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Real-time adaptation erectile dysfunction symptoms cheap tadala_black 80 mg amex, continuous patient moni to erectile dysfunction at age 26 purchase tadala_black 80 mg ring during treatment combined with pre plotted beam trajec to erectile dysfunction caused by high cholesterol purchase 80 mg tadala_black overnight delivery ries to erectile dysfunction watermelon cheap tadala_black 80mg visa make sure that the maximum dose is delivered to the precise target while avoiding other organs. Online adaptation, radiation treatment based on new information on a specific day to account for variations in patient ana to my or physiology, which cannot be corrected by repositioning the patient alone. There are plenty of technologies aiming for a better patient treatment, however, the benefits and drawbacks needs to be evaluated to determine the usability of the new technology in the clinic. This is an interesting development and would fall in the category offline adaption, as mentioned above. This mode is used for visualizing small ana to mical sites such as the brain and head-and-neck regions. The full fan bow-tie filter is symmetrical and thick at both ends, while the half fan bow-tie filter is asymmetrical with a thick and a thin end (Figure 3). In the case of the Pelvis Spot Light mode, the default installation uses the half fan bow-tie filter; use of the full fan bow-tie filter requires a calibration. Pre-study – Inter-patient bladder filling variation Before the main study was carried out, a pre-study was conducted to investigate the inter-patient differences between the use of bladder filling pro to col and instructing patients to maintain a comfortably full bladder volume. The minimum, maximum and mean bladder volumes in each group were compared and a Mann-Whitney test was performed with a 95% level of confidence to test the significance in the volume sample. The volumetric changes of the bladder were compared between the two patients to investigate the impact of the bladder filling pro to col on the bladder volume. The junction between the urethra and the bladder is one of the reference areas in the dose planning for these patients, it is regarded that the position of this site is unaffected by nearby organs. To evaluate this hypothesis, the lowermost part of the bladder’s con to ur in all scans performed for the same patient, were compared in the cranial – caudal direction to determine if any displacement was evident in this area during the treatment period. M is the instrument reading obtained with a chamber corrected to standard pressure and temperature. One measurement was performed 10 cm to the left (off-axis) with the half fan bow tie filter to estimate the increase in absorbed dose received. The ionization chamber was also placed at 2 cm depth in central axis, measurement C, to estimate the skin dose (Figure 4). The current [nA] given by the electrometer were logged to visualize the charge deposited as a function of time and position relative to the central axis. The deformation algorithm is a grayscale-based fully au to matic deformable image registration 26 algorithm originally known as the Demons algorithm, described in a paper by Thirion. In addition, the algorithm’s ability to treat changes such as tumor shrinkage and swellings was tested. When deforming images in SmartAdapt, a rigid registration is required by the software in order to generate a deformable registration. The left image is the pelvis phan to m with the four holes, were the two to p holes are the smaller ones and the two lower holes are the larger ones measuring 2. The naming for the holes is also seen, S1 and S2 are the smaller holes and L1 and L2 are the larger holes. For the 24 patients with the bladder filling 3 3 pro to col the bladder volumes varied between 101 cm and 516 cm with a mean bladder volume of 3 262 cm (Table 5). When performing a Mann-Whitney test on the bladder volumes measured for both patient groups to test for significance, the returned p-value was 0. The variability in bladder volume seen for the patients following the bladder filling pro to col can be due to differences in renal functions between the patients. Other fac to rs can be failure of fulfilling the conditions of the bladder filling pro to col. In order to ensure a reproducible bladder filling throughout the treatment period for the individual patient, the intra patient variation has to be investigated. Results from the pre-study showing the minimum, maximum and mean bladder volume and the p-value from the Mann-Whitney test for patients following and not following a bladder filling pro to col. With bladder filling Without bladder filling 3 3 pro to col [cm ] pro to col [cm ] Minimum volume 111 101 Maximum volume 500 516 Mean volume 253 262 No. Patient#2 – not following a 3 3 3 bladder filling pro to col, had a mean bladder volume of 170 cm, ranging from 50 cm – 290 cm, with 3 the standard deviation of 93. The smaller bladder volumes for patient#1 resulted in a larger part of the bladder was irradiated compared to patient#2. If the bladder filling pro to col induces smaller volumes compared to when patients are instructed to maintain a comfortably full bladder, than the benefits of the bladder filling pro to col can be questioned. Interestingly, the answers given by patient#1 in the questionnaire showed that the conditions for the bladder filling pro to col were not always fulfilled. The fluid intake and voiding of the bladder were in most cases 1 – 2 hours prior to the radiation treatment where the instructed time was 1 hour. Several studies have shown a time trend in decrease of bladder filling volume throughout the 35-37, 39 treatment period. Other studies investigating the impact of bladder filling pro to col on the bladder volume did not show any stability in the bladder 35, 38, 39 volumes measured, it should be noted that the largest patient group in these studies were 25. Since only two patients were included during this study period, no conclusion can be drawn regarding if bladder filling pro to col contributes to a reproducible bladder volume or not. It is clear that further investigation is required with a larger patient group to draw conclusions on the bladder filling pro to cols impact on the bladder volume. However, the experience learned in this study can be used as a framework for future investigation. The bladder filling pro to col should be easy to follow and possible to fulfill independent of patient condition. It should also be integrated in the treatment process in such way that it is unaffected by possible holdups or delays. Regarding the comparison of the lowermost part of the bladder, the results showed at most a 15 mm displacement in the cranial – caudal direction for both patient#1 and patient#2 (Figure 7). These results imply that a movement in the junction between the urethra and the bladder exists. However, it should be noted that these results are dependent on the perception of the clinician drawing the bladder con to urs. To draw any definitive conclusions, a larger patient group is required to determine if the results are representative for pos to perative cancer patients. The left and the right image shows the largest shifts in the bladder’s lowermost part seen for patient#1, following the bladder filling pro to col, and patient#2, not following a bladder filling pro to col, respectively. The minimum, maximum and mean of the bladder volumes are shown to gether with the standard deviation for patient patient#1 and patient#2. The value given for the full fan bow-tie filter is assumed to be within 5 % accuracy (Table 8). The mean mass energy-absorption coefficient used for the half fan bow-tie filter measurement 2 -1 was chosen to be the same as the full fan bow-tie filter at the central axis, 1. This assumption adds further uncertainty to the value presented for the half fan bow-tie filter and is estimated to be within 7 % accuracy (Table 8). For the measurements at 2 cm depth with the full fan bow-tie filter at 5 cm off-axis and at central -1 axis the dose rate were calculated to 9. The large difference in the dose rate for the 5 cm displacement from the central axis is due to the shape of the full fan bow-tie filter (Figure 3). The central axis includes more low-energy pho to ns due to the lesser 17 filtration, causing an increase in surface dose. This was shown by Ding an Coffey (2010) for the pelvis spot light mode, where the relative absorbed dose reduced with 66 % for a 5 cm displacement from the central axis when using full fan bow-tie filter. The charge collected per second at 10 cm depth for central axis, 5 cm off-axis and 10 cm off-axis -1 were 0. These results show the reduced charge collected due to the increased attenuation at 10 cm depth. The measurement at central axis was seen to reduce by 57 % compared to the measurement at 2 cm depth. Similar results were seen for the 2 cm depth measurements where the charge collected decreased the further the ionization chamber were placed from the central axis. Furthermore, the results also showed the relative energy independence of the ion chamber used in this study (Exradin A3) in the kV region where the reduction in the charges collected decreased in similar ratios compared to the measurements at 2 cm depth.


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Children also improve in their ability to erectile dysfunction treatment herbal remedy tadala_black 80 mg low price shift their attention between tasks or different features of a task (Carlson can erectile dysfunction cause infertility buy cheap tadala_black 80mg on-line, Zelazo erectile dysfunction treatment kerala generic tadala_black 80 mg visa, & Faja erectile dysfunction at age 31 generic tadala_black 80 mg line, 2013). A younger child who is asked to sort objects in to piles based on type of object, car versus animal, or color of object, red versus blue, may have difficulty if you switch from asking them to sort based on type to now having them sort based on color. An older child has less difficulty making the switch, meaning there is greater flexibility in their attentional skills. These changes in attention and working memory contribute to children having more strategic approaches to challenging tasks. Memory Strategies: Bjorklund (2005) describes a developmental progression in the acquisition and use of memory strategies. Such strategies are often lacking in younger children but increase in frequency as children progress through elementary school. Examples of memory strategies include rehearsing information you wish to recall, visualizing and organizing information, creating rhymes, such “i” before “e” except after “c”, or inventing acronyms, such as “roygbiv” to remember the colors of the rainbow. Schneider, Kron-Sperl, and Hunnerkopf (2009) reported a steady increase in the use of memory strategies from ages six to ten in their longitudinal study (see Table 5. Moreover, by age ten many children were using two or more memory strategies 172 to help them recall information. A mediation deficiency 10 13 occurs when a child does not grasp the strategy being taught, and thus, does not benefit from its use. If you do not understand why using an acronym might be helpful, or how to create an acronym, the strategy is not likely to help you. In a production deficiency the child does not spontaneously use a memory strategy and must be prompted to do so. In this case, children know the strategy and are more than capable of using it, but they fail to “produce” the strategy on their own. For example, children might know how to make a list, but may fail to do this to help them remember what to bring on a family vacation. A utilization deficiency refers to children using an appropriate strategy, but it fails to aid their performance. Utilization deficiency is common in the early stages of learning a new memory strategy (Schneider & Pressley, 1997; Miller, 2000). Until the use of the strategy becomes au to matic it may slow down the learning process, as space is taken up in memory by the strategy itself. Initially, children may get frustrated because their memory performance may seem worse when they try to use the new strategy. Once children become more adept at using the strategy, their memory performance will improve. Sodian and Schneider (1999) found that new memory strategies acquired prior to age eight often show utilization deficiencies with there being a gradual improvement in the child’s use of the strategy. In contrast, strategies acquired after this age often followed an “all-or-nothing” principle in which improvement was not gradual, but abrupt. Knowledge Base: During middle and late childhood, children are able to learn and remember due to an improvement in the ways they attend to and s to re information. As children enter school and learn more about the world, they develop more categories for concepts and learn more efficient strategies for s to ring and retrieving information. One significant reason is that they continue to have more experiences on which to tie new information. In other words, their knowledge base, knowledge in particular areas that makes learning new information easier, expands (Berger, 2014). Metacognition: Children in middle and late childhood also have a better understanding of how well they are performing a task, and the level of difficulty of a task. As they become more realistic about their abilities, they can adapt studying strategies to meet those needs. Young children spend as much time on an unimportant aspect of a problem as they do on the main point, while older children start to learn to prioritize and gauge what is significant and what is not. Metacognition refers to the knowledge we have about our own thinking and our ability to use this awareness to regulate our own cognitive processes (Bruning, Schraw, Norby, & Ronning, 2004). Critical thinking, or a detailed examination of beliefs, courses of action, and evidence, involves teaching children how to think. The purpose of critical thinking is to evaluate information in ways that help us make informed decisions. Critical thinking involves better understanding a problem through gathering, evaluating, and selecting information, and also by considering many possible solutions. These include: Analyzing arguments, clarifying information, judging the credibility of a source, making value judgements, and deciding on an action. Metacognition is essential to critical thinking because it allows us to reflect on the information as we make decisions. Language Development Vocabulary: One of the reasons that children can classify objects in so many ways is that they have acquired a vocabulary to do so. This language explosion, however, differs from that of younger children because it is facilitated by being able to associate new words with those already known, and because it is accompanied by a more sophisticated understanding of the meanings of a word. New Understanding: Those in middle and late childhood are also able to think of objects in less literal ways. For example, if asked for the first word that comes to mind when one hears the word "pizza", the younger child is likely to say "eat" or some word that describes what is done with a pizza. However, the older child is more likely to place pizza in the appropriate category and say "food". This sophistication of vocabulary is also evidenced by the fact that older children tell jokes and delight in doing do. They may use jokes that involve plays on words such as "knock knock" jokes or jokes with punch lines. Young children do not understand play on words and tell "jokes" that are literal or slapstick, such as "A man fell down in the mud! While younger children are likely to be reluctant to give up saying "I goed there", older children will learn this rather quickly along with other rules of grammar. Communication Disorders At the end of early childhood, children are often assessed in terms of their ability to speak properly. By first grade, about 5% of children have a notable speech disorder (Medline Plus, 2016c). Stuttering is a speech disorder in which sounds, syllables, or words are repeated or last longer than normal. These problems cause a break in the flow of speech, which is called dysfluency (Medline Plus, 2016b). About 5% of young children, aged two-five, will develop some stuttering that may last from several weeks to several years (Medline Plus, 2016c). This is called developmental stuttering and is the most common form of stuttering. Brain injury, and in very rare instances, emotional trauma may be other triggers for developing problems with stuttering. In most cases of developmental stuttering, other family members share the same communication disorder. They can range from problems with specific sounds, such as lisping to severe impairment in the phonological system. Most children have problems pronouncing words early on while their speech is developing. However, by age three, at least half of what a child says should be unders to od by a stranger. Parents should seek help if by age six the child is still having trouble producing certain sounds. It should be noted that accents are not articulation disorders (Medline Plus, 2016a). Voice disorders: Disorders of the voice involve problems with pitch, loudness, and quality of the voice (American Speech-Language and Hearing Association, 2016). It only becomes a disorder when problems with the voice makes the child unintelligible. In children, voice disorders are significantly more prevalent in males than in females. Causes can be due to structural abnormalities in the vocal cords and/or larynx, functional fac to rs, such as vocal fatigue from overuse, and in rarer cases psychological fac to rs, such as chronic stress and anxiety. Theories of Intelligence Psychologists have long debated how to best conceptualize and Figure 5. These questions include: How many types of intelligence are there, the role of nature versus nurture in intelligence, how intelligence is represented in the brain, and the meaning of group differences in intelligence.

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Sacral neuromodulation has been used to erectile dysfunction treatment by injection tadala_black 80 mg without prescription good effect in patients with reduced contractility and poorly relaxing sphincters (183 do erectile dysfunction pumps work buy generic tadala_black 80mg line,184) erectile dysfunction caused by hemorrhoids generic tadala_black 80mg online. Neuromodulation may work by blocking urethral inhibition of afferent signals from the bladder importance of being earnest discount 80mg tadala_black amex, resulting in res to ration of transmission of afferent signals to the brain and a resumption of bladder sensation and voiding (185). A similar picture may be seen in spasticity of the pelvic floor associated with pain, where neuromodulation may inhibit pain and enhance detrusor contraction. Eighteen patients had urodynamic data from the baseline assessment available and 16 had data at follow-up. There was no significant difference in the proportion of patients reporting s to rage or voiding symp to ms. Reconstructive surgery Detrusor myoplasty was first reported in man in 1998 by Stenzl et al. Microsurgical anas to mosis of the muscle pedicle to the inferior epigastric vessels with nerve coaptation to the intercostal branch is undertaken before wrapping the muscle in a spiral arrangement around the bladder, covering approximately 75% of its surface. The muscle is then fixed to the ligamen to us and fascial structures of the pelvic floor based on intra-operative consider ations. A to tal of 24 catheter-dependent patients with acontractile detrusors underwent the procedure with a median follow-up of 46 months. Etiologies included tethered cord syndrome, spinal cord injury, idiopathic, and acontractility post-hysterec to my. Compliance was >50 mL/mbar in all patients and vesico-ureteric reflux was identified post-operatively. The overall complication rate was 33% and included thromboembolism, pelvic abscess, and wound infection, although this rate would seem acceptable given the complex experi mental nature of the procedure. There was no long-term donor site morbidity (muscular deficit or chronic pain) reported, although this has to be interpreted with caution given the small numbers. Ultrastructural changes accompanying aging and disease appear to tell part of the s to ry. The possible roles of the afferent and efferent systems, as well as central control mechanisms, are important avenues for future study. Electrotherapy remains experimental, and a transcutaneous method would be more acceptable than trans-urethral. Detrusor myoplasty is potentially an option for younger patients that accept the risk of surgical morbidity, but expertise with this procedure is currently limited to a small number of groups worldwide. Incidence and progression of lower urinary tract symp to ms in a large prospective cohort of United States men. A shifted paradigm for the further understanding, evaluation, and treatment of lower urinary tract symp to ms in men: focus on the bladder. Prevalence and clinical features of detrusor underactivity among elderly with lower urinary tract symp to ms: A comparison between men and women. Lower urinary tract symp to ms in young men: videourodynamic findings and correlation with noninvasive measures. The pathophysiology of urinary incontinence among institutionalized elderly persons. Assessment of the poorly contractile or acontractile bladder in the older male in the absence of neuropathy. Re: detrusor underactivity: a plea for new approaches to a common bladder dysfunction. Detrusor underactivity: a plea for new approaches to a common bladder dysfunction. Contractility of vascular smooth muscle: maximum ability to contract in response to a stimulus. Urodynamic findings suggesting two-stage development of idiopathic detrusor underactivity in adult men. The natural his to ry of lower urinary tract dysfunction in men: minimum 10-year urodynamic follow-up of untreated detrusor underactivity. Bladder outlet obstruction versus impaired detrusor contractility: the role of outflow. The assessment of prostatic obstruction from urodynamic measurements and from residual urine. Urinary retention and post-void residual urine in men: separating truth from tradition. Evidence-based guidelines for the management of lower urinary tract symp to ms related to uncomplicated benign prostatic hyperplasia in Italy: updated summary. Chronic urinary retention in men: Can we define it, and does it affect treatment outcome. Urodynamic findings in chronic retention of urine and their relevance to results of surgery. Detrusor contractility and compliance characteristics in adult male patients with obstructive and nonobstructive voiding dysfunction. A prospective randomized trial comparing transurethral prostatic resection and clean intermittent self-catheterization in men with chronic urinary retention. Videourodynamic analysis of pathophysiology of men with both s to rage and voiding lower urinary tract symp to ms. Misdiagnosis of urinary incontinence in nursing home women: prevalence and a proposed solution. Prevalence and characteristics of voiding difficulties in women: are subjective symp to ms substantiated by objective urodynamic datafi Post hoc interpretation of urodynamic evaluation is qualitatively different than interpretation at the time of urodynamic study. Contractile and metabolic properties of longitudinal smooth muscle from rat urinary bladder and the effects of aging. Aging effects on contractility of longitudinal and circular detrusor and trigone of rat bladder. Aging differentially modifies agonist-evoked mouse detrusor contraction and calcium signals. Age-related changes in the rat detrusor muscle: the contractile response to inorganic ions. Contractile responses and calcium mobilization induced by muscarinic agonists in the rat urinary bladder: effects of age. Influence of age and bladder dysfunction on the contractile properties of isolated human detrusor smooth muscle. Age-related changes in cholinergic and purinergic neurotransmission in human isolated bladder smooth muscles. Detrusor contractility: Age related correlation with urinary flow rate in asymp to matic males. Urodynamic trends in the female aging population: Detrusor hyperactivity with impaired contractility, two conditions or onefi Smooth muscle caveolae differentially regulate specific agonist induced bladder contractions. Biomechanical properties and innervation of the female caveolin-1-deficient detrusor. Loss of caveolin-1 expression is associated with disruption of muscarinic cholinergic activities in the urinary bladder. A new look at detrusor underactivity: impaired contractility versus afferent dysfunction. The application of ultrastructural studies in the diagnosis of bladder dysfunction in a clinical setting. The detrusor muscle cell in bladder outlet obstruction–ultrastructural and morphometric findings. A prospective controlled quantitative study of ultrastructural changes in the underactive detrusor. Does ultrastructural morphology of human detrusor smooth muscle cells characterize acute urinary retentionfi Studies on experimental bladder outlet obstruction in the cat: long-term functional effects. Effects of partial outflow obstruction on bladder contractility and blood flow to the detrusor: comparison between mild and severe obstruction.

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Gender-Reiated Diagnostic issues Females and males appear to ketoconazole impotence tadala_black 80 mg discount have more similarities than differences in terms of most clin­ ical features— for example erectile dysfunction treatment maryland discount 80mg tadala_black free shipping, disliked body areas statistics for erectile dysfunction cheap 80mg tadala_black, types of repehtive behaviors erectile dysfunction treatment over the counter generic 80 mg tadala_black free shipping, symp to m severity, suicidality, comorbidity, illness course, and receipt of cosmetic procedures for body dysmorphic disorder. However, males are more likely to have genital preoccupa­ tions, and females are more likely to have a comorbid eating disorder. Suicide Risic Rates of suicidal ideation and suicide attempts are high in both adults and children/ado­ lescents with body dysmorphic disorder. A substantial proportion of individuals attribute suicidal ideation or suicide attempts primarily to their appearance concerns. Individuals with body dysmorphic dis­ order have many risk fac to rs for completed suicide, such as high rates of suicidal ideation and suicide attempts, demographic characteristics associated with suicide, and high rates of comorbid major depressive disorder. Functionai Consequences of Body Dysmorphic Disorder Nearly all individuals with body dysmorphic disorder experience impaired psychosocial functioning because of their appearance concerns. More severe body dysmorphic disorder symp to ms are associated with poorer functioning and quality of life. Most individuals experience impairment in their job, aca­ demic, or role functioning. About 20% of youths with body dysmorphic disorder report dropping out of school primarily because of their body dys­ morphic disorder symp to ms. Individuals may be housebound because of their body dysmorphic disorder symp to ms, sometimes for years. A high pro­ portion of adults and adolescents have been psychiatrically hospitalized. D ifferential Diagnosis Normal appearance concerns and clearly noticeable physical defects. Body dysmor­ phic disorder differs from normal appearance concerns in being characterized by exces­ sive appearance-related preoccupations and repetitive behaviors that are time-consuming, are usually difficult to resist or control, and cause clinically significant distress or impair­ ment in functioning. However, skin picking as a symp to m of body dysmofihic disorder can cause noticeable skin lesions and scarring; in such cases, body dys­ morphic disorder should be diagnosed. In an individual with an eating disorder, concerns about being fat are considered a symp to m of the eating disorder rather than body dysmorphic disorder. Eating disorders and body dysmorphic disorder can be comorbid, in which case both should be diagnosed. These disorders have other differences, such as poorer insight in body dysmofihic disorder. When skin picking is intended to improve the appearance of perceived skin defects, body dysmorphic disorder, rather than excoria­ tion (skin-picking) disorder, is diagnosed. When hair removal (plucking, pulling, or other types of removal) is intended to improve perceived defects in the appearance of facial or body hair, body dysmofihic disorder is diagnosed rather than trichotillomania (hair pulling disorder). Individuals with body dysmorphic disorder are not preoccu­ pied with having or acquiring a serious illness and do not have particularly elevated levels of somatization. The prominent preoccupation with appearance and exces­ sive repetitive behaviors in body dysmorphic disorder differentiate it from major de­ pressive disorder. However, major depressive disorder and depressive symp to ms are common in individuals with body dysmofihic disorder, often appearing to be secondary to the distress and impairment that body dysmorphic disorder causes. Body dysmofihic disorder should be diagnosed in depressed individuals if diagnostic criteria for body dys mofihic disorder are met. However, unlike social anxiety disorder (social phobia), agoraphobia, and avoidant personality disorder, body dysmorphic disorder includes prominent appearance-related preoccupation, which may be delusional, and repetitive behaviors, and the social anxiety and avoidance are due to concerns about perceived appearance defects and the belief or fear that other people will consider these individuals ugly, ridicule them, or reject them be­ cause of their physical features. Unlike generalized anxiety disorder, anxiety and worry in body dysmofihic disorder focus on perceived appearance flaws. Many individuals with body dysmorphic disorder have delu­ sional appearance beliefs. Appearance-related ideas or delusions of reference are common in body dysmorphic disorder; however, unlike schizophrenia or schizoaffective disorder, body dysmofihic disorder involves prominent appearance pre­ occupations and related repetitive behaviors, and disorganized behavior and other psy­ chotic symp to ms are absent (except for appearance beliefs, which may be delusional). Koro, a culturally related disorder that usually occurs in epidemics in Southeastern Asia, consists of a fear that the penis (labia, nipples, or breasts in females) is shrinking or retracting and will disappear in to the abdomen, often accompanied by a belief that death will result. Koro differs from body dysmorphic disor­ der in several ways, including a focus on death rather than preoccupation with perceived ugliness. It involves symp to ms reflecting an overconcern with slight or imagined flaws in appearance. Comorbidity Major depressive disorder is the most common comorbid disorder, with onset usually af­ ter that of body dysmorphic disorder. Persistent difficulty discarding or parting with possessions, regardless of their actual value. This difficulty is due to a perceived need to save the items and to distress associated with discarding them. The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use. If living areas are uncluttered, it is only because of the interventions of third parties. The hoarding causes clinically significant distress or impairment in social, occupa­ tional, or other important areas of functioning (including maintaining a safe environ­ ment for self and others). The hoarding is not better explained by the symp to ms of another mental disorder. Specify if: With excessive acquisition: If difficulty discarding possessions is accompanied by ex­ cessive acquisition of items that are not needed or for which there is no available space. Specify if: With good or fair insight: the individual recognizes that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are problematic. With poor insight: the individual is mostly convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisi­ tion) are not problematic despite evidence to the contrary. With absent insight/deiusionai beliefs: the individual is completely convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary. Approximately 80%-90% of individuals with hoarding disorder display excessive acquisition. The most frequent form of acquisition is excessive buying, followed by acquisition of free items. Some individuals may deny excessive acquisition when first as­ sessed, yet it may appear later during the course of treatment. Individuals with hoarding disorder typically experience distress if they are unable to or are prevented from acquiring items. Diagnostic Features the essential feature of hoarding disorder is persistent difficulties discarding or parting with possessions, regardless of their actual value (Criterion A). The term persistent indi­ cates a long-standing difficulty rather than more transient life circumstances that may lead to excessive clutter, such as inheriting property. The difficulty in discarding possessions noted in Criterion A refers to any form of discarding, including throwing away, selling, giving away, or recycling. The main reasons given for these difficulties are the perceived utility or aesthetic value of the items or strong sentimental attachment to the possessions. Some individuals feel responsible for the fate of their possessions and often go to great lengths to avoid being wasteful. The most commonly saved items are newspapers, magazines, old clothing, bags, books, mail, and paperwork, but virtually any item can be saved. The nature of items is not lim­ ited to possessions that most other people would define as useless or of limited value. Many individuals collect and save large numbers of valuable things as well, which are of­ ten found in piles mixed with other less valuable items. Individuals with hoarding disorder purposefully save possessions and experience dis­ tress when facing the prospect of discarding them (Criterion B). This criterion emphasizes that the saving of possessions is intentional, which discriminates hoarding disorder from other forms of psychopathology that are characterized by the passive accumulation of items or the absence of distress when possessions are removed. Individuals accumulate large numbers of items that fill up and clutter active living ar­ eas to the extent that their intended use is no longer possible (Criterion C). For example, the individual may not be able to cook in the kitchen, sleep in his or her bed, or sit in a chair. Clutter is defined as a large group of usually unrelated or marginally related objects piled to gether in a disorganized fashion in spaces designed for other purposes. Criterion C emphasizes the 'active" living areas of the home, rather than more peripheral areas, such as garages, attics, or basements, that are sometimes cluttered in homes of individuals with­ out hoarding disorder.

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