Alcohol Withdrawal Timeline

Withdrawal symptoms from alcohol will vary with quantity and length of time of consumption. Alcohol withdrawal symptoms will be most severe, and careful treatment most necessary, when drinking has been significant for a long time.

The acute withdrawal syndrome can include seizures or psychosis as well as headaches, nausea and vomiting, sweats, irritability and craving. Professional medical help will be necessary to ensure that detoxification is carefully controlled.

Withdrawal symptoms will vary from one patient to another, depending upon general health and other dependence such as drug abuse.

Post-acute withdrawal syndrome, with depression and sleep disturbances and other distressing symptoms, may follow acute alcohol withdrawal after the initial withdrawal symptoms have resolved.

The symptom that tends to cause most distress in acute alcoholic withdrawal during detox from drink or drug use is anxiety, coupled with shivers and shakes. Hallucinations may occur. These symptoms usually resolve within a few days.

The neurologial effect of alcoholism is eventually very severe. Ethanol (the chemical name for alcohol) damages the brain. Chronic alcoholics or heavy drinkers therefore need to be prescribed Thiamine (vitamin B1) in order to protect the nervous system from further damage.

A decreasing dose of Librium (Chlordiazepoxide) given over five to ten days will cover the symptoms of alcohol withdrawal so that the patient is comfortable. Protracted withdrawals from addictive substances beyond ten days are usually not necessary in a supportive environment.

Patients may experience a psychiatric problem in early recovery when they recognise how toxic alcohol and other drugs have been to the body and mind as well as to the family and to the work situation and social environment.

Problems with alcohol and drugs can affect anybody. Addiction is an equal-opportunity condition. It causes social, professional and economic damage long after the acute effects of alcohol have worn off.

Acute withdrawal may be the least of the problems caused by acute alcohol withdrawal. When the individual decides to quit drinking, reality has to be faced.

Medication is generally not necessary in support of long-term abstinence. Antidepressants, tranquillisers and sleeping tablets may lead to more damage than benefit.

The most effective long-term therapy in preventing relapse is regular attendance at meetings of Alcoholics Anonymous and application of the recommended Twelve Step programme.

The disease of alcoholism is exceptional among psychological disorders because it can be put into full remission with, in most cases, no significant sign of previous impairment. The chronic drunk is given a new lease of life.

Symptoms Of Attention Deficit Disorder In Adults

It is commonly believed that ADD is outgrown with age. But, to some people, it comes as a surprise that they are ADD even in their adult years. Normally, they come to realize it when they go to a specialist for treatment of their ADD child. While trying to understand the symptoms of their child they realize that they are also having those same symptoms.

Earlier they did not realize that they were suffering from ADD because in their young years society, in general, was not much aware of this syndrome. It is only recently that people have started taking more interest in ADD in their children and try to get them cured of it. Adults with ADD have developed, over the years, several coping behaviors to deal with the problem.

How can an adult realize that he is suffering from ADD? There are some signs and symptoms through which ADD in an adult can be diagnosed. Following is a list of some such symptoms and behavior patterns –

Easily Distracted – The attention span of ADD adults is very short. They are very easily distracted unless they are very much interested in the subject at hand. People are generally irritated with these people as they do not listen attentively during conversations and their minds wander off the topic being discussed. To the other person, ADD adults appear disinterested and bored. They have difficulty in understanding directions. They also tend to misplace things frequently.

Restlessness – People with ADD suffer from a feeling of restlessness. They find it difficult to sit at one place for long and they keep on fidgeting and moving their legs and arms, if they are required to do so.

Not Organized – ADD adults are poorly organized. They are not able to stick to schedules, they are mostly late and they frequently misplace things. They often start some work or project that they leave unfinished and do not follow through to completion. They are easily distracted and bored. But, they can also be intensely focused on some activity or task in which they are really interested. In such cases they can devote long hours of concentrated activity.

Impulsive – These people often speak without thinking. They get angry quickly and always appear to be on short fuse.

Low Self Esteem – ADD adults often have negative self-images, which might be the result of broken promises, unfinished tasks or adverse comments of others. They mostly suffer from a feeling of anxiety and uncertainty. Even though some of these people are high achievers in their fields, still they suffer from a feeling that they are not good at anything.

Seek Stimulation – Such people are often on the lookout for high stimulus activities like gambling, paragliding or risky projects at their workplace. Such people easily get embroiled in hot arguments with others and waste lots of precious time in fruitless activities.

But, to put things in the right perspective, it is important to realize that many great people, who have excelled in their fields and many times, in more than one field, were ADD. Leonardo Da Vinci, Einstein and Churchill were all ADD adults.

Many of the ADD people become high achievers in their fields of interest because of their ability to get intensely focused on something that holds their interest. Many high achievers in medicine, law, art, science, etc., suffer from ADD.

The ADD adults are mostly very compassionate, though they are often misjudged as aloof and cold due to the fact they are not very sociable and talkative. They are generally very sensitive and brilliantly intelligent.

The ADD adults who are facing negativity in their lives and feel that they are not able to perform to the level they are capable of, should seek expert help to fully realize their potential.

Stop Eating for Comfort by Recognizing Your Triggers and Habits

The longer I work with clients the more I realise that most of us who have issues with food are simply hurting in some way and are looking for love/comfort. We may have a very loving relationship with someone else but if we don’t love ourselves there is something missing and we use food to fill the gap. For others it could be alcohol, drugs, gambling or smoking.

However food seems to be the most common as it is quick and easy, not hurting anyone else and can be easily hidden. Unfortunately however, we only feel good for a split second with the initial taste, then the guilt sets in, we feel uncomfortable and start to beat ourselves up which simply leads to more eating or bingeing. Unfortunately eating food only keeps the emotion inside of us. Instead of facing our issues, we over eat which only creates further problems.

The only time our body actually wants food is when it is physically hungry. So when we eat for emotional reasons, it doesn’t work, because our body doesn’t want food, it wants comfort in some other way. So we keep eating waiting for that magic fix that never comes.

By learning how to eat “naturally” we are reconnecting with our body’s natural instincts of hunger and satisfaction. This will then fill the physical need and enable us to find positive, empowering things that will serve the emotional need. The wonderful thing about natural eating is that it is based on awareness. Once you are aware of your habits/triggers around food you can make a different choice.

The key is to honour your emotions, notice that you are sad or lonely or stressed out. Sometimes a good cry is the answer as this enables you to get the emotion out of your body. Other ways of doing this is to laugh, sing, scream or do something physical like running, biking or martial arts. Then you can think clearly and find that positive thing that will comfort you and move forward.

I encourage you to start thinking about the times that you overeat or binge and look to see if you can see a pattern. You will find it is based around certain activities and events which have led to negative habits. Because once you are aware of what you are doing you can find a way to avoid those triggers and make different positive choices.

Pathological Eating Disorders and Poly-Behavioral Addiction

When considering that pathological eating disorders and their related diseases now afflict more people globally than malnutrition, some experts in the medical field are presently purporting that the world’s number one health problem is no longer heart disease or cancer, but obesity. According to the World Health Organization (June, 2005), “obesity has reached epidemic proportions globally, with more than 1 billion adults overweight – at least 300 million of them clinically obese – and is a major contributor to the global burden of chronic disease and disability. Often coexisting in developing countries with under-nutrition, obesity is a complex condition, with serious social and psychological dimensions, affecting virtually all ages and socioeconomic groups.” The U.S. Centers for Disease Control and Prevention (June, 2005), reports that “during the past 20 years, obesity among adults has risen significantly in the United States. The latest data from the National Center for Health Statistics show that 30 percent of U.S. adults 20 years of age and older – over 60 million people – are obese. This increase is not limited to adults. The percentage of young people who are overweight has more than tripled since 1980. Among children and teens aged 6-19 years, 16 percent (over 9 million young people) are considered overweight.”

Morbid obesity is a condition that is described as being 100lbs. or more above ideal weight, or having a Body Mass Index (BMI) equal to or greater than 30. Being obese alone puts one at a much greater risk of suffering from a combination of several other metabolic factors such as having high blood pressure, being insulin resistant, and/ or having abnormal cholesterol levels that are all related to a poor diet and a lack of exercise. The sum is greater than the parts. Each metabolic problem is a risk for other diseases separately, but together they multiply the chances of life-threatening illness such as heart disease, cancer, diabetes, and stroke, etc. Up to 30.5% of our Nations’ adults suffer from morbid obesity, and two thirds or 66% of adults are overweight measured by having a Body Mass Index (BMI) greater than 25. Considering that the U.S. population is now over 290,000,000, some estimate that up to 73,000,000 Americans could benefit from some type of education awareness and/ or treatment for a pathological eating disorder or food addiction. Typically, eating patterns are considered pathological problems when issues concerning weight and/ or eating habits, (e.g., overeating, under eating, binging, purging, and/ or obsessing over diets and calories, etc.) become the focus of a persons’ life, causing them to feel shame, guilt, and embarrassment with related symptoms of depression and anxiety that cause significant maladaptive social and/ or occupational impairment in functioning.

We must consider that some people develop dependencies on certain life-functioning activities such as eating that can be just as life threatening as drug addiction and just as socially and psychologically damaging as alcoholism. Some do suffer from hormonal or metabolic disorders, but most obese individuals simply consume more calories than they burn due to an out of control overeating Food Addiction. Hyper-obesity resulting from gross, habitual overeating is considered to be more like the problems found in those ingrained personality disorders that involve loss of control over appetite of some kind (Orford, 1985). Binge-eating Disorder episodes are characterized in part by a feeling that one cannot stop or control how much or what one is eating (DSM-IV-TR, 2000). Lienard and Vamecq (2004) have proposed an “auto-addictive” hypothesis for pathological eating disorders. They report that, “eating disorders are associated with abnormal levels of endorphins and share clinical similarities with psychoactive drug abuse. The key role of endorphins has recently been demonstrated in animals with regard to certain aspects of normal, pathological and experimental eating habits (food restriction combined with stress, loco-motor hyperactivity).” They report that the “pathological management of eating disorders may lead to two extreme situations: the absence of ingestion (anorexia) and excessive ingestion (bulimia).”

Co-morbidity & Mortality

Addictions and other mental disorders as a rule do not develop in isolation. The National Co-morbidity Survey (NCS) that sampled the entire U.S. population in 1994, found that among non-institutionalized American male and female adolescents and adults (ages 15-54), roughly 50% had a diagnosable Axis I mental disorder at some time in their lives. This survey’s results indicated that 35% of males will at some time in their lives have abused substances to the point of qualifying for a mental disorder diagnosis, and nearly 25% of women will have qualified for a serious mood disorder (mostly major depression). A significant finding of note from the NCS study was the widespread occurrence of co-morbidity among diagnosed disorders. It specifically found that 56% of the respondents with a history of at least one disorder also had two or more additional disorders. These persons with a history of three or more co-morbid disorders were estimated to be one-sixth of the U.S. population, or some 43 million people (Kessler, 1994).

McGinnis and Foege, (1994) report that, “the most prominent contributors to mortality in the United States in 1990 were tobacco (an estimated 400,000 deaths), diet and activity patterns (300,000), alcohol (100,000), microbial agents (90,000), toxic agents (60,000), firearms (35,000), sexual behavior (30,000), motor vehicles (25,000), and illicit use of drugs (20,000). Acknowledging that the leading cause of preventable morbidity and mortality was risky behavior lifestyles, the U.S. Prevention Services Task Force set out to research behavioral counseling interventions in health care settings (Williams & Wilkins, 1996).

Poor Prognosis

We have come to realize today more than any other time in history that the treatment of lifestyle diseases and addictions are often a difficult and frustrating task for all concerned. Repeated failures abound with all of the addictions, even with utilizing the most effective treatment strategies. But why do 47% of patients treated in private treatment programs (for example) relapse within the first year following treatment (Gorski,T., 2001)? Have addiction specialists become conditioned to accept failure as the norm? There are many reasons for this poor prognosis. Some would proclaim that addictions are psychosomatically- induced and maintained in a semi-balanced force field of driving and restraining multidimensional forces. Others would say that failures are due simply to a lack of self-motivation or will power. Most would agree that lifestyle behavioral addictions are serious health risks that deserve our attention, but could it possibly be that patients with multiple addictions are being under diagnosed (with a single dependence) simply due to a lack of diagnostic tools and resources that are incapable of resolving the complexity of assessing and treating a patient with multiple addictions?

Diagnostic Delineation

Thus far, the DSM-IV-TR has not delineated a diagnosis for the complexity of multiple behavioral and substance addictions. It has reserved the Poly-substance Dependence diagnosis for a person who is repeatedly using at least three groups of substances during the same 12-month period, but the criteria for this diagnosis do not involve any behavioral addiction symptoms. In the Psychological Factors Affecting Medical Condition’s section (DSM-IV-TR, 2000); maladaptive health behaviors (e.g., overeating, unsafe sexual practices, excessive alcohol and drug use, etc.) may be listed on Axis I only if they are significantly affecting the course of treatment of a medical or mental condition.

Since successful treatment outcomes are dependent on thorough assessments, accurate diagnoses, and comprehensive individualized treatment planning, it is no wonder that repeated rehabilitation failures and low success rates are the norm instead of the exception in the addictions field, when the latest DSM-IV-TR does not even include a diagnosis for multiple addictive behavioral disorders. Treatment clinics need to have a treatment planning system and referral network that is equipped to thoroughly assess multiple addictive and mental health disorders and related treatment needs and comprehensively provide education/ awareness, prevention strategy groups, and/ or specific addictions treatment services for individuals diagnosed with multiple addictions. Written treatment goals and objectives should be specified for each separate addiction and dimension of an individuals’ life, and the desired performance outcome or completion criteria should be specifically stated, behaviorally based (a visible activity), and measurable.

New Proposed Diagnosis

To assist in resolving the limited DSM-IV-TRs’ diagnostic capability, a multidimensional diagnosis of “Poly-behavioral Addiction,” is proposed for more accurate diagnosis leading to more effective treatment planning. This diagnosis encompasses the broadest category of addictive disorders that would include an individual manifesting a combination of substance abuse addictions, and other obsessively-compulsive behavioral addictive behavioral patterns to pathological gambling, religion, and/ or sex / pornography, etc.). Behavioral addictions are just as damaging – psychologically and socially as alcohol and drug abuse. They are comparative to other life-style diseases such as diabetes, hypertension, and heart disease in their behavioral manifestations, their etiologies, and their resistance to treatments. They are progressive disorders that involve obsessive thinking and compulsive behaviors. They are also characterized by a preoccupation with a continuous or periodic loss of control, and continuous irrational behavior in spite of adverse consequences.

Poly-behavioral addiction would be described as a state of periodic or chronic physical, mental, emotional, cultural, sexual and/ or spiritual/ religious intoxication. These various types of intoxication are produced by repeated obsessive thoughts and compulsive practices involved in pathological relationships to any mood-altering substance, person, organization, belief system, and/ or activity. The individual has an overpowering desire, need or compulsion with the presence of a tendency to intensify their adherence to these practices, and evidence of phenomena of tolerance, abstinence and withdrawal, in which there is always physical and/ or psychic dependence on the effects of this pathological relationship. In addition, there is a 12 – month period in which an individual is pathologically involved with three or more behavioral and/ or substance use addictions simultaneously, but the criteria are not met for dependence for any one addiction in particular (Slobodzien, J., 2005). In essence, Poly-behavioral addiction is the synergistically integrated chronic dependence on multiple physiologically addictive substances and behaviors (e.g., using/ abusing substances – nicotine, alcohol, & drugs, and/or acting impulsively or obsessively compulsive in regards to gambling, food binging, sex, and/ or religion, etc.) simultaneously.

New Proposed Theory

The Addictions Recovery Measurement System’s (ARMS) theory is a nonlinear, dynamical, non-hierarchical model that focuses on interactions between multiple risk factors and situational determinants similar to catastrophe and chaos theories in predicting and explaining addictive behaviors and relapse. Multiple influences trigger and operate within high-risk situations and influence the global multidimensional functioning of an individual. The process of relapse incorporates the interaction between background factors (e.g., family history, social support, years of possible dependence, and co-morbid psychopathology), physiological states (e.g., physical withdrawal), cognitive processes (e.g., self-efficacy, cravings, motivation, the abstinence violation effect, outcome expectancies), and coping skills (Brownell et al., 1986; Marlatt & Gordon, 1985). To put it simply, small changes in an individual’s behavior can result in large qualitative changes at the global level and patterns at the global level of a system emerge solely from numerous little interactions.

The ARMS hypothesis purports that there is a multidimensional synergistically negative resistance that individual’s develop to any one form of treatment to a single dimension of their lives, because the effects of an individual’s addiction have dynamically interacted multi-dimensionally. Having the primary focus on one dimension is insufficient. Traditionally, addiction treatment programs have failed to accommodate for the multidimensional synergistically negative effects of an individual having multiple addictions, (e.g. nicotine, alcohol, and obesity, etc.). Behavioral addictions interact negatively with each other and with strategies to improve overall functioning. They tend to encourage the use of tobacco, alcohol and other drugs, help increase violence, decrease functional capacity, and promote social isolation. Most treatment theories today involve assessing other dimensions to identify dual diagnosis or co-morbidity diagnoses, or to assess contributing factors that may play a role in the individual’s primary addiction. The ARMS’ theory proclaims that a multidimensional treatment plan must be devised addressing the possible multiple addictions identified for each one of an individual’s life dimensions in addition to developing specific goals and objectives for each dimension.

The ARMS acknowledges the complexity and unpredictable nature of lifestyle addictions following the commitment of an individual to accept assistance with changing their lifestyles. The Stages of Change model (Prochaska & DiClemente, 1984) is supported as a model of motivation, incorporating five stages of readiness to change: pre-contemplation, contemplation, preparation, action, and maintenance. The ARMS theory supports the constructs of self-efficacy and social networking as outcome predictors of future behavior across a wide variety of lifestyle risk factors (Bandura, 1977). The Relapse Prevention cognitive-behavioral approach (Marlatt, 1985) with the goal of identifying and preventing high-risk situations for relapse is also supported within the ARMS theory.

The ARMS continues to promote Twelve Step Recovery Groups such as Food Addicts and Alcoholics Anonymous along with spiritual and religious recovery activities as a necessary means to maintain outcome effectiveness. The beneficial effects of AA may be attributable in part to the replacement of the participant’s social network of drinking friends with a fellowship of AA members who can provide motivation and support for maintaining abstinence (Humphreys, K.; Mankowski, E.S, 1999) and (Morgenstern, J.; Labouvie, E.; McCrady, B.S.; Kahler, C.W.; and Frey, R.M., 1997). In addition, AA’s approach often results in the development of coping skills, many of which are similar to those taught in more structured psychosocial treatment settings, thereby leading to reductions in alcohol consumption (NIAAA, June 2005).

Treatment Progress Dimensions

The American Society of Addiction Medicine’s (2003), “Patient Placement Criteria for the Treatment of Substance-Related Disorders, 3rd Edition”, has set the standard in the field of addiction treatment for recognizing the totality of the individual in his or her life situation. This includes the internal interconnection of multiple dimensions from biomedical to spiritual, as well as external relationships of the individual to the family and larger social groups. Life-style addictions may affect many domains of an individual’s functioning and frequently require multi-modal treatment. Real progress however, requires appropriate interventions and motivating strategies for every dimension of an individual’s life.

The Addictions Recovery Measurement System (ARMS) has identified the following seven treatment progress areas (dimensions) in an effort to: (1) assist clinicians with identifying additional motivational techniques that can increase an individual’s awareness to make progress: (2) measure within treatment progress, and (3) measure after treatment outcome effectiveness:

PD- 1. Abstinence/ Relapse: Progress Dimension

PD- 2. Bio-medical/ Physical: Progress Dimension

PD- 3. Mental/ Emotional: Progress Dimension

PD- 4. Social/ Cultural: Progress Dimension

PD- 5. Educational/ Occupational: Progress Dimension

PD- 6. Attitude/ Behavioral: Progress Dimension

PD- 7. Spirituality/ Religious: Progress Dimension

Considering that addictions involve unbalanced life-styles operating within semi-stable equilibrium force fields, the ARMS philosophy promotes that positive treatment effectiveness and successful outcomes are the result of a synergistic relationship with “The Higher Power,” that spiritually elevates and connects an individuals’ multiple life functioning dimensions by reducing chaos and increasing resilience to bring an individual harmony, wellness, and productivity.

Addictions Recovery Measurement – Subsystems

Since chronic lifestyle diseases and disorders such as diabetes, hypertension, alcoholism, drug and behavioral addictions cannot be cured, but only managed – how should we effectively manage poly-behavioral addiction?

The Addiction Recovery Measurement System (ARMS) is proposed utilizing a multidimensional integrative assessment, treatment planning, treatment progress, and treatment outcome measurement tracking system that facilitates rapid and accurate recognition and evaluation of an individual’s comprehensive life-functioning progress dimensions. The “ARMS”- systematically, methodically, interactively, & spiritually combines the following five versatile subsystems that may be utilized individually or incorporated together:

1) The Prognostication System – composed of twelve screening instruments developed to evaluate an individual’s total life-functioning dimensions for a comprehensive bio-psychosocial assessment for an objective 5-Axis diagnosis with a point-based Global Assessment of Functioning score;

2) The Target Intervention System – that includes the Target Intervention Measure (TIM) and Target Progress Reports (A) & (B), for individualized goal-specific treatment planning;

3) The Progress Point System – a standardized performance-based motivational recovery point system utilized to produce in-treatment progress reports on six life-functioning individual dimensions;

4) The Multidimensional Tracking System – with its Tracking Team Surveys (A) & (B), along with the ARMS Discharge criteria guidelines utilizes a multidisciplinary tracking team to assist with discharge planning; and

5) The Treatment Outcome Measurement System – that utilizes the following two measurement instruments: (a) The Treatment Outcome Measure (TOM); and (b) the Global Assessment of Progress (GAP), to assist with aftercare treatment planning.

National Movement

With the end of the Cold War, the threat of a world nuclear war has diminished considerably. It may be hard to imagine that in the end, comedians may be exploiting the humor in the fact that it wasn’t nuclear warheads, but “French fries” that annihilated the human race. On a more serious note, lifestyle diseases and addictions are the leading cause of preventable morbidity and mortality, yet brief preventive behavioral assessments and counseling interventions are under-utilized in health care settings (Whitlock, 2002).

The U.S. Preventive Services Task Force concluded that effective behavioral counseling interventions that address personal health practices hold greater promise for improving overall health than many secondary preventive measures, such as routine screening for early disease (USPSTF, 1996). Common health-promoting behaviors include healthy diet, regular physical exercise, smoking cessation, appropriate alcohol/ medication use, and responsible sexual practices to include use of condoms and contraceptives.

350 national organizations and 250 State public health, mental health, substance abuse, and environmental agencies support the U.S. Department of Health and Human Services, “Healthy People 2010” program. This national initiative recommends that primary care clinicians utilize clinical preventive assessments and brief behavioral counseling for early detection, prevention, and treatment of lifestyle disease and addiction indicators for all patients’ upon every healthcare visit.

Partnerships and coordination among service providers, government departments, and community organizations in providing treatment programs are a necessity in addressing the multi-task solution to poly-behavioral addiction. I encourage you to support the mental health and addiction programs in America, and hope that the (ARMS) resources can assist you to personally fight the War on pathological eating disorders within poly-behavioral addiction.

For more info see:

Poly-Behavioral Addiction and the Addictions Recovery Measurement System,

By James Slobodzien, Psy.D., CSAC at:

[http://www.geocities.com/drslbdzn/Behavioral-Addictions.html]

Food Addicts Anonymous: http://www.foodaddictsanonymous.org/

Alcoholics Anonymous: http://www.alcoholics-anonymous.org/

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Text Revision. Washington, DC, American Psychiatric Association, 2000, p. 787 & p. 731.

American Society of Addiction Medicine’s (2003), “Patient Placement Criteria for the

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http://www.asam.org/

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McGinnis JM, Foege WH (1994). Actual causes of death in the United States. US Department of Health and Human Services, Washington, DC 20201

Humphreys, K.; Mankowski, E.S.; Moos, R.H.; and Finney, J.W (1999). Do enhanced friendship networks and active coping mediate the effect of self-help groups on substance abuse? Ann Behav Med 21(1):54-60.

Kessler, R.C., McGonagle, K.A., Zhao, S., Nelson, C.B., Hughes, M., Eshleman, S., Wittchen, H. H,-U, & Kendler, K.S. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United

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Morgenstern, J.; Labouvie, E.; McCrady, B.S.; Kahler, C.W.; and Frey, R.M (1997). Affiliation with Alcoholics Anonymous after treatment: A study of its therapeutic effects and mechanisms of action. J Consult Clin Psychol 65(5):768-777.

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Whitlock, E.P. (1996). Evaluating Primary Care Behavioral Counseling Interventions: An Evidence-based Approach. Am J Prev Med 2002;22(4): 267-84.Williams & Wilkins. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services. 2nd ed. Alexandria, VA.

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