Managed Healthcare Essay Example | Topics and Well Written Essays - 750 words

Managed Healthcare - Essay Example It is under such circumstances that the role of a care-giver becomes all the more important. While on the one hand, the care-giver has to take care of the organizational goals and the profitability aspects, on the other hand the care-giver is supposed to provide the best care and guidance to the customer. Once, such arrangements takes cues from corporate management, the healthcare too becomes 'managed healthcare'. From the point of view of a consumer, the pros of such managed healthcare are; v. At times, in situations like the consumer is on tour to place outside the native place, then the tie-up between caregiver companies helps the consumer in getting a good care from some affiliated company as well i. The consumer gets tied up with a particular company for longer time and even if there are better alternatives, he/she cannot go for a change, because of the agreement between the consumer and the healthcare company But entering into a managed healthcare plan with consumer also involves some risk for the company. For example, in these inflationary times, when costs are rising up, the company finds itself unable to charge higher prices, because of the agreement done with the consumer. Some of the well known managed healthcare are plans are, Health Maintenance Organization (HMO); Preferred Provider Organizations (PPO) and Point-of-Service (POS) plans. These plans have evolved over the years and have taken care of some of the deficiencies that included in the traditional insurance covers. While the traditional insurance covers used to take care of limited aspects of the healthcare, the managed healthcare plans are comprehensive in nature and try to include some modern day health hazards like long sitting in front of the computer screen and its ergonomic impacts on our body parts.

Academic Performance and Personal Growth and Development Essay

Academic Performance and Personal Growth and Development - Essay Example The purpose and goal of any educational institution are to introduce and instal a set of knowledge and skills to the students and together with the parents and/or guardians act as the custodians of personal development through discovering and nurturing talents. A given education institutions will have students from all economic, social and cultural divides; students talented differently, with different perspectives on the education and learning systems and with different post-school aspirations, and it’s the work of the institution and relevant stakeholders (Joyce, 2011) to match these traits to help them achieve maximum in school life. These students may explicitly and/or implicitly depict or showcase their attributes in that some are physically active in both the academic and extra curriculum activities whereas others may be passive in any of them or both (Rayner & Cools, 2011). This will in one way or the other influence their academic performance and personal growth and de velopment both at the college and after college which is similar but different to some extent and this paper seeks to contrast the academic performance, leadership/ administrative roles and post-school lives of active and passive students. Apart from ensuring students cognitively understand the subject matter; institutions are also interested to ensure that graduates can make good leaders, an attributed nurtured within the institution. Active students tend are involved in leadership roles to a greater extent than the passive students but comparatively lack administrative skills; a factor that can be attributed to rationality and perceptions between these students (Scherer, 2010).

The Importance of Commodity Derivatives

The Importance of Commodity Derivatives Equity Commodity Investment â€Å"A COMPARATIVE STUDY BETWEEN EQUITY COMMODITY INVESTMENT OPTION† ABSTRACT India, a commodity based economy where two-third of the one billion population depends on agricultural commodities, surprisingly has an under developed commodity market. Unlike the physical market, futures markets trades in commodity are largely used as risk management (hedging) mechanism on either physical commodity itself or open positions in commodity stock. For instance, a jeweller can hedge his inventory against perceived short-term downturn in gold prices by going short in the future markets. The study aims to know how of the commodities market and how the commodities traded on the exchange. The idea is to understand the importance of commodity derivatives and learn about the market from Indian point of view. In fact it was one of the most vibrant markets till early 70s. Its development and growth was shunted due to numerous restrictions earlier. Now, with most of these restrictions being removed, there is tremendous potential for growth of this market in the country. ACKNOWLEDGEMENT SYNOPSIS FOR THESIS DESIRED AREA Investments Commodity Market in India TITLE OF THE THESIS Comparative Study between Equity Commodity Investment Options† PROBLEM DEFINITION / HYPOTHESIS / RESEARCH OBJECTIVE To have a comparative study between two major Investments options Equity Commodity on the basis of their returns. To study simple properties of commodity futures as an asset class and analyze the hedging properties To understand the possible returns by investing in Commodity Futures when the Commodity Spot Prices are falling and comparing them with those in Stocks and Bonds. INTRODUCTION / LITERATURE TO THE AREA OF RESEARCH In the Capital Markets of the world, preferably in India, Stock is considered as the first option of investment. But, as we all know that there are many other options available with the people to invest / park their hard earned in some of these options are Derivative Market, Mutual Funds, NSC, KVPS, Insurance, FD, Savings A/c’s obviously less considered is the Commodity Market. In the above mentioned options there are some options that do not have the risk factor in it thus they give less return, while others having risk gives more return to the investor. One does not know that the Investments in Commodities will also yield almost the same returns as compared with the Stock, having the same amount of risk involved. SCOPE This research would throw light on the mentioned objectives make people aware of Commodity Futures as an Investment option – which is at its growing stage. RESEARCH METHODOLOGY Primary Data Collection Guidance from the External Guide. Guidance from the Internal Guide. Help from Faculties. Commodities Dealers. Commodities Players (Investors). Secondary Data Collection Web sites Journals Magazines (Financial) Newspapers Research Papers on the same topic Reports of Experts â€Å"Investment is a term with different closely-related meanings in business, finance and economics, related to saving or deferring consumption. An asset is usually purchased, or in a similar way a deposit is made in a bank, in hopes of getting a future return or interest from the same. Literally, investment means the action of putting something somewhere else In finance, investment can be referred to as buying securities or other monetary assets in the money markets or capital markets, or in fairly liquid real assets, such as gold, real estate etc. Valuation is the method for finding the true value of an asset. Different financial investments include shares, bonds and other equity investments. These financial assets are then expected to provide income/ positive future cash streams, and may increase or decrease in its value giving the investor capital gains or losses. Trading in contingent claims or derivative securities do not necessarily have future positive cash flows, and so are not considered assets, or securities or investments. Nevertheless, since their cash flows are closely related to or it is derived from cash flow of specific securities, they are often treated as investments. Banks, mutual funds, pension funds, insurance companies, collective investment schemes, and investment clubs can be used to make investments indirectly. An intermediary generally makes an investment using money from many individuals, each of whom receives a claim on the intermediary, though their legal and procedural details differ. LITERATURE REVIEW The capital market (securities markets) is the market for securities, where the companies and the government can raise funds for long term. Stock market and the bond market form part of capital market. Financial regulators, such as the RBI and SEBI, keep a watch on the capital markets in their respective countries to ensure that investors are protected against any fraud. The capital markets consist of the primary market, where the company floats new securities to investors, and the secondary market, where existing securities are traded. STRUCTURE OF CAPITAL MARKET Primary Market Secondary Market Derivative Market Commodity Market International Market IPO Public Issue) Right Issue Private Placement Sale purchase of existing share debenture Mutual fund Option Future Call Option Put Option Gold Silver Material Etc. NYSE Composite NASDAQ Composite Dow Jones I.A. S4P 500 NIKKEI – 225 NSE BSE Dealing in MCX dealing in STRUCTURE OF SECURITY MARKET Primary Market Secondary Market Derivative Market Commodity Market International Market IPO Public Issue) Right Issue Private Placement Sale purchase of existing share debenture Mutual fund Option Future Call Option Put Option Gold Silver Material Etc. NYSE Composite NASDAQ Composite Dow Jones I.A. S4P 500 NIKKEI – 225 NSE BSE Dealing in MCX dealing in A) Primary Market: It is that part of the capital markets that deals with the issuance of new securities. Companies, governments or public sector institutions can obtain funds through the issue of a new stock or bond which is called initial public offering (IPO). This is typically done through a syndication of securities dealers which in return earn a commission that is built into the price of the security offering. B) Secondary Market: The secondary market is the market for trading of securities that have already been issued in the market. Aftermarket is known as the market that exists in a new security just after the new issue. Investors and speculators can easily trade on the exchange once a newly issued stock is listed on a stock exchange, as market makers make bids and offers in the new stock. C) Derivative Market: Derivative Market Future Market Option Market Future Contract Say – One month – Two month – Three month Call Option Put Option Premium will change at the time of buying No Risk Premium will change at the time of sells No Risk Future Contracts: The future contracts are the future contracts or bids for some specific period like one month, two months and three months, accepted from investor in capital market which is put. Option Market :- The option market is the place where trading is for call and put or buy and sell and only the premium is charged for all call and put trading. D) Commodity Market: Commodity trading might sound like a strange term, but simply put, commodities are items like, wheat, corn, gold and silver, and Cattle and Pork Bellies, and Crude Oil and it has emerged as an important player in the way that people invest in and speculate. INVESTMENT ALTERNATIVES INVESTMENT Financial Assets Real Estate Marketable Financial Assets. Non-marketable Financial Assets Treasury Bills C.D. C.P. Repo Govt. Fixed Insurance bond Govt. Securities Debenture Shares Mutual Fund Equity Pref NSS Bank Deposit Post Office KVP NSC Company Deposit EPF/PPF LIC Gold Silver Previous objects Painting /Art Land / Building Machinery/Equipment etc MARKETABLE FINANCIAL ASSETS Equity or Preference shares Govt/PSU/Pvt/other bonds Mutual Funds Shares (Equity and Preference Share): If you have equity shares of a company, you have an ownership stake in that company. This essentially means that you have a residual interest in income and wealth of the company. Equity shares are classified into the following broad categories Blue chip shares Growth shares Income shares Cyclical shares Speculative shares Bonds: Bonds or debentures represent long-term debt instruments where issuer of a bond promises to pay a stipulated stream of cash flow. Bonds may be classified into the following categories Government securities. Savings bonds Government agency securities. PSU bonds Debentures of private sector companies Preference shares Money Market Instruments:- Money market instruments are debt instruments which have a maturity of less than one year at the time of issue. The important money market instruments are: Treasury bills Commercial paper Certificates of deposit Mutual Funds: A Mutual Fund is a trust that collects the savings of a number of investors, and invest in capital market instruments such as shares, debentures and other securities who share a common financial goal. Unit holders share the income earned through these investments and the capital appreciation in proportion to the number of units owned by them. Mutual Fund offers an opportunity to invest in a diversified, professionally managed basket of securities at a relatively low cost and thus is the most suitable investment for the common man. NON-MARKETABLE FINANCIAL ASSETS: A good portion of financial assets is represented by non-marketable financial assets. These can be classified into the following broad categories. Bank deposits Post office deposits Company deposits Provident fund deposits/EPF LIC NSC NSS KVP Life Insurance: Life insurance can also be considered as an investment as insurance premiums represent the sacrifice, and the assured sum represents the benefit. The important types of insurance policies in India are : Endowment assurance policy Money back policy Whole life policy Term assurance policy REAL ESTATES AND OTHERS Real Estate: Residential house is the most important asset in the portfolio for the bulk of the investors. More affluent investors are likely to be interested in the following types of real estate, in addition to a residential house Agricultural land Semi – urban land Commercial property Precious Object: Precious objects are items that are highly valuable in monetary terms. Some important precious objects are ; Gold and silver Precious stones Art objects Financial Derivatives: A financial derivative is an instrument whose value is derived, from the value of an underlying asset be it a real asset, such as gold wheat or oil, or a financial asset, such as a stock, stock index, bond or foreign currency. Forwards Contracts A forward contract, as it occurs in both forward and futures markets, always involves a contract initiated at one time; Performance in accordance with the terms of the contract occurs at one time; Performance in accordance with the terms of the contract occurs at a subsequent time. Further, the type of forward contracting to be considered here always involves an exchange of one asset for another and the price at which the exchange occurs is set at the time of the preliminary contracting. Actual payment and delivery of the good occur afterwards. Futures Contracts A futures contract is highly standardized forward contract with closely specified contract terms and it calls for the exchange of some good at a future date for cash, with the payment for the good to occur at that future date like all forward contracts. The buyer of a futures contract undertakes to receive delivery of the good and pay for it while the seller of a futures promises to deliver the good and take delivery of payment. The price of the good is determined at the initial time of contracting. Option Option contracts grant the right but not the compulsion to buy in the case of a call or sell, in the case of a put a specified quantity of an asset at a predetermined price on or before a specified future date option contract would expire if it is not in the best interest of the option owner to exercise. Swaps Swaps normally trade in the OTC market but there is monitoring of this market segment. Swaps are agreement between two parties to exchange cash flows in the future according to a approved formula and In case of popular interest rate swap, one party agrees to pay a series of set cash flows in exchange for a sequence of variable cost. When compared to global derivatives markets Indian derivative markets are still in the emerging stage. Indian derivatives markets share in the world derivatives market’s value and volumes are very small. But with the starting of trading in different financial and commodities segment, Indian markets are growing very fast. Indian markets are operating with high efficiency and on parity with international standards. The major exchanges and the derivative products traded in India: 1. Bombay Stock Exchange (BSE) 2. National Stock Exchange OF India Ltd (NSE) 3. National Commodity Derivatives Exchange Limited (NCDEX) 4. Multi Commodity Exchange of India Ltd (MCX) 5. National Multi Commodity Exchange of India Ltd (NMCE) INVESTMENT ATTRIBUTES For evaluating an investment values, the following attributes are relevant. Rate of return Risk Safety Profitability Purchasing power risk Maturity Marketability Tax shelter Convenience Rate of Return: The rate of return on an investment for a period (which is usually a period of one year) is defined as follows: Rate of return = Annual income + (Ending price – Beginning price) Beginning price To illustrate, consider the following information about a certain equity share. Price at the beginning of the year: Rs. 80.00 Dividend paid in the year: Rs. 4.00 Price at the end of the year: Rs. 87.00 The rate of return of this share is calculated as follows: 4.00 + (87.0-80.00) = 13.75 percent 80.00 Yield In general, yield is  the yearly rate of return  for any investment and is expressed as a percentage, With stocks, yield can refer to the rate of income generated from  a stock in the form of regular dividends and is often represented in percentage form, calculated as the annual dividend payments divided by the stocks current share price. Investors can use yield to measure the performance of their investments and  compare it to the yield on other investments or securities. Generally, higher risk securities offer higher expected yields as compensation for the additional risk incurred through ownership of the security. Investors looking to make income or cash flow streams from equity investments commonly look for stocks  that shell out high dividend yields, in other words, stocks that give a relatively large amount of annual cash dividends for a relatively low share price. Annual income (interest or dividends) divided by the current price of the security. This measure looks at the current price of  a bond instead of its face value and represents the return an investor would expect if  he/ she  purchased the bond and held it for a year. This measure is not an accurate reflection of the actual return that  an investor  will receive in all cases  because bond and stock  prices are continuously changing due to market factors. Capital Appreciation: It’s the rise in the market price of an asset. Capital appreciation is one of two major ways for investors to profit from an investment in a company. The other is through dividend income. Risk The risk of investment may be classified in following ways Type of Risk Internal Rate of Return Risk Market risk Inflation Risk Default Risk Business Risk Financial Risk Management Risk Liquidity Risk The rate of return from investments like equity shares, real estate, and gold can vary rather widely. The risk of investment refers to the variability of its rate of return: How much do individual outcomes deviate form the expected value? A simple measure of dispersion is the range of values, which is simply the difference between the highest and the lowest values. Other measures commonly used in finance are as follows: Variance :This is the mean of the squares of deviations of individual returns around their average values Standard deviation:This is the square root of variance Beta :This reflects how volatile the return from an investment is, in response to market swings. Risk = Actual Return – Expected Returns Condition: If, Actual Return = Expected Return = Risk Free Investment If, Actual Return > or Low Variance (Low Risk) High Variance (High Risk) Expected Return Marketability: An investment is highly marketable or liquid if: (a) it can be transacted quickly: (b) the transaction cost is low; and (c) the price change between two successive transactions is negligible. The liquidity of a market may be judged in terms of its depth, breadth, and resilience. Depth refers to the existence of buy as well as sell orders around the current market price. Breadth implies the presence of such orders in substantial volume. Resilience means that new orders emerge in response to price changes. Generally, equity shares of large, well – established companies enjoy high marketability and equity shares of small companies in their formative years have low marketability. High marketability is a desirable characteristic and low marketability is an undesirable one. How does one evaluate the marketability of an investment like a provident fund deposit which is non-marketable by its very nature? In such a case, the relevant questions of ask is: can withdrawals be made or loans be taken against the deposit? Such as investment may be regarded as highly marketable if any of the following conditions are satisfied: A substantial portion of the accumulated balance can be withdrawn without significant penalty; A loan (representing a significant portion of the accumulated balance) can be raised at a rate of interest that is only slightly higher than the rate of interest earned on the investment itself. Tax Shelter: Some investments provide tax benefits; others do not. Tax benefits are of the following three kinds. Initial Tax Benefit; An initial tax benefit refers to the tax relief enjoyed at the time of making the investment. For example, when you make a deposit in a Public Provident Fund Account, you get a tax benefit under Section 80 C of the Income Tax Act. Continuing Tax Benefit: A continuing tax benefits represent the tax shield associated with the periodic returns form the investment. For example, dividend income and income from certain other sources are tax – exempts, upto a certain limit, in the hands of the recipient. Terminal Tax Benefits; A terminal tax benefit refers to relief from taxation when an investment is realized or liquidated. For example, a withdrawal from a Public Provident Fund Account is not subject to tax. Convenience: Convenience broadly refers to the ease with which the investment can be made and looked after. Put differently, the questions that we ask to judge convenience are: Can the investment be made readily? Can the investment be looked after easily? The degree of convenience associated with investments varies widely. At one end of the spectrum is the deposit in a savings bank account that can be made readily and that does not require any maintenance effort. At the other end of the spectrum is the purchase of a property that may involved a lot of procedural and legal hassles at the time of acquisitions and a great deal of maintenance effort subsequently. A COMPARATIVE STATEMENT OF VARIOUS INVESTMENTS ALTERNATIVES A summary evaluation of these investment avenues in terms of key investment attributes is given in Exhibit below. It must be emphasized that within each investment category individual assets display some variations. Exhibit: Summary Evaluation of Various Investment Avenues Return Current yield Capital appreciation Risk Marketability / Liquidity Tax shelter Convenience Equity Shares Low High High Fairly high High High Non – convertible Debentures High Negligible Low Average Nil High Equity Schemes Low High High High High Very high Debt Schemes Moderate Low Low High No tax on dividends Very high Bank deposits Moderate Nil Negligible High Nil Very high Public provident fund Nil Moderate Nil Average Section 80 C benefit Very high Residential Moderate Moderate Negligible Low High Fair Gold and Silver Nil Moderate Average Average Nil Average INVESTMENT VERSUS SPECULATION While it is difficult to draw the line of distinction between investment and speculation, it is possible to broadly distinguish the characteristics of an investor from those of a speculator as follows. Investor Speculator Planning horizon An investor has a relatively longer planning horizon. His holding period is usually at least one year. A speculator has a very short planning horizon. His holding may be a few days to a few months. Risk disposition An investor is normally not willing to assume more than moderate risk. Rarely does he knowingly assume high risk. A speculator is ordinarily willing to assume high risk. Return expectation

The Perfect Plan :: Personal Narrative College Essays

The Perfect Plan I had the perfect plan when it came to college. All throughout my childhood I had dreamed about playing soccer at the college level, and rooming with someone I knew well. It was important to me, that I make sure whatever decision I made, I was the happiest I could possibly be. It was now all coming into place, or so I thought. The only thing that I had to wait for was the acceptance letter. Before I get too ahead of myself though, let me explain. I had just finished a weekend at a premier soccer college showcase. College coaches from everywhere came to see the best of the best play. I was there, showing off my skills for all to see. I only wanted one coach to recognize me, and sure enough he did. The Penn State Altoona soccer coach came up to me after I had scored the game-winning goal, and told me if I wanted to play for him, I could. To make matters even better, my best friend told me she wanted to attend Penn State Altoona too. It was perfect. All my worries about leaving home, my family, and my boyfriend seemed to be pushed to the back of my mind. I wouldn’t be alone in college, and that‘s all that mattered. My biggest fear was being a long distance away from home, and I thought that by having my best friend there, I wouldn’t miss the things at home so much. I thought I would keep myself busy with sports and my college material, and I could go back to my dorm where my best friend would always be. I wouldn’t have time to worry about my home life, the life I wasn‘t convinced I was ready to leave behind. Perhaps I should explain to you why I was going to room with my best friend. She had been living at my house for six months because her house was being built, and she didn’t have anywhere to stay. So we spent six months of our lives together, sharing everything. We became inseparable, and truly acted like sisters. I thought I would be happy if we roomed together. This is why rooming with her became so exciting to me. We had already done that, and it didn’t seem like a problem at my house. We received our acceptance letters, and quickly replied stating we wanted to be roommates with each other.

The Vampire Diaries: The Struggle Chapter Fifteen

â€Å"Elena, you're being rude!† Aunt Judith seldom got angry but she was angry now. â€Å"You're too old for this kind of behavior.† â€Å"It's not rudeness! You don't understand – † â€Å"I understand perfectly. You're acting just the way you did when Damon came to dinner. Don't you think a guest deserves a little more consideration?† Frustration flooded over Elena. â€Å"You don't even know what you're talking about,† she said. This was too much. To hear Damon's words coming from Aunt Judith's lips†¦ it was unbearable. â€Å"Elena!† A mottled flush was creeping up Aunt Judith's cheeks. â€Å"I'mshocked at you! And Ihave to say that this childish behavior only started since you've been going out with that boy.† â€Å"Oh, ‘that boy'.† Elena glared at Damon. â€Å"Oh, really?† Elena felt as if she were talking to Damon and Aunt Judith at once, and she looked back and forth between the two of them. All the emotions she'd been suppressing for the last days – for the last weeks, for the months since Stefan had come into her life – were surging forward. It was like a great tidal wave inside her, over which she had no control. She realized she was shaking. â€Å"Well, that's too bad because you're going to have to tolerate it. I am never going to give Stefan up, not for anyone. Certainly not foryou!† This last was meant for Damon, but Aunt Judith gasped. â€Å"That's enough!† Robert snapped. He'd appeared with Margaret, and his face was dark. â€Å"Young lady, if this is how that boy encourages you to speak to your aunt – â€Å" â€Å"He's not ‘that boy'!† Elena took another step back, so she could face all of them. She was making a spectacle of herself, everyone in the courtyard was looking. But she didn't care. She had been keeping a lid on her feelings for so long, shoving down all the anxiety and the fear and the anger where it wouldn't be seen. All the worry about Stefan, all the terror over Damon, all the shame and humiliation she'd suffered at school, she'd buried it deep. But now it was coming back. All of it, all at once, in a maelstrom of impossible violence. Her heart was pounding crazily; her ears rang. She felt that nothing mattered except to hurt the people who stood in front of her, to show them all. â€Å"He's not ‘that boy',† she said again, her voice deadly cold. â€Å"He's Stefan and he's all I care about. And I happen to be engaged to him.† â€Å"Oh, don't be ridiculous!† Robert thundered. It was the last straw. â€Å"Is this ridiculous?† She held up her hand, the ring toward them. â€Å"We're going to get married!† â€Å"You arenot going to get married,† Robert began. Everyone was furious. Damon grabbed her hand and stared at the ring, then turned abruptly and strode away, every step full of barely leashed savagery. Robert was spluttering on in exasperation. Aunt Judith was fuming. â€Å"Elena, I absolutely forbid you – â€Å" â€Å"You'renot my mother !† Elena cried. Tears were trying to force themselves out of her eyes. She needed to get away, to be alone, to be with someone who loved her. â€Å"If Stefan asks, tell him I'll be at the boarding house!† she added, and broke away through the crowd. She half expected Bonnie or Meredith to follow her, but she was glad they didn't. The parking lot was full of cars but almost empty of people. Most of the families were staying for the afternoon activities. But a battered Ford sedan was parked nearby, and a familiar figure was unlocking the door. â€Å"Matt! Are you leaving?† She made her decision instantly. It was too cold to walk all the way to the boarding house. â€Å"Huh? No, I've got to help Coach Lyman take the tables down. I was just putting this away.† He tossed the Outstanding Athlete placard into the front seat. â€Å"Hey, are you okay?† His eyes widened at the sight of â€Å"Yes – no. I will be if I can get out of here. Look, can I take your car? Just for a little while?† â€Å"Well†¦ sure, but†¦ I know, why don't you let me drive you? I'll go tell Coach Lyman.† â€Å"No! I just want to be alone†¦ Oh, please don't ask any questions.† She almost snatched the keys out of his hand. â€Å"I'll bring it back soon, I promise. Or Stefan will. If you see Stefan, tell him I'm at the boarding house. And thanks.† She slammed the door on his protests and revved the engine, pulling out with a clash of gears because she wasn't used to a stick shift. She left him standing there staring after her. She drove without really seeing or hearing anything outside, crying, locked in her own spinning tornado of emotions. She and Stefan would run away†¦ They would elope†¦ They would show everyone. She would never set foot in Fell's Church again. And then Aunt Judith would be sorry. Then Robert would see how wrong he'd been. But Elena would never forgive them. Never. As for Elena herself, she didn't need anybody. She certainly didn't need stupid old Robert E. Lee, where you could go from being mega-popular to being a social pariah in one day just for loving the wrong person. She didn't need any family, or any friends, either†¦ Slowing down to cruise up the winding driveway of the boarding house, Elena felt her thoughts slow down, too. Well†¦ she wasn't mad at all her friends. Bonnie and Meredith hadn't done anything. Or Matt. Matt was all right. In fact, she might not need him but his car had come in pretty handy. In spite of herself Elena felt a strangled giggle well up in her throat. Poor Matt. People always borrowing his clunking dinosaur of a car. He must think she and Stefan were nuts. The giggle let loose a few more tears and she sat and wiped them off, shaking her head. Oh, God, how did things turn out this way? What a day. She should be having a victory celebration because they'd beaten Caroline, and instead she was crying alone in Matt's car. Carolinehad looked pretty damn funny, though. Elena's body shook gently with slightly hysterical chuckles. Oh, the look on her face. Somebody better have a video of that. At last the sobs and giggles both abated and Elena felt a wash of tiredness. She leaned against the steering wheel trying not to think of anything for a while, and then she got out of the car. She'd go and wait for Stefan, and then they'd both go back and deal with the mess she'd made. It would take a lot of cleaning up, she thought wearily. Poor Aunt Judith. Elena had yelled at her in front of half the town. Why had she let herself get so upset? But her emotions were still close to the surface, as she found when the boarding house door was locked and no one answered the bell. Oh, wonderful she thought, her eyes stinging again. Mrs. Flowers had gone off to the Founders' Day celebration, too. And now Elena had the choice of sitting in the car or standing out here in this windstorm†¦ It moaned through the branches of the oak trees, tearing off the remaining leaves and sending them down in showers. The sound was rising steadily now, not just a moan but a howl. And there was something else. Something that came not just from the wind, but from the air itself, or the space around the air. A feeling of pressure, of menace, of some unimaginable force. It was gathering power, drawing nearer, closing in. Elena spun to face the oak trees. There was a stand of them behind the house, and more beyond, blending into the forest. And beyond that were the river and the graveyard. Something†¦ was out there. Something†¦ very bad†¦ â€Å"No,† whispered Elena. She couldn't see it, but she could feel it, like some great shape rearing up to stand over her, blotting out the sky. Shefelt the evil, the hatred, the animal fury. Bloodlust. Stefan had used the word, but she hadn't understood it. Now she felt this bloodlust†¦ focused on her. â€Å"No!† Higher and higher, it was towering over her. She could still see nothing, but it was as if great wings unfolded, stretching to touch the horizon on either side. Something with a Power beyond comprehension†¦ and it wanted tokill †¦ â€Å"No!† She ran for the car just as it stooped and dived for her. Her hands scrabbled at the door handle, and she fumbled frantically with the keys. The wind was screaming, shrieking, tearing at her hair. Gritty ice sprayed into her eyes, blinding her, but then the key turned and she jerked the door open. Safe! She slammed the door shut again and brought her fist down on the lock. Then she flung herself across the seat to check the locks on the other side. The wind roared with a thousand voices outside. The car began rocking. â€Å"Stop it! Damon, stop it!† Her thin cry was lost in the cacophony. She put her hands out on the dashboard as if to balance the car and it rocked harder, ice pelting against it. Then she saw something. The rear window was clouding up, but she could discern the shape through it. It looked like some great bird made of mist or snow, but the outlines were hazy. All she was sure of was that it had huge sweeping wings†¦ and that it was coming for her. Get the key in the ignition. Get it in! Now go! Her mind was rapping orders at her. The ancient Ford wheezed and the tires screamed louder than the wind as she took off. And the shape behind her followed, getting larger and larger in the rearview mirror. If she hadn't been skidding and braking already, the tree would have crashed down on her. As it was, the violent impact shook the car like an earthquake missing the front right fender by inches. The tree was a mass of heaving, pitching branches, its trunk blocking the way back to town completely. She was trapped. Her only route home cut off. She was alone, there was no escape from this terrible Power†¦ Power. That was it; that was the key. â€Å"The stronger your Powers are, the more the rules of the dark bind you.† Running water! Throwing the car into reverse, she brought it around and then slammed into forward. The white shape banked and swooped, missing her as narrowly as the tree had, and then she was speeding down Old Creek Road into the worst of the storm. It was still after her. Only one thought pounded in Elena's brain now. She had to cross running water, to leave this thing behind. There were more cracks of lightning, and she glimpsed other trees falling, but she swerved around them. It couldn't be far now. She could see the river flickering past on her left side through the driving ice storm. Then she saw the bridge. It was there; she'd made it! A gust threw sleet across the windshield, but with the wipers' next stroke she saw it fleetingly again. This was it, the turn should be abouthere. The car lurched and skidded onto the wooden structure. Elena felt the wheels grip at slick planks and then felt them lock. Desperately, she tried to turn with the skid, but she couldn't see and there was no room†¦ And then she was crashing through the guardrail, the rotted wood of the footbridge giving way under weight it could no longer support. There was a sickening feeling of spinning, dropping, and the car hit the water. Elena heard screams, but they didn't seem to be connected with her. The river welled up around her and everything was noise and confusion and pain. A window shattered as it was struck by debris, and then another. Dark water gushed across her, along with glass like ice. She was engulfed. She couldn't see; she couldn't get out. And she couldn't breathe. She was lost in this hellish tumult, and there was no air.She had to breathe. She had to get out of here†¦ â€Å"Stefan, help me!† she screamed. But her scream made no sound. Instead, the icy water rushed into her lungs, invading her. She thrashed against it, but it was too strong for her. Her struggles became wilder, more uncoordinated, and then they stopped. Bonnie and Meredith were hunting around the perimeter of the school impatiently. They'd seen Stefan go this way, more or less coerced by Tyler and his new friends. They'd started to follow him, but then that business with Elena had started. And then Matt had informed them that she'd taken off. So they'd set out after Stefan again, but nobody was out here. There weren't even any buildings except one lonely Quonset hut. â€Å"And now there's a storm coming!† Meredith said. â€Å"Listen to that wind! I think it's going to rain.† â€Å"Or snow!† Bonnie shuddered. â€Å"Where did theygo?† â€Å"I don't care; I just want to get under a roof. Here it comes!† Meredith gasped as the first sheet of icy rain hit her, and she and Bonnie ran for the nearest shelter – the Quonset hut. And it was there that they found Stefan. The door was ajar, and when Bonnie looked in she recoiled. â€Å"Tyler's goon squad!† she hissed. â€Å"Look out!† Stefan had a semicircle of guys between him and the door. Caroline was in the corner. â€Å"He must have it! He took it somehow; I know he did!† she was saying. â€Å"Took what?† said Meredith, loudly. Everyone turned their way. Caroline's face contorted as she saw them in the doorway and Tyler snarled. â€Å"Get out.† he said. â€Å"You don't want to be involved in this.† Meredith ignored him. â€Å"Stefan, can I talk to you?† â€Å"In a minute. Are you going to answer her question? Took what?† Stefan was concentrating on Tyler, totally focused. â€Å"Sure, I'll answer her question. Right after I answer yours.† Tyler's beefy hand thumped into his fist and he stepped forward. â€Å"You're going to be dog meat, Salvatore.† Several of the tough guys snickered. Bonnie opened her mouth to say, â€Å"Let's getout of here.† But what she actually said was, â€Å"The bridge.† It was weird enough to make everyone look at her. â€Å"What?† said Stefan. â€Å"The bridge,† said Bonnie again, without meaning to say it. Her eyes bulged, alarmed. She could hear the voice coming from her throat, but she had no control over it. And then she felt her eyes go wider and her mouth drop open and she had her own voice back. â€Å"The bridge, oh, my God, the bridge! That's where Elena is! Stefan, we've got to save her†¦ Oh, hurry!† â€Å"Yes, oh, God†¦ that's where she's gone. She's drowning!Hurry !† Waves of thick blackness broke over Bonnie. But she couldn't faint now; they had to get to Elena. Stefan and Meredith hesitated one minute, and then Stefan was through the goon squad, brushing them aside like tissue paper. They sprinted through the field toward the parking lot, dragging Bonnie behind. Tyler started after them, but stopped when the full force of the wind hit him. â€Å"Why would she go out in this storm?† Stefan shouted as they sprang into Meredith's car. â€Å"She was upset; Matt said she took off in his car,† Meredith gasped back in the comparative quiet of the interior. She pulled out fast and turned into the wind, speeding dangerously. â€Å"She said she was going to the boarding house.† â€Å"No, she's at the bridge! Meredith, drive faster! Oh, God, we're going to be too late!† Tears were running down Bonnie's face. Meredith floored it. The car swayed, buffeted by wind and sleet. All through that nightmare ride Bonnie sobbed, her fingers clutching the seat in front of her. Stefan's sharp warning kept Meredith from running into the tree. They piled out and were immediately lashed and punished by the wind. â€Å"It's too big to move! We'll have to walk,† Stefan shouted. Of course it was too big to move, Bonnie thought, already scrambling through the branches. It was a full-grown oak tree. But once on the other side, the icy gale whipped all thought out of her head. Within minutes she was numb, and the road seemed to go on for hours. They tried to run but the wind beat them back. They could scarcely see; if it hadn't been for Stefan, they would have gone over the riverbank. Bonnie began to weave drunkenly. She was ready to fall to the ground when she heard Stefan shouting up ahead. Meredith's arm around her tightened, and they broke again into a stumbling run. But as they neared the bridge what they saw brought them to a halt. â€Å"Oh, my God†¦ Elena!† screamed Bonnie. Wickery Bridge was a mass of splintered rubble. The guardrail on one side was gone and the planking had given way as if a giant fist had smashed it. Beneath, the dark water churned over a sickening pile of debris. Part of the debris, entirely underwater except the headlights, was Matt's car. Meredith was screaming, too, but she was screaming at Stefan. â€Å"No! You can't go down there!† He never even glanced back. He dived from the bank, and the water closed over his head. Later, Bonnie's memory of the next hour would be mercifully dim. She remembered waiting for Stefan while the storm raged endlessly on. She remembered that she was almost beyond caring by the time a hunched figure lurched out of the water. She remembered feeling no disappointment, only a vast and yawning grief, as she saw the limp thing Stefan laid out on the road. She remembered how he looked as they tried to do something for Elena. Only that wasn't really Elena lying there, that was a wax doll with Elena's features. It was nothing that had ever been alive and it certainly wasn't alive now. Bonnie thought it seemed silly to go on poking and prodding at it like this, trying to get water out of its lungs and so on. Wax dolls didn't breathe. She remembered Stefan's face when he finally gave up. When Meredith wrestled with him and yelled at him, saying something about over an hour without air, and brain damage. The words filtered in to Bonnie, but their meaning didn't. She just thought it odd that while Meredith and Stefan were screaming at each other they were both crying. Stefan stopped crying after that. He just sat there holding the Elena-doll. Meredith yelled some more, but he didn't listen to her. He just sat. And Bonnie would never forget his expression. And then something seared through Bonnie, bringing her to life, waking her to terror. She clutched at Meredith and stared around for the source. Something bad†¦ something terrible was coming. Was almost here. Stefan seemed to feel it, too. He was alert, stiff, like a wolf picking up a scent. â€Å"What is it?† shouted Meredith. â€Å"What's wrong with you?† â€Å"You've got to go!† Stefan rose, still holding the limp form in his arms. â€Å"Get out of here!† â€Å"What do you mean? We can't leave you – â€Å"Yes, you can! Get out of here! Bonnie, get her out!† No one had ever told Bonnie to take care of someone else before. People were always taking care of her. But now she seized Meredith's arm and began pulling. Stefan was right. There was nothing they could do for Elena, and if they stayed whatever had gotten her would get them. â€Å"Stefan!† Meredith shouted as she was unaccountably dragged away. â€Å"I'll put her under the trees. The willows, not the oaks,† he called after them. Why would he tell us that now? Bonnie wondered in some deep part of her mind that was not taken up with fear and the storm. The answer was simple, and her mind promptly gave it back to her. Because he wasn't going to be around to tell them later.

Adjustment Disorder Diagnosis and Treatment Essay

Adjustment Disorder Diagnosis and Treatment Adjustment disorder is a mental disorder that results from unhealthy responses to stressful or psychologically distressing events in life. This failure to adapt then leads to the development of emotional and behavioral symptoms. All age groups are affected by this disorder; and children have the same chance of developing the illness. While difficult to determine the causes of adjustment disorder, researchers suggest that genetics play a large part, as well as chemical changes in the brain, life experiences and mood. Some common stressor contributing to the disorder ncludes; the ending of a romantic relationship, loss of a Job, career change, an accident, relocating to a new area or loss of a loved one. (Mayo Clinic, 2010) An adjustment disorder causes feelings of depression, anxiousness, crying spells, sadness, desperation, lack of enjoyment, and some have reported experiencing thoughts of suicide. Additionally, the illness causes one to be unable to go about their normal routine or work and visit with friends and family. The lengths of symptoms vary from zero to six months (acute) and longer than six months (chronic). In the cases of acute adjustment disorder, symptoms can go away eventually; however, in chronic cases, symptoms begin to disrupt your life whereas, professional treatment is necessary to prevent the illness from worsening. Lastly, this disorder carries the possibility for abuse of alcohol and drugs, and eventually could result in violent behavior. According to a report issued by Tami Benton of WebMD, â€Å"the development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurs within 3 months of the onset of the stressor(s). These symptoms or behaviors are linically significant, as evidenced by marked distress in excess of what is expected from exposure to the stressor, or significant impairment in social or occupational (academic) functioning. The stress-related disturbance does not meet criteria for another specific axis I disorder and is not merely an exacerbation of a preexisting axis I or axis II disorder. The symptoms do not represent bereavement. Once the stressor (or its consequences) has terminated, the symptoms do not persist for more than an additional 6 months†. A determination is made as to whether the illness is acute or chronic. A differential diagnosis issued by Benton states that, â€Å"Adjustment Disorder’s (AD) are located on a continuum between normal stress reactions and specific psychiatric disorders. Symptoms are not likely a normal reaction if the symptoms are moderately severe or if daily social or occupational functioning is impaired. If a specific stressor is involved and/or the symptoms are not specific but are severe, alternate diagnoses (eg, posttraumatic stress disorder, conduct disorder, depressive disorders, anxiety disorders, depression or anxiety due to a general medical condition) are unlikely’. Benton, 2009) â€Å"Clinical treatment modalities are difficult due to lack of clinical trials; as these AD originates from a psychological reaction to a stressor, the stressor must be identified and communicated by the patient. The non-adaptive response to the stressor may be diminished if the stress can be â€Å"eliminated, reduced or accommodated. Therefore, treatment of ADS entails psychotherapeutic counseling aimed at reducing the stressor, improving coping ability with stressors that cannot be reduced or removed, and formatting an emotional state and support systems to enhance adaptation and coping. Further, the goal of psychotherapy should include; an analysis of the stressors that are affecting the patient, and determine whether they can be eliminated or minimized, clarification and interpretation of the meaning of the stressor for the patient, reframe the meaning of the stressor, illuminate the concerns and conflicts the patient experiences, identification of a means to reduce the stressor, maximize the patient’s coping skills, assist patients to gain perspective on the stressor, establish relationships, attend support groups, and manage themselves and the stressor. Psychotherapy, crisis intervention, family and group herapies, cognitive behavioral therapy, and interpersonal psychotherapy are effective for eliciting the expressions of affects, anxiety, helplessness, and hopelessness in relation to the identified stressor(s)†. (Benton, 2009) For patients with minor or major depressive disorders, who have not responded to psychotherapy and other interventions; trials of antidepressants are recommended.