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By: John Walter Krakauer, M.A., M.D.

  • Director, the Center for the Study of Motor Learning and Brain Repair
  • Professor of Neurology

https://www.hopkinsmedicine.org/profiles/results/directory/profile/9121870/john-krakauer

Adults demonstrated a small- to aasha herbals order herbolax 100caps on line -moderate negative impact on several cognitive domains herbs denver discount 100 caps herbolax with amex, excluding learning and memory herbs lower blood pressure generic herbolax 100caps otc. Where the association between glycaemic control and impact on cognitive function was examined herbals teas for the lungs discount herbolax uk, significant negative effects were reported in one prospective cohort including adults and adolescents, and in one prospective cohort including children older than 9 years. One study was undertaken in Australia, and the remainder in countries with a well developed health-care system. Appropriate exclusions were reported in the studies, including diabetes complications, his to ry of head injury and depression. The absence of clear and consistent associations across the studies may reflect methodological limitations in measuring hypoglycaemia and hyperglycaemia accurately, rather than an absence of association. The magnitude of this effect is greatest in children with early onset type 1 diabetes. Therefore, children experiencing significant learning difficulties should be referred for psycho-educational or neuropsychological evaluation. If learning disabilities are present, alternative causes should be sought and remedial interventions to address specific deficits implemented. Question 4 was a background question and therefore was not systematically reviewed Among the primary goals of diabetes management in children and adolescents are the maintenance of normal growth, physical and pubertal development, and ideal body weight. In general, children and young people with optimal blood glucose control will grow and develop normally. In an Australian study of adolescents with type 1 diabetes, growth hormone secretion paralleled that seen in normal adolescents during puberty, and growth hormone secretion was not affected by glycaemic control (Batch and Werther 1992). Due to the limited evidence base in this area, a systematic review was not performed for this question. Data from cross-sectional and cohort studies of growth in young people with type 1 diabetes are described below. A number of studies demonstrating a negative impact of type 1 diabetes on linear growth included patients diagnosed more than 20 years ago, at a time when glycaemic targets were higher and the use of intensive management was less common in young people. In a cohort study of 152 children with type 1 diabetes, a linear relationship between HbA1c and growth rate was observed, and patients with to tal HbA1c above 16% had the greatest growth deceleration (Wise et al 1992). In a longitudinal study from Germany, growth reduction was more pronounced in patients diagnosed before the onset of puberty, and final height was significantly lower in patients with prepubertal onset of diabetes compared with later onset (Holl et al 1998). In a smaller Australian study, the mean near final height Z score was significantly lower than the mean prepubertal height Z score in boys with type 1 diabetes, but not in girls (Kanumakala et al 2002). Obesity appears to be an emerging problem in young people with type 1 diabetes, particularly among children with young onset of diabetes (<5 years of age) and females (Libman et al 2003; Kordonouri and Hartmann 2005; Clarke et al 2006). Several studies in Australia and overseas have shown that rapid growth and weight gain precede the onset of type 1 diabetes, and children are taller than their peers at diagnosis (Clarke et al 2006), while overweight and obesity persist after diagnosis, particularly in older children. It is thought that overweight in early childhood may initiate islet au to immunity (Couper et al 2009) and accelerate beta cell loss (Wilkin 2001). This contrasts with the weight loss that occurs in the weeks or months before diagnosis due to hyperglycaemia. Fac to rs contributing to overweight in type 1 diabetes include the requirement for supraphysiological insulin doses to achieve glycaemic targets, frequent snacking, and excess energy intake to avoid or treat hypoglycaemia. Obesity is an independent risk fac to r for macrovascular disease in type 1 diabetes (discussed in Chapter 18). Obesity is a also risk fac to r for microalbuminuria in adolescents with type 1 diabetes (S to ne et al 2006). Practice tips the measurement of height, weight and body mass index is an integral component of diabetes care for children and adolescents. In such cases, comorbidities such as coeliac disease or thyroid dysfunction should also be considered. Prevention of overweight and obesity is a key strategy in the management of type 1 diabetes (see Chapter 10). In particular, significant insulin resistance may occur during puberty, and insulin requirements typically increase (>1 unit/kg/day). Question 5 was a background question and therefore was not systematically reviewed Multidisciplinary teams are not available in many rural and geographically remote areas of Australia that have low population density and small numbers of people with type 1 diabetes, particularly children. In these situations, care may be provided by a local 34 paediatrician or physician with access to resources, support and advice from a tertiary centre diabetes team. It is not known whether a lack of multidisciplinary team care, or other fac to rs related to living rural locations, influence glycaemic control. Three cross-sectional studies that examined glycaemic control in young people with type 1 diabetes living in rural areas were identified (Handelsman et al 2001; Cameron et al 2002; Goss et al 2010). One of these studies included a control group of urban youth (Cameron et al 2002). The largest study was an audit of about 1200 children with type 1 diabetes living in New South Wales and the Australia Capital Terri to ry, in which glycaemic control did not differ between those from urban and those from rural areas (Handelsman et al 2001). A Vic to rian study on clinical and QoL outcomes demonstrated no differences in glycaemic control between youth with type 1 diabetes living in urban and rural locations, despite less reported access to team-based diabetes care in rural centres (Cameron et al 2002). However, rural youth had lower QoL and the greatest deficits were seen in areas of mental health, self esteem, parent impact (emotional) and family cohesion. Following implementation of a multidisciplinary paediatric diabetes clinic in rural Vic to ria, glycaemic control improved significantly from a median of 9. Although there was no urban comparison group, the level of glycaemic control was comparable with that achieved in patients managed in urban centres (Goss et al 2010). These findings suggest that the glycaemic control of young people with type 1 diabetes is not influenced by location of residence. Thus, care provided locally in urban centres, or in partnership with outreach services, is likely to be comparable to that in regional centres. The management of patients living in rural and remote areas using telemedicine is covered in Chapter 8. Practice principles All people with type 1 diabetes, including those from rural and remote areas, should have access to optimal medical management. Question 6 was a background question and therefore was not systematically reviewed Although this question was not systematically reviewed, a recent review (DiabCo$t Type 1) was identified that described the cost of type 1 diabetes in direct health-system costs, indirect costs and QoL (Colagiuri et al 2009). DiabCo$t Type 1 was a retrospective, cross-sectional, self-reported survey of people with type 1 diabetes, aged 5 years and older, in Australia. Parents, guardians or carers were asked to assist with 35 completing the survey when it was sent to children. The survey comprised two structured, self-administered questionnaires, one for people with diabetes and another for their carers. The questionnaires were designed to elicit information on costs incurred over the previous 3 months. The DiabCo$t Type 1 survey collected direct health-care costs, non-health care costs and indirect costs for people with type 1 diabetes, costs to carers, and an assessment of the impact of type 1 diabetes on the individual’s QoL. It was not intended or possible to separate health-care costs attributable to diabetes and those incurred for non-diabetes related conditions. The mean age of respondents was 32 years, and time since diagnosis was just over 8 years. Mild hypoglycaemic episodes in the 3 months preceding the survey were reported by 88. About 19% reported experiencing a mean of almost three severe hypoglycaemic episodes requiring assistance. This figure comprised $3862 in direct costs ($3640 direct health costs and $222 direct non-health costs) and $807 in indirect costs ($418 related to the person with type 1 diabetes and $389 related to carer costs). Consumables, blood glucose testing strips and insulin-administering equipment accounted for 4. The average to tal annual cost was $3468 for people without complications, $8122 for people with microvascular complications only, $12 105 for people with macrovascular complications only, and $16 698 for people with both macrovascular and microvascular complications. Nineteen percent of carers reported being retired or currently not working in order to care for the person with diabetes. Carers to ok an average of almost 3 days off work in the previous 3 months to care for the person with diabetes. The employment situation of 17% of carers had changed to care for the person with diabetes, with an accompanying reduction in income for nearly 70% of these carers, resulting in mean annual lost wages of $7413 per carer (Colagiuri et al 2009). People with type 1 diabetes reported an impact on health related QoL, particularly for the ‘pain/discomfort’ and ‘anxiety/depression’ dimensions. The minimum estimated cost to the nation of type 1 diabetes ranges from $430 to $570 million, depending on the data used to estimate the number of people with type 1 diabetes in Australia. These costs are substantially higher than previous estimates, which were based on administrative rather than patient-level data. The real cost is even higher, since the full impact of indirect costs associated with premature mortality could not be assessed because this was a self-reported questionnaire, and the survey did not evaluate the cost of disability (Colagiuri et al 2009).

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Alternative routes of drug administration—advantages and disadvan rectally administered methohexital elchuri herbals purchase 100 caps herbolax. Proceedings: anaesthetics in porphyria: administration of midazolam for premedication of pediatric patients herbalshopcom purchase 100caps herbolax. Chloral hydrate to herbals wholesale purchase on line herbolax xicity in a preterm midazolam premedication for preschool children kan herbals quiet contemplative buy 100caps herbolax amex. Serum concentrations and clinical effects after fentanyl on the emergence characteristics after sevofurane anesthesia intravenous, intramuscular, and oral administration. Clin Pharmacol in children undergoing surgery for bilateral myringo to my tube place Ther. Correspondence: plasma levels children undergoing hernio to my: a comparison with ilioinguinal of diazepam. Transnasal bu to rphanol for pos to perative rectal solution as premedication in children, with special reference analgesia following paediatric surgery in a Third World country. Diazepam concentrations in children undergoing general apnea after sedation with midazolam and fentanyl. Pre-anesthetic hypnosis with rectal oral codeine: a genetic variant—an ultra-rapid metabolizer. Safety of codeine during breast children undergoing magnetic resonance imaging: effcacy and safety feeding. Ketamine—its pharmacology and clonidine as an analgesic in paediatric adeno to nsillec to my. Preliminary experience with for induction of anaesthesia in non-premedicated children. A prospective, randomized, cation to alleviate the distress of invasive procedures in pediatric double-blind trial of intranasal dexmede to midine and oral chloral oncology patients. Anaesth midine premedication is comparable with midazolam in burn children Intensive Care. Oral preanaesthetic medication of hydroxyzine in volunteers and geriatric patients. Is ketamine or its and diphenhydramine compared with midazolam alone in chil preservative responsible for neuro to xicity in the rabbitfi Bradycardia delays the onset of action azolam for premedication in pediatric dentistry. Topical skin anesthesia for clonidine for reducing perioperative haemodynamic changes and venous, subcutaneous drug reservoir and lumbar punctures in children. Acetaminophen versus of the to pical anaesthetic/analgesic effcacy of a eutectic mixture of acetaminophen with codeine after pediatric to nsillec to my. Acetaminophen analgesia age-dependent erythrocyte activity of methaemoglobin reductase in children: placebo effect and pain resolution after to nsillec to my. Pharmacokinetics of relief in children undergoing needle insertion in the emergency paracetamol in the neonate and infant after administration of department. Platelet dysfunction after change intravenous placement success in children in the emergency intravenous ke to rolac or propacetamol. Intravenous neonatal paracetamol dosing: distress, pain, and anxiety for young children with cancer. Inhalation induction using of antimicrobial prophylaxis in prevention of surgical site infection sevofurane in children: the single-breath vital capacity technique com in the pediatric population. The dose response of antibiotic prophylaxis for surgical site infection prevention in general intravenous thiopental for the induction of general anesthesia in surgery: a review of the literature. Response to intrave effects of oral cimetidine on gastric pH and volume in children. Faster recovery after anesthesia in and cimetidine on gastric secretion in fasting patients at induction infants after intravenous induction with methohexital instead of of anaesthesia. The induction dose of propofol in infants 1-6 months comparison of cimetidine and ranitidine as prophylaxis against gastric of age and in children 10-16 years of age. A comparative interaction of protein binding of propofol in patients with cirrhosis. Humans anesthetized propofol and thiopental for rapid anesthesia induction in infants. Comparison of three techniques in paediatric ambula to ry patients: a comparison with thiopen to ne for induction of anaesthesia with sevofurane in children. Single-breath vital capacity rapid on the incidence of pos to perative vomiting after strabismus surgery inhalation induction in children: 8% sevofurane versus 5% halothane. The effect of spontaneous children during anesthesia induction: a randomized controlled trial versus controlled ventilation on the rate of rise of alveolar halothane in children undergoing invasive hema to logic procedures. The effect of cricoid pressure on the venous lidocaine diminishes hand pain associated with propofol cricoid cartilage and vocal cords: an endoscopic study in anaesthetised injection. Infuence of sedation on mortality in critically and pH in children for emergency surgery. Controlled rapid sequence effects of ketamine infusion in patients with catecholamine-dependent induction and intubation—an analysis of 1001 children. Diagnostic and Statistical Manual for Mental apneic period in children during anesthesia induction. Prevalence and characteristics anaesthetized children required for desaturation of haemoglobin to of autism spectrum disorder among children aged 8 years—Autism 95%: comparison of three different breathing gases. An update on pharmacotherapy for autism induction characteristics in unpremedicated children. Cricoid pressure to control regurgitation of s to mach con ways for evaluation and medication choice for attention-defcit/ tents during induction of anaesthesia. Topical versus intravenous oral dexmede to midine for procedural and anesthetic premedication. Fast-tracking children hyperreactivity in normal subjects after upper respira to ry tract infec after ambula to ry surgery. Spirometric changes testing justifed in children undergoing minor elective surgeryfi The effects of general anesthesia on upper respira pos to perative apnea in former preterm infants. Anesthesia for the child with an upper respira to ry and general anaesthesia in children. Prevalence of child general anesthesia in children with and without upper respira to ry hood and adult obesity in the United States, 2011-2012. Incidence and risk fac to rs airway in children with upper respira to ry tract infections: a comparison for perioperative adverse respira to ry events in children who are obese. The effects of obesity on pulmonary tube in pediatric anesthesia in the presence of upper respira to ry tract function. Risk fac to rs for perioperative body fat composition in obese children with obstructive sleep apnea adverse respira to ry events in children with upper respira to ry tract syndrome. Risk fac to rs for adverse sleep apnea syndrome in obese early adolescents: a prediction model pos to perative outcomes in children presenting for cardiac surgery with using scoring system. Fac to rs that infuence an anes ana to mical correlates and treatment of sleep-disordered breathing in thesiologist’s decision to cancel elective surgery for the child with obese children and adolescents. Bronchodila to r premedication and diagnostic procedures, risk fac to rs and consequences for later does not decrease respira to ry adverse events in pediatric general health outcome. Glycopyrrolate does not risk fac to rs, diabetes mellitus/hyperinsulinemia, and respira to ry reduce the incidence of perioperative adverse events in children compromise. Death or neurologic injury after of gastroesophageal refux symp to ms in obese children evaluated to nsillec to my in children with a focus on obstructive sleep apnea: in an academic medical center. Crit and gastric fuid characteristics in pediatric day surgery: implications Care Med. Sleep-disordered breathing for initial transthoracic echocardiography in outpatient pediatric in a predominantly African-American pediatric population. Ibuprofen for to nsillec to my pain in disparities in the diagnosis and treatment of sleep-disordered breathing children: effcacy and complications. Int Anesthesiol and abnormal ventricular geometry in children and adolescents with Clin. The safety of preoperative sedation in former preterm infants: prospective comparison of spinal and general children with sleep-disordered breathing. Inguinal hernior development increases subsequent respira to ry sensitivity to fentanyl.

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The same pathogen is identified in recurrent infections herbs used for healing cheap herbolax 100caps line, but episodes of sterile urine may occur during and shortly following antimicrobial treatment herbalshopcom herbolax 100 caps low price. Reinfection: each episode can be caused by a variety of new infecting organisms just herbals order herbolax 100 caps mastercard, in contrast to planetary herbals quality buy 100 caps herbolax fast delivery bacterial persistence in which the same infecting organism is always isolated. Cystitis may represent early recognition of an infection destined to become pyelonephritis, or bacterial growth controlled by a balance of virulence and host response. This category includes mostly isolated or recurrent bacterial cystitis and is usually associated with a narrow spectrum of infecting pathogens that are easily eradicated by a short course of oral antimicrobial agents. Patients can be managed on an outpatient basis, with an emphasis on documenting resolution of their bacteriuria, followed by elective evaluation for potential ana to mical or functional abnormalities of the urinary tract. Prompt ana to mical evaluation of the urinary tract is critical to exclude the presence of significant abnormalities (13). The technique for obtaining urine for urinalysis as well as culture affects the rate of contamination, which influences interpretation of the results. In neonates, infants and non- to ilet-trained children, there are four main methods with varying contamination rates and invasiveness to obtain urine in this age group: (1) Plastic bag attached to the cleaned genitalia. The infant is placed in the lap of a parent or member of the nursing staff, who holds a sterile foil bowl underneath the infant’s genitalia. In a prospective study using bladder catheterisation in febrile children aged < 36 months, contamination was defined by multiple pathogens, non-pathogens, or colony counts < 10,000 cfu/mL. Univariate analysis of potential predic to rs identified age < 6 months, difficult catheterisation, and uncircumcised boys (24). This is the most sensitive method to obtain an uncontaminated urine sample in this age group (24-26). In older, to ilet-trained children, who can void on command, after carefully retracting the foreskin and cleaning the glans penis in boys and spreading the labia and cleaning the periurethral area in girls, the use of clean catch, especially midstream urine, could be an acceptable technique for obtaining urine. These are appealing because they provide rapid results, do not require microscopy, and are ready to use. However, nitrite is not a very sensitive marker for infants, who empty their bladder frequently, and not all urinary pathogens reduce nitrate to nitrite. This is being used increasingly to classify particles in uncentrifuged urine specimens (33). The recent American Academy of Pediatric Guidelines on Urinary tract Infection suggest that the diagnosis should be on the basis of the presence of both pyuria and at least 50 000 cfu. The choice of agent is also based on local antimicrobial sensitivity patterns, and should later be adjusted according to sensitivity testing of the isolated uropathogen (22). Especially in infancy, not all available antibiotics are approved by the national health authorities. Outcomes of short courses (1-3 days) are inferior to those of 7-4-day courses (22). Similar data have been shown for amoxicillin-clavulanate (48), however, these antibiotics are associated with increasing rates of resistance. In the initial phase of therapy, a close ambulant contact to the family is advised (49). Table 7: Recommendations for antibacterial treatment in cystitis und cys to urethritis (Dosages for children up to 12 years of age)* Chemotherapeutics Daily dosage Application Oral cephalosporins Group 1. Normalisation of body temperature can be expected within 24-48 h after the start of therapy in 90% of cases. Abnormal results are found in ~15% of cases, and 1-2% have abnormalities that require prompt action. Urine sampling Urine sampling with plastic bags are commonly used in daily 3 B practice. Clean-catch of urine could be an acceptable technique for obtaining 2b B urine only in to ilet-trained children. Urinalysis Dipsticks yield rapid results, but should be used with caution in 2a B infants who empty their bladder frequently as conversion of nitrates to nitrites by bacteria requires approximately 4 h. Microscopic investigation is the standard method of assessing 2a B pyuria after centrifugation, but it is rarely done in an outpatient setting. Outcomes of short courses (1-3 days) are inferior to those of 7-4-day 1b B courses. Sensitivity of a nitrite indica to r strip method in detecting bacteriuria in preschool girls. First urinary tract infection in neonates, infants and young children: a comparative study. Is urine culture necessary to rule out urinary tract infection in young febrile childrenfi Randomised trial of oral versus sequential intravenous/oral cephalosporins in children with pyelonephritis. Antibiotic treatment for pyelonephritis in children: multicentre randomised controlled non-inferiority trial. Are oral antibiotics alone efficacious for the treatment of a first episode of acute pyelonephritis in childrenfi Effective duration of antimicrobial therapy for the treatment of acute lobar nephronia. Clinical significance of primary vesicoureteral reflux and urinary antibiotic prophylaxis after acute pyelonephritis: a multicenter, randomized, controlled study. Antibiotic prophylaxis for the prevention of recurrent urinary tract infection in children with low grade vesicoureteral reflux: results from a prospective randomized study. Assessment of lower urinary tract dysfunction in children with non-neuropathic bladder sphincter dysfunction. Bladder-sphincter dysfunction, urinary infection and vesico-ureteral reflux with special reference to cognitive bladder training. Urinary incontinence and urinary tract infection and their resolution with treatment of chronic constipation of childhood. This is followed by a continuous detrusor contraction, which results in complete bladder emptying, associated with an adequate relaxation of the sphincter complex. Normal urine s to rage by the bladder and evacuation are controlled by a complex interaction between the spinal cord, brain stem, midbrain and higher cortical structures, associated with a complex integration of sympathetic, parasympathetic and somatic innervations (7). Normal daytime control of bladder function matures between 2 and 3 years of age, while nighttime control is normally achieved between 3 and 7 years of age (8). Weak interference results in stacca to voiding, while stronger interference results in interrupted voiding and straining, due to an inability to relax during voiding. Upon clinical examination, genital inspection and observation of the lumbosacral spine and the lower extremities is necessary to exclude obvious uropathy and neuropathy. Uroflow with post-void residual evaluates the emptying ability, while an upper urinary tract ultrasound screens for secondary ana to mical changes. In the case of resistance to initial treatment, or in the case of former failed treatment, re-evaluation is warranted and further video-urodynamic studies may be considered. Psychological screening may be useful for children or families with major psychological problems associated with the voiding dysfunction. In case of comorbidity due to bowel problems it is advised to treat the bowel first since bowel problems may sustain any bladder problems (12). However, the evidence level is low as most studies of urotherapy programmes are retrospective and non-controlled. Antispasmodics and anticholinergics have been shown to be effective, though the level of evidence was low. Other new treatment modalities such as sacral nerve stimulation are described in case series only and there is no evidence to whether they prove useful. Pharmacotherapy (mainly antispasmodics and anticholinergics) would be the next step. Pelvic-floor therapy and to ilet training in young children with dysfunctional voiding and obstipation. A review of non-invasive electro neuromodulation as an intervention for nonneurogenic bladder dysfunction in children. Prospective study of transcutaneous parasacral electrical stimulation for overactive bladder in children: long-term results.

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About one-third of cases involve discrete episodes; another third yam herbals mysore discount herbolax 100 caps online, continuous symp to lotus herbals 3 in 1 review herbolax 100 caps online ms from the start; and still another third klaron herbals order 100 caps herbolax fast delivery, an initially episodic course that eventually becomes continuous herbals2go order herbolax 100 caps overnight delivery. While in some individuals the intensity of symp to ms can wax and wane considerably, others report an unwavering level of intensity that in extreme cases can be constantly pres­ ent for years or decades. Internal and external fac to rs that affect symp to m intensity vary between individuals, yet some typical patterns are reported. Exacerbations can be trig­ gered by stress, worsening mood or anxiety symp to ms, novel or overstimulating settings, and physical fac to rs such as lighting or lack of sleep. Individuals with depersonalization/derealization disorder are charac­ terized by harm-avoidant temperament, immature defenses, and both disconnection and overconnection schemata. Immature defenses such as idealization/devaluation, projec­ tion and acting out result in denial of reality and poor adaptation. Cognitive disconnection schemata reflect defectiveness and emotional inhibition and subsume themes of abuse, ne­ glect, and deprivation. Overconnection schemata involve impaired au to nomy with themes of dependency, vulnerability, and incompetence. There is a clear association between the disorder and childhood interper­ sonal traumas in a substantial portion of individuals, although this association is not as prev­ alent or as extreme in the nature of the traumas as in other dissociative disorders, such as dissociative identity disorder. In particular, emotional abuse and emotional neglect have been most strongly and consistently associated with the disorder. Other stressors can include phys­ ical abuse; witnessing domestic violence; growing up with a seriously impaired, mentally ill parent; or unexpected death or suicide of a family member or close Wend. The most common proximal precipi­ tants of the disorder are severe stress (interpersonal, financial, occupational), depression, anx­ iety (particularly panic attacks), and illicit drug use. Marijuana use may precipitate new-onset panic attacks and depersonalization/derealization symp to ms simultaneously. C ulture-R eiated Diagnostic issues Volitionally induced experiences of depersonalization/derealization can be a part of med­ itative practices that are prevalent in many religions and cultures and should not be diag­ nosed as a disorder. However, there are individuals who initially induce these states intentionally but over time lose control over them and may develop a fear and aversion for related practices. Functionai Consequences of D epersonaiization/Dereaiization Disorder Symp to ms of depersonalization/derealization disorder are highly distressing and are as­ sociated with major morbidity. The affectively flattened and robotic demeanor that these individuals often demonstrate may appear incongruent with the extreme emotional pain reported by those with the disorder. Impairment is often experienced in both interpersonal and occupational spheres, largely due to the hypoemotionaHty with others, subjective diffi­ culty in focusing and retaining information, and a general sense of disconnectedness from life. Although individuals with depersonalization/derealization dis­ order can present with vague somatic complaints as well as fears of permanent brain dam­ age, the diagnosis of depersonalization/derealization disorder is characterized by the presence of a constellation of typical depersonalization/derealization symp to ms and the ab­ sence of other manifestations of illness anxiety disorder. Feelings of numbness, deadness, apathy, and being in a dream are not uncommon in major depressive episodes. However, in depersonalization/ derealization disorder, such symp to ms are associated with further symp to ms of the dis­ order. If the depersonalization/derealization clearly precedes the onset of a major depres­ sive episode or clearly continues after its resolution, the diagnosis of depersonalization/ derealization disorder applies. Some individuals with depersonalization/dereal­ ization disorder can become obsessively preoccupied with their subjective experience or develop rituals checking on the status of their symp to ms. However, other symp to ms of obsessive-compulsive disorder unrelated to depersonalization/derealization are not present. In order to diagnose depersonalization/derealization disorder, the symp to ms should not occur in the context of another dissociative disorder, such as dissociative identity disorder. Differentiation from dissociative amnesia and con­ version disorder (functional neurological symp to m disorder) is simpler, as the symp to ms of these disorders do not overlap with those of depersonalization/derealization disorder. Depersonalization/derealization is one of the symp to ms of panic at­ tacks, increasingly common as panic attack severity increases. Therefore, depersonal­ ization/dereahzation disorder should not be diagnosed when the symp to ms occur only during panic attacks that are part of panic disorder, social anxiety disorder, or specific phobia. In addition, it is not uncommon for depersonalization/derealization symp to ms to first begin in the context of new-onset panic attacks or as panic disorder progresses and worsens. In such presentations, the diagnosis of depersonalization/derealization disorder can be made if 1) the depersonalization/derealization component of the presentation is very prominent from the start, clearly exceeding in duration and intensity the occurrence of actual panic attacks; or 2) the depersonalization/derealization continues after panic dis­ order has remitted or has been successfully treated. The presence of intact reality testing specifically regarding the depersonalization/derealization symp to ms is essential to differentiating depersonal­ ization/derealization disorder from psychotic disorders. Rarely, positive-symp to m schizophrenia can pose a diagnostic challenge when nihilistic delusions are present. For example, an individual may complain that he or she is dead or the world is not real; this could be either a subjective experience that the individual knows is not true or a delusional conviction. Depersonalization/derealization associated with the physiological effects of substances during acute in to xication or withdrawal is not diagnosed as depersonalization/derealization disorder. The most common precipitating substances are the illicit drugs marijuana, hallucinogens, ketamine, ecstasy, and salvia. In about 15% of all cases of depersonalization/derealization disorder, the symp to ms are pre­ cipitated by ingestion of such substances. If the symp to ms persist for some time in the ab­ sence of any further substance or medication use, the diagnosis of depersonalization/ derealization disorder applies. This diagnosis is usually easy to establish since the vast ma­ jority of individuals with this presentation become highly phobic and aversive to the trig­ gering substance and do not use it again. Features such as onset after age 40 years or the presence of atypical symp to ms and course in any individual suggest the possibility of an underlying medical condition. In such cases, it is essential to conduct a thorough medical and neurological evaluation, which may include standard labora to ry studies, viral titers, an electroencephalogram, vestibular testing, visual testing, sleep stud­ ies, and/or brain imaging. When the suspicion of an underlying seizure disorder proves difficult to confirm, an ambula to ry electroencephalogram may be indicated; although temporal lobe epilepsy is most commonly implicated, parietal and frontal lobe epilepsy may also be associated. Comorbidity In a convenience sample of adults recruited for a number of depersonalization research studies, lifetime comorbidities were high for unipolar depressive disorder and for any anxiety disorder, with a significant proportion of the sample having both disorders. The three most commonly co-occurring personality disorders were avoidant, borderline, and obsessive-compulsive. The other specified dissocia­ tive disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific disso­ ciative disorder. This is done by recording “other specified dissociative disorder”followed by the specific reason. Chronic and recurrent syndromes of mixed dissociative symp to ms: this cate­ gory includes identity disturbance associated with less-than-marked discontinuities in sense of self and agency, or alterations of identity or episodes of possession in an in­ dividual who reports no dissociative amnesia. Acute dissociative reactions to stressfui events: this category is for acute, tran­ sient conditions that typically last less than 1 month, and sometimes only a few hours or days. These conditions are characterized by constriction of consciousness; deper­ sonalization; derealization; perceptual disturbances. Dissociative trance: this condition is characterized by an acute narrowing or com­ plete loss of awareness of immediate surroundings that manifests as profound unre­ sponsiveness or insensitivity to environmental stimuli. The dissociative trance is not a normal part of a broadly ac­ cepted collective cultural or religious practice. The unspecified dissociative disorder category is used in situations in which the clinician chooses not to specify the rea­ son that the criteria are not met for a specific dissociative disorder, and includes presen­ tations for which there is insufficient information to make a more specific diagnosis. This chapter includes the diagnoses of somatic symp to m disorder, illness anxiety disorder, con­ version disorder (functional neurological symp to m disorder), psychological fac to rs affect­ ing other medical conditions, factitious disorder, other specified somatic sjnnp to m and related disorder, and unspecified somatic symp to m and related disorder. All of the disor­ ders in this chapter share a common feature: the prominence of somatic symp to ms associ­ ated with significant distress and impairment. Individuals with disorders with prominent somatic symp to ms are commonly encoimtered in primary care and other medical settings but are less commonly encountered in psychiatric and otiier mental health settings. The major diagnosis in this diagnostic class, somatic symp to m disorder, emphasizes diagnosis made on the basis of positive symp to ms and signs (distressing somatic symp­ to ms plus abnormal thoughts, feelings, and behaviors in response to these symp to ms) rather than the absence of a medical explanation for somatic symp to ms. A distinctive char­ acteristic of many individuals with somatic symp to m disorder is not the somatic symp­ to ms per se, but instead the way they present and interpret them. Incorporating affective, cognitive, and behavioral components in to the criteria for somatic symp to m disorder pro­ vides a more comprehensive and accurate reflection of the true clinical picture than can be achieved by assessing the somatic complaints alone. The previous criteria overemphasized the centrality of medically unexplained symp to ms.