communicated contaminations or unplanned pregnancy. Analysts frequently assess sexual conduct to see how it upgrades the human experience and to know conditions under which sexual conduct prompts bothersome outcomes. Such assessments can be troublesome on the grounds that sexual conduct for the most part happens in private, between two people, and it is frequently decried and is a socially touchy point. Hence, analyst regularly need to rely upon self-reports, which are liable to psychological (like memory) and social (such as self- show) predispositions. Exploration considers has analysed how best to assess sexual conduct to acquire precise and dependable self-reports, which are crucial to improving sexual working, decreasing explicitly communicated contaminations, and advising the public approach choices. In this section, we will talk about the meaning of estimating sexual practices, survey diverse evaluation strategies and gauges, and examine the difficulties to sexual appraisal. Despite the fact that we will zero in mostly on review evaluation strategies, we will likewise introduce contemporary appraisals techniques. At last, we will submit thoughts for improving sexual conduct appraisal for future exploration. The piece of appropriate appraisal in sex treatment with couples is examined. A case is utilized behaviourally arranged paper-and-pencil trial of oneself report assortment, in clinical settings, at two focuses on schedule, one preceding any advisor customer contact and the other after the consummation of treatment. Such activities are frequently both productive and compelling, creating data appropriate to determination, treatment arranging, and improvement of clinical abilities. The appraisal methodology that are regularly utilized at the Stony Brook Sex Therapy Center are portrayed and delineated utilizing test cases. The creators have proposed that conduct evaluation approaches have impressive clinical potential which are yet to be completely figured it out. 2.4 DSM CRITERIA Diagnosis Your doctor or other mental health professional can do a psychological evaluation, which may involve answering questions about your: • Physical as well as mental health, and your overall emotional well-being. • Sexual thoughts, behaviours and compulsions that are difficult to control. • The use of recreational drugs and alcohol. • Family, relationships and social situation. • Problems caused by sexual behaviour. With the client’s permission, their mental health professional can also request for inputs from family members and friends. 51 CU IDOL SELF LEARNING MATERIAL (SLM)
Determining a Diagnosis There' is a proceeding with banter in the mental local area on the most proficient method to precisely characterize habitual sexual conduct since it isn't in every case simple to decide when the sexual conduct turns into an issue. A few emotional wellness experts utilize the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), that is distributed by the American Psychiatric Association. It goes about as a guide for diagnosing any psychological well-being issues. As enthusiastic sexual conduct doesn't have its own analytic classification, in the DSM-5, it could be analysed as a subcategory of another emotional well-being condition, similar to a drive control problem or a social compulsion. A few psychological well-being experts consider the habitual sexual practices as sexual exercises taken to a limit level, with generous and destructive results. Albeit more exploration examines is expected to explain and arrange every one of the standards, an analysis and treatment by a psychological wellness proficient who has an ability in addictions and urgent sexual practices will in all probability give the best outcomes. Treatment A treatment for enthusiastic sexual conduct ordinarily includes psychotherapy, meds and self- improvement gatherings. The essential point of treatment is to assist a person with dealing with their separate inclinations and decrease inordinate practices while proceeding with sound sexual exercises. Assuming one has habitual sexual conduct, one may likewise require treatment for another psychological wellness condition. People with impulsive sexual conduct frequently experience the ill effects of one or the other liquor or medication misuse issues or other emotional wellness issues, similar to uneasiness or discouragement. These conditions additionally need treatment. People with different addictions or extreme psychological wellness issues or the individuals who represent a peril to other people, may benefit from inpatient treatment at first. The therapy might be extreme at first, regardless of whether it is inpatient or outpatient. One may likewise discover continuous occasional treatment during that time to be useful to keep away from any backslides. Psychotherapy 52 CU IDOL SELF LEARNING MATERIAL (SLM)
Psychotherapy, which is likewise alluded to as 'talk treatment', can assist an individual how with dealing with their habitual sexual conduct. The various sorts of psychotherapy may include: • Cognitive social treatment (CBT): It assists one with distinguishing unfortunate and negative convictions and practices and afterward trade them with more versatile methods of adapting. An individual can learn approaches to make these practices less private and meddle with having the option to get to sexual substance so without any problem. • Acceptance and responsibility treatment: It is a type of CBT that weights on acknowledgment of musings and inclinations and a promise to receive techniques that pick activities that are more reliable with significant qualities. • Psychodynamic psychotherapy: It is a type of treatment that accentuations on expanding a person's consciousness of their oblivious considerations and practices, forming new bits of knowledge into their inspirations, and in this way settling clashes. These treatments should be possible in an individual, couples, family or gathering design. Medications Along with psychotherapy, a few meds may help as they follow up on the cerebrum synthetics that are connected to impulsive considerations and practices, diminish the compound \"compensates\" these practices give when one follows up on them, or decreases sexual desires. It relies upon a person which prescription or drugs are best for them relying upon their circumstance and other psychological wellness conditions that one may have. Medications that are utilized to treat enthusiastic sexual conduct are regularly endorsed basically for different conditions. A few instances of such prescriptions include: • Antidepressants: Antidepressants: Some sorts of antidepressants are utilized to treat sorrow, nervousness or over the top urgent problem and may assist with habitual sexual conduct. • Naltrexone: Naltrexone (Vivitrol) is a drug that is for the most part used to treat liquor and narcotic reliance. It impedes the piece of the cerebrum that feels delight with certain addictive practices. It might assist with conduct addictions like urgent sexual conduct or betting issue. • Mood Stabilizers: These prescriptions are regularly used to treat the state of bipolar problem, however, may likewise lessen habitual sexual inclinations. 53 CU IDOL SELF LEARNING MATERIAL (SLM)
• Anti-androgens: These meds diminish the natural impacts of sex chemicals or androgens in men. Since they decrease sexual inclinations, these are regularly utilized for men whose urgent sexual conduct is hazardous to other people. Self-help Groups Self-help groups can be valuable for individuals with habitual sexual conduct and for managing a portion of the issues that is causes. Numerous such gatherings follow the 12- venture program of Alcoholics Anonymous (AA). These self-improvement gatherings can help a person to: • Learn about their issue. • Understand and discover support for their condition. • Identify extra treatment alternatives, adapting practices and assets. • Help with anticipation of backslide. Such gatherings can be web based or have nearby face to face gatherings, or both. On the off chance that one is keen on joining a self-improvement gathering, they should search for a gathering that has a decent standing and furthermore causes one to feel good. Regularly, a few gatherings don't exactly measure up for a person's taste. A customer ought to enquire with their emotional well-being proficient for recommended gatherings or about choices to help gatherings. 2.5 INCIDENCE To subjectively evaluate sexual practices or rehearses and the event of sexual and conceptive wellbeing programs in young adult and post-juvenile clients from Cali, Colombia, two share tests were done. One from schools in helpless neighbourhoods of the city, and one at Valle University (UNIVALLE). Furthermore, twelve open meetings was completed among two distinctive understudy populace gatherings, one from the schools and one from the college. The investigation reports the sexual practices of young people and post youths, the prophylactic techniques utilized and counteraction of STDs and HIV/AIDS, the employments of sexual and regenerative wellbeing programs by the two populaces, controlling for social class (financial layer), sex, and race. Two sexual and regenerative wellbeing programs were taken as reference, one that of PROFAMILIA (Pro-Wellbeing of the Colombian Family Association), and second one of the sexual and conceptive wellbeing project of the University Medical Service of the UNIVALLE. Results show how the practices and reactions to sexual and regenerative wellbeing programs are intervened by various sociological classifications that situate the examination. 54 CU IDOL SELF LEARNING MATERIAL (SLM)
There are a few legitimate cases in the United States, where teenagers were accused of youngster porn dispersion subsequent to offering naked photos of themselves to heartfelt accomplices or others, which have underlined the issue of sexting practices among youth. Despite the fact that strategy producers, psychological wellness laborers, instructors and guardians have all communicated concern in regard to the expected damage of sexting practices, practically zero exploration has inspected this marvel observationally. The current investigation presents some starter information on the frequency of sexting conduct and related high danger sexual practices in an example size of 207, generally Hispanic young ladies, age between 16-25. Around 20% from this example of young ladies revealed taking part in sexting conduct. Sexting practices were not related with most other high-hazard sexual practices yet were somewhat more normal in ladies who discovered sex to be profoundly pleasurable or who showed sensational character attributes. 2.6 PREVALENCE Risky sexual behaviors (RSB) are characterized as practices prompting explicitly communicated infections and accidental pregnancies. At present around 100,000 college understudies learning at state colleges in Sri Lanka who might be in danger of rehearsing RSB. This examination tries to decide the predominance of such practices among this gathering of understudies. Information were gathered from second- and third-year college understudies with a poll on sexual practices, other danger practices, information and mentalities on sexual and conceptive wellbeing. Of understudies reviewed 12.4% were found to rehearse RSB inside the most recent 1-year time frame. A few different practices, for example, liquor utilization inside the most recent 3 months, going to night clubs in a month ago and those with great information on condoms were related with RSB. The individuals who thought religion was vital to their lives were less inclined to rehearse RSB. Ideas were made to find fundamental ways to limit liquor utilization inside college and outside, to debilitate night clubs participation by working with more sporting exercises and to advance strict exercises. Risky sexual behaviors (RSB) are becoming an important problem all over the world. The Centres for Disease Control and Prevention (CDC) defines RSB as Sexual behaviors leading to unintended pregnancies and sexually transmitted infections (STI) include Human immuno- deficiency Virus (HIV) and acquired immuno-deficiency syndrome (AIDS). It includes having multiple sexual partners, having sex without using a condom or other contraceptive method. In addition to that, several authors have included the following factors into their definition of RSB: initiation of first sex at early age before 18 years, sexual activity done under the influence of alcohol and anal intercourse, sexual violence and transactional sex and paid sex. 55 CU IDOL SELF LEARNING MATERIAL (SLM)
There is restricted writing on sexual practices among different populace bunches in Sri Lanka. The pervasiveness of hazard conduct among teenagers and youthful grown-ups was higher than the normal level by guardians and instructors. Worldwide pervasiveness examines including other Asian nations would give a superior gauge of impressively higher RSB in students. There is a huge measure of writing on students' RSB in African nations demonstrating that higher commonness of RSB among them going from 7 to 47%. Known socio-segment and financial danger factors related with RSB are male sex, smoking, dance club participation and liquor use. Conversely, having a decent connection with companions, friends and guardians, just as strictness have been discovered to be a defensive measure against RSB. There are in excess of 105,000 young people concentrating in colleges in Sri Lanka where the greater part are not in a relationship. College life is a shift towards more noteworthy independence from family and school foundations for the vast majority of them. It gives a chance to rehearse new fellowships, social blending and therefore to take part in unsafe practices including RSB. The discoveries of this investigation might actually support to create projects to diminish RSB and to improve the information and practices by means of the current arrangement of tertiary training. Subsequently, we led this investigation to decide the commonness and components related with RSB among students in the state colleges of the Western Province in Sri Lanka. Study Design A foundation based spellbinding cross-sectional investigation was directed in four state colleges in the Western Province of Sri Lanka (University of Colombo, University of Sri Jayewardenepura, University of Kelaniya and University of Moratuwa), addressing around 17% of all out students took a crack at state colleges in the country. Study Population The examination populace was college understudies concentrating in second and third years which were 18,280 in number. Students from far off nations and ministers students were prohibited. First year understudies were avoided as they are new to the climate. So, their danger practices may not be expected to as similar components as second- and third-year understudies. Fourth- and fifth-year understudies were prohibited as these high-level years are not led in each course. Prohibition of unfamiliar understudies was done due to their diverse socio-social foundation. Sample Size and Sampling Technique 56 CU IDOL SELF LEARNING MATERIAL (SLM)
Determined example size was 1314 with expected pervasiveness of 13% of hetero intercourse without condoms among unmarried, out of school teenagers, 1.96 Z esteem, 3% of accuracy and a rectification for configuration impact of 2.45 and 10% of non-respondents. A multistage group inspecting procedure with likelihood corresponding to estimate (PPS) was utilized to choose an agent test of students. A bunch was characterized as an instructional exercise bunch or an entire clump as per the construction of the chose students bunch. The normal group size was considered as 30. At that point we assigned the groups for every scholastic year and college as per the extent of students. Students were defined by their individual college and scholarly years and scholastic streams. At last groups were recognized inside every layer dependent on PPS as indicated by the quantity of understudies in every college and scholastic year. 2.7 CO-MORBIDITY Compulsive Sexual Behaviour Disorder (CSBD) is portrayed by a tenacious inability to control extreme and intermittent sexual motivations, inclinations, as well as contemplations, bringing about dull sexual conduct that causes a stamped weakness in significant spaces of working. Information gathered from clinical populaces recommend that CSBD often co- happens with other Axis I and II mental problems; in any case, contemplates directed so far experience the ill effects of methodological deficiencies that forestall the assurance of exact mental comorbidity rates (e.g., little example sizes, dependence on non-solid evaluation techniques in the assessment of comorbidity or the avoidance of sound people to analyse pervasiveness rates). The reason for this examination was to investigate mental comorbidity in an example of people with and without CSBD. The investigation test contained 383 members dispersed into two gatherings through a group examinations: 315 members without CSBD (non-CSBD) and 68 qualifying as explicitly compulsives (CSBD). Members were evaluated for co-happening Axis I and II clinical conditions utilizing organized clinical meetings for the DSM-IV (SCID-I and II). Most of CSBD members (91.2%) met the models for at any rate one Axis I problem, contrasted with 66% in non-CSBD members. CSBD members were bound to report an expanded pervasiveness of liquor reliance (16.2%), liquor misuse (44%), significant burdensome problem (39.7%), bulimia nervosa (5.9%), change issues (20.6%), and different substances - primarily cannabis and cocaine-misuse or reliance (22.1%). Concerning Axis II, commonness of marginal behavioural condition was altogether higher in CSBD members (5.9%). True to form, predominance of various mental conditions was fundamentally expanded among explicitly enthusiastic members, uncovering comorbidity designs with significant ramifications in the conceptualization, evaluation, and treatment of patients with CSBD. 57 CU IDOL SELF LEARNING MATERIAL (SLM)
2.8 CAUSES OF SEXUAL DISORDERS There are various reasons for sexual disorder. They are gathered into two classifications: actual causes and mental causes. Physical Causes There are numerous actual reasons for sexual problems. For instance, the accompanying illnesses and conditions can prompt issues with sexual capacity: • Urological contaminations or malignancy • Diabetes • Cardiovascular infection (coronary illness and vein sickness) • High pulse • High cholesterol • Hormonal awkward nature • Alcoholism • Drug misuse • Neurological problems • Chronic infections, like kidney disappointment • Nerve harm Numerous meds can cause issues with typical sexual working, including pulse meds and antidepressants, as can liquor and sporting medication use. Some clinical medicines can influence sexual capacity also. For instance, some surgeries can cause nerve harm that can influence sexual capacity. Psychological Causes Numerous individuals have mentally prompted sexual issues. Things like worry about sexual execution, sensations of blame about sexual craving and action, relationship issues, sadness, stress, tension confidence or self-perception issues, and the impacts of past sexual injury, like assault, attack or a negative sexual encounter would all be able to have an adverse consequence on sexual capacity. In Men • Inability to accomplish or keep an erection (hard penis) reasonable for intercourse (erectile brokenness). • Absent or deferred discharge in spite of sufficient sexual incitement (impeded discharge). • Inability to control the circumstance of discharge (early, or untimely, discharge). 58 CU IDOL SELF LEARNING MATERIAL (SLM)
In Women • Inability to accomplish climax. • Inadequate vaginal grease previously and during intercourse. • Inability to loosen up the vaginal muscles enough to permit intercourse. In Men and Women • Lack of interest in or want for sex. • Inability to get excited. • Pain with intercourse. 2.9 PROGNOSIS AND TREATMENT Most kinds of sexual brokenness can be tended to by treating the fundamental physical or mental issues. Other treatment techniques include: Medication: When a drug is the reason for the brokenness, an adjustment of the prescription may help. People with chemical inadequacies may profit by chemical shots, pills or creams. For men, drugs, including sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra, Staxyn) and avanafil (Stendra) may help improve sexual capacity by expanding blood stream to the penis. For ladies, hormonal alternatives, for example, estrogen and testosterone can be utilized (albeit these drugs are not affirmed for this reason). In premenopausal ladies, there are two drugs that are affirmed by the FDA to treat low craving, including flibanserin (Addyi) and bremelanotide (Vyleesi). Mechanical Aids: Aids, for example, vacuum gadgets and penile inserts may assist men with erectile brokenness (the failure to accomplish or keep an erection). A vacuum gadget is additionally endorsed for use in ladies yet can be costly. Dilators may help ladies who experience narrowing of the vagina. Gadgets like vibrators can be useful to help improve sexual happiness and peak. Sex Therapy: Sex specialists can individuals encountering sexual issues that can't be tended to by their essential clinician. Specialists are frequently acceptable conjugal advisors, also. For the couple who needs to start making the most of their sexual relationship, it's definitely worth the time and exertion to work with a prepared proficient. Behavioural Treatments: These include different strategies, remembering experiences into destructive practices for the relationship, or methods like self-incitement for treatment of issues with excitement and additionally climax. 59 CU IDOL SELF LEARNING MATERIAL (SLM)
Psychotherapy: Therapy with a prepared instructor can help you address sexual injury from an earlier time, sensations of tension, dread, blame and helpless self-perception. These elements may influence sexual capacity. Education and Communication: Education about sex and sexual practices and reactions may assist you with conquering nerves about sexual capacity. Open discourse with your accomplice about your requirements and concerns additionally conquers numerous obstructions to a sound sexual coexistence. The achievement of treatment for sexual brokenness relies upon the fundamental reason for the issue. The standpoint is useful for brokenness that is identified with a condition that can be dealt with or turned around. 2.10 PARAPHILIA: CLINICAL DESCRIPTIONS Paraphilia is sometimes referred to as sexual deviations or perversions. It includes imagination, behaviours, or sexual urges with emphasis on unusual activities, objects, or situations. Paraphilia involves sexual desires or sexual lust with non-living objects. It also involves humiliation or suffering of oneself or another person. This comes under the category of a rare disorder by DSM IV TR and have the attributes of six-month period of intense, recurrence, sexually stimulating fantasies or sexual urges containing a particular act relying on the paraphilia. This act is usually followed by sexual excitement and getting orgasm through masturbation and fantasy. All these are not so recognized and mostly difficult for giving treatment due to numerous reasons. Those having these disorders always conceal them; thereby feel guilty and shame. Moreover, it leads to financial or legal implications and the concerned people don’t cooperate usually. This unit is all about a discussion on the paraphilia, i.e., sexual deviations which is something unusual and state the definitions and various concepts. We will then present the different types of paraphilia’s and how these are caused and what types of treatment are available for the same. The paraphilia revolves around various sexual behaviour patterns that take place on a continuous basis. The patterns are using odd objects, following rituals or situations; all these meet their sexual satisfaction. However, there is a difference between the normal person and paraphilic disorder persons in which sexuality acts are the matter of concern; because without this kind of indulgence, nobody will get orgasm. Paraphilia has a compulsive quality, of orgasmic release 4 to 10 times a day. They generally do not change their sexual preferences. Definition of Paraphilia Paraphilia (in Greek para nun = beside and -philia = friendship, having the meaning of love) is basically a biomedical term. It is used for explaining sexual arousal through using objects 60 CU IDOL SELF LEARNING MATERIAL (SLM)
and situations, or those individuals who don’t like normative stimulation thereby it could lead to distress or serious issues for the paraphilic people or persons related to him/her. A paraphilia is a kind of sexual arousal and fulfilment of sexual behaviour, which is usually atypical and immense on-human objects. There are no universal views on paraphilia’s. There is certain section of the people in the society who demand legal sanctity for this unusual sexual interests and related practices. Paraphilia can’t be diagnosed in the present version of the DSM (DSM-IV-TR), unless it leads to distress to the affected individual or harming others. Here the DSM-5 draft includes a terminology to distinguish between the two different cases; one states that “paraphilia’s aren’t necessarily psychiatric disorders”, another one defines paraphilic disorder in terms of “a paraphilia causing distress or impairment to the concerned person or doing harm to others”. Paraphilia is a type of sexual feeling or behaviours which might involve unhuman sexual partners that are not consenting or suffering by any one the partners or both. As per the Diagnostic and Statistical Manual of Mental Disorders (DSM) the fourth edition text reviewed (DSM-IV-TR), there is a manual used by mental health professionals for making diagnosis of mental disorders; however, it is usual for an individual having multiple paraphilia. 2.10.1 Fetishism Be it Sexual paraphilia or the term sexual fetishism, this is the primary source from where the phrase like Sexual arousal or pleasure has been derived to rob, con, cheat and blackmail. Otherwise, compelled to lose out economically either through a partner or stranger. In this regard, there are various emotions might be drawn by Chremastistophilia person like frustration, rage, annoyance, fear and submission. All these emotions eventually lead to attain sexual arousal or sexual gratification. Thus, this could be construed as Edge play since it could be life threatening for seeking out a stranger for robing oneself only for sexual pleasure. There are certain fetish websites in this respect that put emphasis on such kind of people who have grown substantially. There is something significantly mentioned that financial dominants, interaction with their ‘financial submissive’ and regarding the deeds of the dominant with money collected from the submissive, and so on. It reflects the strong emotions are responsible for influencing paraphilia. Let’s have a brief on symptoms such as: • Getting sexual arousal by wearing opposite gender clothes. • Sexual pleasure related to putting on clothes of the opposite counterpart. • Emergence of recurring intense sexual fantasies due to sporting on the attire of the opposite gender. • Recurring intense sexual appetite that involves wearing garments of the opposite Paraphilias gender. • Recurring intense sexual behaviours or characteristics involving clothed in with the dresses of the opposite gender. 61 CU IDOL SELF LEARNING MATERIAL (SLM)
2.10.2 Voyeurism and Exhibitionism Voyeurism Voyeurism has been coined from a French word or term voyeur means (“one who looks”) have the potential to take various forms. However, it has a principal characteristic where the voyeur usually doesn’t relate directly to the subject of its interest, in which he/she is mostly remain ignorant of being observed. Actually, voyeurism is a psychosexual disorder where a person gets sexual pleasure and gratification if he/she looks at the nude bodies and genital parts or by observing the sexual activities of others. In general, the voyeur is hidden from others ‘views. Voyeurism appears as a form of paraphilia. It is an alternative form of voyeurism that involves hearing to erotic interactions. This is referred as telephone sex, even though it is taken into consideration as considered voyeurism from the viewpoint of listening to unsuspicious persons. Voyeurism aims at observing unsuspecting naked persons while undressing or engaging in many sexual acts. The observer observes a strange person in this regard. People resorting to activities like peeping for getting sexual excitement for themselves. In this case, the observer doesn’t long for sexual contact or any such activity with the concerned person under observation. It has been observed that a voyeur could indulge in fantasy activity with the person who is under surveillance. Truth be told that this fantasy is hardly consummated. Symptoms • Periodic, acute or sexually stimulated fantasies, sexual craving or behaviours. • Fantasies, behaviours or urges causing major distress to a person or are troublesome of his or her routine functioning. • Six-month observation period carried out in this respect hints about recurrent, sexual urges, intense sexually arousing fantasies, or behaviours requiring the act of making observation to an unsuspecting person, but he/she is naked, while into engaging in sexual pursuit. • Clinically, the characteristics such as fantasies, sexual urges and behaviours cause immense distress or inability in social, occupational and important areas related to functioning. Causes As far as voyeurism is concerned, there is no such scientific consensus to endorse it. Most experts have the view on this sexual behaviour through their random observation of an oblivious individual in naked while indulging in Paraphilias sexual activities. The reiteration of the act continuously has the tendency to bolster and carry on the voyeuristic behaviour. For successfully treating a voyeur, he or she should bring changes in the behaviour patterns. This is the initial step to which voyeurs find it difficult to admit. Hence, they need to be forced for 62 CU IDOL SELF LEARNING MATERIAL (SLM)
accepting the treatment. Perhaps it appears as per the court verdict. Behavioural therapy in general is implemented for treating voyeurism. In turn, the voyeur should find was for controlling the impulse of watching non-consenting victims, and more importantly for acquiring acceptable standard of sexual gratification. There is no information on the results of behavioural therapy. There is no such direct drug treatment to overcome voyeurism. Rather it is considered as a criminal act as per various jurisdictions. Moreover, it is categorized as a kind of misdemeanour. This is the reason, legal penalties even if given is minor only. There are chances of getting exposure and humiliation might deterring certain voyeurs. Further, one can’t prosecute voyeurs so easily as the intention of watching can’t be justified. So, what they claim that the observation was purely accidental. Exhibitionism Exhibitionism which is otherwise referred as flashing indicates about the behaviour of a person where the act involves disclosure of private parts to another individual in a circumstance when nobody would like to expose like in a public place; therefore, it shows inclination towards an extravagant. It has its explanation in the DSM-IV-TR in terms of exposing one’s genitals to some stranger, but there is no such intention of involving in sexual activity. That’s why the exhibitionism term is at times grouped with the expression of, “voyeurism,” (“peeping,” or observing an unsuspecting person usually strangers, while undressing or doing sexual activity) is considered to be a “hands off” paraphilia. It is in contrast to the “hands on disorders” involving physical touch with others. The intention behind this act may be to draw the attention of others, or to give a shocking. There are certain people who feel the urge of sexually exposing themselves due to psychological compulsion. The condition might be referred as apodysophilia. On the other hand, if there is an exposure in public, then it comes under a crime activity. This type of offence doesn’t lead to prosecuting the concerned individual, but it is a serious act if the flasher happens to be a man. However, public exhibitionism from the viewpoint of women has their root since traditional times. Mostly, it takes place in context to women resorting to shame a group of men or forcing them to commit certain public action. The exhibitionist does the masturbation act while divulging himself (or fantasizing to expose himself) to others. Still there are a few exhibitionists know the intent desire either to disturb or upset their targeted individuals; meanwhile others fantasize with the aim of sexually arousing the targeted people through their display. There are various types of Severe Mental Disorders involving exposure i) Anasyrma: The act of skirt lifting by a person without underwear for exposing genitals. ii) Flashing: Simple act of displaying female breasts by a lady while doing up-and-down activity of lifting the shirt or bra. Again, it could involve showing genitalia by a man or woman. iii) Martymachlia: A paraphilia that involves sexual seduction by letting others watch a sexual act. iv) Mooning: It is about displaying bare buttocks by removing trousers and underwear. It appears that double standard exists even in the matter of gender: here the act is done by males 63 CU IDOL SELF LEARNING MATERIAL (SLM)
just for the purpose of humour and disparagement rather than sexual excitement; on the contrary, it is just the reverse for the females and there is clear indication of sexual attention. v) Streaking: It is the act of rushing or running nude in public places. vi) Candaulism: Here a person reveals about his/her partner explicitly regarding sexual activities or attributes. Symptoms: While looking at the symptoms, it could be mild or moderate. Even it could be severe to catastrophic. Go through the explanation regarding symptoms given in the following. i) Mild: In this case, the person gets recurrent fantasies whereby he exposes himself, but don’t involve in such activities. ii) Moderate: This symptom specifies about occasional exposure by himself but fails to control the urges. iii) Severe: The person having severe symptom exposes himself with more than 3 people and find it difficult to control. When it comes to symptoms like catastrophic, it is not found among exhibitionists without having other paraphilias. This symptomatic level indicates about the sadistic fantasies and if is enacted then it would yield in severe injury or lead to death of the victim. Since exhibitionism is an act of hands-off paraphilia, then there is hardly any possibility of rising above the moderate to severity level when paraphilias remaining away from it. Causes i. Biological Theories: As per this theory, the general notion is regarding testosterone being a hormone responsible for influencing the sexual drive among men and women, thereby it enhances the susceptibility of men for developing sexual behaviours which is abnormal. There are certain medications used for treating exhibitionists with the intention of lowering the level of testosterone. ii. ii) Learning theories: Various studies conducted in this respect reflects about risk factors such as emotional abuse during childhood as well as family dysfunction for developing the attributes of exhibitionism. iii. Psychoanalytical theories: This theory assumes regarding the identity of male gender where it states about separating the male from his mother at psychological level by virtue of which he fails to identify her being a representative of the Paraphilias identical sex, like a girl. Hence it is perceived that exhibitionists contemplate their mothers rejecting them with the basis of genitals. So, they grow up having a desire for forcing women for accepting them to look at the genitals. iv. Head trauma: Documentaries avail in this regard suggest that men resorting to exhibitionists after traumatic injury (TBI) even without having past histories of sexual offenses or alcohol abuse. When it comes to a childhood history involving attention- deficit/hyperactivity disorder (ADHD), there is no clarity regarding this connection. However, researchers from Harvard have identified that multiple paraphilias patients 64 CU IDOL SELF LEARNING MATERIAL (SLM)
are more likely to have had ADHD as children when compared to men with a paraphilia. Treatments for Psychotherapy: Various types of psychotherapy are there to treat exhibitionism: Cognitive-behavioural therapy (CBT): This is the most effective approach to treat exhibitionism. In this therapy, patients are inspired for recognising their irrational justifications they offer with respect to their behaviour and bring changes to the distorted thought patterns. Orgasmic Reconditioning: Patients in this type of technique are subjected to the condition of replacing fantasies of exposing themselves with fantasies which are accepted in the parlance of sexual behaviour during the act of masturbating. Group therapy Couples therapy Medications Selective serotonin reuptake inhibitors (SSRIs). The SSRIs has immense potential to treat the paraphilias, depression and related mood disorders. As per this therapy, there is reduced level of serotonin present in the brain result thereby spurs more sexual drive. The SSRIs is rightly applicable to patients with mild to moderate-level paraphilias. Here most of the patients are exhibitionists. Female Hormones: Estrogens are used for treating sexual offenders right from the 1940s. MPA (Medroxyprogesterone acetate) is the recognized hormonal medication as followed in the U.S. to treat exhibitionism patients. 2.10.3 Transvestic Fetishism It is about a practice of putting on the dresses of the opposite gender (cross-dressing), usually for getting some sort of sexual pleasure. However, it is wrongly referred to homosexuality in general. In fact, transvestites could be heterosexual or homosexual. The cross-dressing practice is even ridiculed at times among the homosexuals. Hence the need is to distinguish the transvestite from the transsexual, where the highlight is on intention of belonging to the opposite sex population; majority of the transvestites are from the masculine gender who are very much comfortable as being males in society and complacent with the status quo of biological sex. However, transsexuals containing male, and female don’t feel comfortable with their respective sex. To know more about these people, one need to understand the symptoms of transvestic fetishism, where the acts of touching and wearing clothing items t is usually considered feminine. This could be the initial stage of interest of putting undergarments or related items which remain out of the sight of others but gives the pleasure of arousal whosoever wear. Gradually, the dressing sense like women gets expanded after that they start wearing women clothes on a daily basis. When a transvestic fetish person reaches the next level, it is seen that people of this category love to hair styling like a female and use lady’s cosmetics and some accessories. It has been observed that a few diagnosed with transvestic fetishism, their inclination for crossdressing could go for a change in due course of time from the viewpoint of sexual excitement to getting relief from the state of stress, anxiety and depression. Causes: The basis to a transvestic fetish person is attaining 65 CU IDOL SELF LEARNING MATERIAL (SLM)
sexual gratification through dressing like the opposite sex do. Thus, it shows the cause of adolescent curiosity. It happens because a transvestic fetish individual might not be really aware of his/her roots. At some point of time, transvestic fetishism person in his youth might love to dress up himself with the attires of his sister or mother. Once this activity starts, it continues because he is getting enjoyment out of it but the exact reason for doing so need to be uncovered. In certain case, a mother of a boy takes the initiative of e the cross-dressing as if the kid were a girl. This kind behaviour is seen if the mother wants to exhibit or anger or the desire of having a daughter rather than a son. It is better not to consider transvestic fetish persons as homosexual. In accordance with DSM-IV-TR, majority of men practicing cross- dressing is primarily heterosexual. Nonetheless, some like to sexual encounters with men occasionally. Treatment: In the initial days of behaviour therapy, persons with transvestic fetish attributes were viewed as improper behaviour because of confining to a limited number of situations thereby were given treatment with the means of aversion therapy. This approach of Severe Mental Disorders was unsuccessful in most of the occasions. Behaviour therapy is also used to treat fetish persons, which is otherwise popular as orgasmic reorientation. In this therapy, the attempt is made to enable people learning skills for responding sexually and culturally as appropriate to get stimuli. But this treatment was not so successful. Mostly transvestic fetish individual don’t want to be treated professionally. Moreover, they can achieve sexual gratification which is culturally appropriate. Their cross-dressing character is viewed as harmless because it is not a criminal activity, and they don’t force others for making sexual preference. The American society in this context has developed the attitude of tolerance for dealing with transvestites, thereby the demand to seek professional treatment has reduced as of 2002. 2.10.4 Sexual Sadism and Sexual Masochism Sexual Sadism The basic feature involving sexual sadism is like a sexual excitement feel that emanates from administering either pain or suffering, or humiliation caused to anybody. Be it pain or humiliation, it is real if inflicted on others; it can’t be imagined, and it could be physical in nature or psychological. A person having this disorder is known as a sadist. The name has its origin from the name of a French aristocrat known as the Marquis Donatien de Sade (1740- 1814), who was notorious for penning novels that revolve around the theme like inflicting pain being a source for getting sexual pleasure. Severe Mental Disorders Symptoms Individuals having sexual sadism gets sexual lust out of physically or through psychologically dispensing pain, anguishing and/or humiliation to another individual, who might not give consensus for this kind of activity. There are various explanations related to symptoms involving Sexual Masochism in addition to Sadism, intense, recurrent fantasies urging sex or behaviours showcasing the act (in reality, not simulated) of being embarrassed, beaten, restrained, or otherwise forced to suffer. It results in difficulty in getting sleep, like 66 CU IDOL SELF LEARNING MATERIAL (SLM)
issue of falling asleep, feeling restless, insomnia, a need to get adequate sleep or, may be oversleeping. So, sleeplessness in turn leads to a change in order of appetite either through eating more or less. This is a kind of disorder having the characteristics of passionate sexually inducing fantasies, impulses or behaviours where the individual gets sexually aroused due to humiliation or suffering physically by another person. Causes: There is nothing specific about cause or theory to narrate the source of origin involving sexual sadism, or sadomasochism. Still, a few researchers have made attempts for explaining the role of sexual paraphilias generally for which biological factors could be reasoned. Evidence in this support arises from abnormal inferences from neuropsychological and neurological studies of sex offenders. Again, it is believed that sexual disorders are seen if the person has brain injury, schizophrenia or any related mental disorders. There is one more theory regarding paraphilias that has been sourced from learning theory. It states that paraphilias like disorder develop as the person requires suppressing or squelching the unusual sexual fantasies. Since the fantasies remain unacted initially, thereby the urge for carrying them out also increases. Therefore, if the person acts on the fantasies, they remain in considerable distress state or arousal. There are a few people who don’t suppressing fantasies rather indulge in sexual sadism in milder forms at the initial stage to end up in doing harmful things. As a matter of fact, those people have been arrested. This indicates that the severity of sadistic deeds has the tendency of doing more over time. Treatment: i) Behaviour Therapy: This is widely followed for treating paraphilias. This approach of treatment considers of the management and the state of arousal patterns and subsequent masturbation. In this context, therapies include cognitive restructuring and social skill training. ii) Medication: This could be used for reducing fantasies and paraphilias related behaviour. This type of treatment is suitable for people exhibiting sadistic behaviours which are otherwise considered as dangerous. The medications may be in application for including female hormones (generally medroxyprogesterone acetate or MPA), to which Paraphilias expedite the testosterone clearance from the bloodstream. It also includes antiandrogen medications, that block the body’s testosterone assimilation and the chosen serotonin retaking of inhibitors, or SSRIs. There could be complicated health issues arising out of sexual behaviour arising through sexual sadism treatment. There is every possibility of sexually transmitted diseases and related medical problems if the sadistic behaviour happens to the release of body fluids or blood. Sexual Masochism Sexual masochism has its prerequisite features like sensing sexual arousal or elation resulting through getting pain, suffering and/or humiliation. These are real, not imaginary and might be bodily or psychological by its nature. A sexual masochism person sometimes be called as masochist. Sexual masochism comes under the category of psychiatric sexual disorders of paraphilias, means “abnormal or unnatural attraction.” Sexual masochism also refers to indulging in fantasizing state of being beaten and bound; otherwise, the concerned is 67 CU IDOL SELF LEARNING MATERIAL (SLM)
compelled to suffer, which results in sexual satisfaction. There are various methods used by the patients such as blindfolding, humiliation, and spanking in the facet of defecation and urination, and so on. Masochists could resort to inflict their pain by means of shocking, choking and pricking. Approximately 30% paraphilic patients do take part in sadistic behaviour. One specific dangerous method in this respect is known as hypoxyphilia (near- asphyxiation) that happens if the oxygen level gets reduced in the brain. As a result, it leads to the accidental death of millions of people every year. To attain near-asphyxiation condition, masochists could tie a noose all over their necks, and do chest compression, followed by putting airtight bags over their heads or they use amyl nitrates (“poppers”). Symptoms: Individuals having sexual masochism do sense the sexual excitement arousing from physically or psychologically experiencing pain, suffering, and/or humiliation. They may be getting all these by another person, who might not be a sadist, or they may be going through the same condition themselves. They also experience distressed/ impaired functioning due to the masochistic behaviours, fantasies and urges. Causes: Actually, there is nothing like accepted cause or theory to elucidate the root of sexual masochism, or sadomasochism. Nevertheless, there are a few theories making effort to describe the role of sexual paraphilias mostly. One theory is on the basis of learning theory leading to the origin of paraphilias as incorrect sexual fantasies meet suppression. Since no action takes place initially, there is an enhanced urge for carrying out the fantasies, when they are subjected to act, the concerned person remains in distress and/or arousal. On the other hand, sexual masochism, the masochistic behaviour remains engaged with and inevitably linked to sexual behaviour. Severe Mental Disorders: Many believe that masochistic individuals play the dominant role. This in turn leads to be in conflict situation thereby remain submissive with others. There is another theory suggesting people seeking sadomasochistic behaviour as a reason to escape. They start acting out of fantasies to become different people. Treatments i) Behaviour Therapy- It is frequently used for treating paraphilias. This might include management of arousal patterns and their conditioning including masturbation. Therapies also involve cognitive restructuring likewise. ii) Medication: This type of treatment is used for minimizing the urge of fantasies and behaviour in connection with paraphilias. This is applicable for people having severely masochistic behaviours. But there might be some health complication through these kinds of treatment to overcome sexual behaviour. Further, there is an issue of sexually transmitted diseases in case blood releases while treating the sadomasochistic behaviour. Besides, people’s participation in hypoxyphilia and dangerous behaviours could yield in extreme pain and in serious case it might lead to death. 2.10.5 Pedophilia and Incest It comes under the category of a psychiatric disorder among adults or late adolescents (16 years of age or more). It has some characteristics, i.e., presence of sexual interest at primary level or exclusively among the prepubescent children (in the range of 13 years of age or 68 CU IDOL SELF LEARNING MATERIAL (SLM)
younger, even though it leads to varying onset of puberty). The minimum age of the child should be five years less if the need is to treat adolescent pedophiles. This word has the Greek origin: ðá?ò (paîs), means “child,” and öéëßá (philía), “friendly love” or “friendship”. However, the literal meaning has gone for a change for referring sexual attraction in contemporary times, where it is titled as “child love” or “child lover”, by the pedophiles using symbols and codes for sorting out their preferences. As per the definition by the International Classification of Diseases (ICD), it is a “disorder of adult personality and behaviour” where their sexual preference is towards children of prepubertal or those in the early stage of pubertal. There are various definitions to describe this term as identified in the discipline of psychiatry, psychology, and the vernacular including law enforcement. In accordance with the Diagnostic and Statistical Manual of Mental Disorders (DSM), pedophilia is nothing but a paraphilia condition where a person feels the urge intense sexual urges frequently by fantasying about prepubescent children. Then out of those feelings, they act or feel distress or difficulty at interpersonal level. The present DSM-5 draft suggests adding hebephilia in the diagnostic criteria, Paraphilias and subsequently renaming it as pedohebephilic disorder. Majority of the people having pedophiles are men, but some women also women exhibit this disorder. Popularly, pedophilia is about sexual interest with children or a kind of child sexual abuse, also termed as “pedophilic behaviour”. The name Pedophilia came to limelight towards the end part of the 19th century. There are many studies have been carried on this subject since the 1980s. Still, there is no conclusive establishment to get answer for the exact reason behind pedophilia. But there some studies claiming pedophilia disorder happens in case of neurological abnormalities, and it co-exists with contextual personality disorders as well as psychological pathologies. With respect to forensic psychology and law enforcement, there are numerous typologies as suggested for categorizing pedophiles as per the behaviour and motivations. Symptoms: A pedophile person has weakness for the children thereby they become the victims. Therefore, Potential pedophiles might contribute voluntarily their services in various religious and civic activities, athletic teams and Scout troops because there are youth working in these organizations. There is one more reason in support of the pedophiles that they act as a baby-sitter in their family because their attraction is children. They are also good at communicating with children thereby wins their trust. It has been observed that a few pedophiles give some kind of excuses which enable them not to own responsibility due to their actions. Instead, they squarely blame the children being very attractive or proactive sexually. Further, they might defend by saying that they shoulder the responsibility of teaching children regarding the facts related to life or love. This type of rationalisation is usually offered by pedophiles infamous for molesting children. These odd rationalisations could be in pornography having pedophilic themes. Causes: To pinpoint the exact cause, there are various theories in this regard. Some researchers cite pedophilia together with the paraphiliasto biology. As per their studies, testosterone (male sex hormone), make men vulnerable for developing non-typical sexual behaviours. Regarding genetic factors, no researchers have made any claim of discovering or 69 CU IDOL SELF LEARNING MATERIAL (SLM)
mapping a gene supporting pedophilia. Rather some perceive pedophilia is due to a contorted need of dominating a sexual partner. Children due to their age are usually weaker as compared to adults, hence the pedophilia people consider them as unobjectionable potential partners. Hence, this drive of dominant nature is construed as males as pedophiles. Treatments: When the behaviour modification therapy treatment was in its nascent stage, pedophiles was being viewed as infatuation to inappropriate persons. As a part of treatment, aversive stimuli are given where electric shocks are administered to persons going through therapy. However, this approach is not so successful. The year 2002 witnessed psychotherapy as the most popular treatment. But its success rate is not very encouraging for inducing pedophiles in changing their behaviour. Severe Mental Disorders Pedophilia persons could also be administered with medications. The three prominent medications that got widespread recognition for treating pedophilia are: female hormones, especially medroxyprogesterone acetate (MPA); luteinising hormone-releasing hormone (LHRH) agonists, that include drugs like triptorelin (Trelstar), goserelin acetate, leuprolide acetate, and anti-androgens, all these choke the uptake and metabolism activity of testosterone and also lower the blood levels in this hormone. Nearly all the clinical studies involving these drugs have been carried out in Germany since 1970, because the research got legal authority to treat repeated sexual offenders. Specifically, the anti-androgens have been proved successful in minimizing the recidivism rate. 2.10.6 Paraphilia in Women There is no clear information on sex ratio in the epidemiology study of paraphilias. However, two paraphilias cases among women is also mentioned in this study. The first one is the amputee paraphilia also known as (apotemnophilia/acrotomophilia). Another one is the paraphilia for lameness, i.e., difficulty in walking termed as (abasiophilia/autoabasiophilia). The author here tries to present the research review on sexual delinquency and overall incidence of paraphilia among women. He further mentions certain theories explaining the disproportion ration between deviations in men and women and potential reasons of more sexual delinquency in men. At the same time, his effort is to draw the attention of higher latent sexual delinquency possibly in women. 2.11 CAUSES OF PARAPHILIA Biological issues are perceived to be risk elements for paraphilias, where it is held that due to differences in brain activity at the time of sexual arousal, including the role of brain structure. The study conducted by mental health professionals has given an inference that male pedophiles possess lower IQ scores as far as psychological testing is concerned as compared to men without pedophiles. Again, this study has ascertained the fact that pedophiles score 70 CU IDOL SELF LEARNING MATERIAL (SLM)
badly in academics than non-pedophilic counterparts, irrespective of their intellectual abilities and learning potentials. There are numerous studies conducted on the way paraphilias develop. For some researchers, this kind of disorder is due to a manifestation of blocked psychosexual development, where paraphilic behaviours justify the psyche of a person against anxiety (i.e., defense mechanisms). Other researchers are of the opinion that paraphilias like state happen because of the sufferer linking some aspect with sexual arousal and related interests, or through unusual sexual experiences realized in early life supported by having an orgasm. According to a few researchers, these disorders are another version of obsessive-compulsive disorder. Psychologically, pedophiles acting as per their urges by making sexually offence have the proclivity to remain engaged in distorted thinking, where they don’t mind using their authority to view offending is right in fulfilling their needs, imagine children as sexual partners to adults. Again, they consider sexual needs is something uncontrollable. An alternative theory regarding paraphilia risk factors exists where they are associated to various stages of childhood development at psychological level such as temperament, trauma repetition, early relationship formation, and disrupted development of sexuality as briefed in the following: • Temperament: a propensity to be excessively reserved or lack of control over emotions and behaviours. • Early relationship formation: there is no such self-awareness, problem in controlling emotions, searching for help and solace from others. • Trauma repetition: It is about sexual victim people or abused ones; they feel traumatized if they had gone through this state during childhood. They resort to reacting as was inflicted on them where they victimize others in identical way. They could also behave or react due to the trauma they have gone through thereby they harm themselves. • Disrupted development of sexuality: The patterns of bringing one sexual pleasure are prone to be formed by adolescence. People who are brought up in a household is either sexually permissive in excess or inhibited remain at higher risk to develop the condition of paraphilia. There are family risk factors involved for developing paraphilia in case of high conflict situation between parents or poor supervision by both father and mother, lacking affection from mother side, and if not treated well by parents. It has been observed that paraphilia people in general are known for creating troubles, keeping friends and related relationships. • Majority of paraphilias belong to males. 71 CU IDOL SELF LEARNING MATERIAL (SLM)
• Paraphilias is seen as male vulnerability and is associated to their more dependency on sexual imagery. • People having paraphilias have multiple paraphilia. 2.12 ASSESSING AND TREATING PARAPHILIA Treatment revolving around cognitive and behavioural elements seem more successful comparatively for treating this paraphilia condition. One such treatment in this context is aversion therapy that seems working effectively for dealing with this condition. Thus, aversive state to sexual fantasies that are deviant in nature. Assisted covert sensitisation: In this therapy, the patient imagines a scene of deviant sexual arousing. When the arousal becomes high, the patient then visualizes aversive consequences and a disgusting odour getting introduces through an open vial for helping to condition an actual aversion to the deviant ones. Paraphilia Symptom Anxiety Anxiety is kind of a feeling having the characteristic of apprehension and fear through physical symptoms like: • Palpitations, • Sweating, • Irritability, • Feelings of stress. Anxiety disorders comes under serious medical ailments that impact almost 19 million adults in America. In reality, anxiety disorders being a group are considered the most prevalent mental illness in America. It can make adverse health affect right from children and adolescents to adults. 2.12.1 Psychological Treatment Initially, this research paper states that he paraphilias treatment has been thoroughly explained d and reviewed within the realm providing treatment to sex offenders (i.e., rapists, child molesters, and exhibitionists). It is a matter of point to be noted that the literature has not carefully distinguished \"pedophiles\" from child molesters. Moreover, rapists on most occasions are identified in terms of having a \"Not Otherwise Specified\" paraphilia. This indicates both practices seem problematic. Then going by the outline of current approaches regarding the treatment of sex offenders, which have been considered as significant to 72 CU IDOL SELF LEARNING MATERIAL (SLM)
manage all kinds of paraphilias. Further, the historical outcome of treating sexual offender has been mentioned. Thus, it leads to an outline comprising contemporary approaches for overcoming recognized problematic issues in which established procedures are implemented, then the treatment is delivered empirically. Hence it can be concluded with an explanation containing assessment of the effectiveness involving treatment approaches indicating comprehensive positive outcomes. Psychotherapy for treating pedophilia and paraphilias have the tendency to use the cognitive behavioural therapy in general. The psychotherapy focuses on aiding the pedophilia person for recognizing and combating rationalizations concerned to his or her behaviour, which also includes rendering training to the pedophilia sufferer so as to develop empathy for the concerned victim and through techniques for curbing their sexual instincts. This therapy has the approach of handling sexual offenders by using a relapse prevention model identical to treating drug addicted people. This approach is considered an attempt in helping the paraphilic person to anticipate situations responsible for enhancing their risk of sexual activities and finding various ways for avoiding or responding more productively to those kinds of triggers. People having paraphilia could leverage the benefit through participating in social skills training which in turn help them in developing age- appropriate and reciprocal relationships. 2.12.2 Drug Treatments Medications instrumental in suppressing the production of testosterone (male hormone) minimize the recurrence of sexual desire among pedophiles. The time period for testosterone suppression is in the range of three to ten months. Research studies on the efficacy of selective serotonin reuptake inhibitors (SSRIs) for treating pedophilia and related paraphilias differ in their outcomes. Nonetheless, SSRIs might be a useful addition for other treatments, as they have the ability for reducing sexual obsessiveness and urges involving paraphilias. Again, it could intensify the ability of a paraphile for controlling his/her impulses. There are many examples favouring SSRI medications such as fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), vortioxetine (Trintellix) and escitalopram (Lexapro). There are certain preliminary studies conducted in this regard reflect that stimulant medications such as methylphenidate (Ritalin) might boost the effectiveness of SSRIs; whereas, naltrexone could lower the sexual desires related to paraphilias. 2.13 SUMMARY • Sexual dysfunction needs to be evaluated by an impartial health care professional through using the techniques like history-taking and physical examination for assessing complex symptoms if any. However, if the person lacks in sexual activity, then conclusion should not be made as sexual dysfunction provide the patient feels distressing. 73 CU IDOL SELF LEARNING MATERIAL (SLM)
• Sexual dysfunction could be categorized as primary sexual dysfunction, and secondary sexual dysfunction, where the former one is irrelevant at present. • There are many reasons involving developmental disorder leading to primary sexual dysfunction like neurological, urogenital system and endocrine. This disorder may be due to underlying psychiatric issue. However, there is least possibility of arising secondary sexual dysfunction due to developmental anomaly containing the nervous, urogenital, or endocrine system. Rather, it may be emanating from an acquired disorder like cardiovascular disease, obesity, diabetes mellitus, depression, and anxiety. • Whatever may be the reasons but should be refrained from conducting ancillary testing regularly, but its limit is to situations of suspecting specific etiology. The aim of the treatment is to identify the root cause and address it without resorting to medications, otherwise it will make adverse impact on sexual function. Still, nothing to worry as there are surgical procedures like penile implants for patients who have experienced failure in medical therapy. • Most paraphilias seem to be treated more by behaviour modification and cognitive behaviour therapy. • Usually, it has been observed that they don’t prefer treatment on their own, but they have to follow court order in certain cases or by their relatives or neighbours who would have been a victim. • As for as the general causes of paraphilias is concerned, one has to understand the sexual preferences. At the same time, it needs to be noted that the problem is primarily biological in nature. • The biological perspectives receive the most attention and focuses as a main cause for deviation. Each one of the perspectives has something to provide for understanding the paraphilia’s. It is because many of the paraphilic type’s behaviour are being carried out in private areas and come to public attention. Conventional psychotherapy is ineffective but biological treatments involve female hormonal treatment which have been used with benefits on a long-term basis. In some cases, desensitisation has proved useful for the cases. 2.14 KEYWORDS • Sexual Disorders indicates to any kind of difficulty being experienced by a person or couple with the numerous aspects of sexual activity like attraction, pleasure, arousal, and orgasm. Sexual dysfunction could lead to extreme distress and might severely impact the quality of life of the affected person. • Ego Psychology has its source of origin from Freudian psychology. Proponents of this study give emphasis on increasing and maintaining ego function as per the reality 74 CU IDOL SELF LEARNING MATERIAL (SLM)
demands. Ego Psychology emphasizes on an individual's ability regarding defence, reality testing and adaptation. • Fetishism Sexual paraphilia, or sexual fetishism where Sexual arousal or pleasure is acquired from being robbed, conned, cheated, blackmailed or otherwise compelled to missed out financially by a partner or a stranger. • Disorders It is a condition that is characterized in terms of absence of normal functioning of physical or mental processes. • Learning Theories Various studies conducted in this respect have concluded that emotional abuse during childhood and family dysfunction are major risk factors in the development of exhibitionism. 2.15 LEARNING ACTIVITY 1. Conduct a session to educate sexual disorder in your community and explain the outcomes of it? ...................................................................................................................................................... ...................................................................................................................................................... 2. Use the paraphilia? .................................................................................................................................................... ..................................................................................................................................................... 2.16 UNIT END QUESTIONS A. Descriptive Questions 75 Short Questions 1. What are sexual disorders? 2. Mention types of sexual disorders. 3. Define desire disorders, arousal disorders 4. Explain a short note paraphilia? 5. What are the various symptoms of paraphilias? Long Questions 1. Explain assessing and treating paraphilia? 2. Enumerate the causes, symptoms and treatment of fetishism and voyeurism. 3. Discuss in brief causes of sexual disorders. 4. Illustrate why psychotherapy is not effective in most of the paraphilia cases? 5. What are the different types of paraphilia’s? CU IDOL SELF LEARNING MATERIAL (SLM)
B. Multiple Choice Questions 1. Persistent disruptions in the ability to experience sexual arousal, desire, or orgasms, or by pain associated with intercourse is called as: a. Sexual dysfunction b. Sexual function c. Paraphilia d. All of these 2. Persistent and troubling attractions to unusual sexual activities or objectives is called as: a. Sexual dysfunction b. Sexual function c. Paraphilia d. All of these 3. Which of the following is not included in the DSM-5 for a sexual disorders? a. Sexual dysfunction b. Paraphilia c. Sexual function d. They are all included in the DSM-5 4. According to the centres of Disease control and prevention ________ percent of women will be diagnosed with a sexually transmitted illness by the age of 19. a. 10 b. 25 c. 40 d. 60 76 CU IDOL SELF LEARNING MATERIAL (SLM)
5. These are problems that involve a lack or absence of sexual drive, also referred to as a low libido. a. Desire disorders b. Arousal disorders c. Orgasm disorders d. Pain disorders Answers 1. a) 2. c) 3. c) 4. b) 5. a) 2.17 REFERENCES Textbooks • Hickey, Eric, W. (2005). Sex Crimes and Paraphilia Sage Publication, NY. • Holmes, R.M. (2007). Sex Crimes and Paraphilia. Prentice Hall, London. Reference Books • American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000:566 - 576. • Sartorius A, Ruf M, Kief C, Demirakca T, Bailer J, Ende G. Abnormal amygdala activation profile in pedophilia. Eur Arch Psychiatry Clin Neurosci. Aug 2008; 258(5):271-7. • Andersen ML, Poyares D, Alves RS, Skomro R, Tufik S. Sexsomnia: abnormal sexual behaviour during sleep. Brain Res Rev. Dec 2007; 56(2):271-82. Websites • https://manhattanmentalhealthcounseling.com/ • https://www.webmd.com/mental-health/sexual-disorders • https://www.health.harvard.edu/mind-and-mood/paraphilia-type 77 CU IDOL SELF LEARNING MATERIAL (SLM)
UNIT 3: SCHIZOPHRENIA STRUCTURE 3.0 Learning Objectives 3.1 Introduction 3.2 Types of Schizophrenia 3.2.1 Paranoid Schizophrenia 3.2.2 Catatonic Schizophrenia 3.2.3 Undifferentiated Schizophrenia 3.2.4 Schizoaffective Disorder 3.3 DSM Criteria 3.4 Incidence 3.5 Prevalence 3.6 Co-morbidity 3.7 Causes of Schizophrenia 3.8 Prognosis and Treatment 3.9 Summary 3.10 Keywords 3.11 Learning Activity 3.12 Unit End Questions 3.13 References 3.0 LEARNING OBJECTIVES After studying this unit, you will be able to: • Define schizophrenic disorders. • Describe various types of schizophrenia. • State the symptoms of schizophrenia. • Explain the causes of schizophrenia. • Delineate the treatment approaches for schizophrenia. 3.1 INTRODUCTION This unit deals with schizophrenia, a severe mental disorder that has a relatively poorer prognosis. The unit starts with the concept and definition of schizophrenia, the common symptoms of schizophrenia such as the negative and positive symptoms, the cognitive and affective symptoms etc. Then the unit presents the various types of schizophrenia, their symptoms, causes and treatment. The common symptoms of schizophrenia are then discussed and the causes thereof. Amongst the various treatment interventions, apart from medicines, the unit presents the psychosocial treatment of schizophrenia. The rehabilitation of 78 CU IDOL SELF LEARNING MATERIAL (SLM)
schizophrenics and education to the family as to how to look after these patients are presented in detail. Schizophrenia also sometimes called a split personality disorder. It is a chronic, severe, debilitating mental illness that affects about two per cent of the population. It is one of the psychotic mental disorders and is characterised by behavioural and social abnormalities. An individual with this disorder develops: • Confused speech • Shambolic rigid or lax behaviour • Significantly decreased appropriate behaviours or feelings • Development of delusions Delusions are false beliefs. For example: belief that someone is out to kill the person while there is no such entity who has any intention to kill him. It is thus a false belief. However, for the person who believes in it, the line between reality and fantasy is quite blurred. Due to these delusions, the person reacts eccentrically. Sometimes such persons may attack another without reason based on his delusions. Schizophrenic symptoms mostly become visible in late teens or early adulthood. For a long time, this disease which incapacitates the brain and causes catastrophic emotional duress has been misdiagnosed and often misgauged and misinterpreted. There is a stigma related to this health problem that results in rejection of individuals with this condition by society in general. They’re sent to hospitals for mental diseases in extreme cases. Schizophrenia contains a biological basis like polygenic disorder and cancer. One to two per cent of the population is plagued by this health problem making it a reasonably common sickness. According to NIMH: The Prevalence Rate for dementia praecox is around 1.1% of the population over the age of eighteen, in different words, fifty one million individuals worldwide suffer from dementia praecox just the once which has six to twelve million individuals in China, 4.3 to 8.7 million individuals in India, 2.2 million individuals within the USA, 285,000 individuals in Australia, over 280,000 people in North American country, over 250,000 diagnosed cases in Britain(a rough estimate based on the population). Robin Murray claims rates of schizophrenia close to 0.5% to 1 per cent of the population and generally similar in various countries. The prevalence of schizophrenia at any given time is that the range of number of individuals affected per 1,000 total population at any given time. Within the USA, it is 7.2 per 1,000. To elaborate, in a town with a population of three million, twenty-one thousand individuals are going to be littered with schizophrenia. Incidence: The number of individuals who are going to be diagnosed as having schizophrenia during a year are one in 4,000. So about 1.5 million people will be diagnosed with schizophrenia this year, worldwide. About 100,000 people within the U.S are going to be diagnosed with schizophrenia this year. Note: The term ‘prevalence’ of Schizophrenia typically refers to the calculable population of individuals who are living with Schizophrenia at any given time whereas the term ‘incidence’ of Schizophrenia refers to the annual identification rate, or the number of latest cases of 79 CU IDOL SELF LEARNING MATERIAL (SLM)
Schizophrenia diagnosed every year. Early intervention and early use of latest medications result in higher medical outcomes for the individual. Long run prognosis is healthier if identification along with stabilisation of treatment arrange is completed early. 3.2 CLASSIFICATION OF SCHIZOPHRENIA The term ‘Schizophrenia’ was coined at the beginning of this century by Bleuler, a Swiss psychiatrist. It refers to a selected mental disturbance or might comprise a group of disorders and therefore the cause is mostly unknown. It presents with an advanced array of social behaviour thanks to disturbance in thinking and perception. The progression of the unwellness extremely affects the symptoms of the health problem. Schizophrenia is broadly speaking classified into five subtypes that area unit outlined below the foremost distinguished characteristics. The same person could also be analysed with different types of schizophrenia as the illness progresses. The kinds of schizophrenia are: • Paranoid Schizophrenia • Catatonic Schizophrenia • Undifferentiated Schizophrenia • Schizoaffective Disorder Let us discuss them in detail: 3.2.1 Paranoid Schizophrenia The paranoid variety of schizophrenia is marked with: • Thoughts of conspiracy or maltreatment. • Audial hallucinations in some cases. • Patients area unit higher at relationships and work than those having other varieties of schizophrenia. • They will lead a far additional traditional life, particularly if they can manage the unwellness. The explanation is unknown however this can be due to the symptoms that develop in the latter part of life once the patient has already managed to know a stronger functioning life skillset well before the health issue might set in. • The patients could also be hesitant in discussing their health issue and need not categorically look uncommon or odd. • Their delusions and hallucinations circle explicit themes with infrequent changes. • Here, the character of their thoughts determines the general behaviour and temperament. As an example, an individual who imagines being unjustly persecuted might simply flip hostile or short-tempered. These indications area unit typically understood by professionals once further stress triggers the symptoms. The patient may realise the necessity for assistance in such situations. They may take such steps that might attract attention. • However, as a result of features aren’t clear, it is important for the patient to discuss their thought reflections overtly. This might be onerous to achieve whenever paranoia 80 CU IDOL SELF LEARNING MATERIAL (SLM)
or suspicions are high. Severity and nature can vary with time. Once the condition is on the trail of worsening or exacerbation the thought process may become disorderly the patient during such time might find it hard to recall even the recent events or might display disjointed speech, acting in a perverse or a disorganised pattern. As these symptoms are quite similar to other subtypes, based on the state of their illness, the symptoms might vary in many grades in paranoid subtype patients. • Family and friends should be supportive, encouraging the patient to seek help from a professional. • Signs and Symptoms i. Delusions of persecution, innuendo, grandeur, special mission, bodily change, or jealousy. ii. Hallucinatory voices that lurk the patient or give orders to do unjust things or aural hallucinations like whistling, humming or laughing, not having any verbal forms. iii. Hallucinations of smell, taste, sexual or any other bodily sensations. iv. Visual hallucinations might occur but are infrequent. v. Incoherence of speech. vi. Marked loosening of associations. vii. Flat or grossly inappropriate affect. • Causes i. Family history of schizophrenia ii. Exposure to viruses in utero iii. Poor nutrition in utero iv. Stressful life events v. Older paternal age vi. Addiction to psychoactive drugs during adolescence • Treatment The main treatments for paranoid schizophrenia are: i. Medications ii. Psychotherapy iii. Hospitalisation iv. Electroconvulsive therapy (ECT) v. Vocational skills training 3.2.2 Catatonic Schizophrenia Catatonic disorders are a group of symptoms characterised by disturbances in motor behaviour (muscular movement) that may have either a psychological or a physiological basis. Immobility is the most common symptom of this illness. Patients diagnosed with a catatonic disorder may maintain their body position for hours, days, weeks or even months at a time. 81 CU IDOL SELF LEARNING MATERIAL (SLM)
Alternately, catatonic symptoms could seem like agitated, purposeless movements that square measure ostensibly unrelated to the person’s surrounding. This condition is known as catatonia. A mild symptom of the catatonic disorder is dilute motor activity. Often, the body position or posture of a catatonic person is uncommon or inapt. He or she may even hold a posture if placed in it by somebody else. Symptoms These symptoms include: • Catalepsy or stillness maintained over elongated time. • Catatonic excitement, with evident agitation and ostensibly pointless movement. • Catatonic stupor, with evidently slowed motor activity, every so often to the point of immobility and ostensible ignorance of the surrounding. • Catatonic rigidity, within which the individual adopts a rigid position and holds it in contradiction of all efforts to change it. • Catatonic posturing, within which the individual assumes unusual or inappropriate posture and upholds it for a protracted time. • Waxy flexibility, within which the limb or other parts of a catatonic person once affected into a position are then maintained as such. The body part feels to an observer as if it were made of wax. • Akinesis or absence of physical movement. Causes • Brain, as well as the limbic brain, the frontal area and therefore the basal ganglia. • Irregularities within the production of neurotransmitters in the brain. • Several other medical situations Treatment. • Medications. 3.2.3 Undifferentiated Schizophrenia The psychosis related to paranoid schizophrenia, catatonic state in catatonic schizophrenia or the muddled thoughts and expression in disorganised schizophrenia are not seen in individuals suffering with undifferentiated schizophrenia. However, they do suffer from psychosis and various other symptoms related to schizophrenia including behavioural changes, noticeable to family and friends. Diagnosis of this disorder is problematic and can it take weeks or months to substantiate presence of schizophrenia. Throughout this period, various other possible reasons for the symptoms are weeded out. The patient is observed to ascertain any changes in patient’s personality, means of expression, and temperament. members of family and friends may be interviewed and asked for information to establish patient’s state of mind. 82 CU IDOL SELF LEARNING MATERIAL (SLM)
In this schizophrenia type, the patient’s symptoms can vary continuously or can be extremely stable, inflicting doubt in inserting it below the other subtype. The most effective definition for this kind of schizophrenia is a ‘mixed clinical condition’. Symptoms No specific symptoms occur during this disorder and are largely just like most of the symptoms of Schizophrenia, which are as follows: • Delusions • Hallucinations • Snafu speech • Grossly confused or catatonic behaviour • Negative symptoms Causes • Genetic • Migration • Virus • Family • Environment • Other causes Sometimes individuals born in cold and urban environments are more likely to develop undifferentiated schizophrenia. Those infected with influenza, poliovirus, CNS, respiratory diseases have a 10 to 50 per cent higher chance of developing schizophrenia. During the antepartum stage, those youngsters subjected to famine, separated from mother/parents/family, depression, sorrow and total loss of everything during flood etc., are all more prone to develop schizophrenia. Treatment • Psychotherapy • Pharmacotherapy There are numerous options available for treatment of undifferentiated schizophrenia. Patients can discuss treatment choices with their physicians, though it’s vital to bear in mind that it can take time for treatment to be effective. Once patients begin to experience a change, he or she may require periodic changes to their medications and treatment programme to retort to changes they expertise over time. Undifferentiated schizophrenia can’t be cured, however can be managed with a cooperative effort. 3.2.4 Schizoaffective Disorder It is a sporadic disorder within which both affective and schizophrenic symptoms are present at the same time. It could be of the schizo-depressive sort or schizo-manic sort depending on the presence of effective symptoms during the episode. Treatment needs to be planned on a long- term basis with antipsychotic medications and mood stabilizers. 83 CU IDOL SELF LEARNING MATERIAL (SLM)
3.3 DSM CRITERIA Schizophrenia spectrum and other psychotic disorders encompasses schizophrenia, various psychotic disorders, and schizotypal (personality) disorder. They’re outlined by abnormalities in one or more of the subsequent 5 domains: delusions, hallucinations, scrambled thinking (speech), grossly disorganized or abnormal motor behaviour (including catatonia), and negative symptoms. Key yardsticks for outlining the Psychotic Disorders: Delusions Delusions are those fixed beliefs that aren’t compliant for change in view of the conflicting evidence. Their content could embrace variety of themes (e.g., persecutory, referential, somatic, religious, grandiose). • Persecutory delusions (i.e., the supposition that one is going to be hurt, hassled, and so forth by a person, organization, or another group) are extremely common. • Referential delusions (i.e., the assumption that particular gesticulations, remarks, environmental cues, and so on are directed at oneself) also are common. • Grandiose delusions (i.e., once a person believes that he or she has exceptional skills, wealth, or fame). • Erotomania delusions (i.e., once a personal believes incorrectly that another person is smitten with him or her) also are seen. • Nihilistic delusions involve the conviction that a serious catastrophe will occur, and bodily delusions focus on preoccupations concerning health and organ performance. Delusions are deemed off-the-wall if they’re dubious and non-comprehensible to similar ethos peers and don’t derive from standard life experiences. As an example - a belief that an external force has replaced his or her internal organs with someone else’s organs while not leaving any wounds or scars is unusual. A non-weird misapprehension may be a belief that one is under observation by the police, despite a lack of convincing evidence. Delusions that express a loss of control over mind or body are typically thought of to be bizarre; these embrace the assumption that one’s thoughts have been “removed” by some external force (thought withdrawal), that alien thoughts are placed into one’s mind (thought insertion), or that one’s body or actions are being acted on or manipulated by some external force (delusions of control). To differentiate a delusion from a powerfully held idea is kind of tough and depends partly on the degree of conviction with which it’s held on to notwithstanding clear or reasonable contradictory proof concerning its truthfulness. Hallucinations Hallucinations are perception-like experiences that happen without any exterior inducement. They’re intense and clear, with the complete force and impact of traditional perceptions, and are not under intentional control. They may occur in any sensory modality, however auditive 84 CU IDOL SELF LEARNING MATERIAL (SLM)
hallucinations are the foremost common in schizophrenia and connected disorders. Acquainted or unknown voices that are discrete from the patient’s thoughts are the foremost common auditive hallucinations. The hallucinations must occur in the context of a transparent sensorium; ones that occur whilst falling asleep (hypnagogic) or awakening (hypnopompic) are measured to be inside the array of usual experience. Hallucinations may also be a traditional part of religious experience in some cultural contexts. Disorganized Thinking (Speech) Disorganized thinking additionally referred to as formal thought disorder is often inferred from the individual’s speech. The individual can switch from one topic to a different (derailment or lose associations). Answers to queries is also implicitly related or completely unrelated (tangentiality). Speech is also therefore severely unsystematic that it’s nearly incomprehensible and resembles aphasia in its linguistic disorganization in rare cases (incoherence or “word salad”). This symptom should be severe enough to considerably impair effective communication as slightly scrambled speech is indifferent and common. The distinction within the linguistic background of the person diagnosing the patient may interfere within the diagnostic procedure. Less severe muddled thinking or speech may occur during the prodromic and residual periods of schizophrenia. Grossly Disorganized or Abnormal Motor Behaviour (Including Catatonia) There are varied ways within which grossly disorganized or abnormal motor behaviour is articulated that vary from naive “silliness” to impulsive agitation. Complications may be noted in any sort of purposeful behaviour, resulting in difficulties in executing activities of everyday living. Catatonic behaviour is a marked reduction in response to the surroundings. This may entail: • Resistance to directives (negativism). • Preserving a stiff, unsuitable or inexplicable posture. • Absence of verbal and motor responses (mutism and stupor). • May embrace pointless and unnecessary motor activity shorn of clear cause (catatonic excitement). • Further symptoms are recurrent stereotyped actions, staring, smirking, muteness, and the resounding of speech. Although catatonia has traditionally been related to schizophrenia, catatonic symptoms are generic and can occur in other mental illnesses (e.g., bipolar or depressing disorders with catatonia) and health situations (catatonic disorder because to another medical illness). Negative Symptoms Negative symptoms comprise a considerable portion of the morbidity related to schizophrenia but are less prominent in other psychotic illnesses. Two negative symptoms are significantly distinguished in schizophrenia: 85 CU IDOL SELF LEARNING MATERIAL (SLM)
• Diminished emotional expression and • Avolition. Diminished emotional expression comprises reductions in the expression of emotions in the face, eye contact, inflection of speech (prosody), and movements of the hand, head, and associate degree face that unremarkably provide an emotional importance to speech. Reduction in motivated self-initiated purposeful activities is Avolition. The individual could sit for prolonged durations and show diminutive attention in partaking in work or social activities. Other adverse symptoms include alogia, anhedonia, and a sociality. Alogia is manifested by reduced speech output. Anhedonia is the reduced capacity to expertise pleasure from a stimulation or a degradation in the recollection of delight antecedental seasoned. Asociality refers to the seeming lack of interest in communal exchanges and can be associated with avolition, but it can also be a result of inadequate occasions for social interactions. Schizotypal (Personality) Disorder Criteria and text for a personality disorder are illustrated within the chapter “Personality Disorders.” As this disorder is considered as part of the schizophrenia spectrum of disorders and is tagged during this section of ICD-9 and ICD-10 as a schizotypal disorder, it’s listed in this chapter and discussed thoroughly in the DSM-5 chapter “Personality Disorders.” 3.4 INCIDENCE A review of schizophrenia occurrence conducted recently has data that was taken from 158 studies that was done across 32 countries. The median value of rate distribution is 15.2 per 100,000, a value that was positively skewed. According to conservative estimates, presence of schizophrenia was in a range that fell between 7.7and 43.0 per 100,000 a value that is spread over fivefold difference. Epidemiologists in other field such as diabetes have marked such distribution values as “prominent worldwide variation.” Another Incidence How specifically a disorder is distributed inside a particular population is determined by its prevalence and incidence. The term incidence refers to the number of new cases that arise per time unit, which is annual, however the term prevalence refers to the exciting case proportion inclusive of new and old cases. There are three types of prevalence rates which are point prevalence, period prevalence and lifetime prevalence. Point prevalence refers to the cases that have come about at a particular time point, period prevalence shows the cases present over a certain time period and lifetime prevalence gives the number of people who have suffered from the problem during their lifetime, at any point of time. It is indeed difficult to carry out incidence studies on schizophrenia, which is a somewhat rare disorder. Many countries have indeed done their surveys and the results on indices rate annually gives out a small range for schizophrenia, lying between 0.1 and 0.4 per 1000 86 CU IDOL SELF LEARNING MATERIAL (SLM)
population. This is the key outcome determined by the country study of WHO (Jablensky et al., 1992). Schizophrenia incidences are interestingly similar in varying geographical locations and this can be said even with the difference that exists in diagnostic assessment, methods used in case-findings and adulthood definitions. areas (Warner and de Girolamo, 1995). However, in the U.S, the Epidemiologic Catchment Area Study displayed very high rates, Tien and Eaton, 1992) which can also be due to bias in the assessment. In developing countries, he data gained is less and certainly much lesser than what is seen in western industrialized countries how there is no clear confirmation on such data as per the Asian countries investigations. It is in disadvantaged social groups that there are many high incidence rates, more specifically in ethnic minorities in countries of east Europe and also in United Kingdom Afro-Caribbean communities as well as Netherlands Surinam immigrants (King et al., 1994; Selten and Sijben, 1994). However, there are no proper certainties about such reports and the population size, age distribution is put at not clear. Over the past 15 years, there has been report from many countries that people with schizophrenia were not presenting themselves for treatment. (Der et al., 1990). This can also be possible due to changes in the way diagnosis, treatment is carried out or perhaps there are more stringent definitions for this particular disorder. (Jablensky, 1995). When it comes to prevalence there is a wide difference which has been researched in a large way. The point prevalence range is between 1 and 17 per 1000 population for adults and the range is between 1 and 7.5 per 1000for one year. In terms of lifetime prevalence, the rage is between 1 and 18 per 1000 (Warner and de Girolamo, 1995). The variation that can be seen in prevalence depends on so many factors such as migration, illness recovery and also passing away of those who are affected by this problem. In all countries that are developing, you can see a low point and period prevalence and the reason given for this by investigator is that treatment turned out positively. ( Leff et al., 1992). It is also possible that the rise in mortality rates is also a reason for poor prognosis. In central and north part of Europe there is more prevalence of schizophrenia. It is also seen likewise in North America and also in certain pockets of the population living without influence of the industrial world as was seen in the original inhabitants of Australia or Canada. (Warner and de Girolamo, 1995).It is possible to bring out such research by isolating people based on their genetic makeup and healthier people out migrating from a location. It is also possible that when isolated communities first came in contact with\\ western lifestyles the possibility of schizophrenia in people who were weak of mind enhanced. Jablensky and Sartorius, 1975).Based on such information, it can be said that the volume of people with this mental health issue is about 29 million, out of which 20 million are in the developing or less developing nations of the world. 87 CU IDOL SELF LEARNING MATERIAL (SLM)
3.5 PREVALENCE The presence of schizophrenia over the lifetime of a person ranges between 0.3% and 0.7%, however this percentage value varies depending on race and geographic origin in the case of both immigrants as well as their children. The sex ratio also varies based on sample collected from various populations as can be seen in the example of men showing more negative mental health problems which last for a longer period of time. Another example can be seen in mood symptoms and shorter presentation a characteristic that is present in both men and women. 3.6 CO-MORBIDITY In people with schizophrenia those rate of co morbidity arising from complications caused by substance-related disorders is quite high. More than half of those with this problem smoke or heavily use tobacco. Likewise, co-morbidity rates due to anxiety disorder are also rising as is the same with those having obsessive-compulsive disorder, panic disorder when compared to the population in general. Prior to the onset of this problem, it is possible for a person to experience Schizotypal or paranoid personality disorder. Those who have succumbed to schizophrenia due to medical problems have a reduced life expectancy. Some of the health issues that they experience more in comparison to the general population include weight increase, diabetes, cardiovascular, poor metabolism and pulmonary disease. They also do not have proper involvement in these activities essential to maintain health, preventing or curing their health issues. This enhances the possibility of chronic disease setting in and also succumbing to other issues such as smoking, poor diet, bad lifestyle and excessive medications. The reason for such levels of schizophrenia medical co- morbidity is the vulnerability towards succumbing to psychosis and medical disorders Recently, a lot of studies done on clinical and community samples diagnostic patterns revels that the presence of comorbidity in those with mental disorders is quite prevalent(Kessler, 1995). It is to be noted that those who have this particular mental health problem are more likely to succumb to mental disorders than people in the general population. About 25 percent of those with this problem have a depressed mind state. It is in the early stages of a psychotic relapse that depression is said to come about. Those who experience this when they are in the remission state of a psychotic episode are more prone to suicide. This is said to happen particularly to young men with this disorder, premorbid behaviour, lack of hope and big life expectations(Caldwell and Gottesman, 1990). Recently what was noted is that people with schizophrenia succumbed to substance abuse, a problem seen particularly in developed countries. Studies show the level of substance drug usage in those with schizophrenia is more than 25 % for drugs and 30% for alcohol (Regier et al., 1990). Smoking habit is more than 50% (Masterson and O’Shea, 1984). It also reveals that people affected by this problem like to 88 CU IDOL SELF LEARNING MATERIAL (SLM)
take specific drugs such as cocaine, cannabis, amphetamines, hallucinogens (Schneier and Siris, 1987). It is to be noted that complication arising from a person suffering from schizophrenia doing drugs reduces the effectiveness of getting treatment. This situation makes the positive psychotic symptoms worse and can also lead to more violent situation as well as distancing from others socially. (Cuffel et al., 1994). They are also more likely to get into very serious or chronic medical issues, which enhance both morbidity and mortality. This is particularly true with regards to those having heart problems (Jeste et al., 1996). Recently, those suffering from schizophrenia also succumb to HIV infection now and the prevalence rates of this issue are about 7% (Sewell, 1996). 3.7 CAUSES OF SCHIZOPHRENIA Schizophrenia is a problem caused by so many factors and scientists are still trying to get more details on it by finding out more about such factors. Common causes for this problem include: Genetics When diagnosing schizophrenia, factors such as vulnerability caused by genetic issues and the environment is taken into consideration. In assessing genetic vulnerability, it has been found that several genes interacting with one another in multiple ways are the factor. In studies done on individuals, twins and twin study meta-analysis, it is revealed there is about 80 percent risk of inheriting this disorder. (This theory is applying to variations in people from a population affected by genetic factors ). The concordance rates with respect to monozygotic twins are about 50 percent but it is 17 percent in dizygotic twins. Those who have parents with schizophrenia have an increased risk of getting it. Phenotype is influenced by genetics, but it is does not determine it. Gene variation is also inside the normal human variation range and they also have a low risk for individuals as well as those who interact with other and also those exposed to certain types of environmental risks. In the study of schizophrenia development in twins, the rate discovered were as low as 11.0% to 13.8% in the category of monozygotic twins and in the case of dizygotic twins it is 1.8% to 4.1%. The study of “Pairs of Veteran Twins” shows schizophrenia existed in 338 pairs and in only 26 pairs were concordant. In one of the reports of this study, it was stated that genetic factors had little to do with getting affected. In 85 percent of those affected by schizophrenia who were monozygotic pairs discordant results were shown on this disease. Certain scientists 89 CU IDOL SELF LEARNING MATERIAL (SLM)
do not approve of the twin studies research and report that relating genetics to schizophrenia is somewhat not clear and is subject to various forms of interpretations. Prenatal Obstetric Complications This is a problem that is seen to occur in about 25% to 30% of the general population. It is to be noted that most people with schizophrenia did not succumb to a detectable obstetric event. However, it is to be noted that events of prenatal obstetric complications can actually moderately affect genetic, environment risk factors. The exact influence of an event on schizophrenia, and the extent of such an effect are still being studied. It has been studied that people with this disorder are most likely to have their birth in the months that fall in winter and spring season. Foetal Growth It has been observed that the foetus growth is slow and the reason for this is genetic issues and also weight is a little less than the usual birth weight. So, if any problem were to affect the foetus, its growth rate will also be affected. Hypoxia Out of the many factors that highly influence getting into schizophrenia, one is Hypoxia although the research on this is very epidemiological. In such research what is noted is that hypoxic influence is quite strong given the fact that this illness is seen in a specific pattern in certain families and as a result it can also be genetic, which almost leads to the conclusion that hypoxia is the key cause. When there are certain unidentified genes present, foetal hypoxia is related to reduction in hippocampus, which is a factor that also relates with schizophrenia. Infections Out of the many reasons as to why a person can get schizophrenia in the later years of life, succumbing to various types of viral infections inside the uterus else during childhood is the key reason. Those who are born in the months ranging from winter to spring are more likely to get this issue than others as this is the period of the year in which infection spread fast. It can also be triggered by succumbing to influenza. Second trimester foetuses that were exposed to Asian flu are people who have more risk of getting schizophrenia. Other Factors Childhood antecedents: In the process of studying childhood antecedents of this disorder, the deviation from norm in various groups that were examined can be good as well as poor. Only subtle features in behaviour has been noted which indicate this disorder and there is only 90 CU IDOL SELF LEARNING MATERIAL (SLM)
small evidence in the form of psychotic-like experiences and other types of cognitive antecedents. There have been some inconsistencies in the particular domains of functioning identified and whether they continue through childhood and whether they are specific to schizophrenia. A prospective study found average differences across a range of developmental domains, including reaching milestones of motor development at a later age, having more speech problems, lower educational test results, solitary play preferences at ages four and six, and being more socially anxious at age 13. Lower ratings of the mother’s skills and understanding of the child at age 4 were also related. Substance Use Exactly how much schizophrenia is connected with drug use is complicated to estimate. It is noted that there is strong evidence showing that particular drugs can bring on this mental disorder quickly and also cause a relapse in those already affected by it. It is to be noted that those having schizophrenia take drugs so that they can counteract the negative feelings arising due to antipsychotic medication used for treating it as well as the negative feelings caused by the disorder itself in the form of poor emotions, paranoia and anhedonia. It is a fact that people in this group are into substance abuse and it can be even clearly stated that in a recent study what was determined is that about 60 percent of those with this problem used substances while 37 percent can be said to have a substance abuse disorder. Social Adversity If there are more adverse occurrences in childhood, the chances of getting schizophrenia are more. If there are a lot of stressful events, the chance of getting this problem is more. Those whose family has a history of immigration are at considerable risk as it is liked with issues such as family dysfunction, poor housing conditions, unemployment, psychosocial adversity, social defeat from being an outsider, racial discrimination. When a person as a child has undergone significant trauma that person is more at risk of getting schizophrenia in the later stages of life. When this issue is examined in a large population, what is seen is that there is no real indication of this happening. However, the risk of it happening enhances as there is more experience of abuse in such persons. Furthermore, the conceptual and methodological issues of this conclusion need to be further analysed. Urbanicity There is an influence caused by living in an urban environment and schizophrenia development, even in the presence such as ethnic group, social group size and drug usage factors are controlled in the study. In Sweden, a study was done about this on 4.4 million men and women and the findings showed that those who were living in very urban environments 91 CU IDOL SELF LEARNING MATERIAL (SLM)
showed an increased risk of getting psychosis, a huge portion is which is mostly to be considered as schizophrenia. The risk of getting schizophrenia is more in those who have spent many years living in an urban environment during their younger years. This reveals that frequently or constant exposure to this environment in the growing years is the key to an association with this mental illness. The many explanations given on the effect have been judged a not possible due to the findings nature, which include issue such as genetic stress or infections. The risk of getting this disorder is more with those have certain type of genetic makeup and then again it is present in various ways throughout different neighbourhoods. The amount of social interaction such as bonding, safety, trust also have an impact on it developing n growing children living in such circumstances. 3.8 PROGNOSIS AND TREATMENT Prognosis The path that schizophrenia treads is one that is full of complications and also remissions. Improvement is seen more in patients who are living in developing countries than those in developed ones. After the first occurrence in such patients, there is recovery, and they go on to living normally for a long period of time. How the disease influences a person after the first five years from the time of diagnosis shows future trend of this disease. In the event of relapse what is seen is there the patient’s foundation of functioning weakens further. In an individual patient it is not possible to accurately determine the course of schizophrenia. In the event of some factors there is a good prognosis, and this includes history of disorders in the family, onset at a late age, being a female, premorbid work history and social relationships, married, maintaining a job in a stable way, proper support from family etc. If there is poor prognosis, issues such as insidious onset, divorce, history of schizophrenia in the family, neurological signs, prenatal trauma history, no enhancement after three years of treatment, relapse etc are present. Treatment It is possible to manage patients with schizophrenia by administering antipsychotic drugs and also through the use of psychosocial interventions. The aim of giving such treatment is to make the patient gets back to normal life and be productive. The given treatment is in accordance with the patient’s special needs and also their family conditions. The primary treatment course involves use of antipsychotic drugs as they stop the symptoms of this disorder and also prevent any further relapse from occurring. Education about the disorder given to the family member enables them to better manage the problem. It is to be noted that 92 CU IDOL SELF LEARNING MATERIAL (SLM)
rehabilitation is the key to bringing back the vocational and educational normally to the affected person. Primary prevention refers to reducing the incidence of a particular health problem in a population that is yet to be affected by it. Two key strategies involved here are prevention and health promotion. (Eisenberg, 1993). Preventing an illness helps to set up certain types of interventions by changing one or two risk factors while promoting health seeks to improve health raising activities in the community as a whole which works to prevent disorders from setting into it. Prevention of this problem largely lies in finding the problem quickly in those who show its early symptoms, which in turn will bring down mobility by quick treatment. The key difference between primary and secondary treatment given for this problem largely lies in sound knowledge on the patient’s illness history and also proper findings about the complete symptoms, precursors and prodromes of it. It is when the disorder becomes more pronounced that methods for prevention of onset move from primary ones to secondary (Eaton et al., 1995). When schizophrenia sets into a personality, there is a complicated interplay of elements, with prodromal symptoms, low prevalence of risk factors. This situation is aggravated by the fact that there is no proper method to assess disorder vulnerability which actually limited what can be done as a preventative intervention to curb it. There is a lot of documented evidence on how it can be genetically transmitted however as it can also be created with non-genetic disorder the lack of genetic markers make predicting risks caused by genetic factors very wrong. It is only a small group of people who get schizophrenia because someone in the family is also affected by it. Hence such issue rule along with ethical factors out the chance of giving genetic counselling. It is to be noted that preventing pregnancy problems by bringing about safe pregnancy, childbirth conditions will only contribute less towards bringing down the risk of getting schizophrenia and other types of mental, neurological disorders. However, there is no specific data available to support this idea. The psychosocial approach model for preventing schizophrenia has been brought forth recently (Laporta and Falloon, 1992; Birchwood et al., 1997). It involves a mix of the following methods: • Given education to the community about psychoses. • Bringing mental health programs into primary care service . • Finding out the early warning signs of a disorder that can be severe by doctors and community agencies. • Carrying out assessment and treatment methods at home intensively on people who are at arise of developing the problem. 93 CU IDOL SELF LEARNING MATERIAL (SLM)
Key persons in the community should put importance on stress management and using various ways to solve problems quickly. By developing methods that enhances mental health in those who show risk of developing issues due to social environment can actually subside the onset of this mental disorder, even if it is done using non-specific interventions. In the event of a frank psychosis, it is possible to initiate treatment faster. Such methods should be encouraged as they pay attention to bringing about basic health care which brings down the negative association of getting psychiatric treatment and also makes way for early access to treatment. This feature is very important given the fact that the lack of proper treatment when schizophrenia first arises is about one year (Birchwood et al., 1997). However, their effective as a complete preventative method is yet to be determined as more research is needed on this matter. Pharmacological Treatment Only a qualified physician to give drugs for this disorder and their treatment process begins by giving antipsychotic drugs which should be taken at home. These should be taken as soon as possible because symptoms caused by the disorder reduce very slowly. At first, it is the sleep, appetite issues that are resolved, followed by agitated behaviour which reduces, and then psychotic symptoms and negative symptom also reduce by they take a long time to change. Drugs that are administered are given in low dosage and this is increased slowly based on the response showed by the patient. This administration should be done for period of four to six weeks and it is vital to continue giving the drug even after improvement is shown, however this should not be done for a long period of time. This administration is essential to stop a relapse, prevent personality from deteriorating. Upon advice from the doctor, it should be stopped and most patient who are given antipsychotic drugs show proper improvement. It is vital for family members to gain knowledge about the possibility of a relapse, how it will occur, what the symptoms will be like and what to do about the situation. The drug needs to be region in such cases. It is to be noted that even when education is given continuously about 20 percent of the cases get into a relapse. The intensity of the symptoms and how often the relapses occur is lesser than earlier. .The possibility of hospitalisation which extends to some four to six weeks happens in the event of a person being wrongly diagnosed, showing poor behaviour, has ideas about suicide, is showing tendency for behaving violently and is on the whole incapable of being managed. The level to which patients are ready to follow give treatment medication doses influences how much treatment can be actually administered to the person. If the patient is not ready to comply with given medication intake, there is hardly any improvement in the symptoms and as such there can even be a relapse even in those who show improvement. There are several 94 CU IDOL SELF LEARNING MATERIAL (SLM)
factors influencing non-compliance in drug intake, the foremost being the poor outlook towards it by both the patient and family members. Some people think of taking many drugs as an addiction and some feel they are not really ill, so they do not really require the drugs. Suppose the doctor giving the medication has not given proper explanation about it or family members as well as the patients are not clear about the instructions on intake, they take the wrong dose at the wrong time or actually stop taking it thinking that the affected person is better. In order to improve taking drugs regularly, it is vital to inform both patients and family members about what medicines have to be taken. Usually most of them have to be taken at night in a single dose and their intake can be based according to the work and home routines of the patient. It is vital to study the oral intake of these medications because some patients will find it difficult to swallow tablets and can even throw them away. It is also possible to administer certain drugs in the form of injections, usually long acting one, give at an interval of two to four weeks. It was about years ago that schizophrenia treatment through medication administration was initiated and also set into effect as a form of practise. At this point, it is vital to differentiate between conventional and atypical antipsychotic drugs. Traditional antipsychotic drugs that are mostly used are given in Table 2. In spite of the difference in the structure of these drugs, their key function of these medications is to block dopamine D2 receptors in the mesolimbic and nigrostriatal areas of the brain. The kind of effect they have on psychotic symptoms is connected with their effect on the mesolimbic system. All of these drugs basically show the same results but for reasons unknown some patients can improve better with certain drugs than with others. It is very clear as to how such drug can bring down the symptoms of not just a disorder like schizophrenia, but also other types of disorders that have psychotic features. However, it is to be noted that they have a mild impact on negative symptoms. In about 75 percent of patients there is a marked improvement as per the findings of clinical trials in a period ranging from six to fourteen weeks. In this study chlorpromazine equivalents were administered in a dosage ranging from 300 mg to 750 mg for acute schizophrenia symptoms when compared to some 25% treated who were treated with a placebo (Dixon et al., 1995). After a clinical remission, the strength in stopping a relapse is well-established although it is not very impressive. Relapse risk in the first year after an acute episode using antipsychotic medications sis brought down to 20% when compared to the 60% who were given a placebo. The data available is limited for more than a single year and those given a placebos show relapse rates similar to those who have been given medication after some two or three years. Using drugs causes delay but there is no suppression of a relapse. 95 CU IDOL SELF LEARNING MATERIAL (SLM)
After an acute episode, it is yet not clear as to how long treatment should proceed. In case of patients in their first episode and who show a complete remission, medication is tapered or stopped within a time period of six months to two years. (Dixon et al., 1995). Those patients who have had many episodes or who are not exhibiting a full remission, there is so specific rules and medication decisions are based on their individual mentality, costs and also the benefits gained through treatment. The unnecessary exposure to large level of medication can cause the development of tardive dyskinesia as well as other types of side effects. This problem leads to finding out the lowest but safe level of dosage. Hence it can be said that they are two specific truant approaches one which is the targeted approach and the other is the low-dosage one. Until now it is the use of low-dose medication that is highly supported Schooler, 1991). In reality, the advantage of using such drugs is curbed by various issues. These drugs bring about many side effects which are both distressing and also problematic. Such side effect include feeling sleepy, experiencing issues such as stiffness, tremors, acute dystonias, akathisia, akinesia and shuffling gait, enduring anticholinergic effects, having cardiovascular problems like tachycardia and postural hypotension, experiencing endocrine issues like amenorrhea, galactorrhea. Getting obesity, neuroleptic malignant syndrome, skin and eye diseases are also part of the problem. Figure 3.1: Conventional Antipsychotic Drugs Though drug side effects are quite mild and also limited due to the time factor during which they are present, there can be some which need to be given attention as they are signs of something more serious. It is noted that about 70 percent of patients experience Akathisia and other extrapyramidal symptoms and that patients endure a lot of subjective distress such as inability, anxiety, restlessness, anxiety etc, In the event of a patient developing very severe 96 CU IDOL SELF LEARNING MATERIAL (SLM)
akathisia that person can show very aggressive behaviour or suicidal acts (Van Putten and Marder, 1987). Tardive dyskinesia is a huge problem that has come about due to the administration of antipsychotics in which the patient can be seen to exhibit a lot of abnormal involuntary movements of various body parts. This problem can be very difficult to manage in its very severe forms and it can also affect activities such as eating, breathing and also walking. It occurrence is four percent every year during a period of five to six years after exposure to the drug and how it prevails in patients during the maintenance period is about at least 20% (Kane et al., 1988). The outcome of abnormal movements is beyond what can be explained medically and according to findings of studies on this problem, it is enhanced by information given by patients that can enhance negative symptoms which can also trouble interpersonal abilities. (Estroff, 1981). Resistance to the given treatment procedures is also another issue and according to recent study. It is seen that about 20-30% patients do not give any response to strong treatment and such a percentage is likely to relapse even though their treatment process is consistent and on-going (Kane, 1996). As such there is no problem understanding gained as to why this happens. When treating schizophrenia, there is poor compliance in medication intake, with 50% outpatients as well as 20% inpatients not taking the medication as prescribed by the doctor. The use of depot injections is inadequate in problem resolution even in setting that is observed (Young et al., 1986). The reason given for noncompliance include many such as drugs side effect, disagreement between doctor and patient, lack of understanding about the disorder, lack of details about the given drugs, misconception about drug intake (Estroff, 1981). Compliance is a problem that limits the reach of antipsychotics: in disorder treatment. Many users do not want to take the medication and those who do complain about discomfort that it causes emotionally. In clinical trials such problems are overlooked but now they have come to gain a focus (Awad, 1992). It is vital for doctors to listen to the subjective experience occurring with intake of medication and discuss collaboratively with used about its use in long term treatment. In recent times, with the coming of called “new” or “atypical” antipsychotics, hope have risen about better treatment results, primarily because such drugs do not have the side effects seen in traditional schizophrenia medications. The common feature of Atypical antipsychotics is basically two, one which is its effect on mesolimbic neurons and less influence on the nigrostriatal neurons but greater affinity towards the 5-HT2 than D2 receptors. It also shows psychotic symptoms effect with low chances in occurrence of extrapyramidal side-effects. 97 CU IDOL SELF LEARNING MATERIAL (SLM)
The first type of atypical antipsychotic drug to be brought into the treatment procedure is Clozapine which showed as much effectiveness as antipsychotics on positive symptoms. This was the case for both acute as well as maintenance treatment process. It also reduced psychotic symptoms in about 30-60% of those patients who did not show response to proper conventional antipsychotics dosage and it is associated with getting extrapyramidal symptoms extrapyramidal symptoms (Buchanan, 1995). It is seen that clozapine does create many types of side-effects and can also bring about agranulocytosis which can occur win=within first six moth treatment period. Since agranulocytosis can be fatal, it should be detected quickly and after it has been found the drug should be immediately stopped. Furthermore, the patient given the drug must undergo white blood cell monitoring on a weekly basis for the first eighteen weeks and also after every four weeks so as long as they have to intake the drug. Some other problems that can arise due to side effects include tachycardia, sedation, weight gain, hypotension in about ten percent of the patients. It is to be noted that Clozapine is a costly drug with expenses coming to about £2000 in the United Kingdom on an annual basis per patient. In the U.S it costs likewise at $8500 dollars some t times more regular drugs costs (Fitton and Benfield, 1993. Moreover, it is essential to keeping mind that it is not possible to give generalized analysis over social and health care systems on the cost benefits of using it. Since regular blood sampling has to be done clozapine cannot be used very heavily and its usage can actually make patients not stick to their usual treatment process, as is seen with a 50 percent noncompliance in certain studies (Hirsch and Puri, 1993). Use of clozapine therapy is having issues as it is not giving the kind of treatment flexibility and quick access as is demanded in community care. Some of the other atypical antipsychotics currently sold or being developed are olanzapine, risperidone and quetiapine (Pantelis and Barnes, 1996). There is also new information showing that such neuroleptic drug work well both in terms of their effect and also low side effects. In fact, the use of atypical antipsychotics is the first progress that is seen in psychoses medical treatment for the past 40 years. However, they are not used as much as they should be currently and, in the years, to come, how much their usage is being further developed. Psychosocial Treatment It is to be noted that schizophrenia is a problem that affects people at young age, when they are in their schooling period, training for a job else finding friends. Due to the effects of this problem, they will be unable to finish their education else get skills to take up a work opportunity or lack what is needed to make close friendships. In such cases psychosocial interventions can be sued and they are not medically related, which enable in dealing with 98 CU IDOL SELF LEARNING MATERIAL (SLM)
various problems both at the personal and work front. Out of the many only two types of psychosocial interventions will be considered - psycho education and rehabilitation. Psycho Education Psycho education aims at improving the treatment compliance, reducing risk of relapse and admission rates. In India, families are the primary care givers for 95% of the persons with schizophrenia and experience significant burden and stigma. They should be engaged early in the treatment. The psycho education also helps in decreasing the burden and stigma experienced by their families. The families and patients are educated over multiple sessions about the schizophrenia. Common misconception about schizophrenia, especially in the rural areas, is that it is due to curse/black magic/sins of previous births and should be treated by faith healers. They have to be educated that it is a biological disease like heart disease/diabetes mellitus with multi factorial causation and should be treated with drugs prescribed by a qualified physician. They are also explained about various drug treatments available, their side effects, and schedule of how to take these drugs. They may have apprehensions about use of antipsychotic drugs in the treatment. Some may worry that the antipsychotic drugs are addicting and turn the patient into a zombie. It has to be explained that these drugs are not addicting as these do not produce joy or drug seeking behaviour. Also, they may believe that these drugs act as a kind of mind control by sedating the patient. Though sedating effect of these drugs can be useful, but it is their ability to diminish the hallucinations, agitation, confusion, and delusions which is curative. They have to be explained that although medications do have some side-effects, their beneficial effects far outweigh the side effects. They should keep a record of name of medications, side effects and effectiveness of the medications. They need to be psycho-educated about issue of drug compliance in these patients as about 50% of outpatients and 20% of inpatients fail to take prescribed medications. So, ensuring drug compliance is very important. They are also sensitized to the variations in chances of recovery. There is also the wrong idea that some of the patients are lazy, show violent behaviour and trying to cure them is impossible. However, it is to be noted that many stay alone because they want to, and they do not indulge in violent activities. The cognitive symptoms experienced are what bring out the laziness and inactivity in them. It is those that are indulging in drugs or alcohol that are violent in nature and they do such action as a response to the auditory hallucinations that come with threats or persecutory delusions. At such time, it is vital to manage the patient with case, The affected person must do some daily schedule of activities and also carry out simple task inside their home. It is seen that when they are done and some encouragements give, the patient’s self-esteem boosts and also their productivity. It is vital or support to come from 99 CU IDOL SELF LEARNING MATERIAL (SLM)
family members and any emotional reactions from patient must be reduced, considered in a very practical manner. Patients should be interested in having conversation and should also have long regular conversation. No family member should criticise them when they are like this even if the patient sounds dull. The family can be given a checklist of the patient’s illness symptoms so that any relapse signs which can be seen in the form of issues such as lack of sleep, restless feelings, hallucinations etc, can be identified quickly. In such a situation, the affected person must be taken to the psychiatrist right away so that treatment and medication can be administered once again. The causal role of dysfunctional child-rearing patterns and disturbed family communication was a cornerstone of early social theories of schizophrenia between the 1950s and the late 1970s. Such theories, although weakly supported by empirical data, enjoyed wide popularity among professionals, particularly in the USA and other western countries, unfortunately contributing to negative attitudes towards patients’ relatives and adversarial relationships between professionals and families. During the 1950s and the late 1970s, it was thought that the key reason for succumbing to schizophrenia was improper child-rearing and poor communication inside the family. Though such ideas were not properly supported by data, they were quite popular with health care professionals especially those in the U.S and other western countries. This gave a poor impact on the relatives of a patient and also led to patient doctor conflicts. More research was conducted to determine how family interaction factors and family members’ beliefs influenced schizophrenia course and various other types of mental and physical disorders (Leff and Vaughn, 1985). It is due to this approach family-based interventions were designed, and they made use of the caring family unit as a means of taking care of the affected person. As a result, the possibility of a relapse reduced, and it also brought down family burden in managing the problem. Such interventions are called “psycho educational”, “supportive” or “behavioural” and they have many common features such as: • Family should be engaged in the treatment process very early in an environment that is “no fault”. • Family should be educated about the features of about schizophrenia which is given through details such as rationale for various treatments, variation in prognosis, vulnerability-stress model, etc. • Family should get trained in how to communicate with the affected person as this helps in better treatment and aids in the positive and negative feedback exchange inside the family. 100 CU IDOL SELF LEARNING MATERIAL (SLM)
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