Dysfunctional breathing is experienced as a feeling of “difficulty in inhaling” and shortness of breat , which may be similar to the symptoms of coronavirus infection (Gavriatopoulou et al., 2020). The conditions of the COVID-19 pandemic create an increased level of anxiety and attention to respiratory sensations, which becomes a favorable ground for the occurrence of dysfunctional breathing.

To examine the relationship of ideas about the pandemic with the occurrence of dysfunctional breathing in the Russian population during the COVID-19 pandemic.

The Naimigen Questionnaire (Van Dixhoorn, Duivenvoordent, 1985) and the author’s socio-demographic questionnaire were used, which included questions about personal experience of the pandemic. The study was conducted online from April 27 to December 28, 2020. It was attended by 1,362 people from all regions of Russia, including 1,153 women and 209 men aged 15 to 88 years (38.3±11.4).

It was found that respondents who are more confident in the danger of coronavirus have more respiratory difficulties (N=517;NQ=19±10.6) compared to those who consider its danger exaggerated (N=454,NQ=15.9±9.2,p=0.000). Respondents who are completely convinced of the absence of a condemnation for COVID-19 disease have less pronounced dysfunctional breathing (N=331,NQ=15.26±9.5), compared to those who sure about it (N=88,NQ=19.16±10.05, p=0.007). Respondents who have relatives ill COVID-19 (N=430) have a higher score on NQ (18.6±10.5), compared with those dont have (N=932, NQ=17.1±9.7, p =0.011).

The dysfunctional breathing is associated with the respondents’ beliefs about the danger of coronavirus and the expectation of stigmatization in COVID-19 disease, as well as with the experience of COVID-19 disease among relatives.

Research is supported by the Russian Science Foundation, project No. 21-18-00624.

Despite recent legislative changes through the enactment of 2017-58 law on the elimination of violence against women and children, sexual violence remains fairly frequent and is often underestimated.

to describe the epidemiological peculiarities of victims of sexual assault in the Mahdia region and to discuss their medico legal implications.

this is retrospective study of 110 cases of victims of sexual assault examined at the legal medicine department of the TAHER SFAR University Hospital in Mahdia. This work was carried out over the period from January 2016 to August 2018.

the majority of victims were female (80%) and the main vulnerability factor was an age under 15 (26%). The perpetrator was generally unique (74%). Sexual assault by penetration was mostly reported (51% of cases), and was almost exclusively penile (98,2 of cases). The gynecological examination revealed a torn hymn in 43 victims, a compliant hymen without traumatic lesions in 7 victims (8%) and recent vulvar traumatic lesions without hymenal crossing in 5 victims (5,6%). Recent anal penetration was diagnosed in 6 male victims (6,8%). Among female victims, recent anal penetration was diagnosed in 5 victims (22,7%). One in four victims reported a market psychological impact with female predominance in 85% of cases. Complications of the most reported sexual assaults were pregnancy in 7% of cases. In total, only 57,3% of the certificates issued made it possible to conclude that the injuries.

The care of victims of sexual assault requires a multi- disciplinary approach; medical, psychiatric, social and legal.

No significant relationships.

The covid-19 pandemic exerts severe pressure on health systems worldwide and creates stressful working conditions for healthcare workers.

The aim of this study, which used the focus group method, was to investigate the psychosocial experiences of the healthcare personnel working in covid-19 wards.

An interview guide was specially designed and the sample consisted of twelve frontline healthcare workers. Data analysis was based on the empirically grounded theory and thematic analysis was used as a method.

One overarching theme called “Threat” and three main themes were identified: a) Nature of the disease, b) Interpersonal relationships at the hospital, and c) Challenges-Interventions. The concept of “Threat” is dominant throughout the discussion and transcends every issue of the analysis. The first main theme “Nature of the disease” refers to the fear of infection and spread of the virus in the professionals’ environment, the existential concerns brought to the surface by the fear of death, as well as the stigma experienced by health professionals as “potential carriers” of the coronavirus. The second main theme “Interpersonal relationships at the hospital” concerns the relationships developed both among health staff and between health professionals and patients in response to the challenges of the epidemic. The third main theme concerns the obstacles that health professionals face in carrying out their work, the strategies they adopt to deal with stressful situations, but also the type of institutional support they need.

Hospital staff training on the biomedical developments about covid-19 as well as face-to-face self-help groups are recommended.

No significant relationships.

Although antipsychotics are first-line treatments for schizophrenia, benzodiazepines (BZDs) are often used as concomitant medications in acutely exacerbated patients due to their anxiolytic and sedative effects. Cariprazine (CAR), a D3-preferring dopamine D2/D3 partial agonist antipsychotic, has been examined in many clinical studies for the treatment of acute schizophrenia, with and without benzodiazepines.

To delineate the effects of benzodiazepine-use during cariprazine treatment in acute schizophrenia.

Pooled data of cariprazine-treated (1.5-6mg/day) and placebo-treated patients from four short-term, randomised, double-blind trials (NCT00404573, NCT01104766, NCT01104779, NCT00694707) were analysed. Baseline characteristics (age, duration of illness) and efficacy outcome parameters (Total and Hostility Factor Score of the Positive and Negative Syndrome Scale [PANSS]) were compared in patients receiving benzodiazepines (for more ≥3 consecutive days) and not receiving benzodiazepines (<3 consecutive days).

Altogether, 36.7% and 40.7% of the CAR-treated and PBO-treated patients required BZDs. BZD-taking was associated with a higher age in both the CAR-treated (p=0.0002) and PBO-treated (p<0.0001) patients, and with longer illness-duration in both treatment groups (p<0.0001). PANSS Total Score at baseline was similar for BZD users and non-users (CAR: LS Mean=96.36 and 96.27; PBO: LS Mean=95.55 and 96.66). Change from baseline in the PANSS Total Score was greater for patients who did not use BZD vs those who did (CAR: LS Mean= -23.8 vs LS Mean 17.2, p<0.0001; PBO: LS Mean= -14.0 vs LS Mean 12.9, p=0.5776).

These findings may suggest that requiring benzodiazepines is a potential indicator of longer illness duration and poorer response in acute schizophrenia.

I am an employee of Gedeon Richter Plc.

Health Related Quality of Life (HRQOL) is acknowledged as an important construct in describing the individuals overall condition within the health context. In the case of families with Autism Spectrum Disorders (ASD), neurotypical siblings’ HRQOL is an important concept for this at-risk population. Social support has been identified as an important protective factor against parental psychological problems. However, possible associations between HRQOL in neurotypical ASD-siblings and parental variables, such as perceived social support, remained unexplored in the ASD-siblings’ literature.

This study aimed to investigate any association between HRQOL in neurotypical ASD-siblings and parental perceived social support and key demographic variables.

118 parent-child-dyads from Greek ASD-families that fulfilled inclusion criteria participated in this study and answered a demographic questionnaire. Parents were administered the Multidimensional Scale of Perceived-Social-Support (MSPSS), while the children answered the Kidscreen-27. A hierarchical multiple regression was performed to test the hypothesis.

Hierarchical regression showed that neurotypical siblings HRQOL (as measured with KIDSCREEN-27 total score) was associated with perceived social support from the family (std beta=0.184; p=0.027; model 1), and this association persisted after demographics entered the model (std beta=0.369; p=0.015; model 2). Thus, it was found that the sibling’s HRQOL was associated with perceived social support from the family independent of demographics.

The results of the present study showed that the HRQOL in ASD-siblings is associated with perceived social support from the family, pointing to the need for supporting siblings and designing effective interventions in order to prevent possible mental health problems in neurotypical siblings of ASD individuals in the future.

No significant relationships.

During the COVID-19 pandemic, telesimulation became particularly important to continue the education of medical students during disrupted clerkships while maintaining social distancing.

To describe our experiences of adapting to telesimulation and evaluate this from student and faculty perspectives.

The intervention was evaluated using anonymous surveys consisting of statements rated on a five-point Likert scale from strongly disagree to strongly agree and open-ended questions asking students and facilitators what went well, what they would change and why, and for any other comments.

Adaptations addressed the logistics of online delivery and the structure and content of scenarios. Logistical considerations included central organization of sessions to relieve pressures on clinicians. Pre-session case discussions were introduced to maximise time with simulated patients and give students space to socialise. Content was modified to ensure functionality online and reflect the context of the pandemic. A total of 278 students and 24 facilitators participated in the telesimulation sessions. 98.1% of students (N=109) rated the sessions as very good or good. Students benefited from practicing skills, especially clinical situations which they would rarely encounter as students, and receiving feedback. Facilitators (N=6) felt that students learnt both skills for online consultations and skills that can be transferred to face-to-face situations, but were ambivalent on whether students would benefit more from face-to-face sessions.

Telesimulation is a safe and effective option that offers additional opportunities for students to develop telemedicine skills. Going forward, telesimulation should complement face-to-face delivery to develop future clinicians who are proficient in both remote and face-to-face working.

No significant relationships.

COVID-19 is a multifaceted disease establishing differences in terms of its occurrence, manner of clinical presentation and disease predilection. While mental health becomes one of the less analyzed aspects, addressing anxiety and depression allows clinicians to provide more patient-centered care in this pandemic era.

This study determined the prevalence of anxiety and depressive symptoms among patients admitted for at least 14 days at COVID wards of East Avenue Medical using the validated Filipino version of the Hospital Anxiety and Depression Scale (HADS-P), and described the socioeconomic, psychosocial, clinical factors affecting its development among COVID-19 patients.

232 patients admitted at COVID ward of East Avenue Medical Center for at least 14 days were included in the study. Participants were interviewed using the validated Filipino version of the Hospital Anxiety and Depression Score (HADS-P) questionnaire. STATA 13.1 was used for data analysis at 95% confidence interval

Anxiety was significantly correlated with hypertension (p= 0.044), diabetes (p= 0.008), employment status (p= 0.038), and with patients who had family members with COVID- 19 (p= 0.033). Depressive symptoms occurred more likely in Chronic Kidney Disease and in COVID-19 suspects. Most participants had a normal HADS-P anxiety (6) and depression (4) median scores. Mild symptoms of anxiety (n=55) and depression (n=30) were noted among participants. The severity of COVID-19 classification was a statistically significant variable for developing anxiety symptoms.

Identifying predictors of developing anxiety and depressive symptoms enables us to develop better strategies in addressing mental health as one of the important aspects of patient management during this pandemic.

No significant relationships.

Traditional cultural healers -- their methods and their results -- are often invisible to conventional medical practitioners. When confronted with a result that does not make sense, we often ignore it.

We wanted to understand the process that happened between people and traditional cultural healers when these people experienced substantial improvement in mental health without psychiatric treatment.

We collected 56 case stories from people who consulted traditional cultural healers instead of conventional medical practitioners for serious mental health problems. We confirmed the stories with family members and interviewed the healers as well. We used constructivist grounded theory to explore commonalities in the stories from the clients’ points of view and from the healers’ perspectives. The context is indigenous people in North America.

Patients had a range of diagnoses, including psychotic disorders (12), bipolar disorder (28), and evere unipolar depression (16). Co-morbid anxiety disorders were common (22). Improvement in mental health was associated with participation in ceremonies within a community, building relationships with members of that community, engaging in prescribed daily practices endorsed by that community, with a resulting report of feeling increases in social and spiritual connectedness. The healers believed strongly that the embeddedness in community contributed to the results and that spirit beings played important roles in helping people feel better. The use of psychiatric medications was minimal.

Psychiatry can acknowledge that people can have substantial improvements in mental health when working with traditional cultural healers outside of conventional settings. Studying these settings and results can improve conventional practice.

No significant relationships.

Delusional idea disorders are a group of syndromes whose main or unique characteristic is the presence of consolidated delusional ideas that usually have a chronic character and do not fit into other diagnoses such as schizophrenia, affective disorder or other organic diseases. On the other hand, Charles Bonnet syndrome is an organ hallucinosis in whose context visual hallucinations may appear in patients with a visual deficit. Historically, it has been considered that the presence of another psychiatric condition is an exclusion criterion for the diagnosis of Charles Bonnet syndrome, although the presence of similar etiological and maintenance factors means that this situation of dignous exclusion must be reconsidered.

The objective of the present communication is to study the current state of the topics “delusional disorder” and “Charles Bonnet syndrome”. Another objective is to reconsider that the presence of previous or concurrent psychiatric pathology is an exclusion criterion for the diagnosis of Charles Bonnet syndrome..

A bibliographic review on “delusional ideas disorder” and “Charles Bonnet syndrome” has been carried out, as well as a discussion on the diagnostic and exclusion criteria, based on the etiopathogenic and maintenance factors.

Both in “delusional ideas disorder” and in “charles bonnet syndrome” advanced age, social isolation and deficiencies in sense organs constitute etiological factors that facilitate the appearance of these syndromes and make their treatment difficult.

Due to this, we consider that the appearance of another previous or present psychiatric illness should not be an exclusion criterion, both can appear in the same patient.

No significant relationships.

Today the maternal death of black women is four times than the maternal death of white women. A lot has been written about the physical health of black women during pregnancy and childbirth however the perinatal mental health of this group of women is less well researched. I wanted to investigate if black and ethnic minority women in the UK had the same access to perinatal mental health services.

To explore how the access to perinatal mental health services vary between white British and non-white British women.

A literature review was conducted. Papers were selected based on their focus on perinatal mental health service access and differences in access based on ethnicities. Most research focused on the perinatal mental health service access of white British and non-white British groups of women.

The literature review revealed that black African, Asian and minority white women had significantly lower access to community perinatal mental health services when compared to white British women. It was also found that that black African, Asian and minority White women had a higher percentage of involuntary admissions to psychiatric hospitals when compared to white British women.

The literature would suggest that there is less access to perinatal mental health for non-white British women. This suggested that the disparities that exist within perinatal physical health extend into perinatal maternal health.

No significant relationships.

Huntington’s Disease (HD) is an autosomal dominant, neurodegenerative condition with a prevalence of 10.6-13.7 per 100,000, caused by the trinucleotide CAG (cytosine, adenine, guanine) repeat expansion in the HTT gene. HD is characterized by a range of motor, cognitive, and psychiatric symptoms, the latter of which usually manifest prior to the onset of motor or cognitive disturbances. Amongst psychiatric symptoms, changes in personality are most common, followed by depression. Psychosis has a higher prevalence in those with early-onset HD.

This case report aims to demonstrate an apporach to the management of neuropsychiatric disturbances in HD as well as expose the need for development of an evidence-based apprach to treatment.

PubMed was searched for the criteria Huntington’s Disease AND Psychosis, with a secondary search for Management of Psychosis in Huntington’s Disease.

The patient is a 54-year-old male with no psychiatric history and reported past medical history of Huntington’s Disease, diagnosed one month ago. He was brought to the Psychiatric ED due to agitation and disorganized behavior at home. On admission, he demonstrated disorganized behavior, grandiose delusions, neurocognitive deficits, and reported auditory hallucinations. With the initiation of tetrabenazine and risperidone his psychiatric symptoms improved and he was able to be discharged to a long-term care facility.

Literature is scarce regarding treatment of psychiatric manifestations of HD. We catered our approach towards safe and effective symptoms management in a multidisciplinary manner. Further research is required to reach an evidence-based consensus as well as develop specific guidelines for managing psychiatric conditions related to HD.

No significant relationships.

The internshipis a period in which the studentimplements what they have learned from their training to obtain or certification and to promote their professionalintegration, the difficulty of taking initiative and the lack of self-esteemrepresenting an obstacle to their training

This is a quantitative descriptive study conducted at the different placement departments among all 2nd-year students in all sections. Our data collection was done using two questionnaires administered, one for the supervisors and the other for the students.

Theoretical Framework: Theorist Patricia Benner

According to the results found, in oursample, thereis a predominance of females 89.17%, with a sex ratio of 0.121. 88.34% are aged between 20 - 21 years and an averageage of 22.4 years. According to the interpretation of the Rosenberg Self-Esteem Scale scores, 17.5% of the trainees have a “Very Low Self-Esteem”, 47.5% have a “Low Self-Esteem”, 25.83% have an “Average Self-Esteem”, and only 9.17% have a “High Self-Esteem”. In addition, more than half of the respondents, 53.33%, state thatthey “often” have difficultytaking the initiative in the traineeshipenvironment, while 30.83% do not have such difficulty but “rarely”. Indeed, 53.33% of confirmedsupervisorssaythatthey “often” have difficultytaking the initiative in the placement environment

It isnecessary to take into account these obstacles to the trainee’s training through better psychological supervision, which could be the first steptowardssolving the problem

No significant relationships.

In the modern era of instability the problems of human adaptive abilities and mental regulation have become more and more relevant. The study of the processes of mental regulation is impossible without understanding the role of the mental structures: reflection and self-system of personality.

The purpose of the research is to study the interaction and mutual influence of the components of the self-system and reflective structures on the process of mental regulation of students.

52 first year students were offered to complete questionnaires of reflectivity (M. Grant), of self-system (S. Pantileev), as well as the authors’ method of self-regulation effectiveness of mental states. Also we used Spearman’s rank correlation coefficient.

It is revealed the positive direction of the relationships between the reflection and the components of the self-system (p ≤ 0.05). Respondents with a high level of self-system are more successful in coping with the processes of mental regulation. The indicators of internal conflict lead to a decrease in the effectiveness of self-regulation (p ≤ 0.05). The ability of a person to evaluate himself and other people has a positive effect on the success of mental regulation (p ≤ 0.05). However, the excessive desire to reflect on past events is not conducive to self-regulation.

The applied value of the research consists in the creation of a methodology that makes it possible to increase the regulatory and adaptive abilities of students during the educational process. Acknowledgements. This work was supported by the RFBR grant No. 20-013-00076.

No significant relationships.

MT has been consultant/advisor and/or speaker for Gilead Sciences, Merck Sharp & Dohme Corp, Servier, Adamed, Lundbeck, Camurus, Rovi and Molteni.

Technology-based interventions (TBIs), including computer and Internet-based interventions, mobile interventions, health applications, social media interventions, and interventions using technological devices, could become a useful, effective, accessible, and cost-effective approach (Berry et al., 2016; Firth, 2016) to complement conventional interventions for psychosis

to compare TBIs with conventional interventions for psychosis, focusing mainly on functioning and quality of life.

The systematic review preceding this work was based on 58 RCT of TBIs for psychosis. We selected the studies that analyzed functioning (N = 23) and quality of life (N = 15). We calculated the standardized mean change (SMC) and applied a three-level model because there were several effect sizes within the same study.

There were significant differences between TBIs and conventional interventions for functioning (d = 0.25, SE = 0.09, z = 2.72, p = <.01), but not for quality of life (d = 0.14, SE = 0.08, z = 1.78, p = .076) in patients with psychosis.

On average, patients who received TBIs performed better in functioning, but not in quality of life. Functioning is impaired in patients with psychosis, so TBIs should be considered a complement and efficacious intervention, highlighting the power of these type of interventions in improving some outcomes.

No significant relationships.

There is emerging evidence of heterogeneity within treatment-resistance schizophrenia (TRS), with some people not responding to antipsychotic treatment from illness onset and a smaller group becoming treatment-resistant after an initial response period. It has been suggested that these groups have different aetiologies. Few studies have investigated socio-demographic and clinical differences between early and late onset of TRS.

This study aims to investigate socio-demographic and clinical correlates of late-onset of TRS.

Using data from the electronic health records of the South London and Maudsley, we identified a cohort of people with TRS. Regression analyses were conducted to identify correlates of the length of treatment to TRS. Analysed predictors include gender, age, ethnicity, positive symptoms severity, problems with activities of daily living, psychiatric comorbidities, involuntary hospitalisation and treatment with long-acting injectable antipsychotics.

We observed a continuum of the length of treatment until TRS presentation. Having severe hallucinations and delusions at treatment start was associated shorter duration of treatment until the presentation of TRS.

Our findings do not support a clear cut categorisation between early and late TRS, based on length of treatment until treatment resistance onset. More severe positive symptoms predict earlier onset of treatment resistance.

DFdF, GKS, EF and IR have received research funding from Janssen and H. Lundbeck A/S. RDH and HS have received research funding from Roche, Pfizer, Janssen and Lundbeck. SES is employed on a grant held by Cardiff University from Takeda Pharmaceutical Comp

ASD with epileptic seizures (ES) and/or specific epileptic activity on EEG (EEG SEA) and repetitive movements and vocalizations (RMV) can be determined by different variants of genetic polymorphism or by different variants of gene expression, determined by different influences.

To study the features of the clinical phenotype of ASD in preschool and school-age children with ES, EEG SEA and RMV.

: The study group was divided 116 children aged 2-10 years with ASD into three subgroups: subgroup A - 23 children with a history of ES, subgroup B - 35 children with EEG SEA without ES, subgroup C - 19 children with ASD having EEG SEA, RMV (motor stereotypes, motor tics and/or vocal tics). The control group consisted of 39 children with ASD non a history of ES and EEG SEA.

: Children with ASD, complicated by severe and frequent ES are charactered by impaired social reciprocity and communication against the background of regression / stagnation of speech and motor skills development (aOR: 2,7 [1,7-4,8]). Disoders of communication and repetitive behavior in ASD in children of different ages are represented by different monoqualitative syndrome (phenotypes). Movement stereotypes predominated in children with ASD without ES and without EEG SEA (aOR: [1,8-7,9]). In children with ASD and EEG SEA, motor stereotypes and repetitive behavior were equally common ([SD] 2.1 -1, P =0.81).

: Disorders of social reciprocity, communication, repetitive behavior are diagnostically significant for ASD complicated by ES, ASD with EEG SEA.

No significant relationships.

Desperation for cure led to 19th century invention-- electrotherapeutic devices; replete with hyperbolic claims of cure-all, perceived ineffectiveness, and potential harm rendered the modality as quackery but were used in early brain stimulation, melancholia treatment, and cortex mapping. Here, antique devices are restored, and their electrophysiological qualities ascertained.

Determine the comparative capabilities of these devices in delivering electrostimulation and compare with modern standards to understand possible electrophysiological sequelae.

Devices known as “medical batteries” were analyzed. Power delivery utilized a “voltaic battery”, simple circuit, and a conductor wrapped around an iron core. When the circuit is energized, the core is magnetized by direct current of the battery which induces an alternating current that electrifies probes used on the body. Due to their marked age, a common 9-volt battery was exchanged for the corrosive dry cell paste batteries. Electrical parameters were then measured.

Table 1

Devices for electrotherapeutics ranged from anemic vibrations to dangerous tetany inducing shocks. Measuring the capabilities of these devices shows the robust yields possible if the original higher capacity batteries were utilized. The reality is, cure or not, the devices were surprisingly potent. It is interesting that, albeit unrefined, efficacious doses were available before modern electrification.

No significant relationships.

Though BDSM interest (bondage & discipline, dominance & submission and sadism & masochism) has proven to be quite prevalent (46.8% in recent research), there is still significant stigma surrounding it, both in general society and among mental health practitioners.

This research explores the biological mechanisms associated with a BDSM interaction in the hope to strengthen the argument that it does not belong in the psychiatric field.

The present study collected data on peripheral hormone levels, pain thresholds and pain cognitions before and after a BDSM interaction and compared these results to a control group.

show that submissives have increased cortisol and endocannabinoid levels due to the BDSM interaction and that these increases are linked. Dominants showed a significant increase in endocannabinoids associated with power play but not with pain play. BDSM practitioners have a higher pain threshold overall and a BSDM interaction will result in a temporary elevation of pain thresholds for submissives. Additionally, pain thresholds in dominants will be dependent upon their fear of pain and tendency to catastrophize pain and submissives will experience less fear of pain than the control group

Even though this is one of the first studies of its kind, several biological processes can be associated with BDSM interactions, strengthening the hypothesis of BDSM as a healthy form of intimacy and promoting its distinction from paraphilias as they are described in the DSM or ICD classifications.

No significant relationships.

Othello syndrome (OS) is a psychiatric condition consisting of delusional jealousy, and irritability. It is often associated with psychiatric or neurological disorders. The most common are delusional disorder and dementia.

The purpose of this poster is to examine the phenomenon of OS and its etiopathogenesis throughout a case report.

We present the case of a 78-year-old male patient who was treated in our department due to delusional jealousy and depressive symptoms. The patient has a medical history of cardiac events in the past, being stable at the current moment. We performed a detailed psychiatric and physical history paying special attention to personality traits in the past. The patient was administered Mini Mental State Examination and CamCog (subscale of Camdex).

According to him and his family our patient had neither episodes of jealousy nor affective disorders. His results were: 18 in MMSE and 57 in CamCog. Both compatible with a dementia course.

Attending our results we inferred that the OS belongs to a dementia clinical picture instead of a psychotic disorder. Therefore we decided to treat the patient with neuroleptics, with partial improvement, and to start cognitive stimulation treatment in a day centre and a short term psychological family intervention to help the family to understand and cope with the course of dementia. Thus, clinicians should keep in mind the possible organic origin of OS, especially in elderly persons, to develop an appropriate individual and familiar case approach.

No significant relationships.