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volume 7 issue 7 july 2022 international journal of innovative science and research technology issn no 2456 2165 cognitive behavorial therapy a case study of breavement marshall university mwuese c ...

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            Volume 7, Issue 7, July – 2022                                                    International Journal of Innovative Science and Research Technology                                                 
                                                                                                                                                                                       ISSN No:-2456-2165 
                               Cognitive Behavorial Therapy: A Case Study  
                                               of Breavement Marshall University 
                                                                                                      
                                                                               Mwuese C. Titor-Addingi 
                                                                                                      
            Abstract:-  The  need  for  bereavement  services  to  help                                     The  times  and  dates  of  the  meetings  were  also 
            support  individuals  going  through  grief  and  heal                                   discussed  amongst  the  co-facilitators  and  community 
            successfully is an essential need in the society. This work                              member, and were set. Additionally, a centralized location, 
            made  use  of  Cognitive  behavioral  therapy  CBT  as  a                                Bayless  Memorial  Presbyterian  Church,  was  chosen  as  a 
            therapeutic  module  for  the  group  sessions  of  selected                             host  site.  The  church  provided  refreshments  for  the 
            group  of  individuals  going  through  grief.  Assessment                               participants during the session meetings.  
            incorporates clinical  observations,  client  self-reporting,                                    
            evidence  based  tools/questionnaires,  and  diagnostic                                         An  advertisement            campaign        within     the     local 
            criterion  found  within  the  Diagnostic  and  Statistical                              community through a podcast, social media, churches, and 
            Manual of Mental Disorders Fifth Edition (DSM-5), a                                      community organizations  was  initiated  by  the  community 
            preliminary          diagnosis         of      Persistent        Complex                 member. Due to the fact that loss does not have boundaries, 
            Bereavement  Disorder  (PCBD)  was  determined  and                                      although there was an age limit set, there were no limitations 
            studied. It is therefore found that there was a significant                              on gender, race, or ethnicity. The group co-facilitators met 
            drop below the clinically significant mark of 4.0 by the                                 several  times  prior  to  the  first  group  session.  During  the 
            end of the 10 week treatment and final submission of the                                 meetings,  the  co-facilitators  discussed  evidence  based 
            BGQ, and is further found that given the recommended                                     diagnostic tools, treatment plans (including but not limited 
            20-25 Cognitive Behavioral Therapy (CBT) sessions, the                                   to  goals and objectives), and implementation of Cognitive 
            group’s  score  resulted  in  elimination  of  all/nearly  all                           Behavioral Group Therapy (CBGT). The co-facilitators also 
            symptoms of PCBD experienced by group members.                                           decided on which responsibilities each would have during 
                                                                                                     the initial group session, and how often they would meet to 
                                   I.  INTRODUCTION                                                  debrief and discuss future group sessions.  
                                                                                                      
                   The development of the “Grief and Healing Support                                                         II.  ASSESSMENT 
                                                                                                                                            
            Group”  came  from  an  extrinsic  need  for  bereavement                                       Assessments  are  essential  to  providing  adequate  and 
            services  within  the  Grayson,  KY  community  due  to  an                              appropriate  treatment  to  individuals  and  treatment  groups 
            increase  in  suicide  completions  and  deaths  related  to  the                        alike.  Assessment incorporates clinical observations, client 
            current opioid epidemic. A community member reached out                                  self-reporting,  evidence  based  tools/questionnaires,  and 
            to  Marshall  University  Professor,  Paula  Rymer  (CSW,                                diagnostic  criterion  found  within  the  Diagnostic  and 
            LSW,  LICSW),  to  request  assistance  in  facilitating  the                            Statistical Manual of Mental Disorders Fifth Edition (DSM-
            bereavement         group.      Graduate        students      who      have              5).  Using  these  methods,  a  preliminary  diagnosis  of 
            experienced traumatic loss and understand the bereavement                                Persistent  Complex  Bereavement  Disorder  (PCBD)  was 
            process were chosen to facilitate the group.                                             determined and studied.  
                    
                   It was predetermined that the group would be an open                                      
            group  for  individuals  (ages  16  and  older)  who  have                                      Persistent Complex Bereavement Disorder (PCBD) is 
            experienced a death or traumatic death of a family member,                               intense grief after the death of a loved one that lasts longer 
            friend,  or  loved  one.  It  was  also  predetermined  that  the                        than  expected  according  to  social  norms  and  causes 
            graduate students would facilitate a total of eight to twelve                            functional      impairment.  The  condition  is  found  in 
            sessions.  Although  Cognitive  Behavioral  Therapy  (CBT)                               theDiagnostic and  Statistical  Manual  of  Mental  Disorders 
            was  the  module  used  during  therapeutic  group  sessions,                            Fifth Edition (DSM-5) within the chapter titled, Conditions 
            research and pilot studies conducted by Dr. Katherine Shear                              for Further Study (American Psychiatric Association [APA], 
            indicate  that  Complicated  Grief  Therapy  (CGT)  is  an                               2013). The proposed five criteria listed within the DSM-5 
            effective evidence based treatment for complicated grief of                              include (APA, 2013): 
            the bereaved (Zagorski, 2015 and Shear & Bloom, 2017).                                    Individual experienced the death of someone with whom 
            CGT incorporates elements of CBT along with Interpersonal                                  they had a close relationship  
            Psychotherapy  (IPT)  and  Motivational  Interviewing  (MI).                              Since the death, they have experienced at least one of the 
            However, CGT is conducted at a minimum of 16 weekly                                        following symptoms more often than not to a clinically 
            sessions,  and  due  to  time  constraints  along  with  the                               significant degree persistently for at least 12 months for 
            predetermination  for  use  of  an  evidence  based  modality,                             bereaved adults and 6 months for bereaved children: 
            CBT  was  utilized  (2015&  2017).The  structural  basis  for                                Persistent yearning/longing for the deceased 
            implementation of CBT within the bereavement group was                                       Intense sorrow and emotional pain  
            obtained  from  the  book  titled,  Cognitive-Behavioral                                     Preoccupation with the deceased 
            Therapy in Groups (Bieling, McCabe, Antony, 2009).                                           Preoccupation with the circumstances of the death 
                                                                                                                                  
             
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            Volume 7, Issue 7, July – 2022                                                    International Journal of Innovative Science and Research Technology                                                 
                                                                                                                                                                                       ISSN No:-2456-2165 
             Since the death, six or more of the following have been                                per the DSM-5, a diagnosis of MDD and PDD were ruled 
              experienced  at  clinically  significant  degree  and  have                            out.  
              persisted for 12 months after the death for bereaved adults                                    
              and 6 months for bereaved children:                                                           Given the noted information, coupled with the fact that 
                Marked difficulty accepting the death.                                              the majority  of  the  group members experienced their loss 
                Experiencing disbelief or emotional numbness over the                               over 6 months (for children) and/or 12 months (for adults) 
                   loss                                                                              prior  respectively,  and  necessaryDSM-5  was  met,  a 
                Difficulty with positive reminiscing about the deceased                             diagnosis  of  Persistent  Complex  Bereavement  Disorder 
                Bitterness or anger related to the loss                                             (PCBD) was made. There were no members who expressed 
                Maladaptive  appraisals  about  self  in  relation  to  the                         that their loss was associated with a trauma, nor were any 
                   deceased or the death                                                             group members observed to exhibit specifiers of traumatic 
                Excessive avoidance of reminders of the loss                                        bereavement. There was also no comorbid diagnosis such as 
                A desire to die in order to be with the deceased                                    bipolar  disorder,  schizophrenia,  or  substance  use  disorder. 
                Difficulty trusting other individuals since the death                               Therefore,  comorbid  diagnosis  such  as  those  previously 
                Feeling alone or detached from other individuals since                              mentioned were ruled out per specified criterion listed in the 
                   the death                                                                         DSM-5 (APA, 2013). 
                                                                                                            
                Feeling that life is meaningless or empty without the                                      Prior  to  the  Diagnostic  and  Statistical  Manual  of 
                   deceased                                                                          Mental Disorders Fifth Edition (DSM-5), the Diagnostic and 
                Confusion  about  one’s  role  in  life,  or  loss  of  one’s                       Statistical Manual of Mental Disorders Fourth Edition Text 
                   sense of identity                                                                 Revision  (DSM-IV-TR)  described  Persistent  Complex 
                Difficulty  or  reluctance  to  pursue  interests  since  the                       Bereavement  Disorder  (PCBD)  and/or  bereavement  in 
                   loss or to  plan for the future                                                   generally  in  terms  of  “other  conditions  that  might  be  the 
                                                                                                     focus     of     clinical     attention”      (American        Psychiatric 
             The  disturbance  causes  clinically  significant  distress  or                        Association  Diagnostic  and  Statistical  Manual  of  Mental 
              impairment  in  social,  occupational,  or  other  important                           Disorders  Fourth  Edition  Text  Revision  [DSM-IV-TR], 
              areas of functioning.                                                                  2000).For facilitation of the group, the DSM-5 was used for 
             The  bereavement  reaction  is  out  of  proportion  to  or                            diagnostic purposes.  
              inconsistent  with  cultural,  religious,  or  age-appropriate                                 
              norms (2013).                                                                                 Further  assessment  was  made  of  the  group  through 
                                                                                                     implementation  of  the  Brief  Measure  for  Screening 
                                                                                                     Complicated Grief (BGQ) at the onset, halfway mark, and 
                   In addition to the five criteria listed in the Diagnostic                         termination  of  the  group  (Ito,  Nakajima,  Fujisawa,  et  al., 
            and  Statistical  Manual  of  Mental  Disorders  Fifth  Edition                          2012). This is an evidence based tool that was developed in 
            (DSM-5), a specifier is listed along with features supporting                            2002 in response to individuals who sought support for the 
            the    diagnosis,       development  of  Persistent  Complex                             September 11, 2001 terrorist attacks in New York. It was 
            Bereavement Disorder (PCBD), and associated risk factors.                                developed  prior  to  the  DSM-5,  however,  the  BGQ, 
            For those who are bereaved due to traumatic loss such as                                 continues to be the most widely used evidence based tool to 
            homicide  or  suicide,  and  exhibit  persistent  distressing                            assist  in  assessments  of  the  bereaved.  This  screening  tool 
            preoccupations regarding the traumatic nature of the death a                             asks  five  questions  which  organize  information  about  the 
            specifier  of  traumatic  bereavement  is  assigned.  Some                               individual  client.  It  assesses  the  individual,  self-care 
            features  that  may  be  observed  or  reported  can  include                            practices, need for professional care, andsocialization for a 
            hallucinations  and  somatic  symptoms.  An  environmental                               more holistic view  of  the  client’s  environment  in light  of 
            risk  for  PCBD  is  when  the  bereaved  had  increased                                 their loss. The BGQ uses a Likert scale of “Not at all (0),” 
            dependency upon the deceased individual. If an individual                                “Somewhat (1),”  and  “A  lot  (2).”  The  questionnaire  is  a 
            grieves  outside  or  beyond  the  cultural  norms,  they  are  at                       brief self-report, and it can be used in all healthcare settings 
            higher risk  of  developing  PCBD. Clinicians must also be                               (Ito,  Nakajima, Fujisawa, et al., 2012).  The five questions 
            vigilant  as  those  who  are  diagnosed  with  PCBD  more                               asked of the bereaved are:  
            frequently report suicidal ideations (2013).                                               1.  How much trouble are you having accepting the death 
                                                                                                            of ________? 
                   Persistent Complex Bereavement Disorder (PCBD) is                                   2.  How  much  does  your  grief  still  interfere  with  your 
            distinguished from the normal grieving process through the                                      life? 
            aforementioned  criterion  specified  in  the  DSM-5  (APA,                                3.  How  much  are  you  having  images  or  thoughts  of 
            2013).  The  bereaved  experiences  severe  levels  of  grief                                   _______ when s/he died or other thoughts about the 
            responses which persists at least 12 months following the                                       death that really bother you? 
            death,  and  their  grief  responses  interfere  with  their  daily                        4.  Are there things you used to do when ______ was alive 
            functioning.  Some  of  the  symptoms  such  as  depressed 
            mood, sadness, crying, and suicidal ideations may also be                                       that  you  don’t  feel  comfortable  doing  anymore,  that 
            shared  with  Major  Depressive  Disorder  (MDD)  and                                           you  avoid?  Like  going  somewhere  you  went  with 
            Persistent  Depressive  Disorder  (dysthymia),  however,                                        him/her, or doing things you used to enjoy together? 
                                                                                                            Or  avoiding  looking  at  pictures  or  talking  about 
            PCBD  is  “characterized  by  a  focus  on  the  loss”  of  the                                 _______? How much are you avoiding these things? 
            deceased (APA, 2013). Therefore, due to criterion not met 
             
            IJISRT22JUL399                                                                www.ijisrt.com                                                                       203 
            Volume 7, Issue 7, July – 2022                                                    International Journal of Innovative Science and Research Technology                                                 
                                                                                                                                                                                       ISSN No:-2456-2165 
              5.  How much are you feeling cut off or distant from other                             it was found that lemon scent had a positive effect on mood, 
                   people since ______ died, even people you used to be                              and aroma therapy was found to increase functioning in the 
                   close to like family or friends? (2012).                                          parasympathetic          nervous       system       while       decreasing 
                                                                                                     sympathetic        nervous        system       functioning       (Komori, 
                   The  decision  to  utilize  this  tool  was  based  on                            Kageyama, Tamura, Tateishi, &Iwasa, 2018, and National 
            recommendations  of  clinicians  within  the  field  and  on                             Center for Complementary and Integrative Health [NCCIH], 
            evidence found through literary research of peer reviewed                                2012). 
            studies and articles. One such study was conducted in Japan                                      
            and  the  results  of  the  study  supported  the  reliability  and                             Similarly, diaphragmatic breathing has been proven to 
            validity  of  the  BGQ(Ito,  Nakajima,  Fujisawa,  Miyashita,                            decrease  sympathetic  nervous  system  function  while 
            Kim, et al., 2012).  The study was conducted randomly via                                increasing  parasympathetic  nervous  system  responses  and 
            mailed BGQ’s, and examined the responses of individuals                                  studies  have  revealed  that  it  reduces  anxiety,  depression, 
            who were bereaved more than 6 months but less than 10                                    stress, and emotional exhaustion (Ma, Yue, Gong, Zhang, 
            years. The study also supports the view that this instrument                             Duan,  Shi,  &  Li,  2017).  Physiologically,  even  a  single 
            can be utilized in both clinical and non-clinical settings, as                           breathing  practice  significantly  reduced  blood  pressure, 
            well as, the cultural universality of complicated grief as a                             increased heart rate variability and oxygenation, enhanced 
            paradigm for which the BGQ is a way in which clinicians                                  lung  function  and  improved  cardiorespiratory  fitness  and 
            can  easily  assess  complicated  grief  symptoms  associated                            respiratory  muscle  strength.  This  study  showed  that 
            with PCBD (2012).                                                                        diaphragmatic  breathing  has  the  potential  to  improve 
                                                                                                     cognitive  function  while  reducing  negative  physiological 
                   Another       study      which      used      the    Brief      Grief             consequences of stress (2017). 
            Questionnaire (BGQ) was conducted with military service                                          
            members  (Delaney,  Holloway,  Miletich,  United  States                                        To  empower  participants  and  provide  cognitive 
            Navy,  United  States  Marine  Corps,  Webb-Murphy,                                      awareness and insight into emotional regulation, they were 
            &Lanouette,  2017).  The  study  was  conducted  to  help                                provided an additional tool to monitor their own progress on 
            identify  military  service  members  who  suffered  from                                a  daily  and  weekly  basis.  The  Likert  11  point  scale  was 
            complicated grief due to their experiences in theater. It was                            provided to each of the participants and used during check-
            determined through the study that a BGQ “can help capture                                in  as  a  means  of  self-monitoring,  and  for  the  group  and 
            many of those with grief related impairment,” and further                                facilitator  to  monitor  progress.  It  has  been  proven  as  an 
            suggested  that  the  grief  screen  be  utilized  as  a  standard                       effective tool, and by using the 11 point scale, studies have 
            measure to target and treat symptoms associated with grief                               indicated  a greater  validity  “in  the  sense  that  total  scores 
            (2017).                                                                                  more highly estimated the construct underlying the item set 
                                                                                                     (Flamer, 1983).  
                              III.  TREATMENT PLAN                                                           
                                                                                                         IV.  COGNITIVE BEHAVIORAL THERAPY 
                   Current  studies  show  that  Persistent  Complex                                        TREATMENT PLAN IN A GROUP SETTING 
            Bereavement  Disorder  (PCBD)  is  best  treated  with                                    
            Cognitive  Behavioral  Therapy  (CBT)  (Khashab,  Kivi,                                   Long-term Group Goals:  
            &Fathi,  2017  and  (Fields,  Johnson,  Mears,  &  Johnson,                                  Reduce triggers and lessen symptoms of Persistent 
            2018).  Cognitive  Behavioral  Therapy  helps  individuals                                      Complex Bereavement. 
            confront  their  cognitive  distortions,  emotional  issues,  and                            Begin and sustain an emotionally healthy grieving 
            provides the bereaved with a means to accept grief, increase                                    process around the loss. 
            their     spiritual     well-being,       and     increase       emotional                   Develop an awareness of how the avoidance of 
            intelligence(2017).         Recent  studies  have  found  that                                  grieving and the attempts to deny the loss have 
            individuals  with  PCBD  respond  to  an  Integrative  CBT                                      affected life. 
            treatment similarly to those individuals with Post Traumatic                                 Identify feelings associated with the loss of the loved 
            Stress Disorder (PTSD) (Rosner, Pfoh, &Kotoucova, 2010).                                        one. 
            Therefore, exposure therapy is integrated during the course                                  Gradually but steadily return to level of functioning 
            of CBT. This allows for cognitive restructuring whereby the                                     that was normal previous to the loss. 
            individual  identifies  and  confronts  dysfunctional  thoughts                                       
            and provides for them to experience the situation in a safe                                                   V.  METHODOLOGY 
            environment (2010).                                                                       
                                                                                                     A.  Session 1-Introduction to Bereavement Group 
                   In  addition  to  Cognitive  Behavioral  Therapy  (CBT),                              a)  Session 1 Objective # 1:   
            aroma therapy, mindfulness and relaxation techniques were                                         Group members will verbalize an understanding of 
            integrated  into  the  therapeutic  bereavement  group.  In  a                                    the concept and process of grief work 
            controlled  pilot  study  that  measured  the  effects  of                                         
            mindfulness-based  CBT  on  depressive  symptoms  of                                              Interventions:                                     CBT/Rapport 
            bereaved  elderly  individuals,  there  was  a  significant                                       Building/Psychoeducation/BGQ 
            reduction in symptoms (O’Conner, Piet, &Hougaard, 2014).                                           Group members will complete BGQ(Ito, Nakajima, 
            In  other  studies,  which looked  at  aroma therapy  whereby                                       Fujisawa, et al., 2012). 
            different scents such as lavender and lemon were analyzed, 
             
            IJISRT22JUL399                                                                www.ijisrt.com                                                                       204 
            Volume 7, Issue 7, July – 2022                                                    International Journal of Innovative Science and Research Technology                                                 
                                                                                                                                                                                       ISSN No:-2456-2165 
                      Group  members  will  introduce  themselves  and                              C.  Session 3-What is Loss? 
                       share their losses that precipitated them attending                               a)  Session 3 Objective #1:  
                       group therapy.                                                                         Group members will identify types of losses and the 
                      Facilitator  will  provide  an  overview  of  the  grief                               impact of loss on daily functioning.  
                       process and elicit group discussion.                                                    
                      Group  members will  identify  common  emotional                                       Interventions: CBT/Mindfulness 
                       reactions to death of a loved one and participate in                                    Group members will check-in using Likert Scale to 
                       a discussion about the grief process.                                                    discuss current stress level. 
                                                                                                               Group members will discuss  what loss  means to 
                b)  Session 1 Objective# 2:                                                                     them.  
                     Group  members  will  establish  goals  and  rules  for                                   They will discuss how their loss has changed their 
                     group.                                                                                     daily routines and resulted in further losses.  
                                                                                                                 
                     Interventions:                                     CBT/Rapport                      b)  Session 3 Objective #2:  
                     Building/Psychoeducation                                                                 Group  members  will  develop  an  awareness  of  the 
                      Facilitator will elicit group members’ expectations                                    interconnectedness          of    thoughts,      feelings,      and 
                       and/or goals for group therapy.                                                        behaviors. 
                      Group  facilitator  and  members  will  discuss  and                                    
                       establish the group “Rules.” Including:                                                Interventions: CBT/Mindfulness 
                         Confidentiality                                                                      Group  members  will  be  provided  education  and 
                         Check-in                                                                              illustration  handout  of  cognitive  triangulation 
                              Likert Scale                                                                     (Vanderbilt University Medical Center, 2011). 
                              Home practice discussion                                                        Group members will discuss an experience where 
                         Session discussion                                                                    their  cognitions  and  emotions  were  directly 
                         Home practice                                                                         impacted by their loss. They will then discuss their 
                         Attendance                                                                            subsequent behavior. 
                      Home Practice Week 1: Review group goals and                                            Home practice Week 3: Group members will list 
                       prepare  to  discuss  stress  level  using  the  Likert                                  ways their losses affect their daily lives throughout 
                       Scale during next group session.                                                         this  week  and  will  share  during  the  next  group 
                                                                                                                session. 
            B.  Session 2-Stages of Grief                                                                        
                a)  Session 2 Objective # 1:                                                         D. Session 4- I Statements 
                     Group members will verbalize an understanding of                                    a)  Session 4 Objective #1:   
                     the      stages       of      grief      as      a     non-linear                        Group  members  will  explore,  develop,  and 
                     process(Maciejewski,  Zhang,  Block,  &  Prigerson,                                      demonstrate  the  ability  to  use  “I”  statements 
                     2007).                                                                                   (Hansen, 2015). 
                                                                                                               
                     Interventions:CBT/Psychoeducation                                                        Interventions: CBT/Psychoeducation/Mindfulness 
                      Check-in  using  Likert  Scale  to  discuss  current                                    Group  members  will  check  in  using  the  Likert 
                       stress  level  and  home  practice  review  (Flamer,                                     Scale to discuss current stress level 
                       1983; Cirino, 2017).                                                                    Facilitators  will  provide  education  and  worksheet 
                      The facilitator will provide handout and education                                       to group members on “I” statements. 
                       on Stages of Grief (Corn, 2013).                                                          
                      Group  members  will  discuss  how  they  have                                    b)  Session 4 Objective #2:  
                       experienced the various stages and where they are                                      Group members will use “I” statements  to  discuss 
                       within the Stages of Grief at this time.                                               cognitions,  emotions,  and  behaviors  related  to  the 
                                                                                                              loss. 
                b)  Session 2 Objective # 2:                                                                   
                     Group  members  will  develop  an  understanding  of                                     Interventions: CBT/Mindfulness 
                     how the stages of grief are part of the ongoing grief                                     Group members will discuss home practice activity 
                     process and must be experienced in order to heal.                                          using “I” statements.  
                                                                                                               Group members will use “I” statements to discuss 
                     Interventions:CBT/Mindfulness                                                              ways  they  feel  they  have/have  not  adapted  to 
                      Group  members  will  discuss  their  individual                                         changes surrounding their losses. 
                       coping strategies as they relate to the stages, and                                     Home practice Week 3: Group members will list 
                       will  determine  if  they  allowed  themselves  to                                       stressors they experience this upcoming week and 
                       experience  the  stage  or  avoided  the  stage  (Rice,                                  prepare  an  “I”  statement  describing  one  of  their 
                       2015).                                                                                   stressful situations to discuss during the next group 
                      Home  Practice  Week  2:  Group  members  will                                           session. 
                       review the Stages of Grief handout, and note daily                                        
                       their thoughts and feelings related to their loss and                                     
                       experienced stages of grief.                                                              
                                                                                                                 
             
            IJISRT22JUL399                                                                www.ijisrt.com                                                                       205 
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...Volume issue july international journal of innovative science and research technology issn no cognitive behavorial therapy a case study breavement marshall university mwuese c titor addingi abstract the need for bereavement services to help times dates meetings were also support individuals going through grief heal discussed amongst co facilitators community successfully is an essential in society this work member set additionally centralized location made use behavioral cbt as bayless memorial presbyterian church was chosen therapeutic module group sessions selected host site provided refreshments assessment participants during session incorporates clinical observations client self reporting evidence based tools questionnaires diagnostic advertisement campaign within local criterion found statistical podcast social media churches manual mental disorders fifth edition dsm organizations initiated by preliminary diagnosis persistent complex due fact that loss does not have boundaries dis...

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