The patient was referred by her therapist for diagnostic clarification and treatment considerations. Specifically, oatterns of behavior which seem to impede her functioning, especially related to wo-c. were a ocus of examination.
• Clinical Interview • Review of Neuropsychological Evaluation (11/20/2006) • Bender Visual-Motor Gestalt Test, Second Ed - (Bender.2) • MitLón Clinical Multiaxial Inventory, Third Edittion
• Thematic Apperception Test (TAT) • Projective Drawing Tests (Projective Drawings). • Personality Assessment Inventory (PAL)
The patient reported that there is a significant “gap between my
drive and knowledge and the ability” to execute tasks and follow
through. She reported that “somethIng Is getting In the way of me doing what I know I can do Specifically she seems to be suffering from anxiety as well as some cognitive difficulties that frustrate
her and her ability to do “everyday, basic functions.” She reported decision making and attentional problems, as well as a pervasive feeling that there are better ways to do things she tries to do, which in turn stops her from doing them in any way.
Currently, the patient is diagnosed with depression, anxiety, and
Attention-Deficit/Hyperactivity Disorder (ADHD). Shesees a psychotherapist
weekly and a psychiatrist once a month. Currently, she takes Lamictal, WeUbutrin, and Lexapro; she previously took AdderaU
for ADHD. She reported a good appetite (“massive, actually”) and no problems with enjoyment of usual activities and hobbies or her Libido. Her energy level was “okay,” though she reported difficulty waking up in the morning and getting herself going, feeling like she wants to go back to sleep for a long time. Her
sleep “has been an issue for a long time.” In fact, she reported having gone to a sleep center to assess and treat her abnormal sleeping patterns. She used to sleep about 13 hours a night, and at times would sleep for about 28 hours straight, about once a month. Currently, however, she sleeps about 8 hours a night and feels relatively refreshed when she wakes up and finally gets herself going.
She reported a constant, low-grade level of helplessness, feeling
like she cannot handle her own problems and her own life. However, she denied any hopelessness, feeling like she was actually taking steps to help with her problems. She also reported
that she cries excessively, though not only when she is sad: “Any emotion makes me cry—when I‟m angry, frustrated
She reported that she would occasionally stay up all night but
not feel tired the next day, and that at times she felt extremely
“high on myself,” feeling that she was special and “queen of the
world.” She reported that these instances were brief, however, and she generally took no action when she was feeling this way.
The patient reported that her problems with decision making, attention, and anxiety were present in college. She received a Bachelor of Arts in creative writing from a prestigious liberal arts college in California. She reported a good GPA (about 3.4 in college), but she stated that she had difficulty finishing work and handing assignments in on time. She received many Incompletes in classes because of this problem. She stated that her problem handing in final products was largely because she was unhappy with the results, especially for creative writing assignments. She reported that these problems with handing in assignments varied, however, revealing an inconsistency that made her extremely
anxious. “My performance was emotionally affected,” such that she became overwhelmed at times, especially
when she was feeling depressed, but she performed better when challenged and in a good mood.
She reportec that before college, and specifically in high school,
she was “like this,” buy that circumstances were somehow
different. She reported taking on “a million different activities,”
keeping herself extremely busy, “always going, stressed out,” but
she somehow “kept afloat.” She feels that having so many different activities gave her less opportunity to scru tinize her performanceone area. Prior to high school, she could not recall whether she struggle
previous bouts with depressionthough her memory was vague about specific symptoms timing, duration, or any other details aboutthese episodes.
The patient has been seeing a therapist for about a year, but she
has been seeing a psychiatrist since the 11th grade, ~„. when she was first diagnosed with ADHD and depression and was medicate:. She reported that at 2 years old, she was hospitalized with chickenpox because suspicion that she may have Reye Syndrome; she did not have the illness. She denied any other major medical problems or hospitalizations. Her last physical examination and blood workup was two months ago, and she was found to have no medical illnesses.
While she denied overuse of alcohol, reporting that she drinks
socially and rarely gets or has ever gotten drunk, she reported occasional use of marijuana in college. Further, she reported a two-week period in her freshman year of college during which she snorted her Addera in order to get high. However, frightened that she may become dependent, she stopped this substance abuse.
While she denied any major medical illnesses in her family, she
reported an extensive history of mental illness in her family. She reported
Obsessive-Compulsive Disorder, her sister was being treated for an anxiety disorder, and all of her grandparents had been medicated for various mental Illnesses. She reported that her pater-nal grandmother had had several psychotic breaks. She denied any family history of substance use or abuse.
She reported that while pregnant her mother “tumbled down a
staircase,” but there had been no apparent harm to either her or her mother. At birth, she reported that she was noticeably cold, so the doctor put a hat and mittens on her, in addition to the blanket in
which she was wrapped. She reported no known problems with developmental milestones or intellectual or cognitive development, except that she often daydreamed in elementary school. Additionally, she reported that she cried every first day of school throughout elementary and middle schoot— ”l‟m not good with
transitions.” She also reported that during high school she was
“depressed,” spending days sleeping in the nurse‟s office. Otherwise, she reported nothing notable about her development.
The patient is a single, 24-year-old, Caucasian female who is the youngest of three children, having an older brother and sister, neither of whom currently lived at home with her and her parents.
She reported a “normal, dull” childhood, remembering nothing remarkable about how she was raised. Her parents are still married, and she reported feeling that they loved and supported her and her siblings. She reported that her memory of growing up was vague and unspecific. She had difficulty recalling any specific events that occurred within her family before graduating high school.
She reported a “great” social network, currently and in the past,
including four very close girlfriends who have been close for
many years. Included in this group are two “best friends.” At times in her life, however, she reported having difficulty “getting myself
to things,” like group dinners and othersocial engagements. She
reported that these friends have stuck with her “even through my
antisocial phases,” when she went long periods of time without seeing them. She reported dating and being sexually active (“I
guess the normal amount”) in college, though since then she has not had a significant romantic relationship. She denied any history of sexual abuse or early sexual behavior.
She reported that she had had one job since graduating from
college. She worked at an advertising agency for about two years, a job that she enjoyed and found creatively satisfying. After about a year, she began missing work regularly and being consistently late when she did show up. Because she reportedly produced high-quality work, her agency afforded her some flexibility, including the ability to work from home on projects. She continued to have difficulty submitting projects on time or at all, and she was fired from her position. She reported that she felt consistently unsatisfied with the quality of her work, and at times she would spend so much time researching alternative to her process that she would not even begin to work on the content of the project. She is currently unemployed and has recently decided to become an actress. So far, as an aspiring
actress, work has been “inconsistent and sporadic,” and she is both Iiving with and being supported by her parents.
She denied any history of criminal or legal involvement. She reported that as a half-Jewish female born and raised in the
South, she is not currently, nor was she in the past, religious, and she reported having no difficulty transitioning out of Virginia or into California for college or New York City afterward.
The patient was cooperative and friendly, and she made good eye contact. While she exhibited adequate receptive language ability, at times her speech became confused, tangential, and hard to follow. Her volume, articulation, and vocabulary were all appropriate, but her rate of speaking was often very rapid, causing her to clutter some of her words together. She reported euthymic mood currently, with a history of depression, and her affect was appropriate to both the situation and to her reported mood. She smiled freely and showed some variation in affect, seeming generally happy, without evidence of current elevated, depressed, anxious, or angry mood. Her thought content was free of hallucinations and delusions, but had some depressive ideation in the form of helplessness. Suicidality, aggressiveness, and homicidality were not present. Her thought process was notably tangential and confused at times. The patient was alert throughout the clinical interview, and her attention and concentration seemed unimpaired. She reported some abnormalities in her memory func-tioning, as she only has vague memories of her childhood, at times has difficulty remembering details from the previous day, and at the same time has extremely vivid memories of certain aspects of her past. Other than these slight abnormalities, however, her
memory seemed generally intact. The patient‟s judgment and insight are adequate; however, her planning and decision-making abilities are impaired.
The patient was extremely friendly and cooperative throughout testing. She gave effortful attempts on all tests administered. She required several reminders and clarifications related to the time and place of testing, as well as following some directions in order to copy and send her previous evaluation to the assessor She became visibly anxious when she felt she was not portraying herself in the way she wanted to, and she often had
difficulty articulating herself appropriately, especially to a degree that was satisfactory to her. When discussing herself, she alternated between flippantly joking and being genuine and tearful.
In the short amount of time in the accessor‟s presence, her
“moodiness,” or emotional lability, was very apparent. She did not exhibit any overt signs of inattention or hyperactivity, and it is believed that this testing is a valid representation of her current functioning.
Note: The results of the WA/S-Ill are based on review of the Neuropsychological Evaluation (11/20/06). The percentile scores are not included, as they were not reported in the original evaluation.
Overall, on the WAIS-Ill, the patient is functioning within the
Superior range compared to others her age. Both her Verbal IQ and Performance IQ fell within the Superior range, suggesting that her cognitive functioning is relatively consistent across domains. On the Bender-2, which examines visual-perceptual, motor, visual-motor integrative, and short-term memory functioning, the patient performed within the Very High range (around the 98th percentile on each subtest) compared to others her age. This excel-lent performance suggests that there is no evidence of neurological damage or deficit.
Verbal Comprehension. On measures of general verbal skills,
such as verbal fluency, ability to understand and use verbal reasoning, and verbal knowledge, the patient‟s performance fell within the Superior range of functioning compared to others her age (Verbal Comprehension Index). Specifically, she exhibited a significant strength compared to same-age peers and to her own overall performance on a task requiring her to define words presented to her, which assesses word knowledge, long-term mem-ory, and ability to express herself (Vocabulary). Strong verbal functioning suggests that she is intellectually ambitious and has made good use of both formal school and other educational opportunities.
Working Memory. On measures assessing the ability to
memorize new verbal information, hold it in short-term memory, concentrate, and manipulate that information to produce some
result or reasoning outcome, the patient‟s performance fell within the High Average range compared to others her age (Working Memory Index). All subtests that make up this
domain fell within the Average to HighAveragerangés. Good working memory suggests that not only does she have unimpaired attention and concen tration skills, but she can work through and manipulate information in her mind well.
Perceptual Organization. On tests that measure nonverbal
reasoning, visuospatial aptitude, and induction and planning skills on tasks involving nonverbal stimuli such as designs, pictures, and puzzles, the patient per formed within the Superior range of functioning compared to others her age (Perceptual Organization Index) All of the subtests that make up this domain fell within the High Average to Superior ranges Her nonverbal reasoning abi lity also seems to be unimpaired and quite strong compared to others
Processing Speed. On tasks that measure the abilityto focus
attention and quickly scan discriminate between and respond to visual information within a time limit, the patient s performance fell within the Average range compared to others her age (Processing Speed Index) ALthough it is her weakest domain of functioning the speed at which she processes informa tion does not seem impaired
Cognitive Summary. Overall, cognitively, the patient is
functioning extremely weLl compared to others her age. Her strong verbal functioning suggests that she will likely succeed in efforts that require the use of language. Her one area of slight weakness compared to her own overall functioning is the speed at which she processes information It should be noted that her processing speed does not constitute a weakness compared to others her age, but rather only to her own overall Superior functioning
The patient was administered several standardized measures of emotional functioning The results of these tests suggest that she has a style of taking in too much information from the world around her much more than she can efficiently and effectively organize and use This style of overincorpora tion combined with restricted, internalized, and confusing emotions and unmet extreme needs for nurturance, have led her to develop strong mixed feelings about interpersonal relationships Specifically she has both a high need for closeness and involvement with others and resentment toward others when she feels they do not meet her needs, which has led to a fear of being disappointed by others Together her style of taking too much information in, restricting her emotion, and having unmet needs for close ness and a resultant ambivalent style have led to several outcomes she is
currently struggling with: low self-esteem, impairment in her ability to think logically and coherently, emotional disturbance, and a style of withdrawing or being paralyzedwhen needing to make decisions.
Overincorporative Style. The patient has a general style of
taking in too much information, more than she can effectively organize or use in day-today life. This may be an asset in some areas of her life, such as creative writing; however, it can be detrimental as well. Her Rorschach revealed that she is exceedtngly open to experience, being aware of and taking in everything from her environment. This overly broad focus of attention leads her to take in details others may not view as important, that they might selectively screen out in order to efficiently process the world. Her Rorschach also revealed that this style may leave her anxious and dissatisfied with the product of tasks in which she is under time pressure. She will be acutely aware of her hastiness and all the faults of her product. This may lead her to generally underachieve. Additionally, because she is taking in so much information, issues that would be minor annoyances to others likely become somewhat paralyzing and overblown to her. Her PAl revealed that she is overconcerned with issues over which she has no control. AdditionaLly, her Projective Drawings suggested that she is overly aware of minor details and hyper-aware of what she views as small insults or disappointments from others, whether intended or not. Her Rorschach also revealed that she has an underdeveloped method for coping with the demands of the world, showing no consistency in relying on intellectual or emotional resources. Her style of taking in the world, on its own, likely paralyzes her when she has to make decisions or is under time pressure, but it also affects her interpersonal relations and her view of herself.
Emotional Confusion and Restriction. The patient is easily
overwhelmed and confused by her own emotions, and, as such, she has adopted a style of restricting and internalizing them. Her MCMI-Iii, Rorschach, Projective Drawings, and TAT each suggested that she tends to restrict her emotions, opting to “wear a
mask,” which helps her appear generally calm and pLeasant on the surface. Her Rorschach revealed that this is likely due to being generally confused about emotions and disoriented by strong feelings. Her underlying tension, however, is characterized by her MCMI-IlI as anxiety, sadness, and guilt feelings. Her Rorschach revealed that because she is so confused by her emotions, she has difficulty being happy, even when she feels she should be. Her MCMI-III specified that much of the inner turmoil she suppresses is related to anger and resentment toward others in her life and the world
around her, even though this anger is rarely shown publicly. Specifically, she holds in anger toward others she feels do not meet her need for nurturance and affection. Her MCMI-III revealed that this anger threatens her need for security, which is why she chooses to restrict it. Her Rorschach revealed that she is prone to occasional impulsive or angry outbursts, which would
constitute a “leak” in her emotional constriction. Her restriction of emotion, possibly in reaction to taking in too much information from a confusing world, contributes to her interpersonal ambivalence.
Excessive Need for Nurturance. The patient has unusually
strong needs for nurturance and affection from others, needs that easily go disappointed, especially given her tendency to take in even slight cues she views as insults from others and conceptualize them as failures to be nurturing. Her PAl and Rorschach both revealed that she generally feels that her life is overly determined by external forces, that she does not have the power to steer her own life. As such, as revealed in her MCMI-III, Rorschach, and TAT, she has become overly dependent on others in her life, leaning on them for support, imagining that they will make decisions for her, and fearing their abandonment of her. Her Rorschach revealed that this, to an extent, has impeded her forming of a clear identity and sense of purpose in life. Her own self-doubt and discouragement, as well as profound loneliness, as revealed in her Rorschach, have led to several behavioral styJes identified in her MCMI-III, including being interpersonally submissive, noncompetitive, and acting weak, self-doubtful, and needy, all in order to evoke nurturance. Her MCMI-Ill also revealed that she generally avoids autonomy; her lack of clear Identity and her self-doubt have led her to fear making clear decisions that impact her life.
InterpersonalAmbi valence. Because of her significantly unmet
needs for closeness and nurturance, the patient has become extremely ambivalent about relationships, continuing to need affection and closeness on the one hand, but also fearing the inevitable rejection and disappointment (much of which is related to her hyper-awareness of minor cues from others that are likely generally unintended) on the other. Her MCMI-IIl, Rorschach, and TAT all revealed an acute awareness that although she is depend-ent on others to determine her destiny, she generally resents others for disappointing and discouraging her, as well as for being critical or disapproving of her. In fact, her Rorschaeh and TAT revealed a generally pessimistic view that others will ultimately never fulfill her needs for closeness. Her Rorschach suggested that this leads to a chronic state of low-grade irritation, another reason she has difficulty ever being truly happy. Her
Rorschach and Projective Drawings, however, suggested that this interpersonal ambivalence is largely based on judgments made from impaired social perception, and her TAT revealed that she is much too easily discouraged and disappointed interpersonally. Specifically, she has difficulty perceiving the actions of others realistically and making appropriate judgments and decisions based on this. This is likely due to her over-incorporative style, as well as her becoming somewhat disorganized when strong emotions are involved, which they often are in interpersonal relationships.
Low Self-Esteem. The patient currently suffers from low
self-esteem, resulting from her unmet needs for intimacy and closeness and her unclear personal identity. Her Projective Drawings and Rorschach revealed general self-doubt and a sense of being damaged or unworthy. More specifically, however, her PAl suggested a generally fluctuating view of herself, marked by sometimes positive aspects, but often highly self-critical. This extreme self-criticism also appeared on her Rorschach, which suggested that it is a chronic state of criticizing herself in a maladaptively self-conscious way, and her Projective Drawings, which revealed a hypercritical view toward herself. Her MCMI-III additionally revealed a general style of self-effacement. Her Rorschach revealed that at times she avoids self-focusing, in order to cope with her low self-esteem. Her PAl suggested that at times she may actively become grandiose and show inflated self-esteem, again in order to cope with her inner inadequacy.
Impaired Logical Thinking. Currently, likely as a result of her
overincorporative style and being overwhelmed by emotions, the patient is struggling with impairment in her ability to think entirely logically and coherently. Her Rorschach and MCMI-Ill suggested that her thinking at times is not only confused, but also rushed and accelerated, even faster than she herself can keep up with. Her Projective Drawings revealed that in general the world is overwhelming to her, not surprising given her tendency to take in inordinate amounts of information from it. Her TAT revealed that when she is overwhelmed, however, her thinking becomes confused, similar to what the Rorschach and MCMI-ili suggested. More specifically, her PAl revealed that she struggles with confusion, distractibility, and difficulty concentrating, symptoms she reported in the clinical interview. Additionally, her PAl revealed tangential or circumstantial thinking at times, as well as problems with communicating clearly. Her Rorschach reinforced the finding that situational stress can impede clear thinking, specifying that she has impairment in her
logic, significantly misperceives events, and at times confuses reality and fantasy. She has adopted a coping style that is escapist, retreating into fantasy when she becomes overwhelmed, imagining how others or external events will make her decisions for her and at times significantly distorting reality. It is unclear how aware of these problems in thinking she currently is, though they significantly impact her functioning, incLuding her ability to make decisions and effect changes in her life.
Emotional Disturbance. Currently, the patient is struggling with
emotional difficUlties consistent with a diagnosis of Bipolar Disorder. Her MCM1-III, PAi, Rorschach, and TAT suggested signs of depression, including sadness, Loneliness, pessimism, hopelessness, and significant intrusive ideation, specifically about her unmet needs and her inability to prevent others from determining her destiny. Her PAl also suggested a moderate degree of current worry. Her MCMI-IiI suggested, however, that she rarely divulges these negative feelings to others. Additionally, her MCMI-llI and Projective Drawings revealed that she views life as somewhat empty, but significantly draining and effortful. As such, her MCMI-IIl revealed some physical signs of depression, including weakness and fatigue. Also revealed in her MCM1-iil, PAl, and Rorschach, however, were physical signs of mania or hypomanIa, including grandiosity, rushed speech, accelerated thinking, and inflated self-esteem, It is significant to note that there was no evidence of irritability or hyperactivity, though some moodiness was revealed in her MCMI-III. Additionally, her sleep pattern, while unclear the underlying cause for its irregularity, is somewhat consistent with a manic state.
Withdrawal and Impaired Decision-Making Ability. Two major
effects of her current functioning are a coping style of withdrawing from others and from situations and becoming paralyzed when needing to make decisions or follow through on plans. Her TAT, MCMI-iii, and Rorschach all revealed a style of withdrawing when overwhelmed. Specifically, she may withdraw from others in order to moderate her anxiety about being disappointed and her sensitivity to rejection. Her retreat into fantasy, revealed in her Rorschach, also constitutes a withdrawal tactic. Her MCMI-Ill further suggested that her needy behaviors at times serve to distance herself from others, prompting them to leave her alone. Her Rorschach and TAT further suggested that because of her overincorporative style, her restriction of emotion, and her dependence on others, she can become paralyzed when making decisions, leading her to make no decision at all. Because she is so often disappointed by her own efforts, as revealed in the Rorschach, she avoids putting herself in a position to judge her own output. This process,
however, also becomes judged, and it reinforces her low self-esteem and feelings of inadequacy.
Lorraine Ryder is a single, 24-year-old, Caucasian female who currently lives with her parents. She was referred for a psychological assessment to assess the reason for her difficulties with decision making and execution of plans, as well as diagnostic clarification and treatment considerations. Cognitively, she exhibited no evidence of neurological damage or cognitive deficit.
Emotionally, she has a style of taking in too much information
from the world around her, much more than she can efficiently and effectively organize and use. This style interacts with restricted and confusing emotions and unmet needs for nurturance, having led her to develop strong ambivalent feelings about interpersonal relationships. Specifically, she has both a high need for closeness and involvement with others and resentment toward others when she feels they do not meet her needs, which has led to a fear of being disappointed by others. Together, her style of taking in too much information, restricting her emotion, and having unmet needs for closeness and a resultant ambivalent style have led to several outcomes she is currently struggling with: low self-esteem, impairment in her ability to think logically and coherently, emotional disturbance, and a style of withdrawing or being paralyzed when needing to make decisions.
Currently, she is struggling with significant emotional
disturbance characterized both by depression—including sadness, loneliness,
mania—including grandiosity, inflated self-esteem, rushed speech, and accelerated thinking. These, together with significantly impaired thought processes and confusion, are consistent with a diagnosis of Bipolar I Disorder, with Psychotic Features. if the disorder in thinking (i.e., psychotic features) occurs outside of a mood episode (i.e., depressed or manic state), then a diagnosis of Schizoaffective Disorder should be applied. Additionally, her presentation of difficulty with decisions, needing others to assume responsibilities or coax her through processes, extreme need for nurturance and discomfort and disappointment related to this need not being met, and difficulties initiating or completing projects is consistent with a diagnosis of Dependent Personality Disorder.
DiagnostIc Impression and Recommendations
Given the patient‟s current functioning, the following recommendations are being made • The patient should continue to be seen by a psychiatrist, in
order to find the optimal balance of medications for her Bipolar Disorder
• The patient should continue in individual psychotherapy in
order to address some of the underlying issues related to her Bipolar Disorder, as well as her Dependent Personality Disorder. Specifically, areas of focus can include:
o BecOming more realistic in her understanding of
interpersonal interaction, such that she is not disappointed by small failures on the part of others to meet her needs for nurturance and affection.
o Helping her understand what parts of the world are more
meaningful and impactful than others, such that her focus of attention can begin to become less broad and all-encompassing.
o Beginning to find more appropriate and adaptive ways to
both feel and express her emotions, such that they do not become overly internalized and restricted, and such that
they do not spill‟ as impulsive outbursts or crying with every emotion
o Resolving her feelings of ambivalence toward
° Improving her self-esteem through a more realistic view
o Improving her reality-testing abilities, in order to
become more effective and realistic in judging the world.
° Addressing her current feelings of depression, including
Beginning to make decisions and not judge herself
too harshly on the product of those decisions, in order to facilitate her finding more of a sense of who she is and a direction for the future.
FEEDBACK Preparation for Feedback Obviously, the current assessment is very dense, with a great deal of information learned from the testing to relay back to Lorraine, her therapist, and her psychiatrist. The feedback to her psychiatrist would have to rely entirely on the report, and the feedback to her therapist consisted of sending her the report (with Lorraine‟s consent), then following up with a phone call to discuss any questions or concerns. Feedback to Lorraine herself was the primary focus, as feedback sessions balance giving information and providing a safe, therapeutic environment to process the infor-mation relayed. Luckily, Lorraine and the assessor had built good rapport throughout the assessment process, so the groundwork for a good feedback session had already been laid.
The major considerations when deciding exactly how to give
feedback to Lorraine were (a) her level of cognitive and intellectual functioning, (b) her level of insight, and (c) the specific type and amount of information that needed to be relayed to her. Regarding her intellectual capacity, because she is so intelligent, especially_in the verbal domain, it was decided that she would be given the report and taken through it verbally as is. There was
Curriculum vitae Dr. med. Hans P. Ogal Berufliche Funktion: Seit September 2012 als Schmerzspezialist im Ambulatorium der Paramed AG, Zentrum für Komplementärmedizin Fachärztliche Qualifikation: Fähigkeitsausweise: Interventionelle Schmerztherapie SSIPM Akupunktur – Traditionelle Chinesische Medizin (ASA) Weitere Ausbildungen in: Neuraltherapie, Phytother
Does an Aspirin a Day Make Your Brain Bleed? If you or someone you love are one of the 50 million Americans that take aspirin daily in an effort to prevent a heart attack, you’re at risk of getting tiny leaks from blood vessels in your brain. These cerebral microbleeds are linked to memory and language problems, difficulty reasoning and intracranial hemorrhages – full-scale bleeding insid