CU-SEM-III-MA-PSY-CLINICAL DISORDERS-I -Second Draft-converted

MASTER OF ARTS PSYCHOLOGY SEMESTER-III CLINICAL DISORDERS-I MAP615

2 CU IDOL SELF LEARNING MATERIAL (SLM)

CHANDIGARH UNIVERSITY Institute of Distance and Online Learning Course Development Committee Prof. (Dr.) R.S.Bawa Pro Chancellor, Chandigarh University, Gharuan, Punjab Advisors Prof. (Dr.) Bharat Bhushan, Director – IGNOU Prof. (Dr.) Majulika Srivastava, Director – CIQA, IGNOU Programme Coordinators & Editing Team Master of Business Administration (MBA) Bachelor of Business Administration (BBA) Coordinator – Dr. Rupali Arora Coordinator – Dr. Simran Jewandah Master of Computer Applications (MCA) Bachelor of Computer Applications (BCA) Coordinator – Dr. Raju Kumar Coordinator – Dr. Manisha Malhotra Master of Commerce (M.Com.) Bachelor of Commerce (B.Com.) Coordinator – Dr. Aman Jindal Coordinator – Dr. Minakshi Garg Master of Arts (Psychology) Bachelor of Science (Travel &Tourism Management) Coordinator – Dr. Samerjeet Kaur Coordinator – Dr. Shikha Sharma Master of Arts (English) Bachelor of Arts (General) Coordinator – Dr. Ashita Chadha Coordinator – Ms. Neeraj Gohlan Academic and Administrative Management Prof. (Dr.) R. M. Bhagat Prof. (Dr.) S.S. Sehgal Executive Director – Sciences Registrar Prof. (Dr.) Manaswini Acharya Prof. (Dr.) Gurpreet Singh Executive Director – Liberal Arts Director – IDOL © No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording and/or otherwise without the prior written permission of the authors and the publisher. SLM SPECIALLY PREPARED FOR CU IDOL STUDENTS Printed and Published by: TeamLease Edtech Limited www.teamleaseedtech.com CONTACT NO:- 01133002345 For: CHANDIGARH UNIVERSITY 3 Institute of Distance and Online Learning CU IDOL SELF LEARNING MATERIAL (SLM)

First Published in 2021 All rights reserved. No Part of this book may be reproduced or transmitted, in any form or by any means, without permission in writing from Chandigarh University. Any person who does any unauthorized act in relation to this book may be liable to criminal prosecution and civil claims for damages. This book is meant for educational and learning purpose. The author of the book has/have taken all reasonable care to ensure that the contents of the book do not violate any existing copyright or other intellectual property rights of any person in any manner whatsoever. In the event, Authors has/ have been unable to track any source and if any copyright has been inadvertently infringed, please notify the publisher in writing for corrective action. 4 CU IDOL SELF LEARNING MATERIAL (SLM)

CONTENT Unit 1: Substance Abuse............................................................................................................6 Unit 2: Sexual Disorders..........................................................................................................43 Unit 3: Schizophrenia ..............................................................................................................78 Unit 4: Delusional DISORDERS Part 1 ................................................................................109 Unit 5: Delusional Disorders Part Ii.......................................................................................126 Unit 6: Mood Disorders .........................................................................................................165 Unit 7: Dementia Part I ..........................................................................................................192 Unit 8: Dementia Part Ii.........................................................................................................214 5 CU IDOL SELF LEARNING MATERIAL (SLM)

UNIT 1: SUBSTANCE ABUSE 6 STRUCTURE 1.0 Learning Objectives 1.1 Introduction 1.2 Depressants 1.3 Stimulants 1.3.1 Stimulant Use Disorder 1.3.2 Stimulant Intoxication 1.3.3 Stimulant Withdrawal 1.3.4 Other Stimulant-Induced Disorders 1.3.5 Unspecified Stimulant-Related Disorder 1.4 Hallucinogens 1.4.1 What is the Appeal of Hallucinogens? 1.4.2 What are the Effects of using Hallucinogens? 1.4.3 Common Synthetic Hallucinogens 1.4.4 Naturally Occurring Hallucinogens 1.5 Types of Substance Abuse 1.6 DSM Criteria 1.7 Incidence and Prevalence 1.8 Co-morbidity 1.9 Causes of Substance of Abuse 1.10 Prognosis and Treatment 1.11 Summary 1.12 Keywords 1.13 Learning Activity 1.14 Unit End Questions 1.15 References 1.0 LEARNING OBJECTIVES After studying this unit, student will be able to: • Explain the concept of substance abuse disorders. • State the definition and guidance of psychotherapy. • Describe the objectives and principles of psychotherapy. • Outline the history of psychotherapy. • Explain ethical issues in psychotherapy. CU IDOL SELF LEARNING MATERIAL (SLM)

1.1 INTRODUCTION Substance abuse and addictions results from the misuse of harmful or addictive substances which include alcohol, illegal or street drugs, prescription and over-the-counter medicines, and volatile chemicals. The resultant problems include both mental and physical illnesses, and family, housing, employment, and legal difficulties. Treatment of substance abuse disorder is complex and challenging as the reason for substance abuse and addiction is unique for each abuser. Further, the family environment and situation of each abuser is unique. Treatment and management of substance abuse need to consider all these. Both psychological and pharmacological interventions are used that may include detoxification and substitute prescribing. The use and misuse of drugs is increasing and affecting our children, youth, men and women, and the elderly also. In this Unit, you will learn about the substance abuse disorder, various drugs used, and the assessment and treatment of substance abuse. Substance abuse, also known as drug abuse, is the use of a drug in amounts or by methods which are harmful to the individual or others. It is a form of substance-related disorder. The definition of drug abuse is context sensitive and can be different for the judicial system, doctors and public health workers. Many a times, long term changes in personality and criminal behaviour can exhibit in the users of drugs. Apart from the harm caused to the drug user at a mental and physical, drug abuse can also lead to penalties for any criminal behaviour, severity of which varies as per the localized laws. Drugs most often associated with this term include alcohol, amphetamines, barbiturates, benzodiazepines, cannabis, cocaine, hallucinogens, methaqualone, and opioids. While the reason behind abuse of substance is not clearly understood, but there are two predominant theories: a genetic disposition that is imbibed from the actions of other people, or habit that traps the individual in a never-ending loop. As per data procured for 2010, in that year, of 11.5 million people used illegal substances. Out of a total population of 230 million, around 12% were recurrent or high-risk users of drugs. These users are most prone to the ill effects of drugs on their mind, social standing and health. While in the year 1 lakh 65 thousand deaths happened due to drug use.,this number became more than three lakhs by 2015 the main causes of these deaths were related to various substance use, wherein the most happened due to alcohol – around 1.3 lakhs, then from opioids – 1.2 lakhs ,Amphetamine use – 12 thousand and the least from cocaine – around thousand. 1.2 DEPRESSANTS Some of the drugs in this category are benzodiazepines, alcohol, and the barbiturates. The effects of these drugs are produced by wither specific or generalized cortical depression. The purpose of taking these drugs can be either to experience relaxation or pleasure or to handle the unwanted side effects of other drugs. 7 CU IDOL SELF LEARNING MATERIAL (SLM)

A depressant, or central depressant, is a drug that lowers neurotransmission levels, which is to depress or reduce arousal or stimulation, in various areas of the brain. Depending on the kind of effects, depressants are called ‘uppers’ when they help in heightening physical , mental functions and are called ‘downers’ when they have the opposite effect. As per this line of thought opposite drug class of depressants is not anti-depressants but it is stimulants. Depressants are used both as prescribed medicines and as illicit drugs across the world. Prominent among this class of drugs is alcohol which has high prevalence amongst the young age groups. When depressants are used, effects often include ataxia, anxiolysis, pain relief, sedation or somnolence, and cognitive/memory impairment, as well as in some instances euphoria, dissociation, muscle relaxation, lowered blood pressure or heart rate, respiratory depression, and anticonvulsant effects. Depressants also have anaesthetic properties. Due to the presence of cannabidiol, cannabis can also be considered a depressant. Cannabidiol is known to treat insomnia, anxiety and muscle spasms similar to other depressive drugs. However, tetrahydrocannabinol, a stimulant which is also added sometimes, may to a small extent slow brain function and reduce the intensity of reaction to stimuli. Tetrahydrocannabinol is also considered to be a primary psychoactive agent that can lead to anxiety, panic and psychosis. Different types of opiates and drugs like Xanax (a benzodiazepine) are also depressants. Facilitation of GABA, and inhibition of glutamatergic or monoaminergic activity. Are the primary mechanisms that lead to the effects of depressants? Other examples are chemicals such as body blockers and bromides that modify the electrical signalling inside the body. CNS (Central Nervous System) are a class of depressants that include sedatives (barbiturates, non-benzodiazepine sedative hypnotics such as Ambien and Lunesta.), tranquilizers (benzodiazepines, such as Valium and Xanax, muscle relaxants, anti-anxiety medicines), and hypnotics. These drugs can treat panic, anxiety, acute stress reactions, and sleep disorders by slowing down brain activity. Following is a list of CNS depressants grouped along with the respective drug class: 8 CU IDOL SELF LEARNING MATERIAL (SLM)

Table 1.1: Examples of CNS Depressants How do people use and misuse prescription CNS depressants? CNS depressants can be prescribed in the form of liquid or pills. These prescriptions are misused when: • The dosage and form of ingestion is different from what is the prescription is for someone else. • Using it without any underlying issue, just for the euphoria effect. This can be done by ingesting the pill or crushing it and then taking it. Impact of CNS depressants on the brain - These chemicals cause hyper activation of gamma- aminobutyric acid (GABA), a chemical that is known to inhibit brain activity. This same reaction makes it helpful to treat depression related disorders (lack of sleep and anxiety) by producing calming effects and drowsiness. When starting the course of the medicine, some people might feel drowsy and uncoordinated till the body adjusts to the chemicals. Other effects from use and misuse can include: • Slurred speech • Poor concentration • Confusion • Headache • Light-headedness • Dizziness • Dry mouth • Problems with movement and memory • Lowered blood pressure • Slowed breathing. A long-term use of CNS can reduce its efficacy for the user and higher dosage might be needed to achieve the same effect. Usage for many days can cause dependence and chances of withdrawal if stopped abruptly. So much so that when stopped suddenly, it can lead to seizures. Is there a possibility of CNS overdose? This scenario is always there. When someone uses doses high enough to cause chances of a fatality. This can manifest in the form of difficulty in breathing or shortness of breath. This can lead to hypoxia, a condition that can lead to many temporary and long-lasting mental problems due to shortage of oxygen supply to the brain. Harmful effects can be coma or permanent damage to the brain. How can a CNS depressant overdose be treated? 1.3 STIMULANTS Stimulants are a class of drugs that speed up the messages between the brain and the body. On consumption they can have feel good effect on the user. This can be in the form of a feeling full of energy and upbeat. 1. If taken in high dosages, stimulants can lead to ill effects such as paranoia, headaches, aggression and seizures. 9 CU IDOL SELF LEARNING MATERIAL (SLM)

These drugs potentiate neuro-transmission and increase cortical excitability producing effects of increased alertness and endurance, diminished need for sleep, and a subjective sense of well-being. They include cocaine (and crack cocaine), amphetamines, methylene deoxy meth amphetamine (MDMA or ecstasy), and caffeine. Stimulants, including cocaine and amphetamines, are among the most widely used and abused illegal substances in the United States. Historically, coca chewing was pioneered in South America. .1 In 1859 when cocaine was isolated from coca, the former became prevalent more so in 1884 after getting reinforcement from a medical publication. After this, cocaine was made a part of popular beverages and also medicines that were patented such as Vin Mariani and Coca-Cola.2 People started getting concerned when health issues and social issues started to rise, and restrictions were gradually applied until the Harrison Act (1914) banned all over-the-counter (OTC) inclusion of cocaine.3 In the United States, a popularity wave of cocaine use began in the1970s followed by the crack wave of the 1980s.4 These waves have left paths of adverse consequences, including that in later part of the 20th century when it was association with the human immunodeficiency virus(HIV) epidemic. Synthetic stimulants in the form of amphetamine (isolated in 1887), gained prominence in the 1930s .Through OTC nasal decongestant (i.e., Benzedrine inhaler) containing the amphetamine phenylisopropylamine and the following discoveries of clinical applications such as fatigue, narcolepsy, and depression.5 OTC was banned in 1957 after it began to be misused riding on the easy accessibility and increased popularity. Prescription misuse that was common after World War II and illegal diversion of medications. Methamphetamine (isolated in 1919) use peaked during the late 1960s, creating a “speed scene.” The Controlled Substances Act passed in 1971 led to a dramatic decline in prescribed amphetamine and made amphetamines and methamphetamine less popular for a sometime. In the 1990s methamphetamine re - emerged, particularly in the western United States, concurrent to mounting small scale production, aka “meth labs,” first in California and subsequently spreading nationwide.7 new forms of methamphetamine such as “crank” and “ice,” also rose to high prevalence. The popularity of amphetamines is also evident in the cultural representations in literature, movies, and music from 1940s to 1990s. 1.3.1 Stimulant Use Disorder This condition refers to a wide range of issues associated with stimulant use. These can be met, cocaine, and amphetamines, but not including caffeine or nicotine. Various medical conditions may occur depending on the route of administration. Intranasal users often develop sinusitis, irritation, bleeding of the nasal mucosa, and a perforated nasal septum. Individuals who smoke the drugs are at increased risk for respiratory problems (e.g., coughing, bronchitis, and pneumonitis). Injectors have puncture marks and “tracks,” most commonly on their forearms. Risk of HIV infection increases with frequent intravenous injections and unsafe sexual activity. Other sexually transmitted diseases, hepatitis, and 10 CU IDOL SELF LEARNING MATERIAL (SLM)

tuberculosis and other lung infections are also seen. Weight loss and malnutrition are common. Chest pain may be a common symptom during stimulant intoxication. Myocardial infarction, palpitations and arrhythmias, sudden death from respiratory or cardiac arrest, and stroke have been associated with stimulant use among young and otherwise healthy individuals. Seizures can occur with stimulant use. Pneumothorax can result from performing Valsalva-like manoeuvres done to better absorb inhaled smoke. Traumatic injuries due to violent behaviour are common among individuals trafficking drugs. Cocaine use is associated with irregularities in placental blood flow, abruptio placentae, premature labour and delivery, and an increased prevalence of infants with very low birth weights. Individuals with stimulant use disorder may become involved in theft, prostitution, or drug dealing in order to acquire drugs or money for drugs. Neurocognitive impairment is common among methamphetamine users. Oral health problems include “meth mouth” with gum disease, tooth decay, and mouth sores related to the toxic effects of smoking the drug and to bruxism while intoxicated. Adverse pulmonary effects appear to be less common for amphetamine-type stimulants because they are smoked fewer times per day. Emergency department visits are common for stimulant- related mental disorder symptoms, injury, skin infections, and dental pathology. Associated Features Supporting Diagnosis Stimulants are known to produce an instant feeling of euphoria and wellness when smoked or injected. Long term stimulant use disorder can lead to abnormal behaviour such as social isolation, aggressive behaviour, and sexual dysfunction. In a state of acute intoxication, users may experience rambling speech, headache, transient ideas of reference, and tinnitus. And also, aggressive behaviour, paranoid ideation, auditory hallucinations in a clear sensorium, and tactile hallucinations, which the individual usually recognizes as drug effects. Some withdrawal symptoms can be -depression, suicidal ideation, irritability, anhedonia, emotional liability, or disturbances in attention and concentration. Withdrawal symptoms of cocaine usually resolve hours to days after cessation of use but can persist for1 month. The changes that happen physiological on withdrawal are in contract to those that happen at the time when the user is intoxicated. These can be bradycardia, temporary depression, eating disorders, repeated panic attacks, and social anxiety. In extreme case, there can also be psychotic disorders similar to schizophrenia with hallucinations which are induced by the stimulant. Stimulant disorders can also cause conditioned responses in users like craving for substance use when coming across any kind of white powder. These conditioned responses can cause relapse and are difficult to eliminate even after detoxification. The most serious effects seen of stimulant withdrawal are suicidal tendencies. 1.3.2 Stimulant Intoxication The essential feature of stimulant intoxication, related to amphetamine-type stimulants and cocaine, is the presence of clinically significant behavioural or psychological changes that 11 CU IDOL SELF LEARNING MATERIAL (SLM)

develop during, or shortly after, use of stimulants (Criteria A and B). Auditory hallucinations may be prominent, as many paranoid ideation, and these symptoms must be distinguished from an independent psychotic disorder such as schizophrenia. Stimulant intoxication usually begins with a “high” feeling and includes one or more of the following: • Euphoria with enhanced vigour, gregariousness, hyperactivity, restlessness, hyper vigilance, interpersonal sensitivity, talkativeness, anxiety, tension, alertness, grandiosity, stereotyped and repetitive behaviour, anger, impaired judgment, and, in the case of chronic intoxication, affective blunting with fatigue or sadness and social withdrawal. Most of these alterations at the behavioural and psychological levels are accompanied by two or more of the following post substance use symptoms: • Tachycardia or bradycardia; pupillary dilation; high or low blood pressure; perspiration or chills; nausea; weight loss; psychomotor agitation or retardation; muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias; and confusion, seizures, dyskinesias, dystonias, or coma (Criterion C). Intoxication, either acute or chronic, is often associated with impaired social or occupational functioning. Severe intoxication can lead to convulsions, cardiac arrhythmias, hyperpyrexia, and death. For the diagnosis of stimulant intoxication to be made, the symptoms must not be attributable to another medical condition and not better explained by another mental disorder (Criterion D). While stimulant intoxication occurs in individuals with stimulant use disorders, intoxication is not a criterion for stimulant use disorder, which is confirmed by the presence of two of the 11 diagnostic criteria for use disorder. Associated Features Supporting Diagnosis The severity and type of the behavioural and physiological changes depend on many factors, such as the dosage and the characteristics of the substance user or the context (e.g., tolerance, rate of absorption, chronicity of use, context in which it is taken). Most commonly observed stimulant effects are euphoria, increased pulse and blood pressure, and psychomotor activity. Side effects such as such as sadness, bradycardia, decreased blood pressure, and decreased psychomotor activity are uncommon and much occurs only when the substance is consumed in high doses. 1.3.3 Stimulant Withdrawal Acute withdrawal symptoms (“a crash”) are often associated with “runs” or “binges” i.e., periods marked by repetitive high-dose use Depression/lassitude and increased in appetite are some of the prominent symptoms. The user might seek rest for several days to feel better. The most disturbing sign during “crashing” or any other form of substance withdrawal is the development of suicidal tendencies. The majority of individuals with stimulant use disorder experience a withdrawal syndrome at some point, and virtually all individuals with the disorder report tolerance. Withdrawal from stimulant use is marked by appearance of withdrawal symptoms. These manifest anytime within hours or days of stopping or reducing 12 CU IDOL SELF LEARNING MATERIAL (SLM)

stimulant use. (Criterion A). Characteristics of this stage are dysphoric mood and multiple other options from: fatigue, vivid and unpleasant dreams, insomnia or hypersonic, increased appetite, and psychomotor retardation or agitation (Criterion B). Bradycardia is often present and is a reliable measure of stimulant withdrawal. As per the diagnostic criteria, while craving for the drug and anhedonia can be also symptoms, they are not requirements. These symptoms can lead to depression significant to seek medical help or disruption of life in a social, work or home setting. (Criterion C). The symptoms must not be attributable to another medical condition and are not better explained by another mental disorder (Criterion D). 1.3.4 Other Stimulant-Induced Disorders The following stimulant-induced disorders (which include amphetamine-, cocaine-, and other stimulant–induced disorders) are described in other chapters of the manual with disorders with similar phenomenology (see the substance/medication-induced mental disorders in these chapters): stimulant-induced psychotic disorder (“Schizophrenia Spectrum and Other Psychotic Disorders”); stimulant-induced bipolar disorder (“Bipolar and Related Disorders”); stimulant-induced depressive disorder (“Depressive Disorders”);stimulant-induced anxiety disorder (“Anxiety Disorders”); stimulant-induced obsessive compulsive disorder (“Obsessive-Compulsive and Related Disorders”); stimulant-induced sleep disorder (“Sleep- Wake Disorders”); and stimulant-induced sexual dysfunction (“Sexual Dysfunctions”). For stimulant intoxication delirium, see the criteria and discussion of delirium in the chapter “Neurocognitive Disorders.” In contrast with the diagnosis of substance intoxication and withdrawal, the substance induced disorders exhibit themselves only when they become very severe, so much so that independent medical attention is warranted. 1.3.5 Unspecified Stimulant-Related Disorder These are the scenarios in which symptoms of substance related disorder cause significant medical conditions or lead to disruption of social, work, or other important areas of life. These are predominating but do not fulfil all the conditions for any specific substance-related disorder or any of the disorders in the substance-related and addictive disorders diagnostic class. Coding note: The ICD-9-CM code is 292.9. The ICD-10-CM code depends on whether the stimulant is an amphetamine, cocaine, or another stimulant. The ICD-10-CM code for an unspecified amphetamine- or other stimulant-related disorder is F15.99. The ICD-10-CM code for an unspecified cocaine-related disorder is F14.99. 1.4 HALLUCINOGENS The word hallucinogen refers to a wide variety of drugs that produce a change in the user's perception of the world. These drugs can produce effects as per which the user can sense things that are not present; this is called ‘hallucinations’. Some use hallucinogens in order to experience hallucinations and this is termed as ‘tripping’. 13 CU IDOL SELF LEARNING MATERIAL (SLM)

These hallucinogens can be artificial/synthetic (made with chemicals) or naturally available from seeds, vines, trees, leaves and fungi. Historians have evidence to believe that these substances have been in use in various cultures since thousands of years now. These drugs were used in ancient cultures such as those of India, China, Greece, Rome, Assyria, Persia and Egypt in religious rituals as well as in medicine, sorcery and for magical applications. In Europe, hallucinogens have been prevalent during the medieval period and the Renaissance - times of widespread demonology and witchcraft. The effects of hallucinogens in the form of abnormal behaviour and strange visions were seen as proof of people being in contact with satanic forces. Also, these were used for many medicines and rituals by many Indian tribes of North and South America and the West Indies. The use of these substances became prevalent in western societies only by 1960s with the rise in the use of synthetic drug LSD (lysergic acid diethylamide) and the naturally occurring cannabis plant by the young age groups. Following substances also have hallucinogenic effects: Synthetic • LSD (lysergic acid diethylamide) • PCP (phencyclidine) • Ketamine • Ecstasy (MDMA - methylene dioxy meth amphetamine) Naturally Occurring • Magic mushrooms (psilocybin) • DMT (di methyl tryptamine) • Mescaline (peyote cactus) • Datura • Cannabis • Corkwood tree 1.4.1 What is the Appeal of Hallucinogens? As substances, Hallucinogens are attractive to some people because they can help them feel and perceive their surroundings in a totally different way. Some reasons for people to use these substances can be to: • Free themselves of inhibitions • Get a feeling of happiness and enjoyment. • Become an accepted part of a group of friends. • Enjoy the company of people. • Avoid normal life becoming monotonous. • Enjoy music and dancing more. • Just experiment for thrills. • Be rebellious. 14 CU IDOL SELF LEARNING MATERIAL (SLM)

• Get an outlet to relax. It is very important to note the potency of these substances, as if they can change the perceptions of the brain then it must definitely have many short term or long-term side effect, and also, they can prove to be a risk for a person’s mental and physical health. 1.4.2 What are the Effects of using Hallucinogens? Some of the immediate and long-term effects of using hallucinogens can include: Seeing things in a distorted way or seeing things that do not exist. • Able to sense more in a more intense manner like bright colours, sharper sounds. • Intermingles sensations - colours are heard, sounds are seen. • Distorted sense of time - minutes can seem like hours, space and images. • Emotional alterations. • Dilation of pupils. • Increase in vitals like body temperature, heart rate and blood pressure. Also leading to sweating. • Feeling of dizziness, nausea and drowsiness. • Tension and anxiety, leading to panic and even paranoia. • Impaired coordination and tremors. Long-term Effects of Hallucinogen Abuse One of the long-term effects of drug use is Flashbacks – This is a spontaneous and unpredictable recurrence of tripping (prior drug experience).It is unusual because, this effect happens even when the person has not used drugs. This could occur after a period of time has elapsed from the last drug use in terms of days, weeks, or even years. Certain triggers like stress, fatigue, physical exercise, stimulation of the senses or any other drug can lead to this condition. Some harmful effects can be: • Enhanced risk of developing severe mental disturbances Memory impairment and loss of concentration. 1.4.3 Common Synthetic Hallucinogens LSD (lysergic acid diethylamide) LSD is the most commonly used hallucinogen in Australia and is a powerful, mind-altering drug. LSD is a chemical that is produced from a fungus called ergot which primarily grows on rye. The manufacturing process is carried on illegally in laboratories. The product is sold on the street by keeping it on small pieces of absorbent paper. These papers contain graphical or emoji designs. There are other forms also in which it can be sold like capsule, liquid or tablet form, on sugar cubes and gelatine squares. The effect of LSD kicks in within 30 – 60 minutes of consumption and can be injected by either swallowing or putting it under the 15 CU IDOL SELF LEARNING MATERIAL (SLM)

tongue. The effects peak in 3 – 5 hours and last for 6 – 9 hours. But the outer limit for the effects to be felt is 24 hours. LSD is a very potent hallucinogen and even a small quantity can produce the desired effects for the user. The LSD ‘trip’ is the desired effect of the drug, involving a radical change in consciousness and dramatic psychic effects. Perceptual changes can include visual, auditory and tactile hallucinations, which the user is usually aware, are not real. Post LSD use effects or ‘trip’ can either have positive feelings like making the user feel a sense of happiness or enjoyment or it can be negative when the user feels anxious or even panic. A 'bad trip' is the most common adverse effect of the drug. Under the effect of a ‘bad trip’, the user could get a feeling that he/she is confused, overwhelmed by crowds and loud noises, hallucinations, paranoia and even as if they are losing their ability to think. PCP (phencyclidine) Street names: Angel dust As per its genesis, PCP was created as an anaesthetic but later as people noticed that it causes delirium and also confusion, this use was abandoned. Found in the market as powder, crystal or tablets, in current times PCP is very rarely used for animals. As a substance, it can be smoked, snorted or even swallowed. Substance use of PCP is very rare in Australia but more prevalent in America. PCP has a wide range of effects on brain activity, and as a result, it is difficult for the user to predict what they will experience. The effect of using PCP is like consuming alcohol, hallucinogen and amphetamine all together. The effect also has similarity to anaesthesia. Depending on how the drug is taken, the effects may start almost immediately or within about 30 minutes. A single dose usually lasts four to six hours, although the lingering effects can last for up to two days in some cases. Though it can cause undesirable effects such as drowsiness, slur in speech and issues in coordination, still it is used for the high that it produces. If taken in high amounts, it can even cause people to go into a dissociative state (disconnect with the environment) or even go into a state of coma. And in very high dosage cases, it has even proved fatal as it could cause heart attacks and fits. Ketamine Street names: K, Special K, vitamin K This chemical is also an anaesthetic similar to PCP. Ketamine can lead to amnesia, hallucinations and lower sensitivity to pain. It is used in preparing medications for both humans as well as animals in Australia. As medicines, this chemical is sold as a clear liquid but on the streets, it is available as a tablet and the white colour powder. In terms of the ways to ingest, it can be injected, swallowed or snorted in small quantities known as ‘bumps’. Some users may be unaware that they have taken the drug as it is increasingly used in ecstasy pills to create an ‘ecstasy-like’ effect in those pills that do not actually contain ‘true ecstasy’, i.e., MDMA. It has a very quick response, and the effects can start kicking in a matter of just 30 seconds post consumption via injection, in 20 – 3 minutes is swallowed. These effects last 16 CU IDOL SELF LEARNING MATERIAL (SLM)

for approximately three hours. The range of effects of this drug can be varied (as with PCP) such as paralysis or numbness, delusions, extreme hallucinations and a state wherein the mind is not able to make sense of the surroundings and feels confused. Researchers believe that Ketamine blocks the memory and the sensory parts of the brain. That is the reason for the brain creating false reality under the effect of this drug. These false realities can materialise for the users in many forms like near death experiences, chance meeting with aliens and being stuck inside the computer network. Under the effect of Ketamine, some users also harm themselves unknowingly. Apart from this it can cause high level of addiction and risk related to sex as the drug impairs judgement. Ecstasy (Methylene dioxy meth amphetamine - MDMA) Street names: E, ecky, MDMA, X, XTC MDMA has hallucinogenic properties .It is also known as empathogen (dance drug) as it releases chemicals like serotonin which create good moods in the users in the form of friendliness, intimacy, feelings of love and joy. It could distort reality because of it being similar to hallucinogens. Very high doses can even lead to death in some cases. This chemical is produced in laboratories in an illegal manner. It is available on streets in the form of powder or capsule which have engraved designs like hearts or doves or even logos of brands like ‘Calvin Klien’/’Rolls Royce’. Many chemicals like ketamine, amphetamine and asephedrine can be mixed to make the drug more potent , but still at an overall level, it remains less toxic than MDMA. Sometimes, even OMA which is a much more toxic drug is also found added to this pill .PMA (para methoxy amphetamine) is an amphetamine-type drug with both stimulant and hallucinogenic properties. It has no medical use. Its effects are similar to those of MDA, although PMA is much more potent and far more toxic. PMA has- been linked to a number of Australian deaths over the years. Six people died in South Australia between September 1995 and January 1996 after taking PMA, either alone or combined with MDMA. In such cases, it has been found that the users are unaware about the presence of PMA with ecstasy. Ecstasy takes effect after half an hour peaking within an hour and lasting for about 2 -3 hours. The effects due to which users ingest the drug are high levels of energy, increased affinity to socialise, high self-esteem, feeling of happiness and difference in perceiving visuals. However, some users find the experience far from pleasurable. In terms of the negative effects, they can range from nausea, sweating, and blurred vision to anxiety, depression and paranoia. Generally, users do not expect these effects to happen. The deaths reported as a result of the use of ecstasy have mainly been associated with kidney or heart failure caused by a dangerously high body temperature. Ecstasy users who participate in all night dance sessions may not drink enough water to replace the fluids lost through sweat in the hot environment. 17 CU IDOL SELF LEARNING MATERIAL (SLM)

1.4.4 Naturally Occurring Hallucinogens Psilocybin is a member of the same family as LSD and is a hallucinogenic chemical found in some varieties of mushrooms. The psilocybin mushroom is native to Mexico, but many other species of magic mushrooms grow in different places around the world. There are believed to be between 15-20 species of magic mushrooms growing wild in Australia. The difficulty in separating the magic mushrooms from the poisonous mushrooms that might look similar, makes it risky to pick and eat wild mushrooms. Moreover, any symptoms related to poisoning can take up to 40 hours to manifest. Some ill effects of eating poisonous mushrooms are stomach pains, nausea and diarrhoea. In extreme cases, there can be permanent liver damage, respiratory failure, unconsciousness and this can even prove fatal. Both fresh and dried mushrooms are eaten raw or cooked, or they’re boiled up into a mushroom tea. Dried mushrooms are usually smoked in a rolled cigarette or pipe. It usually takes at least 30 minutes for the hallucinations to begin, with peak effects occurring after about 3 hours. The whole experience can last for nine hours or more. The desired mushroom ‘trip’ usually involves feelings of happiness and euphoria, spontaneous laughter, and visual and auditory hallucinations. However, if too many mushrooms are taken, or the user is anxious or uncomfortable with their surroundings, they could end up experiencing a bad trip, involving feelings of paranoia, panic and terrifying hallucinations. 1.5 TYPES OF SUBSTANCE ABUSE Psychotherapy is more than a talk between two people regarding some problem. It is a collaborative undertaking, started and maintained on a professional level towards specific therapeutic objectives. These are: • Removing existing symptoms: To eliminate the symptoms that are causing distress and impediments is one of the prime goals in psychotherapy. • Modifying existing symptoms: Certain circumstances may militate against the object of removing symptoms (e.g., inadequate motivation, diminutive ego strength or financial constraints); the objective can be modification rather than cure of the symptoms. • Retarding existing symptoms: There are some malignant forms of problems e.g., dementia where psychotherapy serves merely to delay an inevitable deteriorative process. This helps in preserving client’s contact with reality. • Mediating disturbed patterns of behaviour: Many occupational, educational, marital, interpersonal, and social problems are emotionally inspired. Psychotherapy can play vital role from mere symptom relief to correction of disturbed interpersonal patterns and relationships. • Promoting positive personality growth and development: Deals with the immaturity of the normal person and characterological difficulties associated with inhibited growth. 18 CU IDOL SELF LEARNING MATERIAL (SLM)

Here psychotherapy aims at a resolution of blocks in psychosocial development to a more complete creative self-fulfilment, productive attitudes, and more relationships that are gratifying with people. It also aims at • Strengthening the client’s motivation to do the right things. • Reducing emotional pressure by facilitating the expression of feeling. • Releasing the potentials for growth. • Changing maladaptive habits. • Modifying the cognitive structure of the person. • Helping to gain self-knowledge. • Facilitating interpersonal relations and communications. 1.6 DSM CRITERIA Depressants In cases of overdose, it is critical to seek immediate medical attention. Overdose from both sleep medicines and from benzodiazepine can be treated using the medicine Romazicon or Flumazenil. However, it, it cannot completely reverse the symptoms like slowed breath in and for patients who ate also on anti-depressants, and it can lead to seizures. Romazicon is slow acting and might have to be administered every 20 minutes for full recovery. For cases involving benzoic spines and barbiturates the vitals like blood pressure, temperature, etc need to be monitored while the drug is getting eliminated from the body. Can there be a scenario where prescribed CNS anti-depressants can cause addiction? Yes, misuse of CNS can lead to (Substance Use Disorder).In severe cases this can translate into addiction. Even long duration use as per prescription can reduce the potency of the anti- depressant and higher dose might be needed to get the same therapeutic effect. Indications of SUD are that the use of the medication interferes with normal life by impacting performance of duties at home, work or school and causes health issues. For addicts, abrupt stoppage of the drug can cause withdrawal symptoms like anxiety, insomnia, hallucinations, sweating, severe cravings, increased blood pressure/heart rate and seizures. The negative effects can exhibit themselves even within few hours of stopping the drug use. In some cases, withdrawal symptoms can also be life threatening. What is the treatment for addiction caused from prescription CNS anti-depressants? Supervised detoxification is very beneficial for gradual detoxification of the body. Inpatient or outpatient counselling and specific type of counselling called cognitive behavioural counselling are also beneficial. Cognitive behavioural counselling works to modify the attitudes and thinking of the person in such a manner that they are able to handle stress better without needing to use any drugs. This has been very helpful in cases linked with 19 CU IDOL SELF LEARNING MATERIAL (SLM)

benzodiazepines. In many cases, CNS misuse is part of multiple addictions and the addicts use alcohol and opioids as well. In such cases multi addiction treatment must be sought. Stimulant Use Disorder Diagnostic Criteria A pattern of amphetamine-type substance, cocaine, or other stimulant use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a period of 1 year: • The stimulant is often taken in higher dosages and throughout a longer duration that initially thought • Unsuccessful efforts or there is presence of a persistent desire curtail the stimulant use. • A lot of = is spent in obtaining, using or recovering from the ill effects of the stimulant. • A strong desire (Craving) for using the stimulant. • Performance of duties at home, school or work getting majorly impacted. • Despite the issues created in relationships and social life, continuing the stimulant use. • Ceasing or reducing the level of important social, work related, or recreational activities due to stimulant use. • Using the stimulant repeatedly even though it causes major ill effects on health. • Despite being aware about the mental and physical issues associated, continue with stimulant use, • Following are the definitions of Tolerance: i. A need for markedly increased amounts of the stimulant to achieve intoxication or desired effect. ii. A markedly diminished effect with continued use of the same amount of the stimulant. Note: For users taking the stimulant as per medical prescription, this criterion is does not hold good. These can be taken as medication f for attention-deficit/hyperactivity disorder or narcolepsy. i. Withdrawal can be identified in terms of the following in an either-or scenario: The characteristic withdrawal syndrome for the stimulant (refer to Criteria A and B of the criteria set for stimulant withdrawal, p. 569). ii. The stimulant (or a closely related substance) is taken to relieve or avoid withdrawal symptoms. Note: For people taking medications such as treatment for attention-deficit/hyperactivity disorder or narcolepsy under medical supervision, fulfilment of this criterion is not deemed to be applicable. 20 CU IDOL SELF LEARNING MATERIAL (SLM)

Specify if In Early Remission: Criteria for stimulant use disorder are not met for more than three months and less than a year even though it was met earlier. (With the exception that Criterion A4, “Craving, or a strong desire or urge to use the stimulant,” may be met). In Sustained Remission: Criteria for stimulant disorder are not met for a year or more even though it was met earlier. (With the exception that Criterion A4, “Craving, or a strong desire or urge to use the stimulant,” may be met). Specify if In A Controlled Environment: This is used additionally if the user is in a restricted access environment. Coding Based On Current Severity: Note for ICD-10-CM codes: If amphetamine intoxication, amphetamine withdrawal, or another amphetamine-induced mental disorder is also present, do not use the codes below for amphetamine use disorder. Instead, the 4th character of the amphetamine induced disorder code indicates the comorbid amphetamine use disorder. Please refer to the coding note for amphetamine intoxication, amphetamine withdrawal, or a specific amphetamine-induced mental disorder. For example, if there i comorbid amphetamine-type or other stimulant-induced depressive disorder and amphetamine-type or other stimulant use disorder, only the amphetamine-type or other stimulant induced depressive disorder code is given, with the 4th character indicating whether the comorbid amphetamine-type or other stimulant use disorder is mild, moderate, or severe:F15.14 for mild amphetamine-type or other stimulant use disorder with amphetamine- type or other stimulant-induced depressive disorder or F15.24 for a moderate or severe amphetamine-type or other stimulant use disorder with amphetamine-type or other stimulant induced depressive disorder. Similarly, in a scenario wherein there is comorbid cocaine- induced depressive disorder and cocaine use disorder, only the code for the latter is provided. The 4th character of the code indicates the severity of the comorbid cocaine use disorder - mild, moderate, or severe: F14.14 for mild cocaine use disorder with cocaine-induced depressive disorder or F14.24 for a moderate or severe cocaine use disorder with cocaine- induced depressive disorder. Specify Current Severity Mild: Presence of 2–3 symptoms. 305.70 (F15.10) Amphetamine-type substance 305.60 (F14.10) Cocaine 21 CU IDOL SELF LEARNING MATERIAL (SLM)

305.70 (F15.10) Other or unspecified stimulant Moderate: Presence of 4–5 symptoms. • 304.40 (F15.20) Amphetamine-type substance • 304.20 (F14.20) Cocaine • 304.40 (F15.20) Other or unspecified stimulant • Severe: Presence of 6 or more symptoms. • 304.40 (F15.20) Amphetamine-type substance • 304.20 (F14.20) Cocaine • 304.40 (F15.20) Other or unspecified stimulant “In a controlled environment” applies as a further specifier of remission if the individual is both in remission and in a controlled environment (i.e., in early remission in a controlled environment or in sustained remission in a controlled environment). Examples of these environments are closely supervised and substance-free jails, therapeutic communities, and locked hospital units. Diagnostic Criteria Stimulant Intoxication • Recent use of an amphetamine-type substance, cocaine, or other stimulant. • Clinically significant problematic behavioural or psychological changes (e.g., euphoria or affective blunting; changes in sociability; hyper vigilance; interpersonal sensitivity; anxiety, tension, or anger; stereotyped behaviours; impaired judgment) that developed during, or shortly after, use of a stimulant. • Two (or more) of the following signs or symptoms, developing during, or shortly after, stimulant use: i. Tachycardia or bradycardia. ii. Pupillary dilation. iii. Elevated or lowered blood pressure. iv. Perspiration or chills. v. Nausea. vi. Weight loss. vii. Psychomotor agitation or retardation. viii. Muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias. ix. Confusion, seizures, dyskinesias, dystonias, or coma. • Symptoms cannot be attributed to any other medical cause or mental disorder, including intoxication with another substance. Specify the specific intoxicant (i.e., amphetamine- type substance, cocaine, or other stimulant). Specify if 22 CU IDOL SELF LEARNING MATERIAL (SLM)

With Perceptual Disturbances: This specifier may be noted when hallucinations with intact reality testing or auditory, visual, or tactile illusions occur in the absence of a delirium. Coding Note: The ICD-9-CM code is 292.89. The ICD-10-CM code depends on whether the stimulant is an amphetamine, cocaine, or other stimulant; whether there is a comorbid amphetamine, cocaine, or other stimulant use disorder; and whether or not there are perceptual disturbances. For Amphetamine, Cocaine, Or Other Stimulant Intoxication, Without Perceptual Disturbances: If a mild amphetamine or other stimulant use disorder is comorbid, the ICD- 10-CM code is F15.129, and if a moderate or severe amphetamine or other stimulant use disorder is comorbid, the ICD-10-CM code is F15.229. If there is no comorbid amphetamine or other stimulant use disorder, then the ICD-10-CM code is F15.929. Similarly, if a mild cocaine use disorder is comorbid, the ICD-10-CM code is F14.129, and if a moderate or severe cocaine use disorder is comorbid, the ICD-10-CM code is F14.229. If there is no comorbid cocaine use disorder, then the ICD-10-CM code is F14.929. Diagnostic Criteria Stimulant Withdrawal • Cessation of (or reduction in) prolonged amphetamine-type substance, cocaine, or other stimulant use. • Dysphoric mood and two (or more) of the following physiological changes, developing within a few hours to several days after Criterion A: i. Fatigue. ii. Vivid, unpleasant dreams. iii. Insomnia or hypersomnia. iv. Increased appetite. v. Psychomotor retardation or agitation. • The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Symptoms cannot be attributed to any other medical cause or mental disorder, including intoxication with or withdrawal from another substance. Specify The Specific Substance That Causes The Withdrawal Syndrome (i.e., amphetamine-type substance, cocaine, or other stimulant). Coding Note: The ICD-9-CM code is 292.0. The ICD-10-CM code depends on whether the stimulant is an amphetamine, cocaine, or other stimulant. The ICD-10-CM code for amphetamine or another stimulant withdrawal is F15.23, and the ICD-10-CM for cocaine withdrawal is F14.23. Regarding ICD-10-CM code note that the presence of comorbidity related to moderate to severe stimulant use disorder because of cocaine, amphetamine or other stimulants, points to the observation that withdrawal can happen only in the above- mentioned scenario. It is not permissible to code a comorbid mild amphetamine, cocaine, or other stimulant use disorder with amphetamine, cocaine, or other stimulant withdrawal. 23 CU IDOL SELF LEARNING MATERIAL (SLM)

1.7 INCIDENCE AND PREVALENCE This survey was a pilot that aimed to achieve multiple objectives such as – Exploring the conditions in the field, To do a feasibility analysis and To run tests for research instruments used in the ICMR funded project “Epidemiology of substance use and dependence in the state of Punjab. “As a process we sought written consent from participants after making them aware of the content and also approached Institute Ethics Committee for an ethical clearance. The techniques RAS and door to door household were deployed to conduct the survey. The scope of this paper is limited to RAS while door to door is covered in a companion paper. Sample Size 300 respondents recruited from two sites (to create diversification) were surveyed. Establishing the Respondent-Driven Sampling (RDS) Centres Office spaces of two NGOs were chosen as the RDS centres using the aid from Society for the Promotion of Youth and Masses. These NGOs were primarily providers of oral substitution therapy and were working with opiod drug users. Inclusion Criteria • Age: 11–60 years • Total duration of any substance use for at least 2 years. Living in Chandigarh at least the past 1.5 years. Willingness to participate. Capable of having conversations that are meaningful. Prepared to share details of at least three potential respondents. Instruments The instruments used were as follows: 1. The check list for symptoms - ICD-10 mainly used for psychoactive substance use, mental disorders, syndromes module. 2. ASSIST which is the alcohol, smoking, and substance involvement screening test from WHO. 3. In order to do a sampling that is respondent driven, a drug user questionnaire was distributed: The themes in this questionnaire were behaviour, drug using network and substance misuse. Along with questions that death with drug use such as physical and mental health, social functioning, offending behaviour and crime. In addition to questions on support, care and treatment for high-risk behaviour and injecting drug use. While designing the questionnaire, the team search for an exhaustive list of similar studies that were done both in foreign countries and in India. Post which a rigorous process comprising of repeated consultations, compilation was followed before finalising the questionnaire. 24 CU IDOL SELF LEARNING MATERIAL (SLM)

4. Theme used for FGD (Focused group discussion): \\These discussions were guided using specific questions rather than just a pro forma. The aim of these discussions was to study the perceptions and views of the substance users that are related to genesis, maintenance and the genesis of the substance use problem and also its management and prevention. FGD of the national survey on extent, pattern, and trends of drug abuse in India was referenced to shortlist the themes and the response formats were not structured. 5. Form for = consent and information. Definitions of study parameters: To label the substance consumption patterns, the following key terms were used: Lifetime use: Whether harmful or otherwise, at least using the substance once. (not necessarily problematic use, harmful use, or dependence). • Annual use: Use in last 12 months. • Current use: Use in last 30 days. • Lifetime dependence: Dependence (as per ICD-10 criteria) on any substance in lifetime. Sampling A kind of chain referral method of recruitment called RDS was used. This method has many points of differences Vis a Vis snowball sampling that is done traditionally. The name of this technique RDS refers to the chain referral process by which respondents themselves recruit more respondents and so on. This system also has rewards connected to two stages – one for recruiting respondents (secondary) and the other for the interview (primary).Following steps were followed for recruiting samples for the study. i. As a first step, “seeds “were selected. ii. These were recruited basis demographics (age, geographical area, and socio – economic background) from both the RDS sites. iii. He primary reward to the ‘seeds’ was given in the form of mobile recharge coupons (worth two hundred rupees) rather than in the form of cash as we believed that cash could be misused. The secondary reward was given in the form of two coupons which were joined together with a dotted line. The upper half was to be passed on by a ‘seed’ to a peer who used drugs and the other half got converted to a primary reward for the ‘seed’ if the peer came for the interview. Both these halves were logically connected by means of a common number printed on both these coupons. iv. 4. In a similar fashion, the new recruits also got these dual coupons and got rewarded for both the interview as well as for bringing in their peers. In this manner, each of the respondents had the opportunity to earn a maximum of four coupons- one primary 25 CU IDOL SELF LEARNING MATERIAL (SLM)

reward and three secondary rewards. 5. Careful numbering of coupons was done to make the incentive redemption process seamless and simple. Estimation of Size of Substance Users For estimation of the prevalence of substance dependence, data is collected from two sources as per the Benchmark multiplier method .Post which a multiplier is applied to the benchmark – calculated as a total of subgroups formed from the population using drugs. As an example, “benchmark” data can either be the total number arrested as per police data, the morality rate or total number of drug-related deaths or total number in-treatment. An estimation of the total size of drug using population can be calculated by multiplying the benchmark with a relevant multiplier. Formula used is as follows (in the case of treatment data): T=Cumulative number that estimates the size of the problematic drug users from the area being studied = The benchmark which is the size of population that sought treatment in the past 12 months, obtained from treatment facilities=Estimated In treatment rate for the patients living in communities M=“Multiplier,” i.e., reciprocal of c. Therefore, T=B/c=B×M According to this study, benchmark was taken as the size of substance addicted users seeking in the past year; de-addiction treatment in government recognized centres in Chandigarh Multiplier was calculated by estimating the inverse of proportion of the sample reporting that they had undergone inpatient treatment in the past year from the de-addiction facilities in Chandigarh. Then, benchmark and multiplier were multiplied to get the number of substance- dependent individuals in Chandigarh. To calculate prevalence of substance dependence the estimations were extrapolated on the entire Chandigarh population. Statistical Analysis It was done using Statistical Package for Social Sciences (SPSS), version 22, SPSS Inc., Chicago, IL, USA, and Respondent Driven Sampling Analysis Tool (RDSAT), version 7.1, Cornell University, USA. Sociodemographic Profile 300 substance-dependent respondents who were from Chandigarh were surveyed to collect the data. A majority were middle level educated males. About 50% of the respondents were married, and a substantial percentage was employed. The level of education was significantly higher (mean years: female = 13.8 and male = 8.5, P ≤ 0.001); however, the probability of being unemployed was higher for females (female = 80% and male = 20%, P ≤ 0.001) 26 CU IDOL SELF LEARNING MATERIAL (SLM)

Figure 1.1 Sociodemographic Profile of Respondents Distribution of Substance Use and Dependency Opioids had the highest rate of prevalence of 74.00% and the second most prevalent was alcohol with a prevalence rate of 68.33%. [Figure 1.1]. Further, 52.00%, 29.33%, 2.66%, 2.00%, and 2.66%, was the reported lifetime use figures of tobacco, cannabinoids, inhalants, sedatives/hypnotics, and stimulants, respectively. Figure 1.4 shows the distribution details for substance use as annual, current along with annual dependence and lifetime. Further, it was also observed that approx. 28% reported that they have used only bone substance, 31%reported use of two substances and 41% reported to have used more than two substances. 27 CU IDOL SELF LEARNING MATERIAL (SLM)

Figure 1.2 Distribution of Lifetime Use of Substance Figure 1.3 Distribution of Substance Use of Dependence in the Respondents In terms of stimulant use, 2.00%, 1.66%, and 1.66% was the percentage of respondents who used cocaine, amphetamines, and hallucinogens, respectively. For opioids use, the most prevalent were inject able opioids (46.66%), followed by illicit opioids (30.00%) and noninjectable opioids (13.66%), respectively. Inject able buprenorphine was the most used opioids with 54.50% of the opioids users, followed by bhukki/doda/afeem (27%). Further, heroin was reported to be used by 19.36% opioids users. Inject able heroin was reported to be used by 7.65% of opioids users. Refer to the table for more details. Figure 1.4 Types of Opioids 28 CU IDOL SELF LEARNING MATERIAL (SLM)

Most commonly used substance was alcohol (80.00%) for females, followed by tobacco (60.00%) and opioids (30.00%), respectively. However, with regard to the type of substance being used, the statistics were similar irrespective of gender. Figure 1.5 Distribution of Lifetime Substances Transitional Probabilities The respondent’s gender and status regarding inject able drug and opiod use formed the basis to estimate Transitional probabilities. Probability of a male recruiting was observed to be 96% while probability of female recruiting was close to nil. The probability of an opioids user to recruit another opioids user was estimated to be 73%; and that of opioids users recruiting nonopioid users was 27%. The probability of a IDUs recruiting other inject able users was 50%. Estimate of Prevalence of Substance Dependence Benchmark–Multiplier method was deployed to estimate prevalence of substance dependence. Amongst the surveyed respondents, 16 (5.33%) reported to have been admitted in the past 1 year for treatment of substance dependence, yielding a figure of 18.80 as the multiplier. As shared by the government recognized de-addiction centres in Chandigarh a total of 1115 substance-dependent individuals were admitted to these centres in the previous year. By 29 CU IDOL SELF LEARNING MATERIAL (SLM)

multiplying these figures, we arrive, at the estimated number of substance-dependent individuals in Chandigarh which was 20,962.Finally; the prevalence (in percentage) for substance dependence was calculated by dividing this figure as numerator (20962) by the suitable denominator. As per 2011 consensus, the total population of the Union Territory .of Chandigarh is 1,055,450. Both numerator and denominator were synchronised to consider the population between 11–60-years (814,978, of which 453,027 are males and 361,951 are females). Further, because the sample from which the size estimate of 20,962 was derived was 97% male and only 3% female, we weighted the denominator based on gender (97% of 453,027 plus 3% of 361,951 = 450,295)and arrived at the final figure for the denominator. Thus, the prevalence rate of any substance dependence was calculated as 20962/450,295 × 100 = 4.65%. In a similar fashion, prevalence rates of dependence on specific substances was calculated, and following were the results - 1.53% for opioids dependence, 0.52% for cannabis dependence, and 0.015% for inhalants. Figure 1.6 Prevalence of Substance Dependence Using Benchmark Multiplier Method In the absence of specific benchmark data on IDUs, we used the available data on opioids- dependent persons in the RDS sample (210) - IDUs (125, i.e., 59.52%), and we extrapolated the total IDU number by calculating it from the total opioids-dependent number (59.52% of 6904 = 4109.26, rounded to 4109). We this figure (4109) by our 11–60-year gender-weighted denominator of 450,295, to obtain the IDU prevalence rate of 4109/450,295 = 0.91%. Substance-Related Behaviour and Problems The most common reason for came out to be fun (75%) followed by curiosity (53%). Nearly 75.66% of the substance users reported to be spending <500 rupees on substance use per day. Out of which 80% reported that they spent their own funds. The most common source of drug was reported to be a dealer (71.66%) followed by pharmacy/outlet (55.66%).Work related problems due to drug use was reported by the majority (89.66%) and the rest reported to have no work-related problem. About 14% of the respondents reported to be arrested by police on at least one occasion. 37% reported physical medical problems and 31% reported mental problems. 30 CU IDOL SELF LEARNING MATERIAL (SLM)

High-risk Behaviour 46.66% of the respondent, reported to have used inject able drugs (59.5% of the opioids- dependent persons were IDUs). Body piercing was reported by 13.00% of the respondents. Nearly 40.30% reported sexual contact with multiple sexual partners and 10.30% reported sexual contact with commercial sex workers. Figures 1.8 and figure 1.9 provide details regarding, inject able drug use-related risk behaviour and route of administration of inject able drugs, respectively. Odds ratio of 5.78 and 2.87 indicate that Body piercing and contact with a multiple sex partners was more common in IDUs as compared to non-IDUs. 5.9% reported to be seropositive among the IDUs subjected to HIV testing in the past., Similarly, of inject able opioids users ,hepatitis B was reported to be positive in 15% and hepatitis C in 14% of them. High-risk behaviour such as history of a tattoo or body piercing and contact with a sex worker was more prevalent in HIV-positive inject able users as compared to those with HIV-negative status with odds ratio of 35.60 and 5.75, respectively. Figure 1.7 High Risk Behaviour 31 CU IDOL SELF LEARNING MATERIAL (SLM)

Figure 1.8 Sharing of Needles and Paraphernalia Figure 1.9 Route of Inject able Drug Administrator According to the study, prevalence rate of substance dependence was observed to be 4.65%. Which is low compared to the rates reported earlier for Chandigarh. The difference in the 32 CU IDOL SELF LEARNING MATERIAL (SLM)

methodologies use could explain this disparity. One other reason could be that our study had mostly opiod users and the de addiction centre admissions also were for opiod use thus, resulting in lower estimates for alcohol and tobacco substance dependence. \\ However, this rate is higher than the 2.96% prevalence found in our household survey for any substance dependence and very similar to the 4.74% prevalence in males (the RAS prevalence figures are primarily generated on male gender). The prevalence of opioids dependence in our survey came out to be 1.53%.A recent survey deploying similar techniques had reported a higher number - 0.85% in Punjab. Thus, indicating that U.T of Chandigarh has also been ravaged by opiod use as is the case in many parts of Punjab. An interesting observation is that the prevalence of opioids dependence in Chandigarh estimated house-to-house survey technique when done by the authors of this paper, amounted to 0.17%. While 0.2% was the result of a similar survey done earlier in Chandigarh. This puts into focus the fact that opiod dependence might be under reported when door to door surveys are used to collect data. With a prevalence rate of 0.91%, injectable opioids were the most commonly used substance as per our survey with 46.66% of total respondents and 59.52% of opioids users. This is very high compared to prevalence rate reported by Ambedkar and Tripathi which was 0.15%.This spike indicates that the prevalence of inject able opioids in Chandigarh might have increased. Moreover, the results of the Punjab Opioids Dependence Survey, also support this finding as 33% of opioids users were using the inject able drug vs. 63% (very high use) as per our study. Another observation from our study was that, after injecting able drugs; use of bhukki/afeem/doda was most common, roughly around 27% of opioids users. And this was followed by heroin use (19% of opioids users). While the numbers reported from Punjab were 53% of the opioids users used heroin and 33% was the usage of opioids/doda/bhukki. These differences could have been caused by disparity in factors such as enforcement of law, and order, geographical locations and drug availability. Moreover, the prevalence rates of cannabis dependence and sedative dependence for which reported nil figures as per the door-to-door survey by the authors, the figures that came out in the RAS were 0.52% and 0.015%. While there were also reports of using substances such as inhalants, cocaine, and other stimulants; the prevalence of these could not be calculated because of two reasons –unavailability of benchmark values and none of the users being admitted to the de addiction centre. This makes it important to come up with improved prevalence rate estimation strategies for future studies. 31.6% of IDUs shared needles and 40.7% shared injection equipment. These figures are similar to the numbers reported by previous studies - -36%–69% and 34%–95% respondents, respectively, at different sites. IDUs exhibited body piercing and contact with multiple sex workers, categorised as at a level significantly higher than that observed in users of non-inject able opioids. Similar numbers were also reported by a study done in Chandigarh earlier. 5.6% was the prevalence of seropositive HIV cases in IDUs, a figure which is less than the number of 9.7% reported in Chandigarh by National AIDS Control Organization. This could be 33 CU IDOL SELF LEARNING MATERIAL (SLM)

explained by noting that our survey did the calculation for prevalence of HIV basis retrospective reporting by respondents, thus giving results that are biased. Still, the number reported is significant and nonetheless, it exceeds the rate of 0.35% in general population in Chandigarh. Also, as per a logical extension, other risk behaviours such as contact with a sex worker were more likely to be present in IDUs who tested HIV positive. High prevalence of infections such as hepatitis C and hepatitis B was also found in Inductees infections have also been found prevalent in many other parts of the country also. The conclusion of these studies emphasises the need for awareness programs and needle exchange programs that can curtail spread of infection and risky behaviour in IDUs. Focussed Groups showed that many of the substance users believed that awareness and treatment programs are very beneficial. Yet, despite a substantial number of respondents willing to curtail substance use, only one third had visited any de-addiction centre. This was also observing as part of the Punjab opioids dependence survey. Further, only 5% individuals had been admitted in a de-addiction centre in the past year even less than the 8% reported in the neighbouring state of Punjab. It was also sad to know that majority of the respondents did not know of any awareness programs. Many respondents did not seek treatment due to the fear of social stigma and social problems. This makes it even more important to have outreach and awareness programs to curtail substance use. Some of the limitations of the study were – calculation of prevalence rates is based on some assumptions but with some exceptions. 1. As per the benchmark-multiplier method, the assumption is that residents of Chandigarh would get admitted in Chandigarh located de-addiction centres only. But there can be scenarios wherein people can get admitted in de addiction centres that are located in the neighbouring cities to Chandigarh as well. 2. The study considered data from only government recognized de-addiction centres. But there can be admissions in privately owned centres also. Despite these limitations, the study uses an efficient method to approximate the size substance user population. 1.8 CO-MORBIDITY Spread of awareness and sympathy with the users were touted as the most recommended ways to curtail substance use by the respondents. This can also be done by making treatment free of costs. The views on role of religious scholars as catalyst for change was varying. Still, many of the respondents did not know about the awareness programs. Also, many respondents viewed strict laws as a means to tackle the problem. In order to evaluate the high rate of comorbidity observed between substance use and mental disorders, a comprehensive approach is required. Following this line of thought, people seeking help for any mental disorders or substance addictions and its ill effects should be assessed for both the possibilities and the treatment should be prescribed in accordance. It has been seen that many behavioural therapies that can be customized as per patient age, misuse 34 CU IDOL SELF LEARNING MATERIAL (SLM)

of a particular substance and as per many other factors have been effective in cases of com or bid conditions. Some of these therapies are: DBT (Dialectic Behavioural Therapy): These therapies focus on self-harming behaviours like suicidal tendencies, drug use and cuts to oneself. CBT (Cognitive Behavioural Therapy): This helps on transforming harmful attitudes and behaviours. ACT (Assertive Community Treatment): This method deploys community outreach to treat at an individual's level. TC (Therapeutic Communities): This form of treatment works to socialise the person by way of a long duration residential program me. CT (Contingency Management): These programs give rewards in form of vouchers to encourage healthy behaviours. Many medications that treat mental disorders and substance (alcohol, nicotine, opioids) addiction effectively have not been studied on comorbid population. There are medicines that are effective in multiple conditions. For example, bupropion is approved for treating both depression (Wellbutrin®) and nicotine dependence (Zyban®). However, there in a need for in depth research to study the response of patients with co morbidities to these medicines. Comorbidity refers to a condition where a patient suffers from more than one condition either simultaneously or in quick succession. Since substance use and mental disorders have similar risk factors, these are found together in nearly 50% of the comorbid population. Also, presence of a mental disorder can make a person more predisposed to substance use and vice versa. Thus, it is important to treat these disorders together rather than in isolation. 1.9 CAUSES OF SUBSTANCE OF ABUSE The cause of substance use disorders is still unknown, though genetics are thought to account for 40% to 60% of a person’s risk. The starting of substance use is connected to childhood or early adolescence curiosity or a means to feel joy. Addiction and related disorders are caused after multiple uses and after attaining high level of tolerance. Some adults who develop a substance use disorder have pre-existing mental illness, such as depression, anxiety, or bi- polar disorder. They take support of alcohol or drugs to tackle the suffering. Additional factors related to substance use disorder can be: • History of addiction in the family 35 CU IDOL SELF LEARNING MATERIAL (SLM)

• Sleep related issues • Chronic pain • Financial problems • Divorce or the loss of a loved one • Use of tobacco • Home environment not being pleasant • Difficult childhood • Issues in close relationship While the presence of these factors does not ascertain that a person will definitely develop a substance abuse disorder, but when combined with repeated use, the presence of a set of these factors can lead to addiction. Unexpected or extreme violence almost always manifest as an ill effect of drug/stimulant use. And indicate a change in behaviour in extreme degrees. Some of the most recent, well-known instances of extreme behaviour caused by stimulants have been caused by salts. This is a stimulant drug that has an effect similar to that produced by cocaine or meth. The psychological and behavioural effects of these types of drugs include paranoia, agitation, panic attacks, and hallucinations, leading to extremely violent behaviour. Other drugs that have a similar reaction include cocaine, meth, synthetic marijuana or K2/Spice and even some prescription drugs used to treat attention deficit hyperactivity disorder. 1.10 PROGNOSIS AND TREATMENT While majority of substance users believe in self-control to stop substance use, most of them cannot do it on their own. The prerequisite for effectively treating addictive behaviour is to mellow down the physical withdrawal of the user from the substance that they have been using. This phase of treatment is called detoxification or \"detox. “And it often requires inpatient hospital treatment. According to research long-term use of drugs reinforces compulsion to use the substance by altering the brain function. So much so that the substance craving remains even after use is stopped. Presence of cravings in an ongoing sense makes it very important to avoid relapse so that recovery is effective Basis the user and the substance used, treatment in a rehabilitation (rehab) program is adopted. Behavioural treatment is done as an individual or as group therapy. The plan to deal with the drug craving and strategies to nullify chances of a relapse are provided by a counsellor (like a social worker, psychologist, psychiatrist, psychiatric nurse, or nurse practitioner). Post an exhaustive assessment of the user’s condition, a doctor or nurse practitioner may prescribe medications, such as nicotine patches and methadone. These help to keep the withdrawal symptoms in check and deal with the drug cravings. Random drug testing and 36 CU IDOL SELF LEARNING MATERIAL (SLM)

drug – abuse hotlines are also systems that can prove very effective in supporting treatment and in avoiding relapse of substance use. Mostly it is found that an underlying behavioural disorder or mental illness increases the likelihood of substance abuse. Dual diagnosis happens when a user is found to be suffering from substance abuse as well as from a mental disorder. Treatment for such disorders is through medical intervention and through counselling along with treatment of the drug abuse. Chemical Dependence Treatment Programs These programs offer treatment in the following forms: • Therapy sessions for Individual, group or family. • Attempt to understand the nature of addiction and focus on making the patient drug-free with minimal chances of relapse. • The treatment can be done in residential, inpatient or outpatient set ups. Detoxification The main purpose of detoxification or “detox\" or withdrawal therapy, is to help the user become drug free within a small duration of time and also in a safe manner. Depending on the type of patient, the level of suitable treatment can either in the form of outpatient, inpatient or residential programs. Different ways of treatment might be needed for different substances (depressants, stimulants or opioids) as withdrawal of each of them could have different side effects. Any of the approaches primarily focus on either lowering the drug use in a gradual manner or substituting the drug with other substances, such as methadone, buprenorphine, or a combination of buprenorphine and naloxone. Opioids Overdose Naloxone (opioids antagonist) is generally administered by the emergency respondent in cases of opioids overdose. This medication can reverse the effects of the drug on a temporary basis. While naloxone has been sold commercially since many years, varied expensive delivery mechanisms - Narcan, nasal spray) and Evzio, injection device have only become available now. Evzio also has accompanying voice instruction guide and uses an automatic system to insert the needle. Despite the method of administering the medicine, medical care should be sought. 37 CU IDOL SELF LEARNING MATERIAL (SLM)

Behaviour Therapy Behaviour or psychotherapy from a psychologist or psychiatrist or counselling from a from a licensed alcohol and drug counsellor are important aspects of a drug treatment program. Therapy and counselling may be done with an individual, a family or a group. Following are some ways in which counselling can help: • Helps the user to overcome drug cravings. • Suggest strategies to avoid drugs and prevent relapse. • Create a plan to tackle a relapse in case it occurs. • Create a platform to share problems related to different aspects of life like work, relationships or legal issues. • Create a better support system by including members of the family. • Address other mental health conditions. Self-help Groups 12 – Step model pioneered by Alcohol Anonymous has been adopted by many if not all of the self-help groups. To help drug addicts, there are self-help groups such as Narcotics Anonymous. The self-help support group message is that addiction is a chronic disorder with a danger of relapse. The support platform provided by the self help support groups can reduce the social stigma and alienation that could also lead to a relapse in many cases. Support groups can be found on the internet or in the community or can be suggested by the therapist or counsellor (licensed) of the substance user. 1.11 SUMMARY • Substance intoxication is a reversible, substance-specific syndrome due to the recent ingestion of a substance of abuse. Signs of intoxication often include confusion, impaired judgment, inattention, and impaired motor and spatial skills. • Depressants or tranquilisers or sedatives act by reducing the pace of brain activity. Some examples of these substances are anxiolytics, hypnotics, alcohol. Of these, alcohol is most common in usage. Out of these the most prevalent depressant is alcohol. With only 2% of female population and 21% of male population using alcohol, use of alcohol by Indians is one of the lowest among any other country in the world. However, 20% of the population that consumes alcohol are addicts who need “help”. (More et al, 2015). In the past 15 years, in the age group less than 21 38 CU IDOL SELF LEARNING MATERIAL (SLM)

years, the percentage of population using alcohol increased from 2% to 14% over a span of fifteen years as reported by Kerala by Alcohol and Drugs Information Centre India (NGO). Alarmingly, the study found that the “average age of initiation” had dropped from 19 years to 13 years in the past two decades. • Stimulants act on the central nervous system to increase energy and alertness while suppressing appetite and fatigue. They include cocaine (such as freebase and ‘crack’), amphetamines (for example Dexedrine, Benzedrine), methamphetamine (methedrine: ‘speed’, ‘crystal’, ‘ice’, ‘crank’), MDMA (ecstasy), nicotine, caffeine and amphetamine like products (preluding or Ritalin.) Some of these are also discussed in the following sections. Continued stimulant use can alter brain functioning and lead to inability of the user to experience pleasure naturally. For example, chronic use of amphetamines (and cocaine) may result in the temporary loss of approximately 20% of dopamine receptors in the nucleus accumbens, at least for 4 months since the last exposure. • Hallucinogens or psychedelics are a class of drugs that produce sensory distortions or hallucinations, including major alterations in colour perception and hearing in addition to effects such as relaxation and euphoria or, in some cases, panic. Hallucinogens include lysergic acid diethylamide (LSD), psilocybin, and mescaline. PCP, Marijuana, PCP, LSD are the most commonly used hallucinogens. Only one third of the users had sought treatment in the past year. Even though treatment facilities are available. It was also sad to know that majority of the respondents did not know of any awareness programs. Many respondents did not seek treatment due to the fear of social stigma and social problems. And most believed that strict laws and awareness programs could be beneficial in curtailing substance use. The findings of this study can be taken as a basis by the policy makers and other stakeholders to plan out effective strategies to control the issue of substance use in Chandigarh. Some of the limitations of the study were – calculation of prevalence rates is based on some assumptions using the benchmark multiplier. But this method proved more effective than using the house-to-house survey method which is difficult to implement. 1.12 KEYWORDS • Ataxia is a degenerative disease of the nervous system. Many symptoms of Ataxia mimic are similar to the state of alcohol intoxication, such as slurred speech, stumbling, falling, and in coordination. Damage to the cerebellum-the part of brain responsible for coordinating movement, leads to these symptoms. • Anxiolysis A level of sedation in which a person is very relaxed and may be awake. The person is able to answer questions and follow instructions. • Anxiolysis is caused by special drugs and is used to help relieve anxiety during certain medical or surgical procedure. 39 CU IDOL SELF LEARNING MATERIAL (SLM)

• Anaesthesia or anaesthesia (from Greek \"without sensation\") Anaesthesia a temporary state characterised by loss of awareness in a controlled environment. This is induced to carry out medical procedures. It may include some or all of analgesia (relief from or prevention of pain), paralysis (muscle relaxation), amnesia (loss of memory), and unconsciousness. • Gamma-aminobutyric Acid an amino acid which acts to inhibit the transmission of nerve impulses in the central nervous system. • Neurotransmission- the transmission of nerve impulses between neurons or between a neuron and a muscle fibre or other structure. 1.13 LEARNING ACTIVITY 1. Conduct a survey in a locality to identify the people affected by substances. ………………………………………………………………………………………………… …………………………………………………………………………………………………. 2. Conduct a session with a person affected with substance abuse, list down the session points, and measure the outcome and provide the solutions for the same. ………………………………………………………………………………………………… …………………………………………………………………………………………………. 1.14 UNIT END QUESTIONS A. Descriptive Questions Short Questions 1. Define substance abuse. 2. List down types of substance abuse. 3. What are the lists of stimulants in substance abuse? 4. What are Hallucinogens? 5. Write a short note DSM of substance abuse. Long Questions 1. Meaning of substance abuse and list down its causes. 2. Explain the types of stimulants. 3. Illustrate the hallucinogens. 4. What is the DSM for stimulants? 5. Explain the incidence and prevalence of substance abuse. B. Multiple Choice Questions 40 CU IDOL SELF LEARNING MATERIAL (SLM)

1. __________ is a drug that lowers neurotransmission levels. a. Depressant b. Stimulants c. Hallucinogens d. None of these 2. _______are a class of drugs that speed up the messages between the brain and the body. a. Depressant b. Stimulants c. Hallucinogens d. None of these 3. _________ captures a range of problems associated with the use of a wide variety of stimulant drugs, including meth, cocaine, and amphetamines, but not including caffeine or nicotine. a. Stimulant Withdrawal b. Stimulant Intoxication c. Stimulant use disorder d. None of these 4. Acute withdrawal symptoms (“a crash”) are often seen after periods of repetitive high-dose use is known as. a. Stimulant use disorder b. Stimulant Intoxication c. Stimulant Withdrawal d. None of these 5. Which of the below needs to be taken in consideration while conducting psychotherapy? a. Informed Consent Issues b. Privacy, Confidentiality c. Security Issues d. All of these Answers 1. a) 2. c) 3. c) 4. c) 5. d) 41 CU IDOL SELF LEARNING MATERIAL (SLM)

1.15 REFERENCES Textbooks • Advisory Council on the Misuse of Drugs (ACMD). Hidden Harm: Responding to the Needs of Children of Problem Drug Users. London: Home Office; 2003. • Garfield, S.L. and Bergin, A.E. (Eds.) (1986) Handbook of Psychotherapy and Behaviour Change. New York: John Wiley. • Wolman, B.B. (1965). Handbook of Clinical Psychology. New York: McGraw Hill. Reference Books • Ksir, Oakley Ray; Charles (2002). Drugs, society, and human behaviour (9th ed.). Boston [u.a.]: McGraw-Hill. • Basu, D., Aggarwal, M., Das, P. P., Mattoo, S. K., Kulhara, P., & Varma, V. K. (2012). Changing pattern of substance abuse in patients attending a de-addiction centre in north India (1978-2008). The Indian journal of medical research, 135(6), 830. Websites • https://en.wikipedia.org/ • https://www.verywellmind.com/ • https://www.emedicinehealth.com/ 42 CU IDOL SELF LEARNING MATERIAL (SLM)

UNIT 2: SEXUAL DISORDERS 43 STRUCTURE 2.0 Learning Objectives 2.1 Introduction 2.2 Types of Sexual Disorders 2.2.1 Desire Disorders 2.2.2 Arousal Disorders 2.2.3 Psychodynamic Therapy 2.2.4 Orgasm Disorders 2.2.5 Pain Disorders 2.3 Assessing Sexual Behaviours 2.4 DSM Criteria 2.5 Incidence 2.6 Prevalence 2.7 Co-morbidity 2.8 Causes of Sexual Disorders 2.9 Prognosis and Treatment 2.10 Paraphilia: Clinical Descriptions 2.10.1 Fetishism 2.10.2 Voyeurism and Exhibitionism 2.10.3 Transvestic Fetishism 2.10.4 Sexual Sadism and Sexual Masochism 2.10.5 Pedophilia and Incest 2.10.6 Paraphilia in Women 2.11 Causes of Paraphilia CU IDOL SELF LEARNING MATERIAL (SLM)

2.12 Assessing and Treating Paraphilia 2.12.1 Psychological Treatment 2.12.2 Drug Treatments 2.13 Summary 2.14 Keywords 2.15 Learning Activity 2.16 Unit End Questions 2.17 References 2.0 LEARNING OBJECTIVES After studying this unit, student will be able to: • Explain the concepts of sexual disorders. • Describe the types of sexual disorders. • Illustrate history of sexual disorders. • Explain causes of paraphilia. 2.1 INTRODUCTION Sexual dysfunctions include delayed ejaculation, erectile disorder, female orgasmic disorder, female sexual interest/arousal disorder, genito-pelvic pain/penetration disorder, early or premature ejaculation, male hypoactive sexual desire disorder, substance/ medication induced sexual dysfunction, other any unidentified sexual dysfunction, and unidentified sexual dysfunction. a Heterogeneous group of disorders consist of sexual dysfunctions that are naturally categorised by a clinically important disorder in an individual’s capability to respond sexually or for experiencing sexual kind of pleasure. These dysfunctions can be many at a time for any individual and they all need to be diagnosed on time. These days clinical judgment must not be determined whether the sexual difficulties are present because of any inadequate sexual stimulations. They will still need to be taken care of even if the analysis of a sexual dysfunction would not be made. These cases may include, but are not limited to, conditions in which lack of knowledge about effective stimulation prevents the knowledge of stimulation or sexual orgasm. Subtypes are used to designate at the start of the difficulty. In many individuals with any kind of sexual disorders or dysfunctions, the time of onset may indicate different etiologies and interventions. When we say lifelong, we are referring to when the problem with sex actually started how acquired here applies when the individual developed these sexual disorders after a period of comparatively normal sexual activity. When we refer to Generalized in sexual 44 CU IDOL SELF LEARNING MATERIAL (SLM)

problems we are not limiting to any kind of situations, stimulation, partners and when we refer to situational, we are talking about the sexual problems with definite types of situations, or stimulation, and partners. We must not only keep the factors like lifelong/acquired and generalized/situational subtypes but also remember to consider relevant to etiology and/or treatment when we are assessing an individual’s sexual dysfunction. This could be different for different people. 1) Partner factors (e.g., partner’s sexual problems; partner’s health status). 2) Relationship factors (e.g., poor communication; discrepancies in desire for sexual activity). 3) Individual vulnerability factors (e.g., poor image of body; any history of sexual or emotional abuse), any kind of psychiatric comorbidity (e.g., depression, anxiety), or stressors (e.g., job loss, bereavement). 4) Cultural or religious factors (e.g., inhibitions related to prohibitions against sexual activity or pleasure; attitudes toward sexuality); and 5) medical factors relevant to prognosis, course, or treatment. Many factors like culture, expectations or engender prohibitions should be considered while clinical judgment is done for the diagnosis of sexual dysfunction. While we will consider aging as normal and it decreases sexual response in many. Sexual response has a requisite biological underpinning, yet is usually experienced in an intrapersonal, interpersonal, and cultural context. Thus, sociocultural, biological and psychological factors constitute sexual functions. In many clinical contexts, a precise accepting of the etiology of any kind of sexual difficulties are unknown. Any sexual disorder or dysfunction analysis requires the elimination of problems that are nonsexual mental disorder, any drug or medication effects, or any pelvic nerve issue that is a medical condition, or any liaison distress, or violence among partners or any other kind of stress. If we observe that the individual has any sexual dysfunction due to explained nonsexual mental disorder like any depression or any bipolar activity, any anxiety disorders, posttraumatic anxiety disorders or any, psychological disorder, then the other psychological disorder diagnosis must be made. In case the problem is caused by the usage/misuse or suspension of a drug or medication, then that must be diagnosed as a medication-induced sexual dysfunction. In case the sexual dysfunction is because of any medical condition like peripheral neuropathy, then the person will not receive a mental or psychiatric diagnosis. If we observe that individual has relationship distress, or violence with his/ her partner, or any other stress explained with the sexual problems , then the individual does not get any sexual dysfunction diagnosis, however a suitable V or Z code for the any relationship issues or stress can be listed. Usually, we cannot connect precise etiological relationship between any another medical condition and the individual’s sexual dysfunction. 45 CU IDOL SELF LEARNING MATERIAL (SLM)

2.2 TYPES OF SEXUAL DISORDERS 2.2.1 Desire Disorders These are problems that involve a lack or non-appearance of any kind of sexual drive, which is called a low libido. The absence of desire may apply in general or towards the current partner. This can be any pre-existing disorder, or it could happen after a normal period of sexual function. Sexual desire decreases when the levels of the female hormone estrogenic and the male testosterone are low. . This testosterone is important as it maintains the sexual drive along with the production of the sperms, muscles, bone development and also helps in the male pattern of hair growth. Important factors like aging, pregnancies, depression, any kind of anxiety, usage of medications like serotonin re-uptake inhibitors, conflicts in relationships, and body illness like diabetes or hypertension contribute to desire disorders. 2.2.2 Arousal Disorders Although, the terms “frigidity” for women and “impotence” for men have been used to describe a disorder in sexual arousal, these terns are not used now. The term “Impotence” is now used to describe erectile dysfunction while several other terms are used to describe frigidity. Individuals with this condition may exhibit a dislike or an inclination to avoid any sexual contact with a partner. While some males find that they can only maintain a partial erection, others may be unable to even obtain one. Some males have reported that they gain no excitement or pleasure from the sexual activity. The condition “Erectile dysfunction” is being incapable to maintain an erection during intercourse. It is estimated that roughly about 50 percent of American males after 40 years of age suffer from it. Erectile dysfunction can be caused due to : • The hardening of arteries or other vascular diseases. • Neurological ailments. • Psychological factors like stress, depression, performance anxiety conflicts between partners, • Penile ordeal. • Chronic disease like diabetes mellitus, hypertension and so on. • Smoking, alcoholism, obesity and an inactive lifestyle. 46 CU IDOL SELF LEARNING MATERIAL (SLM)

The vagina of affected females may be unable to be lubricated before intercourse. 2.2.3 Psychodynamic Therapy Background of Psychodynamic Therapy The hypothesis supporting psychodynamic treatment started in and educated by psychoanalytic hypothesis. Four key schools of psychoanalytic hypothesis have each exclusively impacted the psychodynamic treatment. These key schools are Freudian, Object Relations , Ego Psychology, and Self Psychology. Freudian Psychology: It depends on the speculations voiced in the early piece of this century by Sigmund Freud. It is infrequently alluded to as the drive or the primary model. The essence of Freud's hypothesis is that any sexual and forceful energy ascends in the id (or oblivious) balances by the personality, which thusly is a bunch of capacities that moderates between the id and the outer reality. All protection systems are manifestations of the sense of self that works to decrease torment and to maintain clairvoyant balance. Superego that is framed during dormancy (that is between age 5 and adolescence), works to control id passes through blame. Object Relations Psychology: It was first voiced by a few British investigators, as Melanie Klein, D.W. Winnicott, W.R.D. Fairbairn, and Harry Guntrip. This hypothesis expresses that people consistently moulded themselves according to the huge others around them. The battles and objectives in existence of a human spotlights on keeping up associations with others, and simultaneously separating themselves from others. These interior portrayals of self as well as other people are created in the youth which later works out in their grown-up relations. People will in general recurrent old article associations with the endeavour to dominate them, and at last be liberated from them. Ego Psychology: It is gotten from Freudian brain science. Its supporters that people centre their work around expanding and keeping up inner self capacity as indicated by the real world. This part of brain research weights on a person's ability for guard, variation, and reality testing (Pine, 1990). Self-Psychology: It is started by Heinz Kohut, M.D, in Chicago during the 1950s. Kohut tracked down that a human's self alludes to his/her impression of his/her experience of his/herself, just as the presence or nonappearance of a self-appreciation regard. Oneself sees itself comparable to the limits and the separations of self from the others (or the shortfall of limits and separations). \"The informative force of the new brain science of oneself is no place as obvious similarly as concerning the addictions\" (Blaine and Julius, 1977, p. vii). Kohut proposed that people experiencing any type of substance misuse additionally experience the ill effects of a shortcoming as a part of their character centres, that is there is a deformity in 47 CU IDOL SELF LEARNING MATERIAL (SLM)

the arrangement of their \"self.\" It creates the impression that the actual substance appears to the client to have the option to fix the focal imperfection in oneself. The utilization of the medication furnishes a person with a confidence, which the individual doesn't have. Through drug use, the individual supplies for oneself, the sensation of acknowledgment and hence of acting naturally certain. The individual establishes the climate of being joined with the force that gives the person in question the sensation of being solid and beneficial. From the abovementioned, it is apparent that every one of these schools of psychoanalytic hypothesis, present particular speculations of character development, psychopathology arrangement, and change. Thusly they additionally propose procedures to lead treatment and ideas and counter-ideas for treatment. Psychodynamic treatment is not the same as analysis in a few different ways like the way that psychodynamic treatment doesn't have to incorporate every single insightful strategy and can't be directed simply by psychoanalytically prepared examiners. The psychodynamic treatment is additionally led throughout a more limited time span and with less routineness than analysis. A couple of the psychodynamic treatment strategies are considered less proper for people with substance misuse problems, for the most part due to their various discernments making it difficult to acknowledge bits of knowledge and goals. Notwithstanding, some psychodynamic specialists work with substance-manhandling people, in mix with customary medication and liquor treatment programs or as the solitary advisor for people with existing together conditions, utilizing types of brief psychodynamic treatment that are portrayed in detail beneath. Meaning of Psychodynamic Therapy This is a \"worldwide treatment,\" or a treatment structure with an all-encompassing accentuation on the customer point of view. Elective treatments like \"issue based\" treatments, or intellectual social treatment, attempt to diminish or eliminate side effects as opposed to investigating the customer's profound situated urges, needs, and wants. The Dynamic psychotherapy, which empowers a patient's revising of their biography, their image of himself, their past, present, and future, shows up separately situated to address the profundity of a person's experience.” A Psychodynamic treatment meeting is solid and open-finished and is coordinated by the customer's free relationship rather than a set schedule or program. These meetings are normally orchestrated once in a week and might be of a term of 60 minutes. Despite the fact that Freud's psychoanalytic treatment requests a lot more noteworthy time speculation, current psychodynamic treatments are drilled in a substantially less serious way. 48 CU IDOL SELF LEARNING MATERIAL (SLM)

The essential focal point of psychodynamic treatment are: • To improve a customer's mindfulness and encourage a comprehension of the customer's sentiments, contemplations, and convictions concerning past encounters, uncommonly of their encounters as a youngster. A specialist who manages the customer through an assessment of huge occasions and uncertain struggles in the customer's previous existence, achieves this in the treatment meetings. • The theory in a psychodynamic treatment is that waiting issues are established in the oblivious brain and should be exposed for purifying to happen. The customer should in this manner have a mindfulness to understand these oblivious idea designs and have a comprehension of how these examples became, in order to manage them. Clients Most Suitable for Psychodynamic Therapy A present moment psychodynamic treatment is now and again reasonable for certain customers with substance misuse problems than different treatments. For these customers, psychodynamic treatment is best acknowledged when they are recuperating great and are available to a more elevated level of self-information. Despite the fact that there are a few conflicts this kind of momentary treatment is for the most part thought to be more appropriate for the accompanying sorts of people: • Those who have equal psychopathology with substance misuse issue. • Those who have finished detoxification and don't require or have finished inpatient hospitalization. • Those whose recuperation is consistent and stable. • Those who don't have natural mind harm or different limits because of their intellectual ability. 2.2.4 Orgasm Disorders People who are influenced by a climax issue, either neglect to accomplish peak or find that their peak is frequently postponed. These problems can be because of actual components, disease or even because of utilization of specific prescriptions. Among guys, climax issues incorporate discharge problems. Ejaculation disorders can be classified as: i. Premature discharge, that is discharge previously or not long after entrance happens. ii. Delayed or Inhibited discharge, that is setting aside an extremely long effort to discharge after infiltration. iii. Retrograde discharge, that is discharge into the bladder as opposed to through the penile opening. This happens particularly in people with diabetics, yet additionally because of certain drugs or after specific medical procedures of bladder, neck or prostate. 49 CU IDOL SELF LEARNING MATERIAL (SLM)

A few reasons that cause untimely discharge can likewise be mental in nature, for example: • Performance anxiety during intercourse. • Stress or depression. • Shyness. • Communication barriers or Conflict between the partners. A couple of actual reasons s could include: • Chronic illness • Alcoholism • Adverse effects due to certain medications • Surgeries 2.2.5 Pain Disorders Sexual torment problems are generally found in ladies and are caused because of deficient oil of the vagina during sex. This could be because of a few reasons like an absence of incitement or energy about the sexual action, because of hormonal changes because of pregnancy, breastfeeding or menopause. Other likely explanations are bothering because of the utilization of prophylactic creams, and uneasiness about taking part in sex. ‘'Vaginismus' is a condition that causes sexual torment , where the muscles of the vaginal divider, during intercourse, fit automatically. The reason for these fits isn't clear yet it has been recommended that a past sexual injury, for example, misuse or attack could go about as a trigger of the condition. ‘'Priapism' is a sexual torment issue that happens in guys , which is an agonizing erection that may keep going for a few hours, even without sexual incitement. This is caused because of blood getting captured inside the penis, neglecting to deplete adequately. In the event that this problem is left untreated, it might prompt a perpetual loss of erectile capacity. Other reason for sexual agony in guys are because of Peyronie's illness that is post-awful, prostatic irritation, urinary contaminations, , genital herpes, yeast contaminations, and skin sickness. 2.3 ASSESSING SEXUAL BEHAVIOURS Abstract Sexual conduct supplements the human experience, permitting people to communicate their fondness, grow close securities and make relational connections, and experience delight. Notwithstanding, sexual conduct can likewise have unfortunate results, as explicitly 50 CU IDOL SELF LEARNING MATERIAL (SLM)