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This periodic evaluation of program effectiveness may be performed internally womens health weekly buy 100 mg clomid amex, either by the compliance officer or other internal source or by an external organization menstrual kit for girls cheap clomid 100mg otc. These periodic evaluations must be performed at least annually pregnancy symptoms week by week generic clomid 50mg line, or more frequently 6teen menstrual cycle discount clomid 25mg without prescription, as appropriate. Monitoring – Contractor must have a means of following up on recommendations and corrective action plans to ensure that they have been implemented. Contractor must develop an Exit Interview Questionnaire that includes questions regarding whether the exiting employee observed any violations of the compliance program, including the code of conduct, as well as any violations of applicable statutes, regulations and Medicaid program requirements during the employee’s tenure with the Contractor. The Compliance Department must review any positive responses to questions regarding compliance violations. Contractor must have the right to recover overpayments directly from Providers for the post payment evaluations initiated and performed by the Contractor. Performed a post payment evaluation of the Provider in the previous 12-month period or; b. The Provider will be permitted opportunity to submit additional information by the due date indicated on the preliminary results letter (normally 30 Days) to substantiate their claims. Provision for a method to verify, by sampling or other methods, whether services that have been represented to have been delivered by network providers were received by Enrollees and the application of such verification processes on a regular basis. Contractor must have adequate staffing and resources to investigate unusual incidents and develop and implement corrective action plans to assist the Contractor in preventing and detecting potential Fraud, Waste and Abuse activities. It must be separate from the Contractor’s utilization review and quality of care functions. Contractor must utilize statistical models, complex algorithms and pattern recognition programs to detect possible fraudulent or abusive practices. Contact the subject of the investigation about any matters related to the investigation; ii. Enter into or attempt to negotiate any settlement or agreement regarding the incident; or iii. Accept any monetary or other thing of valuable consideration offered by the subject of the investigation in connection with the incident. Audit Requirements – Contractor must conduct risk-based auditing and monitoring activities of provider transactions, including, but not limited to, claim payments, vendor contracts, credentialing activities and Quality of Care/Quality of Service concerns that indicate potential Fraud, Waste or Abuse. These audits should include a retrospective medical and coding review on the relevant claims. In accordance with the Affordable Care Act, Contractor must promptly report overpayments made by Michigan Medicaid to the Contractor as well as overpayments made by the Contractor to a provider and/or Subcontractor. The data or information relied upon in placing the provider on prepayment review. The documentation to be reviewed by the Contractor prior to approval of the selected claims and how that review will mitigate the risk(s) identified. Provision for written policies for all employees of the Contactor, and of any contractor or agent, that provide detailed information about the False Claims Act and other Federal and State laws described in section 1902(a)(68) of the Act, including information about rights of employees to be protected as whistleblowers. The Contractor must have internal controls and policies and procedures in place that are designed to prevent, detect and report known or suspected Fraud, Waste and Abuse activities. A credible allegation of Fraud may be an allegation, which has been verified by the State, from any source, including, but not limited to the following: a. Patterns identified through provider audits, civil false claims cases and law enforcement investigations. Allegations are considered to be credible when they have indicia of reliability and the State Medicaid agency has reviewed all allegations, facts and evidence carefully and acts judiciously on a case-by-case basis. Contractor must indicate that reporting of Fraud, Waste, and Abuse may be made anonymously. See Appendix 18 for the listing of notification forms and reports and their respective due dates: 1. This report must include any improper payments identified and overpayments recovered by the Contractor during the course of its program integrity activities. It is understood that identified overpayments may not be recovered during the same reporting time period. The plan must include the Contractors plan of activities for the upcoming year including, but not limited to, the following activities: a. The report must include a report of all provider and service-specific program integrity activities such as, but not limited to, the following activities: a. The certification must attest that, based on best information, knowledge and belief, the information specified is accurate, complete and truthful. Contractor will receive a score of incomplete for any compliance review quarter where it has not complied with the deliverable due dates. Availability of Records – Contractor must cooperate fully in any further investigation or prosecution by any duly authorized government agency, whether administrative, civil or criminal. Such cooperation must include providing, upon request, information, access to records and access to interview Contractor employees and consultants, including but not limited to those with expertise in the administration of the program and/or in medical or pharmaceutical questions or in any matter related to an investigation. Access will be either through on-site review of records or by any other means at the government agency’s discretion and during normal business hours, unless there are exigent circumstances, in which case access will be at any time. Records other than medical records may be kept in an original paper state or preserved on micromedia or electronic format. Medical records must be maintained in their original form or may be converted to electronic format as long as the records are readable and/or legible. Provider Manual and Bulletins – Contractor must issue Provider Manual and Bulletins or other means of Provider communication to the providers of medical, behavioral, dental and any other services covered under this Contract. The manual and bulletins must serve as a source of information to providers regarding Medicaid covered services, policies and procedures, statutes, regulations and special requirements to ensure all Contract requirements are being met. The Contractor’s provider manual must provide all of its Providers with, at a minimum, the following information: a. Description of the Michigan Medicaid managed care program and covered populations; b. The Contractor’s policies and procedures including, at a minimum, the following information: i. Policies and instructions for billing and reimbursement for all covered services; iv. Contractor must review its Provider Manual, Bulletins and all Provider policies and procedures at least annually to ensure that Contractor’s current practices and Contract requirements are reflected in the written policies and procedures. Contractor must not knowingly have a director, officer, partner, managing employee or person with beneficial ownership of more than 5% of the Contractor’s equity who has been are currently debarred or suspended from participating in procurement activities under the Federal Acquisition Regulation or from participating in non-procurement activities under regulations issued pursuant to Executive Order No. Contractor must not have a Network Provider or person with an employment, consulting or any other contractual agreement with a debarred or suspended person or entity for the provision of items or services that are significant and material to this Contract. Contractor must agree and certify it does not employ or contract, directly or indirectly, with: a. Any individual or entity excluded from Medicaid or other federal health care program participation under Sections 1128 (42 U. Any individual or entity discharged or suspended from doing business with Michigan Medicaid; or c. Any entity that has a contractual relationship (direct or indirect) with an individual convicted of certain crimes as described in Section 1128(b)(8) of the Social Security Act. The identification of any person or corporation with a direct, indirect or combined direct/indirect ownership interest of 5% or more of the Contractor’s equity (or, in the case of a Subcontractor’s disclosure, 5% or more of the Subcontractor’s equity); b. The identification of any person or corporation with an ownership interest of 5% or more of any mortgage, deed of trust, note or other obligation secured by the Contractor if that interest equals at least 5% of the value of the Contractor’s assets (or, in the case of a subcontractor’s disclosure, a corresponding obligation secured by the Subcontractor equal to 5% of the Subcontractor’s assets); c. The name, address, date of birth and Social Security Number of any managing employee of the Managed Care organization. For the purposes of this Subsection “managing employee” means a general manager, business manager, administrator, corporate officer, director. The name, address and financial statement(s) of any person (individual or corporation) that has 5% or more ownership or control interest in the Contractor. The name and address of any person (individual or corporation) that has 5% or more ownership or control interest in any of the Contractor’s Subcontractors. Indicate whether the individual/entity with an ownership or control interest is related to any other Contractor’s employee such as a spouse, parent, child or siblings; or is related to one of the Contractor’s officers, directors or other owners. Indicate whether the individual/entity with an ownership or control interest owns 5% or greater in any other organizations. The address for corporate entities must include as applicable primary business address, every business location and P.
Researchers are studying novel therapies and drugs as well as looking at ways of combining drugs already known to breast cancer rash clomid 50mg discount be efective in new ways or using diferent doses menstruation breast pain cheap clomid 50mg without a prescription. Some classes of novel therapies and drugs under investigation include {{Immune checkpoint inhibitors—a type of immunotherapy which helps a person’s own immune system attack cancer cells women's health center uvm generic 100mg clomid free shipping. Cancer cells can make proteins that allow them to women's health center new lenox il cheap clomid 25mg without a prescription “hide” from the patient’s immune system. When these proteins are blocked, T cells are better able to detect and attack cancer cells. For this treatment, a light-activated drug such as aminolevulinic acid hydrochloride is applied to skin lesions. But because the chemical must be activated by light, it can only kill cancer cells near the surface of the skin. Researchers continue to improve stem cell transplantation methods, including new ways to harvest stem cells and reduce side efects. Therapy may induce fatigue, nausea, fever, chills, dizziness, blood clots, infertility and other efects. Some treatment options, such as retinoids, can cause severe birth defects; it is strongly recommended that women of childbearing age use birth control when using these drugs. Most side efects can be managed without compromising the efectiveness of treatment. In fact, aggressive management of side efects often leads to better treatment outcomes. However, some side efects are long term and may appear years after the treatment has been completed. Late side efects may include developing another type of cancer, heart disease, low levels of thyroid hormones (hypothyroidism) and loss of fertility. Supportive Care In addition to cancer treatment, patients may also receive supportive care to prevent or control other health conditions. Severe itching (pruritus) and skin infections are also serious concerns for these patients. Dry, cracked skin can intensify itching and can allow infectious agents to penetrate the skin. To protect the skin, patients should {{Take shorter showers or baths (10 to 15 minutes maximum) in warm, not hot, water. The fragrances in these products can come in contact with the skin and cause irritation. Supportive therapies that may help manage itching include {{Placing ice packs on itchy area {{Soaking in an oatmeal bath {{Using topical corticosteroids (either with or without occlusion). Occlusion involves covering the treated area with a dry, protective dressing (wrapping it in cloth). Cutaneous T-Cell Lymphoma I 23 {{Taking oral medications such as {{Antihistamines, such as diphenhydramine (Benadryl) or hydroxyzine (Atarax), may relieve itching. The major side efects of these drugs are drowsiness so they are frequently prescribed for use at night. Nonsedating antihistamines such as loratadine (Claritin), cetirizine (Zyrtec), and fexofenadine (Allegra) can be prescribed for daytime use but these drugs are generally less efective. Patients should consider taking the following preventive measures to minimize infections: {{Routinely, use skin moisturizers to protect the skin. Signs of skin infection may include redness, swelling, increased pain or pus (weeping fuid). Some patients may have stable or slowly progressive disease, while others may have a more rapidly progressive disease. These patients may live normal lives for many years while being treated for their disease and some are able to remain in remission for long periods of time. A minority of patients will experience a more progressive disease with the disease spreading to the lymph nodes and/or other organs. It is important to emphasize that outcomes for patients with advanced disease is improving as a result of new treatment options. Use this information to learn more, to ask questions, and to make the most of your healthcare team. Information Specialists are master’s level oncology social workers, nurses and health educators. When appropriate, personalized clinical-trial navigation by trained nurses is also available. Access free one-on-one nutrition consultations by a registered dietitian with experience in oncology nutrition. Dietitians assist callers with information about healthy eating strategies, side efect management, and survivorship nutrition. Listen in as experts and patients guide listeners in understanding diagnosis, treatment, and resources available to blood cancer patients. The one-stop virtual meeting place for talking with other patients and receiving the latest blood cancer resources and information. Moderated online chats can provide support and help cancer patients reach out and share information. For more information about these programs or to contact your chapter, please {{Call: (800) 955-4572 {{Visit: There are resources that provide help with fnancial assistance, counseling, transportation, patient care and other needs. Let your doctor know if you need a language interpreter or other helper, such as a sign language interpreter. Veterans with lymphoma who were exposed to Agent Orange while serving in Vietnam may be able to get help from the United States Department of Veterans Afairs. Seek medical advice if your mood does not improve over time, for example, if you feel depressed every day for a two-week period. For clinical trial participants: Am I responsible for any costs associated with the clinical trialfi The 2016 revision of the World Health Organization classifcation of lymphoid neoplasms. European Organisation for Research and Treatment of Cancer consensus recommendations for the treatment of mycosis fungoides/Sezary syndrome-Update 2017. Cutaneous T-cell lymphoma: 2017 update on diagnosis, risk stratifcation, and management. The State of Queensland makes no statements, representations or warranties about the accuracy, completeness or reliability of any information contained in this publication. The State of Queensland disclaims all responsibility and all liability (including without limitation for liability in negligence) for all this document is licensed under a Creative Commons expenses, losses, damages and costs you might incur as a result Attribution 3. To view a copy of this licence, of the information being inaccurate or incomplete in any way, visit creativecommons. For more information contact: You are free to copy, communicate and adapt the work, as long as you attribute the State of Queensland (Queensland Health). The service system 33 Accessibility 33 Partnerships and collaboration 34 Service profle 34 Workforce profle 36 eHealth, metrics and evidence 38 References 40 Queensland Sexual Health Strategy 2016–2021 3 Foreword Queensland has a proud tradition of being the frst this is why the Palaszczuk Government committed to jurisdiction in Australia to tackle challenging issues. For develop a statewide sexual health strategy in partnership example, Queensland pioneered the state secondary with community organisations to ensure the mix of education system in the early 1860s when the community education and clinical services best meets the government subsidised municipalities to set up grammar needs of all Queenslanders including at-risk populations. This Strategy is another element to our vision for health Good sexual and reproductive health is fundamental in Queensland outlined in My health, Queensland’s to our overall health and wellbeing. It is one of the future: Advancing health 2026—by 2026 foundations upon which our society relies upon Queenslanders will be among the healthiest people in to exist and is an important element in successful the world. There is, however, a number health can be realised in the everyday lives of all of challenges that we face as a community including Queenslanders. Through working collaboratively, we reproductive health issues, rising rates of sexually can realise our vision. Minister for Ambulance Services Queensland Sexual Health Strategy 2016–2021 Introduction Why do we need a sexual What is sexual healthfi Sexual health is defned by the World Health Organization Good sexual and reproductive health is fundamental to our as ‘a state of physical, emotional, mental and social overall health and wellbeing.
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Fear of being judged by health providers may discourage some trans people from seeking treatment for substance use disorders whole woman's health generic 50 mg clomid, including dependence pregnancy early symptoms discount 25mg clomid with mastercard. Tere is minimal research on these issues—particularly on whether access to women's health clinic pico 25mg clomid for sale gender-afrming health services can reduce over-reliance on drugs or alcohol womens health magazine customer service discount clomid 25mg fast delivery. In Asia and the Pacifc, there are very limited quantitative data on alcohol and drug use amongst trans people. Anecdotal evidence suggests that drug use may be an emerging health issue for trans men in Asia. In the fve countries in Asia where data are available (Bangladesh, Indonesia, Malaysia, Pakistan, and the Philippines46), between 0. Behavioral Surveillance Survey 2006fi07; (2) Ministry of Health Republic of Indonesia. For this reason, research also has focused on the extent to which trans people, including sex workers, have used drugs or alcohol before sex. A 2010 report from India identifed the need to address harmful alcohol and substance use amongst hijras and trans women. Twenty hijras interviewed as part of a 2012 needs assessment in India listed a wide range of drugs taken to reduce social isolation or, in some cases, relieve pain associated with laser treatment or nirvaani (traditional castration). This report cited a 2009 study of hijras in Lahore, Pakistan that found 3 percent had injected drugs; however, more than half had taken what were described as “hard drugs,” such as cocaine, heroin, morphine, or amphetamines (Rehan and Chaudhary, 2009, cited in Humsafar Trust, 2012). A 2012 survey of sex workers in Fiji concluded that self-reported alcohol use was not high, though 55 percent reported using marijuana daily (Mossman et al. They were also signifcantly more likely than other female sex workers to have transactional sex for alcohol (31% compared to 13%, respectively) or for drugs (14% compared to 4%, respectively). This section summarises some of the mental health stresses that trans people may experience due to the stigma and discrimination attached to gender diversity. However, trans people are no diferent from other groups in seeking mental health services for a wide range of reasons, ofen unconnected to their gender identity. For information related to mental health approaches and practices for health providers, please see Section 4. The combined figures for all sex workers showed that 8 percent reported drinking alcohol daily and 14 percent reported glue sniffing. Thus, at least half of all leiti will have consumed 10 or more drinks on a normal drinking session. In Japan, statistical data collected by gender clinics in Okayama and Tokyo found that trans people were more likely to report school bullying, dropping out of school, and suicidal ideation/attempts. They were more likely to report school bullying, suicide attempts and depressive symptoms, and less likely to perceive that at least one parent cared a lot for them (Clarke et al. The study called for improved access to healthcare, including gender-affrming health services, based on an informed consent model. This can cause signifcant personal distress, heightened by a fear that others will reject their bodily diversity. Family obligations can be particularly strong in many parts of Asia and the Pacifc, and can place constraints on a person’s decisions about transitioning. Family and peer support, along with identity pride, have been shown to mediate the negative impact of stigma and discrimination on trans people’s mental health (Bockting et al. Peer support networks potentially can fll some of these gaps and reduce isolation. Many trans people also fear that they will never have an intimate, loving relationship. Higashi, Professor Mikiya Nakatsuka from the Graduate School of Health Science, Okayama University, undertook the Okayama study. Nakatsuka’s research looked at suicidal attempts and self-injury amongst 1,167 people who sought support for gender identity disorder between 1999 and 2010. Addressing the stigma attached to gender and bodily diversity is vital to improving the mental health and well-being of trans people. Instead of being accepted for who they are, trans people commonly report that their gender identity was viewed as a “problem” to be remedied. Two-thirds of youth in the 2014 Australian research had seen a health professional for their mental health in the last 12 months; 60 percent of them were satisfed with their experiences. They valued health professionals who were knowledgeable in gender diversity and trans healthcare. More than half of all participants had experienced at least one negative experience with a healthcare professional. A quarter of the research participants avoided medical services due to their gender presentation (Smith et al. However, those working in mental health ofen are poorly trained and ill equipped to work with trans people from a diversity perspective rather than a pathological or curative perspective. Tese issues are compounded when trans people are reliant upon a letter of referral from a mental health professional to access gender-afrming health services. In some cases, mental health professionals respond to pressure from family members to impose reparative therapies that attempt to change a trans person’s gender identity so they identify as cisgender. Treatment aimed at trying to change a person’s gender identity and expression to become more congruent with sex assigned at birth has been attempted in the past without success Such treatment is no longer considered ethical (Coleman et al. Trans people from Indonesia, Malaysia, and Viet Nam have described being forced to go to religious leaders to be healed by prayers. Tese examples included psychologists or psychiatrists in parts of Indonesia who were reluctant to see trans children or youth and recommended that parents consult a traditional healer or shaman instead. In the following Viet Nam example, a trans woman was both hospitalised and taken to a religious leader. When “J,” a 26-year-old trans woman in Ho Chi Minh City [Viet Nam] frst announced that she was female, she was involuntarily checked into the hospital by her family. She had to undergo a blood test and later was subjected to “curative” treatments by a shaman. The term “gender-afrming health services” encompasses all of the medical support needed by trans people from the point they begin to consider a medical transition. It includes, for example, access to counselling and peer support, hormone therapy, hair removal, chest or breast reconstruction surgeries, genital surgeries, and other body modifcation surgeries. In Asia and the Pacifc, most gender-afrming health services, including any medical oversight of hormonal therapy, are not available through public healthcare systems. This section looks specifcally at the experiences of trans adults in this region when trying to access hormones and gender-afrming surgeries. The experiences of children and youth, including good practice guidance, are covered in Chapter 5. Good practice guidance on gender-afrming health services for adults can be found in Section 4. As a result, trans people have to pay out of pocket to access counselling, a diagnosis, laboratory tests, hormone treatment, hair removal, surgeries, and/or other treatment. Tese services are ofen available only in private hospitals or clinics and thus are prohibitively expensive for most trans people. For those who have private health insurance, reimbursement requests are rejected more ofen than not. This means that trans people may be forced to seek out cheaper and less clinically sound options or have irregular or incomplete treatment, and are lost to follow-up. Public sector hospitals or clinics have little or no capacity to provide trans healthcare, as these procedures are not reimbursable and thus are rarely performed, if at all. The lack of capacity and non-reimbursable procedures create a vicious circle in many situations in the region. The lack of coverage, absence of specialist expertise, few protocols for trans healthcare, and negative attitudes of many healthcare personnel drive trans people into the arms of unregulated and nonqualifed healthcare providers. Even in high-income countries such as Australia and New Zealand, trans people and health professionals have criticised the very limited availability of gender-affirming health services through their public health systems (Hyde at al. The cost of consultations with these professionals will easily exceed the budget of the average trans person. As “Appendix A” 1 notes, this can be done by an appropriately trained primary care or mental health provider.
For I know that in me (that is women's health center reno buy clomid online, in my fesh womens health fort wayne discount clomid 100 mg on line,) dwelleth no good thing; for to women's health clinic toledo ohio order clomid will is present with me; but how to menstruation on full moon order 50 mg clomid with mastercard perform that which is good I fnd not. Now if I do that I would not, it is no more I that do it, but sin that dwelleth in me. I fnd then a law, that, when I would do good, evil is present with me But I see another law in my members, warring against the law of my mind, and bringing me into captivity to the law of sin which is in my members. The Epistle of Paul the Apostle to the Romans (1662) this is the most unsatisfactory subject area in clinical psychopathology. The dissatisfaction derives partly from the loss of interest in the subject since the end of the nineteenth century and the lack of conceptual clarity that has resulted from the impoverished literature but also because of the inherent complexity of the subject. As Berrios (1996) put it, ‘The “will” no longer plays a role in psychiatry and psychology. A hundred years ago, however, it was an important descriptive and explanatory concept, naming the human “power, potency or faculty” to initiate action’. The distinctions between related but distinct concepts such as instinct, urge, impetus, impulse, drive, motivation, will, involuntary and voluntary movements and responsibility have until very recently ceased to be regarded as proper subjects of inquiry. A distinction can correctly but theoretically be drawn between the instinct and thus desire to carry out an action in order to satisfy a particular need, the drive and motivation to effect the action and the will to execute the action. All these are different from the end product, the observable action or behaviour itself (Figure 18. Urge, Drive and Will, and Their Disturbance Jaspers (1959) distinguishes between the different experiences of primary, contentless nondirectional urge; natural instinctual drive directed towards some target; and the volitional act with a consciously conceived goal and an awareness of how to achieve it and its consequences. Thus, for Jaspers, there is a distinction, subjectively, between impulsive acts, awareness of inhibition of will and awareness of loss of will or availability of will-power. Scharfetter then describes those primary needs that are innate and not learned as hunger, thirst, breathing, urination and defecation, sleep and self-preservation. Other needs are not essential for survival; their demands can be postponed and they are more affected by acquired patterns of behaviour, such as sexual need and prosocial need. Human beings are so complex that, although primary needs require rapid satisfaction, they account for only a small proportion of the individual’s subjective experience and psychological activity. While I write this, I allow myself to become aware of the primary need for breathing, but I shall not be giving it a thought ten minutes from now. The acquired primary needs and secondary needs have a greater infuence on the individual mental state than innate primary needs. In this view, it can either activate or determine selectivity or strength of actions. Hull (1943) introduced the concept of need as a preliminary to introducing the more mechanical concept of drive. For Hull, ‘When a condition arises for which action on the part of the organism is a prerequisite to optimum probability of survival of either the individual or the species, a state of need is said to exist’ and ‘Animals may almost be regarded as aggregations of need. The function of the effector apparatus is to mediate the satiation of these needs. For Freud, instinct ‘appears as a borderline concept, being both the mental representative of the stimuli emanating from within and penetrating to the mind, and at the same time a measure of the demand made upon the energy of the latter in consequence of its connection with the body’ (Freud, 1915). Motivation, as a phenomenological concept, is readily understood by the layman but is ultimately tautologous: ‘I do it because I am motivated’, ‘I am motivated to do it’. In other words, it includes the pleasurable rewards that govern and regulate behaviour as well as the reasons proffered for behaviour. Intrinsic factors are those that are internal to the person, and extrinsic factors are those, such as supermarket reward cards, that are external incentives to behave in particular ways. Thus, the term motivation refers not only to the goal towards which behaviour is directed but also to emotional states that set it off as well as those that act to reward the behaviour. Similarly, will is a necessary concept but we have great diffculty in comprehending it. Thomas Reid (1710–1796), founder of the Scottish School of Common Sense, regarded the will as the power to put into effect our voluntary actions. For Reid (1863), ‘all our power is directed by our will, we can form no conception of power, properly so called, that is not under the direction of will. And therefore our exertions, our deliberations, our purposes, our promises, are only in things that depend upon our will. Our advices, exhortations, and commands, are only in things that depend upon the will of those to whom they are addressed. We impute no guilt to ourselves, nor to others, in things where the will is not concerned’. Other authorities make similar points but emphasize different aspects of will: ‘Will has a consciously conceived goal and is accompanied with an awareness of the necessary means and consequences. It implies decision making ability, intention and responsibility’ (Jaspers, 1959). Hence, theories of will have implications for notions of moral responsibility, for what being an agent entails and for any description of guilt, shame and punishment. There are more modern attempts to clarify and delineate the phenomenology of will. Metzinger (2006) makes the point that the experiential content of will is fundamentally diffcult to pin down, what he terms ‘thin’ and evasive’ characteristics of the phenomenal content of will. By this, he means the fact that ‘will’ lacks sensory concreteness unlike say vision or taste; that the awareness of the process of ‘willing’ something is intermittent and not functionally stable; that episodes of ‘will’ are not temporally segmented and are inherently fuzzy; and fnally that the intended goal of ‘will’ is often less than clear. To amplify these points, Bayne and Levy (2006) write: We typically experience our actions as purposive. We do not simply fnd ourselves walking towards a door and, on the basis of this, form the belief that we must be intending to open it; instead, we experience ourselves as walking towards the door in order to open it. For example, one might experience oneself: walking towards a door in order to open it; opening the door in order to feed the dog; and feeding the dog in order to keep him quiet. The phenomenology of a single action can include the nested purposes for which the action is being performed. The range of defnitions and understandings of the various terms underlines the intrinsic complexity of the subject area and the current absence of a unifying theory or model for making sense of the subject. There may be a disturbance of need, which may involve hunger, thirst, exploratory behaviour or sleep. An absence of hunger can result in anorexia occurring in chronic physical illness, an increase in hunger causing hyperphagia in Kleine–Levin syndrome and a perversion in pica. Abnormality of thirst can take the form of increased thirst in lithium-induced polydipsia (diabetes insipidus) or of compulsive water drinking in psychosis (Singh et al. Abnormality of exploratory behaviour can take the form of diminution, which is manifest as lack of curiosity and exploration of the environment. There are different patterns of insomnia, including initial insomnia, which is more often associated with anxiety-based disorders, and early morning wakening, which is characteristic of depression. Hypersomnia can occur in narcolepsy, Kleine–Levin syndrome and Pickwickian syndrome. Diminution of drive towards primary needs occurs in schizophrenia and depression, and is probably indistinguishable from abnormalities of need. It is manifest as an absence of the activating tension that initiates behaviour and is observable as apathy. Exacerbation of drive to satisfy sexual need is most prominent in mania but can occur as part of Kleine–Levin syndrome or indeed following acquired brain injury or in L-dopa-induced hypersexuality in Parkinson’s disease. If drive determines strength and selectivity of goal of behaviour, then perversion of drive will include such conditions as fetishism. In schizophrenia and depression, the pleasurable intrinsic motivation that acts as incentive for behaviour may be lost. This is most accurately described as anhedonia, the absence of pleasure in relation to usually pleasurable activities. In mania, it may be increased so that mundane activities become unduly fascinating and rewarding. Disorder of motivation can also be understood as involving the abnormalities of reasoning, justifcation and explanation, as described in the psychoanalytical literature. As Jeannerod (2006) put it, disorder of volition should only refer to those pathological conditions in which the ability to make choices, to express preferences, or possibly to experience pleasure and freedom in making these choices or expressing these preferences is affected. This can take the form of impairment of the will to act in schizophrenia and severe depression. The observable end result is lack of action in the absence of any motor abnormality impairing action.