Psychiatric Disorder

Pervasive developmental disorder are characterized by severe deficits and impairment in reciprocal social interaction and communication, and include the presence of stereotyped behavior, interests, and activities refers to a group of five disorders characterized by delays in the development of multiple basic functions including socialization and communication. The pervasive developmental disorders are 1.Autism sometimes called “classical autism” the most common condition in a group of developmental disorders known as the autism spectrum disorders (ASDs). the most commonly known, brain development disorder that impairs social interaction and communication refers to a disorder of development consisting of gross and sustained impairment in social interaction and communication accompanied by restricted and stereotypical patterns of behavior These symptoms all start before a child is three years old. Some common signs of autism There are three distinctive behaviors that characterize autism. Autistic children have difficulties with social interaction, problems with verbal and nonverbal communication, and repetitive behaviors or narrow, obsessive interests. These behaviors can range in impact from mild to disabling. The hallmark feature of autism is impaired social interaction. Parents are usually the first to notice symptoms of autism in their child. As early as infancy, a baby with autism may be unresponsive to people or focus intently on one item to the exclusion of others for long periods of time. A child with autism may appear to develop normally and then withdraw and become indifferent to social engagement. Children with autism may fail to respond to their name and often avoid eye contact with other people. They have difficulty interpreting what others are thinking or feeling because they can’t understand social cues, such as tone of voice or facial expressions, and don’t watch other people’s faces for clues about appropriate behavior. They lack empathy. Many children with autism engage in repetitive movements such as rocking and twirling, or in self-abusive behavior such as biting or head-banging. They also tend to start speaking later than other children and may refer to themselves by name instead of “I” or “me.” Children with autism don’t know how to play interactively with other children. Some speak in a sing-song voice about a narrow range of favorite topics, with little regard for the interests of the person to whom they are speaking. Many children with autism have a reduced sensitivity to pain, but are abnormally sensitive to sound, touch, or other sensory stimulation. These unusual reactions may contribute to behavioral symptoms such as a resistance to being cuddled or hugged. Children with autism appear to have a higher than normal risk for certain co-existing conditions, including fragile X syndrome (which causes mental retardation), tuberous sclerosis (in which tumors grow on the brain), epileptic seizures, Tourette syndrome, learning disabilities, and attention deficit disorder. For reasons that are still unclear, about 20 to 30 percent of children with autism develop epilepsy by the time they reach adulthood. While people with schizophrenia may show some autistic-like behavior, their symptoms usually do not appear until the late teens or early adulthood. Most people with schizophrenia also have hallucinations and delusions, which are not found in autism. What causes autism? Scientists aren’t certain what causes autism, but it’s likely that both genetics and environment play a role. Researchers have identified a number of genes associated with the disorder. Studies of people with autism have found irregularities in several regions of the brain. Other studies suggest that people with autism have abnormal levels of serotonin or other neurotransmitters in the brain. These abnormalities suggest that autism could result from the disruption of normal brain development early in fetal development caused by defects in genes that control brain growth and that regulate how neurons communicate with each other. While these findings are intriguing, they are preliminary and require further study. The theory that parental practices are responsible for autism has now been disproved. How is autism treated? There is no cure for autism. Therapies and behavioral interventions are designed to remedy specific symptoms and can bring about substantial improvement. The ideal treatment plan coordinates therapies and interventions that target the core symptoms of autism: impaired social interaction, problems with verbal and nonverbal communication, and obsessive or repetitive routines and interests. Most professionals agree that the earlier the intervention, the better. Educational/behavioral interventions: Therapists use highly structured and intensive skill-oriented training sessions to help children develop social and language skills. Family counseling for the parents and siblings of children with

autism often helps families cope with the particular challenges of living with an autistic child. Medications: Doctors often prescribe an antidepressant medication to handle symptoms of anxiety, depression, or obsessive-compulsive disorder. Anti-psychotic medications are used to treat severe behavioral problems. Seizures can be treated with one or more of the anticonvulsant drugs. Stimulant drugs, such as those used for children with attention deficit disorder (ADD), are sometimes used effectively to help decrease impulsivity and hyperactivity. Other therapies: There are a number of controversial therapies or interventions available for autistic children, but few, if any, are supported by scientific studies. Parents should use caution before adopting any of these treatments. Rett syndrome (also called Rett disorder) is a neurodevelopmental disorder that is classified as a pervasive developmental disorder by the DSM-IV. It was first described by Austrian neurologist Andreas Rett in 1966. is an X-linked, progressive neurodevelopmental disorder and one of the most common causes of mental retardation in girls. The gene for this disorder has been found (Baker, 2000). For families who have an identified mutation in the gene, genetic testing may be considered for prenatal diagnosis. That is, for those families who have a child with Rett's disorder or someone in the family with Rett's disorder and the identified gene, genetic testing will be done to help with a possible prenatal diagnosis.The clinical features include a deceleration of the rate of head growth (including microcephaly in some) and small hands and feet. Stereotypic, repetitive hand movements such as mouthing or wringing are also noted. Symptoms of the disorder include cognitive impairment and problems with socialization, the latter during the regression period. Socialization typically improves by the time they enter school. Girls with Rett syndrome are prone to gastrointestinal disorders and up to 80% have seizures.[1] They typically have no verbal skills, and about 50% of females are not ambulatory. Scoliosis, growth failure, and constipation are very common and can be problematic. Cause Rett syndrome (symbolized RTT) is caused by mutations in the gene MECP2 located on the X chromosome and can arise (1) sporadically or (2) from germline mutations. Development and symptoms The infant with Rett syndrome often avoids detection until 618 months due to a relatively normal appearance and some developmental progress. However closer scrutiny reveals disturbance of the normal spontaneous limb and body movements that are thought to be regulated in the brain stem. The brief period of developmental progress is followed by stagnation and regression of previously acquired skills. During regression some features are similar to those of autism. It is, hence, easy to mistakenly diagnose Rett syndrome for autism. Symptoms of Rett syndrome that are similar to autism: screaming fits panic attack inconsolable crying avoidance of eye contact lack of social/emotional reciprocity general lack of interest markedly impaired use of nonverbal behaviors to regulate social interaction loss of speech Balance and coordination problems, including losing the ability to walk in many cases Symptoms of Rett syndrome that are also present in cerebral palsy (regression of the type seen in Rett syndrome would be unusual in cerebral palsy; this confusion should rarely be made): possible short stature, and/or might be unusually proportioned because of difficulty walking or malnutrition due to difficulty swallowing. hypotonia delayed or absent ability to walk gait/movement difficulties ataxia microcephaly in some - abnormally small head, poor head growth some forms of spasticity chorea - spasmodic movements of hand or facial muscles dystonia bruxism - grinding of teeth Symptoms may stabilize for many decades, particularly for interaction and cognitive function such as making choices. Anti-social behavior may change to highly social behavior. Motor functions may slow as rigidity and dystonia appear. Seizures may be problematic, with a wide range of severity. Scoliosis occurs in most and requires corrective surgery in about 10%. Those who remain ambulatory tend to have less progression of scoliosis. Treatment and prognosis Currently there is no cure for Rett syndrome, although there have been some promising results with gene therapy in mice.[9] Treatment of Rett syndrome includes: management of gastrointestinal (reflux, constipation) and nutritional (poor weight gain) issues surveillance of scoliosis and long QT syndrome increasing the patient's communication skills, especially with augmentative communication strategies

parental counseling modifying social medications sleep aids SSRIs anti-psychotics (for self-harming behaviors) beta-blockers rarely for long QT syndrome Occupational therapy, Speech therapy and Physical therapy are use to treat children with Rett syndrome. Childhood disintegrative disorder also known as Heller's syndrome and disintegrative psychosis, is a rare condition characterized by late onset (>3 years of age) of developmental delays in language, social function, and motor skills. Researchers have not been successful in finding a cause for the disorder. CAUSE The exact causes of childhood disintegrative disorder are still unknown. Sometimes CDD surfaces abruptly within days or weeks, while in other cases it develops over a longer period of time. A Mayo Clinic report indicates: "Comprehensive medical and neurological examinations in children diagnosed with childhood disintegrative disorder seldom uncover an underlying medical or neurological cause. Although the occurrence of epilepsy is higher in children with childhood disintegrative disorder, experts don't know whether epilepsy plays a role in causing the disorder."[2] CDD has also been associated with certain other conditions, particularly the following: Lipid storage diseases: In this condition, a toxic buildup of excess fats (lipids) takes place in the brain and nervous system. Subacute sclerosing panencephalitis: Chronic infection of the brain by a form of the measles virus causes subacute sclerosing panencephalitis. This condition leads to brain inflammation and the death of nerve cells. Tuberous sclerosis (TSC): TSC is a genetic disorder. In this disorder, tumors may grow in the brain and other vital organs like kidneys, heart, eyes, lungs, and skin. In this condition, noncancerous (benign) tumors grow in the brain. Signs and symptoms A child affected with childhood disintegrative disorder shows normal development, generally up to an age of 2 years, and he/she acquires "normal development of age-appropriate verbal and nonverbal communication, social relationships, motor, play and self-care skills" comparable to other children of the same age. However, from around the age of 2 through the age of 10, skills acquired are lost almost completely in at least two of the following six functional areas: Language skills Receptive language skills Social skills & self-care skills Control over bowel and bladder Play skills Motor skills Lack of normal function or impairment also occurs in at least two of the following three areas: Social interaction Communication Repetitive behavior & interest patterns Treatment There is no permanent cure for CDD - loss of language and skills related to social interaction and self-care are rather serious. The affected children face permanent disabilities in certain areas and require long term care. Treatment of CDD involves both behavior therapy and medications. Behavior therapy: Its aim is to teach the child to relearn language, self-care and social skills. The programs designed in this respect "use a system of rewards to reinforce desirable behaviors and discourage problem behavior." The behavior therapy is used by a number of health care personnel from different fields like psychologists, speech therapists, physical therapists and occupational therapists. At the same time, parents, teachers and caregivers also use the behavior therapy. A consistent approach by all concerned result into a better treatment. Medications: There are no medications available to treat directly CDD. Antipsychotic medications are used to treat severe behavior problems like aggressive stance and repetitive behavior patterns. Anticonvulsant medications are used to control seizures. Asperger syndrome, a disorder similar to autism characterized by impaired behavior and social interaction but with no impairment in communication is unknown, family studies suggest a possible relationship to autistic disorder. The similarities between the two disorders support the presence of genetic, metabolic, infectious, and perinatal contributing factors. Although definitive data regarding the prevalence of Asperger's disorder are lacking, the disorder appears to be diagnosed much more frequently in males (at least 5 times more) than in females (APA, 2000; Sadock & Sadock, 2003). Asperger syndrome (AS) is a developmental disorder that is characterized by: 1 limited interests or an unusual preoccupation with a particular subject to the exclusion of other activities repetitive routines or rituals peculiarities in speech and language, such as speaking in an overly formal manner or in a monotone, or taking figures of speech literally socially and emotionally inappropriate behavior and the inability to interact successfully with peers

problems with non-verbal communication, including the restricted use of gestures, limited or inappropriate facial expressions, or a peculiar, stiff gaze clumsy and uncoordinated motor movements AS is an autism spectrum disorder (ASD), one of a distinct group of neurological conditions characterized by a greater or lesser degree of impairment in language and communication skills, as well as repetitive or restrictive patterns of thought and behavior. Other ASDs include: classic autism, Rett syndrome, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (usually referred to as PDD-NOS). Parents usually sense there is something unusual about a child with AS by the time of his or her third birthday, and some children may exhibit symptoms as early as infancy. Unlike children with autism, children with AS retain their early language skills. Motor development delays – crawling or walking late, clumsiness – are sometimes the first indicator of the disorder. The incidence of AS is not well established, but experts in population studies conservatively estimate that two out of every 10,000 children have the disorder. Boys are three to four times more likely than girls to have AS. Studies of children with AS suggest that their problems with socialization and communication continue into adulthood. Some of these children develop additional psychiatric symptoms and disorders in adolescence and adulthood. Although diagnosed mainly in children, AS is being increasingly diagnosed in adults who seek medical help for mental health conditions such as depression, obsessivecompulsive disorder (OCD), and attention deficit hyperactivity disorder (ADHD). No studies have yet been conducted to determine the incidence of AS in adult populations. 1 Adapted from the Diagnostic and Statistical Manual of Mental Disorders IV and the International Classification of Diseases - 10 Why is it called Asperger syndrome? In 1944, an Austrian pediatrician named Hans Asperger observed four children in his practice who had difficulty integrating socially. Although their intelligence appeared normal, the children lacked nonverbal communication skills, failed to demonstrate empathy with their peers, and were physically clumsy. Their way of speaking was either disjointed or overly formal, and their all-absorbing interest in a single topic dominated their conversations. Dr. Asperger called the condition “autistic psychopathy” and described it as a personality disorder primarily marked by social isolation. Asperger’s observations, published in German, were not widely known until 1981, when an English doctor named Lorna Wing published a series of case studies of children showing similar symptoms, which she called “Asperger’s” syndrome. Wing’s writings were widely published and popularized. AS became a distinct disease and diagnosis in 1992, when it was included in the tenth published edition of the World Health Organization’s diagnostic manual, International Classification of Diseases (ICD-10), and in 1994 it was added to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), the American Psychiatric Association’s diagnostic reference book. What are some common signs or symptoms? The most distinguishing symptom of AS is a child’s obsessive interest in a single object or topic to the exclusion of any other. Some children with AS have become experts on vacuum cleaners, makes and models of cars, even objects as odd as deep fat fryers. Children with AS want to know everything about their topic of interest and their conversations with others will be about little else. Their expertise, high level of vocabulary, and formal speech patterns make them seem like little professors. Children with AS will gather enormous amounts of factual information about their favorite subject and will talk incessantly about it, but the conversation may seem like a random collection of facts or statistics, with no point or conclusion. Their speech may be marked by a lack of rhythm, an odd inflection, or a monotone pitch. Children with AS often lack the ability to modulate the volume of their voice to match their surroundings. For example, they will have to be reminded to talk softly every time they enter a library or a movie theatre. Unlike the severe withdrawal from the rest of the world that is characteristic of autism, children with AS are isolated because of their poor social skills and narrow interests. In fact, they may approach other people, but make normal conversation impossible by inappropriate or eccentric behavior, or by wanting only to talk about their singular interest. Children with AS usually have a history of developmental delays in motor skills such as pedaling a bike, catching a ball, or climbing outdoor play equipment. They are often awkward and poorly coordinated with a walk that can appear either stilted or bouncy. Many children with AS are highly active in early childhood, and then develop anxiety or depression in young adulthood. Other conditions that often co-exist with AS are ADHD, tic disorders (such as Tourette syndrome), depression, anxiety disorders, and OCD. What causes AS? Is it genetic?

Current research points to brain abnormalities as the cause of AS. Using advanced brain imaging techniques, scientists have revealed structural and functional differences in specific regions of the brains of normal versus AS children. These defects are most likely caused by the abnormal migration of embryonic cells during fetal development that affects brain structure and “wiring” and then goes on to affect the neural circuits that control thought and behavior. For example, one study found a reduction of brain activity in the frontal lobe of AS children when they were asked to respond to tasks that required them to use their judgment. Another study found differences in activity when children were asked to respond to facial expressions. A different study investigating brain function in adults with AS revealed abnormal levels of specific proteins that correlate with obsessive and repetitive behaviors. Scientists have always known that there had to be a genetic component to AS and the other ASDs because of their tendency to run in families. Additional evidence for the link between inherited genetic mutations and AS was observed in the higher incidence of family members who have behavioral symptoms similar to AS but in a more limited form. For example, they had slight difficulties with social interaction, language, or reading. A specific gene for AS, however, has never been identified. Instead, the most recent research indicates that there are most likely a common group of genes whose variations or deletions make an individual vulnerable to developing AS. This combination of genetic variations or deletions will determine the severity and symptoms for each individual with AS. How is it diagnosed? The diagnosis of AS is complicated by the lack of a standardized diagnostic screen or schedule. In fact, because there are several screening instruments in current use, each with different criteria, the same child could receive different diagnoses, depending on the screening tool the doctor uses. To further complicate the issue, some doctors believe that AS is not a separate and distinct disorder. Instead, they call it high-functioning autism (HFA), and view it as being on the mild end of the ASD spectrum with symptoms that differ -only in degree -- from classic autism. Some clinicians use the two diagnoses, AS or HFA, interchangeably. This makes gathering data about the incidence of AS difficult, since some children will be diagnosed with HFA instead of AS, and vice versa. Most doctors rely on the presence of a core group of behaviors to alert them to the possibility of a diagnosis of AS. These are: abnormal eye contact aloofness the failure to turn when called by name the failure to use gestures to point or show a lack of interactive play a lack of interest in peers Some of these behaviors may be apparent in the first few months of a child’s life, or they may appear later. Problems in at least one of the areas of communication and socialization or repetitive, restricted behavior must be present before the age of 3. The diagnosis of AS is a two-stage process. The first stage begins with developmental screening during a “well-child” check-up with a family doctor or pediatrician. The second stage is a comprehensive team evaluation to either rule in or rule out AS. This team generally includes a psychologist, neurologist, psychiatrist, speech therapist, and additional professionals who have expertise in diagnosing children with AS. The comprehensive evaluation includes neurologic and genetic assessment, with in-depth cognitive and language testing to establish IQ and evaluate psychomotor function, verbal and non-verbal strengths and weaknesses, style of learning, and independent living skills. An assessment of communication strengths and weaknesses includes evaluating non-verbal forms of communication (gaze and gestures); the use of non-literal language (metaphor, irony, absurdities, and humor); patterns of inflection, stress and volume modulation; pragmatics (turn-taking and sensitivity to verbal cues); and the content, clarity, and coherence of conversation. The physician will look at the testing results and combine them with the child’s developmental history and current symptoms to make a diagnosis. Are there treatments available? The ideal treatment for AS coordinates therapies that address the three core symptoms of the disorder: poor communication skills, obsessive or repetitive routines, and physical clumsiness. There is no single best treatment package for all children with AS, but most professionals agree that the earlier the intervention, the better. An effective treatment program builds on the child’s interests, offers a predictable schedule, teaches tasks as a series of simple steps, actively engages the child’s attention in highly structured activities, and provides regular reinforcement of behavior. This kind of program generally includes: social skills training, a form of group therapy that teaches children with AS the skills they need to interact more successfully with other children cognitive behavioral therapy, a type of “talk” therapy that can help the more explosive or anxious children to manage

their emotions better and cut back on obsessive interests and repetitive routines medication, for co-existing conditions such as depression and anxiety occupational or physical therapy, for children with sensory integration problems or poor motor coordination specialized speech/language therapy, to help children who have trouble with the pragmatics of speech – the give and take of normal conversation parent training and support, to teach parents behavioral techniques to use at home Do children with AS get better? What happens when they become adults? With effective treatment, children with AS can learn to cope with their disabilities, but they may still find social situations and personal relationships challenging. Many adults with AS are able to work successfully in mainstream jobs, although they may continue to need encouragement and moral support to maintain an independent life. What research is being done? The National Institute of Neurological Disorders and Stroke (NINDS) is one of the federal government’s leading supporters of biomedical research on brain and nervous system disorders. The NINDS conducts research in its laboratories at the National Institutes of Health (NIH) in Bethesda, Maryland , and awards grants to support research at universities and other facilities. Many of the Institutes at the NIH, including the NINDS, are sponsoring research to understand what causes AS and how it can be effectively treated. One study is using functional magnetic resonance imaging (fMRI) to show how abnormalities in particular areas of the brain cause changes in brain function that result in the symptoms of AS and other ASDs. Another large-scale study is comparing neuropsychological and psychiatric assessments of children with possible diagnoses of AS or HFA to those of their parents and siblings to see if there are patterns of symptoms that link AS and HFA to specific neuropsychological profiles. NINDS is also supporting a long-range international study that brings together investigators to collect and analyze DNA samples from children with AS and HFA, as well as their families, to identify associated genes and how they interact. Called the Autism Genome Project, it’s a consortium of scientists from universities, academic centers, and institutions around the world that functions as a repository for genetic data so that researchers can look for the genetic “building blocks” of AS and the other ASDs. Since there are so many different forms of ASD, understanding the genetic basis of each opens the door to opportunities for more precise diagnosis and treatment. Knowing the genetic profile of a particular disorder could mean early identification of those at risk, and early intervention when treatments and therapies are likely to be the most successful. Pervasive Developmental Disorder - Not Otherwise Specified (PDD-NOS) is one of the pervasive developmental disorders and autism spectrum disorders. PDD-NOS is a diagnosis for people who are well-described by the "PDD" label, but can't be categorized by any other disorder. It is usually milder than autism and has similar symptoms to autism, with some symptoms present, and others absent.[1] The boundaries between PDD-NOS and nonautistic conditions are not fully resolved.[2] Sexual disorders include problems of sexual identity, sexual performance, and sexual aim. 4 There are three major catergories of sexual disorders: sexual dysfunctions, paraphilia, and gender identity disorders. Sexual Dysfunctions Sexual dysfunctions prevent or reduce an individual's enjoyment of normal sex and prevent or reduce the normal physiological changes brought on normally by sexual arousal.1 These dysfunctions can be classified by the phase of the sexual cycle in which they occur. It is important to keep in mind that the diagnosis of sexual dysfunction is made only when the disability persists.1 Any of them could occur occasionally or be caused by a temporary factor such as fatigue, sickness, alcohol, or drugs. The Desire Phase There are two types of dysfunctions that can occur during the desire phase. One is hypoactive desire, which is basically a disinterest in sexual activity. It results in a complete or almost complete lack of desire to have any type of sexual relation. This can often result in the participation in intercourse as a simple marital duty. 1 The second type is an aversion to sex. This is different from simple hypoactive sexual desire in that sexual activity actually repulses the person or makes them unusually apprehensive. This is most often the result of a traumatic sexual experience, such as molestation as a child or rape. The Arousal Phase Erectile dysfunction is the inability of males to attain or sustain erection long enough for coitus. The inability of females to become sexually aroused is sexual arousal disorder. The Orgasm Phase When males are unable to control ejaculation so that it occurs before satisfying sexual relations can take place with the partner, it is known as premature ejaculation. Ejaculatory incompetence is the lack or delay of reaching orgasm in males. The female version of this is inhibited

female orgasm, the lack or delay of reaching orgasm in females. Sexual Pain Disorders There are two sexual pain disorders. Dyspareunia is when pain occurs during intercourse. This is predominantly a female complaint, but it does occur in males occasionally. Vaginismus is a female disorder in which involuntary spasmodic muscle contractions occur at the entrance to the vagina when an attempt is made to insert the penis. If intercourse is attempted despite these contractions, a painful sexual experience results. Paraphilia Paraphilias are sexual behaviors in which unusual objects or scenarios are necessary to achieve sexual excitement.1 Eight paraphilias are recognized which are grouped into 3 broad catergories. Preferences for Nonhuman Objects There are two types of preferences for nonhuman objects: fetishism and transvestism. Fetishism A fetish exists when a person is sexually aroused by a nonliving object. It can manifest in two ways, one more extreme than the other. One form associates coitus with some object (most frequently women's panties or other undergarments1 ). It is relatively harmless if the action is taken playfully and is acceptable to the person's partner. Focus on certain parts of the body (feet, hair, ears, etc) aside from those part of the pleasurable foreplay, can become fetishistic in its hold on the individual. The more extreme form of fetishism is when a nonliving object completely substitutes for a human partner, such as underwear, boots, and shoes or such textured objects as velvet or silk. Here, orgasm is achieved when the person is alone, fondling the object. Transvestism This paraphilia exists when the person achieves sexual excitement by cross-dressing. This is very rarely found in females so the male side of this paraphilia will be used as the example. Two different purposes seem to be associated with this act in different individuals. In one aspect the person seeks to intensify sexual excitement in intercourse with a partner by only partially dressing as a woman. In the other form, the male moves about in full female regailia, which suggests some type of gender identity problem but not necessarily homosexuality. Preferences for Situations Causing Suffering Sadism and Masochism The term sadist is derived from the reported violent sexual exploits of the Marquis de Sade. "Sadist" is applied to those who derive sexual excitement from the pain of others. The term masochist was derived from the writing of Leopold von Sacher-Masoch whose characters sought out women who would beat them. "Masochist" is applied to those who derive sexual excitement through their own pain. Hence, sadists and masochists go hand in hand, one depending on the need of the other. The danger of these needs is that each may need succesively more brutal treatment to satisfy their sexual needs. Preference for Nonconsenting Partners The three types of this catergory of paraphilia are exhibitionism, voyeurism, and pedophilia. All three are considered crimes in this country and are almost entirely male crimes. Exhibitionism Exhibitionism is the exposure of one's genitals in a public place. It is the most prominent sexual offense leading to arrest and makes up one third of all sexual crimes.1 From the psychological point of view, there are three characteristic features of the exhibition. First, it is always performed for unknown women; second, it always takes place where sexual intercourse is impossible, for example in a crowded shopping mall; and third, it must be shocking for the unknown woman or it seems to lose its power to produce sexual arousal in the individual. Exhibitionists are not assaultive and are considered more of a nuisance than an actual danger. Voyeurism Looking at sexually arousing pictures or situations is a relatively common, apparently normal activity. The difference between this and voyeurism is that in normal watching, the viewing is a prelude to normal sexual activity. In the voyeur or "Peeping Tom" the experience replaces normal sexual activity. Nevertheless, voyeurism may exist in a person who also engages in normal heterosexual activity.1 Pedophilia Pedophilia is the act of deriving sexual excitement through the physical contact of children. This paraphilia is radically different from exhibitionism and voyeurism in its severely damaging impact on the nonconsenting partner, a child. Ordinarily, the pedophiliac is someone who has ready access to the child. The child or parent would have no reason to suspect that the individual has a pedophilic orientation. Gender Identity Disorder A gender identity disorder exists when a person, male or female, experiences confusion, vagueness or conflict in their feelings about their own sexual identity. 1There is a struggle between the individual's anatomical sex gender and subjective feelings about choosing a masculine or feminine style of life.

Children can distinguish the difference between males and females by the age of two and by their fourth birthday can recognize the different roles that each sex plays in society. By the age of fifteen or so a person can relate to what arouses sexual feelings in themselves. Those with a gender identity disorder may have a problem with one or all of these aspects of identity. Sexual Disorders What are sexual disorders? Sexual dysfunctions are disorders related to a particular phase of the sexual response cycle. For example, sexual dysfunctions include sexual desire disorders, sexual arousal disorders, orgasm disorders, and sexual pain disorders. If a person has difficulty with some phase of the sexual response cycle or a person experiences pain with sexual intercourse, he/she may have a sexual dysfunction. Examples of sexual dysfunctions include: Hypoactive Sexual Desire Disorder. This disorder may be present when a person has decreased sexual fantasies and a decreased or absent desire for sexual activity. In order to be considered a sexual disorder the decreased desire must cause a problem for the individual. In this situation the person usually does not initiate sexual activity and may be slow to respond to his/her partner's sexual advances. This disorder can be present in adolescents and can persist throughout a person's life. Many times, however, the lowered sexual desire occurs during adulthood, often times following a period of stress. Sexual Aversion Disorder. A person who actively avoids and has a persistent or recurrent extreme aversion to genital sexual contact with a sexual partner may have sexual aversion disorder. In order to be considered a disorder, the aversion to sex must be a cause of difficulty in the person's sexual relationship. The individual with sexual aversion disorder usually reports anxiety, fear, or disgust when given the opportunity to be involved sexually. Touching and kissing may even be avoided. Extreme anxiety such as panic attacks may actually occur. It is not unusual for a person to feel nauseated, dizzy, or faint. Female Sexual Arousal Disorder. Female sexual arousal disorder is described as the inability of a woman to complete sexual activity with adequate lubrication. Swelling of the external genitalia and vaginal lubrication are generally absent. These symptoms must cause problems in the interpersonal relationship to be considered a disorder. It is not unusual for the woman with female sexual arousal disorder to have almost no sense of sexual arousal. Often, these women experience pain with intercourse and avoid sexual contact with their partner. Male Erectile Disorder. If a male is unable to maintain an erection throughout sexual activity, he may have male erectile disorder. This problem must be either persistent or recurrent in nature. Also, the erectile disturbance must cause difficulty in the relationship with the sexual partner to be defined as a disorder. Some males will be unable to obtain any erection. Others will have an adequate erection, but lose the erection during sexual activity. Erectile disorders may accompany a fear of failure. Sometimes this disorder is present throughout life. In many cases the erectile failure is intermittent and sometimes dependent upon the type of partner or the quality of the relationship. Female Orgasmic Disorder. Female orgasmic disorder occurs when there is a significant delay or total absence of orgasm associated with the sexual activity. This condition must cause a problem in the relationship with the sexual partner in order to be defined as a disorder. Male Orgasmic Disorder. When a male experiences significant delay or total absence of orgasm following sexual activity, he may have male orgasmic disorder. In order to be qualified as a disorder, the symptoms must present a significant problem for the individual. Premature Ejaculation. When minimal sexual stimulation causes orgasm and ejaculation on a persistent basis for the male, he is said to have premature ejaculation. The timing of the ejaculation must cause a problem for the person or the relationship in order to be qualified as a disorder. Premature ejaculation is sometimes seen in young men who have experienced premature ejaculation since their first attempt at intercourse. Dyspareunia. Dyspareunia is a sexual pain disorder. Dyspareunia is genital pain that accompanies sexual intercourse. Both males and females can experience this disorder, but the disorder is more common in women. Dyspareunia tends to be chronic in nature. Substance Abuse Disorders “First you take a drink, then the drink takes a drink, then the drink takes you.” - F. Scott Fitzgerald Basically, an addiction to a substance. Definition Substance-related disorders are disorders associated with the use of alcohol, nicotine, drugs, medications, or toxins. Substances that can be abused include amphetamines, alcohol, caffeine, cocaine, hallucinogens, inhalants, marijuana, nicotine, opiods, phencyclidine (PHP), sedatives, hypnotics, anabolic steroids, club drugs or anxiolytics. Prescribed and over the counter medications can also cause a substance related disorder.

The two disorders in this category refer to either the abuse or dependence on a substance. A substance can be anything that is ingested in order to produce a high, alter one's senses, or otherwise affect functioning. The most common substance thought of in this category is alcohol although other drugs, such as cocaine, marijuana, heroin, ecstasy, special-K, and crack, are also included. Probably the most abused substances, caffeine and nicotine, are also included although rarely thought of in this manner by the layman. Alcohol Alcohol Withdrawal A patient who has been drinking heavily and for a long time suddenly stops or markedly reduces its intake. Within a few hours to several days of reducing intake, 2 or more of the following develop: -autonomic overactivity (sweating or rapid heartbeat) -worsened tremor of hands -insomnia -nausea or vomiting -short-lived hallucinations or illusions (visual, tactile or auditory) -psychomotor agitation -anxiety -grand mal seizures These symptoms cause clinically important distress or impair work, social or personal functioning. These symptoms are neither the result of a general medical condition nor better explained by a different mental disorder. Specify if: With Perceptual Disturbances. The patient has altered perceptions: auditory, tactile or visual illusions or hallucinations with intact insight.* Coding Notes If the patient meets criteria for Alcohol Withdrawal Delirium, do not also code 291.8 Alcohol Withdrawal. *Intact insight implies that the patient recognizes that the symptoms are unreal, caused by the substance use. Hallucinations without this insight suggest a diagnosis of Substance-Induced Psychotic Disorder. Alcohol Intoxication The patient has recently drunk alcohol. During or shortly after drinking, the patient develops clinically important behavioral or psychological changes that are maladaptive. These could include inappropriate sexuality or aggression, lability of mood, impaired judgment and impaired job or social functioning. Shortly after drinking, 1 or more of: -slurred speech -poor coordination -unsteady walking -nystagmus -impaired attention or memory -stupor or coma These symptoms are neither the result of a general medical condition nor better explained by a different mental disorder. Amphetamines Amphetamine Intoxication The patient has recently used amphetamine or a related substance. During or shortly after its use, the patient develops clinically important behavioral or psychological changes that are maladaptive. These could include blunted affect, hypervigilance, interpersonal sensitivity, anger, anxiety or tension, changes in sociability, stereotyped behaviors, impaired judgment and impaired job or social functioning. Shortly after use, 2 or more of: -slowed or rapid heart rate -dilated pupils -raised or lowered blood pressure -chills or sweating -nausea or vomiting -weight loss -psychomotor agitation or retardation -muscle weakness, shallow or slowed breathing, chest pain or heart arrhythmias -coma, confusion, dyskinesias, dystonias or seizures These symptoms are neither the result of a general medical condition nor better explained by a different mental disorder. Specify if: With Perceptual Disturbances. The patient has altered perceptions: auditory, tactile or visual illusions or hallucinations with intact insight.* Coding Note *Intact insight implies that the patient recognizes that the symptoms are unreal, caused by the substance use. Hallucinations without this insight suggest a diagnosis of Amphetamine-Induced Psychotic Disorder. Amphetamine Withdrawal A patient who has been using an amphetamine or a similar substance heavily and for a long time suddenly stops or markedly reduces its intake. Within a few hours to several days of reducing intake, the patient develops dysphoric mood and 2 or more of the following: -fatigue

-unpleasant, vivid dreams -hypersomnia or insomnia -increased appetite -psychomotor agitation or retardation These symptoms cause clinically important distress or impaired work, social or personal functioning. These symptoms are neither the result of a general medical condition nor better explained by a different mental disorder. Caffeine Caffeine Intoxication The patient has recently consumed caffeine (usually, more than 250 mg, or 2-3 cups of coffee). Beginning during or shortly after ingestion, 5 or more of: -restlessness -nervousness -excitement -insomnia -red face -increased urination -gastrointestinal upset -muscle twitching -rambling speech -rapid or irregular heart beat -periods of tirelessness -psychomotor agitation These symptoms cause clinically important distress or impair work , social or personal functioning. These symptoms are neither the result of a general medical condition nor better explained by a different mental disorder. Cannabis Cannabis Intoxication The patient has recently used cannabis. During or shortly after its use, the patient develops clinically important behavioral or psychological changes that are maladaptive. These could include anxiety, euphoria, impaired judgment, social withdrawal and the sensation that time has slowed down. Within 2 hours of use, 2 or more of: -red eyes -increased appetite -dry mouth -rapid heart rate These symptoms are neither the result of a general medical condition nor better explained by a different mental disorder. Specify if: With Perceptual Disturbances. The patient has altered perceptions: auditory, tactile or visual illusions or hallucinations with intact insight.* Coding Note *Intact insight implies that the patient recognizes that the symptoms are unreal, caused by the substance use. Hallucinations without this insight suggest a diagnosis of Cannabis-Induced Psychotic Disorder. Cocaine Cocaine Intoxication The patient has recently used cocaine. During or shortly after its use, the patient develops clinically important behavioral or psychological changes that are maladaptive. These would include blunted affect, hypervigilance, interpersonal sensitivity, anger, anxiety or tension, changes in sociability, stereotyped behaviors, impaired judgment and impaired job or social functioning. Shortly after use, 2 or more of: -slowed or rapid heart rate -dilated pupils -raised or lowered blood pressure -chills or sweating -nausea or vomiting -weight loss -psychomotor agitation or retardation -muscle weakness, shallow or slowed breathing, chest pain or cardiac arrhythmias -coma, confusion, dyskinesias, dystonias or seizures These symptoms are neither the result of a general medical condition nor better explained by a different mental disorder. Specify if: With Perceptual Disturbances. The patient has altered perceptions: auditory, tactile or visual illusions or hallucinations with intact insight.* Coding Note *Intact insight implies that the patient recognizes that the symptoms are unreal, caused by the substance use. Hallucinations without this insight suggest a diagnosis of Cocaine-Induced Psychotic Disorder. Cocaine Withdrawal A patient who has been using cocaine heavily and for a long time suddenly stops or markedly reduces its intake. Within a few hours to several days of reducing intake, the patient has dysphoric mood and 2 or more of the following: -fatigue -unpleasant, vivid dreams -hypersomnia or insomnia -increased appetite -psychomotor agitation or retardation

These symptoms cause clinically important distress or impair work, social or personal functioning. These symptoms are neither the result of a general medical condition nor better explained by a different mental disorder. Hallucinogens Hallucinogen Intoxication The patient has recently used a hallucinogen. During or shortly after its use, the patient develops clinically important behavioral or psychological changes that are maladaptive. These could include severe depression or anxiety, ideas of reference, fear of becoming insane, persecutory ideas, impaired judgment and impaired job or social functioning. During or shortly after use, while fully alert the patient has perceptual changes (depersonalization, derealization, illusions, hallucinations, synesthesias or subjective intensification of experience). Shortly after use, 2 or more of: -dilated pupils -rapid heart rate -sweating -irregular heartbeat -blurred vision -tremors -incoordination These symptoms are neither the direct result of a general medical condition nor better explained by a different mental disorder. Hallucinogen Persisting Perception Disorder (Flashbacks) After stopping the use of a hallucinogen, the patient reexperiences at least one of the symptoms of perception that occurred during intoxication. These could include flashes of color, trails of images, afterimages, halos, macropsia, micropsia, geometric hallucinations and false peripheral perception of movement. These symptoms cause clinically important distress or impair work, social or personal functioning. These symptoms are neither the result of a general medical condition nor better explained by hypnopompic hallucinations or a different mental disorder such as Schizophrenia or dementia. Inhalants Inhalant Intoxication Recently the patient has intentionally used volatile inhalants or has had brief, high-dose exposure to them. During or shortly after this experience, the patient develops clinically important behavioral or psychological changes that are maladaptive. These could include apathy, assaultiveness or belligerence, impaired judgment and impaired job or social functioning. During or shortly after this experience, 2 or more of: -dizziness -nystagmus -incoordination -slurred speech -unsteady walking -lethargy -diminished reflexes -psychomotor retardation -blurred or double vision -tremors -generalized muscle weakness -stupor or coma -euphoria These symptoms are neither the result of a general medical condition nor better explained by a different mental disorder. Coding Notes Do not include anesthetic gasses or short-acting vasodilators in this category. They are coded under Other SubstanceRelated Disorders (page 112). Because most commercial products contain a number of different gasses and other volatile substances, it is often impossible to determine which have produced the toxic effects observed. That is why, in coding, it is often necessary to use the generic term "Inhalant Intoxication." Nicotine Nicotine Withdrawal The patient has used nicotine daily for several weeks or more. Within 24 hours of abruptly reducing nicotine intake, the patient develops 4 or more of: -dysphoria or depression -insomnia -anger, frustration or irritability -anxiety -trouble concentrating -restlessness -slowed heart rate -increased appetite or weight These symptoms cause clinically important distress or impair work, social or personal functioning. These symptoms are neither the result of a general medical condition nor better explained by a different mental disorder.

Opioid Intoxication The patient has recently used an opioid. During or shortly after its use, the patient develops clinically important behavioral or psychological changes that are maladaptive. These could include euphoria leading to apathy, depression or anxiety, psychomotor agitation or retardation, impaired judgment and impaired job or social functioning. During or shortly after use, the patient develops constricted pupils (or dilation due to brain damage following a severe overdose) and 1 or more of: -drowsiness or coma -slurred speech -impaired memory or attention These symptoms are neither the result of a general medical condition nor better explained by a different mental disorder. Specify if: With Perceptual Disturbances. The patient has altered perceptions: auditory, tactile or visual illusions or hallucinations with intact insight.* Coding Note *Intact insight implies that the patient recognizes that the symptoms are unreal, caused by the substance use. Hallucinations without this insight suggest a diagnosis of Opioid-Induced Psychotic Disorder. Opioid Withdrawal The patient has either: -Recently stopped or reduced use of opioids after heavy, prolonged use (at least several weeks) or -Been given an opioid antagonist after using opioids for some time Within minutes to several days after this experience, the patient develops 3 or more of: -dysphoria -nausea or vomiting -aching muscles -tearing or runny nose -dilated pupils, piloerection or sweating -diarrhea -yawning -fever -insomnia These symptoms cause clinically important distress or impair work, social or personal functioning. These symptoms are neither the result of a general medical condition nor better explained by a different mental disorder. Phencyclidine Phencyclidine (or Related Substance) Intoxication The patient has recently used PCP or a related substance. During or shortly after its use, the patient develops clinically important behavioral or psychological changes that are maladaptive. These would include assault, belligerence, impulsivity, agitation, unpredictability, impaired judgment and impaired job or social functioning. Within an hour of use (less, if snorted, smoked or used IV), the patient develops 2 or more of: -nystagmus -rapid heartbeat or high blood pressure -numbness or decreased response to pain -trouble walking -trouble speaking -rigid muscles -coma or seizures -abnormally acute hearing These symptoms are neither the result of a general medical condition nor better explained by a different mental disorder. Specify if: With Perceptual Disturbances. The patient has altered perceptions: auditory, tactile or visual illusions or hallucinations with intact insight.* Coding Note *Intact insight implies that the patient recognizes that the symptoms are unreal, caused by the substance use. Hallucinations without this insight suggests a diagnosis of Phencyclidine-Induced Psychotic. Sedative, Hypnotic or Anxiolytic Sedative, Hypnotic or Anxiolytic Intoxication The patient has recently used a sedative, hypnotic or anxiolytic drug. During or shortly after use, the patient develops clinically important behavioral or psychological changes that are maladaptive. These would include inappropriate sexuality or aggression, lability of mood, impaired judgment and impaired job or social functioning. Shortly after use, 1 or more of: -slurred speech -incoordination -unsteady walking -nystagmus -impaired attention or memory -stupor or coma These symptoms are neither the result of a general medical condition nor better explained by a different mental disorder. Sedative, Hypnotic or Anxiolytic Withdrawal

Opioids

A patient who has been using one or more of these drugs heavily and for a long time suddenly markedly reduces its intake. Within a few hours to several days, 2 or more of the following develop: -autonomic overactivity (sweating, rapid heartbeat) -worsened tremor of hands -insomnia -nausea or vomiting -short-lived hallucinations or illusions (visual, tactile or auditory) -psychomotor agitation -anxiety -grand mal seizures These symptoms cause clinically important distress or impair work, social or personal functioning. These symptoms are neither the result of a general medical condition nor better explained by a different mental disorder. Specify if: With Perceptual Disturbances. The patient has altered perceptions: auditory, tactile or visual illusions or hallucinations with intact insight.* Coding Note *Intact insight implies that the patient recognizes that the symptoms are unreal, caused by the substance use. Hallucinations without insight suggest a diagnosis of Phencyclidine-Induced Psychotic Disorder.