INTERNATIONAL MENTAL HEALTH NETWORK, LTD.
P.O. Box 578
Poway, CA 92074-0578
Phone: (858) 486-9745
Fax: (858) 486-9760
E-mail: nac01@juno.com
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Test Description
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S A M P L E P R O F I L E
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BECK ANXIETY INTERPRETIVE PROFILE
International Mental Health Network, Ltd.
TC: 134
FACILITY ID: 123
PATIENT ID: 1231234
SOCIAL SECURITY NUMBER: 123-45-6789
LAST NAME: Doe
FIRST NAME: John
GENDER: Male
AGE: 35
RACE: White
HIGHEST GRADE COMPLETED: 12
MARITAL STATUS: Married
OCCUPATION: Teacher
CURRENT EMPLOYMENT STATUS: Employed
INPATIENT/OUTPATIENT: Outpatient
NUMBER OF INPATIENT ADMISSIONS: 1
NUMBER OF OUTPATIENT ADMISSIONS: 2
DATE OF LAST DISCHARGE: 04/01/1998
YEARS OF ALCOHOL USE: 5
YEARS OF DRUG USE: 2
SUBSTANCES USED LAST 2 YEARS: Marijuana
Cocaine
SOURCE OF REFERRAL: Physician
FINANCIAL CLASS: HMO
DATE OF LAST PHYSICAL EXAM: 01/01/1998
ADMISSION DATE: 08/01/1998
DATE OF TESTING: 09/01/1998
BECK SCORE: 31
____________________________________________________________________________
This clinical profile is a confidential assessment report intended for use
by professional staff only. Its purpose is to provide clinicians with a
comprehensive clinical picture of each patient under their care, and to help
maximize therapeutic effectiveness through careful assessment, treatment
planning, relapse prevention, and aftercare. Recommendations made in this
profile do not imply that existing clinical approaches should be replaced or
modified. Their intent is to further promote individualization of patient
treatment planning, multidisciplinary approach to treatment of each patient,
patient's participation in own recovery process, and continuous monitoring
and reassessment of the therapeutic process for mutual benefit of both the
patient and clinical staff. Statements in this profile are hypotheses for
further consideration in combination with other clinical factors utilized
in therapy. This profile is intended for use by a multidisciplinary clinical
team.
____________________________________________________________________________
________________________________ _______________ ______________
Reviewing Professional Title Date
COPYRIGHT (C) 1998 IMH-NETWORK ISBN 1-58028-074-9
_______________________________________________________________________________
Patient: John Doe 09/01/1998
PROFILE CHARACTERISTICS
John Doe is a 35 years old male who, during the administration of Beck
Anxiety Inventory, reported a number of clinical symptoms indicating a high
level of anxiety, and a presence of a clinically valid disorder.
It is possible that John Doe may experience anxiety in various degrees,
and for various reasons. This could also be related to a variety of causes.
In a clinical situation, although often nonspecific as a symptom, anxiety may
be an indicator of a presence of significant underlying pathology, and it if
not addressed and treated properly, it can exacerbate and easily inhibit
various aspects of his rehabilitative process.
Since all anxiety disorders can have medical cause or component, it is
highly recommended that John Doe receives a comprehensive medical exam prior
to initiating strictly psychological or psychiatric care. This could help
rule out biological or environmental etiology.
Symptoms of anxiety reported by John Doe should be assessed for duration,
constancy, and intervals during which it appears to diminish or cease
completely. Possible precipitating factors should be identified such as
stress, lack of sleep, substance abuse, smoking, excessive caffeine intake,
or other types of behavioral patterns which may be the causative factors.
Also, his own method of coping and alleviation should be identified. A
complete medical history should be obtained from him with an emphasis on drug
use. If required, a physical examination should be performed with a focus on
his complaints which may triggered or aggravated by anxiety.
Due to the level of anxiety reported by John Doe it is recommended that
his vital signs should be taken and the chief complaint identified. Symptoms
such as temporary losses of consciousness, sudden sharp pain, appearance of
sudden confusion or fugue states, dizziness, chest pains, etc. should be
regarded as indicators of possible physiological pathology.
Should psychotherapy be a treatment of choice for him, it should be
oriented toward resolving the presence of both acute, and eventually chronic
anxiety states. Psychosocial side effects of such anxiety are often shown in
poor planning skills, high stress levels, and difficulty in relaxing.
Reducing his stress and increasing overall coping skills may prove to be
beneficial in helping him. Individual therapy is the recommended treatment
modality. Medication should be prescribed if the anxiety symptoms are serious
and interfering with normal daily functioning. Psychotherapy and relaxation
techniques can't be worked on effectively if John Doe is overwhelmed by
anxiety or cannot concentrate.
Tricyclic antidepressants often are an effective treatment alternative to
benzodiazepines and may be a better choice over a longer treatment period.
Medication for this disorder should only be used to treat acute symptoms of
anxiety. Medication should be tapered off when it is discontinued.
An ability to discern and respond appropriately to real danger should be
maintained. Complications are probably more common in more severe or more
chronic cases and may include any of the following:
- fatigue and/or excessive daytime sleepiness due to sleep disturbance
and/or sedating medications;
- social isolation due to phobic avoidance or stigmatization;
_______________________________________________________________________________
Patient: John Doe 09/01/1998
- poor academic or vocational performance due to impaired concentration;
- unnecessary medical procedures or treatments for somatization;
- secondary depression, comorbidity, and exacerbation of other
disorders;
- "contagion" of anxiety within family, creating family problems or
exacerbating preexisting family difficulties;
- impaired self-esteem and distorted self-concept, impacting on
continuing development.
Many support groups exist within communities throughout the world which
help individuals with this disorder share their common experiences and feelings
of anxiety. John Doe should first be able to tolerate and effectively handle a
social group interaction.
_______________________________________________________________________________
Patient: John Doe 09/01/1998
DIAGNOSTIC CONSIDERATIONS
These diagnostic impressions are formulated on the basis of clinical
characteristics of this profile type, and symptoms presented by the patient
at the time of administration of this assessment. They are intended to
provide clinical staff with a diagnostic framework within which finaldiagnoses
should be formulated based on ongoing clinical observations, multidisciplinary
assessment, and continuing interactions with John Doe throughout the treatment
process.
As each type of psychopathology is based on very dynamic psychological
processes, John Doe's clinical picture may change along the course of the
therapeutic continuum. Such changes could be caused by the nature of the
disorder, individual differences among patients, types of psychiatric
comorbidities, a possibility of patient's negative reaction to treatment,
specific issues inherent in treatment philosophy, nature of operant clinical
modalities, an numerous other complex factors.
DSM-IV DIAGNOSTIC IMPRESSIONS
300.3 - Obsessive-Compulsive Disorder;
300.01 - Panic Disorder Without Agoraphobia;
293.89 - Anxiety Due to a General Medical Condition;
- Substance Induced Anxiety Disorder;
In order to maximize the John Doe's rehabilitative potential, the initial
diagnostic impressions about him should be carefully scrutinized and closely
monitored throughout the entire treatment process, allowing for appropriate
changes in diagnostic framework when they become clinically indicated and
necessary.
At times, it is possible that a diagnostic uncertainty may exist and it
may be difficult to make a final diagnosis. Only partial information may be
presented by the patient, or the disorder may be early in its course and may
not yet have revealed its nature. It is also possible that a patient may
present a mixed symptom picture that does not fit any specific diagnosis.
In cases where clinical evidence exists favoring a particular diagnosis,
such syndrome can be identified as the provisional diagnosis. If a mixed
syndrome persists, or if symptoms do not satisfy the criteria for a specific
diagnosis but an anxiety disorder should be identified, a diagnosis of
anxiety disorder not otherwise specified (NOS) should be considered.
Clinicians should be reminded that these initial diagnostic impressions
are based on the findings of a single psychometric instrument. Should a
diagnostic discrepancy, or a contradiction, exist between any single measure
and the complete spectrum of the assessment process, the final diagnostic
impressions about John Doe should be formulated based on the results of the
total assessment battery, rather than an individual test.
_______________________________________________________________________________
Patient: John Doe 09/01/1998
COGNITIVE SPECTRUM OF SYMPTOMS
The level and magnitude of affective symptoms presented by John Doe
indicate that a possibility exists that some cognitive disturbances may also
be present. Consistent with Beck's theory about the role of cognitive
distortions in depressive and anxiety disorders, it is clinically advisable
that John Doe be further assessed for the following symptomatology:
____ impaired attention ____ poor concentration
____ forgetfulness ____ errors in judgment
____ preoccupation ____ blocking of thoughts
____ decreased perceptual field ____ reduced creativity
____ diminished productivity ____ confusion
____ hypervigilance ____ self-consciousness
____ loss of objectivity ____ fear of losing control
____ frightening visual images ____ fear of injury or death
____ objects seem distant and blurry ____ environment seems different
____ feelings of unreality ____ self-consciousness
____ confusion ____ inability to control thinking
____ distractibility ____ blocking
____ difficulty in reasoning ____ loss of perspective
____ cognitive distortion ____ fear of inability to cope
____ fear of mental disorder ____ frightening visual images
____ fear of negative evaluation ____ repetitive fearful ideation
Positive findings of cognitive pathology should be further examined for
history and duration, and a comprehensive neuropsychological evaluation may
be required if the symptoms exceed the levels typical for this score, or if
John Doe manifests below average treatment responsiveness, or a negative
treatment reaction.
_______________________________________________________________________________
Patient: John Doe 09/01/1998
SUSCEPTIBILITY TO TREATMENT
When considering treatment options and approaches for John Doe, it is
significant to also consider conditions under which his rehabilitative
efforts and possibility of effective recovery shall be maximized.
In view of the high quantity of the symptoms reported by John Doe, and
possible limitations of this instrument, further assessment is strongly
recommended and it should include a thorough consideration of the severity
and chronicity of his current disorder, systemic distribution of symptoms,
extent, degree and length of past and present dysfunctionality, and
quantity, type, and severity of clinical impairments experienced by him.
John Doe's previous health record, appropriateness and frequency of
utilization of health care resources, adherence and compliance with
treatment, and success or failure of the previous episodes of care will
provide useful information based on which confirmation of necessity, and
predictions about success or failure of his treatment can be made.
Among additional factors which need to be considered are John Doe's
understanding of need for professional assessment and acceptance and
compliance with complexity of such assessment, manifested by him during this
initial phase of clinical interaction with the professional staff.
Further assessment should include his understanding and acceptance of
rationale for proposed treatment, his willingness to participate in and
adhere to treatment regimen(s), understanding of risks, benefits and
alternatives to treatment, and specifically, his ability to rationally weigh
and communicate above considerations.
If John Doe has been previously treated for same or similar emotional and
psychological problems, documentable rehabilitative progress in previous
episodes of care are of great significance in predicting the outcomes of
current, and possibly future treatment efforts.
John Doe' participation in formulation, assessment and implementation of
his treatment goals should be given special attention. Of detrimental
importance will be his ability for and honesty of disclosure during the
entire treatment continuum, realistic self-appraisal which is not in gross
excess of assessed disturbance(s), and a development of realistic, measurable
criteria of goal assessment. John Doe's anticipation of treatment success
should be another factor to be considered in the assessment of his
susceptibility to treatment and his rehabilitative potential.
_______________________________________________________________________________
Patient: John Doe 09/01/1998
TREATMENT CONSIDERATIONS
Level and intensity of clinical symptoms reported by John Doe indicate
that treatment for his disorder should definitely be required, and an
appropriate treatment approach developed and implemented as soon as possible.
It is frequently the case that patients who are experiencing similar levels
of disturbances do not spontaneously improve and recover without a
comprehensive treatment intervention, and a longitudinal adherence to the
treatment regimen.
Treatment approach for John Doe's level of anxiety could be varied and a
number of approaches may work equally well. Typically the most effective
treatment will be an approach which incorporates both psychological and
psychopharmacologic approaches. Medications, while usually helpful in
treating the bodily symptoms of acute anxiety (e.g., panic attacks), are best
used for this disorder as a short-term treatment only (a few months).
Psychotherapy should be oriented toward combating John Doe's low-level,
ever-present anxiety. Such anxiety may often be accompanied by poor planning
skills, high stress levels, and difficulty in relaxing. Relaxation skills can
be taught either alone or with the use of biofeedback. Education about
relaxation and simple relaxation exercises, such as deep breathing, are
excellent places to begin therapy. While biofeedback is beneficial, it is not
required for effective relaxation to be taught to most people. Progressive
muscle relaxation and more general imagery techniques can be used as therapy
progresses. Teaching him how to relax, and the ability to do it in any place
or situation is vital to reducing his low-level anxiety levels.
From the onset of therapy, John Doe should be encouraged to set a regular
schedule to practice relaxation skills learned in session, at least twice a
day for a minimum of 20 minutes (although more often and for longer periods
of time is better). Reducing stress and increasing overall coping skills may
also be beneficial in helping him find a better balance in his life between
self-enrichment, family, significant others, and work.
Individual therapy is usually the recommended treatment modality. Many
times people who present this level of anxiety, like John Doe, feel a bit
awkward discussing their anxiety in front of others, especially if they are
less than accepting. A clear distinction should be made at the onset of the
evaluation to differentiate his type of anxiety disorder from social phobia,
however, and the appropriate diagnosis should be made.
The minor tranquilizers or anxiolytics are excellent means of treating
anxiety symptoms. However, they do not appear to block the actual process of
panic attacks. Second, certain of the tricyclic antidepressants have been
used in some patients, often in doses well below those used for the Affective
Disorders.
In addition, insight psychotherapy should be considered for those
patients who fulfill the criteria for this form of treatment; with the acute,
disabling symptoms under pharmacological control, such patients may be helped
to resolve the psychological conflicts that frequently play a significant
role in producing the surface symptoms.
In the last 25 years, medications have been found to be fairly
successful in the treatment of OCD. First was the tricyclic antidepressant
clomipramine. This has been followed by several of the newer SSRI class
anti-depressants that act selectively on the re-uptake of serotonin, a
neurotransmitter. In the last few years, neuro-imaging studies have begun to
disclose the underlying pathophysiology of OCD. The area of the brain that
functions abnormally is directly next to those areas that relate to tick
disorders such as Tourette's Syndrome and to Attention Deficit Disorder.
Patient: John Doe 09/01/1998
It now seems that variable amounts of disfunction produce clinical
symptoms that may be virtually all in one of these areas, or may be
overlapping. Many people with ADD also have ticks, as do many people with
OCD. Most unexpected is the finding that children who have Rheumatic Fever
and develop Sydinham's Chorea have a significantly increased risk of OCD.
Therefore treatment with antibiotics early in an infectious illness may
reduce the chances of future obsessive thinking.
The likelihood for John Doe of developing PTSD may increase as the
intensity of and physical proximity to the stressor increase. There may be
increased risk of Panic Disorder, Agoraphobia, Obsessive-Compulsive
Disorder, Social Phobia, Specific Phobia, Major Depressive Disorder,
Somatization Disorder, and Substance-Related Disorders.
The minor tranquilizers have a particularly important place in the
treatment of the anxiety disorders. Chlordiazepoxide (Librium) and diazepam
(Valium) are both effective aids to the patient in his struggle with the
phobic situation if they are taken in sufficient doses to produce a
relaxation of tension and musculature. However, they do not appear to block
the actual process of panic attacks.
The following treatment recommendations are made for patients either in
inpatient or outpatient treatment. Their intent is not to replace clinical
approaches which may be in progress at the time this profile is being
generated, but to further promote individualization of treatment planning
and patient's participation in own recovery process. Additionally, they can
be utilized as guidelines of continuous monitoring and evaluation of the
therapeutic process, for the mutual benefit of both the patient and the
clinical staff rendering treatment.
- Provide recreational and diversionary activities such as swimming,
jogging, walking, running errands, simple tasks and repetitive
activities.
- Promote sleep with comfort measures (warm bath, music, back rub and
quiet presence of a significant person).
- Assist patient in relaxing with relaxation exercises and deep
breathing and in reducing hyperventilation.
- If patient is a victim of rape, assault, abuse, or molestation, refer
to appropriate professional person if you are unable to help patient
deal with the anxiety.
- Treat physical complaints matter-of-factly.
- Help patient refrain from dwelling on physical complaints through
distractions such as music or physical activity.
- Help patient identify threat causing anxiety.
- Identify duration of stress.
- Provide feedback on behavior that indicates anxiety.
- Identify behaviors that indicate that anxiety is mounting such as
restlessness, pacing, tenseness, or irritability.
- Refrain from false reassurance.
_______________________________________________________________________________
Patient: John Doe 09/01/1998
- Be aware of responses to patient's anxiety; helplessness, anger,
demands and repetitive questions.
- Refrain from making demands on or requiring decisions from patient.
- Discuss what relieves patient's anxiety.
- Initiate problem solving when anxiety is lessened.
- Focus on present situation that is producing anxiety.
- Assist patient in identifying sources of frustration, unmet needs and
conflicts that cause anxiety.
- Help patient identify consequences of maladaptive coping with anxiety.
- Help client assess threats as realistic or distorted.
- Give specific information on all tests, procedures and expectations.
- Motivate patient to assume responsibility for lessening anxiety by
involving client in decisions about care and treatment.
- Explore secondary gains patients may be receiving from others through
their anxious behavior.
- If patient is unemployed or relocated because of anxiety problems,
refer to a social worker for services.
- Identify patient's support system.
- Discuss cultural and religious influences and implications for
anxiety-producing situations (divorce, abortion, out-of-wedlock
pregnancy, rape, incest, mental illness and mercy killing).
- Recognize early stages of anxiety and introduce methods of prevention
of escalation, loss of control, and communication to other patients.
- With patient's cooperation, identify coping techniques and behaviors
which are adaptive vs. maladaptive ones.
- Observe whether patient manifests avoidance behaviors when confronted
with anxiety producing stimuli. Patient should be helped in
recognizing, identifying, and reinforcing those behaviors which are
helpful in reducing anxiety and are not maladaptive.
- Assist the patient in identification of different levels of his/her
own anxiety. Such process of identification can be helpful in
establishing a more realistic perspective from which an evaluation of
a stressor can be made.
- Explore with the patient level(s) of anxiety which the patient can
tolerate without engaging in self-defeating behaviors, inefficient
coping, and possible sense of loss of control, and the extent of
patient's awareness of such thresholds.
- Analyze with the patient situations which are stressful to him/her,
and focus on possible discrepancies between patient's perception of
such situations and actual events and circumstances.
_______________________________________________________________________________
Patient: John Doe 09/01/1998
ASSESSMENT OF TREATMENT OUTCOMES
Upon completion of John Doe's treatment, an objective assessment of the
would be appropriate, based on which prediction for his
permanent recovery can be made.
The following components of such assessment should be included:
___ reduction in morbidity;
___ reduction in comorbidity;
___ reinstated and stable homeostatic functioning;
___ stability and control over remaining symptomatology;
___ reduction of diagnostic complexity;
___ stability of average rate of recovery;
___ attainment of majority of treatment goals;
___ transformation of long term treatment goals to personal goals;
_______________________________________________________________________________
Patient: John Doe 09/01/1998
CRITERIA FOR ASSESSMENT OF PROGNOSIS FOR RECOVERY
Realistic prognosis about the extent and course of John Doe's successful
recovery should be based on an assessment of a number of factors inherent in
the rehabilitative process.
First, it is important to determine whether his primary symptomatology
has stabilized after the initiation of treatment, and whether there was
reduction in acuity, severity, and its occurrence, as well as reoccurrence.
Second, the same factors should be assessed in relationship to any secondary
symptomatology which may have been reported by the patient.
Additionally, John Doe's movement along the therapeutic continuum should
be carefully monitored, continually reassessed, documented, and, if so
required, adjusted in such a way that the therapeutic efforts by both the
clinical staff and the patient are maximized, as well as the effects of
treatment.
A set or realistic and measurable criteria should be established based
on which his progress should be evaluated. Objective appraisal of the extent
of John Doe's disorder, clinical impairments, his rehabilitative potential,
availability and efficacy of the resources at his disposal, and attainable
goals of recovery will be the essential components of his lasting recovery.
During th course of John Doe's treatment, the following issues should
also be carefully assessed and monitored:
___ Completion of treatment goals within specified time frames;
___ Temporal stability of rate of positive therapeutic change;
___ Awareness of therapeutic progress and positive change(s);
___ Continuing and realistic self-reassessment of treatment goals;
___ Continuing and realistic self-reassessment of treatment progress;
___ Acceptance of responsibilities inherent in the role of recovery;
___ Self-initiated regulation of health behaviors;
___ Discontinuation of potentially adverse self-medication practice(s);
___ Discontinuation of substance abuse for any reason;
___ Self-awareness of constitutional vulnerabilities
___ Significant reduction in number of critical impairments;
___ Realistic assessment of potential for retraumatization;
___ Development of successful coping mechanisms:
___ Identification and utilization of external resources for recovery;
___ Significant reduction in range of rehabilitative limitations;
___ Significant reduction in impairments for future achievements;
___ Increase in major areas of psychosocial functioning;
___ Self-initiated reinstatement of economic stability;
___ Emergence of identifiable milieu of support systems;
_______________________________________________________________________________
Patient: John Doe 09/01/1998
FEEDBACK TO THE PATIENT AND SUGGESTIONS FOR SELF-HELP
The following are some suggestions to John Doe for self-management of
anxiety and stress.
Stress is the "wear and tear" which your body experiences as you adjust
to your continually changing environment. It has physical and emotional
effects on you and consequently creates positive or negative feelings. As a
positive influence, stress can help compel you to action; it can result in a
new awareness and an exciting new perspective.
When you are adjusting to different circumstances, stress will help or
hinder you depending on how you react to it.
As a negative influence, it can often result in feelings of distrust,
rejection, anger, and depression, which in turn can lead to health problems
such as headaches, upset stomach, rashes, insomnia, ulcers, high blood
pressure, heart disease, and stroke. With the death of a loved one, the birth
of a child, a job promotion, or a new relationship, we experience stress as
we re-adjust your lives.
Positive stress adds anticipation and excitement to life, and we all
thrive under a certain amount of stress. Numerous deadlines, competitions,
confrontations, and even your frustrations and sorrows add depth and
enrichment to your lives. Your goal is not to eliminate stress but to learn
how to manage it and how to use it to help you.
There is no single level of stress that is optimal for all people. We are
all individual creatures with unique requirements. As such, what is
distressing to one may be a joy to another. And even when we agree that a
particular event is distressing, we are likely to differ in your
physiological and psychological responses to it.
It has been found that most illness is related to unrelieved stress. If
you are experiencing stress symptoms, you have gone beyond your optimal
stress level; you need to reduce the stress in your life and/or improve your
ability to manage it.
Perhaps there are times when you wander how can you manage stress more
effectively. Identifying unrelieved stress and being aware of its effect on
your life is not sufficient for reducing its harmful effects. Just as there
are many sources of stress, there are many possibilities for its management.
However, all require effort toward change: changing the source of stress
and/or changing your reaction to it.
- Become aware of your stressors and your emotional and physical
reactions. Notice your distress. Don't ignore it. Don't gloss over your
problems. Determine what events distress you. What are you telling
yourself about meaning of these events?
- Determine how your body responds to the stress. Do you become nervous
or physically upset? If so, in what specific ways?
- Recognize what you can change. Can you change your stressors by
avoiding or eliminating them completely? Can you reduce their intensity
(manage them over a period of time instead of on a daily or weekly
basis)?
_______________________________________________________________________________
Patient: John Doe 09/01/1998
- Can you shorten your exposure to stress (take a break, leave the
physical premises)? Can you devote the time and energy necessary to
making a change (goal setting, time management techniques, and delayed
gratification strategies may be helpful here)?
- Reduce the intensity of your emotional reactions to stress. The stress
reaction is triggered by your perception of danger...physical danger
and/or emotional danger. Are you viewing your stressors in exaggerated
terms and/or taking a difficult situation and making it a disaster?
- Are you expecting to please everyone? Are you overreacting and viewing
things as absolutely critical and urgent? Do you feel you must always
prevail in every situation? Work at adopting more moderate views. Try
to see the stress as something you can cope with rather than something
that overpowers you.
- Try to temper your excess emotions. Put the situation in perspective.
Do not labor on the negative aspects and the "what if's."
- Learn to moderate your physical reactions to stress. Slow, deep
breathing will bring your heart rate and respiration back to normal.
Relaxation techniques can reduce muscle tension.
- Build your physical reserves. Exercise for cardiovascular fitness three
to four times a week (moderate, prolonged rhythmic exercise is best,
such as walking, swimming, cycling, or jogging). Eat well-balanced,
nutritious meals.
- Maintain your ideal weight. Avoid nicotine, excessive caffeine, and
other stimulants. Mix leisure with work. Take breaks and get away when
you can. Get enough sleep. Be as consistent with your sleep schedule as
possible.
- Maintain your emotional reserves. Develop some mutually supportive
friendships/relationships. Pursue realistic goals which are meaningful
to you, rather than goals others have for you that you do not share.
- Expect some frustrations, failures, and sorrows. Always be kind and
gentle with yourself - be a friend to yourself!