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This information is produced and provided by the National Cancer Institute (NCI). The information in this topic may have changed since it was written. For the most current information, contact the National Cancer Institute via the Internet web site at http://cancer.gov or call 1-800-4-CANCER.
For a number of years, investigators have reported stress or trauma-related symptoms such as avoidant behaviors, intrusive thoughts, and heightened arousal in survivors of cancer.[1,2,3,4] These symptoms resemble those seen in persons who have experienced traumatic events such as military combat, violent personal assault (e.g., rape), natural disasters, or other threats to life and are referred to collectively as post-traumatic stress disorder (PTSD).[5,6,7,8,9,10] Acute stress disorder (ASD) is a Diagnostic and Statistical Manual of Mental Disorders (DSM) mental disorder with a profile similar to that of PTSD but a shorter time to onset, within 4 weeks of a traumatic event. Thus the occurrence of PTSD and trauma-related symptoms in patients with cancer has been under increasing study, influenced by changes in the diagnostic criteria for PTSD in the DSM, fourth edition (DSM-IV).[5] The DSM, third revised edition (DSM-III-R),[11] specifically excluded patients with medical illnesses such as cancer from PTSD. The diagnostic criteria for PTSD in the DSM-IV, text revision (DSM-IV-TR), however, specifically include "being diagnosed with a life-threatening illness" as one example of a traumatic event.[12] Thus, people with histories of cancer can now be evaluated and considered at risk for PTSD.
Reviews note that post-traumatic stress has been studied in a variety of cancers including melanoma, Hodgkin lymphoma, breast cancer, and mixed cancers. Studies have varied, however, in whether they assessed patients for the full syndrome of PTSD (i.e., all DSM-IV criteria met) or only some of the PTSD-related symptoms (e.g., intrusive thoughts as measured by the Impact of Event Scale [IES]). Thus, incidence rates have varied accordingly. The incidence of the full syndrome of PTSD (meeting full DSM-IV diagnostic criteria) ranges from 3% to 4% in early-stage patients recently diagnosed to 35% in patients evaluated after treatment. When incidence of PTSD-like symptoms (not meeting the full diagnostic criteria) is measured, the rates are higher, ranging from 20% in patients with early-stage cancer to 80% in those with recurrent cancer.
In one German study, patients with breast cancer (n = 127) were evaluated for PTSD immediately postsurgery and 6 months after the first assessment.[13] The assessments included screening instruments for ASD and PTSD, such as the IES-Revised (IES-R) and the PTSD Checklist-Civilian (PCL-C). First assessment also included a semistructured interview with the Structured Clinical Interview for DSM (SCID). On the basis of the SCID, 2.4% of participants met the criteria for mild to moderate cancer-related PTSD, and 2.4% were diagnosed with ASD. However, the screening instruments IES-R and PCL-C identified PTSD in 18.5% of participants at the first assessment and in 11.2% to 16.3% of participants at the second assessment. The study authors seem to suggest that unlike the SCID, the screening instruments IES-R and PCL-C measure diffuse emotional distress and adjustment problems and not precise PTSD symptoms. One of the main differences between symptom-based measures such as the PCL-C and an actual SCID-based diagnosis is the dysfunction caused by the symptoms. The symptoms are rather common, but only a very small percentage of people who have the symptoms are disabled by them.
Factors suggesting which patients might be at increased risk for the development of PTSD have not been extensively studied; however, one study of women with early-stage breast cancer [14] found that younger age, lower income, and fewer years of formal education were associated with PTSD-like symptoms. Another study of men and women treated with bone marrow transplant [15] found that lower levels of social support and the use of avoidance coping correlated significantly to a higher number of PTSD-like symptoms. One German study mentioned earlier [13] that evaluated patients with breast cancer for PTSD and ASD concluded that patients with lifetime PTSD (8.7%) were much more likely to experience cancer-related ASD or PTSD (odds ratio 14.1).
Although no specific therapies for PTSD in the cancer setting have been developed, treatment modalities used with other people with PTSD can be useful in alleviating distress in cancer patients and survivors.
In this summary, unless otherwise stated, evidence and practice issues as they relate to adults are discussed. The evidence and application to practice related to children may differ significantly from information related to adults. When specific information about the care of children is available, it is summarized under its own heading.
Reviews of the literature [1] note that post-traumatic stress has been studied in a variety of cancers, including melanoma, Hodgkin lymphoma, breast cancer, and mixed cancers. The incidence of the full syndrome of post-traumatic stress disorder (PTSD) (meeting the full Diagnostic and Statistical Manual of Mental Disorders, fourth edition [DSM-IV], diagnostic criteria) ranges from 3% to 4% in early-stage patients recently diagnosed to 35% in patients evaluated after treatment. When incidence of PTSD-like symptoms (not meeting the full diagnostic criteria) are measured, the rates are higher, ranging from 20% in patients with early-stage cancer to 80% in those with recurrent cancer.
The earliest research (predating DSM-IV) on PTSD among survivors of cancer concentrated on the prevalence and characteristics of the disorder in patients who had been or were undergoing treatment, adult and child survivors of cancer, and/or the family members of these patients and survivors. A wide variety of cancer types were studied, including leukemia,[2] breast cancer, and head and neck cancers.[3] Much of the earlier research dealt with survivors of Hodgkin disease, probably because diagnoses at an early age and higher rates of survival resulted in a larger population available for study.[4] These survivors were found to have a particularly high prevalence of intrusive thoughts and avoidance behaviors, even though they were many years posttreatment.[5,6,7] Most of these studies investigated PTSD-like symptoms, rather than the complete mental disorder with all diagnostic criteria.
The first study of cancer patients utilizing the current DSM-IV diagnostic criteria looked at 27 patients (mostly breast cancer), all at least 3 years postdiagnosis and no longer receiving any cancer treatments. In this study, a prevalence rate of 4% for current PTSD and 22% lifetime prevalence was found.[8] Those who met criteria for lifetime prevalence were noted to have higher levels of general psychologic distress, suggesting that individuals with a history of PTSD are at a substantial risk for continued emotional difficulties.
Studies using the Structured Clinical Interview for DSM (SCID) [9] have found prevalence rates of PTSD between 3% and 10% in adult cancer patients. Most of these studies looked at women with early-stage breast cancer, evaluated a few months to a few years after their cancer treatments. Similarly, in a prospective study of 115 patients with all stages of breast cancer being treated in a comprehensive cancer center, 4% met the full diagnostic criteria for PTSD; 41% met the subsyndromal criteria for PTSD (experiencing intense fear, helplessness, or horror after being diagnosed with cancer). This set of subsyndromal criteria was a weak predictor of PTSD (12%) but an equally useful predictor of major depressive disorder, global anxiety disorder, and past major depressive disorder, and it may better serve as a marker for elevated distress.[10] In a few studies of patients with bone marrow transplants, slightly higher prevalence rates have been reported, ranging from 5% [11] to 12% to 19% [12] to as high as 35%.[13] The range in prevalence appears to be influenced by time of assessment (higher rates occurring with more time since transplant) and the assessment method used. Studies reporting lower rates typically used a self-report questionnaire,[14] whereas those reporting higher rates [13] used the SCID and evaluated for symptoms at multiple times since diagnosis (i.e., lifetime prevalence).
As an illustration of the distinction between these tools, a German study evaluated patients with breast cancer (n = 127) for PTSD immediately postsurgery and 6 months after the first assessment.[15] The assessments included screening instruments for acute stress disorder (ASD) and PTSD, such as the Impact of Event Scale-Revised (IES-R) and the PTSD Checklist-Civilian (PCL-C). The first assessment also included a semistructured interview using the SCID. On the basis of the SCID, 2.4% of participants met the criteria for mild-to-moderate cancer-related PTSD, and 2.4% were diagnosed with ASD. However, the screening instruments IES-R and PCL-C identified PTSD in 18.5% of participants at the first assessment and in 11.2% to 16.3% of participants at the second assessment. Authors of the study seem to suggest that unlike SCID, the screening instruments IES-R and PCL-C measure diffuse emotional distress and adjustment problems and not precise PTSD symptoms. One of the main differences between symptom-based measures such as PCL-C and an actual SCID-based diagnosis is the dysfunction caused by the symptoms. The symptoms are rather common, but only a very small percentage of people who have the symptoms are disabled by them.
Post-traumatic stress disorder (PTSD) was initially characterized as an anxiety disorder that developed in response to a severe trauma in which an individual experienced, witnessed, or was confronted by actual or threatened death, injury, or loss of physical integrity of self or others. The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), stipulated for the first time that being diagnosed with a life-threatening illness or learning that one's child had such an illness qualifies as a stressful event.[1]
In 1994, the application of PTSD to patients with cancer began with the redefinition of the trauma criteria in the DSM-IV to include life-threatening illness.[1] The essential feature of this disorder is the development of characteristic symptoms following exposure to an extreme traumatic stressor.[2] These events elicit responses of intense fear, helplessness, or horror and trigger three clusters of PTSD symptoms. Symptoms from each of the following three clusters must be present for an individual to meet the full criteria for a diagnosis of PTSD:
These symptoms must last for at least 1 month and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Symptoms that last for at least 1 day but less than 1 month and that cause significant distress or impairment in social, occupational, or other important areas of functioning might meet the diagnostic criteria for Acute Stress Disorder (ASD). ASD is often a prodrome to PTSD.
The Conceptual Fit of PTSD and Cancer
Conceptual and practical problems can arise in the application of PTSD to cancer patients and survivors. The basic concept of an extreme traumatic stressor has been described variously as an event involving direct personal experience that involves actual or threatened death or serious injury.[2] This event can be protracted and continuous but is more frequently a single, time-limited event (e.g., rape, natural disaster). In this context, for the person who has experienced a diagnosis of cancer, the exact nature of the trauma is unclear. Is it the actual diagnosis, aspects of the treatment process, information given about recurrence, negative test results, or some other aspect of the cancer experience? Identifying a discrete stressor within the multiple crises that constitute a cancer experience is much more difficult than it is for other traumas. In one study of breast cancer patients [3] who underwent autologous bone marrow transplant, more PTSD-like symptoms were reported at the time of initial diagnosis.
Another concern regarding conceptual fit is related to reexperiencing the trauma. Diagnostic criteria B require persistent reexperiencing of the traumatic event, implying that the patient would first encounter a trauma and then, at a later time, reexperience it in various ways. In a study of women with early-stage breast cancer, however, researchers [4] found that the traumatizing aspects of the cancer experience were receiving the diagnosis and waiting for test results from node dissection. Arguing that these "information traumas" are future oriented and tend to cause intrusive worry about the future—not intrusive recollections of past events—the authors questioned whether cancer fits a conceptual model of PTSD trauma. Reexperiencing the trauma is often measured in terms of unwanted intrusive thoughts of the traumatic event. The cognitive processing of a current and ongoing health threat with uncertain outcome might differ significantly from unwanted intrusive thoughts about a single past event. Some researchers have argued that not all intrusive thoughts are negative or indicate reexperiencing a trauma, but rather that they might represent appropriate vigilance and attention to potential symptoms that could result in appropriate help-seeking.[5,6]
Conversely, a unique study assessing the physiological reactivity of breast cancer patients to a personalized imagery script of their most stressful experiences with breast cancer found elevated physiologic responses that were comparable to those of PTSD patients who had experienced other (noncancer-related) traumas. This finding suggests a good fit between cancer patients and the PTSD trauma model, as it shows comparable symptoms of increased arousal in cancer patients. Also, in a factor analytic study [7] designed to confirm the presence of the three broad PTSD symptom clusters (reexperiencing, avoidance of reminders, and hyperarousal), researchers found some tentative support for the DSM-IV symptom clusters in a sample of breast cancer survivors.
In a study of 74 women breast cancer survivors interviewed at 18 months postdiagnosis via the Structured Clinical Interview for DSM (SCID), three groups were identified: one meeting the full criteria for PTSD (n = 12), another meeting partial but not full criteria for PTSD (i.e., subsyndromal, n = 5), and a no-PTSD group (n = 47). Further analyses investigated group differences. Some notable differences between the full-criteria PTSD group and the subsyndromal group include a significantly higher number of violent traumas (e.g., physical abuse, rape) and a higher number of anxiety disorders prior to a cancer diagnosis among the full-criteria PTSD group.[8]
The PTSD group was also found to have more advanced disease (75% stage III vs. 7% in the subsyndromal group and 6% in the no-PTSD group), more extensive surgeries (83% modified radical mastectomy vs. 47% in the subsyndromal group and 38% in the no-PTSD group), and a higher lifetime prevalence of prior PTSD (42%) than the subsyndromal group (7%) and the no-PTSD group (9%).[8]
Further research will be needed to continue to investigate the important question of how well the conceptual model of PTSD as an anxiety response to a major life trauma fits the life experience of patients with cancer. Reviews have argued both in favor of [9] and against [6] the continued use of trauma models for conceptualizing the experience of cancer. Others have proposed alternate conceptual models.[5,10]
A variety of sociodemographic, disease-related, psychosocial, and psychological variables have been investigated to determine their relationship to post-traumatic stress disorder (PTSD). At present, no clear picture emerges about who is at increased risk of developing PTSD following diagnosis or treatment of cancer.
Sociodemographic Variables
Few patient characteristics have been shown to predict the occurrence of PTSD. High levels of psychologic distress have been correlated with both stress symptoms [1,2,3] and full-syndrome PTSD diagnoses in adult survivors.[1] In addition, trait anxiety was found to predict post-traumatic symptoms in the parents of survivors of childhood cancer.[4] Women who are survivors of cancer and who have a diagnosis of lifetime PTSD tend to have a history of exposure to trauma.[1,5] Demographic characteristics such as age, sex, and education level at time of diagnosis have not been reliable predictors of stress symptoms.[1,6,7]
Demographic variables that have been associated with a higher incidence of PTSD include younger age,[8,9] fewer years of formal education, and lower income;[10,11] however, one study [1] failed to find any significant differences between the mean age of cancer patients with or without PTSD. In noncancer community samples, PTSD occurs almost twice as often in women; however, the gender differences in incidence of PTSD in cancer patients has been mixed.
Disease-Related Variables
Disease-related variables that have been associated with a higher incidence of PTSD in patients who underwent bone marrow transplant include more advanced disease and a longer hospital stay.[12] Other studies, however, have found no association between time since diagnosis and treatment, severity of disease, or type of cancer treatment received.[1,9,11] The relationship between disease stage and post-traumatic symptoms has not been adequately studied. Most studies have not found an association; however, they typically include a limited range of disease stages or are studying early-stage cancer.[13]
The time since diagnosis and treatment has been shown to correlate with and predict post-traumatic symptoms in survivors of osteogenic sarcoma [2] and Hodgkin lymphoma.[7,14] Specifically, persons who were farther from diagnosis and treatment tended to exhibit fewer symptoms. This effect, however, has not been found in studies of patients with recent recurrences,[15] survivors of breast cancer,[1] or survivors of childhood cancers.[16] Duration of treatment, rather than time since treatment, has been shown to predict stress symptoms in survivors of childhood cancer.[16] (Refer to the PDQ summary on Pediatric Supportive Care for more information.)
The presence of pain and other physical symptoms has been shown to correlate with levels of intrusive thoughts.[2] Cancer recurrence has also been shown to increase the likelihood of stress symptoms in patients.[15]
Psychosocial and Psychological Variables
The experience of past traumatic events appears to be an important psychosocial risk factor associated with post-traumatic symptoms,[5,17,18] as was found in both early-stage [19] and metastatic breast cancer.[20] Previous trauma in combination with recent stressful life events was significantly related to post-traumatic symptoms.[21]
Other psychosocial risk factors such as premorbid psychopathology,[22,23] high levels of general psychologic distress,[24] and dysfunctional coping and attributional styles [17,25,26] have been linked to a risk for PTSD in war veterans, Holocaust survivors, and other disaster victims. In addition, several investigators have linked predisposing genetic factors [27] and other biologic factors (e.g., overly reactive hormonal systems and reduced hippocampal volume) to risk for PTSD.[28,29,30] Among social factors, the quality of the recovery environment, often measured in terms of social support, has been shown to affect risk for PTSD following exposure to combat [22] and burn injury.[31] The effect of threat to life and body integrity has been documented in samples of adults and families [1,4,14] but not children.[16]
Psychological variables that have been related to a higher incidence of PTSD include a history (precancer diagnosis) of PTSD,[5,10] increased use of avoidance coping, and lower levels of social support.[32]
Protective Factors
Greater perceived availability of social support is associated with fewer stress response symptoms in early-stage breast cancer patients [19,21] and in bone marrow transplant patients.[32]
The availability and timeliness of accurate health-related information may also offer protection from stress response symptoms. Women who met the diagnostic criteria for Acute Stress Disorder (ASD) reported significantly less satisfaction with the communication of their cancer diagnosis;[33] similarly, women who were unaware of their cancer stage reported higher stress response symptoms than those who were more knowledgeable about the stage of their disease.[34] To the extent that adequacy of information reflects the quality of a patient's relationship with medical staff, another protective factor may be the quality of those relationships. Difficult patient-staff relationships have been reported to be predictors of stress response symptoms in women with cancer.[35]
Hypothesized Mechanisms
PTSD is precipitated by an intensely distressing event; however, this factor alone is not sufficient to explain the disorder. Not everyone exposed to a traumatic stressor develops the full-blown syndrome (or subsets of symptoms) or qualifies for the diagnosis. Attempts to explain these differences and to predict who is vulnerable have focused on psychologic (i.e., learning theory), biologic (especially hormonal), and social (i.e., social support) factors. Early studies of Vietnam War veterans suggested a two-factor learning theory to account for trauma-related pathology.[36,37] The same theory has also been applied to development of PTSD in patients with cancer.[38,39,40]
PTSD symptoms develop as a function of both classical conditioning and instrumental learning. Classical conditioning accounts for the fear responses elicited by various stimuli that are associated with the original traumatic event. Neutral stimuli (e.g., smells, sounds, and visual images) previously paired with the aversive stimuli (e.g., chemotherapy or painful procedures) eventually evoke anxiety, arousal, and fear when presented alone, even after the trauma has ended. Higher order conditioning and stimulus generalization account for the exacerbation and extension of symptoms to additional stimuli. Once established, PTSD symptoms are maintained through instrumental learning, that is, avoidant responses are reinforced because avoidance of the stimuli prevents unpleasant feelings and thoughts.
Estimates from epidemiologic studies suggest that on average, 25% to 33% of individuals who are exposed to traumatic events, including cancer, develop PTSD.[28,41] Although the disorder appears to be a result of learning processes, many factors have been suggested to explain why one person develops PTSD and another does not.
A timely and careful assessment of cancer patients is critical to identify the symptoms of post-traumatic stress disorder (PTSD), to note the deleterious impact of the symptoms on functioning, and to plan interventions targeted at the most distressing symptoms. It is also critical that the assessment distinguishes between the full Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), PTSD syndrome (meets all required diagnostic criteria) and PTSD-related symptoms only.
The most difficult aspect of PTSD assessment in the cancer setting is the determination of precisely when to evaluate the patient. Diagnosis is complicated because cancer is not an acute or discrete event, but is an experience marked by repeated traumas and indeterminate length. Thus, an individual may exhibit the symptoms of PTSD at any point from diagnosis through treatment, to treatment completion and, possibly, to recurrence.[1] Patients such as Holocaust survivors whose history of victimization causes PTSD or its symptoms can have the symptoms activated by any number of stimuli encountered during their treatment (e.g., clinical procedures such as being inside magnetic resonance imaging or computed tomography scanners). While such patients may have more difficulty in adjusting to cancer and cancer treatment, their PTSD symptomatology is likely to vary greatly according to their circumstances. The relative predominance of specific PTSD symptoms may wax and wane throughout the cancer experience and beyond.[2]
The definition in the DSM-IV indicates that although PTSD symptoms usually begin within the first 3 months after trauma, there may be a delay of months or even years before symptoms appear.[2,3] These findings support the necessity for long-term monitoring of survivors of cancer and their family members.
At least one study found that individuals who have experienced a traumatic event may exhibit early symptoms without meeting the full criteria for a diagnosis of PTSD.[4] Nonetheless, the appearance of these early symptoms was found to predict later development of full PTSD syndrome. These results lend further credence to the need for both repeated and long-term follow-up of individuals exposed to the trauma of cancer. (Refer to the PDQ summary on Adjustment to Cancer: Anxiety and Distress for further information.)
The difficulty in properly diagnosing PTSD may be compounded by the overlapping of PTSD symptoms with those of other psychiatric disorders and by the time-related aspects of normal adjustment. For example, irritability, poor concentration, hypervigilance, excessive fear, and disturbed sleep are also symptoms of generalized anxiety disorder. Other arousal and avoidance symptoms are common to PTSD, phobias, and panic disorder, but loss of interest, sense of a foreshortened future, avoidance of other people, and sleep impairment might suggest both PTSD and depressive disorders. Even normal reactions to the diagnosis and treatment of life-threatening disease can consist of responses such as intrusive thoughts, disassociation and depersonalization, sleep disturbances, and heightened arousal. Therefore, clinicians and researchers must be particularly attuned to the causes, duration, and severity of PTSD-like symptoms when considering PTSD among several diagnoses. For instance, in a study of women with breast cancer, 41% reported experiencing "intense fear, helplessness, or horror" (DSM-IV PTSD diagnostic criterion A2); however, on further comprehensive diagnostic interview, only 4% met the full PTSD criteria. Assessment must be able to distinguish between general psychological distress and symptoms of PTSD.[5]
The accurate diagnosis of PTSD also requires the use of reliable and valid instruments. Many studies have used the PTSD module of the Structured Clinical Interview for DSM-III-R–Nonpatient Edition (SCID-NP).[6] This is a clinician-administered, structured clinical interview that is time intensive and may not be feasible in settings without adequately trained mental health professionals. However, one study [7] investigated the utility of a cost-effective screening tool, the PTSD Checklist-Civilian Version (PCL-C).[8] In this study of 82 women diagnosed with breast cancer assessed 6 to 72 months after cancer treatment, use of the PCL-C resulted in a sensitivity of .60 and specificity of .99. Other cutoff scores for the PCL-C that could be used were discussed, depending on the clinical resources available in specific cancer treatment settings. Most research studies have used the Impact of Event Scale, a self-report of intrusive thoughts;[9] however, it is important to note that this is not designed to be an assessment procedure for PTSD.
In attempting to diagnose PTSD, it is important to be aware that this disorder is often marked by comorbid psychopathology. Substance abuse, affective disorders, and other anxiety disorders are consistently encountered in samples of people with PTSD.[2,10,11,12] It has been reported that war veterans with PTSD exhibited substantial comorbid pathology that included major depression (32% to 72%), alcohol dependence (65%), drug dependence (40%), social phobia (50%), and obsessive-compulsive disorder (10%).[13] High rates of concurrent disorders have also been documented in other trauma victims. For example, 40% to 42% of disaster survivors with PTSD also qualified for a diagnosis of major depression, and 20% to 42% met the criteria for concurrent generalized anxiety disorder.[13,14] While this has not yet been studied in cancer patients or survivors, the presence of co-occurring psychiatric disorders in Vietnam War veterans and other trauma victims would indicate that cancer clinicians should be alert to the need to identify and treat such related syndromes in their patients.
The chronic and sometimes devastating psychologic and interpersonal sequelae of post-traumatic stress disorder (PTSD) necessitates timely and effective treatment of people with this syndrome.[1,2] The avoidant responses associated with PTSD often delay or prevent these individuals from seeking professional assistance. While no specific therapies for PTSD in the cancer setting have been developed, treatment modalities used with other people with PTSD can help alleviate distress in cancer patients and survivors.[3,4]
Most clinicians recommend using a multimodal approach, choosing components to meet the specific needs of each patient and taking into account any concurrent psychiatric disorders such as depression or substance abuse. Multiple modalities are frequently considered in a crisis intervention approach to facilitating adjustment of cancer patients.
The crisis intervention model comprises a broad range of therapies that can be helpful in the treatment of PTSD. The goals of this model are to reduce symptoms and restore patients to their usual levels of functioning. In this model, the therapist often takes an active, directive stance with the patient, focusing on resolving concrete problems, teaching specific coping skills, and providing a safe and supportive environment.[5][Level of evidence: II]
Cognitive-behavioral techniques have proven especially helpful within the crisis intervention setting. Some of these methods include helping the patient to understand symptoms, teaching effective coping strategies and stress management techniques (such as relaxation training), restructuring cognitions, and providing exposure to opportunities for systematic desensitization of symptoms.[6] In a single case study, a 10-session cognitive-behavioral intervention for a male cancer patient 3 years post–bone marrow transplant with PTSD was found to be effective. This study used a combination of cognitive coping strategies, relaxation procedures, relapse prevention, and generalization techniques; benefits were found to be maintained at a 6-month follow-up.[7][Level of evidence: III] Behaviorally oriented approaches to sexual therapy may also be useful when the avoidance manifested by patients is decreased sexual activity and avoidance of intimate situations.
Support groups also appear to benefit people who experience post-traumatic symptoms. In the group setting, such patients can receive emotional support and encounter others with similar experiences and symptoms, thereby validating their own experiences and learning a variety of coping and management strategies.
For patients with particularly distressing or severe symptoms, psychopharmacology may provide an additional means of treatment. Several classes of medications have been used in the treatment of individuals with PTSD.[8,9] (See the table below for a list of pharmacological treatments for PTSD.) For example, tricyclic and monoamine oxidase-inhibitor antidepressants are commonly used, particularly when the symptoms of PTSD are accompanied by depression. Selective serotonin reuptake inhibitors such as fluoxetine are effective in reducing the hyperarousal and intrusive symptoms of PTSD.[1] Antianxiety medications may help reduce overall arousal and anxiety symptoms. Infrequently, antipsychotic medications may reduce severe intrusive flashbacks.
Check NCI's list of cancer clinical trials for U.S. supportive and palliative care trials about post-traumatic stress disorder that are now accepting participants. The list of trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.
Editorial changes were made to this summary.
If you have questions or comments about this summary, please send them to Cancer.gov through the Web site's Contact Form. We can respond only to email messages written in English.
Purpose of This Summary
This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the diagnostic criteria for and treatment of post-traumatic stress disorder. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.
Reviewers and Updates
This summary is reviewed regularly and updated as necessary by the PDQ Supportive and Palliative Care Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).
Board members review recently published articles each month to determine whether an article should:
Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.
Any comments or questions about the summary content should be submitted to Cancer.gov through the Web site's Contact Form. Do not contact the individual Board Members with questions or comments about the summaries. Board members will not respond to individual inquiries.
Levels of Evidence
Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Supportive and Palliative Care Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.
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The preferred citation for this PDQ summary is:
National Cancer Institute: PDQ® Post-traumatic Stress Disorder. Bethesda, MD: National Cancer Institute. Date last modified <MM/DD/YYYY>. Available at: http://cancer.gov/cancertopics/pdq/supportivecare/post-traumatic-stress/HealthProfessional. Accessed <MM/DD/YYYY>.
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According to the Bureau of Labor Statistics, people who earned a Master's degree in 2016 earned about $25,000 more per year when compared to all workers;E-Bike 24V 14.5Ah Battery Electric Bicycle Bike Falter Wisper Fischer Mobime and people who earned a Doctorate degree in 2016 earned about $40,000 more per year when compared to all workers.ii
Item specifics
New: A brand-new, unused, unopened and undamaged item in original retail packaging (where packaging is ... Read moreabout the condition
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Finding the right graduate school is not easy for everyone. Life happens, and for various reasons some folks may face challenges they think may prevent them from becoming a graduate student. shoes Trekking Escursionismo TECNICA FORGE S GTX MSWe have extensively researched these biggest pain points and are happy to say, you do have options! Here is our list of top 5 resolutions to your biggest issues.
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According to a recent Aslanian Market Research report, more than 80% of respondents cited a career change as the #1 reason for continuing education[iii]. The reality is, when looking for a new job past experience may not be relevant enough to switch careers without going back to school.Ultra Max 48V 10AH Rechargeable Battery Electric Bicycle E-Bikes With Charger
Fortunately, most graduate degree programs do not require an applicant to have majored in the same content area, which makes it easier for someone to pursue a graduate degree in a new field as long as they at least hold a bachelor's degree.
While a profession may not require an advanced degree, it may be helpful to advance or to distinguish yourself from the pack.
Some people may choose to specialize in certain areas of a particular subject such as a Master of Accountancy (MAcc) or a Masters of Taxation (MTax), MS in Strategic Human Resource Management (MSSHRM), an MS or a MHA in Gerontology just to name a few.Vintage Champion Size 40 NBA bulk lot basketball jersey Jordan Payton Sprewell
While a four-year bachelor's degree used to be enough to reach most career goals, in today's world a graduate degree may set you apart.
Naturally advancing in a career could lead to higher pay, however, the attainment of a graduate degree also has the potential to increase earning potential in certain fields[ii].
For example, in the education field, the degree you have earned could determine your pay scale (in combination with the amount of years one has worked)[iv].
If you are considering going to graduate school for this reason, be very careful to weigh the costs of education (including the loss of earnings if you go to school full time) with your potential salary after graduation.
It is common undertstanding that practice-based doctorates are required for highly regarded and skilled careers such as a Doctor of Medicine (MD) or Doctor of Jurisprudence (JD) in order to practice law.
But, it is also true for other professional occupations as well!. It is qutie typical that a teacher can't become an adminitrator without earning a Supervisors Certificate or a MA in Education Leadership.[iv]Racing bike boeris campagnolo vintage
And it doesn't stop there, the same can be true for Physical Therapists, Counselors, Psychologists, Occupational Therapists, and Social Workers.[v]
While the undergrad years are marked by generalist coursework, graduate school typically entails more highly-focused studies and research in a chosen discipline. To this end, many grad school programs encourage students to narrow down their interests through a concentration. This focal area is often used to anchor independent research, internship experience, supervised practice and/or teaching. Learn more about the basics of grad school and view a comprehensive list of CTK LIGHT GUARNITURA X-HOLLOW SL-1 SPIDERLESS 530 gr. black.
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and Certificates
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Are you ready to commit the next one to two years taking a deep dive into a particular subject area? Considering an MBA? Check out our Step-by-Step Guide guide of the MBA enrollment process.
TRP Dash Carbon MTB Hydraulic Disc Brake Set F&R With 160mm redor ,WhiteOk, you've researched your preferred graduate degree, and have applied to multiple graduate schools. Now it's time to get down to the nitty gritty of your chosen graduate school's requirements as well as figuring out how you are going to finance your higher education degree.
It is possible you may be required to take part in a one on one or group interview. Show 'em what a stellar candidate you are by preparing your answers to some of the more commonly asked questions by colleges.
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subset: commoncrawl


text:
Eight Games That Changed Mid-Development
During development, video games go through hundreds if not thousands of changes before making it to the consumer. It's a regular part of the development of any game. For some games, however, we get to see them as they evolve, and by the time they release they look or feel much different than what we expected. Sometimes, after the game releases, the developers reveal just how much the game changed during development. These are some of the most drastic changes.
Okami is one of gaming's most visually-compelling experiences, but it didn't start out that way. In the beginning, Okami strived for realism. Switching to the cel-shaded art-style was done out of technical necessity so that Clover could fit as much onto the disc as possible. Once Clover landed on an art style it liked, however, it ran with it at full speed and created a game that will never look dated.
Borderlands, much like Okami, began its life with a realistic visual direction. The first teaser trailer for the game showed off a realistic shooter set in an intimidating wasteland. When the switch occurred, people were upset, but after the game released, everyone could see why the cartoonish-style meshed perfectly with the game's humor.
Resident Evil 2
Often referred to as Resident Evil 1.5, Resident Evil 2 was scrapped and restarted late in development before it became the game it is today. Leon didn't change much during the transition, but Claire was originally a character named Elza Walker, a college student vacationing in Raccoon City. Apparently, the game was nearly 80% finished before game director Shinji Mikami decided he wasn't happy with it and wanted to restart. You can find footage of the nearly finished game online today. Apparently, the story for the scrapped version of Resident Evil 2 was much more conclusive, and could have served as an ending to the series.
Resident Evil 4 and Devil May Cry
Resident Evil 4 and Devil May Cry have a strange developmental bond. Devil May Cry began its life as Resident Evil 4, but as the team moved further and further into development, they realized that the idea of playing as a super-powered bad-ass with a sword didn't fit into the Resident Evil canon. The characters were renamed, demons were added, and a new franchise was born.
Meanwhile, development truly began on Resident Evil 4. In a similar story to what happened with Resident Evil 2, the game was quite far into development when everyone threw up their hands and said, "Screw this! Let's start over!" The original version of the game had Leon fighting an evil fog, experiencing hallucinations, and fighting apparitions and ghosts. A trailer was released based on this version of the game, and you can even see a full three and a half minutes of gameplay footage above.
Conker's Bad Fur Day
It might not be surprising to learn that Conker started out as a children's platformer. The game was announced in 1997 and it looked like an unspectacular platformer that did little to separate itself from Rare's other Nintendo 64 titles like Banjo-Kazooie and Donkey Kong 64. The game went underground after it was first shown for three years, and re-emerged in 2000 as the profane adult-oriented game we know today. Outside of the trailer below, there is other evidence of Conker's childish roots in the form of Conker's Pocket Tales for Game Boy Color.
Bioshock's original story had nothing to do with Andrew Ryan, underwater cities, or genetic superpowers. Players took on the role of character hired by a senator to rescue someone from a cult and reprogram them back into the normal society. At one time, it even took place in the 21st century in a recently unearthed Nazi laboratory.
Splinter Cell
Splinter Cell began internally as an RTS at Ubisoft, and before it made its way to a stealth action game, it took a pit stop where it spent some time as an adventure game on a floating island. Ubisoft was basically throwing ideas at a board until something stuck, and that idea ultimately became a Metal Gear Solid stealth game competitor.
Team Fortress 2
Valve is renowned for allowing its games to gestate over a long period of time, and Team Fortress 2 was one of the developer's biggest offenders. The game was in development for nearly a decade. It was shown off for the first time in 1999 at E3 with a realistic military art direction, and then it just sort of disappeared. Many assumed the game had been abandoned as most of the team was working on other Valve projects. In 2006 the game was re-unveiled with its vastly altered art direction. In an interview with Robin Walker, co-creator of the original Team Fortress, about the development of Team Fortress 2 he said, "We ended up building probably three to four different games."


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There are a number of ways to redesign, remodel or redecorate your bathroom to new effect. Two popular ways to rethink your bathroom are via green technology (energy-efficient and water-saving toilets, LED lighting, all natural toiletries, organic cotton towels) or spa-style amenities (luxurious robes, scented candles, water jets in the tubs, radiant floor heating), but while these are great ways to approach bathroom design they don't need to be the singular theme in your bathroom.
While your function may be eco-friendly, spa or a mixture of the two, why not give your bathroom a little aesthetic push as well. Redesigning around a visual theme can give your bathroom flair and style to spare. Consider these five great options.
1. The library. While you won't want to bring your most beloved collection of books into the bathroom, there's no reason you can't go for a literary theme. Whether you've put up prints of your favorite authors, found a soap dish in the shape of an open tome, or simply keep a healthy stack of magazines and journals close by for commode browsing, books and bathrooms go better than one would expect.
2. The ocean. Freshness is key in any bathroom, and nothing feels quite as lively and clean as the ocean. Seagull prints, cool blue and green walls, a few nautical touches or a collection of seashells, all of these can help contribute to an oceanic quality.
3. Cities. This theme is especially fun to spread amongst several bathrooms. Devote your downstairs bathroom to New York City, while your upstairs revolves around London and the master bath takes Paris. Wallpaper with maps, frame photos of classic landmarks, buy a shower curtain printed with the subway system - there are a variety of ways to make each city your bathroom's own.
4. Classic movies. Consider going black and white with your bathroom's coloring and continuing the theme with film stills and vintage posters. Celebrate your favorite dramas, comedies and musicals of the silver screen!
5. Sports. Why not devote a bathroom to your favorite team? Pennants, wallpaper and a stack of Sports Illustrated back issues can help make this the fan's dream bathroom.
We won't share your information and you can unsubscribe at any time with a single click.


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There is goddess legend of Palace of the Dragon King in Shigira district of Miyakojima, and romance which small spring was in place where goddess met lover is conveyed.
And, based on findings of geologist that splendid hot spring appeared on this ground, we would excavate hot spring.
We dealt with hot water pulse at depth of 1,250m below ground, and hot water pillar stood, and spring in forest was born. Hot water which is abundant in good quality of source temperature 50 degrees, daily output 800t, color of hot spring shining in gold, besides.
Asia is the biggest continent on Earth, a darling little gem floating around in space.Hm, what is Asia? Who's in on it?China and India are safe bets for Asian nations. Korea, Japan, Thailand, you're fine.Europe? No. Europe would sort of be on the "Asian continent" if not for those pesky Ural mountains dividing things up in the middle, and then also the whole lineage of kings and wealth and nations and the EU and all that "give me my respect" stuff.Russia would probably be happiest as its own continent, so for now we'll leave it in "Eurasia" and just hope the natural gas supplies keep flowing.Pakistan and Afghanistan are dang close to Asia, but politically they show up in "Middle East" news stories an awful lot. Verdict: Eurasia.I guess we'll actually have to consider everything from Turkey on eastward to be "Eurasian", although the moniker seems overlappitory of the territory.The Asian economy is now officially raging like a wild furnace of lava that consumes everything in its path. Japan has had the largest individual economy in Asia for decades, but it is forecast that both India and China will outstrip Japan within twenty years.China is the largest holder of United States debt and is positioned to become the world's next superpower, provided that Godzilla doesn't return and decide to stomp everybody back into the Shang Dynasty.Text by Steve Smith.


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Dec. 14, 2009
All-American swimmer Anne Marie May, UC Santa Barbara men's volleyball coach Rick McLaughlin and baseball's Associate Head Coach Tom Myers will be featured on Tuesday's Talk'n Gauchos, UCSB Athletics' weekly radio show. The show will be broadcast live from the Thunderdome prior to Tuesday night's women's basketball game vs. UCLA. The show will air live on AM 1490 KIST from 6-6:45 p.m. on Tuesday, leading into the women's basketball broadcast vs. UCLA, on AM 990. For more information on Talk'n Gauchos, click here.
Fans can e-mail questions to the weekly guests, which will be read live on air. Click here to send in your questions. In addition, the show will be streamed live and archived online and fans can hear it by clicking here. This new streaming audio is also available for men's and women's basketball and baseball.
Anne Marie May recently won the 50 freestyle at the Finis Collegiate Invitational with a time of 22.34 which is currently tops in the country and a consideration time for the NCAA's. May was crowned Ms. Gaucho at last year's SB Awards.
McLaughlin is set to open the men's volleyball season in a couple weeks. Entering his second season as head coach, McLaughlin recently brought in one of the nation's top recruiting classes.
Myers will talk about his upcoming season - the 2010 baseball schedule was recently released as well as talk in depth about the Gauchos' plan to enhance Caesar Uyesaka Stadium with the exclusive "A Night With Tommy" featuring legendary Dodgers manager Tommy Lasorda. The event is scheduled for Feb. 5.
To purchase tickets to any UCSB athletics event, please call (805) 893-UCSB, visit the Ticket Office located inside the Intercollegiate Athletics building on campus or click here.
The Intercollegiate Athletics Ticket Office now has two parking spaces adjacent to the building and is now open on Saturdays, making it easier than ever for fans to purchase tickets. The ICA Ticket Office will be open from 10:00 am to 1:00 pm on Saturdays. The two parking spots, designated specifically for the ticket office, are already available during weekday hours, which are 9:00 a.m. to 4:00 p.m. Monday through Friday.
About the Gaucho Fund (G-Fund for short): The program was launched as part of the Dare to Be Great strategic plan and is UCSB Athletics' annual giving program to provide vital funding support for scholarships, academic success and leadership development for Gaucho student-athletes. The Gaucho Fund is the anchor to the Dare to Be Great campaign. For more information on Dare to Be Great, please click here.


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text:
Mountainsmith Specter
Light(ish), tough, with just enough pockets. Great…
Source: bought it new
Price Paid: $125
Light(ish), tough, with just enough pockets. Great multi-day pack.
I have the older steel blue version which I believe has a larger capacity. Not ultralight but for as large and tough as it is I can't complain.
I love the big J zip which let you get to nearly every layer in the main bag. The hip-belt buckle disintegrated the first time I used it. Very annoying but none of the smaller buckles have been a problem, even in the winter. Great suspension and ventilation. Starts to hurt around 50lbs.
This is my main pack and I'm quite happy with it.
I've owned this pack for about 10 years. It's a very…
Source: bought it new
Price Paid: $200
I've owned this pack for about 10 years. It's a very comforatable and durable. Lightweight too. Because it's a lightweight pack, the comfortable weight limit is around 35 to 40 lbs, although I've packed heavier loads.
- Comfortable
- Lightweight
- Weight limit around 35-40 lbs
That's it!
No longer made, so they are probably pretty hard to…
Price Paid: $180
No longer made, so they are probably pretty hard to find, but this is an outstanding pack. It's, big, lightweight and sturdy.
It's very comfortable and has a lot of great features. Includes a removal (small) daypack, J zipper, good venting, etc. You usually sacrifice things like the extra zipper and daypack on lightweight bags, but that's not the case here.
No complaints and it has held up well through about 5 years of occasional use for both backpacking and international traveling.
Very lightweight for a weeklong and beyond pack. 1,000…
Design: front and top loading internal frame
Size: 5200 cubic inches
Number of Pockets: 4
Price Paid: $329.95
Very lightweight for a weeklong and beyond pack. 1,000 miles of hiking with this pack. My only pick is the zippers are hard to use.
I have used the pack for a skiing hut trip in Colorado…
Design: Top loading with J zipper
Size: 5600
Number of Pockets: 3
Max. Load Carried: 25 pounds
Height of Owner: 5' 10"
Price Paid: $320
I have used the pack for a skiing hut trip in Colorado and day trips. It replaces my old Frostfire 5500 that was too heavy. This pack is light enough to use as a day pack, and carries a moderate load well enough to X ski. I also will use it to replace my weekend small pack. My only concern is that I will pack too heavy for short trips becasue I have the room.
Where to Buy
The Specter has been discontinued.previously retailed for:
$149.95 - $261.97
The Mountainsmith Specter is not available from the stores we monitor. It was last seen March 22, 2006 at Backcountry.com.


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If you are new to this forum family then you may be wondering what kind of goofy question is that on a health care forum. We all suffer with medical conditions and with most of us there is pain involved...sometimes a lot of pain. Or maybe you are the loved one of one of these persons. This forum is all about how we help and support each other, how we gain back more quality to our lives, and how we can learn and share what we gain along the way and hopefully make not only our lives better but the lives of others who come to join us. But we need to also remember that there is the other side of life...the side that isn't concentrated on illness and pain. That's why we started the daily Koffee Klatch. This is a time to laugh, reminisce, chit-chat about the silly things in our lives...all fun things and no pain. In fact the 'P' word is not allowed... So each day we share our thoughts or experiences on a different topic. Often it includes food, sometimes we talk about our past, and other times we just get goofy! Laughter is our goal. So, please join us whether this is your very first day on Healing Well or you're a seasoned veteran.
All the bugs die!
I don't like the cold weather like I used to. I've lost most of my insulation and I'm constantly looking for warm stuff to wear. I enjoy being inside and making cookies or candy and keeping warm in the process.


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We have been keeping a little bit of a not so secret…secret…
Follow our social media on Facebook and Instagram, @sttropezbistroyxe and @parlorroom236 to find out more.
Cher & Jay
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DEAR JOAN: I have apparently angered a big crow and he (or she) harasses me every time he sees me in my yard, front or back. The crow makes lots of noise and flies by my head so close that I can feel the wind of it passing.
Do you know of any way to discourage crows from a neighborhood? We have far too many in our area.
I may have angered the crow as I often shoot at it with a crummy little pellet gun. The noise of the gun scares it off for about two minutes.
Chuck Roberts
Santa Clara
DEAR CHUCK: I had a good explanation, completely exonerating you of being the object of a crow's hatred, until I got to the part of your letter about your shooting at it. Now I'm thinking maybe you've picked on the wrong bird and it is personal.
Usually, crows, as well as mockingbirds and others, will swoop down on innocent bystanders as a way to warn them away from a nest. They usually don't make contact, except maybe a gentle brushing of the wings. Actually hitting you will likely cause more harm to them than you. But don't blame them; they are just being good parents, trying to distract you from their babies.
However, because you've engaged in a war with the bird, it may now recognize you and it's obvious that it doesn't like you at all. Crows are particularly bright. Scientists have classified their intelligence as being on the same level of the great apes.
If it were just about the nest, the attacks should have stopped by now, as the babies will have fledged. If the crow is still after you, it's definitely about you.
I know you want to get rid of the crows, but it may be easier to just make friends with them by tossing out some bird seed when you see them. The angry crow will eventually come to recognize you as the bringer of food, instead of the bringer of a crummy pellet gun.
The Bay Area — in fact, much of the nation — has a serious problem with an overabundance of crows, and there is concern that these smart, aggressive birds are pushing out others. Getting them to move elsewhere is difficult.
First, remove as many sources of food from your yard as possible (bring pet food inside, empty the bird feeders and keep the lid on your garbage can tightly closed); take away water sources; cover fruit trees and vegetable gardens; and lastly, pick up a CD of predator calls and play it loudly in your yard, several times a day and at different times.
DEAR JOAN: I am having a problem with some type of animal that comes every evening and leaves its deposit of poop close to my house. At first, it resembled human feces, but lately they're more runny.
I looked on Google for information and they suggested either a concoction of strong spices and liquid, or mothballs. I spread an entire box of mothballs around after cleaning the area and depositing sand over it. Lo and behold, the mothballs all disappeared, but the poop is back.
Could this be an opossum? And do you have any idea as to how I can get this animal to frequent another area away from my house?
Pat Humphrey
South Bay
DEAR PAT: It could be an opossum, but the repeat visiting sounds more like a raccoon.
I'd try Critter Ridder, available at a home supply store near you. Use as directed. Motion detectors that turn on lights or shoot a burst of water also may work. You can even leave a radio, tuned to a talk show, playing at night.
I'd be careful with the mothballs as they are toxic, but they obviously didn't work, so no problems there.
Contact Joan morris at firstname.lastname@example.com.


text:
Wife to Public Enemy No. 1, George "Machine Gun" Kelly, Kathryn Kelly tells the story of how she and her notorious husband almost pulled off the kidnapping and ransom of Oklahoma oil tycoon,Charles Urschel under the regime of FBI Director J. Edgar Hoover in 1933. *****
Back to All Events
Earlier Event: March 27History In Hand - 3rd Floor Prohibition Saloon
Later Event: March 28History In Hand - 3rd Floor Landing


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J R Consumer Resources Inc., Clarkston, Wash., in August will release an updated edition of its 170-page "RV Comparison Guide" covering the years 2008-2010 with ratings of RV manufacturers broken down into "premium," "above average" and "economy RV" manufacturers.
"I try to be an non-biased as possible," said J R Consumer President Randall Eaton. "I don't own an RV. Nobody pays me, and I don't go to conventions or club gatherings. I'm an outsider in the sense that I don't rub shoulders with anyone in the RV industry."
The company since 1999 also has published comparison guides for the manufactured housing and modular home markets.
The "RV Comparison Guide" doesn't rate brands specifically, but rather details how they are made, what their MSRP and retail values are and the types of uses they are designed for along with other information. "If a consumer isn't going to be a fulltimer, he doesn't need to buy a coach that is designed for full-time use," Eaton said.
The company talked to representatives from more than 50 manufactures to determine construction techniques, MSRPs and other information.
"I know that a lot of the information is one-sided coming from the company, but we gather data from places other than the manufacturers," Eaton said.
All of J R's books, including "2009 Top 100 RV Dealers," "How to Buy an RV and Save Thousands" and "RV Extended Warranties: How to Select the Best Warranty and Save Thousands!" — are available for download online at jrconsumer.com or in printed versions for prices ranging from $19.95 to $49.95.
Because the books are published in PDF format online and "on-demand" in printed form, they can be updated as necessary, Eaton said.
Additionally, the company has published on its website a variety of articles that explain the different types of RVs, their intended uses and other information the RV consumer might be interested in.
"How much a consumer wants to spend is a big part of it," Eaton said. "It's a general rating using a number of criteria. How does Keystone compare to Jayco? How does Country Coach compare to Damon?"
The first guide was published in 2006 and updated through 2008. The next version will duplicate 2008's reviews and add those from 2009 and new reviewed for the 2010 model year.


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Sony Ericsson Spiro a Manual / User Guide
This is the official Sony Ericsson Spiro a User Guide in English provided from the manufacturer. If you are looking for detailed technical specifications, please see our Specs page.
Sony Ericsson Spiro is a dual-band GSM slider phone for the music fans. It has a QVGA display, 2MP camera, microSDHC card slot, stereo Bluetooth, and organizer.


text:
Oracle embraces old Java apps in next IDE
Preview two
Oracle has come a step closer to releasing the next version of its popular Java integrated development environment (IDE), by posting a second technology preview.
The JDeveloper 11g preview is a significant update to the first, released this spring, as Oracle claimed it would let developers migrate applications they've built using the current version of its IDE - version 10.1.3.
This latest technology preview has been released by Oracle with a view to getting feedback from developers and ironing out bugs and features. While there's still no official word on JDeveloper 11g, the database giant's IDE is expected next year.
JDeveloper 11g is expected to feature improved data binding and application server integration, Ant debugger support and improved JUnit 4.0 support. JDeveloper 11g should also serve as the development tools for Oracle's Fusion-branded suite of applications and middleware. That will mean more use of JavaServer Faces (JSF) components for things like AJAX to "web 2.0 enable" applications, such as the next release of Oracle's customer relationship management (CRM).®
Sponsored: What next after Netezza?


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Caribbean Restaurant Featuring
Authentic CaribbeanFood in a Family AtmosphereBakersfield, CaliforniaTakeout Available
Come to
Mama Roomba for authentic Caribbean food in a
relaxing family-style restaurant. Our family-owned-and-operated
Caribbean restaurant is located in Bakersfield, California, and
offers all of our dishes "tapas" style, which means small family
style dishes, and are perfect for sharing. Each dish is cooked with
different spices grown on the Islands. Among the most commonly used
are cinnamon, nutmeg, mace, allspice, and cloves. Other distinctive
flavorings include ginger, garlic, coconut, and rum. These
flavorings make our dishes more flavorful, enjoyable and
Stop by our Caribbean restaurants excellent location on
Wall Street Alley and Eye Street.
Top Selling Items:Seafood | Sampler w/ Mango Salsa | Mussels |
Calamari | Beef | ChickenSalads | Soups | Desserts | Corn Cakes | Mozzarella | Rice |
Beer, Wine, & Specialty
Drinks:Beer | Wine | Sangria | Mojitos Cocktails
The Best Caribbean
Restaurant in TownOur Caribbean restaurant not only gives you great
food choices, it gives you a fun and relaxing atmosphere with good
feeling background music, and reasonable prices. You don't need a
reservation when you come, but it is required for parties of 8 or
more. We do have handicapped accessibility, and offer you a
bi-lingual staff.
Contact us at our Caribbean restaurant in Bakersfield,
California, for greatauthentic Caribbean food in a fun family
Hours of Operation:Monday–Friday, 11:00 a.m.–10:00 p.m.Saturday, 5:00 p.m.–10:00 p.m.
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EAU CLAIRE, Wis. (Blugolds.com) – The fourth-ranked UW-Eau Claire men's hockey team remained undefeated on the season with a 6-3 victory over Concordia University (Wis.) at Hobbs Ice Center today.
The Blugolds also won 12-4 last night to push their unbeaten streak to 10 games as they improve to 9-0-1 on the season. Eau Claire is currently on its longest undefeated streak in school history.
Eau Claire had two goals in each period today.
Jon Waggoner (Jr.-Fairbanks, Alaska/Lathrop) led five Blugolds who scored goals as he finished with two. Waggoner scored both Blugold goals in the third period, a short-handed goal at 4:30 and the team's final goal of the game at 17:27.
Mark Pustin (Jr.-Northridge, Calif./Granada Hills) got the Blugolds on the board today with an even strength goal at 11:17 in the first period and Isaiah Bennis (Sr.-Eau Claire, Wis./Memorial) followed with another at 12:01 to give the Blugolds a 2-0 lead. Concordia scored less than a minute later and the score was 2-1 at the end of the first period.
In the second period, The Blugolds also scored two goals. Jordan Singer (Sr.-Lino Lake, Minn./Centennial) found the back of the net at 8:27 and Brian Nehring (Jr.-Hopedale, Mass./Milford) scored what eventually proved to be the game-winner at 18:10.
Pustin led the Blugolds with three assists.
Eau Claire outshot the Falcons 53-20 and Blugold goalie Alex Bjerk (Sr.-Roseau, Minn.) made 17 saves to improve to 2-0 on the season.
Concordia drops to 4-5 on the season.
The Blugolds will be home again next Friday and Saturday for a series against conference opponent UW-Stevens Point. The puck will drop at 7 p.m. both nights.


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Business Consultation Request
At Webster, we take your banking personally and our committed team of certified business bankers will work hard for your business. We teamed with Moody's Analytics to certify our business bankers in financial analysis, risk evaluation, and management expertise. Let us put our experience to work for your business.


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By Ray Beckerman
Man's inhumanity to man and other living things threatens the whole human experiment. Let's fight it, and try to build a future.
Friday, August 10, 2012
Don't Let Wyoming's Wolves Be Sacrificed
Posted by raybeckerman at 5:43 PM
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Important news!
Starting May 1st, the Willis-Ekbom Disease Foundation is reverting to its original name: Restless Legs Syndrome (RLS) Foundation.
After adopting the term Willis-Ekbom disease in 2013, the Foundation and the board believes that the terms restless legs syndrome will better support its mission of improving the lives of people with RLS by increasing awareness, improving treatments and through research, finding a cure.
Karla Dzienkowski, the executive director of the RLS Foundation, explained why. "We have heard from countless Foundation members, healthcare providers and researchers that restless legs syndrome is their preferred term. It is descriptive and easy to use. And it is the name almost universally used in medical and scientific circles, including the daily conversations that our members have with their doctors and families. The familiarity and name recognition of restless legs syndrome will best support the Foundation's fundraising, membership and education efforts going forward."
As moderators, we recall that there were many strong opinions about the name change in 2013. Some of us may prefer the return, some of us may not. Either way, the decision is made and we hope that the name is much less important to us than what the Foundation can do to support and help us, its members.
http://www.rls.org/file/press-releases/ ... id=2825699
WED/RLS occurs more frequently in certain populations, including people with end-stage renal disease, women during pregnancy, and people with iron deficiency. Also, RLS/WED in the elderly and children brings other challenges. Sharing your experiences may be extraordinarily helpful to others.
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Opinions presented by Discussion Board Moderators are personal in nature and do not, in any way, represent the opinion of the RLS Foundation
Opinions presented by Discussion Board Moderators are personal in nature and do not, in any way, represent the opinion of the RLS Foundation
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14 November 2012 at 8.43am | Comment on this article
Wayne McGregor | Random Dance and Infra composer Max Richter are presenting a monthly performance of a new work in the Barbican's Rain Room installation.
The piece sees a troupe of dancers respond to the installation, a room filled with rain by Random International, except where visitors are standing. It is described as an opportunity to "control the rain". This is made possible by 3d sensory cameras fixed to the ceiling, which turn the water supply on and off depending on visitors' movements.
Wayne and Max have collaborated on a number of projects. As well as Infra, they also created Sum; a chamber opera based upon David Eagleman's book Sum: Forty Tales from the Afterlives.
Upcoming performances in the Rain Room will take place on 18 November, 2 December, 20 January and 24 February. The installation is open daily for free without performances until 3 March 2012.
Listen to Max Richter's score for the work
Max Richter's Infra is on stage at the Royal Opera House until 14 November as part of a Mixed Bill also featuring Viscera and Fool's Paradise. Wayne McGregor | Random Dance perform FAR from 15 - 17 November and a Mixed Programme of new works in the Linbury Studio Theatre from 22 - 24 November.


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My Content
Membership has its privileges! Sign up or sign in to gain full access to both All About Jazz and Jazz Near You. Learn more.
When Basie passed away in 1984, the guys decided to stay together and their saxophonist/arranger Frank Foster led the group for a number of years, followed by trombonist Grover Mitchell. Recently another alumni trombonist, Bill Hughes, was called upon to take the director spot. In just a short time Hughes has shaped the Basie orchestra into a crack team that combines the Basie sound with just a touch of modernism in the arrangements. The orchestra creates both nostalgic joy and rocking sound for their audiences, with traditional charts, some newer ones and state-of-the-art solos by every musician in the 17-piece ensemble. Bill has maintained the Basie tradition while at the same time bringing in his own unique qualities as a leader and musical force. The combination of old timers from the original band and young guys with a real flair for their instruments assures continuity while keeping the band up-to-date in today's competitive jazz scene.
When I heard the band at the Kimmel Center in May (2005), their thrilling performance got me off my seat and backstage to ask Bill if he would do an interview for All About Jazz. He was delighted to do so. Bill is a guy who comes across as easygoing, warm and friendly, yet totally aware of everything going on around him at every moment. It was a pleasure to interview him. I am sure you will enjoy reading the interview as much as I did speaking with him.
Bill Hughes, The Trombonists and joining the Basie Band
The Evolution of the Basie Sound
The Good Old Times
Getting Up To Date
One More Time: A Summing Up
Bill Hughes: I'm ready to go when you're ready to go. By the way, your review of the Kimmel concert was great, man.
AAJ: Thanks, Bill. First we'll go back to the past, then talk about the Basie Orchestra today.
BH: Sort of a chronological line.
AAJ: Right. By the way, Count Basie's autobiography, Good Morning, Blues, which you recommended to me, is a fabulous book. Thanks for turning me on to it. Also, a propos of your instrument, I'm a former trombonist myself. I studied with Alan Raph in New York.
BH: Oh, yes. I know Alan. He's had a great career.
AAJ: Let's start out with the usual warmup question. If you were going to be on a desert island, which recordings would you take with you?
BH: Gustav Mahler. There's something about his music that keeps me locked on the whole time the orchestra is playing.
AAJ: I too appreciate Mahler's music. The connection between jazz and classical influences runs deep. Charlie Parker and the bebop generation were turned on by Stravinsky, for example.
BH: That's true.
AAJ: What about jazz recordings?
BH: I was a great J.J. Johnson lover. Early on, I tried to fashion my phrases after J.J. He came up a few years before me and was very innovative as to the way he was phrasing, as if he had a valve instrument rather than a slide. That affected me greatly. And he was also able to manipulate that thing very fast and, of course, I tried to hook onto that too. He was one of my main heroes.
AAJ: J.J. and I became friends in his last years.
BH: Well, I became a friend of his, too, and although I never got a chance to work with him I had many conversations with him. He meant a lot to me. By the way, are you still playing, Schermer?
AAJ: No, I'm too much of a perfectionist. I don't have time enough to keep my chops up.
BH: I understand.
Start your music shopping from All About Jazz and you'll support us in the process. Learn how.


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Sunday, February 24... Attention Brazoria County tennis enthusiasts: Community Tennis Clinic at the Columbia Lakes Tennis Center in West Columbia today: 2-3:30PM. Adults and Juniors welcome... Perfect activity for the family...! Text 713-818-9109 to attend! ~ Coach Sam Chadwell
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Tennis Center physical address: On property at 188 Freeman Blvd, West Columbia, Texas 77486
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- Windows: Download (Requires XNA 4.0 runtime)
- Mac (OS X 10.5+): Download (Req. Mono Framework, opt. 360 Gamepad Driver)
- Linux: Download (see official Linux thread)
NOTE: We'd love to do every single goal listed here regardless of the amount raised, but we will be constrained by both time and money. If we don't reach a listed goal, that doesn't necessarily mean it won't be in the game. These targets are just a way to ensure you that it will be in the final copy on release day. We will do everything in our power to get every single one of them in. They are ordered roughly by amount of content & time required, as well as how much longevity they will add to the gameplay.
- $160,000 - Extended Soundtrack - A digital double album: one of remixes, the other of demos, out-takes and unused material.
- $175,000 - Achievements - Challenging Achievements to obtain in all versions of the game. These won't be awarding you for pressing jump!
- $200,000 - Arena Mode - Battle waves of enemies and bosses in an arena for unique items after you complete the main game.
- $215,000 - Crafting - Search for long-lost recipes of rare items, and the difficult to obtain ingredients to craft them.
- $230,000 - Roguelike Mode - Challenge yourself with unidentified & cursed items, hunger, permadeath, & constantly shifting dungeons in this mode.
- $250,000 - New Game+ - Play through the game again with your character, battle harder enemies, and find an array of new items.
- $275,000 - Gender Swap - Play as a female soldier on the same perilous journey.
- $300,000 - Language Translations - Professional translations and localization into Spanish, French, German, & Italian.
- $325,000 - Extra Area - A seventh area added to the main game with its own unique challenges, treasure, and enemies.
- $350,000 - Community Choice Mode - Backers vote for their favorite from a selection of game modes by the developers.
The Game
Chasm (pronounced kaz-um) is a 2D Action-RPG Platformer currently in development for Windows, Mac, & Linux. Taking equal inspiration from hack 'n slash dungeon crawlers (procedurally generated dungeons, loot drops, etc) and Metroidvania-style platformers, the game aims to immerse you in its 2D fantasy world full of exciting treasure, deadly enemies, and abundant secrets.
We are attempting to create an authentic retro experience similar to the games you remember. Chasm was heavily influenced by games like Castlevania: Symphony of the Night, The Legend of Zelda, Metroid and Diablo. If these games are your style, then this is the game you have been waiting for!
In Chasm, players take up the role of a soldier passing through a remote mining town on their journey home from a long war. The town's miners have recently disappeared after breaching a long-forgotten temple far below the town, and reawakened an ancient slumbering evil. Now trapped in the town by supernatural forces, you're left with no option but to explore the mines below, battle enemies and bosses, and increase your abilities in hopes of finally escaping and returning home.
Current and Planned Features
- Explore Metroid-like dungeons procedurally assembled from hand-crafted rooms in six diverse areas.
- Enjoy challenging retro gameplay and gorgeous authentic pixel art (320×180 native resolution)
- Discover new special abilities and powers to reach previously inaccessible areas
- Play how you want by equipping weapons, spellbooks, shields, and more to both hands
- Uncover random loot drops and rare items
- Battle massive bosses & mini-bosses
- Avoid devious traps and platforming hazards
- Includes Normal and Hardcore (Scored with Permadeath) Modes
- Leaderboards for Hardcore playthroughs featuring quickest time, least damage taken, and more
- Windows, Mac, & Linux versions with Gamepad support
Why Kickstarter?
Since James quit his job last year to focus on Discord Games, he has been relying on income from sales of Take Arms to keep the company running. He knew Chasm was a much bigger game than he could afford to make, but thought that if he could do it right, people would see the potential of the idea.
We met our initial goal of a playable demonstration, but funds for development are now depleted. Simply put, this game can not be made without your support. We've been waiting forever for a game like this, but game publishers today just aren't interested in projects like this one. With your support, we will be able to finish the game ourselves and give you a truly amazing experience. Your generous pledges will go towards:
- Living Costs: James and Tim still need to eat, pay bills, and afford life-giving coffee while they develop the game.
- Paying Artists and Sound Designer: We will need money to pay our wonderful team for their hard work.
- Polish and Improvement: Making sure Chasm is a quality, bug-free game with enough time dedicated to it.
- Business & Legal Costs: To officially sell the game, we need to keep up with administrative costs and other expenses related to the business.
- Promotion & Marketing: We will need to commission awesome final box art, promotional graphics, video trailers, etc.
Access to the Game
Your pledge of $15 or greater will get you a copy of the final game when it's released. We do not know what will be our primary method of distribution, but regardless, we will give you a DRM-free copy for Windows, Mac and/or Linux. See below for estimated system requirements. We're aiming to be content complete early 2014 and then release the game by May 2014. This is subject to change, and the closed Beta will likely cause delays.
Pledging $30 or more ($25 for early birds!) will also give you access to our closed Beta. The exact date and details are still uncertain, but we will attempt to start it a couple months before the game is officially released to the public.The game will be highly playable at this phase (at least 90% content complete), but we will still be adding, removing and testing features. As a tester, you will have a direct effect on the game by playing and voicing your opinions and feedback on the private Developer forum. This also includes identifying any performance issues and bugs.
System Requirements
The requirements are subject to change. Chasm is being developed with older hardware in mind, and shouldn't be too demanding. However, due to how XNA's graphics system works, you will need at least a Pixel Shader 2.0+ capable graphics card. If you have any question of compatibility, please download the demo and try it out for yourself!
- OS: Windows (XP/Vista/7), MacOS X, or Linux
- Processor: 2ghz+
- Memory: 512 MB
- Graphics: Pixel Shader Model 2.0+
The Team
James is the founder of Discord Games, and serves as Producer, Game Designer and Programmer on Chasm. His two previous games 48 Chambers and Take Arms were released on Xbox 360 and PC, and have sold over 20,000 copies combined. He quit his corporate office job in 2012 to devote himself solely to the development of Chasm.
Tim has worked on both released Discord Games titles, and served as Lead Programmer on Discord's 2D multiplayer shooter Take Arms. He has been programming for over 10 years as both hobbyist and professional. He will be writing tools for content production in Chasm, as well as advanced engine features and gameplay programming.
Tony has worked as a 2D environment artist on over five released titles in the last two years. While environment art is his specialty, he worked tirelessly to develop Chasm's distinctive visual style. He will be handling the art direction and environment pixel art in Chasm.
Glauber has been working as a 2D game artist since 2004, on more than 30 released games (indie and commercial). His specialties are pixel art and animation, but is also very keen of game design and development. He will be handling sprite animations on Chasm.
Jimi has been writing music, recording and doing audio production for the last 15 years. In addition to his two albums and EP, he also wrote the music for both Discord releases (48 Chambers and Take Arms). He will be handling the music and sound effects in Chasm, as well as assisting with story and script.
Thank you and Follow Our Progress
- Website: www.chasmgame.com
- Forums: Talk about the game!
- Facebook: Like and share!
- Twitter: Follow us!
- Tumblr: Follow us!
- YouTube: Subscribe and watch!
- Steam: Greenlight this game!
If you have any questions about the game, please visit the FAQ at the bottom. If you'd like to reach out to us directly, drop us a line: firstname.lastname@example.com
Risks and challenges
Aside from normal game development risks that affect every project, the biggest risk is if James is suddenly unable to work. Rest assured, he rarely ever leaves his work space, so the chances of being hit by a bus are slim. The game would also not happen if we don't reach our funding goal.
We have put a lot of time and energy into this game, making something that we feel passionate about. We have done our best to create a realistic schedule and budget for development of the game. In addition, we have estimated every cost related to kickstarter rewards, including shipping and physical items.Learn about accountability on Kickstarter
Funding period
- (30 days)


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"If any of you lack wisdom, let him ask of God, that giveth to all men liberally, and upbraideth not; and it shall be given him.
"But let him ask in faith, nothing wavering. For he that wavereth is like a wave of the sea driven with the wind and tossed" (James 1:5–6).


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How to Use the Images
Photo 1
Photo 1
Questions for Photo 2
1. How does this landscape compare with the one shown in Photo 1? Based on the readings and the photo, what difficulties would a wagon train have had in getting through Raton Pass? Which kind of area do you think would have been more difficult to navigate?
2. How do you think the 400 Colorado volunteers managed to cross here in the deep snow? How might the fact that many of the volunteers were miners have made a difference?
* The image on this screen has a resolution of 72 dots per inch (dpi), and therefore will print poorly. You can obtain a larger version of Photo 2, but be aware that the file will take as much as 35 seconds to load with a 28.8K modem.


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Leadership Development
Trusted Coaching Croxton
Give your professional life a makeover and make a new resume and profile, or take the plunge to find a new employment you will enjoy. Have your resume stand apart from others and have a whole new outlook along with the creation of a new Linkedin profile expertly written. You can find out how to achieve this through our workshops.
Make that change to an interesting employment you really want, use the expert services on offer for better performance when searching for new employment and balancing your work experience with your qualifications to achieve the type of work you want. This could be to aim higher in your chosen career, or a completely new career change.
One to one or group workshops Croxton
In the workshops, you can have access to effective job search strategies and learn comprehensive interview skills. This includes a mock interview to practise your skill.
Our workshops are useful to graduates just leaving education, international graduates, young people just starting out on a career, and business professionals and executives who are looking to change career or aim higher in the one they already have.
Assistance with employment development will definitely aid any career you have or are interested in starting.
Career workshops will find emerging leaders that may not realise their potential. The workshops give purpose to your career planning, more confidence, and help you with personal branding. Any change of career will need some sort of training, and there is a relationship between work training and leadership development.
Perhaps you don't immediately think of being a leader, but your confidence will develop through the workshops.
With career workshops Croxton, the coaching includes career planning. This will depend on what you want to achieve. You will have access to vacancy searches, tier 2 and tier 5 vacancy search coaching, and help with internships if you need this.
Then, of course, the wonderful resume you have newly created will give you opportunities to practise your skill at interview. These workshops include comprehensive interview skills to give you confidence in your own abilities to achieve better performance at interview.