Disorders of personality and behavior: types, treatment. Personality disorders are special mental conditions

Modern living conditions bring many conveniences to humanity. These are the latest technologies designed to make life easier, and the information environment where you can find out any information, and the possibility of communication regardless of distance. However, in the modern world there are many problems that have brought all these benefits to civilization. Practice has shown that innovations also appear among human diseases. Moreover, these can be not only viruses, but also psychosomatic diseases, which have become relevant in recent decades. In this article, we'll talk about personality disorders.

Causes of psychological personality disorders

Personality disorder is a severe disruption of people's perception patterns and responses to various events that render a person incapable of social adaptation. This disease can appear spontaneously or be a manifestation of other mental illnesses. What are the causes of personality disorder? First of all, it should be said about functional disorders in the main areas:

• thinking;
• perception;
• behavior;
• emotions;
• relationships with other people.

As a rule, personality disorder is congenital and will haunt a person for life. However, it can also manifest itself during puberty and later in life. In this case, the disease is caused by other reasons:

• stressful situations;
• mental illness;
• diseases of the brain.

According to research, it was found that in a mild form this ailment occurs in 10% of the adult population, and in 40% of patients in psychiatric clinics it manifests itself as an independent disease or a component of another mental disorder. Until the end, it was not possible to find out the cause of this violation.

Personality disorder has a variety of symptoms. Most often it manifests itself in the fact that patients cannot adequately respond to problems and find out their relationship with others. Most of them are not happy with their lives and know how to deal with a lot of problems in the public and social spheres. Sometimes there are signs of personality disorder such as frequent mood swings, anxiety, substance abuse, and eating disorder. The patients themselves do not notice any deviations. They do not see that their thoughts and forms of behavior are not acceptable to society, and do not seek help from psychotherapists. An exception is considered when patients complain of depression or chronic tension caused by a personality disorder and believe that this is not a manifestation of the disease, but symptoms caused by other people and circumstances.

Diagnosing personality disorders is difficult. This is due to at least two reasons:

1. First you need to find out when the disorder arose - at an early stage of human development, or it appeared already at an older age. You can only find out with the help of a person who knows the patient well and who knows his character and properties of behavior.
2. The second reason is the assessment of those factors that contributed to the emergence of personality maladjustment and led to deviations in behavior. This also includes the impossibility of defining the boundary between norm and pathology.

Types of personality disorders

Thus, it is impossible to make an accurate diagnosis on the basis of only one conversation with the patient. Different types of personality disorders have both common and distinctive features. The phenomenon is considered common when they are mixed with each other.

According to the Diagnostic Statistical Manual of Mental Illness (DSM), there are several main types of personality disorders:

1. Avoiding - a person is afraid to get closer to others because of fears of rejection. It is accompanied by anxiety (due to fear of rejection) and sadness (due to a lack of harmonious relationships with others).
2. Dependent - a feeling of weakness and helplessness. Such people try to find a “guardian” for themselves and are in a state of anxiety if there is no such person around.
3. Passive-aggressive - on the one hand, such a person cares for freedom, but cannot cope with it, if there is one. In other words, a person lives between two extremes. Those around him are both demanding and caring.
4. Obsessive-compulsive (comes from the two words "obsession" and "compulsion"). A serious person whose favorite thoughts are about duty and control. He is self-controlled and self-critical, but demanding of others and craves punishment for everyone.
5. Paranoid. It is characterized by a total distrust of others. In other words, everyone is lying and you have to wait for a catch from everyone.
6. Antisocial- a lone man. Jealous that others have the benefits that he deserves more than they do.
7. Narcissistic - believes that he is special, unique and inimitable, and those around him are a gray mass. Easily gets angry if not admired.
8. Schizoid - a detached and reserved person. He is not inclined to let anyone into his inner experiences. However, those who have managed to get closer to such a person will only see sadness as a result of isolation.
9. Histrionic - a person who radiates joy to everyone and everything. Considers that he is charming and noteworthy. Deep down, he has a feeling of anxiety, which is replaced by sadness if it was not possible to make others happy.

There is also an American classification of personality disorders, where they are divided into three classes (A, B, C) and divided into clusters.

How are personality disorders treated?

Several forms of treatment are used depending on the type and nature of the disease.

The importance of corrective classes with people with personality disorders is to gradually return them to an adequate life, normal communication with the outside world and a change in thoughts and beliefs. Full or at least partial recovery of personality requires an average of three years of training with a psychotherapist.

Personality disorder, also called personality disorder, is a separate form of severe pathological abnormalities in the mental sphere of a person. According to statistics, the incidence of personality disorder reaches a very high level - over 12% of the human population. Pathology is more common in males.

Personality disorder - description and causes

Personality Disorder used in modern psychiatry in accordance with the recommendations of ICD-10 instead of the outdated name "Constitutional psychopathy"... The previous name of personality disorder did not quite correctly reflect the essence of the disease, since it was accepted that the basis of psychopathies are congenital defects of the nervous system, inferiority that arose against the background of unfavorable heredity, negative factors provoking developmental defects in the fetus. However, the pathogenetic mechanisms of personality disorder are more diverse and variable depending on the subspecies of the disease and the purely individual typological characteristics of a person. The cause of personality disorder can be a genetic predisposition, and an unfavorable course of pregnancy in the patient's mother, and birth trauma, and physical or psychological abuse in early childhood, and severe stressful situations.

Personality disorder implies the presence of a person's characterological constitution, personality structure, and behavior patterns that cause significant discomfort and pronounced distress in the existence of the individual and contradict the norms that exist in society. Several spheres of personality are simultaneously involved in the pathological mental process, which almost always leads to personal degradation, makes integration impossible, and makes it difficult for a person to fully function in society.

The onset of personality disorder occurs in late childhood or adolescence, while the symptoms of the disease appear much more intensively in the later life of a person. Since the juvenile period is characterized by peculiar psychological changes in a teenager, it is quite problematic to make a differential diagnosis at the age of sixteen. However, it is quite possible to identify the present accentuation of the personality and predict the further direction of the development of human characteristics.

Characterological structure - a set of stable psychological characteristics of an individual, regardless of time and situations, in the spheres of thinking, perception, in ways of reacting and in relationships with oneself and the surrounding world. A typical set of individual traits finishes forming before the beginning of early adulthood and, despite the further dynamic fading or development of individual elements, the structure of the psyche remains relatively unchanged in the future. The development of personality disorder can be assumed when individual components of the personality become extremely inflexible, destructive, maladaptive, immature and deprive them of the opportunity to function fruitfully and adequately.

Individuals with personality disorders are often in a state of frustration and cannot control their behavior, which gives them significant problems in all aspects of life. Such pathological conditions often coexist with depressive and anxiety disorders, hypochondriacal manifestations. For such, the abuse of psychostimulants and a pronounced violation of eating habits are especially characteristic. Often they are distinguished from healthy members of society by a clear contradiction in behavior, fragmentation and illogicality of individual actions, emotionally colored manifestations, cruel and aggressive actions, irresponsibility and a complete lack of rationalism.

According to the International Classifier of Diseases of the 10th revision, ten diagnoses are distinguished into separate forms of personality disorder. Pathological conditions are also grouped into three distinct clusters.

The forms of specific personality disorders are similar conditions observed in accentuated individuals, however, the main difference between the phenomena: a significant severity of manifestations, a bright contrast between the variation of individuality in a common human norm. The fundamental difference between pathology is that with accentuation of a personality, three dominant signs of mental pathology are never simultaneously determined:

• impact on all life activities;
• static in time;
• significant hindrances to social adaptation.

In accentuated personalities, a set of excessive psychological characteristics never has an immediate effect on all spheres of life. They have the opportunity to both achieve positive social achievements, and there is a negative charge, which is transformed over time in pathology.

Signs of a personality disorder

Despite the lack of precise terminology, the concept of "personality disorders" means the manifestation in a person of a number of clinical symptoms and signs of a destructive model of behavior that cause mental suffering to the individual and prevent full functioning in society. The group of "personality disorders" does not include abnormal manifestations of the psyche that have arisen as a result of direct damage to the brain, neurological diseases and cannot be explained by the presence of another mental pathology.

To be diagnosed with personality disorder, a patient's symptoms must meet the following criteria:

• There is a tangible contradiction in life attitudes and behavior of a person, affecting several mental spheres.
• A destructive, unnatural model of behavior has been formed in a person for a long time, is chronic, not limited to periodic episodes of mental pathology.
• An abnormal behavioral manner is global and significantly complicates or makes impossible the normal adaptation of a person to diverse life situations.
• Symptoms of the disorder were always first observed in childhood or adolescence and continue to show in the mature individual.
• The pathological condition is strong and pervasive distress, but this fact can be recorded only as the personality disorder worsens.
• Abnormal mental status can lead, but not always, to a significant deterioration in the quality and volume of work performed and cause a decline in social efficiency.

Forms of personality disorder and symptoms according to ICD-10

In traditional psychiatric practice, there are ten subtypes of personality disorder. Let's describe their brief description.

View 1. Paranoid

The basis of paranoid disorder is the pathological persistence of affect, a tendency to suspicion. In a patient of a paranoid type, feelings that caused a strong emotional reaction do not subside over time, but persist for a long time and manifest themselves with renewed vigor at the slightest mental memory. Such persons are overly sensitive to mistakes and failures, painfully touchy, easily vulnerable. They have ambition, arrogance, arrogance. In paranoid personality disorder, people do not know how to forgive insults, they are distinguished by secrecy and excessive suspicion, a general attitude towards an all-encompassing distrust. Paranoid personalities have a tendency to distort reality, refer to hostile and harmful motives all actions of others, including not only neutral but also friendly ones. Such people are distinguished by groundless pathological jealousy. They stubbornly defend their innocence, showing intractability and going into protracted litigation.

View 2. Schizoid

Obsessive-compulsive disorder is manifested by the regular occurrence of obsessive thoughts (obsessions) and / or the performance of stereotyped actions (compulsions).

Pathologies related to human activity in the mental plane include personality disorder, the symptoms of which can be determined only with a detailed acquaintance with the disease. To understand what kind of condition it is, you need to pay attention to the patient's behavior and, if detected, consult a doctor. Better yet, take preventive measures to eliminate a serious illness.

Mental illness is a whole cluster of disorders to which the ailment we are describing is directly related. To understand more competently in this matter, you need to start with the examples that are familiar to us. Let's start with the fact that each of us is an individual with a certain, normal type of thinking, perception of reality, environment, attitude to different kinds situations, time, space, etc. As soon as adolescence begins, until recently, an unintelligent child is already able to show his personal character traits, has his own style of behavior. Despite the fact that with age, certain traits are activated or fade away, they still accompany a person until the last moment of life. But this is an example of an ordinary person who does not suffer from mental pathology. In the case of the patient, personality disorder is rigidity, maladjustment of traits that cause a failure in his functioning. Sick people from time to time are exposed to psychological protection for no reason or irritating factors, which is why such persons remain maladaptive almost all their lives, with an immature type of thinking, etc.

According to international standards, there is a code "Personality disorder mkb 10", since the problem affects all spheres of human life, and only an experienced specialist is able to identify ten types of disorders, three specific clusters of ailment, based on clinical indicators.

Personality disorder affects all areas of human life

Let's first examine the signs of mental disorder. A person suffering from a disorder can hide their characteristics for a long time, which is called frustration in medicine, and at certain moments show their anger and aggression towards others. A large number of patients are worried about their lives, they almost always have problems with employees, relatives, friends. Pathology is often accompanied by mood swings, anxiety, panic attacks, excessive intake of psychotropic, sedative drugs, moreover, there is a malfunction in eating behavior.

Important: experts pay attention to the fact that in severe forms of the disease, a person can fall into deep hypochondria, capable of violent actions, self-destructive actions.

In the family, the patient can behave very contradictory, be too emotional, tough or indulge in connivance, allow family members anything that leads to the development of somatic and physical pathologies in children.

For reference: studies have shown that about 13% of the total population of the planet suffers from PD, and antisocial pathology is more common among men than among women (ratio 6 to 1), borderline condition is more common in women (ratio 3 to 1).

Symptoms of personality disorder

The provoking factors of the disease can occur in childhood, adolescence. At first they can definitely be considered, but with the stage of maturation, already in the future life, there is no specific outline. The manifestation of signs is not observed in specific aspects, but relate to all spheres of human activity - emotional, mental, interpersonal, volitional. The main symptoms of the disease include:

• pathology in character manifests itself totally: at work, at home, among friends;
• pathology in the personality remains stable: it begins in childhood and haunts all life;
• due to problems with behavior, character, etc., social maladjustment occurs, regardless of the attitude of the environment.

Personality disorder can be identified by a number of symptoms

Personality disorder: types

According to the psychoanalytic classification, doctors distinguish a number of disorders and the most characteristic of them are:

Socialized conduct disorder

In this case, a person (child, adolescent and older) strives to attract the attention of others by his inadequacy to the generally accepted social norms of behavior. Persons with such a pathology always have a certain charm, special manners, they tend to impress others. Their main character trait is to receive benefits without investing any physical effort. Literally from childhood, they are accompanied by a continuous series of wrong actions: absenteeism from school, escaping from the garden, at home, constant lies, fights, joining gangs, criminal groups, theft, consumption of drugs, alcohol, manipulation of loved ones. The peak of the pathology most often falls on the pubertal period from 14 to 16 years.

Unsocialized conduct disorder

This type of behavior is accompanied by persistent dissociation, aggression, disruption of relationships with peers and loved ones. Domestic psychiatry calls the type "deviant", the symptoms of which are manifested:

• Affective excitability - irritability, bouts of anger, aggression (fights, humiliation, insults) prevail in the character. With prohibitions and restrictions, a protest reaction arises - refusal to attend school, teach lessons, etc.
• Mental instability - excessive suggestibility, dependence on pleasures from external conditions, a tendency to deceive.
• Impairment of drives - vagrancy, running away from home, aggression, sadistic tendencies, violation of sexual behavior (conversions).
• Impulsive-epileptoid - a tendency to lingering outbursts of affective behavior, prolonged recovery from the state of anger, revenge, stubbornness.

Organic personality disorder

Psychopathy is an organic disorder that occurs as a result of previous brain diseases:

• traumatic brain injury;
• infectious diseases: encephalitis, meningitis;
• excessive alcohol consumption;
• taking drugs;
• abuse of psychotropic drugs;
• neoplasms in the brain;
• atherosclerosis, diabetes, hypertension;
• autoimmune pathologies;
• powerful intoxication.

According to experts, the disorder often becomes a companion of epilepsy, about 10% of the total number of patients suffer from mental disorders.

Important: the listed provoking factors can cause serious damage to the human psyche, therefore it is necessary to consult a doctor in time for adequate treatment in order to prevent mental disorders.

Seasonal personality disorder

Many of us are familiar with seasonal depression, especially in those seasons when there is little sun, it rains, and the sky is cloudy. But you should not confuse this state with the affective behavior of a person, which is repeated at a certain time of the year. People with SAD also have a problem due to the lack of sunlight, the main supplier of the hormone of cheerfulness, joy, energy. But at the same time, they absolutely cannot cope with the disorder of conduct, which is expressed in such signs as:

• long sleep;
• feeling overwhelmed;
• desire to sleep during the daytime;
• earlier awakening;
• low mood;
• falling self-esteem;
• feeling of hopelessness, despair;
• tearfulness;
• inability to cope with everyday affairs, activities;
• irascibility;
• attacks of aggression, anger, irritability;
• stressful state, anxiety.

With affective disorder, it is difficult for a seasonal person to endure any stress, even minor troubles, he does not control not only social, but also eating, sexual behavior, which leads to an increase in body weight, sexual problems.

Tearfulness is one of the symptoms of personality disorder.

Pathology can occur at any age, but more often people aged 18 to 30 are exposed to it.

Disorder of personality and behavior in adulthood

In this case, the pathology can be expressed in different ways, it all depends on what clinical manifestations accompany a person throughout life. The individual characteristics of the individual matter, how his relationship with others has developed. Many signs are acquired not only at an early age, but also in later stages. Symptoms such as mixed, persistent for a long time refer to protracted and deeply rooted behaviors, since the person has managed to survive a lot of serious situations, and the psyche has developed a response.

A number of diseases inherent in the aging body are also a factor in the development of disorders in advanced age.

Important: personality disorder is a very serious diagnosis and for it you can miss a more dangerous ailment - schizophrenia, so you urgently need to consult a specialist and undergo a thorough examination.

Personality disorder and work

For individuals with certain types of PD, it is necessary to select a job taking into account the characteristics of behavior. With the right choice, work helps a person realize himself, adapt with society, meet financial needs, and most importantly, switch from disorders to more positive activities. Employment includes several stages:

1. Protected - the patient works under the constant supervision of a doctor or social worker, the work is simplified, the regime is sparing.
2. Transition - work with the usual regime, but control by a social worker or doctor continues.
3. Common grounds - work at the usual place, with training at the enterprise, control is maintained.

No specialist will give universal recommendations regarding the employment of a person with PD. It all depends on individual abilities and the severity of the symptoms of the disease.

Work and work are not at all prohibited in personality disorder, but, on the contrary, are shown

With complex forms of disorders, doctors do not recommend getting a job, attending educational institutions until effective treatment has been completed and the diagnosis is eliminated.

How to treat personality disorder

To eliminate symptoms such as anxiety, panic, depression and others, medication is being taken. The drugs include psychotropic, neuroleptic drugs, serotonin inhibitors. Risperidone is used to exclude depresonalization.

Psychotherapy is aimed at correcting inadequate signs, but it is worth remembering that the treatment will be long. The cognitive-behavioral method allows the patient to pay attention to his behavior, and not the consequences caused by his actions. The specialist can force the patient to obey his orders, for example, stop screaming, speak quietly, calmly, control himself in moments of seizures. Of no small importance is the participation of relatives of the patient, who should also know the diagnosis of personality disorder, what it is, communicate with a specialist and develop a certain demeanor. Positive results can be expected after 5-6 months of constant exposure to the patient. The optimal treatment period is from 3 years.

How to remove a diagnosis of personality disorder

In Russia, free medical and consulting assistance is provided to persons with PD. Registration of patients with this diagnosis, as in the past, no longer exists. After appropriate treatment, patients are under dynamic examination at the dispensary for some time, that is, it is necessary to visit doctors within six months. People who want to find a job as a driver or a security guard tend to remove the diagnosis. If a patient does not visit a doctor for five years, then his card is transferred to the medical archive, from where it can be claimed by law enforcement agencies, the personnel department, etc.

Theoretically, it is possible to remove the diagnosis only after 5 years, but only if the patient was under observation for a year, and the doctor canceled the therapeutic therapy. For premature withdrawal of the diagnosis, it is necessary to go to a psychiatric clinic, undergo an examination, and obtain the approval of the commission. Some people with PD, feeling completely healthy, are confident in the positive decision of doctors, but the latter, in turn, may draw the opposite conclusion.

Personality disorders are a range of mental disorders that are accompanied by disturbances in consciousness, feeling, thinking and acting. Previously, this deviation was called constitutional psychopathy.

general information

A person with a personality disorder changes behavior completely. In social circles, behavior may differ from what is generally accepted and "normal." This type of psychopathy is accompanied by the destruction of consciousness. Each person has a different course of disorder. Lighter forms only distort the idea of \u200b\u200bthe world and people, and the severe course of psychopathy leads to asocial behavior and uncontrolled actions. The symptoms of the disorder are as follows:

Causes of occurrence

Personality disorder is most common in adolescents. In this case, the disease progresses and worsens the condition of a person at a more mature age.

According to the WHO (World Health Organization, labeling F60-F69), one in 20 people suffers from constitutional psychopathy.

As a rule, chronic and severe forms are rare.

The following aspects affect the development of the disorder:

Are personality disorders treated?

It is impossible to answer this question unequivocally. To do this, you need to study 3 types of personality disorder. Their treatment is prescribed individually, based on the degree and type of the disease:

A personality disorder is treated if a mental disorder is detected early. As a rule, many people are shy or afraid to visit a therapist who would help fight their inner "demons".

In 80% of cases, psychopathy ends with serious complications, which are accompanied by inappropriate behavior, problems with communication. It all depends on the type and type of disorder. If there is a genetic predisposition, then the treatment will be difficult, long and ineffective. If psychopathy is acquired, then with the help of regular psychological assistance, attending trainings and the use of medications, a person will be able to lead a full life.

What is avoidant personality disorder?

In clinical psychology, this type of psychopathy is called anxious or avoidant. Most often occurs in adolescents and young people aged 16 to 25 years. The reason is indifference, aggression, violence from parents, guardians and peers.

Manifestation of anxiety disorder:

This type of psychopathy is a serious disorder that is rarely examined and treated. The deviation can only be detected in a clinical setting.

Diagnosis of psychopathy

Only a psychiatrist can make a clinical diagnosis and prescribe treatment. If the cause of the personality disorder is head trauma or neoplasms on soft tissues, then the patient is referred to a neurologist and a surgeon, as well as for anamnesis: X-ray examination, MRI and CT.

When a diagnosis is needed, it is listed below:

Before making a diagnosis, a psychiatrist performs dozens of tests and monitors the patient. At this point, it is very important to be open and not hide your past, especially if the issues involve relationships with parents and peers.

Treatment of personality disorder

Two techniques are used to treat personality disorder. Treatment methods consist of medications and psychotherapy.

Treatment with medicines is prescribed if psychological assistance does not help. Indications for use: depression, anxiety and paranoia. Selective serotonin reuptake inhibitors (SSRI labeling), anticonvulsants, and anti-anxiety drugs are commonly used. For example, the most effective antidepressant is Amitriptyline. It not only reduces anxiety, but also acts on the central nervous system as an antiserotonin drug. Antipsychotics include Haloperidol, Aminazine, Olanzapine, and Rispolept.

Antipsychotics are psychotropic drugs that help with hallucinatory, paranoid, and delusional disorders. Antipsychotics are prescribed for the treatment of severe forms of personality disorder, which are accompanied by depression, manic excitement. The most powerful drugs are determined by the amount of chlorpromazine and its antipsychotic effect. The weakest are estimated at 1.0 coefficient, the strongest reach 75.0.

It is a proven fact that medications do not cure the root cause, but only muffle and calm the emotional state.

Also, medicines are intended to relieve painful symptoms (anxiety, apathy, anger). The psychiatrist's job is to analyze the patient and draw up the big picture.

To make the treatment effective, rules are introduced. For example, control aggression or anger, change thinking and attitude towards life. With personality disorder, individual therapy is recommended first so that the specialist gains confidence in the patient. Then group lessons are introduced. On average, psychotherapy takes 2-4 years.

If you ignore mental health problems, it can lead to the development of new mental illnesses. Against the background of constitutional psychopathy, schizophrenia appears, a paranoid, expansive and fanatical personality develops, as well as psychosis, delusional disorder and Asperger's syndrome. It is important to remember that with personality disorder, you cannot self-medicate, ignore warning signs, and avoid professional help.

Last updated: 22/11/2014

What is meant by personality disorder? How exactly is this type of disorder diagnosed and classified?
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), under personality disorder means “internal sensations and a stable tendency in behavior, markedly deviating from the norms accepted in the individual's native culture, penetrating into several spheres of personality at once, first appearing in adolescence or early adulthood, stable over time, capable of leading to suffering or significant deterioration of the condition. " Because these disorders are chronic and affect a wide variety of areas of the personality, they can seriously impair the quality of both daily life and activities.

What causes personality disorders?

The causes of personality disorders have long been the subject of significant controversy and controversy. Some experts believe that personality disorders are triggered by early experiences that interfere with the development of normal thinking and behaviors. Other researchers believe that the true cause of personality disorders is biological or genetic.
Although psychologists have not been able to conclusively determine the cause, it is likely that a combination of genetic predisposition and environmental factors contributes to the development of personality disorders.

How are personality disorders diagnosed?

For a person to be diagnosed with a personality disorder, they must exhibit symptoms that meet the criteria set out in the Guidelines.

• These behaviors must be chronic, affecting various aspects of a person's life - including social interaction, work, study, and close relationships.
• The person must exhibit symptoms that affect thoughts, emotions, interpersonal relationships, or impulse control.
• Behavior characteristics must be stable over a long period of time; the process of their formation can be traced back to adolescence or early adulthood.
• This behavior cannot be explained by any other mental disorder, addiction, or medical condition.

What are personality disorders?

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) lists a total of ten different personality disorders. These violations fall into three distinct groups:
Cluster A. Unusual or eccentric

Cluster B. Theatrical, emotional or hesitant

Cluster C. Anxious or panicky

Differential diagnosis

Before a doctor diagnoses a personality disorder, he must rule out other disorders or diseases that may also be causing the symptoms. After all, the symptoms characteristic of personality disorders are often similar to those of other disorders. I must say that personality disorders can also be accompanied by other diseases.
Prior to diagnosis should be ruled out.