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Jyothis Prakash
Jyothis Prakash

Obsessive-compulsive disorder (OCD) is a mental disorder characterized by unwanted and repeated thoughts (obsessions) and behaviors (compulsions). It can range from mild to severe and negatively impact daily functioning if left untreated. While historically thought to be caused by religious or moral failings, modern research indicates OCD has biological and genetic causes involving abnormalities in brain circuits. Serotonin dysregulation and infections have also been linked to OCD development. Diagnosis requires obsessions, compulsions, or both according to diagnostic criteria and can be performed by a mental health professional.

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Jp's ocd
Obsessive- Compulsive Disorder JYOTHIS PRAKASH
Introduction Obsessivecompulsive disorder (OCD) is a mental disorder where people feel the need to check things repeatedly, have certain thoughts repeatedly, or feel they need to perform certain routines repeatedly. People are unable to control either the thoughts or the activities.
History In the 1600s it was thought of as symptoms of religious melancholy and naughty thoughts. Pierre Janet and Sigmund Freud isolated OCD from the disorders it was grouped with. Continuing research is being done about the causes of OCD and better treatments.
Cont Recent research on mice points toward a genetic cause. A missing gene making a certain protein caused the mice to scratch and groom themselves compulsively until an OCD drug was introduced.
Epidemiology Obsessivecompulsive disorder affects about 2.3% of people at some point in their life. Rates during a given year are about 1.2% and it occurs worldwide.
Cont It is unusual for symptoms to begin after the age of thirty five and half of people develop problems before twenty. Males and females are affected about equally.
Definition Obsessive-compulsive disorder (OCD) is an anxiety disorder in which people have unwanted and repeated thoughts, feelings, ideas, sensations (obsessions), or behaviours that make them feel driven to do something (compulsions).
Cont A person's level of OCD can be anywhere from mild to severe, but if severe and left untreated, it can destroy a person's capacity to function at work, at school or even to lead a comfortable existence in the home.
Signs & Symptoms What is an obsession? Involuntary intrusive cognition. Types Doubts (74%) Thinking (34%) Fears (26%) Impulses (17%) Images (7%) Other (2%)
Obsessions-examples Doubt Did I lock the door Thought that he had cancer Thought / Image that he had knocked someone down in his car Impulse + thought to shout obscenities in church Image of corpse rotting away Impulse to drink from inkpot and to strangle son
Themes in obsession Obsessions often have common themes Contamination, dirt, disease, illness (46%) Violence and aggression (29%) Moral and religious topics (11%) Symmetry and sequence (27%) Sex (10%) Other (22%) The themes often reflect contemporary concerns (the devil, germs, AIDS)
Compulsions Some people with OCD perform compulsive rituals because they inexplicably feel they have to, others act compulsively so as to mitigate the anxiety that stems from particular obsessive thoughts.
Cont Excessive skin picking (i.e., dermatillomania) or hair plucking (i.e.,trichotillomania) and nail biting (i.e., onychophagia) are all on the obsessive-compulsive spectrum.
Examples of compulsions Scanning text for life having read death. Touching the ground after swallowing saliva. Driving back to check he hadnt knocked someone down in his car. Counting 6,5,8,3,7,4 in your head. Hand washing.
Linking Obsessions and Compulsions
OCD Experiences OCD Not OCD A man who washes his hands 100 times a day until they are red and raw A woman who unfailingly washer her hands before every meal A women who locks and relocks her door before going to work every day for half an hour A woman who double- checks that her apartment door and windows are locked each night before she goes to bed. A college student who must tap on the door frame of every classroom 14 times before entering A musician who practices a difficult passage over and over again until its perfect A man who stores 19 years of newspapers just in case with no system for filling or retrieving A woman who dedicates all her spare time and money to building her record collection
Cognitive Performance-Recent Research Findings A 2013 meta-analysis confirmed people with OCD to have mild but wide-ranging cognitive deficits; significantly regarding spatial memory, to a lesser extent with verbal memory, fluency, executive function and processing speed, while auditory attention was not significantly affected.
Cont Spatial memory had been evaluated by results from Corsi block-tapping test, Rey- Osterrieth Complex Figure Test-immediate recall and Spatial Working Memory between search errors.
Cont Verbal memory had been evaluated by Verbal Learning Test - delayed recall and Logical Memory II. Verbal fluency was evaluated by Category fluency and Letter fluency.
Cont Auditory attention was evaluated by the Digit Span Test. Processing speed was evaluated by Trail Making Test part A.
Associated conditions obsessivecompulsive personality disorder major depressive disorder bipolar disorder generalized anxiety disorder anorexia nervosa social anxiety disorder bulimia nervosa Tourette syndrome
Cont Asperger syndrome attention deficit hyperactivity disorder dermatillomania (compulsive skin picking) body dysmorphic disorder trichotillomania (hair pulling)
Cont In 2009 it was reported that depression among those with OCD is particularly alarming because their risk of suicide is high; more than 50 percent of people experience suicidal tendencies, and 15 percent have attempted suicide.
Cont Depression is also extremely prevalent among sufferers of OCD. One explanation for the high depression rate among OCD populations was posited by Mineka, Watson, and Clark (1998), who explained that people with OCD (or any other anxiety disorder) may feel depressed because of an "out of control" type of feeling.
Causes GENETIC FACTORS: genetic factors account for 4565% of OCD symptoms in children diagnosed with the disorder. identical twins more often affected than non- identical twins
Genetic Factors cont Individuals with OCD are more likely to have first-degree family members exhibiting the same disorders than do matched controls. A mutation has been found in the human serotonin transporter gene, hSERT, in unrelated families with OCD.
CHEMICAL AND BRAIN DYSFUNCTION The chemical messenger, Serotonin seems to be heavily involved. According to research, Serotonin is involved with biological processes such as mood, aggression, sleep, appetite and pain. It also seems that Serotonin is capable of connecting to nerve cells in the brain in many different ways and so can cause many different responses. Causes
Chemical and Brain Dysfunction cont It is not even fully established if it is all or part of the Serotonin chemical or another chemical entirely acting on it; or a malfunction in one or more of the receptors in the brain that Serotonin attaches to that causes the OCD problems.
INFECTION A streptococcal infection of the throat is known to occasionally result in the body confusing healthy cells with the infection and causing cellular damage. Causes
Infection cont If this has happened with the brain, the bodys infection fighting system can attack the outside of nerve cells in the Basal Ganglia part of the brain with the result that OCD symptoms occur. Some research suggests that these symptoms dont seem to last very long and the occurrence of this infection OCD seems to be very rare.
Causes DEPRESSION People with depression sometimes develop OCD symptoms, and those with OCD very often develop depression. Dealing with both together is very difficult without clinical intervention and it is notoriously difficult to undertake an exposure programme while the depression is high.
Causes-Recent findings OCD is no longer believed to be caused by life experiences. Modern research suggests a biological and neurological cause fMRI scans show the circuit connecting the amygdala, frontal cortex, caudate nucleus (motor control), and thalamus is abnormally active in people with OCD.
Causes-Recent Findings cont Genetic research on families with OCD members have found a genetic link. Theres a link between OCD and other tick disorders such as Tourettes disorder.
Causes-Recent Findings cont Glutamate dysregulation has also been the subject of recent research, although its role in the disorder's etiology is not yet clear. Glutamate is known to act as a cotransmitter with dopamine in dopamine pathways that project out of the ventral tegmental area.
Causes-Recent Findings cont People with OCD evince increased grey matter volumes in bilateral lenticular nuclei, extending to the caudate nuclei, while decreased grey matter volumes in bilateral dorsal medial frontal/anterior cingulate gyri.
Causes-Recent Findings cont Orbitofrontal cortex overactivity is attenuated in people who have successfully responded to SSRI medication, a result believed to be caused by increased stimulation of serotonin receptors 5- HT2A and 5-HT2C.
Freuds View A patient's mind responds maladaptively to conflicts between unacceptable, unconscious sexual or aggressive id impulses and the demands of conscience and reality. The ego defends against the id by isolation and reaction formation. The imperfect success of the ego gives rise to OCD symptoms.
Diagnosis Formal diagnosis may be performed by a psychologist, psychiatrist, clinical social worker, or other licensed mental health professional. To be diagnosed with OCD, a person must have obsessions, compulsions, or both, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM).
Cont According to ICD-10 criteria- For a definite diagnosis, obsessional or compulsive acts, or both, must be present on most days for at least 2 successive weeks and be a source of distress or interference with activities. The obsessional symptoms should have the following charecteristics:
Cont 1. They must be recognised as the individuals own thoughts or impulses; 2. There must be atleast one thought or act that is still resisted unsuccessfully, even though others may be present which the sufferer no longer resists;
Cont The thought of carrying out the act must not in itself be pleasurable (simple relief of tension or anxiety is not regarded as pleasure in this sense); The thoughts, images, or impulses must be unpleasantly repetitive.
Treatment Pharmacotherapy- treatment using drugs that affect the neurotransmitter serotonin decrease the symptoms of OCD. Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac) and sertraline (Zoloft) prevent excess serotonin from being pumped back into neurons causing it to bind to receptor sites that regulate anxiety.
Cont SSRIs are a second line treatment of adult obsessive compulsive disorder (OCD) with mild functional impairment and as first line treatment for those with moderate or severe impairment.
Cont Disadvantage: Once medication is stopped, symptoms usually re-occur so the person needs to be put on medication indefinitely. The atypical antipsychotics such as quetiapine have also been found to be useful when used in addition to an SSRI in treatment-resistant OCD. However, these drugs are often poorly tolerated, and have metabolic side effects that limit their use. None of the atypical antipsychotics appear to be useful when used alone.
Treatment Behavior Therapy- "exposure and response prevention where the patient deliberately confronts their feared object or idea. Ex: OCD hand washer touched contaminated object and is forced to not wash hands until anxiety goes down.
Cont Behavior therapy is successful for most patients as long as the therapist is fully trained and the person is highly motivated and has a positive attitude. It lasts longer after treatment than drug therapy. Cognitive-behavioral- therapy emphasizing changing the OCDs patients beliefs and thinking patterns.
Cognitive behavioral therapy (CBT) has been shown to be the most effective type of psychotherapy for this disorder. The patient is exposed many times to a situation that triggers the obsessive thoughts, and learns gradually to tolerate the anxiety and resist the urge to perform the compulsion. Medication and CBT together are considered to be better than either treatment alone at reducing symptoms. Treatment cont
Cont Psychotherapy can also be used to: Provide effective ways of reducing stress Reduce anxiety Resolve inner conflicts
Nursing Management Diagnoses Nursing Care Plans For Obsessive Compulsive Disorder Anxiety Chronic low self-esteem Fear Ineffective coping
Cont Ineffective role performance Impaired social interaction Risk for injury Social isolation
Some interesting facts English footballer David Beckham has been outspoken regarding his struggle with OCD. He said that he has to count all of his clothes, and his magazines have to lie in a straight line. British poet, essayist, and lexicographer Samuel Johnson is an example of a historical figure with a retrospective diagnosis of OCD. He had elaborate rituals for crossing the thresholds of doorways, and repeatedly walked up and down staircases counting the steps.
Research Findings Nutrition deficiencies may also contribute to OCD and other mental disorders. Vitamin and mineral supplements may aid in such disorders and provide nutrients necessary for proper mental functioning. 亮-Opioids, such as hydrocodone and tramadol, may improve OCD symptoms. Administration of opiate treatment may be contraindicated in individuals concurrently takingCYP2D6 inhibitors such as fluoxetine and paroxetine.
Cont Much current research is devoted to the therapeutic potential of the agents that affect the release of the neurotransmitter glutamate or the binding to its receptors. These include riluzole, memantine, gabapentin, N- acetylcysteine, topiramate and lamotrigine.
Jp's ocd
References "What is Obsessive-Compulsive Disorder (OCD)?". Retrieved 27 May2015. Diagnostic and statistical manual of mental disorders : DSM-5 (5 ed.). Washington: American Psychiatric Publishing. 2013. pp. 237 242. ISBN 9780890425558. Angelakis, I; Gooding, P; Tarrier, N; Panagioti, M (25 March 2015). "Suicidality in obsessive compulsive disorder (OCD): A systematic review and meta-analysis.". Clinical Psychology Review 39: 1 15. doi:10.1016/j.cpr.2015.03.002. PMID 25875222. Fenske JN, Schwenk TL (August 2009). "Obsessive compulsive disorder: diagnosis and management". Am Fam Physician 80 (3): 239 45. PMID 19621834.
Jp's ocd

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Jp's ocd

  • 3. Introduction Obsessivecompulsive disorder (OCD) is a mental disorder where people feel the need to check things repeatedly, have certain thoughts repeatedly, or feel they need to perform certain routines repeatedly. People are unable to control either the thoughts or the activities.
  • 4. History In the 1600s it was thought of as symptoms of religious melancholy and naughty thoughts. Pierre Janet and Sigmund Freud isolated OCD from the disorders it was grouped with. Continuing research is being done about the causes of OCD and better treatments.
  • 5. Cont Recent research on mice points toward a genetic cause. A missing gene making a certain protein caused the mice to scratch and groom themselves compulsively until an OCD drug was introduced.
  • 6. Epidemiology Obsessivecompulsive disorder affects about 2.3% of people at some point in their life. Rates during a given year are about 1.2% and it occurs worldwide.
  • 7. Cont It is unusual for symptoms to begin after the age of thirty five and half of people develop problems before twenty. Males and females are affected about equally.
  • 8. Definition Obsessive-compulsive disorder (OCD) is an anxiety disorder in which people have unwanted and repeated thoughts, feelings, ideas, sensations (obsessions), or behaviours that make them feel driven to do something (compulsions).
  • 9. Cont A person's level of OCD can be anywhere from mild to severe, but if severe and left untreated, it can destroy a person's capacity to function at work, at school or even to lead a comfortable existence in the home.
  • 10. Signs & Symptoms What is an obsession? Involuntary intrusive cognition. Types Doubts (74%) Thinking (34%) Fears (26%) Impulses (17%) Images (7%) Other (2%)
  • 11. Obsessions-examples Doubt Did I lock the door Thought that he had cancer Thought / Image that he had knocked someone down in his car Impulse + thought to shout obscenities in church Image of corpse rotting away Impulse to drink from inkpot and to strangle son
  • 12. Themes in obsession Obsessions often have common themes Contamination, dirt, disease, illness (46%) Violence and aggression (29%) Moral and religious topics (11%) Symmetry and sequence (27%) Sex (10%) Other (22%) The themes often reflect contemporary concerns (the devil, germs, AIDS)
  • 13. Compulsions Some people with OCD perform compulsive rituals because they inexplicably feel they have to, others act compulsively so as to mitigate the anxiety that stems from particular obsessive thoughts.
  • 14. Cont Excessive skin picking (i.e., dermatillomania) or hair plucking (i.e.,trichotillomania) and nail biting (i.e., onychophagia) are all on the obsessive-compulsive spectrum.
  • 15. Examples of compulsions Scanning text for life having read death. Touching the ground after swallowing saliva. Driving back to check he hadnt knocked someone down in his car. Counting 6,5,8,3,7,4 in your head. Hand washing.
  • 17. OCD Experiences OCD Not OCD A man who washes his hands 100 times a day until they are red and raw A woman who unfailingly washer her hands before every meal A women who locks and relocks her door before going to work every day for half an hour A woman who double- checks that her apartment door and windows are locked each night before she goes to bed. A college student who must tap on the door frame of every classroom 14 times before entering A musician who practices a difficult passage over and over again until its perfect A man who stores 19 years of newspapers just in case with no system for filling or retrieving A woman who dedicates all her spare time and money to building her record collection
  • 18. Cognitive Performance-Recent Research Findings A 2013 meta-analysis confirmed people with OCD to have mild but wide-ranging cognitive deficits; significantly regarding spatial memory, to a lesser extent with verbal memory, fluency, executive function and processing speed, while auditory attention was not significantly affected.
  • 19. Cont Spatial memory had been evaluated by results from Corsi block-tapping test, Rey- Osterrieth Complex Figure Test-immediate recall and Spatial Working Memory between search errors.
  • 20. Cont Verbal memory had been evaluated by Verbal Learning Test - delayed recall and Logical Memory II. Verbal fluency was evaluated by Category fluency and Letter fluency.
  • 21. Cont Auditory attention was evaluated by the Digit Span Test. Processing speed was evaluated by Trail Making Test part A.
  • 22. Associated conditions obsessivecompulsive personality disorder major depressive disorder bipolar disorder generalized anxiety disorder anorexia nervosa social anxiety disorder bulimia nervosa Tourette syndrome
  • 23. Cont Asperger syndrome attention deficit hyperactivity disorder dermatillomania (compulsive skin picking) body dysmorphic disorder trichotillomania (hair pulling)
  • 24. Cont In 2009 it was reported that depression among those with OCD is particularly alarming because their risk of suicide is high; more than 50 percent of people experience suicidal tendencies, and 15 percent have attempted suicide.
  • 25. Cont Depression is also extremely prevalent among sufferers of OCD. One explanation for the high depression rate among OCD populations was posited by Mineka, Watson, and Clark (1998), who explained that people with OCD (or any other anxiety disorder) may feel depressed because of an "out of control" type of feeling.
  • 26. Causes GENETIC FACTORS: genetic factors account for 4565% of OCD symptoms in children diagnosed with the disorder. identical twins more often affected than non- identical twins
  • 27. Genetic Factors cont Individuals with OCD are more likely to have first-degree family members exhibiting the same disorders than do matched controls. A mutation has been found in the human serotonin transporter gene, hSERT, in unrelated families with OCD.
  • 28. CHEMICAL AND BRAIN DYSFUNCTION The chemical messenger, Serotonin seems to be heavily involved. According to research, Serotonin is involved with biological processes such as mood, aggression, sleep, appetite and pain. It also seems that Serotonin is capable of connecting to nerve cells in the brain in many different ways and so can cause many different responses. Causes
  • 29. Chemical and Brain Dysfunction cont It is not even fully established if it is all or part of the Serotonin chemical or another chemical entirely acting on it; or a malfunction in one or more of the receptors in the brain that Serotonin attaches to that causes the OCD problems.
  • 30. INFECTION A streptococcal infection of the throat is known to occasionally result in the body confusing healthy cells with the infection and causing cellular damage. Causes
  • 31. Infection cont If this has happened with the brain, the bodys infection fighting system can attack the outside of nerve cells in the Basal Ganglia part of the brain with the result that OCD symptoms occur. Some research suggests that these symptoms dont seem to last very long and the occurrence of this infection OCD seems to be very rare.
  • 32. Causes DEPRESSION People with depression sometimes develop OCD symptoms, and those with OCD very often develop depression. Dealing with both together is very difficult without clinical intervention and it is notoriously difficult to undertake an exposure programme while the depression is high.
  • 33. Causes-Recent findings OCD is no longer believed to be caused by life experiences. Modern research suggests a biological and neurological cause fMRI scans show the circuit connecting the amygdala, frontal cortex, caudate nucleus (motor control), and thalamus is abnormally active in people with OCD.
  • 34. Causes-Recent Findings cont Genetic research on families with OCD members have found a genetic link. Theres a link between OCD and other tick disorders such as Tourettes disorder.
  • 35. Causes-Recent Findings cont Glutamate dysregulation has also been the subject of recent research, although its role in the disorder's etiology is not yet clear. Glutamate is known to act as a cotransmitter with dopamine in dopamine pathways that project out of the ventral tegmental area.
  • 36. Causes-Recent Findings cont People with OCD evince increased grey matter volumes in bilateral lenticular nuclei, extending to the caudate nuclei, while decreased grey matter volumes in bilateral dorsal medial frontal/anterior cingulate gyri.
  • 37. Causes-Recent Findings cont Orbitofrontal cortex overactivity is attenuated in people who have successfully responded to SSRI medication, a result believed to be caused by increased stimulation of serotonin receptors 5- HT2A and 5-HT2C.
  • 38. Freuds View A patient's mind responds maladaptively to conflicts between unacceptable, unconscious sexual or aggressive id impulses and the demands of conscience and reality. The ego defends against the id by isolation and reaction formation. The imperfect success of the ego gives rise to OCD symptoms.
  • 39. Diagnosis Formal diagnosis may be performed by a psychologist, psychiatrist, clinical social worker, or other licensed mental health professional. To be diagnosed with OCD, a person must have obsessions, compulsions, or both, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM).
  • 40. Cont According to ICD-10 criteria- For a definite diagnosis, obsessional or compulsive acts, or both, must be present on most days for at least 2 successive weeks and be a source of distress or interference with activities. The obsessional symptoms should have the following charecteristics:
  • 41. Cont 1. They must be recognised as the individuals own thoughts or impulses; 2. There must be atleast one thought or act that is still resisted unsuccessfully, even though others may be present which the sufferer no longer resists;
  • 42. Cont The thought of carrying out the act must not in itself be pleasurable (simple relief of tension or anxiety is not regarded as pleasure in this sense); The thoughts, images, or impulses must be unpleasantly repetitive.
  • 43. Treatment Pharmacotherapy- treatment using drugs that affect the neurotransmitter serotonin decrease the symptoms of OCD. Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac) and sertraline (Zoloft) prevent excess serotonin from being pumped back into neurons causing it to bind to receptor sites that regulate anxiety.
  • 44. Cont SSRIs are a second line treatment of adult obsessive compulsive disorder (OCD) with mild functional impairment and as first line treatment for those with moderate or severe impairment.
  • 45. Cont Disadvantage: Once medication is stopped, symptoms usually re-occur so the person needs to be put on medication indefinitely. The atypical antipsychotics such as quetiapine have also been found to be useful when used in addition to an SSRI in treatment-resistant OCD. However, these drugs are often poorly tolerated, and have metabolic side effects that limit their use. None of the atypical antipsychotics appear to be useful when used alone.
  • 46. Treatment Behavior Therapy- "exposure and response prevention where the patient deliberately confronts their feared object or idea. Ex: OCD hand washer touched contaminated object and is forced to not wash hands until anxiety goes down.
  • 47. Cont Behavior therapy is successful for most patients as long as the therapist is fully trained and the person is highly motivated and has a positive attitude. It lasts longer after treatment than drug therapy. Cognitive-behavioral- therapy emphasizing changing the OCDs patients beliefs and thinking patterns.
  • 48. Cognitive behavioral therapy (CBT) has been shown to be the most effective type of psychotherapy for this disorder. The patient is exposed many times to a situation that triggers the obsessive thoughts, and learns gradually to tolerate the anxiety and resist the urge to perform the compulsion. Medication and CBT together are considered to be better than either treatment alone at reducing symptoms. Treatment cont
  • 49. Cont Psychotherapy can also be used to: Provide effective ways of reducing stress Reduce anxiety Resolve inner conflicts
  • 50. Nursing Management Diagnoses Nursing Care Plans For Obsessive Compulsive Disorder Anxiety Chronic low self-esteem Fear Ineffective coping
  • 51. Cont Ineffective role performance Impaired social interaction Risk for injury Social isolation
  • 52. Some interesting facts English footballer David Beckham has been outspoken regarding his struggle with OCD. He said that he has to count all of his clothes, and his magazines have to lie in a straight line. British poet, essayist, and lexicographer Samuel Johnson is an example of a historical figure with a retrospective diagnosis of OCD. He had elaborate rituals for crossing the thresholds of doorways, and repeatedly walked up and down staircases counting the steps.
  • 53. Research Findings Nutrition deficiencies may also contribute to OCD and other mental disorders. Vitamin and mineral supplements may aid in such disorders and provide nutrients necessary for proper mental functioning. 亮-Opioids, such as hydrocodone and tramadol, may improve OCD symptoms. Administration of opiate treatment may be contraindicated in individuals concurrently takingCYP2D6 inhibitors such as fluoxetine and paroxetine.
  • 54. Cont Much current research is devoted to the therapeutic potential of the agents that affect the release of the neurotransmitter glutamate or the binding to its receptors. These include riluzole, memantine, gabapentin, N- acetylcysteine, topiramate and lamotrigine.
  • 56. References "What is Obsessive-Compulsive Disorder (OCD)?". Retrieved 27 May2015. Diagnostic and statistical manual of mental disorders : DSM-5 (5 ed.). Washington: American Psychiatric Publishing. 2013. pp. 237 242. ISBN 9780890425558. Angelakis, I; Gooding, P; Tarrier, N; Panagioti, M (25 March 2015). "Suicidality in obsessive compulsive disorder (OCD): A systematic review and meta-analysis.". Clinical Psychology Review 39: 1 15. doi:10.1016/j.cpr.2015.03.002. PMID 25875222. Fenske JN, Schwenk TL (August 2009). "Obsessive compulsive disorder: diagnosis and management". Am Fam Physician 80 (3): 239 45. PMID 19621834.