In sustained remission: After full criteria for phencyclidine use disorder were previ? ously met, none of the criteria for phencyclidine use disorder have been met at any time during a period of 12 months or longer (with the exception that Criterion A4, Craving, or a strong desire or urge to use the phencyclidine,?may be met). Specify if: In a controlled environment: this additional specifier is used if the individual is in an environment where access to phencyclidines is restricted. Instead, the comorbid phencyclidine use disorder is in? dicated inthe 4th character of the phencyclidine-induced disorder code (see the coding note for phencyclidine intoxication or a specific phencyclidine-induced mental disorder). For ex? ample, if there is comorbid phencyclidine-induced psychotic disorder, only the phencyclidine induced psychotic disorder code is given, with the 4th character indicating whether the co? morbid phencyclidine use disorder is mild, moderate, or severe: F16. Diagnostic Features the phencyclidines (or phencyclidine-like substances) include phencyclidine. These substances were first developed as dissociative anesthetics in the 1950s and became street drugs in the 1960s. They produce feelings of separation from mind and body (hence "dissociative") in low doses, and at high doses, stupor and coma can result. These substances are most commonly smoked or taken orally, but they may also be snorted or injected. The hallucinogenic effects in vulnerable individuals may last for weeks and may precipitate a persistent psychotic episode resembling schizophrenia. Ketamine has been observed to have utility in the treatment of major depressive disorder. Withdrawal symp? toms have not been clearly established in humans, and therefore the withdraw^al criterion is not included in the diagnosis of phencyclidine use disorder. Associated Features Supporting Diagnosis Phencyclidine may be detected in urine for up to 8 days or even longer at very high doses. In addition to laboratory tests to detect its presence, characteristic symptoms resulting from intoxication v^ith phencyclidine or related substances may aid in its diagnosis. Phencycli? dine is likely to produce dissociative symptoms, analgesia, nystagmus, and hypertension, with risk of hypotension and shock. Violent behavior can also occur with phencyclidine use, as intoxicated persons may believe that they are being attacked. There appears to have been an in? crease among 12th graders in both ever used (to 2. Risic and Prognostic Factors There is little information about risk factors for phencyclidine use disorder. Among indi? viduals admitted to substance abuse treatment, those for whom phencyclidine was the primary substance were younger than those admitted for other substance use, had lower educational levels, and were more likely to be located in the West and Northeast regions of the United States, compared with other admissions. C uiture-R eiated Diagnostic issues Ketamine use in youths ages 16-23 years has been reported to be more common among whites (0. Among individuals ad? mitted to substance abuse treatment, those for whom phencyclidine was the primary sub? stance were predominantly black (49%) or Hispanic (29%). G ender-Reiated Diagnostic issues Males make up about three-quarters of those with phencyclidine-related emergency room visits. Diagnostic iViaricers Laboratory testing may be useful, as phencyclidine is present in the urine in intoxicated in? dividuals up to 8 days after ingestion. Functional Consequences of Pliencyclidine Use Disorder In individuals with phencyclidine use disorder, there may be physical evidence of injuries from accidents, fights, and falls. Chronic use of phencyclidine may lead to deficits in mem? ory, speech, and cognition that may last for months. Other consequences include intracranial hemorrhage, rhabdomyolysis, respiratory problems, and (occasionally) cardiac arrest. Distinguishing the effects of phencychdine from those of other substances is important, since it may be a common additive to other substances. Some of the effects of phencychdine and related substance use may resemble symptoms of other psychiatric disorders, such as psy? chosis (schizophrenia), low mood (major depressive disorder), violent aggressive be? haviors (conduct disorder, antisocial personality disorder). Discerning whether these behaviors occurred before the intake of the drug is important in the differentiation of acute drug effects from preexisting mental disorder. Phencyclidine-induced psychotic disorder should be considered when there is impaired reality testing in individuals experiencing disturbances in perception resulting from ingestion of phencyclidine. A problematic pattern of hallucinogen (other than phencyclidine) use leading to clini? cally significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period: 1. The hallucinogen is often taken in larger amounts or over a longer period than was intended. There is a persistent desire or unsuccessful efforts to cut down or control halluci? nogen use. A great deal of time is spent in activities necessary to obtain the hallucinogen, use the hallucinogen, or recover from its effects. Recurrent hallucinogen use resulting in a failure to fulfill major role obligations at work, school, or home. Continued hallucinogen use despite having persistent or recurrent social or inter? personal problems caused or exacerbated by the effects of the hallucinogen. Important social, occupational, or recreational activities are given up or reduced be? cause of hallucinogen use. Hallucinogen use is continued despite knowledge of having a persistent or recur? rent physical or psychological problem that is likely to have been caused or exac? erbated by the hallucinogen. A need for markedly increased amounts of the hallucinogen to achieve intoxi? cation or desired effect. A markedly diminished effect with continued use of the same amount of the hal? lucinogen. Note: Withdrawal symptoms and signs are not established for hallucinogens, and so this criterion does not apply. Specify if: In early remission: After full criteria for other hallucinogen use disorder were previ? ously met, none of the criteria for other hallucinogen use disorder have been met for at least 3 months but for less than 12 months (with the exception that Criterion A4, Craving, or a strong desire or urge to use the hallucinogen,? may be met). In sustained remission: After full criteria for other hallucinogen use disorder were previously met, none of the criteria for other hallucinogen use disorder have been met at any time during a period of 12 months or longer (with the exception that Criterion A4, Craving, or a strong desire or urge to use the hallucinogen,? may be met). Specify if: In a controlled environment: this additional specifier is used if the individual is in an environment where access to hallucinogens is restricted. Instead, the comorbid hallucinogen use disorder is indicated in the 4th character of the hallucinogen-induced disorder code (see the coding note for halluci? nogen intoxication or specific hallucinogen-induced mental disorder). For example, if there is comorbid hallucinogen-induced psychotic disorder and hallucinogen use disorder, only the hallucinogen-induced psychotic disorder code is given, with the 4th character indicating wheth? er the comorbid hallucinogen use disorder is mild, moderate, or severe: F16. Diagnostic Features Hallucinogens comprise a diverse group of substances that, despite having different chem? ical structures and possibly involving different molecular mechanisms, produce similar alterations of perception, mood, and cognition in users. In addition, miscellaneous other ethnobotanical compounds are classified as "hallucinogens," of which Salvia divinorum and jimsonweed are two examples. These substances can have hallucinogenic effects but are diagnosed separately because of significant differences in their psychological and behavioral effects. Tolerance to hallucinogens develops with repeated use and has been reported to have both autonomic and psychological effects. Among heavy ecstasy users, continued use despite physical or psychological problems, tolerance, hazardous use, and spending a great deal of time obtaining the substance are the most commonly reported criteria?over 50% in adults and over 30% in a younger sample, while legal problems related to substance use and persis? tent desire/inability to quit are rarely reported. As found for other substances, diagnostic cri? teria for other hallucinogen use disorder are arrayed along a single continuum of severity. Both psychological and physical problems have been commonly reported as withdrawal problems. Associated Features Supporting Diagnosis the characteristic symptom features of some of the hallucinogens can aid in diagnosis if urine or blood toxicology results are not available. Individuals intoxicated with hallucinogens may exhibit a temporary increase in suicidality. Prevalence Of all substance use disorders, other hallucinogen use disorder is one of the rarest. Rates are highest in individuals younger than 30 years, with the peak occurring in individuals ages 18-29 years (0. There are marked ethnic differences in 12-month prevalence of other hallucinogen use disorder. Among youths ages 12-17 years, 12-month prevalence is higher among Native Americans and Alaska Natives (1. Among adults, 12-month prevalence of other hallucinogen use disorder is similar for Native Americans and Alaska Natives, whites, and Hispanics (all 0. Development and Course Unlike most substances where an early age at onset is associated with elevations in risk for the corresponding use disorder, it is unclear whether there is an association of an early age at onset with elevations in risk for other hallucinogen use disorder. However, patterns of drug consumption have been found to differ by age at onset, with early-onset ecstasy users more likely to be polydrug users than their later-onset counterparts. Little is knovm regarding the course of other hallucinogen use disorder, but it is generally thought to have low incidence, low persistence, and high rates of recovery. Adolescents are es? pecially at risk for using these drugs, and it is estimated that 2. Other hallucinogen use disorder is a disorder observed primarily in individuals younger than 30 years, with rates vanishingly rare among older adults. Other substance use disorders, particu? larly alcohol, tobacco, and cannabis, and major depressive disorder are associated with ele? vated rates of other hallucinogen use disorder. Antisocial personality disorder may be elevated among individuals who use more than two other drugs in addition to hallucinogens, compared with their counterparts with less extensive use history. The influence of adult anti? social behaviors?^but not conduct disorder or antisocial personality disorder?on other hal? lucinogen use disorder may be stronger in females than in males. Cannabis use has also been implicated as a precursor to initiation of use of hallucinogens. Higher drug use by peers and high sensation seeking have also been associated with elevated rates of ecstasy use. Among male twins, total variance due to additive genetics has been estimated to range from 26% to 79%, with inconsistent evidence for shared envi? ronmental influences. Culture-R elated Diagnostic issues Historically, hallucinogens have been used as part of established religious practices, such as the use of peyote in the Native American Church and in Mexico. Ritual use by indige? nous populations of psilocybin obtained from certain types of mushrooms has occurred in South America, Mexico, and some areas in the United States, or of ayahuasca in the Santo Daime and Uniao de Vegetal sects. Regular use of peyote as part of religious rituals is not linked to neuropsychological or psychological deficits. For adults, no race or ethnicity dif? ferences for the full criteria or for any individual criterion are apparent at this time. G ender-Related Diagnostic Issues In adolescents, females may be less likely than males to endorse 'hazardous use," and fe? male gender may be associated with increased odds of other hallucinogen use disorder. Diagnostic M arkers Laboratory testing can be useful in distinguishing among the different hallucinogens. The effects of hallucinogens must be distinguished from those of other substances. Other potential disorders or conditions to consider include panic disorder, depressive and bipolar disorders, alcohol or sedative withdrawal, hypoglycemia and other metabolic conditions, seizure disorder, stroke, oph thalmological disorder, and central nervous system tumors. Careful history of drug tak? ing, collateral reports from family and friends (if possible), age, clinical history, physical examination, and toxicology reports should be useful in arriving at the final diagnostic de? cision. Individuals who use hallucinogens exhibit eleva? tions of nonsubstance mental disorders (especially anxiety, depressive, and bipolar disor? ders), particularly with use of ecstasy and salvia. Rates of antisocial personality disorder (but not conduct disorder) are significantly elevated among individuals with other hallucinogen use disorder, as are rates of adult antisocial behavior. However, it is unclear whether the mental illnesses may be precursors to rather than consequences of other hallucinogen use disorder (see the section "Risk and Prognostic Factors" for this disorder). Both adults and adolescents who use ecstasy are more likely than other drug users to be polydrug users and to have other drug use disorders. Within 1 hour, two (or more) of the following signs or symptoms: Note: When the drug is smoked, snorted,? or used intravenously, the onset may be particularly rapid. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including Intoxication with another substance. Note: In addition to the section "Functional Consequences of Phencyclidine Intoxication," see the corresponding section in phencyclidine use disorder. Diagnostic Features Phencyclidine intoxication reflects the clinically significant behavioral changes that occur shortly after ingestion of this substance (or a pharmacologically similar substance). The most common clinical presentations of phencyclidine intoxication include disorientation, confusion without hallucinations, hallucinations or delusions, a catatonic-like syndrome, and coma of varying severity. The intoxication typically lasts for several hours but, de? pending on the type of clinical presentation and whether other drugs besides phencycli? dine were consumed, may last for several days or longer. Prevalence Use of phencyclidine or related substances may be taken as an estimate of the prevalence of intoxication. Past-year use of ketamine, which is assessed separately from other substances, has remained stable over time, with about 1. Functional Consequences of Phencyclidine Intoxication Phencyclidine intoxication produces extensive cardiovascular and neurological.

Where a state of delirium is superimposed upon such a disorder in this block allergy rash treatment home remedy buy clarinex no prescription, it should be coded by means of F1x allergy symptoms heart racing clarinex 5 mg sale. This should be a main diagnosis only in cases where intoxication occurs without more persistent alcohol or drug-related problems being concomitantly present allergy testing queenstown order 5 mg clarinex mastercard. Where there are such problems allergy over the counter proven clarinex 5mg, precedence should be given to diagnoses of harmful use (F1x gluten allergy symptoms quiz buy clarinex 5mg with amex. Exceptions to this may occur in individuals with certain underlying organic conditions allergy kid buy clarinex on line. Intensity of intoxication lessens with time, and effects eventually disappear in the absence of further use of the substance. Recovery is therefore complete except where tissue damage or another complication has arisen. Symptoms of intoxication need not always reflect primary actions of the substance: for instance, depressant drugs may lead to symptoms of agitation or hyperactivity, and stimulant drugs may lead to socially withdrawn and introverted behaviour. Effects of substances such as cannabis and hallucinogens may be particularly unpredictable. Moreover, many psychoactive substances are capable of producing different types of effect at different dose levels. For example, alcohol may have apparently stimu lant effects on behaviour at lower dose levels, lead to agitation and aggression with increasing dose levels, and produce clear sedation at very high levels. Consider also the possibilities of intoxication as the result of mixed substance use. The following five-character codes may be used to indicate whether the acute intoxication was associated with any complications: F1x. Sudden onset of aggression and often violent behaviour that is not typical of the individual when sober, very soon after drinking amounts of alcohol that would not produce intoxication in most people. The damage may be physical (as in cases of hepatitis from the self-administration of injected drugs) or mental. Diagnostic guidelines the diagnosis requires that actual damage should have been caused to the mental or physical health of the user. Harmful patterns of use are often criticized by others and frequently associated with adverse social consequences of various kinds. The fact that a pattern of use or a particular substance is disapproved of by another person or by the culture, or may have led to socially negative consequences such as arrest or marital arguments is not in itself evidence of harmful use. A central descriptive characteristic of the dependence syndrome is the desire (often strong, sometimes overpowering) to take psychoactive drugs (which may or may not have been medically prescribed), alcohol, or tobacco. Diagnostic guidelines A definite diagnosis of dependence should usually be made only if three or more of the following have been present together at some time during the previous year: (a)a strong desire or sense of compulsion to take the substance; (b)difficulties in controlling substance-taking behaviour in terms of its onset, termination, or levels of use; (c)a physiological withdrawal state (see F1x. Narrowing of the personal repertoire of patterns of psychoactive substance use has also been described as a characteristic feature. It is an essential characteristic of the dependence syndrome that either psychoactive substance taking or a desire to take a particular substance should be present; the subjective awareness of compulsion to use drugs is most commonly seen during attempts to stop or control substance use. This diagnostic requirement would exclude, for instance, surgical patients given opioid drugs for the relief of pain, who may show signs of an opioid withdrawal state when drugs are not given but who have no desire to continue taking drugs. Includes: chronic alcoholism dipsomania drug addiction the diagnosis of the dependence syndrome may be further specified by the following five-character codes: F1x. Onset and course of the withdrawal state are time-limited and are related to the type of substance and the dose being used immediately before abstinence. Diagnostic guidelines Withdrawal state is one of the indicators of dependence syndrome (see F1x. Withdrawal state should be coded as the main diagnosis if it is the reason for referral and sufficiently severe to require medical attention in its own right. Typically, the patient is likely to report that withdrawal symptoms are relieved by further substance use. It should be remembered that withdrawal symptoms can be induced by conditioned/learned stimuli in the absence of immediately preceding substance use. In such cases a diagnosis of withdrawal state should be made only if it is warranted in terms of severity. Many symptoms present in drug withdrawal state may also be caused by other psychiatric conditions. Simple "hangover" or tremor due to other conditions should not be confused with the symptoms of a withdrawal state. The diagnosis of withdrawal state may be further specified by using the following five-character codes: F1x. Delirium tremens is a short-lived, but occasionally life-threatening, toxic-confusional state with accompanying somatic disturbances. It is usually a consequence of absolute or relative withdrawal of alcohol in severely dependent users with a long history of use. In some cases the disorder appears during an episode of heavy drinking, in which case it should be coded here. The classical triad of symptoms includes clouding of consciousness and confusion, vivid hallucinations and illusions affecting any sensory modality, and marked tremor. Delusions, agitation, insomnia or sleep-cycle reversal, and autonomic overactivity are usually also present. The sensorium is usually clear but some degree of clouding of consciousness, though not severe confusion, may be present. The disorder typically resolves at least partially within 1 month and fully within 6 months. Diagnostic guidelines A psychotic disorder occurring during or immediately after drug use (usually within 48 hours) should be recorded here provided that it is not a manifestation of drug withdrawal state with delirium (see F1x. Late-onset psychotic disorders (with onset more than 2 weeks after substance use) may occur, but should be coded as F1x. Psychoactive substance-induced psychotic disorders may present with varying patterns of symptoms. These variations will be influenced by the type of substance involved and the personality of the user. For stimulant drugs such as cocaine and amfetamines, drug-induced psychotic disorders are generally closely related to high dose levels and/or prolonged use of the substance. A diagnosis of a psychotic disorder should not be made merely on the basis of perceptual distortions or hallucinatory experiences when substances having primary hallucinogenic effects. In such cases, and also for confusional states, a possible diagnosis of acute intoxication (F1x. Particular care should also be taken to avoid mistakenly diagnosing a more serious condition. Many psychoactive substance-induced psychotic states are of short duration provided that no further amounts of the drug are taken (as in the case of amfetamine and cocaine psychoses). False diagnosis in such cases may have distressing and costly implications for the patient and for the health services. Consider the possibility of another mental disorder being aggravated or precipitated by psychoactive substance use. In such cases, a diagnosis of psychoactive substance-induced psychotic state may be inappropriate. Disturbances of time sense and ordering of events are usually evident, as are difficulties in learning new material. Other cognitive functions are usually relatively well preserved and amnesic defects are out of proportion to other disturbances. Diagnostic guidelines Amnesic syndrome induced by alcohol or other psychoactive substances coded here should meet the general criteria for organic amnesic syndrome (see F04). The primary requirements for this diagnosis are: (a)memory impairment as shown in impairment of recent memory (learning of new material); disturbances of time sense (rearrangements of chronological sequence, telescoping of repeated events into one, etc. Personality changes, often with apparent apathy and loss of initiative, and a tendency towards self-neglect may also be present, but should not be regarded as necessary conditions for diagnosis. Although confabulation may be marked it should not be regarded as a necessary prerequisite for diagnosis. Consider: organic amnesic syndrome (nonalcoholic) (see F04); other organic syndromes involving marked impairment of memory. Diagnostic guidelines Onset of the disorder should be directly related to the use of alcohol or a psychoactive substance. Cases in which initial onset occurs later than episode(s) of substance use should be coded here only where clear and strong evidence is available to attribute the state to the residual effect of the substance. The disorder should represent a change from or marked exaggeration of prior and normal state of functioning. The disorder should persist beyond any period of time during which direct effects of the psychoactive substance might be assumed to be operative (see F1x. Alcohol or psychoactive substance-induced dementia is not always irreversible; after an extended period of total abstinence, intellectual functions and memory may improve. The disorder should be carefully distinguished from withdrawal-related conditions (see F1x. It should be remembered that, under certain conditions and for certain substances, withdrawal state phenomena may be present for a period of many days or weeks after discontinuation of the substance. Conditions induced by a psychoactive substance, persisting after its use, and meeting the criteria for diagnosis of psychotic disorder should not be diagnosed here (use F1x. Consider: pre-existing mental disorder masked by substance use and re-emerging as psychoactive substance-related effects fade (for example, phobic anxiety, a depressive disorder, schizophrenia, or schizotypal disorder). Consider also organic injury and mild or moderate mental retardation (F70-F71), which may coexist with psychoactive substance misuse. This diagnostic rubric may be further subdivided by using the following five-character codes: -75 F1x. Schizotypal disorder possesses many of the characteristic features of schizophrenic disorders and is probably genetically related to them; however, the hallucinations, delusions, and gross behavioural disturbances of schizophrenia itself are absent and so this disorder does not always come to medical attention. Most of the delusional disorders are probably unrelated to schizophrenia, although they may be difficult to distinguish clinically, particularly in their early stages. They form a heterogeneous and poorly understood collection of disorders, which can conveniently be divided according to their typical duration into a group of persistent delusional disorders and a larger group of acute and transient psychotic disorders. Schizoaffective disorders have been retained in this section in spite of their controversial nature. F20 Schizophrenia the schizophrenic disorders are characterized in general by fundamental and characteristic distortions of thinking and perception, and by inappropriate or blunted affect. Clear consciousness and intellectual capacity are usually maintained, although certain cognitive deficits may evolve in the course of time. The disturbance involves the most basic functions that give the normal person a feeling of individuality, uniqueness, and self-direction. Perception is frequently disturbed in other ways: colours or sounds may seem unduly vivid or altered in quality, and irrelevant features of ordinary things may appear more important than the whole object or situation. Perplexity is also common early on and frequently leads to a belief that everyday situations possess a special, usually sinister, meaning intended uniquely for the individual. In the characteristic schizo phrenic disturbance of thinking, peripheral and irrelevant features of a total concept, which are inhibited in normal directed mental activity, are brought to the fore and utilized in place of those that are relevant and appropriate to the situation. Thus thinking becomes vague, elliptical, and obscure, and its expression in speech sometimes incomprehensible. Breaks and interpolations in the train of thought are frequent, and thoughts may seem to be withdrawn by some outside agency. Ambivalence and disturbance of volition may appear as inertia, negativism, or stupor. The onset may be acute, with seriously disturbed behaviour, or insidious, with a gradual development of odd ideas and conduct. The course of the disorder shows equally great variation and is by no means inevitably chronic or deteriorating (the course is specified by five-character categories). In a proportion of cases, which may vary in different cultures and populations, the outcome is complete, or nearly complete, recovery. The sexes are approximately equally affected but the onset tends to be later in women. Diagnostic guidelines the normal requirement for a diagnosis of schizophrenia is that a minimum of one very clear symptom (and usually two or more if less clear-cut) belonging to any one of the groups listed as (a) to (d) above, or symptoms from at least two of the groups referred to as (e) to (h), should have been clearly present for most of the time during a period of 1 month or more. Conditions meeting such symptomatic requirements but of duration less than 1 month (whether treated or not) should be diagnosed in the first instance as acute schizophrenia-like psychotic disorder (F23. Symptom (i) in the above list applies only to the diagnosis of Simple Schizophrenia (F20. Viewed retrospectively, it may be clear that a prodromal phase in which symptoms and behaviour, such as loss of interest in work, social activities, and personal appearance and hygiene, together with generalized anxiety and mild degrees of depression and preoccupation, preceded the onset of psychotic symptoms by weeks or even months. Because of the difficulty in timing onset, the 1-month duration criterion applies only to the specific symptoms listed above and not to any prodromal nonpsychotic phase. The diagnosis of schizophrenia should not be made in the presence of extensive depressive or manic symptoms unless it is clear that schizophrenic symptoms antedated the affective disturbance. If both schizophrenic and affective symptoms develop together and are evenly balanced, the diagnosis of schizoaffective disorder (F25. Schizophrenia should not be diagnosed in the presence of overt brain disease or during states of drug intoxication or withdrawal. Similar disorders developing in the presence of epilepsy or other brain disease should be coded under F06. Pattern of course the course of schizophrenic disorders can be classified by using the following five-character codes: F20. The clinical picture is dominated by relatively stable, often paranoid, delusions, usually accompanied by hallucinations, particularly of the auditory variety, and perceptual disturbances. Disturbances of affect, volition, and speech, and catatonic symptoms, are not prominent.

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