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In the obsessive-compulsive reaction, the irrational idea or the impulse persistently intrudes into awareness Obsessions (constantly recurring thoughts such as fears of exposure to germs) and compulsions (repetitive actions such as washing the hands many times) are recognized by the individual as absurd and are resisted, but anxiety is alleviated only by ritualistic performance of the action or by deliberate contemplation of the intruding idea or emotion Many patients do not mention the symptoms and must be asked about them These patients are usually predictable, orderly, conscientious, and intelligent traits that are seen in many compulsive behaviors such as food binging and purging and compulsive exercise There is an overlapping of OCD and other behaviors ( OCD spectrum ), including tics, trichotillomania (hair pulling), onychophagia (nail biting), hypochondriasis, Tourette s syndrome, and eating disorders (see 29) The 2 3% incidence of OCD in the general population is much higher than was previously recognized In addition, there is a high comorbidity of OCD and major depression; two-thirds of OCD patients will develop major depression during their lifetime Male to female ratios are similar, with the highest rates occurring in the young, divorced, separated, and unemployed (all high-stress categories) Neurologic abnormalities of fine motor coordination and involuntary movements are common Under extreme stress, these patients sometimes exhibit paranoid and delusional behaviors, often associated with depression, and can mimic schizophrenia

This appendix lists common UNIX commands and their Mac OS X equivalents. These lists are in no way exhaustive, but they show you how to perform common UNIX operations using Mac OS X procedures.

This is the most common of the clinically significant anxiety disorders Initial manifestations appear at age 20 35 years, and there is a slight predominance in women The anxiety symptoms of apprehension, worry, irritability, difficulty in concentrating, insomnia, and somatic complaints are present more days than not for at least 6 months Manifestations can include cardiac (eg, tachycardia, increased blood pressure), gastrointestinal (eg, increased acidity, nausea, epigastric pain), and neurologic (eg, headache, near-syncope) systems The focus of the anxiety may be a number of everyday activities

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This is characterized by short-lived, recurrent, unpredictable episodes of intense anxiety accompanied by marked physiologic manifestations Agoraphobia, fear of being in places where escape is difficult, such as open spaces or public places, may be present Distressing symptoms and signs such as dyspnea, tachycardia, palpitations, headaches, dizziness, paresthesias, choking, smothering feelings, nausea, and bloating are associated with feelings of impending doom (alarm response) Recurrent sleep panic attacks (not nightmares) occur in about 30% of panic disorders Anticipatory anxiety develops in all these patients and further constricts their daily lives Panic disorder tends to be familial, with onset usually under age 25; it affects 3 5% of the population, and the female-to-male ratio is 2:1 The premenstrual period is one of heightened vulnerability Patients frequently undergo emergency medical evaluations (eg, for heart attacks or hypoglycemia ) before the correct diagnosis is made Gastrointestinal symptoms are especially common, occurring in about onethird of cases Myocardial infarction, pheochromocytoma, hyperthyroidism, and various recreational drug reactions can mimic panic disorder Mitral valve prolapse may be present but is not usually a significant factor Patients who have recurrent panic disorder often become demoralized, hypochondriacal, agoraphobic, and depressed These individuals are at increased risk for major depression and the suicide attempts associated with that disorder Alcohol abuse (about

IStorable isDocument = theDocument as IStorable;

Phobic ideation can be considered a form of displacement in which patients transfer feelings of anxiety from their true object to one that can be avoided However, since phobias are ineffective coping mechanisms, there tends to be an increase in their scope, intensity, and number Social phobias are global or specific; in the former, all social situations are poorly tolerated, while the latter group includes performance anxiety or well-delineated phobias (eg, fear of bridges) Agoraphobia (fear of open places and public areas) is frequently associated with severe panic attacks, and it often develops in early adult life, making a normal lifestyle difficult

Fugue (the sudden, unexpected travel away from one s home with inability to recall one s past), amnesia, somnambulism, dissociative identity disorder (multiple personality disorder), and depersonalization are all dissociative states The reaction is precipitated by emotional crisis The symptom produces anxiety reduction and a temporary solution of the crisis Mechanisms include repression and isolation as well as particularly limited scope of attention as seen in hypnotic states

anxiety (Table 25 1) They are almost immediately effective Antidepressants can be efficacious for the long-term treatment of generalized anxiety disorder, panic disorder, social phobia, and OCD All of the benzodiazepines may be given orally, and several are available in parenteral formulations Benzodiazepines such as lorazepam are absorbed rapidly when given intramuscularly In psychiatric disorders, the benzodiazepines are usually given orally; in controlled medical environments (eg, the ICU), where the rapid onset of respiratory depression can be assessed, they are often given intravenously Onset of action is a function of the rate of absorption (related to lipophilic property) and varies, with diazepam and clorazepate being the most rapidly absorbed orally This characteristic, along with

Then invoke the Read( ) and Write( ) methods for theDocument through that interface:

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