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Consult the standard iconographies on Western Christian art: Karl Kunstle buy discount emsam line anxiety yoga poses, Ikonographie der christlicher Kunst buy cheap emsam line anxiety 911, 2 vols purchase emsam visa social anxiety symptoms quiz. Boase, Death in the Middle Ages: Mortality, Judgement and Remembrance (New York: McGraw-Hill, 1972). On the impact of time on the French death-image, see Richard Glasser, Time in French Life and Thought, trans. Klein, Die Bereitung zwn Sterben: Studim zu den evangelischen Sterbebchem des 16. For customs see Placidus Berger, "Religiser Brauchtum im Umkreis der Sterbelitur-gie in Deutschland," Zeitschrift fur Missionswissenschaft und Religionswissenschqft 5 (1948): 108-248. See also Manfred Bambeck, "Tod und Unsterblichkeit: Studien zum Lebensgefhl der franzsischen Renaissance nach dern Werke Ronsarde," ms. Eberhard Klass, Die Schilderung des Sterbens im mittelhochedeutscken Epos: Ein Beitrag zur mittelhochdeutschen Stilgeschichte, dissertation, Univ. Patch, The Other World According to Descriptions in Medieval Literature (Cambridge, Mass. Emir Rodriguez Monegal, "Death as a Key to Mexican Reality in the Works of Octavio Paz," mimeographed, Yale Univ. Albert Freybe, Das alte deutsche Leichmmahl in seiner Art und Entartung (Gtersloh: Bertelsmann, 1909), pp. Henri Rondet, "Extrme onction," in Dictionnaire de Sfriritualit (1960), 4:2189-2200. Leibowitz, "A Responsum of Maimonides Concerning the Termination of Life," Koroth (Jerusalem) 5 (September 1963): 1-2. Paul Fischer, Strafm und sichemde Massnahmen gegen Tote im germanischen und deutschen Recht (Dsseldorf: Nolte, 1936). Fehr, "Tod und Teufel im alten Recht," Zeitschrift der Savigny Stiftung fur Rechtsgeschichte 67 (1950): 50-75. Karl Knig, "Die Behandlung der Toten in Frankreich im spteren Mittelalter und zu Beginn der Neuzeit (1350-1550)," ms. Hans von Hentig, Der nekrotrope Mensch: Vom Totenglauben zur morbiden Totennhe (Stuttgart: Enke, 1964). He was only the master of his life to the extent that he was the master of his death. From the 17th century onward, one began to abdicate sole sovereignty over life, as well as over death. These matters came to be shared with the family which had previously been excluded from the serious decisions; all decisions had been made by the dying person, alone and with full knowledge of his impending death. John Koty, Die Behandlung der Alien and Kranken bet den Naturvlkem (Stuttgart: Hirschfeld, 1934). Will-Eich Peuckert, "Altenttung," in Handwrterbuch der Sage: Namens des Verbandes der Vereine fr Volkskunde (Gottingen: Vandenhoeck & Ruprecht, 1961). Infanticide remained important enough to influence population trends until the 9th century. Death remained a marginal problem in medical literature from the old Greeks until Giovanni Maria Lancisi (1654-1720) during the first decade of the eighteenth century. The same philosophers who were the minority which positively denied the survival of a soul also developed a secularized fear of hell which might threaten them if they were buried while only apparently dead. Philanthropists fighting for those in danger of apparent death founded societies dedicated to the succor of the drowning or burning, and tests were developed for making sure that they had died. Elizabeth Thomson, "The Role of the Physician in Human Societies of the 18th Century," Bulletin of the History of Medicine 37 (1963): 43-51. The hysteria about apparent death disappeared with the French Revolution as suddenly as it had appeared at the dawn of the century. Doctors began to be concerned with reanimation a century before they were employed in the hope of prolonging the life of the old, 42 Theodor W. Adorno, Minima Moralia: Refiexionm aus dan beschdigten Leben (Frankfurt am Main: Suhrkamp, 1970). Ebstein, "Die Lungenschwindsucht in der Weltliteratur," Zeitschrift fr Bcherfreunde 5 (1913). Shryock, The Development of Modem Medicine: An Interpretation of the Social and Scientific Factors Involved, 2nd ed. The Social Organization of Death," in International Encyclopedia of the Social Sciences (New York: Macmillan, 1968), 4: 19-28. The thesis of death repression is usually promoted by people of profoundly anti-industrial persuasions for the purpose of demonstrating the ultimate powerlessness of the industrial enterprise in the face of death. Talk about death repression is used with insistence to construct apologies in favor of God and the afterlife. The fact that people have to die is taken as proof that they will never autonomously control reality. Fuchs interprets all theories that deny the quality of death as relics of a primitive past. He considers as scientific only those corresponding to his idea of a modern social structure. His image of contemporary death is a result of his study of the language used in German obituaries. He believes that what is called the "repression" of death is due to a lack of effective acceptance of the increasingly general belief in death as an unquestionable and final end. Cassel, "Dying in a Technical Society," Hastings Center Studies 2 (May 1974): 31-36: "There has been a shift of death from within the moral order to the technical order. I do not believe that men were inherently more moral in the past when the moral order predominated over the technical. A new kind of terminal therapy is suggested by Elisabeth Kubler-Ross in On Death and Dying (New York: Macmillan, 1969). She maintains that the dying pass through several typical stages and that appropriate treatment can ease this process for well- managed "morituri. There is a growing agreement among moralists in the early 1970s that death has again to be accepted and all that can be done for the dying is to keep them company in their final moments. But beneath this accord there is an increasingly mundane, naturalistic, and antihumanistic interpretation of human life. Morison, "The Last Poem: The Dignity of the Inevitable and Necessary: Commentary on Paul Ramsey," Hastings Center Studies 2 (May 1974): 62-6. Morison criticizes Ramsey, who suggests that anyone unable to speak as a Christian ethicist must do so as some "hypothetical common denominator. The cross-denominational analogies in their expressions, feelings, and attitudes towards death are much stronger than their differences due to varying religious beliefs or practices. But having determined that the condition is hopeless, I cannot agree that it is either prudent or fair to physicians as a fraternity to saddle them with the onus of alone deciding whether to let the patient go. This practical convergence of Christian and medical practice is in stark opposition to the attitude towards death in Christian theology. By working creatively and in ways as yet unthought of, the lobby of the dying and the gravely ill could become a healing force in society.

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The drug treatment of high blood pressure is effective and warrants the risk of side-effects in the few in whom it is a malignant condition; it represents a considerable risk of serious harm buy line emsam anxiety, far outweighing any proven benefit buy discount emsam 5 mg line anxiety symptoms in 12 year olds, for the 10 to 20 million Americans on whom rash artery-plumbers are trying to foist it order emsam 5 mg online anxiety lack of sleep. Among murderous institutional torts, only modern malnutrition injures more people than iatrogenic disease in its various manifestations. They are as old as medicine itself,49 and have always been a subject of medical studies. Some take the wrong drug; others get an old or a contaminated batch, and others a counterfeit;53 others take several drugs in dangerous combinations;54 and still others receive injections with improperly sterilized syringes. In some patients, antibiotics alter the normal bacterial flora and induce a superinfection, permitting more resistant organisms to proliferate and invade the host. In a complex technological hospital, negligence becomes "random human error" or "system breakdown," callousness becomes "scientific detachment," and incompetence becomes "a lack of specialized equipment. Less than half of all malpractice claims were settled in less than eighteen months, and more than 10 percent of such claims remain unsettled for over six years. Between 16 and 20 percent of every dollar paid in malpractice insurance went to compensate the victim; the rest was paid to lawyers and medical experts. The problem, however, is that most of the damage inflicted by the modern doctor does not fall into any of these categories. The United States Department of Health, Education, and Welfare calculates that 7 percent of all patients suffer compensable injuries while hospitalized, though few of them do anything about it. Moreover, the frequency of reported accidents in hospitals is higher than in all industries but mines and high-rise construction. In proportion to the time spent there, these accidents seem to occur more often in hospitals than in any other kind of place. One in fifty children admitted to a hospital suffers an accident which requires specific treatment. It has also been established that one out of every five patients admitted to a typical research hospital acquires an iatrogenic disease, sometimes trivial, usually requiring special treatment, and in one case in thirty leading to death. Half of these episodes result from complications of drug therapy; amazingly, one in ten comes from diagnostic procedures. No wonder that the health industry tries to shift the blame for the damage caused onto the victim, and that the dope-sheet of a multinational pharmaceutical concern tells its readers that "iatrogenic disease is almost always of neurotic origin. Such attempts to avoid litigation and prosecution may now do more damage than any other iatrogenic stimulus. On the one hand defectives survive in increasing numbers and are fit only for life under institutional care, while on the other hand, medically certified symptoms exempt people from industrial work and thereby remove them from the scene of political struggle to reshape the society that has made them sick. Second-level iatrogenesis finds its expression in various symptoms of social overmedicalization that amount to what I shall call the expropriation of health. The patient in the grip of contemporary medicine is but one instance of mankind in the grip of its pernicious techniques. It occurs when people accept health management designed on the engineering model, when they conspire in an attempt to produce, as if it were a commodity, something called "better health. This ultimate evil of medical "progress" must be clearly distinguished from both clinical and social iatrogenesis. I hope to show that on each of its three levels iatrogenesis has become medically irreversible: a feature built right into the medical endeavor. The unwanted physiological, social, and psychological by-products of diagnostic and therapeutic progress have become resistant to medical remedies. Technical and managerial measures taken on any level to avoid damaging the patient by his treatment tend to engender a self-reinforcing iatrogenic loop analogous to the escalating destruction generated by the polluting procedures used as antipollution devices. For them, nemesis represented divine vengeance visited upon mortals who infringe on those prerogatives the gods enviously guard for themselves. Nemesis was the inevitable punishment for attempts to be a hero rather than a human being. I believe that the reversal of nemesis can come only from within man and not from yet another managed (heteronomous) source depending once again on presumptious expertise and subsequent mystification. My final chapter proposes guidelines for stemming medical nemesis and provides criteria by which the medical enterprise can be kept within healthy bounds. I do not suggest any specific forms of health care or sick-care, and I do not advocate any new medical philosophy any more than I recommend remedies for medical technique, doctrine, or organization. However, I do propose an alternative approach to the use of medical organization and technology together with the allied bureaucracies and illusions. It fostered the tendency of wounds to heal, of blood to clot, and of bacteria to be overcome by natural immunity. Grafts involve the outright obliteration of genetically programmed immunological defenses. Social Iatrogenesis Medicine undermines health not only through direct aggression against individuals but also through the impact of its social organization on the total milieu. Social iatrogenesis designates a category of etiology that encompasses many forms. Medical Monopoly Like its clinical counterpart, social iatrogenesis can escalate from an adventitious feature into an inherent characteristic of the medical system. When the intensity7 of biomedical intervention crosses a critical threshold, clinical iatrogenesis turns from error, accident, or fault into an incurable perversion of medical practice. In the same way, when professional autonomy degenerates into a radical monopoly8 and people are rendered impotent to cope with their milieu, social iatrogenesis becomes the main product of the medical organization. A radical monopoly goes deeper than that of any one corporation or any one government. When cities are built around vehicles, they devalue human feet; when schools pre-empt learning, they devalue the autodidact; when hospitals draft all those who are in critical condition, they impose on society a new form of dying. Ordinary monopolies corner the market;9 radical monopolies disable people from doing or making things on their own. They impose a society-wide substitution of commodities for use-values by reshaping the milieu and by "appropriating" those of its general characteristics which have enabled people so far to cope on their own. The malignant spread of medicine has comparable results: it turns mutual care and self-medication into misdemeanors or felonies. Just as clinical iatrogenesis becomes medically incurable when it reaches a critical intensity and then can be reversed only by a decline of the enterprise, so can social iatrogenesis be reversed only by political action that retrenches professional dominance. Iatrogenic medicine reinforces a morbid society in which social control of the population by the medical system turns into a principal economic activity. People who are angered, sickened, and impaired by their industrial labor and leisure can escape only into a life under medical supervision and are thereby seduced or disqualified from political struggle for a healthier world. If it were recognized that diagnosis often serves as a means of turning political complaints against the stress of growth into demands for more therapies that are just more of its costly and stressful outputs, the industrial system would lose one of its major defenses. The issue of social iatrogenesis is often confused with the diagnostic authority of the healer. To defuse the issue and to protect their reputation, some physicians insist on the obvious: namely, that medicine cannot be practiced without the iatrogenic creation of disease.

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Drawbacks are the painful nature of the necessary arterial puncture order emsam 5mg otc anxiety symptoms 7 year old, the small risk of arterial injury purchase generic emsam online anxiety untreated, and the fact that they provide only a snapshot look at the status of respiratory function purchase 5 mg emsam overnight delivery anxiety symptoms nervousness. Thus, although bicarbonate measurements without blood gases do not rule in or rule out respiratory failure, a normal venous bicarbonate can be reassuring, especially when the pulse oximeter reading is normal and the patient s mental status is well preserved. Pulse oximetry is a noninvasive technique to allow measurement and monitoring of blood oxygen (SpO2). A patient s fingertip is transilluminated by two wavelengths of light, typically 660nm (red) and approximately 900 nm (infrared), in rapid alternation. Changes in absorbance of each of the two wavelengths, caused by pulsing arterial blood is measured, and the ratio of the two is used to calculate percent oxygen saturation. It can quickly rule in or rule out most cases of hypoxic respiratory failure and those cases of hypercapnic respiratory failure where the oxygen level is also low. Pulmonary function testing is usually valuable in the evaluation of the underlying pulmonary condition(s) that cause or contribute to respiratory failure. Severe reductions suggest pulmonary parenchymal disease (pneumonia, pulmonary fibrosis, etc. Thus, central drive impairment due to drug overdose can often by treated by specific antidotes (e. Adjunctive treatments, especially the administration of supplemental oxygen, can be beneficial, while awaiting improvement in the underlying disease or in the situations in which the underlying disease cannot be corrected. The FiO2 actually delivered by nasal cannulae is quite variable and not reliably predictable by the liter per minute flow rate, in part because of variable amounts of mouthbreathing, but more importantly because inspiratory flow rates and consequent entrainment of room air are tremendously variable. The Venti-mask uses a jet of oxygen at high flow rate (5-15 liters per minute) through a delivery device shaped to entrain predictable amounts of room air (using the Venturi principle), so that FiO2 can be adjusted relatively precisely. The Venti-mask results in more predictable FiO2 than does nasal cannula, but it still suffers from entrainment of variable amounts of room air around the edges of the mask and through the holes that are built into the mask to allow egress of excess flow. The non-rebreather mask provides 100% oxygen from a bag reservoir into the mask and uses one-way valves to direct exhaled gases out of the mask. Even a non-rebreather mask, however, entrains a variably small but not negligible amount of room air around the mask and through one of the expiratory one-way valves, which is routinely left open so as to avoid suffocation if the reservoir runs dry. Supplemental oxygen is the major adjunctive treatment for respiratory failure, and in patients with hypoxic respiratory failure, it can be used safely (for short periods) at any dose and for indefinite periods at nontoxic concentrations (FiO2 <50%). For the hypoxemia that often accompanies the hypercapnic type of respiratory failure, however, oxygen must be used with more caution. Consequently, their ventilatory drive is based primarily on oxygenation with low levels of oxygen stimulating increased breathing. For that reason, in hypercapnic respiratory failure (and in persons suspected of having hypercapnic respiratory failure in whom blood gases have not been measured), oxygen must be administered at low enough flow rates or FiO2 to avoid over-oxygenation. In practice, pulse oximetry is used to guide oxygen therapy, aiming for a pulse oximetriy reading (SpO2) that is safe but less than normal, 88 - 93% in persons with hypercapnic respiratory failure. Mechanical support is most clearly indicated in hypercapnic respiratory failure, but it can also be beneficial for hypoxemic respiratory failure, by blowing open collapsed regions of the lung and by improving the distribution of ventilation even in regions already open. In addition to correcting hypoxemia and hypercapnia, there are other benefits of mechanical ventilatory support, including: Maintenance of oxygenation and acid/base balance Comfort Improved sleep Prevention of inspiratory muscle fatigue Perhaps most important is the comfort issue. Dyspnea (shortness of breath) comes in many different varieties and has many potential physiologic causes, but in hypercapnic respiratory failure, one of the main problems appears to be the perception of the need for excessive respiratory effort. Although me- chanical ventilation does not totally take over the work of breathing, it can substantially reduce the load on the respiratory muscles, especially if adequate inspiratory flow rates are used. Mechanical ventilatory support also has a clear and established role in obstructive sleep apnea, being able to splint the upper airways open, preventing the upper airway collapse that is the major pathophysiologic cause of obstructive sleep apnea. Invasive Mechanical Ventilatory Support Ventilatory support can be accomplished by noninvasive or invasive means, the latter via endotracheal intubation or tracheostomy. The noninvasive techniques have the advantages of (usually) less discomfort, preserved ability to talk and to cough, less risk of airway (laryngeal and tracheal) injury and of ventilator associated pneumonia and the likelihood that the duration of support will be shorter (Table 4-5. When respiratory failure is severe, noninvasive methods are just not adequate to provide the necessary volumes to correct it. With invasive mechanical ventilation, although secretions can still be aspirated alongside the endotracheal or tracheostomy tube, the risk of massive aspiration is considerably less than with noninvasive techniques. There is also easier access to secretions, both for culture and for therapeutic purposes. The advantage over the previously-available pressure ventilation, is that the ventilator adapts to changing mechanics by essentially guaranteeing the delivery of a reasonable tidal volume, thereby avoiding the unexpected hypoventilation that were problems of the old pressure ventilation mode. A disadvantage is that over-ventilation is a constant threat; every effort by the patient results in a full tidal volume, so patients with severe shortness of breath often are found to over-breathe or over-ventilate, with consequent respiratory alkalosis (hypocapnia), elevated pressures and subsequent difficulties with weaning. Another disadvantage is that patients who are not sedated often find the set flow rates too low to satisfy their perceived need, so shortness of breath and discomfort may persist, despite mechanical ventilation. Specialized Modes A number of specialized modes of mechanical ventilation have been developed but are beyond the scope of this chapter. To date, none has been unequivocally demonstrated to improve outcomes over conventional modes. The only mechanical ventilation strategy that has proven better outcomes than its competitors is ventilating at low volumes (<7 ml/kg tidal volumes) in severe acute lung injury5. They were intubated for surgical procedures or for a clearly temporary medical condition (ex. Shortly after the anesthesia wears off or the acute medical condition resolves, the patient is assessed and in most cases, the patient is breathing well, mechanical ventilation is discontinued and the endotracheal tube removed. In these cases, weaning may be necessary to help re-train the patient s muscles or more likely to provide repetitive assessments to allow both the patient and medical team to gain confidence that the underlying condition has improved to the point where spontaneous ventilation could be successful. Some clinicians favor one daily trial with gradually lengthening duration, while other favor several daily trials of shorter duration. In practice, at least at the beginning of the weaning process, most clinicians wean patients primarily during the day and return them to a more comfortable mode of mechanical ventilation during the night. No technique for weaning has been unequivocally shown to be better than any other. In most jurisdictions, intubation and mechanical ventilation can legally be withheld in such cases on the basis of medical futility. All patients with chronic disease and their families should be encouraged to avoid this stress and instead to make their wishes known early on, before the threat of respiratory failure. They remain empowered to change their decision at any time as their condition, circumstances or outlook changes. It is defined as a failure of gas exchange, either for oxygen, for carbon dioxide, or both. Considerable progress has been made in improving the delivery of ventilatory support, especially in the relatively recent development of safe and effective forms of noninvasive ventilatory support. Ventilation with lower tidal volumes for acute lung injury and the acute respiratory distress syndrome. Comparison of three methods of gradual withdrawal from ventilatory support during weaning from mechanical ventilation. Evaluation of a decision aid for making choices about intubation and mechanical ventilation in chronic obstructive pulmonary disease. Patient preferences for communication with physicians about end-of-life decisions.

Jessica Benjamin (5) has written about the mutuality of relating that occurs wherein both caregiver and child feel known and responded to buy emsam 5mg with mastercard anxiety symptoms 37. The child may feel hungry discount emsam anxiety zinc, need to be changed buy emsam 5mg on line anxiety symptoms night sweats, or have some other sense of discomfort or bodily pain. When the caregiver is able to understand the need and be responsive, the child begins to develop a sense of trust, well-being, and security toward him or her. The caregiver can sense what the child needs, respond to that need, and effect a transaction in which the child is soothed and comforted. A healthy relationship between child and caregiver is vitally important for the future relationship between patient and physician. When there is a failure in these early experiences, the sense of trust, alliance, and connection with the physician becomes impaired. These unmet needs lead to a rupture of the interpersonal bridge between caregiver and child. Heinz Kohl, the developer of a model of narcissism and disorders of the self, states that there is a basic need of the developing child for someone to admire and idealize (8). However, when these needs have not been sufficiently addressed, the child is much more vulnerable to psychological insult and the need to idealize and then devalue the other. When these individuals are responded to in an empathic and understanding manner, they begin to perk up again and recover. The ability to let go of anger and get on with other activities can make the difference between suffering through the whole day versus using the day in positive, satisfying ways. If the caregiver does not teach the child how to handle negative emotions, a child may not be able to recover from a disagreement with a playmate; these children are not able to let go of the anger and reinvest in new play. When a child has been effectively soothed, loved, and redirected toward new activities, the child is better able to internalize these behaviors throughout life. The child has learned strategies for defusing, distracting, and reinvolving with less emotional upset. They are also the basis for Buddhist psychology in which the skill of becoming less identified with difficult feelings is developed ( 10). He uses the analogy of a spring that becomes more tightly wound as the level of anxiety increases. The higher this gets, the less it takes to develop into a full-blown anxiety attack. This hypervigilance leads to a vicious cycle of more adrenaline being released, more anxiety, and more vigilance. In asthma, the hypervigilance could be focused on the nature and level of breathing or wheezing. Each of these unhealthy relationships between caregiver and child can result in the so-called difficult patient. Considering these unhealthy early relationships, it is possible for physicians to postulate the causes of the difficulties and to experiment with strategies that may help the treatment alliance. A deep interest in understanding is an essential aspect of treating and healing the patient. A failure in child caregiver interactions in prior experiences is often what has gone wrong in the so-called difficult patient. How a caregiver responds to these effects can result in teaching the child healthy or unhealthy relationships. When the caregiver is able to respond effectively to the discomfort of a child, there is a foundation of security, trust, and well-being. On the other hand, the caregiver may become frustrated or anxious about the illness and can overrespond or even withdraw. The caregiver may feel helpless, resulting in behaviors that are excessively lenient or excessively controlling. In some personality styles, the individual needs to maintain a great amount of control and can become very disturbed by lack of control. As in any chronic illness, depression, and loss of self-esteem also may occur in asthma. In the situation in which there is curtailment of previous activities, the patient may experience feelings of loss, anger, and depression. Some of problems with the so-called difficult patient arise when this talking process is not encouraged. These personality styles are primarily formed in the relationships that children have with their caregivers. These relationships are very intense; how children are responded to in daily activities defines how they feel about themselves, their self-esteem, their sense of being loved, and how they believe they should treat other people. When there are failures in these early interactions the character styles become character disorders. The physician does not look forward to appointments with the so-called difficult patient because the physician feels angry, helpless, and guilty. These patients are often discharged from the practice for noncompliance or referred out of the system. Physicians give their best efforts and attempt to help the difficult patient who is frustrating and defeating them. But just as the physician pulls away, the difficult patient may entreat the physician to help. Some difficult patients seem to become angry or withdrawn with no clear reason, in response to something we have said. By looking more closely at a psychodynamic understanding of the borderline personality disorder and the narcissistic personality disorder, we can better understand the mystery of these reactions. The various theories include genetic predisposition and childhood trauma and abuse, as well as a psychodynamic model based on early childhood relationships. A model has been developed by Margaret Mahler, The Psychological Birth of the Human Infant, and by James Masterson (13) in The Search for the Real Self: Unmasking the Personality Disorders of Our Time. She evaluated how children use their parents to develop independence and relative separation. Gradually, by 18 months, they begin to realize that they are vulnerable and need their parent. They believe that they are individuals, both different and similar to their parents. The crucial phase for the development of problems is around the vulnerable 18-month-old stage. Children need the mother to be sensitive to both the needs for dependence and independence. If both can be sensitively responded to, children can continue their quest for selfhood. For example, parents may need the child to depend and be attached to them and may be threatened by the push for emancipation. The child is vulnerable and influenced by this and does damage to his or her own development to keep the mother connected. Masterson characterizes selectively rewarding and punishing these needs as leading to an abandonment depression. He or she may fear overinvolvement or intrusiveness, but also withdrawal and abandonment.