Study Guide Final 12-13-2005



Dan Judge’s Guide to Psychology

Enjoy

1. Advantages and disadvantages of newer antipsychotic medications

I’m not sure what she means by “newer.” According to some sources, that means atypical antipsychotics (neuropleptics) only, but she gave info on antipsychotics in general.

Antipsychotic drugs began being used in the 50’s with the discovery of chloropromazine (thorazine) in 1952. Drugs in this group are considered “typical” or “old.” This was the first time that psychotic patients could be in communities rather than locked away like One Flew Over the Cuckoo’s Nest, so that was a major plus. The big disadvantage was the extrapyramidal effects, such as tardive dyskinesia, distonia, akathisisia, etc. These drugs act by blocking various dopamine receptors in the brain. The limit psychosis, but also affect the motor system, leading to the side-effects.

Typical neuroleptics are separated into three categories, low, medium and high-potency. Low-potency meds tend to be more sedating and are associated with lower blood pressure, dizziness, dry mouth, blurred vision and difficulty urinating. Examples of low-potency drugs are promazine, chlorpromazine, chlorprothixene, thioridazine and mesoridazine.

High-potency drugs are less sedating but are associated with tremors, rigidity, muscle spasms and restlessness. Examples are thiothixene, trifluoperazine, fluphenazine, halperidol and pimozide.

Medium-potency drugs have side-effects somewhere in between and include: droperidol, acetophenazine, loxapine, molindone, perphenazine and prochloroperazine.

The atypical neuroleptics (antipsychotics), also known as the “newer” drugs, all date from the introduction of Clozaril. These drugs may target specific dopamine receptors and/or may block or inhibit re-uptake of seratonin. The most dramatic difference between the typical and atypical drugs the atypicals ability to address negative symptoms of schizophrenia and cognitive disturbances. There is also thought to be a lower risk of tardive dyskinesia as a side-effect, as well as lower side-effects in general. They also have a more stabilizing mood effect and may be used for bi-polar disorder. These drugs are only available in tablet form and no generic forms are available yet. Atypicals currently available in the US are Clozaril (Clozapine), Risperdal (Risperidone) and Zyprexa (aka Lanzac) (Olanzapine).

2. Major side effects of antipsychotic drugs

Sedation, autonomic effects, endocrine effects, skin and eye complications, neurologic effects (dystonia, pseudo parkinsonism, akinesia, akathisia), tardive dyskinesia, Neuroleptic Malignant Syndrome, agranulocytosis, seizures, sudden death (whoops…).

In case you were wondering, like me, here is the definition of akithisia: A movement disorder characterized by a feeling of inner restlessness and a compelling need to be in constant motion as well as by actions such as rocking while standing or sitting, lifting the feet as if marching on the spot and crossing and uncrossing the legs while sitting. People with akathisia are unable to sit or keep still, complain of restlessness, fidget, rock from foot to foot, and pace. Apparently it is a pretty common side-effect of psych meds.

3. Symptoms of panic attacks

Psychos consider it a panic attack if you have “a discrete period of intense fear or discomfort in which 4 or more of the following symptoms develop abruptly and reach a peak in 10 minutes or less.” It is not uncommon to see a panic attack person in the ER because they think they are having a heart attack or other physical disease.

• Palpitation, pounding heart or accelerated heart rate

• Sweating

• Trembling or shaking

• Sensations of shortness of breath or smothering

• Feeling of choking

• Chest pain or discomfort

• Nausea or abdominal distress

• Dizzy, light-headed, faint

• Derealization (feeling of unreality) or depersonalization

• Fear of losing control/going crazy

• Fear of dying

• Paresthesia

• Chills, hot flashes

Imagine how you would feel if I told you they eliminated Diversified, Basic and all elective techniques from the curriculum and made Logan’s core technique Pro-Adjuster. You just had a panic attack.

4. Criteria for Panic Disorder with Agoraphobia

Panic disorder can occur by itself or with agorophobia. Criteria for Panic Disorder are:

A. Recurrent, unexpected panic attacks.

B. At least one attack has been followed by one month or more of one of the following:

• Persistent concern about having additional attacks.

• Worry about the implications of the attack or its consequences.

C. Panic attacks not due to substance abuse or med. condition.

D. Not better accounted for by another mental disorder.

Criteria for agorophobia are:

A. Anxiety about being in places or situations where they feel that escape is difficult or embarrassing or that help would not be available if the panic attack occurs.

B. The situations are avoided or endured with marked distress or anxiety about having a panic attack, or they require a companion to enter certain situation.

C. The anxiety or phobic avoidance is not better accounted for by another mental disorder, such as social phobia, specific phobia, obsessive-compulsive disorder, PTSD or separation anxiety.

A major component of both panic disorder and agorophobia is the fear of another attack. Symptoms of agorophobia keep getting worse. They are often home-bound becaue they are so fearful of leaving the safety of their own environment.

5. Comorbidity of Panic Disorder

Comorbid with asthma, mitral valse prolapse….., etc. Age of onset is late teens to mid-30s. 1st degree biological relatives are 8x more likely to develop it.

6. Criteria for Conduct Disorder

A. Repetitive and persistent pattern of behavior in which the rights of others or societal norms are violated and manifested by 3 or more of the following criteria for 12 months:

• Aggression to people or animals

• Destruction of property

• Deceitfulness or theft

• Serious violations of rules

B. Causes significant impairment in social, academic or occupational functioning.

Conduct disorder is coded as mild, moderate or severe and by age of onset.

For anyone who has ever played grand theft auto, conduct disorder is pretty much the point of the game. Except that conduct disorder usually applies to children or adolescents and isn’t quite so destructive as GTA.

7. Depersonalization Disorder definition and criteria

This is a disorder in which the person feels detached, or like they are having an “out-of-body” experience.

1. Persistent experience of feeling detached from ones own body or mental processes.

2. Reality testing remains intact.

3. causes significant distress or impairment in functioning.

4. Rule out schizophrenia, substance abuse or temporal lobe epilepsy.

8. Differential diagnosis for Pain Disorder

Pain disorder must first be dif. dx. with any actual condition that could be causing the pain, such as OA, RA, facet syndrome, tumor, diabetic neuropathy, trigger point, substance abuse, etc. It can also be comorbid with any physical condition, but psychological factors are judged to be have an important role in the process. When diagnosing pain disorder it is also important to rule out other mental disorders, such as mood, anxieity or pyschotic disorders. Pain disorder is also often comorbid with depression and anxiety.

9. Criteria for Dissociative identity Disorder

This is one of several Dissociative disorders. The others are Dissociative Amnesia, Dissociative Fugue and Depersonalization Disorder. All of them have some degree of disruption in the usually integrated function of consciousness, memory, identity or perception of the environment.

Criteria for Dis. Identity Disorder, formerly called multiple personality disorder, are as follows:

1) Two or more distinct identities or personality states.

2) At least two of these identities recurrently take control of behavior (uncommon to have > 10 or 11).

3) Inability to recall important personal info.

4) Rule out substance abuse or medical conditions.

These people almost always have a history of childhood physical or sexual abuse and a chaotic family background (97-98%). From my notes in class, she said that the more passive personalities have more restricted memories, whereas the more aggressive personalities know more details about the person’s life and past.

10. Anxiety Disorders

All of these disorders are marked by intense anxiety and/or fear. Keep in mind that some degree of anxiety is normal and actually enhances performance, but in these disorders the anxiety is debilitating. Some of these are discussed elsewhere in the study guide, so I’ll just list them. If this is their only appearance, I’ll give the definition too. Don’t spend much time, if any, on specific phobia, GAD or PTSD, since she didn’t ask about them specifically.

Panic Disorder and Agorophobia

Obsessive-compulsive disorder

Acute stress disorder

Social phobia

Post-traumatic stress disorder

Generalized anxiety disorder

Specific phobia

GAD:

The essential characteristic of Generalized Anxiety Disorder is excessive uncontrollable worry about everyday things. This constant worry affects daily functioning and can cause physical symptoms. GAD can occur with other anxiety disorders, depressive disorders, or substance abuse. GAD is often difficult to diagnose because it lacks some of the dramatic symptoms, such as unprovoked Panic Attacks, that are seen with other anxiety disorders; for a diagnosis to be made, worry must be present more days than not for at least 6 months.

The focus of GAD worry can shift, usually focusing on issues like job, finances, health of both self and family; but it can also include more mundane issues such as, chores, car repairs and being late for appointments. The intensity, duration and frequency of the worry are disproportionate to the issue and interferes with the sufferer's performance of tasks and ability to concentrate. Physical symptoms include:

|Muscle tension; |Difficulty swallowing; |

|Sweating; |Jumpiness |

|Nausea; |Gastrointestinal discomfort or diarrhea; |

|Cold, clammy hands; | |

Sufferers tend to be irritable and complain about feeling on edge, are easily tired and have trouble sleeping.

SPECIFIC PHOBIA:

Specific Phobia is characterized by the excessive fear of an object or a situation, exposure to which causes an anxious response, such as a Panic Attack. Adults with phobias recognize that their fear is excessive and unreasonable, but they are unable to control it. The feared object or situation is usually avoided or anticipated with dread.

Specific Phobia is diagnosed when an individual's fear interferes with their daily routine, employment (e.g., missing out on a promotion because of a fear of flying), social life (e.g., inability to go to crowded places), or if having the phobia is significantly distressful. The level of fear felt by the sufferer varies and can depend on the proximity of the feared object or chances of escape from the feared situation. If a fear is reasonable it cannot be classed as a phobia.

Specific Phobia may have its onset in childhood, and is often brought on by a traumatic event; being bitten by a dog, for example, may bring about a fear of dogs. Phobias that begin in childhood may disappear as the individual grows older. Fear of certain types of animals is the most common Specific Phobia. The disorder can be comorbid with Panic Disorder and Agoraphobia.

PTSD: anxiety caused by an extreme stressor

Acute: 3 months or less

Chronic: 3 months or more

Delayed: > 6 months

Key Symptoms of PTSD:

1. Re-experiencing the traumatic event

a. Intrusive, distressing, recollections of the event

b. Flashbacks

c. Nightmares

d. Exaggerated emotional and physical reactions to triggers that remind the person of the event

2. Avoidance of activities, places, thoughts, feelings, or conversations related to the trauma

3. Emotional numbing

a. Loss of interest

b. Feeling detached from others

c. Restricted emotions

4. Increased arousal

a. Difficulty sleeping

b. Irritability

c. Difficulty concentrating

d. Hypervigilance

e. Exaggerated startle response

Co-Morbid Conditions with PTSD:

1. Substance abuse or dependence

2. Major depressive disorder

3. Panic disorders/agoraphobia

4. Generalized anxiety disorder

5. OCD

6. Social disorder

7. Bipolar disorder

Causes of PTSD:

1. Serious accident

2. Natural disaster

3. Criminal assault

4. Military combat

5. Sexual assault

6. Sexual/physical abuse or neglect as a child

7. Hostage/imprisonment/torture

8. Witnessing or learning about traumatic events (shooting or devastating accident, sudden unexpected death of a loved one)

The Impact of the Stressor:

1. Must be extreme, not just severe (actual or threatened death, serious injury, rape, or childhood sexual abuse)

2. Causes powerful subjective responses – intense fear, helplessness, or horror

*The most effective treatment for PTSD is psychotherapy/(EMDR) – Eye Movement Desensitization and Reprocessing

Treatment for PTSD:

1. SSRI’s and SNRI’s

2. TCA’s and MAO inhibitors (last line of defense due to the side effects)

3. Anticonvulsant medications; 2nd generation antipsychotics

4. Benzodiazepines (addiction is common)

5. Cognitive and behavioral therapies

6. Eye Movement Desensitization Reprocessing (EMDR)

7. Psychodynamic psychotherapy

8. Psychological debriefing

9. Psycho-education and support

10. Stress inoculation, imagery rehearsal, and prolonged exposure

11. Present-centered and trauma-focused group therapies

11. Chronic pain symptoms, prevalence and comorbidity

For people with chronic pain, life revolves around their pain. It is the #1 complaint of all older Americans. 1/5 people suffer from chronic pain. 15%/ year due to back pain alone. It is comorbid with depression, anxiety and drug abuse. Up to 50% of chronic pain sufferers have reported depression.

12. Diagnosis of Conduct Disorder

I couldn’t find this in her notes anywhere, so this from . The italicized portions are the most important to know.

Conduct disorder (CD) is one of the most difficult and intractable mental health problems in children and adolescents. CD involves a number of problematic behaviors, including oppositional and defiant behaviors and antisocial activities (eg, lying, stealing, running away, physical violence, sexually coercive behaviors).

This disorder is marked by chronic conflict with parents, teachers, and peers and can result in damage to property and physical injury to the patient and others. These patterns of behavior are consistent over time. Formal classification with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) defines the essential characteristics as "a persistent pattern of behavior in which the basic rights of others or major age-appropriate social norms are violated."

Behaviors used to classify CD fall into the 4 main categories of (1) aggression toward people and animals, (2) nonaggressive destruction of property, (3) deceitfulness, lying, and theft, and (4) serious violations of rules.

CD usually appears in early or middle childhood as oppositional defiant behavior. Nearly one half of children with early oppositional defiant behavior have an affective disorder, CD, or both by adolescence. Thus, careful diagnosis to exclude irritability due to another unrecognized internalizing disorder is important in childhood cases. Evaluation of parent-child interactions and teacher-child interactions is also critical. Even in a stable home environment, a small number of preschool-aged children display significant irritability and aggression that results in disruption severe enough to be classified as CD.

The DSM-IV specifies that CD can be diagnosed in children younger than 10 years if they demonstrate even one of the criterion antisocial behaviors. Diagnosis after 10 years of age requires the presence of 3 of the criteria behaviors from the categories of (1) aggression toward people and animals; (2) nonaggressive destruction of property; (3) deceitfulness, lying, and theft; and (4) serious violations of rules.

Oppositional defiant disorder (ODD) is discriminated from CD based on the defiance of rules and argumentative verbal interactions involved in ODD; CD involves more deliberate aggression, destruction, deceit, and serious rule violations, such as staying out all night or chronic school truancy.

The DSM-IV defines the 2 major subtypes of CD as childhood-onset type and adolescent-onset type.

The childhood-onset type is defined by the presence of 1 criterion characteristic of CD before an individual is aged 10 years; these individuals are typically boys displaying high levels of aggressive behavior. These individuals often also meet criteria for attention deficit/hyperactivity disorder (ADHD). Poor peer and family relationships are present, and these problems tend to persist through adolescence into adult years. These children are more likely to develop adult antisocial personality disorder than individuals with the adolescent-onset type.

Adolescent-onset type is defined by the absence of any criterion characteristic of CD before an individual is aged 10 years. These individuals tend to be less aggressive and have more normative peer relationships. They often display their conduct behaviors in the company of a peer group engaged in these behaviors, such as a gang. These patients are less likely to fit criteria for ADHD; however, the diagnosis of ADHD is still possible. These individuals are also far less likely to develop adult antisocial personality disorder. While boys are identified more often, the estimated sex ratio of this type of CD approaches 50% for girls and boys in some communities. The prognosis for an individual with adolescent-onset type is much better than for a person with the childhood-onset type.

CD is highly resistant to treatment. It follows a clear developmental path with indicators that can be present as early as the preschool period. Treatment is more successful when initiated early and must include medical, mental health, and educational components as well as family support.

13. Use of SSRI’s and effectiveness

Psychiatrists like to use SSRIs for almost everything, but there a few things even they admit they are not good for. Their effectiveness does not appear to be higher than tricyclic antidepressants, which were the most commonly used class of antidepressants before the development of SSRIs. However, SSRIs have the important advantage that their toxic dose is high, and, therefore, they are much more difficult to use as a means to commit suicide. Further, they have fewer or milder side effects. Here is a basic list of things SSRIs are generally thought to be helpful for, or not.

not helpful:

anorexia, not very helpful with dissociative disorders, not always very effective with psychotic disorders (like schizophrenia), tendency to promote suicide in adolescence

helpful:

bulimia, anxiety disorders, depression, sometimes IBS, sometimes premature ejaculation, pain disorder

14. Bulimia symptoms

This is the “binge and purge” eating disorder. These people experience large amounts of guilt and shame. Criteria are as follows:

A. Recurrence of binge eating

B. Recurrence of inappropriate compensatory behaviors (such as vomiting, use of diuretics, etc)

C. Self-evaluation process. They are aware that what they are doing is wrong, feel incredibly guilty and ashamed, but feel out of control over their own eating.

D. 2x/week for 3 months to make the diagnosis.

Symptoms:

• Evaluate body and shape differently than reality. Think they are much fatter than they really are.

• Behavior does not lead to significant weight loss

• High degree of secrecy, shame and denial

• Evidence of binge eating (wrappers, disappearance of food, etc)

• Frequent trips to the bathroom after meals

• Rigid exercise regiment

• May have unusual swelling in cheeks and jaw area

• Callouses on knuckles from gagging themselves

• Discoloration of teeth (vomit eating away at the teeth)

• Lifestyle changes to accommodate binging and purging

• Withdrawal of friends and peers

• Dehydration

• Often comorbid with depression and poor self-esteem

Many times friends notice the behavior first and address it with the person. These people can appear functional, allowing the bulimia to last for years without people knowing. May have these physical signs: electrolyte imbalance, irregular heart beat, dehydration, loss of Na+ and K+, chronic irregular IBS.

15. Anorexia symptoms

Begins as a restriction of calories and becomes quite obsessional in nature. Patient must be 1 month

• Sleep causes distress, is non-restorative

• History of light sleeping

• Lots of verbalized distress about sleep

o Afraid it will happen again, they become obsessed with not sleeping.

These people have very high levels of muscle tension. Their own evaluation about their sleep is worse than data suggests. They usually have poor sleep habits (go to bed late and not at any regular time, etc). It may last for over a year. ¼ of elderly suffer from insomnia.

36. Neuroleptic malignant syndrome

Basically, you’re screwed up in the head so you take some antipsychotic drugs. Unfortunately, the drugs screw you up even more and you almost die. Dang.

from :

*I would learn the first paragraph for the test. If you want to know more, I copied a lot from the website, but let’s be serious here, do you really want to read it?*

Background: The neuroleptic malignant syndrome (NMS) is a rare, but life-threatening, idiosyncratic reaction to a neuroleptic medication. The syndrome is characterized by fever, muscular rigidity, altered mental status, and autonomic dysfunction.

Although potent neuroleptics (eg, haloperidol, fluphenazine) are more frequently associated with NMS, all antipsychotic agents, typical or atypical, may precipitate the syndrome. For example, these agents have been associated with NMS: prochlorperazine (Compazine), promethazine (Phenergan), clozapine (Clozaril), and risperidone (Risperdal). NMS has also been associated with non-neuroleptic agents that block central dopamine pathways, eg, metoclopramide (Reglan), amoxapine (Ascendin), and lithium.

Pathophysiology: All medications implicated in NMS have dopamine D2-receptor antagonist properties. NMS has also been noted following withdrawal of anti-Parkinson medication. The clinical syndrome is thought to be secondary to decreased dopamine activity in the central nervous system (CNS), either from blockade of dopamine D2-receptors or decreased availability of dopamine itself, and shares similarities with malignant hyperthermia and the serotonin syndrome. Blockade of dopamine neurotransmission in the nigrostriatum and hypothalamus results in muscular rigidity and altered thermoregulation, respectively. There is evidence that sympathetic nervous system activation or dysfunction may play a significant role in the pathogenesis of NMS.

Frequency:

• In the US: Incidence is uncommon, with rates ranging from 0.02-12.2% of patients treated with a neuroleptic medication. Prospective studies and pooled data from the literature report an incidence of 0.07-0.2%. Because of increased awareness of this syndrome and efforts at prevention, the incidence is probably less now than in the past.

Mortality/Morbidity:

• The incidence of mortality, once reported at 20-30% is now estimated at 5-11.6%. Death usually results from respiratory failure, cardiovascular collapse, myoglobinuric renal failure, arrhythmias, or diffuse intravascular coagulation (DIC).

• Morbidity from NMS includes rhabdomyolysis, pneumonia, renal failure, seizures, arrhythmias, DIC, and respiratory failure.

Sex: NMS has been reported to be more common in males most likely because of increased use of neuroleptics in males. Male-to-female ratio is 2:1.

Age: No age predilection for NMS exists. NMS may occur in patients of any age who are receiving neuroleptics or other precipitating medications.

History:

• Neuroleptic malignant syndrome (NMS) is more likely to develop following initiation of neuroleptic therapy or an increase in the dose.

• The onset can be within hours, but on average, it is 4-14 days after initiation of therapy. However, NMS can occur at any time during neuroleptic use, even years after initiating therapy.

• Of those patients who develop NMS, 90% of them will do so within 10 days.

• NMS is a heterogenous syndrome that spans a broad severity continuum. The diagnosis is made on clinical grounds based on the presence of certain historical, physical, and laboratory findings. The diagnosis is confirmed, but not necessarily excluded, by the presence of the following 5 criteria:

o Recent treatment with neuroleptics within past 1-4 weeks

o Hyperthermia (above 38°C)

o Muscular rigidity

o At least 5 of the following:

▪ Change in mental status

▪ Tachycardia

▪ Hypertension or hypotension

▪ Diaphoresis or sialorrhea

▪ Tremor

▪ Incontinence

▪ Increased creatinine phosphokinase (CPK) or urinary myoglobin

▪ Leukocytosis

▪ Metabolic acidosis

▪ Exclusion of other drug-induced, systemic, or neuropsychiatric illness

• Clinical signs

o Hyperthermia

o Profuse diaphoresis

o Generalized rigidity (lead pipe)

o Mental status changes

o Autonomic instability

Physical:

• Hyperthermia

• Diaphoresis

• Generalized muscular rigidity (lead pipe)

• Tachycardia

• Hypertension or hypotension

• Tremor

• Incontinence

• Altered mental status

• Tachypnea

Causes:

• All classes of neuroleptics (dopamine D2-receptor antagonists) are associated with NMS, and dopamine receptor blockade is considered the cause of NMS.

o Experimental blockade of dopamine in the striatum can cause rigidity, tremor, and rhabdomyolysis.

o Blockade of dopamine in the hypothalamus can cause impaired temperature regulation and hyperthermia.

o This theory does not explain why only some patients develop NMS. It also does not explain why patients rechallenged with neuroleptics do not always redevelop NMS.

• Risk factors for developing NMS include the following:

o Increased ambient temperature

o Dehydration

o Patient agitation or catatonia

o Rapid initiation or dose escalation of neuroleptic

o Withdrawal of anti-Parkinson medication

o Use of high-potency agents and depot intramuscular preparations

o History of organic brain syndrome or affective disorder

o History of NMS

o Concomitant use of predisposing drugs (eg, lithium, anticholinergic agents)

37. Psychological aspects of persistent pain

Factors that increase pain, psychological distress and disability are: pain catastrophizing, pn related anxiety and fear, feeling of helplessness.

Factors that decrease pain, psychological distress and disability are: increased self-efficacy, pn coping strategies, readiness to change, and acceptance.

38. Symptoms of Somatization Disorder

This is a type of Somatoform Disorder. Somatoform disorders are similar to anxiety disorders. The person does not realize that their concerns are excessive or unreasonable. Reassurance of normal functioning from others, including physicians, is not helpful. The distinguishing characteristic of somatization disorder is a group or pattern of symptoms in several different organ systems that cannot be accounted for by medical illness. In order to understand the symptoms, you probably will need the criteria too.

Criteria:

A. History of many physical complaints beginning before age 30 that occur over a period of several years and result in treatment sought.

B. Significant impairment in social, occupational or other important areas of functioning:

C. Each of the following criteria must have been met, with individual symptoms occurring at any time during the course of the disturbance:

a. Four pain symptoms: Hx of pn related to at least 4 different sites or functions (such as head, abdomen, back, joints, extremities, chest, rectum, during sex, urination or menstruation).

b. Two GI symptoms: Hx of at least two GI symptoms other than pn (such as nausea, diarrhea, bloating, vomiting or intolerance to several foods).

c. One sexual symptom: Hx of at least one sexual or reproductive symptom other than pn (such as sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy).

d. One pseudoneurologic symptom: Hx of at least one symptom or deficit suggesting a neurological disorder not limited to pain (conversion symptoms such as blindness, double vision, deafness, loss of touch or pain sensation, hallucinations, aphonia, impaired coordination or balance, paralysis or localized weakness, difficulty swallowing, difficulty breathing, urinary retention, seizures; dissociative symptoms such as amnesia; or loss of consciousness other than fainting).

Remember, in order to have somatization disorder the person needs to have met all of the above symptom criteria.

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