Psychobiologic Disorders Part Two

Psychobiologic Disorders Part Two
PVN 123 Mental Health Nursing

Cognitive Disorders Delirium Dementia Amnestic Disorders

Cognitive Disorders Group of conditions characterized by disruption of: Thinking Memory Processing Problem-solving Treatment requires compassion and understanding of clients and families Cognitive Disorders (DSM-IV-TR) Delirium Dementia Amnestic disorders

Is it Delirium or Dementia?
DEMENTIA Onset Rapid onset over short time (hours to days) Gradual deterioration of function (months to years) Clinical Manifestations Impaired (may fluctuate throughout the day) Memory Judgment Ability to focus Ability to calculate LOC Altered Restless / agitated Sundowning (confusion at night) Rapid personality change Some hallucinations /illusions Unstable vital signs (due to medical illness) Impaired (do not change throughout the day) Speech (aphasia) Ability to recognize familiar objects (agnosia) Executive functioning (managing daily tasks Movement (apraxia) LOC usually unchanged Sundowning Gradual personality changes Stable vital signs (unless another illness present) Cause Secondary to another medical condition Infection (older adults) Substance abuse Caused by chronic disease Alzheimer’s Chronic alcohol abuse May be caused by permanent head trauma Outcome Reversible ! (if prompt Dx and Tx) Irreversible and progressive

Stages of Alzheimer’s Disease
Clinical Manifestations 1 No impairment Normal Functioning No memory problems No problems evident to provider 2 Mild cognitive decline May be normal age-related changes (early signs of Alzheimer’s) Forgetfulness (eyeglasses / wallet) No memory problems evident to provider / friends / co-workers 3 Mild cognitive deficits (memory/concentration) Measurable in clinical testing Mild deficits (losing /misplacing important objects Decreased ability to plan Decreased attention span Difficulty remembering words / names Difficulty in social or work situations 4 Moderate cognitive decline Clearly detected in clinical interview (mild / early stage Alzheimer’s) Personality changes (withdrawn / subdued) Obvious memory loss Limited knowledge/memory of recent occasions, events, personal history Difficulty with planning and organizing (bill paying / managing money) Difficulty with complex mental arithmetic 5 Moderately severe cognitive decline (moderate stage Alzheimer’s) Increasing cognitive deficits Unable to recall important details (address/phone number) Still able to remember information about self and family Disoriented to time and place 6 Severe cognitive decline (mid-stage Alzheimer’s) Worsening memory problems Loss of awareness of recent events and surroundings Can recall own name but not personal history Significant personality changes (delusions, hallucinations, compulsive behaviors) Wandering Requires assistance with ADLs Disrupted sleep/wake cycle Increased urinary and fecal incontinence Violent tendencies (potential danger to self and others) 7 Very severe cognitive decline (late-stage Alzheimer’s) Unable to respond to environment Unable to speak or control movement Unrecognizable speech Incontinence Requires assistance for eating / impaired swallowing Gradual loss of ability to move Stupor or coma Death (frequently related to choking or infection)

Amnestic Disorder May be secondary to substance abuse or other medical condition No personality change or impairment in abstract thinking Changes include: Decrease awareness of surroundings Inability to learn new information despite normal attention Inability to recall previously learned information Possible disorientation to time and place

Labs / Tests / Screening Tools Cognitive Disorders
Labs and Diagnostic Tests Standardized Screening Tools See handouts! Chest / skull Xray EEG ECG Liver function studies Thyroid function studies Brain neuro-imaging (CT / PET scan) Urinalysis Serum electrolytes MMSE Mini-Mental State Exam FAST Functional Assessment Screening Tool Global Deterioration Scale Geriatric Depression Scale Short form Michigan Alcoholism Screening Test – geriatric version

Nursing Care & Communication Cognitive Disorders
Self-Assessment Nursing interventions focused on protection from injury and promoting dignity and quality of life Room close to nurse’s station Low level visual and auditory stimuli Well-lit environment Room with windows Time orientation ID bracelet Restraints as last resort Medications PRN Agitation / anxiety Safe physical environment Memory aids Clocks/calendars/seasonal photos Eye glasses and hearing aids Consistent daily routine Consistent caregivers Adequate food and fluid intake Allow for pacing and safe wandering Cover/remove mirrors Decrease fear / agitation Calm and reassuring Don’t argue or question hallucinations / delusions Reinforce reality Orient to time/place/person Introduce self with each new contact Eye contact Short simple sentences Reminisce Short time frames for activities and instructions Limit numbers of choices (eating / dressing) Avoid abstract thinking situations Avoid confrontation Encourage family visitation

Medications Cognitive Disorders
Common Meds (use with caution in patients with asthma/COPD – may cause bronchoconstriction) Aricept (donepezil) Exelon (rivastigmine) Razadyne (galantamine) Increase acetylcholine Improves ability to perform self-care Slows cognitive deterioration (mild to moderate dementia Side effects Nausea/diarrhea (about 10% of patients) Bradycardia Nursing interventions / client education Monitor GI side effects / fluid volume deficits Promote fluid intake Dosage may be titrated to reduce symptoms Monitor pulse (teach family if client at home) Clients should be screened for underlying heart disease Medication/Food Interactions NSAIDS (aspirin) May cause GI Bleeding Antihistamines/tricyclic antidepressants / antipsychotics Can reduce therapeutic effects of Aricept

Medication Nursing Considerations Cognitive Disorders
Cholinesterase Inhibitors Start dosage low / gradually increase until side effects are no long tolerable med no longer beneficial Monitor for adverse side effects Reinforce patient and family teaching Taper med when discontinuing Prevents abrupt progression of symptoms Monitor ability to swallow tablets Meds are available in tables and oral solutions Aricept available in orally disintegrating tablet Administer with or without food Aricept has a long half-life (administered once daily at HS) Other cholinesterase inhibitors administered BID Namenda (memantine) Blocks calcium entry to nerve cells Slows down brain cell death Only med approved for moderate to severe stages of Alzheimer’s Can be used concurrently with cholinesterase inhibitor Administer with or without food Monitor for common side effects Dizziness Headache Confusion constipation

Alternative Therapies
Alternative Therapies / After Discharge Care / Client Outcomes Cognitive Disorders After Discharge Care Educate family/caregivers Care methods Adapting home environment Ensure safe home environment Support caregivers Alternative Therapies Estrogen therapy (women) May prevent Alzheimer’s Not useful for decreasing effects of pre-existing dementia Ginkgo Biloba (herbal) Used by some to aid memory Potential interactions Bleeding (with antiplatelet meds) Risk for seizures (combined with anti-seizure medications (lowers seizure threshold) Client Outcomes Client will demonstrate improvement in cognition, memory, self care ability Client will remain free from injury

Quick Quiz! How does Exelon (rivastigmine) work? What are the benefits of the medication for the client?

Quick Quiz! A client who has moderately severe dementia is admitted to a long-term care facility. Which of the following findings should the nurse expect? _____ No change in LOC _____ Stable vital signs _____ Daily changes in behavior _____ Restlessness _____ Disorientation

Substance and Other Dependencies
Substance Abuse Substance Dependence Non-Substance Dependency

Substance Abuse (Want It!)
Repeated use of chemical substance Clinically significant impairment over 12 month period Includes at least one of the following Unable to perform normal home/school/work duties Taking part in hazardous situation/risky behaviors while impaired Driving Repeated problems caused by substance abuse Legal problems Losing job Missed time at work Continued use despite problems

Substance Dependence (Need It!)
Repeated use of chemical substances Impairment over 12 month period Three or more of the following: Presence of tolerance Need for higher and higher dosages Withdrawal Stopping or reducing substance results in physical and psychological manifestations Tremors Headaches Substance taken in larger amounts or for longer time Continuing pain medication after pain ceased Persistent, but unsuccessful desire to control use Progressively more time spent using and recovering from use Reduction in social / occupational duties Continued use in the presence of related physical and psychological problems acknowledged by the client.

Non-Substance Related Dependency (Process Addictions)
Dependence on a behavior Gambling Sexual behaviors Shopping / spending Internet use

Defense Mechanisms Substance and Other Dependencies
Denial Most common “I can quit whenever I want!” “Smoking doesn’t really cause my problems!” Can prevent client from seeking help

Risk Factors Genetics Low self-esteem
Predisposition Low self-esteem Low tolerance for pain/frustration Few life successes Risk-taking tendencies Sociocultural Theories Native Americans High alcohol abuse percentages Asian Groups Lower alcohol abuse percentages Older clients may have history of alcohol abuse or develop patterns of abuse later in life due to stressors Losing spouse Retirement Social isolation

Data Collection Nursing history should include the following:
Type of substance or compulsive behavior Pattern and frequency of substance use Amount of substance used Age at substance abuse onset Changes in use patterns Periods of abstinence Previous withdrawal symptoms Date of last substance use / compulsive behavior Review of systems Black out or loss of consciousness Changes in bowel movements Weight loss / gain Stressful situations experienced Sleep problems Chronic pain Concern over substance abuse Cutting down on consumption behavior Older Adults Alcohol use leads to: Falls Injuries Memory loss Somatic reports (headaches) Sleep changes Dependence may include decreased ability for self care Urinary incontinence Signs of dementia May show clinical manifestations at lower dosages Exposure to multiple medications in addition to psychological changes (age-related) raises likelihood of adverse effects

CNS Depressants Can produce physiological and psychological dependence
May have: (when taken concurrently) Cross tolerance (tolerant to the effects of a certain drug and develops a tolerance to another drug) Cross dependency ("addicted to everything”) a person who is addicted to one drug (alcohol for example) can become addicted to any drug if they use it Addictive effect

Commonly Abused Substances
Alcohol Benzodiazepines Barbiturates Cannabis Cocaine Amphetamines Nicotine Opioids Inhalants Hallucinogens

Alcohol Alcohol Intended Effect Toxic Effects Withdrawal S/S
Relaxation Decreased social anxiety Maintaining calm BAC 0.08% = legal intoxication May be less – 18yrs < Depends on Body wt Gender Alcohol concentration # of drinks Gastric absorption rate Individual’s tolerance Death may occur BAC > 0.35% (acute toxicity) Alters judgment Decreases motor skills Decreased LOC Respiratory arrest Peripheral collapse Potential for death (with large doses) Chronic use leads to: Cardiovascular damage Liver damage (fatty liver / cirrhosis) Erosive gastritis GI Bleeding Acute pancreatitis Sexual dysfunction Effects usually start within 4 to 12 hours of the last intake of alcohol Peak after 24 to 48 hours (then subside) Clinical findings: Abdominal cramping Vomiting Tremors Restlessness Inability to sleep Increased HR/BP/T Tonic-Clonic seizures Alcohol Withdrawal Delirium 2-3 days post cessation May last 2-3 days Considered medical emergency Clinical manifestations: Severe disorientation Psychotic symptoms (hallucinations) Severe hypertension Cardiac dysrhythmias Delirium May progress to death

Benzodiazepines/Barbiturates/ Cannabis
Benzodiazepines (diazepam [Valium] - can be taken orally or injected Intended Effects Toxic Effects Withdrawal S/S Decreased anxiety Sedation Increased: Drowsiness / sedation Agitation Disorientation Nausea Vomiting Respiratory depression Antidote for toxicity= flumazenil (Romazicon) IV Rapid dependence Anxiety Insomnia Diaphoresis Hypertension Possible psychotic reactions Seizure activity (sometimes Barbiturates (phenobarbital [Nembutal] / secobarbital [Seconal]) – can be taken orally or injected Decreased LOC (may be fatal) No antidote! Mild symptoms Same as with alcohol W/D Severe symptoms (similar to alcohol withdrawal) Life threatening convulsions Delirium Cardiovascular collapse Cannabis (marijuana, hashish [more potent] – can be smoked or eaten Euphoria Hallucinations Decrease nausea/vomiting secondary to chemo Pain management for chronic pain Focus only on one task Chronic use: Lung cancer Chronic bronchitis Other respiratory effects High doses: Paranoia (delusions/hallucinations) Some depression

Cocaine/Amphetamines/Nicotine
Cocaine – can be inhaled (snorted), smoked, or injected Intended Effects Toxic Effects Withdrawal S/S Rush of euphoria and pleasure Increased energy Mild toxicity Irritability Tremor Blurred vision Severe effects Hallucinations Seizures Extreme fever Tachycardia/Hypertension/Chest pain Possible cardiovascular collapse Possible death Characteristic withdrawal syndrome Occurs within 1 hour to several days of cessation Depression Fatigue Craving Excess sleeping / insomnia Dramatic and unpleasant dreams Psychomotor retardation or agitation Amphetamines – can be taken orally, smoked or injected Euphoria similar to cocaine Impaired judgment Psychomotor agitation Hyper vigilance Extreme irritability Acute cardiovascular effects Tachycardia Elevated BP (could cause death) Sleeping (similar to cocaine) Not life threatening Nicotine – can be inhaled (cigarettes, cigars) or snuffed or chewed (smokeless tobacco) Relaxation Decreased anxiety Highly toxic Acute toxicity only in children / nicotine exposed to pesticides Contains harmful chemicals (highly toxic / long term effects) Long term effects Cardiovascular disease Hypertension Stroke Respiratory disease Smokeless (irritation of oral mucosa / cancer) Abstinence syndrome Nervousness Restlessness Anxiety Insomnia Increased appetite Difficulty concentrating

Opioids/Inhalants/Hallucinogens
Opioids (heroin, morphine, hydromorphone [Dilaudid] – can be injected, inhaled, or smoked Intended Effects Toxic Effects Withdrawal S/S Rush of euphoria Relief from pain Decreased respirations, LOC (may cause death) Antidote – naloxone [Narcan] - IV Abstinence syndrome Begins with sweating/rhinorrhea Progresses to: Piloerection (gooseflesh) Tremors Irritability Followed by: Severe weakness Nausea/vomiting Muscle and bone pain Muscle spasms Unpleasant but not life-threatening Self-limiting (7 to 10 days) Inhalants (amyl nitrate, nitrous oxide, solvents) – sniffed, huffed or bagged (frequent users include children and teenagers) Euphoria Depends on the drug Generally can cause CNS depression Clinical findings include: Psychosis (hallucinations) Respiratory depression Possible death None Hallucinogens (lysergic acid diethylamide [LSD], mescaline [peyote], phencyclidine piperidine [PCP]) – can be taken orally, injected or smoked Heightened sense of self Altered perceptions vivid colors Panic attacks and flashbacks Visual disturbances / hallucinations Can occur intermittently for years

Standardized Screening Tools
Michigan Alcohol Screening Test (MAST) Addiction Severity Index Recovery Attitude and Treatment Evaluator Brief Drug Abuse Screen Test CAGE-AID Asks clients to determine how they perceive their current substance abuse See Handouts

Nursing Care (during treatment)
Self-assessment (nurse) Feelings about abuses These can be transferred to the client Nonjudgmental approach by nurse is imperative Use open-ended questions (“When was your last drink?”) Focus on safety Safe environment Close observation Reorientation to time/place/person Adequate nutrition and fluid balance Low stimulation environment Administer withdrawal medications as prescribed Monitor for covert substance abuse during detox Provide emotional support (clients and families) Reinforce teaching about codependent behaviors Instruct clients and families Addiction Treatment goal of abstinence Remove meds in the home that are not being used No sharing of medications Begin developing motivation and commitment for abstinence and recovery Encourage self-responsibility Help clients develop an emergency plan (what to do and who to contact) Encourage attendance in self-help groups

Other Care and Treatment
Dual diagnosis Both mental health and substance abuse problem Use team approach Individual psychotherapy Group therapy Family therapy Pharmacology Therapy Alcohol Withdrawal Valium, Ativan, Librium, Tegretol, Catapres Alcohol Abstinence Antabuse, ReVia, Campral Opioid Withdrawal Dolophine, Catapres, Subutex, Suboxone Nicotine Withdrawal Wellbutrin, nicotine replacement (Nicorette/Nicotrol) Nursing Considerations and Client Education: Monitor vital signs and neuro status Provide for client safety and implement seizure precautions Encourage adherence to treatment plan Advise clients taking Antabuse to avoid all alcohol Can lead to neuro and GI complications

Discharge Care and Client Outcomes
Reinforce how to recognize S/S of relapse and factors that can contribute to relapse Reinforce cognitive-behavioral techniques to maintain sobriety and find pleasure in activities other than using substances Help client develop communication skills Encourage 12-step program The client will verbalize coping strategies to use in times of stress The client will remain substance free The client will remain free from injury The client will attend a 12-step program regularly

Quick Quiz! Which of the following medications should the nurse anticipate administering to help clients maintain their abstinence from alcohol? A. Ativan (lorazepam) B. Wellbutrin (Bupropion) C. Antabuse (Disulfiram) D. Catapres (Clonidine)

Quick Quiz Which of the following is an adverse effect of hallucinogens such as LSD and PCP? A. panic attacks B. hypothermia C. constricted pupils D. muscle flacidity

Eating Disorders Anorexia Nervosa Bulimia Nervosa

Watch a Video My Name is Anna

Eating Disorders Eating disorders recognized by DSM-IV-TR
Anorexia Nervosa Bulimia Nervosa Mortality rate for eating disorders is high Suicide is a risk Treatment focuses on normalizing eating patterns and beginning to address issues raised by the illness Comorbidities include Major depressive disorder Dysthymia (50-75%) OCD Substance abuse Anxiety disorders

Anorexia Nervosa Preoccupation with food and eating rituals
Voluntary refusal to eat Exhibit morbid fear of obesity Refusal to maintain minimally normal body weight (85% of expected normal weight for the individual) Body image disturbance Occurs most often in females Adolescence to young adulthood 5% to 10% of clients with anorexia are male Two types: Restricting type Drastic food restriction (no binging or purging) Binge-eating type Engages in binge eating or purging behaviors

Bulimia Nervosa Recurrent eating of large quantities of food over short period of time (bingeing) Followed by inappropriate compensatory behaviors to get rid of excess calories Self-induced vomiting (purging) Most clients maintain a normal or slightly higher weight Average age of onset in females = 15 to 18 years About 10% to 15% of clients are males Onset generally occurs between 18 – 26 years Binging with use of excessive exercise is most common Two types: Purging Type Self-induced vomiting, laxatives, diuretics and/or enemas Nonpurging Type: May compensate for binging through other means Excessive exercise Misuse of laxatives Diuretics Enemas

Risk Factors Female Male Family genetics
Hypothalamic/neurotransmitter/hormonal/biochemical imbalance Disturbance in Serotonin Interpersonal relationships Psychological influences Rigidity/ritualism Separation/individualization conflics Feeling ineffective Helplessness Depression Distorted body image Environmental factors Pressure from society “the perfect body” History of being a “picky” eater during childhood Participation in athletics Elite level of competitition Male Participation in sport where lean body is prized or necessary Bicycling Wrestling History of obesity

Subjective / Objective Data
Nursing history should include: Client’s perception of the issue Eating habits History of dieting Methods of weight control Value attached to a specific shape / weight Interpersonal and social functioning Difficulty with impulsivity / cumpulsivity Family and interpersonal relationships Frequently troublesome and chaotic, reflecting a lack of nurturing

Common Data Findings Objective Data Findings Mental Status
Cognitive distortions Overgeneralizations (“Other girls don’t like me because I’m fat”) All-or-nothing thinking (“If I eat any dessert, I’ll gain 50 pounds”) Catastrophizing (“My life is over if I gain weight”) Personalization (“When I walk through the hospital hallway, I know everyone is looking at me”) Emotional Reasoning (“I know I look bad because I feel bloated”) High interest in preparing food, but not eating Terrified of gaining weight Perception is that he/she is severely overweight and sees image reflected in the mirror May exhibit low self-esteem / impulsivity/ difficulty with interpersonal relationships May participate in an intense physical regimen Vital Signs Low blood pressure with possible orthostatic hypotension Decreased pulse and body temp Weight Anorexics – body weight less than 85% of expected normal weight Bulimics – weight within normal range or slightly higher Skin / Hair / Nails Anorexics – fine downy hair (lanugo) on the face and back / yellowed skin/ mottled / cool extremities / poor skin turgor Head / Neck / Mouth / Throat Bulimics – enlarged parotid glands / dental erosion / caries (if purging) Cardiovascular System Bulimics – dysrhythmias / heart failure / cardiomyopathy / peripheral edema Musculoskeletal System Muscle weakness Gastrointestinal System Constipation / self-induced vomiting / excessive use of diuretics or laxatives Reproductive System Anorexics – amenorrhea for at least three consecutive cycles Nutritional Status Electrolyte imbalances and severe dehydration

Criteria for Treatment / Labs and Diagnostics
Rapid wt loss or wt loss > 30% of body weight over 6 months Unsuccessful weight gain in outpatient treatment for failure to adhere to treatment contract Vital signs HR < 40 BPM Systolic BP < 70 Temp < 98.6 ECG changes Electrolyte disturbance Severe depression Suicidal behavior Family crisis Common abnormalities Hypokalemia (bulimics) Potassium loss from purging Increased aldosterone Sodium and water retention Results from dehydration Anemia / leukopenia/ lymphyocytosis Possible impaired liver function ( ^ enzyme levels) Possible ^ cholesterol Abnormal thyroid function tests ^ carotene (causes yellow skin) Decreased bone density Possible osteoporosis Abnormal blood glucose levels ECG changes Electrolyte Imbalances Hypokalemia Hyponatremia Hypochloremia

Standardized Screening Tools
Eating Disorders Inventory Body Attitude Test Diagnostic Survey for Eating Disorders Google These!! Make notes! Then come back!!

Nursing Care Highly structured milieu (for those requiring intensive therapy) Maintain trusting nurse/client relationship Positive approach and support Support self esteem and positive self image Encourage client decision making and participation in plan of care Establish realistic goals for weight gain Promote cognitive-behavioral therapies Cognitive reframing Relaxation techniques Journal writing Desensitization exercises Monitor vital signs, I&O, and weight Use behavioral contracts to modify behaviors Rewards for positive behaviors Monitor during and after meals Monitor for maintenance of exercise Reinforce self-care teaching Provide nutrition education Consider client’s preferences Establish a structured eating schedule Provide small, frequent meals Diet high in fiber, low in sodium Limit high-fat and gassy foods at start of treatment Administer multivitamin and mineral supplement Instruct client to avoid caffeine Make arrangements for clients to attend individual, group, family therapy

Medications and other care
Selective Serotonin Reuptake Inhibitors (SSRIs) Prozac (fluoxetine) Client Education Med may take 1 to 3 weeks for initial response Up to 2 months for maximal response Avoid hazardous activities Notify MD if sexual dysfunction occurs and is intolerable Include registered dietician for nutritional and dietary guidance After Discharge Help to develop and implement a maintenance plan Encourage follow-up treatment Encourage support group Continue individual and family therapy as indicated

Watch a Video Role of Nutrition in Refeeding Syndrome (UNC Chapel Hill)

Complications of Eating Disorders
Refeeding Syndrome Circulatory collapse Occurs when client’s compromised cardiac system is overwhelmed by a replenished vascular system after normal fluid intake resumes. Nursing actions: Care for clients in hospital setting Implement refeeding for at least 7 days Monitor serum electrolytes and administer fluid replacement as prescribed Cardiac dysrhythmias, severe bradycardia, hypotension May be admitted to ICU until stable

Quick Quiz! A client is hospitalized on an eating disorders unit. The client has a history of and current diagnosis of bulimia nervosa. Which of the following should the nurse expect to find? (select all that apply) _____ hyperkalemia _____ amenorrhea _____ ECG changes _____ cool extremities _____ peripheral edema _____ yellowed skin _____ body weight below the expected range _____ tooth decay

Quick Quiz! A client who has bulimia has stopped vomiting on the unit and describes to the nurse feelings of being afraid of gaining weight. Which of the following is an appropriate response by the nurse? A. “As long as you stick to the diet you have here, you are not going to gain enough weight to worry about”. B. “Forget about your weight for now. We are going to work on other problems while you are in the hospital”. C. “I understand you have concerns about your weight, but tell me about your National Honor Society invitation. That’s quite an accomplishment”. D. You are not overweight, and we’ll make sure you do not become overweight. We know that is important to you”.

Summary Identified common subjective and objective evidence associated with common mental health disorders Anxiety Disorders Depression Bipolar Disorders Schizophrenia Personality Disorders Cognitive Disorders Substance and other dependencies Eating Disorders Identified nursing interventions, therapies, screening tools, that may be utilized in the safe care, management, and health promotion, for individuals who experience these disorders. Determined desired outcomes associated with these disorders

Assignment – Due Day 2 See Schedule for assignments due for next class

Next Class Q&A Review Test #1 ATI Tutorial and Quiz
Psychobiological Disorders Pharmacology and Alternative Therapies Test #1 ATI practice test #1 Graded – open book (one hour time limit) PN Mental Health Online Practice 2011B ID Password – 5C6753P55 ATI Tutorial and Quiz Take home assignment due Day 3 May begin after completing test

Study!!! You can do it!!!

Psychobiologic Disorders Part Two

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