Internet Mental Health

OPPOSITIONAL DEFIANT DISORDER






Internet Mental Health Quality of Life Scale (Client Version)

Internet Mental Health Quality of Life Scale (Therapist Version)

Big 5 Factors Of Mental Illness And Code For This Disorder
(The "6th Big Factor" of Mental Health, "Physical Health", Is Coded Normal or Green)

  • Children or adolescents with oppositional disorder have aggressive disrespect for non-siblings (e.g., defiance, disobedience, and disruptiveness).

  • For children younger than 5 years, the behavior should occur on most days for a period of at least 6 months, unless otherwise noted.

  • For individuals 5 years or older, the behavior should occur at least once per week for at least 6 months.

  • This disorder lacks delinquent behaviors (e.g., physical violence, property destruction, law-breaking, reckless thrill-seeking) or more serious antisocial behaviors (e.g., callousness, manipulativeness, and deceitfulness).

  • Not due to a medical or substance use disorder, or a more serious mental disorder.

Prediction

    Onset before age 8 and usually not later than early adolescence. Most children grow out of this; otherwise it usually becomes conduct disorder.

Problems

    Occupational-Economic Problems:

    • Limited: Present at home, but may not be evident at school or in the community.

    • Generalized: Frequent conflict with parents, teachers, and peers.

    Antagonistic (Low Agreeableness):

    • Angry/Irritable Mood:

      • Often loses temper.

      • Is often touchy or easily annoyed.

      • Is often angry and resentful.

    • Argumentative/Defiant Behavior:

      • Often argues with authority figures or with adults.

      • Often actively defies or refuses to comply with requests from authority figures or with rules.

      • Often deliberately annoys others.

      • Often blames others for his or her mistakes or misbehavior.

    • Vindictiveness:

      • Has been spiteful or vindictive at least twice within the past 6 months.

    Associated Findings:

    • Precocious use of alcohol, tobacco, or illict drugs.

    • Unlike Conduct Disorder, doesn't have the following delinquent behaviors: deceitfulness, physical violence, property destruction, or law-breaking.

    • Unlike Antisocial Personality Disorder, doesn't have the following antisocial behaviors: callousness, deceitfulness, manipulativeness, irresponsibility, impulsivity, or reckless risk taking.

    • More prevalent in families in which child care is disrupted by a succession of different caregivers or in families in which harsh, inconsistent, or neglectful child-rearing practices are common.

    • Unclear to what extent maternal depression results from or causes ODD in children.

    • Increased rates of Attention Deficit - Hyperactivity Disorder

    • May be associated with Learning Disorders, Communication Disorders



Back to top


Click Here For Free Diagnosis

Limitations of Self-Diagnosis

Self-diagnosis of this disorder is often inaccurate. Accurate diagnosis of this disorder requires assessment by a qualified practitioner trained in psychiatric diagnosis and evidence-based treatment.

However, if no such professional is available, our free computerized diagnosis is usually accurate when completed by an informant who knows the patient well. Computerized diagnosis is less accurate when done by patients (because they often lack insight).

Example Of Our Computer Generated Diagnostic Assessment

Oppositional Defiant Disorder 313.81

This diagnosis is based on the following findings:
  • Criteria are not met for Antisocial Personality Disorder or Conduct Disorder
  • Often loses temper (still present)
  • Often is touchy or easily annoyed (still present)
  • Often is angry and resentful (still present)
  • Often argues with authority figures (or, for children and adolescents, with adults) (still present)
  • Often actively defies or refuses to comply with requests from authority figures or with rules (still present)
  • Often deliberately annoys others (still present)
  • Often blames others for own mistakes or misbehavior (still present)
  • These symptoms cause clinically significant distress or disability (still present)
  • This hostile or defiant behavior is not due to a Substance Use, Psychotic or Mood Disorder

Back to top


Oppositional Defiant Disorder F91.3 - ICD10 Description, World Health Organization

Conduct disorder, usually occurring in younger children, primarily characterized by markedly defiant, disobedient, disruptive behavior that does not include delinquent acts or the more extreme forms of aggressive or dissocial behavior. The disorder requires that the overall criteria for F91 be met; even severely mischievous or naughty behavior is not in itself sufficient for diagnosis. Caution should be employed before using this category, especially with older children, because clinically significant conduct disorder will usually be accompanied by dissocial or aggressive behavior that goes beyond mere defiance, disobedience, or disruptiveness.

    F91 Conduct disorders
    Disorders characterized by a repetitive and persistent pattern of dissocial, aggressive, or defiant conduct. Such behavior should amount to major violations of age-appropriate social expectations; it should therefore be more severe than ordinary childish mischief or adolescent rebelliousness and should imply an enduring pattern of behavior (six months or longer). Features of conduct disorder can also be symptomatic of other psychiatric conditions, in which case the underlying diagnosis should be preferred.
    Examples of the behaviours on which the diagnosis is based include excessive levels of fighting or bullying, cruelty to other people or animals, severe destructiveness to property, fire-setting, stealing, repeated lying, truancy from school and running away from home, unusually frequent and severe temper tantrums, and disobedience. Any one of these behaviours, if marked, is sufficient for the diagnosis, but isolated dissocial acts are not.
Oppositional Defiant Disorder - Diagnostic Criteria, American Psychiatric Association

An individual diagnosed with oppositional defiant disorder needs to meet all of the following criteria:

  • A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling.

    • Angry/Irritable Mood

    • Often loses temper.

    • Is often touchy or easily annoyed.

    • Is often angry and resentful.

    • Argumentative/Defiant Behavior

    • Often argues with authority figures or, for children and adolescents, with adults.

    • Often actively defies or refuses to comply with requests from authority figures or with rules.

    • Often deliberately annoys others.

    • Often blames others for his or her mistakes or misbehavior.

    • Vindictiveness

    • Has been spiteful or vindictive at least twice within the past 6 months.

      Note: The persistence and frequency of these behaviors should be used to distinguish a behavior that is within normal limits from a behavior that is symptomatic. For children younger than 5 years, the behavior should occur on most days for a period of at least 6 months, unless otherwise noted. For individuals 5 years or older, the behavior should occur at least once per week for at least 6 months, unless otherwise noted. While these frequency criteria provide guidance on a minimal level of frequency to define symptoms, other factors should also be considered, such as whether the frequency and intensity of the behaviors are outside a range that is normative for the individual's developmental level, gender, and culture.

  • The disturbance in behavior is associated with distress in the individual or others in his or her immediate social context (e.g., family, peer group, work colleagues), or it impacts negatively on social, educational, occupational, or other important areas of functioning.

  • The behaviors do not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder. Also, the criteria are not met for disruptive mood dysregulation disorder.


Back to top


Diagnostic Features

Oppositional Defiant Disorder is characterized by a frequent and persistent pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness. The symptoms of this disorder may be confined to only one setting (usually home). In more severe cases, the symptoms are present in multiple settings (e.g., home, school, community). The behavior must lead to significant problems in school or social activities. WARNING: Because symptoms of this disorder are more likely to occur with people the individual knows well, these symptoms may not be apparent during a clinical examination. Individuals with this disorder usually do not regard themselves as angry, oppositional, or defiant. Instead, they often justify their behavior as a response to unreasonable demands or circumstances.

Course

Oppositional Defiant Disorder usually starts during the preschool years and rarely later than early adolescence. Often these individuals develop Conduct Disorder, but many do not. Those with defiant, argumentative, and vindictive symptoms are most at risk for developing Conduct Disorder. Those with angry-irritable mood symptoms are most at risk for developing anxiety and depression.

Complications

This disorder causes frequent conflicts with parents, teachers, supervisors, peers, and romantic partners. This disorder is associated with increased risk for suicide attempts.

Associated Laboratory Findings

No laboratory test has been found to be diagnostic of this disorder.

Prevalence

The average prevalence of Oppositional Defiant Disorder is 3.3%. It is somewhat more prevalent in males than in females (1.4:1) prior to adolescence, but the males and females are equally prevalent in adolescence and adulthood.

Comorbidity

This disorder often co-occurs with Attention Deficit - Hyperactivity Disorder, Anxiety Disorders, Major Depressive Disorder, and Substance Use Disorders. High levels of emotional reactivity and poor frustration tolerance are predictive of this disorder.

Outcome

Ten years after diagnosis, the majority of these children no longer have this disorder. If this disorder perisists and worsens, it develops into Conduct Disorder in adolescence, and some of these individuals develop Antisocial Personality Disorder in adulthood. These individuals are also at increased risk for developing antisocial behavior, impulse-control problems, substance abuse, anxiety, and depression.

Risk Factors

Oppositional Defiant Disorder is more prevalent in families in which child care is disrupted by a succession of different caregivers or in families in which harsh, inconsistent, or neglectful child-rearing practices are common.

Effective Therapies

Parent training and developing the child's skills in tolerating frustration, being flexible, and avoiding emotional overreaction has proven to be effective.

Ineffective therapies

Physical punishment is seldom effective; likewise medication is seldom effective against the core features of this disorder. Vitamins and dietary supplements are ineffective for this disorder.

Back to top


Videos

Stories

Rating Scales


Back to top


Treatment Guidelines



World Health Organization Behavioral Disorder Treatment Guidelines

Download Printable Version


Back to top




Improving Positive Behavior

Philosophers for the past 2,500 years have taught that it is very beneficial to start the day with goal-setting, and end the day with a brief review.

This habit of planning your day in the morning, and reviewing your day in the evening, is a time-proven technique for more successful living.

Note: When each of the following videos finishes; you must exit YouTube (by manually closing the window) in order to return to this webpage.



Morning Meditation (5-Minute Video)



Afternoon Meditation (Learn How To Have Healthy Relationships)



Evening Meditation (5-Minute Video)



Life Satisfaction Scale (Video)



Healthy Social Behavior Scale (Video)



Mental Health Scale (Video)




Click Here For More Self-Help



Back to top




    "In physical science a first essential step in the direction of learning any subject is to find principles of numerical reckoning and practicable methods for measuring some quality connected with it. I often say that when you can measure what you are speaking about and express it in numbers you know something about it; but when you cannot measure it, when you cannot express it in numbers, your knowledge is of a meagre and unsatisfactory kind: it may be the beginning of knowledge, but you have scarcely, in your thoughts, advanced to the stage of science, whatever the matter may be."

    Lord Kelvin (1824 – 1907)


  • The best summary on bad research is given by Laura Arnold in this TEDx lecture. If you read nothing else about research, you owe it to yourself to watch this short video - it is excellent!

  • Canadian researchers who commit scientific fraud are protected by privacy laws: There are criminals in every community - even in the scientific research community (especially if a lot of money is at stake). Criminal researchers can hide their fraud behind outdated privacy laws.

  • The power of asking "what if?"

  • The active placebo effect: 2300 years ago, the Greek Stoic philosophers taught that it is not the objective event, but our subjective judgment about the event, that determines our behavior. The active placebo effect bears witness to this ancient wisdom.

  • Criteria For High Quality Research Studies

  • It is troubling that a recent study found that two-thirds of important psychological research studies couldn't be replicated. High quality research must meet the following criteria:

    • Randomized Controlled Trial:
      Ask: Was the trial randomized? Was the randomization procedure described and was it appropriate? The best research design is to have research subjects randomly assigned to an experimental or control group. It is essential that confounding factors be controlled for by having a control group or comparator condition (no intervention, placebo, care as usual etc.).

    • Representative Sample:
      Ask: Do the research subjects represent a normal cross-section of the population being studied? Many psychological research studies using university students are flawed because their subjects are not representative of the normal population since they are all W.E.I.R.D. (White, Educated, Intelligent, Rich, and living in a Democracy).

    • Single Blind Trial:
      Ask: Was the treatment allocation concealed? It is essential that the research subjects are kept "blind" as to whether they are in the experimental or control group (in order to control for any placebo effects).

    • Double Blind Trial (Better Than Single Blind Trial):
      Ask: Were blind outcome assessments conducted? In a double blind study, neither the research subjects nor the outcome assessors know if the research subject is in the experimental or control group. This controls for both the placebo effect and assessor bias.

    • Baseline Comparability:
      Ask: Were groups similar at baseline on prognostic indicators? The experimental and control groups must be shown to be comparable at the beginning of the study.

    • Confounding Factors:
      Ask: Were there factors, that weren't controlled for, that could have seriously distorted the study's results? For example, research studies on the effectiveness of mindfulness cognitive therapy in preventing depressive relapse forgot to control for whether the research subjects were also simultaneously receiving antidepressant medication or other psychological treatments for depression.

    • Intervention Integrity:
      Ask: Was the research study protocal strictly followed? The research subjects must be shown to be compliant (e.g., taking their pills, attending therapy) and the therapists must be shown to be reliably delivering the intervention (e.g., staying on the research protocol).

    • Statistical analysis:
      Ask: Was a statistical power calculation described? The study should discuss its statistical power analysis; that is whether the study size is large enough to statistically detect a difference between the experimental and control group (should it occur) and usually this requires at least 50 research subjects in the study.

      Ask: Are the results both statistically significant and clinically significant? The results should be both statistically significant (with a p-value <0.05) and clinically significant using some measure of Effect Size such as Standardized Mean Difference (e.g., Cohen's d >= 0.33). The summary statistics should report what percentage of the total variance of the dependent variable (e.g., outcome) can be explained by the independent variable (e.g., intervention). In clinical studies, the study should report the number needed to treat for an additional beneficial outcome (NNTB), and the number needed to treat for an additional harmful outcome (NNTH).

        Number Needed To Benefit (NNTB): This is defined as the number of patients that need to be treated for one of them to benefit compared with a control in a clinical trial. (It is defined as the inverse of the absolute risk reduction.) Note: Statistically, the NNTB depends on which control group is used for comparison - e.g., active treatment vs. placebo treatment, or active treatment vs. no treatment.

        Number Needed To Harm (NNTH): This is defined as the number of patients that need to be treated for one of them to be harmed compared with a control in a clinical trial. (It is defined as the inverse of the absolute increase in risk of harm.)

        Tomlinson found “an NNTB of 5 or less was probably associated with a meaningful health benefit,” while “an NNTB of 15 or more was quite certain to be associated with at most a small net health benefit.”

      Ask: Does the researcher accept full responsibility for the study's statistical analysis? The researcher should not just hand over the study's raw data to a corporation (that may have $1,000 million invested in the study) to do the statistical analysis.

    • Completeness of follow-up data:
      Ask: Was the number of withdrawals or dropouts in each group mentioned, and were reasons given for these withdrawals or dropouts? Less than 20% of the research subjects should drop out of the study. The intervention effect should persist over an adequate length of time.

    • Handling of missing data:
      Ask: Was the statistical analysis conducted on the intention-to-treat sample? There must be use of intention-to-treat analysis (as opposed to a completers-only analysis). In this way, all of the research subjects that started the study are included in the final statistical analysis. A completers-only analysis would disregard those research subjects that dropped out.

    • Replication of Findings:
      Ask: Can other researchers replicate this study's results? The research study's methodology should be clearly described so that the study can be easily replicated. The researcher's raw data should be available to other researchers to review (in order to detect errors or fraud).

    • Fraud:
      Ask: Is there a suspicion of fraud? In a research study, examine the independent and dependent variables that are always measured as a positive whole number (e.g., a variable measured on a 5-point Likert-type scale ranging from "1 = definitely false to 5 = definitely true" etc.). For each of these variables, look at their sample size (n), mean (M) and standard deviation (SD) before they undergo statistical analysis. There is a high suspicion of fraud in a study's statistics:

      • If the M is mathematically impossible (online calculator): This is one of the easiest ways to mathematically detect fraud. The mean (M) is defined as "the sum (Sum) of the values of each observation divided by the total number (n) of observations". So: M = Sum/n. Thus: (Sum) = (M) multiplied by (n). We know that, if a variable is always measured as a positive whole number, the sum of these observations always has to be a whole number. For these variables to test for fraud: calculate (M) multiplied by (n). This calculates the Sum which MUST be a positive whole number. If the calculated Sum isn't a positive whole number; the reported mean (M) is mathematically impossible - thus the researcher either cooked the data or made a mistake. A recent study of 260 research papers published in highly reputable psychological journals found that 1 in 2 of these research papers reported at least one impossible value, and 1 in 5 of these research papers reported multiple impossible values. When the authors of the 21 worst offending research papers were asked for their raw data (so that its reliability could be checked) - 57% angrily refused. Yet such release of raw data to other researchers is required by most scientific journals. (Here is an example of a research paper filled with mathematically impossible means.)

      • If the SD is mathematically impossible (online calculator): When researchers fraudulently "cook" their data, they may accidently give their data a mean and standard deviation that is mathematically impossible for a (normally distributed) strictly positive variable (because the "cooked" M and SD would mathematically require the strictly positive variable's range of data to include negative numbers). For a normally distributed sample of size of 25-70, this occurs when the SD is greater than one-half of the M; for a sample size of 70+, this occurs when the SD is greater than one-third of the M [using these formulas].

      • If the SD/M is very small (i.e., the variable's standard deviation is very small compared to the mean suggesting data smoothing).

      • If the SD's are almost identical (i.e., the variables have different means but almost identical standard deviations).

      • If the 4th digit of the values of the variables aren't uniformly distributed - since each should occur 10% of the time (Benford's Law).

      • If the researcher is legally prevented from publishing negative findings about a drug or therapy because that would violate the "nondisclosure of trade secrets" clause in the research contract (i.e., it is a "trade secret" that the drug or therapy is ineffective - hence this can not be "disclosed"). Approximately half of all registered clinical trials fail to publish their results.

      • If the researcher refuses to release his raw data to fellow researchers (so that they can check its validity). In order to be published in most scientific journals, a researcher must promise to share his raw data with fellow researchers. Thus a researcher's refusal to do so is almost a sure indicator of fraud.

      • If the research study's data contradicts the study's own conclusions - surprisingly, this often occurs.

  • Calling Bullshit In The Age of Big Data - "Bullshit is language, statistical figures, data graphics, and other forms of presentation intended to persuade by impressing and overwhelming a reader or listener, with a blatant disregard for truth and logical coherence." Reading the syllabus of this university course should be required reading for every student of mental health. This syllabus is absolutely fantastic!

  • Statistical Methods in Psychology Journals: Guidelines and Explanations - American Psychologist 1999

  • Not All Scientific Studies Are Created Equal - video

  • The efficacy of psychological, educational, and behavioral treatment

  • Estimating the reproducibility of psychological science

  • Psychologists grapple with validity of research

  • Industry sponsorship and research outcome (Review) - Cochrane Library

  • 'We've been deceived': Many clinical trial results are never published - (text and video)

  • Junk science misleading doctors and researchers

  • Junk science under spotlight after controversial firm buys Canadian journals

  • Medicine with a side of mysticism: Top hospitals promote unproven therapies - Are some doctors becoming modern witchdoctors?

  • When Evidence Says No, But Doctors Say Yes


  • Cochrane Reviews (the best evidence-based, standardized reviews available)

Research Topics

Oppositional Disorder - Latest Research (2016-2017)


Back to top



Which Behavioral Dimensions Are Involved?

Research has shown that there are 5 major dimensions (the "Big 5 Factors") of personality disorders and other mental disorders. There are two free online personality tests that assess your personality in terms of the "Big 5 dimensions of personality". Although not computerized online, the Big Five Inventory (BFI) is a 44-item test often used in personality research.

This website uses these 5 major dimensions of human behavior to describe all mental disorders. (This website adds one more dimension, "Physical Health", but our discussion will focus on the first 5 major dimensions.)

These major dimensions of human behavior seem to represent the major dimensions whereby our early evolutionary ancestors chose their hunting companions or spouse. To maximize their chance for survival, our ancestors wanted companions who were agreeable, conscientious, intelligent, sociable, emotionally stable, and physically healthy.

Which Dimensions of Human Behavior are Impaired in Oppositional Defiant Disorder?

THE POSITIVE SIDE OF THE "BIG 5" PERSONALITY DIMENSIONS THE NEGATIVE SIDE OF THE "BIG 5" PERSONALITY DIMENSIONS THIS DISORDER
Agreeableness Antagonism       Antagonism
Conscientiousness Disinhibition       Conscientiousness
Intellect Decreased Intellect       Intellect
Sociability (Extraversion) Detachment       Sociability (Extraversion)
Emotional Stability Negative Emotion       Emotional Stability


The 5 Major Dimensions of Mental Illness

The Big 5 Factors or dimensions of mental illness each has a healthy side and an unhealthy side. Thus the Big 5 Factors are: (1) Agreeableness vs. Antagonism, (2) Conscientiousness vs. Disinhibition, (3) Intellect vs. Decreased Intellect, (4) Sociability (Extraversion) vs. Detachment (Introversion), and (5) Emotional Stability vs. Negative Emotion.

The problems that are diagnostic of this disorder are highlighted in   Pink  . Other problems that are often seen in this disorder are highlighted in   Yellow  .



Treatment Goals for Individuals With Antagonism

AGREEABLENESS VS. ANTAGONISM
.
AGREEABLENESS
.
Description: Agreeableness is synonymous with compassion and politeness. Compassion reflects empathy, sympathy, and caring for others. Politeness reflects respect for others. Agreeable people are interested in others, and they make people feel comfortable. The Agreeableness dimension measures the behaviors that are central to the concept of JUSTICE and equality (fair, honest, and helpful behavior - living in harmony with others, neither harming nor allowing harm). Justice is then the public manifestation of love. High agreeableness is associated with better: longevity, helping others, giving to charity, job [team] performance, and marital success. (This dimension appears to measure the behaviors that differentiate friend from foe.)
Descriptors: Compassionate, polite, warm, friendly, helpful, unselfish, generous, modest.
Language Characteristics: Pleasure talk, agreement, compliments, empathy, few personal attacks, few commands or global rejections, many self-references, few negations, few swear words, few threats, many insight words.
Research: Higher scores on Agreeableness are associated with deeper relationships. *MRI research found that Agreeableness was associated with increased volume in regions that process information about the intentions and mental states of other individuals.
"I am helpful and unselfish with others."
"I have a forgiving nature."
"I am generally trusting."
"I am considerate and kind to almost everyone."
"I like to cooperate with others."
"I don't find fault with others."
"I don't start quarrels with others."
"I am not cold and aloof."
"I am not rude to others."
"I feel other's emotions."
"I inquire about others' well-being."
"I sympathize with others' feelings."
"I take an interest in other people's lives."
"I like to do things for others."
"I respect authority."
"I hate to seem pushy."
"I avoid imposing my will on others."
"I rarely put people under pressure."
.
ANTAGONISM
.
Description: Antagonism is synonymous with competition and aggression. Antagonistic people are self-interested, and do not see others positively.
Descriptors: Manipulative, deceitful, grandiose, callous, disrespectful, unfriendly, suspicious, uncooperative, malicious.
Language Characteristics: Problem talk, dissatisfaction, little empathy, many personal attacks, many commands or global rejections, few self-references, many negations, many swear words, many threats, little politeness, few insight words.
.
* Callousness:
"It's no big deal if I hurt other people's feelings."
"Being rude and unfriendly is just a part of who I am."
"I often get into physical fights."
"I enjoy making people in control look stupid."
"I am not interested in other people's problems."
"I can't be bothered with other's needs."
"I am indifferent to the feelings of others."
"I don't have a soft side."
"I take no time for others."
.
* Deceitfulness:
"I don't hesitate to cheat if it gets me ahead."
"Lying comes easily to me."
"I use people to get what I want."
"People don't realize that I'm flattering them to get something."
.
* Manipulativeness:
"I use people to get what I want."
"It is easy for me to take advantage of others."
"I'm good at conning people."
"I am out for my own personal gain."
.
* Grandiosity:
"I'm better than almost everyone else."
"I often have to deal with people who are less important than me."
"To be honest, I'm just more important than other people."
"I deserve special treatment."
.
* Suspiciousness:
"It seems like I'm always getting a “raw deal” from others."
"I suspect that even my so-called 'friends' betray me a lot."
"Others would take advantage of me if they could."
"Plenty of people are out to get me."
"I'm always on my guard for someone trying to trick or harm me."
.
* Hostility:
"I am easily angered."
"I get irritated easily by all sorts of things."
"I am usually pretty hostile."
"I always make sure I get back at people who wrong me."
"I resent being told what to do, even by people in charge."
"I insult people."
"I seek conflict."
"I love a good fight."
.
("Agreeableness vs. Antagonism" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five)
*MRI Research: Testing predictions from personality neuroscience. Brain structure and the big five.



Back to top

Internet Mental Health © 1995-2018 Phillip W. Long, M.D.