Because individuals with other medical conditions often take medications for those conditions mens health 012013 chomikuj discount alfuzosin line, the clinician must consider the possibility that the mood symptoms are caused by the physiological consequences of the med ical condition rather than the medication prostate 5k greensboro order alfuzosin 10 mg on line, in which case depressive disorder due to mens health watches cheap alfuzosin 10mg with visa another medical condition is diagnosed man health care generic alfuzosin 10 mg with mastercard. If the clinician has ascertained that the disturbance is a function of both another medical condition and substance use or withdrawal, both diagnoses. When there is insufficient evidence to determine whether the depres sive symptoms are associated with substance (including a medication) ingestion or with drawal or with another medical condition or are primary. Compared with individuals with major depressive disorder and a comorbid substance use disorder, individuals with substance/medication-induced depressive disorder are more likely to have alcohol use disorder, any other substance use disorder, and histrionic per sonality disorder; however, they are less likely to have persistent depressive disorder. A prominent and persistent period of depressed mood or markedly diminished interest or pleasure in all, or almost all, activities that predominates in the clinical picture. Coding note: Include the name of the other medical condition inthe name of the mental dis order. The other medical condition should also be coded and listed separately immediately before the depressive disorder due to the medical condition. Diagnostic Features the essential feature of depressive disorder due to another medical condition is a promi nent and persistent period of depressed mood or markedly diminished interest or plea sure in all, or almost all, activities that predominates in the clinical picture (Criterion A) and that is thought to be related to the direct physiological effects of another medical con dition (Criterion B). In determining whether the mood disturbance is due to a general medical condition, the clinician must first establish the presence of a general medical con dition. Further, the clinician must establish that the mood disturbance is etiologically re lated to the general medical condition through a physiological mechanism. A careful and comprehensive assessment of multiple factors is necessary to make this judgment. Al though there are no infallible guidelines for determining whether the relationship between the mood disturbance and the general medical condition is etiological, several considerations provide some guidance in this area. One consideration is the presence of a temporal association between the onset, exacerbation, or remission of the general medical condition and that of the mood disturbance. A second consideration is the presence of fea tures that are atypical of primary Mood Disorders. Evidence from the literature that suggests that there can be a di rect association between the general medical condition in question and the development of mood symptoms can provide a useful context in the assessment of a particular situation. There are numerous other conditions thought to be associated with depression, such as multiple sclerosis. In the largest series, the duration of the major depressive episode following stroke was 9-11 months on average. The association with frontal regions and laterality is not observed in depressive states that occur in the 2-6 months following stroke. G ender-Related Diagnostic issues Gender differences pertain to those associated with the medical condition. Diagnostic iVlarlcers Diagnostic markers pertain to those associated with the medical condition. Suicide Risic There are no epidemiological studies that provide evidence to differentiate the risk of sui cide from a major depressive episode due to another medical condition compared with the risk from a major depressive episode in general. There are case reports of suicides in association with major depressive episodes associated with another medical condition. There is a clear association between serious medical illnesses and suicide, particularly shortly after onset or diagnosis of the illness. Thus, it would be prudent to assume that the risk of suicide for major depressive episodes associated with medical conditions is not less than that for other forms of major depressive episode, and might even be greater. Functional Consequences of Depressive Disorder Due to Another iViedicai Condition Functional consequences pertain to those associated with the medical condition. However, it is also suggested, but not established, that mood syndromes, including depressive and manic/ hypomanie ones, may be episodic. D ifferential Diagnosis Depressive disorders not due to another medical condition. Determination of whether a medical condition accompanying a depressive disorder is causing the disorder depends on a) the absence of an episode(s) of depressive episodes prior to the onset of the medical condition, b) the probability that the associated medical condition has a potential to pro mote or cause a depressive disorder, and c) a course of the depressive symptoms shortly after the onset oi^worsening of the medical condition, especially if the depressive symp toms remit near the time that the medical disorder is effectively treated or remits. An important caveat is that some medical con ditions are treated with medications. In these cases, clinical judgment, based on all the evidence in hand, is the best way to try to separate the most likely and/or the most important of two etiological fac tors. It is important to differentiate a depressive episode from an ad justment disorder, as the onset of the medical condition is in itself a life stressor that could bring on either an adjustment disorder or an episode of major depression. The major dif ferentiating elements are the pervasiveness the depressive picture and the number and quality of the depressive symptoms that the patient reports or demonstrates on the mental status examination. The differential diagnosis of the associated medical conditions is rel evant but largely beyond the scope of the present manual. Comorbidity Conditions comorbid with depressive disorder due to another medical condition are those associated with the medical conditions of etiological relevance. The association of anxiety symptoms, usually generalized symptoms, is common in depressive disorders, regardless of cause. The other specified depressive disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific depressive disorder. This is done by recording “other specified depressive disorder”followed by the specific reason. Examples of presentations that can be specified using the “other specified”designation include the following: 1. Recurrent brief depression: Concurrent presence of depressed mood and at least four other symptoms of depression for 2-13 days at least once per month (not associ ated with the menstrual cycle) for at least 12 consecutive months in an individual whose presentation has never met criteria for any other depressive or bipolar disorder and does not currently meet active or residual criteria for any psychotic disorder. Short-duration depressive episode (4-13 days): Depressed affect and at least four of the other eight symptoms of a major depressive episode associated with clinically significant distress or impairment that persists for more than 4 days, but less than 14 days, in an individual whose presentation has never met criteria for any other depressive or bipolar disorder, does not currently meet active or residual criteria for any psychotic dis order, and does not meet criteria for recurrent brief depression. Depressive episode with insufficient symptoms: Depressed affect and at least one of the other eight symptoms of a major depressive episode associated with clinically significant distress or impairment tliat persist for at least 2 weeks in an individual whose presentation has never met criteria for any other depressive or bipolar disorder, does not currently meet active or residual criteria for any psychotic disorder, and does not meet criteria for mixed anxiety and depressive disorder symptoms. The unspecified depressive disorder category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific depressive disorder, and includes presentations for which there is insuf ficient information to make a more specific diagnosis. Specifiers for Depressive Disorders Specify if: With anxious distress: Anxious distress is defined as the presence of at least two of the following symptoms during the majority of days of a major depressive episode or persistent depressive disorder (dysthymia): 1. Note: Anxious distress has been noted as a prominent feature of both bipolar and ma jor depressive disorder in both primary care and specialty mental health settings. High levels of anxiety have been associated with higher suicide risk, longer duration of ill ness, and greater likelihood of treatment nonresponse. As a result, it is clinically useful to specify accurately the presence and severity levels of anxious distress for treatment planning and monitoring of response to treatment. At least three of the following manic/hypomanic symptoms are present nearly every day during the majority of days of a major depressive episode: 1. Decreased need for sleep (feeling rested despite sleeping less than usual; to be contrasted with insomnia). Mixed symptoms are observable by others and represent a change from the per son’s usual behavior. The mixed symptoms are not attributable to the physiological effects of a substance. As a result, it is clinically useful to note the presence of this specifier for treatment planning and monitoring of response to treatment. One of the following is present during the most severe period of the current epi sode: 1. Lack of reactivity to usually pleasurable stimuli (does not feel much better, even temporarily, when something good happens). A distinct quality of depressed mood characterized by profound despondency, despair, and/or moroseness or by so-called empty mood. Note: the specifier “with melancholic features” is applied if these features are present at the most severe stage of the episode. There is a near-complete absence of the ca pacity for pleasure, not merely a diminution. A guideline for evaluating the lack of reac tivity of mood is that even highly desired events are not associated with marked brightening of mood. The “distinct quality”of mood that is characteristic of the “with melancholic features”specifier is experienced as qual itatively different from that during a nonmelancholic depressive episode.
The drafts were distributed among American and international psychiatrists for comments and review prostate 75 10 mg alfuzosin sale. Soon after its publication prostate with grief purchase genuine alfuzosin line, it became widely accepted in the United States as the common language of mental health clinicians and researchers for communicating about mental disorders prostate wiki buy 10 mg alfuzosin with amex. Although it was intended primarily for use in the United States prostate cancer causes buy generic alfuzosin on-line, it was translated into 13 languages and widely used by the international research community. Its reliance on a comprehensive review of the literature and other empirical data as a justification for making changes. Efforts made to solicit and incorporate input and guidance from the widest variety of sources. However, because of the lack of precision in defining diagnostic syndromes, actual clinical experience was considered necessary to fully understand the nature of the diagnostic entities. Since clinical experience and traditions for evaluating potential causes for disorders vary widely, the reliability of diagnoses across different national boundaries was found to be low. The second phase (1981±1982) was the planning and execution of a major International Conference on Diagnosis and Classification of Mental Disorders and Alcoholand Drug-Related Problems, which took place in April 1982 in Copenhagen, Denmark, involving 150 invited participants from 47 different countries . Rather than having diagnostic constructs containing untestable aetiological assumptions. As a result of clinical and epidemiological research with the resulting diagnostic assessment instruments, it became apparent that the increased specificity of diagnostic criteria had not eliminated wide ranges of disability and impairment within diagnostic groups. These workgroups, guided by emerging epidemiological and clinical research findings from studies using most of the above instruments, were able to obtain consensus on the overall framework of the diagnostic system and on the great majority of explicit criteria for specific disorders. The few remaining discrepancies in criteria are being subjected to empirical tests to determine the impact of such differences on prevalence and service use rates [44, 45]. Diagnostic criteria, based solely on descriptive phenomenology, were specified with a greater degree of precision than with previous diagnostic systems, increasing the reliability of diagnosis between diagnosticians in various settings. Such objective criteria, it was hoped, would facilitate the validation of psychiatric diagnoses, much in the way described by Robins and Guze , i. Once validated, the classification would form the basis for the identification of standard, homogeneous groups for aetiologic and treatment studies. Over the succeeding 20 years, however, fulfilling the Robins and Guze validity criteria has remained an elusive goal. Epidemiologic and clinical studies have shown high rates of non-specific comorbidities among the disorders, making a clear delimitation of disorders difficult [18, 49]. Long-term follow-up studies have been relatively rare, due to their complexity and cost, but epidemiologic studies have shown a high degree of short-term diagnostic instability for many disorders [50, 51]. There is not strong evidence that treatment response is indicative of the specificity of individual diagnoses. Many of the new psychotropic medications that have been developed, such as the selective serotonin reuptake inhibitors, are efficacious across different diagnoses, such as major depression, obsessive-compulsive disorder, panic disorder, binge-eating disorder, and post-traumatic stress disorder. A major underlying concept with all of the limitations is a concern for the validity of the classification. In addition, this syndrome or pattern must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one. Whatever its original cause, it must currently be considered a manifestation of a behavioral, psychological or biological dysfunction in the individual. In practical terms, this problem is most pronounced in ``threshold' cases, which barely meet diagnostic criteria, are of mild severity, or associated with only mild distress or impairment in functioning. The clinical significance or need for treatment in such cases is a hotly debated issue . For example, Wakefield  argues for a definition of mental disorder based on the concept of ``harmful mental dysfunction', which requires both evidence that the symptoms are a manifestation of a mental dysfunctionfithe failure of a mental mechanism to perform its natural. While this definition is appealing, because it combines both scientific/factual elements. It can be argued that the inclusion of such a criterion increases the likelihood that cases meeting symptom criteria have a clinically significant disorder, or are ``true cases', at least for health policy and planning purposes . The developmental trajectories and interrelationships of psychiatric symptoms and associated disabilities are not yet clear. It is well-known, for example, that significant disability and mental health service use can occur in persons with symptoms that do not meet criteria for major depressive disorder [67±69]. Also, symptom patterns, regardless of disability, are important for aetiologic research such as genetic epidemiology . This argument has been particularly pointed in the child and adolescent field, in which the discipline of developmental psychopathology has sought an increased role . Ideally, a research base for mental disorder nosology and classification should include studies representing epidemiology, genetics, clinical research, basic brain research, social and behavioral science, and psychometrics. The current research base varies widely from this ideal, both in quality and quantity. For example, in the child and adolescent field, research on disability and its relationship to symptoms has outpaced the same research for adult populations [73, 74]. There is a fast-growing body of work in basic child development and its relationship to psychopathology. Yet treatment research has lagged for children, and there is still no widely generalizable epidemiological study of mental disorders for this population in the United States [75, 76]. A relative lack of data has prevented a needed overhaul of the personality disorder diagnoses which are universally agreed to be unsatisfactory, and there are virtually no data on the ``not otherwise specified' diagnoses. A weak database undermines confidence in the reliability and validity of a diagnosis among clinicians and scientists. As the research base grows, and as the classification is used and scrutinized by clinicians, limitations inevitably emerge, as well as opportunities for modification. Further, the personality pattern must occur in areas that are not generally thought of as categorical: cognition. Several personality disorders have been implicated as ``spectrum disorders' of Axis I conditions in genetic studiesfifor example, schizotypal personality disorder with schizophrenia . Specific criteria were not provided, due to a lack of relevant data, although research has been accumulating. A better conceptualization of relational problems may help elucidate some Axis I disorders, for example oppositional defiant disorder. This has been due in part to a lag in research to accurately and efficiently identify persons at high risk for mental disorders and a paucity of rigorously tested, effective interventions. Current research with depressed mothers and their children , and with persons having the syndrome of schizotaxia , have shown promise as targets for preventive interventions. Several of these have been alluded to above, including gaps in the research base and insufficient attention to the vicissitudes of normative and pathological development, the contributions of relational problems and other contextual factors, and high-risk conditions. Little attention has been paid to changes in the diagnostic picture as an individual ages, and with a rapidly aging population in the United States, the phenomenology of mental disorders in the elderly is of crucial importance . The United States continues to increase in its ethnic, racial and cultural diversity. Western or Euro-American social norms, meanings of illness and treatment, and idioms of distress cannot be assumed for other cultural groups. It does not, however, provide guidance on applying specific cultural features to specific disorders. This is a tall order indeed, considering the wide diversity of cultural groups in the United States, encompassing those identified by language, color, religion, sexual orientation, disability, and a host of other factors [86±90]. This limitation is particularly important in rural areas with low concentrations of specialty providers, and in areas where primary care providers do the majority of mental health care. More research and training are needed to fully integrate mental health evaluations into primary care settings. Thus, as each year passes, the information presented in the text runs the risk of becoming increasingly out of date with the large volume of research published each year. Criteria set changes are disruptive to both researchers and clinicians in terms of the costs of revamping the myriad of assessment tools, the cost of the educational efforts, and its effect on complicating the comparison of studies that used different versions of the criteria sets. The conference resulted in a series of forums to identify gaps within the current classification systems and to develop a research agenda to be pursued over the coming years. Workgroups corresponding to the six topic areas were comprised of leading experts in the field and were charged with the task of writing research recommendations in the form of white papers. In addition to writing a separate white paper on core crosscultural issues and gender-specific issues that span all diagnostic criteria, cross-cultural workgroup members were also involved in the remaining workgroups to contribute recommendations on cross-cultural issues and gender-specific issues as they specifically related to the other five topic areas.
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These mundane rail lines to mens health 5 minute workout buy alfuzosin 10 mg with mastercard me illustrate the comprehensive aesthetic treatment witnessed in the form of Industrienatur where not even marginalia can be automatically dismissed mens health online order cheap alfuzosin online. As a tool which announces a more patient attitude towards the complex entanglements of industry and nature that industrial history has spawned prostate cancer zyflamend generic alfuzosin 10 mg mastercard, it can thrive on the confusion concerning where waste begins and value ends prostate 24 buy 10mg alfuzosin with mastercard. Many contemporary approaches which set out to deal with industrial obsolescence demonstrate the will to inclusion rather than exclusion of the unwanted and it is occasioned by the realization that this kind of waste often will not go away. Hauser (2001) thinks of this practice terms of a subtle change from borders to limits, and the ways in which industrial waste are treated today is different from how it used to be dealt with. The clear-cut divisions of pure and impure, of clean and dirty, and between the orderly and the disorderly realms have been revised and confused to the extent that it is difficult to speak of a clear transgression. This change from borders to limits may be viewed as an expansion of the realm of visibility where nothing is automatically written off as useless. I think it makes sense to view the heritage site and Industrienatur of Kokerei Hansa in this light, because it too contributes to a blurring of established categories and realms of “purity and danger” (Douglas 1966). Hauser (2001) convincingly claims that the binary structure of clean and dirty has been challenged in old industrial areas where attempts are made to question these rigid zones and establish a more unstable category. The Industrienatur we encounter at Kokerei Hansa amounts to this unstable form where the sharp contours of natural and cultural dissolve. The industrial obsolescence and the excess matter is not disposed and removed for good, it rather becomes an important vehicle in the negotiation of visibility and borders. According to Hauser “waste, residue in its numerous forms has become a metaphor for and paradigmatic thing renders visible and allows us to see borders, the liquidation of borders and the transgression of borders” (Hauser 2001: 32, my translation). Industrienatur allows for a playful and provocative dissolution of borders which separate our world from the world of waste and pollution. For so-called junk artists waste is used as a raw material which can challenge conventional categories of things. Similarly Industrienatur is a clever invention to reintegrate the frequently ignored excess space into an aesthetic, recreational or representational realm. This is not a recipe for immediacy, but a call for aesthetic education and the defamiliarization of an undesired object, building or site. Industrienatur is a way of dealing with the superfluous in a way which questions the stability of categories like the natural and the artificial. While these ideas closely resemble catchphrases of much postmodern social and cultural theorizing, I think Industrienatur diverts from the obsession with origins and it also questions whether a resolute and final exclusion of the unwanted is even possible anymore. Today the old material burdens inherited from the industrial age are revealed and transformed rather than concealed and forgotten. With reference to old industrial sites it concerns remaining substances which causes ground contamination and seeps into the ground water. In a more figurative sense it describes a legacy and a burden of the past which sticks with a person or culture. Altlast would translate directly into ‘old load’, and its opposite Lastenfrei implies that an object, relation or business is free from old debts. As for post-industrial brownfield sites the toxins buried in the ground makes it difficult to make a property marketable without extensive cleanup. This illustrates how the subsurface stores residues from industrial era which undermine present attempts of moving on. The past may be understood as a burden which haunts the present and makes people unable to the break the emotional attachment with the past. Hence, personal ads in newspapers sometimes state that the ideal partner is a person “ohne Altlasten”. In the present culture of memory, repression has been extensively discredited, politically as well as aesthetically. To cover over the misdemeanors of the past is seen as politically suspect and aesthetically dishonest. The alternative to this suspect practice is to acknowledge the burdens of the past and grant them presence by integrating them into an inflated idea of beauty that is Industrienatur. Very much like contemporary art tries to make the public question conventional orders of things and conventional notions of beauty the category of Industrienatur is a means of assembling burdensome and ill-defined sites into a postmodern panoply of confused boundaries. In contrast to the heydays of coal and steel production, the pressing issue is no longer how to prepare for continued expansion and growth, but how to deal with economic decline, leftover space and the presence of burdensome objects and a comprehensively artificial landscape. The strategy is not to cover over, but to aestheticize the old burdens to make them stand out and be visible. These spoil tips were often covered with soil and revegetated in order to reduce erosion and the risk of slides or to prevent dust from spreading. In the longer run it would seamlessly integrate spoil tips in the lush scenery where an agreeable form of landscape could once again prevail. This came to be regarded as a conservative aesthetic practice which would be equated with effacing the historically specific constitution of the industrial landscape (Dettmar 1999). In contrast, the concept of Industrienatur is a way for planners and preservationists to counter old modes of landscaping and claim that to efface all traces of the industrial activity via traditional green space planning is a generic approach which disregards both local context and existing historical structures. Attempts to cover over the thoroughgoing artificiality of the local area may amount to a form of aesthetic dishonesty. For Claus Stiens at the foundation in charge of maintaining Kokerei Hansa this elicits the question of how one should approach the accumulated spoil tips with regards to the memories and insight they might harbor. One would not recognize it straight away as something man-made that is ‘artificial’ [uses the English word] if it is recultivated, regreened and made accessible again. Should one not instead leave it as it is, yes, as a grey mountain, a deposit of rocks and stone, to make it evident that this is something artificial made by men as a result of coal mining activities” (Stiens 2010). The legibility of the industrial landscape is at stake and the practice of regreening is treated as an approach which fosters forgetfulness. Here, an honest rendition of the industrially constituted landscape is contrasted with practices that cause the gradual disappearance of the industrial past. If we contrast this idea with predominant attitudes during the heyday of industrial growth, the change of attitude is striking. The industrial society believes it can produce anything and turn back the clock again according to Karl Ganser (in Hauser 2001: 76). Today the repair of built environment and man-made landscape at hand (rather than inventing the new) has gained influence due to the wide-ranging influence of the sustainability discourse from the 1980s onward. It is not sufficient to appeal by way of pathos and sentiment to the safeguarding of the built environment; preservation has had to prove itself through other means as we will see. Their mandate was to address the challenges of resource scarcity and overconsumption in line with a clear focus on sustainable development. It was claimed that one important purpose for the preservation of built environment of the industrial era was to secure material witnesses of the age of exhaustive and ruthless exploitation of resources (Hassler 1996). The emphasis on repair, recycling and reuse of existing resources was stressed as a contrast to a modernity which believed and presupposed it could perpetually invent the new. The repair project of the postmodern is precisely a repair project and not a project of new constructions (Neubautenprojekt). A frugal treatment of existing resources was considered necessary from an ecological and economic perspective and the aim was to prepare for a continued use of the existing stock (des vorhandenen Bestand) of structures and objects (Hassler 1996: 107). The practice of industrial heritage preservation was described as particularly challenging field because it was not a question isolated to technical viability of preservation, but a question of funding, ecological considerations as well as questions pertaining to aesthetics (Petzet 1996). Moreover, the link between Altlast and contemporary art was established and it was conceived as way to prepare a museal presentation of unwieldy and burdensome relics (ibid). Owing to the burgeoning influence of sustainable management of existing resources the cards were reshuffled and the modern construction project of rapid replacement was sharply contrasted with the modern preservation project of working with buildings already at hand. For the latter model to stabilize and accrue wider public legitimacy it had to operate not only according to aesthetic requirements and notions of beauty, but to prove financially viable, ecologically conscious and technically feasible. Kokerei Hansa clearly draws currency from this frame of ecological sustainability within the preservation discourse. Against an admittedly suitable opponent of reckless resource exploitation, any model which cares for the resources at hand will be judged in a more favorable light. Present-day values are superimposed on the modernist ensemble and these are consciously contrasted with cost-intensive planning regimes or unsustainable resource exploits of earlier epochs: “The expensive and labourintensive methods of conventional planning practice would now be replaced by naturedominated development” (Dettmar 2005). This is how Jorg Dettmar describes the break from earlier regimes of planning and in this account the economic and ecological rationale behind Industrienatur is given a clear expression. Municipal budgets are limited in the Ruhr and the resource-demanding character of streamlined landscape practices or the comprehensive cleansweep development has faced sustained criticism (Gunter 1999). The influence of sustainable development discourse means that minimal interventions, spontaneous regrowth and patient treatment of built structures are associated with sustainable development rather than political and cultural defeat. The idea that nature is about to reconquer the rationally planned and thoroughly regulated spaces of industry reflects this new idea of resource use, which can only thrive in opposition to an industrial regime that is by now often dismissed as unsustainable. Moreover, minimal intervention can even be justified with reference to nature conservation as the ruderal vegetation came to be seen as an important contribution to a specific and local expression of industrial nature.
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