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Survivor’s Guilt in Caretakers of Cancer
Shulamith Kreitler, Frida Barak, Yasmin Alkalay, Nava Abstract
The paper deals with survivor’s guilt. The purpose was to describe the
phenomenon and to study some of its correlates, functions and consequences
in the context of the caretakers of cancer patients. The first part presents a
brief review of what is known about survivor’s guilt, focusing on its
frequency, the circumstances in which it has been observed and explanations
offered in the frameworks of the psychoanalytic, the social-evolutionary and
existentialist approaches. The second part presents findings of an empirical
study of survivor’s guilt by the authors. The participants were 113 caretakers
of cancer patients, to whom questionnaires were administered 2-3 weeks
before the patient’s death and 2-3 weeks following it. Interviews were
conducted with 42 caretakers 6 months later. Survivor’s guilt was reported by
65.4% of the caretakers. The major results were that survivor’s guilt is
distinct from the emotions of guilt and remorse, and that it is only moderately
related to demographic, emotional, circumstantial and other variables
characterising the relationship to the deceased. Interviews after 6 months
showed that most of those with survivor’s guilt were engaged in voluntary
pro-social activities and showed evidence of enhanced ‘contact’ with the
deceased whose presence was maintained in their life space.

Key Words:
Cancer, caretakers, guilt, survivor’s guilt.
Review of the Literature about Survivor’s Guilt
Guilt is usually defined as an affective state that occurs when an individual believes that he or she has violated a moral standard either by having done something that one believes one should not have done, or conversely, by not having done something one believes one should have done, and that one is responsible for that violation.1 Thus, the major necessary antecedents for guilt are the following three cognitions: the cognition that one has done or not done some behavior, the cognition that this entails violation of some moral standard, and the cognition that one is responsible. Guilt is closely related to shame from which it differs in crucial respects.2 Early theorists distinguished between guilt and shame by emphasising that shame is a reaction to public or external exposure of some ______________________________________________________________ disapproved act while guilt is a private internal event, limited to the relations between one’s self and ones’ conscience.3 Later conceptualisations emphasised that both shame and guilt are negative evaluations of the self by the self, but while shame is a more global evaluation guilt refers to specific acts.4 Further developments in theorising about shame and guilt were affected by ethological, social and evolutionary approaches, emphasising the dependence of guilt on the constructs of attachment and empathy.5 Accordingly, guilt came to be seen as related to altruism and the tendency to feel empathy towards the suffering of the other6 arising from the belief that one has hurt another.7 This view assumes that guilt is rooted in the need to help or at least not to harm others, as part of the adaptive tendency of human beings to maintain their ties to those who are close to them - family members, friends, and other loved ones. More psychologically-oriented investigators emphasise that individuals suffering from guilt may in some cases have deliberately harmed or wished to harm another; but more often their feeling of guilt has to do with a fear of hurting others, not because they want to hurt them, but because they believe that by attempting to further their own interests, they may cause harm to others even without wanting or intending to do so.8 Weiss’ conception serves to highlight another important distinction concerning guilt, based on the degree to which actual harm has been perpetrated. Thus, on the one hand, there may be so-called ‘neurotic’ guilt, that reflects the individual’s assumption that he or she is responsible for some morally evil event, which actually may not be the case; and on the other hand, there is so-called real guilt experienced because of some harm, pain or inconvenience that the person has been involved in inflicting, directly or indirectly. Neurotic guilt can be irrational, for example, because it refers to things about which the person has no control; or because it is displaced, i.e., transferred from the real source of the guilt to another less-threatening situation; or because it is disproportionate relative to the harm. It seems likely that the two kinds of guilt - neurotic and real - define a continuum that reflects differential degrees of irrationality and proneness to psychopathology. However, the irrational components that may attach to guilt, do not change the basic conception shared by most investigators that guilt is a highly adaptive emotion, buttressed by affinity to moral standards, and serves to maintain attachments to others for the purpose of stabilising a comfortable social existence.9 The conception of guilt as an interpersonal emotion, based on the individual’s fear of harming others in the pursuit of his or her own goals, gave rise to a differentiation of several distinct though related categories of guilt: separation/disloyalty guilt, omnipotent responsibility guilt, and survivor guilt. ______________________________________________________________ Separation guilt is characterised by feeling that one is harming one’s parents or other loved ones by separating from them or by differing from them and thereby being disloyal. It is based on the belief that one’s right to life depends on preserving one’s similarity and intimate bonds to one’s parents and other loved ones.10 Omnipotent responsibility guilt is characterised by feeling anxiety and concern about real and particular acts concerning others that may have caused them wrong or discomfort in any way and for which reparation needs to be undertaken. It is based on the belief that one is responsible for the happiness and well-being of others, mainly one’s loved ones. Finally, survivor guilt is characterised by the feeling that one has harmed others, especially loved ones, by the mere fact of having been spared some misfortune or even death that have befallen them. All three kinds of guilt manifest their rootedness in the interpersonal context. Hence one component they share is concern for the others - maintaining the relation with them, their well-being and their physical survival. However, there seems to be another component they share, no less important than the mentioned one, and this is: preserving the presence of the other - by continuing to be a part of the other, by improving the other’s well-being and by promoting the other’s physical existence. This component has been less discerned than the first component of ‘concern for others’ and rarely mentioned in previous discussions of guilt. However, it seems to us to be of crucial psychological importance for the individual. Just as ‘concern for others’ reflects mainly altruism and fulfils an important social role for the community, ‘preserving the presence of the other’ reflects egotism and fulfils an important psychological role for the individual. The latter component is manifested most clearly in survivor’s guilt, which forms the focus of the present chapter. Survivor’s guilt or survivor’s syndrome is generally defined as the mental condition resulting from the appraisal that a person is guilty by the mere fact of having survived a traumatic event whereas others did not. Freud referred to survivor guilt in the wake of his father’s death, in a letter to Wilhelm Fliess, in which he noted ‘. that tendency toward self-reproach which death invariably leaves among the survivors . .’11 It was first diagnosed in the 1960s when several therapists identified a set of symptoms including survivor’s guilt in holocaust survivors.12 The traumatic events that may engender survivor’s guilt usually refer to combat, natural disasters and significant job lay-offs, but includes also political concentration camps, automobile accidents, wartime bombing attacks, and deaths from disease.13 The others in regard to whom survivor’s guilt is felt may include family members, friends, colleagues but also unknown strangers. There has been some unclarity about the differential diagnosis between survivor’s guilt and ______________________________________________________________ post-traumatic stress disorder, with the result that the latter but not the former was included in the DSM-IV.14 Nevertheless some unclarity seems to persist, because survivor’s guilt is still sometimes listed as one of the symptoms of post-traumatic disorder and sometimes as a completely distinct category of trauma-related guilt. Yet, although both post-traumatic stress disorder and survivor’s guilt develop following a trauma, they are very different phenomena. A basic distinction between them is that post traumatic stress disorder is a psychopathological phenomenon, whereas survivor’s guilt appears to be an expression of a normal concern for other human beings singly and as a society. Similarly, survivor’s guilt differs from the guilt sometimes felt by rescuers who blame themselves for not having done enough to help others in emergencies or the guilt that therapists may feel for their patients’ suffering. In both of the latter cases the guilt refers to not having done something for saving the others or alleviating their suffering whereas in survivor’s guilt the guilt is based solely on the survival per se. In which Contexts or Circumstances Survivor’s Guilt Arises? Some investigators emphasise that survivor’s guilt hits people who have not done anything wrong or have not done much of anything at all. In order to better characterise the phenomenon, it is necessary to focus on the original circumstances in which it occurs. As noted, survivor’s guilt appears after a disaster or a trauma. The person who feels the guilt has not been hit or affected by the trauma but there was a fair probability that he or she could have been a victim. Further, survivor’s guilt is more frequent in people who have suffered themselves in the circumstances in which the disaster occurred than in those who did not. Again, it is more frequent in people who have been somehow involved in the disaster than in those who observed it from a safe distance. The suffering of those who feel the survivor’s guilt may have been serious, for example, it may have involved death risk, hunger, oppression, severe worries but in any case it was more moderate or at least ended better than in the case of the other victims, who may have died, or undergone imprisonment, torture or lay-off from work. An interesting case of survivor’s guilt is described in Kurt Vonnegut’s novel, Bluebird. The protagonist Rabo Karabekian’s father had survivor guilt from witnessing some parts of the Armenian genocide by hiding in a deserted village. In contrast, his wife who actually witnessed the killings and pretended to be dead while hiding under corpses, did not feel any survivor’s guilt. In regard to rescuers, the survivor’s sense of guilt may be enhanced if the rescuer died while saving one’s life. Another example of a similar effect would be when a soldier switches a patrol with a friend, and the friend ______________________________________________________________ dies during that particular patrol. The surviving friend thinks that it should have been him and is left with survivor’s guilt. Further, survivor’s guilt has been observed in situations that involve being put in a place where one was not able to revive or otherwise prevent the death of someone one may have loved, in short, situations where nothing can be done for the victim. What are the Symptoms and Manifestations of Survivor’s Guilt? The characteristic symptoms of survivor’s guilt include primarily guilt and self-blame, as well as anxiety, depression, sleep disturbances, emotional liability, loss of drive, lower motivation and morale (e.g., increased absences from work if the trauma was lay-offs), and sometimes physical complaints. In general, survivor’s guilt has been related to longer mourning period and complicated bereavement. In the survivors of concentration camps of World War II, survivor’s guilt was sometimes manifested in more subtle forms, for example, behaving as if they themselves were dead, inhibiting themselves from success or engaging in self-destructive acts in response to survivor’s guilt in regard to a dead parent or sibling.15 How Common is Survivor’s Guilt? Studies have detected survivor’s guilt in a great variety of contexts. According to a literature review survivor’s guilt occurs in: patients after a death takes place within a treatment setting for chronic illness;16 people who keep their job when others are fired; homosexual men who have tested negative for the human immunodeficiency virus whereas their friends tested positive (‘spared at random’); survivors of the Vietnam war; ‘survivor-friends’ (bereaved friends) who have experienced the death of a close friend;17 individuals faced with the sudden death of a partner in an extramarital relationship (secret survivors);18 after death in the family, more survivor’s guilt in widows if the death was by suicide than by accident;19 mothers of children who died of leukemia; psychotherapists working with the unique group of patients of holocaust survivors;20 in a surviving twin, or siblings of a cancer patient child who died;21 in survivors who suffer increased guilt due to not having completed certain courses of action prior to death of loved one and may blame themselves for failure to achieve an appropriate death for their loved one, or for not having perceived clues of impending death;22 in survivors of beloved ones, more so when death has been sudden than if not. F. What are the Reasons for or Causes of Survivor’s Guilt? There are various theoretical approaches to survivor’s guilt that will ______________________________________________________________ According to Freud,23 guilt in general is the product of intra-psychic conflicts between the superego and the ego, and can be considered as a kind of weapon used by the superego to influence the ego's decisions in cases that involve prohibited or tabooed id impulses. Accordingly, survivor’s guilt would be the result of repressed impulses that the survivor has had in regard to the deceased, such as aggressiveness, wishes of death or tabooed sexuality (e.g., incest). Rank,24 another proponent of psychoanalysis, considered guilt as a function of the individuation process, originating in the infantile attachment to mother and in the fear and anxiety over breaking that attachment. Accordingly, guilt operates as a force that perpetuates that relationship. Survivor’s guilt reflects the guilt over enhanced individuation resulting inevitably from the deceased death. Hence, the ubiquity of survivor’s guilt. Actually, Rank equates survivor’s guilt with separation guilt. A somewhat different perspective on survivor’s guilt is presented by another group of psychotherapists who assume that individuals have ‘an unconscious bookkeeping system’ which considers the distribution of the available ‘good’ within a given family so that the current fate of all family members will determine how much ‘good’ one possesses. Thus, if fate has dealt harshly with other members of the family, the survivor may feel guilty because he or she have apparently obtained more than their share of the ‘good.’25 Similarly, survivor’s guilt may be interpreted as due to the irrational belief people may have that the attainment of good things or the simple promotion of one’s own interests is unfair or is at the expense of those who have not attained them and may in addition make others feel bad by comparison.26 A most interesting claim has been raised by a group of dynamically- oriented investigators who assume that survivor’s guilt originates in the survivor’s identification with the victim, which according to the mimetic theory of trauma, is an attempt to understand psychologically the painfully incomprehensible.27 The fantasy-based identification with the harmed one or the dead consists in incorporating the image of the victim in oneself. This has the further benefit of enabling the survivor to uphold the sense of immortality, which is integral to human existence. The dead are experienced unconsciously as if they were still living on in the survivor. However, on the conscious level the survivor knows that the victims are dead and that the proper order of things has been irreparably disrupted, which is the source of the guilt the survivor experiences.28 (b) According to evolutionary theorists the preservation of relationships is vital for survival and reproduction.29 Hence, human guilt is assumed to ______________________________________________________________ have emerged from natural selection because it prevented human beings from performing destructive actions that might damage their relationships with others. In view of the importance of maintaining the group, it is likely that guilt mostly reflects an offense against the group.30 Guilt is assumed to help maintain beneficial relations, such as reciprocal altruism in various ways.31 For example, a person who feels guilty because he or she have harmed someone else or failed to reciprocate kindness, is less likely to get involved in conflicts with other group members, harm others or behave selfishly. In this way, that person reduces the chances of retaliation by other group members, and increases the chances of his own and the group’s survival. Further, if a person who has harmed another feels guilty and demonstrates sorrow and regret, the harmed person or those close to him are likely to forgive. The mentioned elements play a role also in survivor’s guilt. In addition, survivor’s guilt is considered as rooted in the empathy system which seems to depend to a large extent on mirror neurons that enable to feel the other’s suffering as if it were our own.32 Empathy may support the belief that we should do something to relieve or avoid the suffering of others. If we cannot help the other or fail in our efforts to help, we experience guilt which turns into survivor’s guilt if the other is irreparably harmed. Thus, on the whole group functioning and cohesion benefit from having a large number of individuals who tend to feel guilt, and even more so survivor’s guilt, which extends the beneficial impact of guilt beyond the life span of the harmed one.33 The social interpersonal approach considers guilt from the perspective of its role in communal relatedness, supported by its biological importance for survival and reflected in the affective responses of empathy, belongingness and attachment. Hence, guilt serves three broad functions for relationships. First, it motivates relationship-enhancing patterns of behaviour, by helping to enforce the communal norms prescribing mutual concern, respect, and positive treatment in the absence of self-interested return. Secondly, it may operate as an interpersonal influence technique that allows even a relatively powerless person to get his or her way. Thirdly, guilt helps to redistribute emotional distress within the dyad following a transgression. If the transgressor feels guilty his or her enjoyment is diminished, and the victim may feel better. Accordingly, survivor’s guilt helps to restore emotional equity experienced by family members, friends, and co-workers in regard to significant others. In this way survivor’s guilt contributes to promoting fair, equitable, and durable relationships. The Existentialist Approach The existentialist approach redresses the balance and returns guilt into the domain of the individual. The major emphasis of the existentialist ______________________________________________________________ approach is that guilt remains a personal emotional experience, beyond any other role it may have. The existentialist-oriented thinkers consider guilt as a normal part of life and of grieving. Guilt is the affective reaction of human beings to the existential predicament of the necessity to realise to the full the human potentiality of existence.34 Human potentialities may be conceptualised in terms of three dimensions: the physical world of objects, defined by the struggle between survival and death; the social world of other people, defined by the contradictions between our need to belong and the possibility of our isolation; the personal dimension, defined by the tension between integrity and disintegration. The basic need of human beings is to find or construct meaning in regard to each of these existential dimensions.35 Guilt is the feeling we tend to have when we fail to extract or construct meaning in each of these dimensions.36 The struggle and need for meaning become particularly poignant when we face the ‘tragic triad’ of pain, guilt and death, which confront us with awareness of human suffering, of human fallibility and transitoriness of human life.37 It seems to us that survivor’s guilt is involved most intimately in the tragic triad of existence. The death or misfortunes of one or more human beings makes us aware of the missed opportunities for life, and underscores the fact that as human beings we have not succeeded in preventing or diminishing the suffering, our own fallibility or the death of fellow human beings. Survivor’s guilt is the manifestation of our awareness of our limitations as human beings physically, socially and personally. Various additional circumstances may contribute to enhancing survivor’s guilt. For example, survivor’s guilt may reflect the decreased sense of vitality the grievers may feel because of their ‘embracing’ of death, for example, by their previous readiness to give up their own life for the deceased, their identification with the dead one or their decreased motivation for life now that the beloved deceased is no longer with them. G. What is there in Survivor’s Guilt for the Surviving Individual? In dealing with psychological issues it is often necessary to distinguish between explanations of antecedents and causes for the phenomenon and the functions of the phenomenon for the individual. The three approaches to explaining survivor’s guilt differ in the answer they provide to the question about the role of survivor’s guilt for the individual. According to the psychoanalytic approach the role would be to seek expiation or forgiveness for one’s meditated, intended or carried out deeds that violated some real or fictional norm. According to the evolutionary-social approach survivor’s guilt serves to cement the cohesion of the group and thus indirectly contributes to the well-being of the individual. According to the view that guilt is a tool of social control, survivor’s guilt should be manifested in submissive behaviour, ______________________________________________________________ expressions of regret and behaviours designed to placate the harmed one so as to elicit his or her forgiveness. Notably, it has been argued that individuals with proneness to high levels of empathy-based guilt may be likely to suffer from anxiety and depression, but they are also more likely to cooperate with others and behave altruistically. This suggests that guilt-proneness may not always be beneficial for the individual, or within-group competition, but may be highly beneficial in between-group competition.38 According to the existential approach, survivor’s guilt should benefit the survivor by enhancing his or her motivation to live, to realise one’s potential for existence in the full sense of the term, and to use his or her survival for expanding and deepening the meaningfulness of one’s life by changing himself for the better and by changing the world so that it becomes a better place for human beings. The psychoanalytic and evolutionary-social approaches lead us to expect that the individual with survivor’s guilt would show a tendency to be punished, or in the very least to confess to one’s ‘sin,’ apologise and make some kind of reparation. Acts of this kind are assumed to alleviate the guilt. However, empirical studies have failed to demonstrate that survivor’s guilt stimulates a wish for punishment.39 If there is no evidence for regretting, confessing and craving for punishment on the part of the individual with survivor’s guilt, there is no reason to expect that the individual would feel relieved and freed of the unpleasantness of the experienced guilt. No data is available about the enhancement of motivation for life elicited by survivor’s guilt. So what is there in survivor’s guilt for the individuals - who seem to be on the losing side in both respects: they have been separated socially or
physically from other people, mostly close to them, and they have been
afflicted with survivor’s guilt about which they seem to be able to do very
little. One suggestion which may contribute to resolving the problem has
been mentioned earlier: survivor’s guilt seems to preserve for the individual
the presence of the other who has been harmed. It occurs possibly by means
of identification with the victim, which consists in incorporating the victim’s
image and personality into oneself in a psychological manner, and it is
apparently maintained by means of the guilt itself. This function of
preserving the presence of the victim is of special importance when the harm
inflicted on the other is death or some other trauma that introduces distance in
time or place between the harmed individual and the one afflicted with
survivor’s guilt. This aspect of survivor’s guilt is among those handled in the
study to be reported.


______________________________________________________________ The Study
This second part of the paper reports findings of a study of survivor
guilt in the caretakers and family members of cancer patients. Purpose The objectives were (a) to check the frequency of survivor’s guilt in the family members and caretakers of cancer patients; (b) to identify demographic, circumstantial and psychological correlates of survivor’s guilt; and (c) to explore the behavioural and experiential consequences of survivor’s guilt. Method: Participants The participants in the study were 195 family members of cancer patients who had been involved in taking care of the patients and had a continuous relationship with them. The sample of caretakers was chosen for the following reasons: (a) the sample is potentially large and fairly homogenous in the circumstances of contact with the deceased; (b) the sample enables testing the participants prior to the death of the patient and following it, so as to determine the impact of the death itself on survivor’s guilt and also to explore the immediate as well as long-term effects of survivor’s guilt. Method: Procedure A part of the participants (n=82) were studied only prior to the patient’s death (2-3 weeks), and the rest (n=113) both prior and after the patient’s death (2-3 weeks) and 42 of these also six months later. All participants were recruited in oncology wards in different hospitals and clinics in Israel. Method: Tools The participants were administered two questionnaires: (a) the Profile of Mood States which assessed the participants’ current levels of different emotions, such as depression and anxiety, to which guilt and remorse were added;40 (b) a questionnaire that referred to the relationship of the participant with the patient and the nature and reasons for possible reactions of guilt and remorse, and reactions to it. This questionnaire was constructed on the basis of interviews with 20 pre-test participants, prior to the study itself, who were caretakers of cancer patients and were asked about possible reasons for guilt feelings following death of a close person. The following reasons that were referred to by at least 50% of the participants were incorporated into the questionnaire: (a) Things they have not done in regard to the treatment and relationship with the patient but should have done; (b) Things they have done in regard to the treatment and relationship ______________________________________________________________ with the patient but should not have done; (c) Feelings they had in regard to the patient or feelings they did not have; (d) Death wishes they have had in regard to the patient or feeling glad/relieved at patient’s death; (d) Being/staying alive whereas patient is dying/dead. Results The results showed that the major emotions reported by the participants prior to the patient’s death were remorse, guilt, anger and confusion, and following the death the major emotions were remorse, guilt, fatigue and confusion. Hence, following the death, anger was replaced by fatigue. Sixty two percent of the sample reported guilt above the medium level after the patient’s death. The scores for guilt were significantly higher after the patients’ death than before it. Further, comparing the means of the emotional responses prior and after the patient’s death shows that that there were declines in anger, anxiety and energy, and increases in depression, fatigue, confusion, guilt and remorse. Comparing the results in the first months after the death with those six months later showed that there were significant declines in depression, anger, confusion, anxiety and fatigue, and a slight increase in energy. Guilt persisted as a reported emotion, but its level was lower than before. The major focus of the study was placed on three variables that seemed to us as closest to the theme of survivor’s guilt. These were the feelings of guilt and remorse experienced before and after the death of the patient and the feeling of survivor’s guilt, which was assessed only after the death of the patient. On a scale of 1-4, the means and standard deviations for guilt and remorse prior to the death of the patient and after it were 1.70 (.67), 1.66 (.66), 3.05 (.66), 2.92 (.65), respectively. After the death, 65.4% admitted they had survivor’s guilt and the rest reported they had none. The justification for retaining for our further analyses all three variables - guilt, remorse and survivor’s guilt, all assessed after the death of the patient - was the finding that they were not correlated significantly with each other, except for the significant relation between survivor’s guilt and remorse (t=2.494, p<.01). There are two important conclusions based on these findings. The first is that guilt and remorse are two separate emotions; the second is that guilt as such and survivor’s guilt are two separate emotions. Hence, a person may feel guilty after the death of someone but experience neither remorse nor survivor’s guilt. Again, a person may experience survivor’s guilt but not guilt following the death of others. However, the person who experiences survivor’s guilt does tend to feel remorse concerning the other. We explored the correlates of these three variables - guilt, remorse and survivor’s guilt - in terms of the four following sets of variables: (a) Demographic variables: age and gender of the caretaker, being a close ______________________________________________________________ relative of the deceased, disease duration of the deceased, number of months the caretaker took care of the deceased, and the degree of treatment (how many hours per week); (b) Interpersonal contact characteristics and things or actions bothering the caretaker: things concerning the treatment of the deceased that the caretaker thinks he/she should not have done but did; things concerning the treatment of the deceased that the caretaker thinks he/she should have done but did not do; things concerning the relationship with the deceased that the caretaker thinks he/she should have done but did not do; things concerning the relationship with the deceased that the caretaker thinks he/she should have done but did not do; feelings and intentions that the caretaker has had concerning the treatment of the deceased; feelings and intentions that the caretaker has had concerning the overall relationship with the deceased; death wishes in regard to the deceased because of the suffering; (c) Feelings experienced by the caretaker prior to the death of the deceased: depression, vigour, confusion, tension, anger, fatigue, remorse and guilt; (d) Feelings experienced by the caretaker following the death of the deceased: depression, vigour, confusion, tension, anger, fatigue, remorse and guilt. In the statistical analyses each of the four sets of correlates listed above was used as a set of independent variables, whereas remorse, guilt and survivor’s guilt were used as dependent variables, each separately. In the case of guilt and remorse, we used regression analyses, and in the case of survivor’s guilt we used logistic regression. Results concerning guilt: overall results were significant only when the predictors were the set of feelings experienced after the death of the deceased (F=3.25, df=9/92, p<01). The variables with significant contributions were vigour (t=2.25, p<05), confusion (t=2.27, p<.05) and fatigue (t=2.28, p<.05). This indicates that caretakers who experienced guilt after the death of the deceased also experienced less vigour, more fatigue and more confusion. Hence, the feeling of guilt after the death of the patient may be considered as a natural part of the emotional state of the caretaker after the patient’s demise. In addition there were several variables of other sets with significant contributions to predicting the emotion of guilt: the duration of the patient’s disease (t=2.16, p<.05; the longer it lasted, the lower the guilt); things one has done in regard to the treatment (t=1.89, p=.07) and things one has done in regard to the relationship with the deceased (the fewer, the higher the guilt; t=1.95, p=.05); and the level of confusion prior to death (the lower, the higher the guilt; t=2.01, p<.05). Results concerning remorse: overall results were significant only when the predictors were the set of interpersonal contact characteristics and things or actions bothering the caretaker (F=2.42, df=9/92, p<01). The variable with the significant contribution in this set was things that have been done in regard to the relationship (the fewer things, the higher the remorse; t=3.51, p<.001). In addition there were several variables of other sets with ______________________________________________________________ significant contributions to predicting the emotion of remorse: the feeling of vigour after the death of the deceased (t=1.94, p=.05) and the feeling of anger prior to the death (t=2.33, p<.05). These findings indicate that remorse had fewer correlates than guilt. It was related mainly to things done in regard to the relationship with the deceased. Further, the emotions to which it was related were energy-laden, in contrast to guilt that was related to emotions marked by confusion and fatigue. Results concerning survivor’s guilt: results in regard to each of the four sets of predictors were similar in the sense that all the variables in the set enabled a significant prediction of survivor’s guilt: correct identification of the individuals with survivor’s guilt by means of the demographic variables in 64.4%, Critical Ratio=2.102, p<05; by means of the interpersonal contact variables in 68.8%, Critical Ratio=2.707, p<.01; by means of the emotions after the death of the deceased in 67.3%, Critical Ratio=2.536, p<.01; by means of the emotions prior to the death of the deceased in 65.3%, Critical Ratio=2.201, p<.05). However, only in one case there was evidence for a significant contribution of any of the single variables in the set to the prediction. This was in the case of remorse felt after the death of the deceased (t=5.376, p<.05). These findings indicate that survivor’s guilt is related but not closely to demographic, emotional and circumstantial characteristics of the caretaker and his or her relationship to the patient. Further analyses showed that survivor’s guilt is not related to having come from a holocaust family; the number of deaths in the family in the previous five years; the participant’s marital status and number of children; and the participant’s religiosity (or observance of religious habits/procedures). As noted, 42 of the participants were available for interviewing also six months after the patient’s death. The obtained information made it possible to explore the long-term effects of survivor’s guilt. In the case of all 42 subjects, the level of mourning for the deceased was reported to have become low (1 or 2 on a scale of 4). Out of the 42, 34 participants still reported survivor’s guilt (80.95%), whereas 8 did not. All those who reported survivor’s guilt at this stage also reported it following the patient’s death. A comparison of the subjects with and without survivor’s guilt showed that 67.65% of the participants with survivor’s guilt were engaged six months after the death in pro-social voluntary work, such as collecting food for the needy, helping victims of burglaries and robberies or taking care of hospitalised patients. Only two participants without survivor’s guilt engaged in similar voluntary activities. Another important finding yielded by the interviews six months after the death of the patient is that the majority of the participants with survivor’s guilt reported they felt close to the deceased in various respects. The indices of closeness included the following: thinking about the deceased more than ______________________________________________________________ once every day, ‘talking’ in fantasy to the deceased at least once a week, talking about the deceased to others at least once in three days, having images of the deceased at least once a week, having insights about different things the deceased has said or done while alive and long before the disease. Reporting 5 or 4 of these indices can be considered as evidence for maintaining close contact with the deceased, while reporting 2 or 3 of these indices may be considered as evidence for medium contact, and reporting 0 or 1 as evidence for low degree of contact. These degrees of closeness were scored as 3, 2 and 1, respectively. Notably, the mean of closeness in the participants who reported survivor’s guilt was 2.5 while in the group of those with no survivor’s guilt it was 0.4. This indicates that one of the outcomes of survivor’s guilt, which is possibly one of its functions too, is to help maintain the presence of the deceased in the inner life space of the survivor. Some Conclusions The findings of the study are to be considered as preliminary. The results found so far show that survivor’s guilt is prevalent among the caretakers of cancer patients. It is distinct from the experiences of guilt and of remorse. Further, the findings that survivor’s guilt is unrelated to demographic, circumstantial and habitual common emotional responses, including gender, age, duration of treatment of the deceased, the relationship with the deceased, number of deaths in the family, marital status, number of children and religiosity, suggest that survivor’s guilt is an affective response rooted in deeper layers of the personality. Most importantly, the observations about the correlates of survivor’s guilt six months following the patient’s death support the theses that survivor’s guilt exerts a pro-social impact on the person’s behaviour and that it helps maintain the presence of the deceased in the life space of the survivor. Both of these effects led the deceased a kind of metaphorical immortality, thus helping the survivor preserve his or her own sense of immortality and the sense of continued contact with the deceased. In these respects survivor’s guilt contributes to overcoming death, at least on the psychological level. Notably, the results concerning the roots of survivor’s guilt correspond partially to the theoretical accounts provided in the frameworks of all three above reviewed approaches: the psychoanalytic, the social-evolutionary and the existentialist. The more general implication of these findings is that survivor’s guilt should not be treated as a pathological phenomenon to be reduced, alleviated and mitigated at all costs. Rather it may be an intrinsically human response to the occurrence of death which leads to pro-social behaviours designed to strengthen the human bond as well as to fantasy acts designed to psychologically preserve the presence of the deceased, and thereby to transcend the existential plight of limited existence. ______________________________________________________________ 1 B. R. Strickland, ‘Guilt’, Encyclopedia of Psychology, 2nd Edition, Gale Group, Farminton Hill, MI, 2001. 2 J. P. Tangney, P. Wagner, R. Gramzow, ‘Proneness to Shame, Proneness to Guilt, and Psychopathology’, Journal of Abnormal Psychology, Vol. 10, 1992, pp. 469-478. 3 D. P. Ausubel, ‘Relationships between Shame and Guilt in the Socializing Process’, Psychological Review, Vol. 62, 1955, pp. 378-390; R. Benedict, The Chrysanthemum and the Sword: Patterns of Japanese Culture, Houghton Mifflin, Boston, 1946. 4 H. B. Lewis, Shame and Guilt in Neurosis, International Universities Press, Madison, CT, 1971; R. Janoff-Bulman, ‘Characterological versus Behavioral Selfblame: Inquiries into Depression and Rape’, Journal of Personality and Social Psychology, Vol. 17, 1979, pp. 1798-1809. 5 M. Hoffman, ‘Is Altruism a Part of Human Nature?’, Journal of Personality and Social Psychology, Vol. 40, 1981, pp. 121-137; R. Plutchik, ‘Evolutionary Basis of Empathy’, in Empathy and its Development, N. Eisenberg and J. Strayer (eds) Cambridge University Press, Cambridge, 1987, pp. 38-46. 6 Hoffman, pp. 47-80. 7 M. Bush, ‘The Role of Unconscious Guilt in Psychopathology and Psychotherapy’, Bulletin of the Meninger Clinic, Vol. 53, 1989, pp. 97-107; M. Friedman, ‘Towards a Reconceptualization of Guilt’, Psychoanalysis, Vol. 21, 1985, pp. 501-547; H. Sampson, ‘Pathogenic Beliefs and Unconscious Guilt in the Therapeutic Process: Clinical Observations and Research Evidence’, Bulletin # 6, San Francisco, The Psychotherapy Research Group (The Mount Zion Psychotherapy Research Group), Department of Psychiatry, Mount Zion Hospital and Medical Center, 1983; J. Weiss, ‘Notes on Unconscious Guilt, Pathogenic Beliefs, and the Treatment Process’, Bulletin # 6, San Francisco, The Psychotherapy Research Group (The Mount Zion Psychotherapy Research Group), Department of Psychiatry, Mount Zion Hospital and Medical Center, 1983; J. Weiss, ‘Unconscious Guilt’, in The Psychoanalytic Process: Theory, Clinical Observation, and Empirical Research, J. Weiss and H. Sampson (eds), Guilford Press, New York, 1986, pp. 43-67; J. Weiss, How Psychotherapy Works: Process and Technique, Guilford Press, New York, 1993. 8 Weiss, ‘Notes on Unconscious Guilt’, op. cit.; Weiss, How Psychotherapy Works, op. cit. 9 L. E. O’Connor, J. W. Berry, J. Weiss, M. Bush, H. Sampson, ‘Interpersonal Guilt: The Development of a New Measure’, Journal of Clinical Psychology, Vol. 53, 1997, pp. 73-89. ______________________________________________________________ 10 A. H. Modell, ‘On Having the Right to a Life: An Aspect to the Superego’s Development’, International Journal of Psycho-Analysis, Vol. 46, 1965, pp. 323-331. 11 S. Freud, 1896; cited from E. L. Freud (ed), Letters of Sigmund Freud: Selected and Edited by Ernst L. Freud, T. Stern and J. Stern (trans), Basic Books, Inc., New York, 1960, p. 111. 12 W. G. Niederland, ‘The Problem of the Survivor’, Journal of the Hillside Hospital, Vol. 10, 1961, pp. 233-247. 13 R. J. Lifton, Death in Life, Simon & Schuster, New York, 1967. 14 Freud, op. cit., p. 111. 15 A. H. Modell, ‘The Origin of Certain Forms of Pre-Oedipal Guilt and the Implications for a Psychoanalytic Theory of Affects’, International Journal of Psychoanalysis, Vol. 52, 1971, pp. 337-346; Lifton, ‘Death in Life’, op. cit. 16 M. Vamos, ‘Survivor Guilt and Chronic Illness’, Australian and New Zealand Journal of Psychiatry, Vol. 31, No. 4, August, 1997, pp. 592-596. 17 F. Sklar and S. F. Hartley, ‘Close Friends as Survivors: Bereavement Patterns in a “Hidden” Population’, Omega: Journal of Death and Dying, Vol. 21, No. 2, 1990, pp. 103-112. 18 R. W. Weinbach, ‘Sudden Death and Secret Survivors: Helping those Who Grieve Alone’, Social Work, Vol. 34, No. 1, January, 1989, pp. 57-60. 19 D. E. McNeil, C. Hatcher, R. Reubin, ‘Family Survivors of Suicide and Accidental Death: Consequences for Widows’, Suicide and Life-Threatening Behavior, Vol. 18, No. 2, 1988, pp. 137-148. 20 Y. Danieli, ‘Confronting the Unimaginable: Psychotherapists’ Reactions to Victims of the Nazi Holocaust’, in Human Adaptation to Extreme Stress: From the Holocaust to Vietnam, J. P. Wilson, Z. Harel, B. Kahana (eds), The Plenum Series on Stress and Coping, Plenum Press, New York, 1988, pp. 219-238. 21 J. Woodward, ‘The Bereaved Twin’, Acta Geneticae Medicae et Gemellologiae: Twin Research, Vol. 37, No. 2, 1988, pp. 173-180. 22 M. Porot, A. Couadau, M. Plenat, ‘Le Syndrome de Culpabilité du Survivant/The Survivor’s Guilt Syndrome’, Annales Médico-Psychologiques, Vol. 143, No. 3, 1985, pp. 256-262. 23 S. Freud, New Introductory Lectures on Psycho-Analysis, J. Strachey (trans), Norton, New York, 1964 [1933]. 24 O. Rank, The Trauma of Birth, Harcourt, Brace, New York, 1929. 25 Modell, ‘On Having the Right to a Life’, pp. 323-340. 26 Weiss, ‘Unconscious Guilt’, pp. 43-67. 27 R. Leys, Trauma: A Genealogy, University of Chicago Press, Chicago, 2000. ______________________________________________________________ 28 R. Leys, ‘Image and Trauma’, Science in Context, Vol. 19, 2006, pp. 137-149; R. J. Lifton, The Broken Connection: On Death and the Continuity of Life, Basic Books, New York, 1983. 29 R. L. Trivers, Social Evolution, Benjamin-Cummings, Redwood City, CA, 1985. 30 Ausubel, pp. 378-390. 31 S. Pallanti and L. Quercioli, ‘Shame and Psychopathology’, CNS Spectrum, Vol. 5, 2000, pp. 28-43. 32 G. Rizzolatti and L. Craighero, ‘The Mirror-Neuron System’, Annual Review of Neuroscience, Vol. 27, 2004, pp. 169-192. 33 J. Tooby and L. Cosmides, ‘The Evolutionary Psychology of Emotions and Their Relationship to Internal Regulation Variables’, in Handbook of Emotions, 3 rd Edition, M. Lewis, J. M. Haviland-Jones, L. Feldman Barrett (eds), Guilford, New York, pp. 114-137. 34 M. Buber, ‘Guilt and Guilt Feelings’, Psychiatry, Vol. 20, 1957, pp. 114-129. 35 V. E. Frankl, The Unheard Cry for Meaning: Psychotherapy and Humanism, Washington Square Press, New York, 1984. 36 E. van Deurzen-Smith, Everyday Mysteries: Existential Dimensions of Psychotherapy, Routledge, London, 1997; M. Hersen, J. C. Thomas, D. L. Segal, Comprehensive Handbook of Personality and Psychopathology, Wiley, Chichester, UK, 2005. 37 V. E. Frankl, The Doctor and the Soul: From Psychotherapy to Logotherapy, Vintage Books, New York, 1986. 38 Tooby and Cosmides, pp. 114-137. 39 M. Friedman, ‘Toward a Reconceptualization of Guilt’, Contemporary Psychoanalysis, Vol. 21, 1985, pp. 501-547; M. L. Hoffman, ‘Development of Prosocial Motivation: Empathy and Guilt’, in The Development of Prosocial Behavior, N. Eisenberg (ed), Academic Press, San Diego, CA, 1982, pp. 281-313; H. B. Lewis, Shame and Guilt in Neurosis, International Universities Press, Madison, CT, 1971; C. Zahn-Waxier and G. Kochanska, ‘The Origins of Guilt’, in The Nebraska Symposium on Motivation 1988: Socioemotional Development, R. A. Thompson (ed), Vol. 36, University of Nebraska Press, Lincoln, NE, 1990, pp. 182-258; R. F. Baumeister, A. M. Stillwell, T. F. Heatherton, ‘Guilt: An Interpersonal Approach’, Psychological Bulletin, 1994, Vol. 115, No. 2, pp. 243-267. 40 D. M. McNair, M. Lorr, L. F. Droppleman, Manual for the Profile of Moods States, Educational and Industrial Testing Service, San Diego, CA, 1971. ______________________________________________________________ Bibliography
Ausubel, D. P., ‘Relationships between Shame and Guilt in the Socializing Process’. Psychological Review, Vol. 62, 1955, pp. 378-390. Baumeister, R. F., Stillwell, A. M., Heatherton, T. F., ‘Guilt: An Interpersonal Approach’. Psychological Bulletin, Vol. 115, No. 2, 1994, pp. 243-267. Benedict, R., The Chrysanthemum and the Sword: Patterns of Japanese Culture. Houghton Mifflin, Boston, 1946. Buber, M., ‘Guilt and Guilt Feelings’. Psychiatry, Vol. 20, 1957, pp. 114-129. Bush, M., ‘The Role of Unconscious Guilt in Psychopathology and Psychotherapy’. Bulletin of the Meninger Clinic, Vol. 53, 1989, pp. 97-107. Danieli, Y., ‘Confronting the Unimaginable: Psychotherapists’ Reactions to Victims of the Nazi Holocaust’, in Human Adaptation to Extreme Stress: From the Holocaust to Vietnam. J. P. Wilson, Z. Harel, B. Kahana (eds), The Plenum Series on Stress and Coping, Plenum Press, New York, 1988, pp. 219-238. Deurzen-Smith, van E., Everyday Mysteries: Existential Dimensions of Psychotherapy. Routledge, London, 1997. Frankl, V. E., The Unheard Cry for Meaning: Psychotherapy and Humanism. Washington Square Press, New York, 1984. —––, The Doctor and the Soul: From Psychotherapy to Logotherapy. Vintage Books, New York, 1986. Freud, E. L., Letters of Sigmund Freud: Selected by Ernst Freud. T. Stern and J. Stern (trans), New York Basic Books, New York, 1960 [1896]. —––, New Introductory Lectures on Psycho-Analysis. J. Strachey (trans), Norton, New York, 1964 [1933]. Friedman, M., ‘Toward a Reconceptualization of Guilt’. Contemporary Psychoanalysis, Vol. 21, 1985, pp. 501-547. ______________________________________________________________ Hersen, M., Thomas, J. C., Segal, D. L., Comprehensive Handbook of Personality and Psychopathology. Wiley, Chichester, 2005. Hoffman, M., ‘Is Altruism a Part of Human Nature?’. Journal of Personality and Social Psychology, Vol. 40, 1981, pp. 121-137. —––, ‘The Contribution of Empathy to Justice and Moral Judgment’, in Empathy and its Development. N. Eisenberg and J. Strayer (eds), Cambridge University Press, Cambridge, 1987, pp. 47-80. Hoffman, M. L., ‘Development of Prosocial Motivation: Empathy and Guilt’, in The Development of Prosocial Behavior. N. Eisenberg (ed), Academic Press, San Diego, CA, 1982, pp. 281-313. Janoff-Bulman, R., ‘Characterological versus Behavioral Selfblame: Inquiries into Depression and Rape’. Journal of Personality and Social Psychology, Vol. 17, 1979, pp. 1798-1809. Lewis, H. B., Shame and Guilt in Neurosis. International Universities Press, Madison, CT, 1971. Leys, R., Trauma: A Genealogy. University of Chicago Press, Chicago, 2000. —––, ‘Image and Trauma’. Science in Context, Vol. 19, 2006, pp. 137-149. Lifton, R. J., Death in Life. Simon & Schuster, New York, 1967. —––, The Broken Connection: On Death and the Continuity of Life. Basic Books, New York, 1983. McNair, D. M., Lorr, M., Droppleman, L. F., Manual for the Profile of Moods States. Educational and Industrial Testing Service, San Diego, CA, 1971. McNeil, D. E., Hatcher, C., Reubin, R., ‘Family Survivors of Suicide and Accidental Death: Consequences for Widows’. Suicide and Life-Threatening Behavior, Vol. 18, No. 2, 1988, pp. 137-148. Modell, A. H., ‘On Having the Right to a Life: An Aspect to the Superego’s Development’. International Journal of Psycho-Analysis, Vol. 46, 1965, pp. 323-331. ______________________________________________________________ —––, ‘The Origin of Certain Forms of Pre-Oedipal Guilt and the Implications for a Psychoanalytic Theory of Affects’. International Journal of Psychoanalysis, Vol. 52, 1971, pp. 337-346. Niederland, W. G., ‘The Problem of the Survivor’. Journal of the Hillside Hospital, Vol. 10, 1961, pp. 233-247. O’Connor, L. E., Berry, J. W., Weiss, J., Bush, M., Sampson, H., ‘Interpersonal Guilt: The Development of a New Measure’. Journal of Clinical Psychology, Vol. 53, 1997, pp. 73-89. Pallanti, S. and Quercioli, L., ‘Shame and Psychopathology’. CNS Spectrum, Vol. 5, 2000, pp. 28-43. Plutchik, R., ‘Evolutionary Basis of Empathy’, in Empathy and its Development. N. Eisenberg and J. Strayer (eds), Cambridge University Press, Cambridge, 1987, pp. 38-46. Porot, M., Couadau, A., Plenat, M., ‘Le Syndrome de Culpabilité du Survivant/The Survivor's Guilt Syndrome’. Annales Médico-Psychologiques, Vol. 143, No. 3, 1985, pp. 256-262. Rank, O., The Trauma of Birth. Harcourt, Brace, New York, 1929. Rizzolatti, G. and Craighero, L., ‘The Mirror-Neuron System’. Annual Review of Neuroscience, Vol. 27, 2004, pp. 169-192. Sampson, H., ‘Pathogenic Beliefs and Unconscious Guilt in the Therapeutic Process: Clinical Observations and Research Evidence’. Bulletin # 6, San Francisco, The Psychotherapy Research Group (The Mount Zion Psychotherapy Research Group), Department of Psychiatry, Mount Zion Hospital and Medical Center, 1983. Sklar, F. and Hartley, S. F., ‘Close Friends as Survivors: Bereavement Patterns in a “Hidden” Population’. Omega: Journal of Death and Dying, Vol. 21, No. 2, 1990, pp. 103-112. Strickland, B. R., ‘Guilt’, in Encyclopedia of Psychology. 2nd Edition, Gale Group, Farmington Hill, MI, 2001. ______________________________________________________________ Tangney, J. P., Wagner, P., Gramzow, R., ‘Proneness to Shame, Proneness to Guilt, and Psychopathology’. Journal of Abnormal Psychology, Vol. 10, 1992, pp. 469-478. Tooby, J. and Cosmides, L., ‘The Evolutionary Psychology of Emotions and Their Relationship to Internal Regulation Variables’, in Handbook of Emotions, 3 rd Edition, M. Lewis, J. M. Haviland-Jones, L. Feldman Barrett (eds), Guilford, New York, pp. 114-137.
Trivers, R. L., Social Evolution. Benjamin-Cummings, Redwood City, CA,
1985.
Vamos, M., ‘Survivor Guilt and Chronic Illness’. Australian and New
Zealand Journal of Psychiatry
, Vol. 31, No. 4, 1997, pp. 592-596.
Weinbach, R. W., ‘Sudden Death and Secret Survivors: Helping those Who
Grieve Alone’. Social Work, Vol. 34, No. 1, 1989, pp. 57-60.
Weiss, J., ‘Notes on Unconscious Guilt, Pathogenic Beliefs, and the
Treatment Process’. Bulletin # 6, San Francisco, The Psychotherapy Research
Group (The Mount Zion Psychotherapy Research Group), Department of
Psychiatry, Mount Zion Hospital and Medical Center, 1983.
—––, ‘Unconscious Guilt’, in The Psychoanalytic Process: Theory, Clinical
Observation, and Empirical Research
. J. Weiss and H. Sampson (eds),
Guilford Press, New York, 1986, pp. 43-67.
—––, How Psychotherapy Works: Process and Technique. Guilford Press,
New York, 1993.
Woodward, J., ‘The Bereaved Twin’. Acta Geneticae Medicae et
Gemellologiae: Twin Research
, Vol. 37, No. 2, 1988, pp. 173-180.
Zahn-Waxier, C. and Kochanska, G., ‘The Origins of Guilt’, in The Nebraska
Symposium on Motivation 1988: Socioemotional Development
, Vol. 36, R. A.
Thompson (ed), University of Nebraska Press, Lincoln, NE, 1990, pp. 182-
258.
Yasmin Alkalay, has a M.A. in Sociology and is the Head of Unit for
Statistical Data Analysis, Social Sciences Faculty, Tel Aviv University. Her
major interests are multivariate statistical models of data.
______________________________________________________________
Frida Barak, MD, is the Director of Oncology, Barzilai Medical Center, in
Ashkelon, Israel. Her fields of interest and research are: Epidemiologic,
genetic and physiological characteristics of cancer patients

Shulamith Kreitler
is a PhD., Professor of Psychology at Tel-Aviv
University (Israel), Haifa University (Israel) and Freud University (Vienna)
and Head of Psychooncology Research Center at Sheba Medical Center, Tel
Hashomer (Israel). She has published over 200 scientific papers and 10
books. Her major research interests are psychooncology, creativity, and
psychological impact on physical health.
Nava Siegelmann-Danieli, MD, is the Director of Oncology Service Line, at
the Maccabi Health Services in Israel. Her major interests and research are:
Medical, physiological, epidemiological, genetic and psychological factors
decreasing the occurrence of oncological diseases and improving the state of
health in oncology patients.
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