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PubMed2006

Environmental barriers to health care among persons with disabilities--Los Angeles County, California, 2002-2003.

In 2002, an estimated 51.2 million persons in the United States (approximately 18.1% of the population) had a disability. Recent data suggest that substantial disparities in health behaviors and overall health status exist between persons with and without disabilities. Nonetheless, when they have access to adequate health care, persons with disabilities can lead healthy lives. The World Health Organization's International Classification of Functioning, Disability, and Health stresses the importance of environment (e.g., physical environment, attitudes of others, or policies) as either a barrier or facilitator in the daily activities of persons with disabilities. In addition, increasing access to health and wellness treatment programs for persons with disabilities and reducing the proportion of persons with disabilities who report environmental barriers to participation in daily activities are goals of Healthy People 2010 (objectives 6-10 and 6-12). However, few population-based studies have explored how environment affects the lives of those with disabilities. To determine the prevalence of disability among persons in Los Angeles County, California, and assess the effects of environmental barriers on these persons, residents were surveyed during 2002-2003. The results of that survey suggested that persons with physical or sensory disabilities experienced several environmental barriers and that the prevalence of barriers varied by demographic characteristics, household income, and severity of disability. To improve quality of life among persons with disabilities, public and private health agencies should implement measures to remove environmental barriers to health care and other services.

Adolescent↗
PubMed1998

Personality in patients with affective disorders and their relatives.

BACKGROUND: In studies of both patients and high-risk subjects, particular patterns of personality have been found to be associated with affective disorders. Neuroticism and features of the melancholic type of personality seem to be risk factors for depression while premorbid features of the manic type of personality predominate in patients with more manic than depressive episodes. While neuroticism prevails in the majority of mental disorders, the 'affective' personality variants appear to be more specifically associated with affective disorders. METHODS: Personality features were investigated in 122 recovered patients with affective disorders, 58 first-degree relatives (high-risk subjects (HR)) and in the respective control groups (n=48; n=29). Patients were subdivided into: unipolar depression (melancholic subtype); bipolar II; bipolar I with more depressive episodes and bipolar I with more manic episodes. Personality measures were based on the Biographical Personality Interview (BPI) and the Munich Personality Test (MPT). RESULTS: The melancholic personality type (BPI) decreased from the unipolar depressives to the mainly manic group, while features of the manic type increased. MPT scores failed to discriminate between subgroups of patients. HR were significantly more introverted and had a stronger orientation towards social norms than controls according to the MPT, and showed a tendency towards the melancholic type according to the BPI. LIMITATIONS: The sizes of some groups or subgroups are relatively small. Therefore, they have to be enlarged in the continuation of the study so as to increase the power of the statistical tests and thus to ascertain the robustness of the results. CONCLUSION: Features of the typus melancholicus seem to be a risk factor for depression. The identification of highly predictive risk factors provides an opportunity for the development of prevention programs.

Adult↗
PubMed2006

Tryptophan hydroxylase-2 gene variation influences personality traits and disorders related to emotional dysregulation.

Variation in the tryptophan hydroxylase-2 gene (TPH2) coding for the rate-limiting enzyme of serotonin (5-HT) synthesis in the brain modulates responses of limbic circuits to emotional stimuli and has been linked to a spectrum of clinical populations characterized by emotional dysregulation. Here, we tested a set of common single nucleotide polymorphisms (SNPs) in and downstream of the transcriptional control region of TPH2 for association with personality traits and with risk for personality disorders in two cohorts comprising of 336 healthy individuals and 420 patients with personality disorders. Personality dimensions were assessed by the Tridimensional Personality Questionnaire (TPQ) and the revised NEO Personality Inventory (NEO-PI-R). Personality disorders were diagnosed with the Structured Clinical Interview of DSM-IV and were allocated to clusters A, B, and C. Individual SNP and haplotype analyses revealed significant differences in genotype frequencies between controls and cluster B as well as cluster C patients, respectively. In both patient groups, we observed overrepresentation of T allele carriers of a functional polymorphism in the upstream regulatory region of TPH2 (SNP G-703T, rs4570625) which was previously shown to bias responsiveness of the amygdala, a structure critically involved in emotionality. Furthermore, significant effects of TPH2 variants on anxiety-related traits defined primarily by the TPQ Harm Avoidance were found in healthy individuals. The results link potentially functional TPH2 variants to personality traits related to emotional instability as well as to cluster B and cluster C personality disorders. These findings implicate alterations of 5-HT synthesis in emotion regulation and confirm TPH2 as a susceptibility and/or modifier gene of affective spectrum disorders.

Adolescent↗
PubMed2000

Psychiatric symptomatology in borderline and other personality disorders: dissociation and fragmentation as mediators.

This study considered the role of dissociation and personality fragmentation as psychological factors that might distinguish borderline and personality disorder (BPD) patients, and that might explain why BPD patients have higher levels of other psychiatric symptomatology than those with other personality disorders. Two groups of personality-disordered patients (personality disorders including BPD; personality disorders other than BPD) completed measures of dissociation, personality fragmentation, and psychiatric disturbance. The BPD group had higher levels of a number of aspects of psychiatric symptomatology. Those differences were mediated by aspects of dissociation. Personality fragmentation differentiated the two groups but was not related to the higher levels of other aspects of psychiatric disturbance. Treating the syndrome of BPD may depend on addressing both dissociation and personality fragmentation. In contrast, reducing the level of comorbid psychiatric disturbance in BPD is likely to be more strongly dependent on reducing levels of different aspects of dissociation. Psychotherapeutic techniques and targets for achieving such change are discussed.

Adult↗
PubMed2004

Personality characterizations of outpatients with schizophrenia, schizophrenia with substance abuse, and primary substance abuse.

The study extended previous research on the relationship between personality traits and Axis I disorders. It examined personality differences between individuals diagnosed with schizophrenia and substance abuse and also included individuals dually diagnosed with both schizophrenia and substance abuse. Comparisons were made with respect to characteristics of both normal personality, as measured by the NEO Five-Factor Inventory (NEO-FFI), and disordered personality, as measured by the Millon Multiaxial Personality Inventory. On the NEO-FFI, all groups differed significantly from the NEO-FFI normative sample on at least three personality domains. As predicted, the dual diagnosis group showed the most personality deviance and pathology. The schizophrenia group was primarily distinguished by higher levels of agreeableness, whereas the substance abuse group was more extroverted and showed a prominence of Cluster B personality patterns. An unexpected finding was an interaction between diagnostic group and age, such that older relative to younger individuals in the single diagnosis groups showed greater personality adaptivity and moderation, whereas older individuals in the dual diagnosis group showed less.

Adult↗
PubMed2007

Childhood antecedents of personality disorder.

PURPOSE OF REVIEW: Given the substantial continuity of personality and axis I psychopathology from childhood to adult life, the present review explores whether and how recent research findings support the notion that personality disorders have their developmental precipitants in childhood. Potential childhood personality disorder antecedents will be reviewed from different research areas to enhance an insight into the genesis of a major set of adult psychiatric disorders with profound impact on the daily life. RECENT FINDINGS: There exists increasing evidence that personality disorders have their origins in early years of life at the observable symptomatic, biological, and genetic levels. A clear need for prospective (behavior genetic) studies, however, exists that will ultimately verify how and when childhood personality disorder features turn into adult maladaptive trait patterns. It is further suggested that these designs require a comprehensive taxonomy for the description of personality disorder antecedents in a developmentally appropriate way. SUMMARY: The call for a developmental perspective on adult personality disorders in recent debates on the construction of Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, has created new avenues for an integrative longitudinal perspective on personality disorders and should stimulate child psychiatrists to consider the significance of emerging personality disorder symptoms at a young age.

Activities of Daily Living↗
PubMed1994

A longitudinal family study of personality change and stability.

The 19-year stability of personality from late adolescence to early adulthood was examined in a sample of 121 men and women who had participated in an earlier study of articulation and language development (Templin, 1966; Templin & Glaman, 1976). Personality was assessed using the Eysenck Personality Inventory (EPI). At the time of retest, personality data were also collected from the participants' mothers. Modest stability of individual differences in personality was observed, consistent with the literature on longitudinal studies of personality during late adolescence and early adulthood. For the Extraversion and Neuroticism scales, offspring means decreased significantly over the 19-year period such that the offspring means were closer to the mean scores of their mothers when they were followed up in adulthood as compared to their first testing in adolescence. There was, however, no change in mother-offspring resemblance from the initial test to retest. Mother-offspring resemblance appears to be due largely to aspects of personality that were stable from adolescence to early adulthood. Implications of these results are discussed in relation to the findings of previous longitudinal studies of adult personality and recent behavioral genetic evidence regarding personality change and stability.

Adolescent↗
PubMed1993

Development of personality disorders in children and adolescents with obsessive-compulsive disorder. A 6- to 22-year follow-up study.

Forty-seven people with admissions in childhood for obsessive-compulsive disorder (OCD) and 49 child psychiatric controls were followed up in young adulthood and assessed for DSM-III-R personality disorders with the Structured Clinical Interview for DSM-III-R Personality Disorders. The number of personality disorders in OCD patients did not differ significantly from the number in controls. The most common personality disorder was avoidant personality disorder (significantly more frequent than in controls), whereas obsessive-compulsive personality disorder (OCPD) was not found more often in the OCD group. Subjects with OCD in adulthood seemed to have OCPD more often than childhood OCD patients with no OCD at follow-up. In the whole group, histrionic personality disorders were more common in women than in men and OCPD more common in men than in women, whereas borderline personality disorder was most common among women in the OCD group. The presence of a personality disorder in adulthood could not be correlated with such childhood factors as social background, symptoms or age of onset of OCD.

Adolescent↗
PubMed1998

Comorbidity between obsessive-compulsive disorder (OCD) and personality disorders.

The aims of the present study were to examine the frequency of personality disorders in 36 patients with obsessive-compulsive disorder (OCD), and to investigate whether patients with a coexisting personality disorder could be characterized by certain personality traits assessed by means of the Karolinska Scales of Personality (KSP). In total, 27 (75%) of the OCD patients fulfilled the DSM-III-R criteria for a personality disorder, and 13 patients (36%) had an obsessive-compulsive personality disorder. Subjects with a comorbid personality disorder had significantly higher scores on most of the KSP scales, including all anxiety scales, as well as scales measuring indirect aggression, irritability, guilt and detachment, whereas subjects without personality disorders did not differ significantly from healthy controls with regard to personality traits.

Adult↗
PubMed2002

Characterizing affective instability in borderline personality disorder.

OBJECTIVE: This study sought to understand affective instability among patients with borderline personality disorder by examining the degree of instability in six affective domains. The authors also examined the subjective intensity with which moods are experienced and the association between instability and intensity of affect. METHOD: In a group of 152 patients with personality disorders, subjective affective intensity and six dimensions of affective instability were measured. The mean scores for lability and intensity for each affective domain for patients with borderline personality disorder were compared with those of patients with other personality disorders through analyses that controlled for other axis I affective disorders, age, and sex. RESULTS: Greater lability in terms of anger and anxiety and oscillation between depression and anxiety, but not in terms of oscillation between depression and elation, was associated with borderline personality disorder. Contrary to expectation, the experience of an increase in subjective affective intensity was not more prominent in patients with borderline personality disorder than in those with other personality disorders. CONCLUSIONS: By applying a finer-grained perspective on affective instability than those of previous personality disorder studies, this study points to patterns of affective experience characteristic of patients with borderline personality disorder.

Adult↗
PubMed2002

The etiology of personality function: the University of British Columbia Twin Project.

The UBC Twin Project is an on-going study of personality and personality disorder that has collected personality data on approximately 1000 adult volunteer twin pairs. The primary purpose of the study is to develop and validate measures of the major forms of personality disorder as a quantitative alternative to the classificatory system first proposed by the DSM-III using the standard methods of personality and behavioural genetics research. To date, the study has explored the univariate and multivariate relationships between the major personality and personality disorder inventories, and their relationships to other psychopathologies including the mood and anxiety disorders and key psychological variables, such as cognitive ability, attachment and attitudes. The results have several implications for personality and personality disorders, most notably a rationalized diagnostic/nosological system to enhanced measurement instruments that index and reflect the influence of specific genetic and environmental influences.

Adult↗
PubMed2003

Evaluating facet-level predictions and construct validity of depressive personality disorder.

The purpose of this study was to evaluate Widiger, Trull, Clarkin, Sanderson, and Costa's (1994) facet-level predictions about depressive personality disorder, thereby evaluating the validity of the depressive personality disorder construct. A sample of 67 patients was collected from two treatment facilities. Participants completed three different measures of depressive personality disorder and the NEO-PI-R (Costa & McCrae, 1992). All measures of depressive personality disorder were significantly correlated with three of the four predicted facets: Anxiety, Depression, and Self-Consciousness. All three measures were significantly correlated with the Vulnerability, Warmth, Gregariousness, Assertiveness, Positive Emotions, Actions, Trusts, and Achievement Striving facets. A series of regression analyses was performed. Two of the predicted facets--Self-Consciousness and Tendermindedness--were able to uniquely account for variance in all three measures of depressive personality across most analyses. However, there was a lack of specificity across other facets in predicting the depressive personality disorder. A facet-level understanding of depressive personality disorder appears to be empirically justified, and the validity of the depressive personality disorder further supported. Additional work is needed on improving the measurement of depressive personality disorder.

Depressive Disorder↗
PubMed2004

The prevalence of diabetic retinopathy among adult type 1 diabetic persons in the United States.

OBJECTIVE: To estimate the US prevalence of diabetic retinopathy (DR) among persons with type 1 diabetes mellitus (DM). METHODS: Prevalence data from the New Jersey 725 and Wisconsin Epidemiologic Study of Diabetic Retinopathy were used to estimate the prevalence of DR by age, gender, and race among persons 18 years and older having type 1 DM diagnosed before age 30 years. Severity of DR was determined via masked grading of 7-field stereoscopic fundus photographs. Any DR was defined as retinopathy severity level of 14 or more; and vision-threatening retinopathy, as retinopathy severity level of 50 or more, the presence of clinically significant macular edema, or both. The estimates of the prevalence of DR among persons with type 1 DM were applied to the estimated number of persons with type 1 DM diagnosed before age 30 years in the 2000 US population to obtain prevalence estimates of DR due to type 1 DM in the general population. RESULTS: Among 209 million Americans 18 years and older, an estimated 889 000 have type 1 DM diagnosed before age 30 years. Among persons with type 1 DM, the crude prevalences of DR of any level (74.9% vs 82.3% in black and white persons, respectively) and of vision-threatening retinopathy (30.0% vs 32.2%, respectively) are high. The prevalence of DR due to type 1 DM diagnosed before age 30 years in the general population 18 years and older is estimated at 767 000 persons having DR of any level (0.37%), and 376 000 persons having vision-threatening retinopathy (0.18%). CONCLUSION: Retinopathy due to type 1 DM is an important public health problem in the United States, affecting 1 per 300 persons 18 years and older, and 1 per 600 persons with advanced, vision-threatening retinopathy.

Adolescent↗
PubMedDate not supplied

Adverse events associated with prescription drug cost-sharing among poor and elderly persons.

CONTEXT: Rising costs of medications and inequities in access have sparked calls for drug policy reform in the United States and Canada. Control of drug expenditures by prescription cost-sharing for elderly persons and poor persons is a contentious issue because little is known about the health impact in these subgroups. OBJECTIVES: To determine (1) the impact of introducing prescription drug cost-sharing on use of essential and less essential drugs among elderly persons and welfare recipients and (2) rates of emergency department (ED) visits and serious adverse events associated with reductions in drug use before and after policy implementation. DESIGN AND SETTING: Interrupted time-series analysis of data from 32 months before and 17 months after introduction of a prescription coinsurance and deductible cost-sharing policy in Quebec in 1996. Separate 10-month prepolicy control and postpolicy cohort studies were conducted to estimate the impact of the drug reform on adverse events. PARTICIPANTS: A random sample of 93 950 elderly persons and 55 333 adult welfare medication recipients. MAIN OUTCOME MEASURES: Mean daily number of essential and less essential drugs used per month, ED visits, and serious adverse events (hospitalization, nursing home admission, and mortality) before and after policy introduction. RESULTS: After cost-sharing was introduced, use of essential drugs decreased by 9.12% (95% confidence interval [CI], 8.7%-9.6%) in elderly persons and by 14.42% (95% CI, 13.3%-15.6%) in welfare recipients; use of less essential drugs decreased by 15.14% (95% CI, 14.4%-15.9%) and 22.39% (95% CI, 20.9%-23.9%), respectively. The rate (per 10 000 person-months) of serious adverse events associated with reductions in use of essential drugs increased from 5.8 in the prepolicy control cohort to 12.6 in the postpolicy cohort in elderly persons (a net increase of 6.8 [95% CI, 5.6-8.0]) and from 14.7 to 27.6 in welfare recipients (a net increase of 12.9 [95% CI, 10.2-15.5]). Emergency department visit rates related to reductions in the use of essential drugs also increased by 14.2 (95% CI, 8.5-19.9) per 10 000 person-months in elderly persons (prepolicy control cohort, 32.9; postpolicy cohort, 47.1) and by 54.2 (95% CI, 33.5-74.8) among welfare recipients (prepolicy control cohort, 69.6; postpolicy cohort, 123.8). These increases were primarily due to an increase in the proportion of recipients who reduced their use of essential drugs. Reductions in the use of less essential drugs were not associated with an increase in risk of adverse events or ED visits. CONCLUSIONS: In our study, increased cost-sharing for prescription drugs in elderly persons and welfare recipients was followed by reductions in use of essential drugs and a higher rate of serious adverse events and ED visits associated with these reductions.

Adult↗
PubMed2000

Psychosocial impact of predictive testing for Huntington disease on support persons.

Although a support person is required by many centers during the predictive testing protocol for Huntington disease (HD), little is known about the psychosocial impact of predictive testing on persons serving in this role. Eighteen adults who were support persons during predictive HD testing in one HD testing center completed a semi-structured interview to describe their experiences. Participants also completed the Impact of Events Scale (IES) to assess perceptions of emotional distress regarding predictive testing and the State Anxiety Scale of the State Trait Anxiety Inventory (STAI) to assess anxiety regarding the interview. State anxiety scores were similar to normative values for working adults. Although support persons for individuals with a positive gene test scored higher on all measures of the IES than those who were support persons for persons with negative gene mutation results, these differences were not statistically significant. Support persons identified aspects of the protocol that did not fit their needs, perceived the testing process as extending into subsequent caregiving responsibilities when the test was positive, and were uninformed regarding specific caregiving issues for family members with the gene mutation. The impact of the testing experience appeared to be most intense for those support persons who were at-risk offspring of probands. Findings suggest that individual assessment of support person needs may allow more focused counseling of support persons during predictive genetic HD testing. Collaboration with health care providers may facilitate symptom management following testing.

Adaptation, Psychological↗
PubMedDate not supplied

Symptomatic cervical disc herniation following a motor vehicle collision: return to work comparative study of workers' compensation versus personal injury insurance status.

BACKGROUND CONTEXT: Patients with approved workers' compensation injuries receive guaranteed compensation for the duration of their injury, whereas patients with personal injury claims are only compensated, if at all, at the time of a successful settlement or trial verdict at a time point distant from their injury. PURPOSE: This study compares the financial impact and loss of work patterns due to a workers' compensation (WC) claim or personal injury in patients with a symptomatic cervical disc herniation resulting from a motor vehicle collision. STUDY DESIGN: A prospective study of patients who were seen by a single spine specialist between 1/2/96 and 9/1/01. PATIENT SAMPLE: A consecutive evaluation of 531 patients who were treated for a cervical pain syndrome caused by a motor vehicle collision. OUTCOME MEASURES: Mechanism of injury and insurance type, ie, workers' compensation or personal injury, was recorded for each patient as well as treatment response and return to work patterns. The data were analyzed using the two-way Z test. METHODS: All patients were managed in a similar manner with noninvasive treatment initially, followed by injections, and finally surgical intervention in those who failed conservative measures. Return to work rates and work disability were determined at either final follow-up or at the last doctor's visit before loss to follow-up. RESULTS: 270 of 531 patients were diagnosed with a symptomatic one or two level disc herniation by a cervical magnetic resonance imaging scan. Fifty-four patients were insured through the workers' compensation board, and 216 reported their crash as a personal injury claim. In the WC group the work disability at 3 months follow-up revealed a cumulative 2,262 total lost days of work (average 37.1 days per person). At the point of maximal medical improvement (MMI) or 2-year follow-up, total days lost from work were 7,107 (average 131.6 days per person.) In the personal injury non-WC group, the 3-month follow-up of lost days of work was 1,093 days (average 5.1 days per person.) At 2 years follow-up, the total lost days of work were 6,206 (average 28.7 days per person.) CONCLUSIONS: Participants compensated through the workers' compensation system demonstrated a significant loss of days of work as compared with injured patients who received compensation by other means. This may be a reflection of the guaranteed method of compensation afforded to WC patients as opposed to patients who receive no form of financial support (i.e., personal injury) during the recuperative process. Further analysis as to injury severity and a stratification of non-workers' compensation reimbursement methods are needed to further improve the validity of this study.

Accidents, Traffic↗
PubMed1995

Differences between persons with right or left cerebral vascular accident on the Assessment of Motor and Process Skills.

OBJECTIVE: Persons with right and left cerebral vascular accident (RCVA and LCVA) differ in terms of discrete impairments, but there is limited information with regard to how such impairments translate into differences in disability. The following hypotheses were tested: (1) persons with stroke have lower instrumental or domestic activities of daily living (IADL) ability than do matched nondisabled controls, (2) persons with RCVA do not differ from persons with LCVA in IADL ability, and (3) persons with RCVA and LCVA differ in specific motor and process skills that affect IADL performance. DESIGN: Descriptive comparison. SETTING: Subjects were tested in settings where rehabilitation services were received (home or clinic). SUBJECTS: 71 persons with RCVA, 76 persons with LCVA, and 83 community-living nondisabled individuals drawn from the Assessment of Motor and Process Skills (AMPS) database, matched for age, gender, and number of tasks performed. MAIN OUTCOME MEASURE: AMPS, designed to measure type and severity of impairments manifested in the context of IADL performance. The AMPS was administered to all subjects in accordance with standardized testing procedures. RESULTS: The two stroke groups did not differ significantly in IADL ability, but both stroke groups had significantly lower IADL performance than did the nondisabled subjects. On the AMPS motor scale, persons with RCVA demonstrated greater impairment in pacing, transporting, and coordinating two body parts. Persons with LCVA demonstrated greater impairments in calibrating movements. No differences were found between the two groups in AMPS process skills. CONCLUSIONS: Persons with RCVA and LCVA have hemisphere-specific differences in motor impairments, but do not differ significantly in IADL ability.

Activities of Daily Living↗
PubMed2002

Person-centered approach to care, teaching, and research in fibromyalgia syndrome: justification from biopsychosocial perspectives in populations.

OBJECTIVES: To describe complex interactions of multiple factors believed to contribute to fibromyalgia syndrome (FMS) at a person-centered level to enhance approaches to care, teaching, and research. The main factors addressed were central nervous system sensory sensitization, autonomic nervous system (ANS) activation, neurohumoral perturbations, and psychosocial and environmental stressors. A person-centered approach is defined as attention to major biopsychosocial issues of affected individuals. METHODS: Literature on classification, mechanistic pathways, course and outcomes, and management of FMS was reviewed to assess applications of person-centered approaches to care, teaching, and research. Various biopsychosocial influences were considered in relation to the heterogeneous subjective manifestations of this illness, including central hyperalgesia, ANS and other neurohumoral perturbations, functional hyperexcitability, nonrestorative sleep, and psychologic distress. RESULTS: A person-centered approach to FMS can expand on and strengthen traditional biomedical concepts. Adding such a focus can help to untangle current controversies in the course, outcomes, and treatment of FMS. A person-centered approach can also help in the subgrouping of affected patients for greater specificity in care programs and in improved clinical investigations. In the biomedical model, diverse symptoms of FMS are often addressed separately and apart from their interconnectedness and linkages to the patient's individualized biopsychosocial factors. However, the causes of FMS symptomatology are not likely to be caused by uniform biologic abnormalities across populations. Rather, the syndrome likely results from personal reactivities to varied multifactorial biopsychosocial influences. Common denominators among individuals may include varying degrees of ANS activation (or personal susceptibility to ANS activation), nonrestorative sleep, negative affectivity, and other central pain sensitization mechanisms, among the pathways reviewed. CONCLUSIONS: Innovative analytical methodologies will need to be developed to more effectively investigate complex interacting biopsychosocial dynamics at a person-centered level, including qualitative research, and multifactorial and multilevel techniques. Adding person-centered approaches to biopsychosocial concepts of FMS promises to show new physiopathogenetic insights and more effective treatment than current biomedical models alone. Person-centered approaches enhance patient-physician relationships and help prioritize patients' goals in mutually derived treatment plans.

Adolescent↗