Addiction (chemical dependency, substance abuse) is a complex but treatable brain disease.

It is characterized by compulsive drug craving, seeking and use that persist even in the face of severe adverse consequences. For many people, drug addiction becomes chronic, with relapses possible even after long periods of abstinence. In fact, relapse to substance abuse occurs at rates similar to those for other wellcharacterized, chronic medical illnesses such as diabetes, hypertension and asthma. As a chronic, recurring illness, addiction may require repeated treatments to increase the intervals between relapses and diminish their intensity, until abstinence is achieved. Through treatment tailored to individual needs, people with drug addiction can recover and lead productive lives. The ultimate goal of drug addiction treatment is to enable an individual to achieve lasting abstinence, but the immediate goals are to reduce drug abuse, improve the patients ability to function and minimize the medical and social complications of drug abuse. Like people with diabetes or heart disease, people in treatment for drug addiction will need to change behavior to adopt a healthier lifestyle. Substances to which people get addicted are numerous, but the most common ones in the Indian setting are Alcohol Cannabis (ganja, pot, grass) Opium (heroin, brown sugar, smack) Tobacco (cigarettes, gutkha etc.) Inhalants (petrol, glue etc.) When is someone chemical-dependent? The American Psychiatric Association says that a person is dependent if their pattern of substance use leads to clinically significant impairment or distress shown by three or more of the following in a 12-month period: Tolerance, as defined by a need for markedly increased amounts of the substance to achieve intoxication or desired effect markedly diminished effect with continued use of the same amount of the substance Withdrawal, as manifested by the characteristic withdrawal symptom of the substance the same or a closely related substance is taken to relieve or avoid withdrawal symptoms The substance is often taken in larger amounts or over a longer period than was intended (loss of control) There is a persistent desire or unsuccessful efforts to cut down or control substance use A great deal of time is spent in activities necessary to obtain the substance, use the substance or recover from its effects (preoccupation) Important social, occupational or recreational activities are given up or reduced because of substance use The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (continuation despite adverse consequences) Why do some people become addicted? For two decades, researchers have been struggling to identify the biological and environmental risk factors that can lead to addiction to alcohol and other drugs. These factors form a complex mlange in which the influences combine to bring

about addiction and to make its treatment challenging. But scientists know more about addiction now than they did even 10 years ago, and have learned much about how the risk factors work together. The widely recognized risk factors include: Genes. Genetics plays a significant role - having parents with alcoholism, for instance, makes a person four times more likely than others to become an alcoholic. More than 60 percent of alcoholics have family histories of alcoholism. Mental illness. Many addicted people also suffer from mental health disorders, especially anxiety, depression or psychosis. Early use of drugs. The earlier a person begins to use drugs, the more likely they are to progress to more serious abuse. Social environment. People who live, work or go to school in an environment in which the use of alcohol and other drugs is common - such as a workplace in which people see heavy drinking as an important way to bond with coworkers - are more likely to abuse drugs. Childhood trauma. Scientists know that abuse or neglect of children, persistent conflict in the family, sexual abuse and other traumatic childhood experiences can shape a child's brain chemistry and subsequent vulnerability to addiction. Recognizing the illness Friends and family may be among the first to recognize the signs of substance abuse. Early recognition increases chances for successful treatment. Signs to watch for include the following: Getting drunk or high on drugs on a regular basis Lying, particularly about how much alcohol or other drugs he is using Avoiding friends or family in order to get drunk or high Planning drinking in advance, hiding alcohol, stocking up on alcohol Drinking or doing drugs alone Having to drink more to get the same high Believing that in order to have fun you need to drink or use other drugs Frequent hangovers Giving up / losing interest in routine activities such as work, studies or sports Hanging out with new friends Aggressiveness and irritability Disappearing money or valuables Sounding selfish and not caring about others Use of room deodorizers and incense Having "blackouts" - forgetting what he did the night before Getting in trouble with the law Suspension from school/college or work for an alcohol- or drug-related incident Unexplained injection sites Tremors (shakes) / seizures (fits) Principles of effective treatment Scientific research since the mid-1970s shows that treatment can help many people change destructive behaviors, avoid relapse and successfully remove themselves from a life of substance abuse and addiction. Recovery from drug addiction is a long-term process and frequently requires multiple episodes of treatment. Based on this research, key principles have been identified that should form the basis of any effective treatment program: No single treatment is appropriate for all individuals.

Effective treatment attends to multiple needs of the individual, not just his or her drug addiction. An individuals treatment and services plan must be assessed often and modified to meet the persons changing needs. Remaining in treatment for an adequate period of time is critical for treatment effectiveness. Medication, counseling and other behavioral therapies are critical components of virtually all effective treatments for addiction. Chemical-dependent individuals with coexisting mental disorders should have both disorders treated in an integrated way. Medical management of the withdrawal syndrome (detox) is only the first stage of addiction treatment and by itself does little to change long-term drug use. Treatment does not need to be voluntary to be effective. As is the case with other chronic, relapsing diseases, recovery from drug addiction can be a long-term process and typically requires multiple episodes of treatment, including booster sessions and other forms of continuing care. Treating the illness No available therapy, program, medication or surgical procedure can remove the recurrent desire or craving for alcohol and/or other drugs. Eliminating the desire to use drugs or alcohol is not a goal of treatment. A more reasonable expectation is that medication may reduce this urge and effective rehabilitation will teach a person what they must do to manage and contain their recurrent desires to use, much in the same way as a person with diabetes or hypertension must learn to manage their lives to control their illness. It is best to think of three stages of addiction treatment, each with a different function in the larger picture of care: Detoxification / stabilization Rehabilitation Continuing care Detoxification / stabilization Detoxification is not treatment it is merely preparation for treatment, and must be followed by rehab and after-care for lasting improvement. Following cessation of heavy and sustained alcohol or drug use, most individuals develop significant physical and emotional symptoms (the withdrawal syndrome). Detox is the medical management of these symptoms. It is almost always undertaken in an in-patient setting, in a hospital / deaddiction centre. It usually lasts for between one and two weeks, though, for severely dependent individuals, it can last much longer. Desired results include reduced physical and emotional instability caused by substance use and a patient who is motivated to recognize and accept that there is a problem that he needs to and can - address. Rehabilitation Rehabilitation is appropriate for patients who are no longer suffering from the acute physical or emotional effects of recent substance use. It typically offers an array of treatment components to help to address the many health and social problems associated with substance use. Most rehabilitative care for addiction occurs in specialty "programs" that include Medical management of craving Individual, group and family therapy Relapse prevention training Developing a plan for a drug-free lifestyle

Familiarization with mutual-help groups (AA/NA) Continuing Care The first 3-6 months following discharge from hospital is the period of greatest vulnerability to relapse. Consequently, continuing care services are designed to monitor the emotional health of recovering people, remind them of their commitment to lifestyle change and support their needs as they attempt the difficult job of living their former lives with a new perspective and resolve. If the patient is on aversive medication, the family is encouraged to take responsibility for its administration. Individual, group and family therapy sessions continue, but typically occur less frequently than during the residential program. Some rehabilitation programs offer telephone counseling and support services for people to talk with their former counselors. The recovering addict is encouraged to continue association with mutual-help groups. Relapse To ordinary people, relapse is one of the most perplexing aspects of addiction. People recovering from addiction can experience a lack of control and return to their substance use at some point in their recovery process. This faltering, common among people with most chronic disorders, is called relapse. Relapse, when defined as return to excessive or problematic use, occurs in approximately 20-30% of those who have completed formal care in the previous 12 months. When defined as re-use of alcohol or drugs even in minimal quantities, relapse rates can be as high as 50%. The road to recovery is usually long and hard. Few people with chemical dependency travel it gracefully. There are many slips, trips and lapses. Those who eventually do recover, learn to pick themselves up when they fall, brush off the dust and keep going. By doing so, they keep temporary lapses from turning into fullblown relapses. Alcoholic drinks have been consumed for thousands of years, and the problems that can accompany excess alcohol intake have undoubtedly been around just as long. In moderation, alcohol can be the oil that makes a social occasion go with a bit more flow or helps a shy person overcome his inhibitions. However, high levels of alcohol consumption can lead to physical illness and psychological and social distress. Alcohol, therefore, has always had an ambivalent position in society. What is alcoholism? Alcoholism or alcohol dependence is a medical term with a deliberately more precise meaning than the problems that can occur, sometimes as one-offs, through an uncharacteristic alcoholic binge. In alcohol dependence a number of features come together in the behavior of the person affected. These include - but are not limited to - the following: Drinking begins to take priority over other activities. It becomes a compulsion. Tolerance develops, so it takes more alcohol to produce drunkenness. Withdrawal symptoms such as anxiety and tremor develop after a short period without a drink, and are reduced by taking more alcohol. The alcoholic is unable to control his drinking in any given occasion. Often alcohol dependence remains undetected for years. Both the availability of alcohol and the way it is used (the social patterns) appear to be major factors in influencing the likelihood of a person becoming alcohol dependent. Alcoholism is a disease One of the difficulties in recognizing alcoholism as a disease is it just plain doesn't seem like one. It doesn't look, sound, smell and act like a disease. To make matters worse, generally it denies it exists and resists treatment.

Alcoholism has been recognized for many years by professional medical organizations as a primary, chronic, progressive and sometimes fatal disease. The National Council on Alcoholism and Drug Dependence offers a detailed and complete definition of alcoholism, but probably the simplest way to describe it is as "a mental obsession that causes a physical compulsion to drink." Mental obsession? Did you ever wake up in the morning with a song playing over and over in your head? It might have been a commercial jingle you heard on television or a song from the radio, but it kept playing... and playing and playing. That is an example of a simple mental obsession - a thought process over which you have no control. Such is the nature of the disease of alcoholism. When the drinking "song" starts playing in the mind of an alcoholic, he is powerless. He didn't put the song there and the only way to get it to stop is to take another drink. The problem is the alcoholic's mental obsession with alcohol is much more subtle than a song playing in his mind. In fact, he may not even know it's there. All he knows is he suddenly has an urge to take a drink - a physical compulsion to drink. Compounding the problem is the progressive nature of the disease. In its early stages, taking one or two drinks may be all it takes to get the "song" to stop. But soon it takes six or seven and later maybe ten or twelve. Somewhere down the road, the only time the song stops is when he passes out. The progression of the disease is so subtle and usually takes place over such an extended period of time, that even the alcoholic himself failed to notice the point at which he lost control over - and alcohol took over - his life. No wonder denial is an almost universal symptom of the disease. For those who have come to the realization that they do have a problem, help may be as close as their family physician. But for those who need help and do not want it, assertive outreach may be the only alternative. Recognizing the illness... There are many symptoms related to drinking problems. Alcoholism is considered a progressive disease, meaning that the symptoms and effects of drinking alcohol become increasingly more severe over time. Early signs of alcoholism include frequent intoxication, an established pattern of heavy drinking and drinking in dangerous situations, such as when driving. Other early signs of alcoholism include black-out drinking or a drastic change in demeanor while drinking, such as consistently becoming angry or violent. The main symptom of alcohol abuse occurs when someone continues to drink after their drinking reaches a level that causes recurrent problems. Continuing to drink after alcohol causes someone to miss work, drive drunk, shirk responsibilities or get in trouble with the law is considered alcohol abuse. The Diagnostic and Statistical Manual of the American Psychiatric Association defines alcohol abuse as drinking despite alcohol-related physical, social, psychological, or occupational problems, or drinking in dangerous situations, such as while driving. When alcohol abuse reaches the alcohol dependence stage, the person also experiences at least three of seven other symptoms, including neglect of other activities, excessive use of alcohol, impaired control of alcohol consumption, persistence of alcohol use, large amounts of time spent in alcohol-related activities, withdrawal symptoms and tolerance of alcohol. Are you an alcoholic?

How can you tell whether you, or someone close to you, may have a drinking problem? Answering the following four questions can help you find out. (To help remember these questions, note that the first letter of a key word in each of the four questions spells "CAGE".) Have you ever felt you should Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)? One "yes" response suggests a possible alcohol problem. If you responded "yes" to more than one question, it is highly likely that a problem exists. In either case, it is important that you see your family doctor right away to discuss your responses to these questions. He or she can help you determine whether you have a drinking problem and, if so, recommend the best course of action for you. Denial One of the most frustrating factors in dealing with alcoholism, as a relative, friend or addiction professional, is it is almost always accompanied by a phenomenon known as "denial". In the long path the alcoholic takes toward emotional and physical decline, usually the first thing to go is honesty. He simply lies about his drinking. Little lies at first. I only had two... I haven't had a drink in a week... I don't drink as much as he does... As the alcoholic begins to drink more, and more often, he begins to hide this fact from those around him. Depending upon his circumstances he may drink openly, but usually he will conceal the amount he drinks, by not drinking around those who are closest to him. If someone tries to discuss his drinking with him, he simply refuses to talk about it or dismisses it as not a real problem. After all, he's a big boy now and he can drink if he wants to, it's nobody else's business. But these simple acts of denial, lying about his drinking or refusing to discuss it, are clues that the alcoholic himself deep down inside knows that he has a problem. If it's not a problem, why lie about it to anyone? The alcoholic covers up and denies his drinking out of his own feelings that there is something different or "wrong" about it. Somewhere inside he realizes that his drinking means more to him that he is willing to admit. As the disease progresses and his drinking begins to cause real problems in his life, remarkably, the denial likewise increases. Even though his sprees have gotten him into some real trouble, he denies it has anything to do with his drinking. The drinking and the denial continue until he hits rock-bottom, at which point one of two things usually happen: either he admits there is a problem and seeks help, or the family decides to assertively intervene. Treating the illness... No available therapy, program, medication or surgical procedure can eliminate the recurrent desire or craving for alcohol. Eliminating the desire to drink is not a goal of treatment. A more reasonable expectation is that medication may reduce this urge and effective rehabilitation will teach a person what they must do to manage and contain their recurrent desires to consume alcohol, much in the same way as a person with diabetes or hypertension must learn to manage their lives to control their illness.

It is best to think of three stages of alcoholism treatment, each with a different function in the larger picture of care: Detoxification / stabilization Rehabilitation Continuing care Detoxification / stabilization Detoxification is not treatment - it is merely preparation for treatment, and must be followed by rehab and after-care for lasting improvement. Following cessation of heavy and sustained alcohol use, most individuals develop significant physical and emotional symptoms (the withdrawal syndrome). Detox is the medical management of these symptoms. It is almost always undertaken in an in-patient setting, in a hospital / deaddiction centre. It usually lasts for between one and two weeks, though, for severely dependent individuals, it can last much longer. Desired results include reduced physical and emotional instability caused by substance use and a patient who is motivated to recognize and accept that there is a problem that he needs to - and can - address. Rehabilitation Rehabilitation is appropriate for patients who are no longer suffering from the acute physical or emotional effects of recent alcohol use. It typically offers an array of treatment components to help address the many health and social problems associated with alcohol dependence. Most rehabilitative care for addiction occurs in specialty "programs" that include Medical management of craving Individual, group and family therapy Relapse prevention training Developing a plan for an alcohol-free lifestyle Familiarization with mutual-help groups (Alcoholics Anonymous, AA) Continuing Care The first 3-6 months following discharge from hospital are the period of greatest vulnerability to relapse. Consequently, continuing care services are designed to monitor the emotional health of recovering people, remind them of their commitment to lifestyle change and support their needs as they attempt the difficult job of living their former lives with a new perspective and resolve. If the patient is on disulfiram, the family is encouraged to take responsibility for its administration. Individual, group and family therapy sessions continue, but typically occur less frequently than during the residential program. Some rehabilitation programs offer telephone counseling and support services for people to talk with their former counselors. The recovering addict is encouraged to continue association with mutual-help groups. Are There Any Medications for Alcoholism? Let me repeat: No available medicine can eliminate the recurrent desire or craving for alcohol. A more reasonable expectation is that medication may reduce this urge.

However, three different types of medicines are used in the treatment of alcohol dependence, during various stages of the treatment process: The first are the benzodiazepines which are used during the first few weeks of treatment to help patients safely withdraw from alcohol. The second type of medication are the anti-craving drugs like naltrexone and baclofen. When used together with counseling, these medications lessen the craving for alcohol in many people and help maintain sobriety. Another medication, distinct in function from the previous two types, is disulfiram, which discourages drinking by causing nausea, vomiting and other unpleasant physical reactions when alcohol is concurrently used. The Sinclair Method Developed by Dr. David Sinclair, a psychologist and alcohol researcher, this method is based on the principle of pharmacological extinction. It involves the prescription of naltrexone, a drug approved by USFDA for reducing alcohol craving, even as the patient continues to drink. Many patients experience decreased craving over a period of three to six months. Assertive Outreach How can I get him to stop drinking? Usually, by the time family members ask this question, he has ceased to be a social drinker: he is now alcohol dependent. Unless he admits - or can be persuaded to admit - that he needs help, assertive outreach may well be the only alternative. Assertive outreach should be resorted to only when an individual requires intensive support or where it is no longer reasonable to step back and allow someone you care for continue to harm themselves through their addiction to alcohol. On behalf of the family, a team of professionals assertively intervenes in an individuals addictive process. In addition to the other treatment modalities, programs which offer assertive outreach ensure round-the-clock supervision and entry and environmental control. Relapse To ordinary people, relapse is one of the most perplexing aspects of alcoholism. People recovering from alcohol dependence can experience a lack of control and return to their alcohol use at some point in their recovery process. This faltering, common among people with most chronic disorders, is called relapse. Relapse, when defined as return to excessive or problematic use, occurs in approximately 20-30% of those who have completed formal care in the previous 12 months. When defined as re-use of alcohol even in minimal quantities, relapse rates can be as high as 50%. The road to recovery is usually long and hard. Few people with alcohol dependence travel it gracefully. There are many slips, trips and lapses. Those who eventually do recover, learn to pick themselves up when they fall, brush off the dust and keep going. By doing so, they keep temporary lapses from turning into full-blown relapses. Smoking is a major health hazard. There is now an exhaustive body of evidence including hundreds of epidemiological, experimental, pathological and clinical studies - to demonstrate that smoking increases the smokers risk of illness and death from a wide variety of diseases. It would be fair to describe cigarette smoking as the chief preventable cause of death in our society. 120 million smokers -

almost 10 per cent of the world's smokers - live in India. What is even more alarming is that, while smoking is declining in many Western countries, its prevalence is on the rise in India. A recent study published in the New England Journal of Medicine estimates that, during the decade beginning 2010, smoking will cause about 930,000 adult deaths in India annually; of the dead, about 70 per cent will be between the ages of 30 and 69 years. Health problems caused by smoking Smoking harms nearly every organ of the body and diminishes a persons overall health. Smoking is a leading cause of cancer and of death from cancer. It causes cancers of the lung, esophagus, larynx (voice box), mouth, throat, kidney, bladder, pancreas, stomach and cervix, as well as acute myeloid leukemia. Smoking also causes heart disease, stroke, lung disease (chronic bronchitis and emphysema), hip fractures and cataracts. Smokers are at higher risk of developing tuberculosis, pneumonia and other airway infections. A pregnant smoker is at higher risk of having her baby born too early and with an abnormally low weight. A woman who smokes during or after pregnancy increases her infants risk of death from Sudden Infant Death Syndrome (SIDS). Millions of Indians have health problems caused by smoking. Beedi and cigarette smoking, and exposure to tobacco smoke, cause around 850,000 premature deaths each year in India alone. Of these premature deaths, about 35 percent are from tuberculosis, 10 percent from other lung diseases, 30 percent from cancer and 25 percent from heart disease and stroke. Regardless of their age, smokers can substantially reduce their risk of disease, including cancer, by quitting. Immediate benefits of quitting smoking The immediate health benefits of quitting smoking are substantial. Heart rate and blood pressure, which were abnormally high while smoking, begin to return to normal. Within a few hours, the level of carbon monoxide in the blood begins to decline. (Carbon monoxide, a colorless, odorless gas found in cigarette smoke, reduces the bloods ability to carry oxygen.) Within a few weeks, people who quit smoking have improved circulation, dont produce as much phlegm and dont cough or wheeze as often. Within several months of quitting, people can expect significant improvements in lung function. Long-term benefits of quitting smoking Quitting smoking reduces the risk of cancer and other diseases, such as heart disease and lung disease, caused by smoking. People who quit smoking, regardless of their age, are less likely than those who continue to smoke to die from smokingrelated illness. Studies have shown that quitting at about age 30 reduces the chance of dying from smoking-related diseases by more than 90 percent. People who quit at about age 50 reduce their risk of dying prematurely by 50 percent compared with those who continue to smoke. Does quitting smoking lower the risk of cancer? Quitting smoking substantially reduces the risk of developing and dying from

cancer, and this benefit increases the longer a person remains smoke free. However, even after many years of not smoking, the risk of lung cancer in former smokers remains higher than in people who have never smoked. The risk of premature death and the chance of developing cancer due to cigarettes depend on the number of years of smoking, the number of cigarettes smoked per day, the age at which smoking began, and the presence or absence of illness at the time of quitting. Why is quitting so hard? Many ex-smokers say quitting was the hardest thing they ever did. Do you feel hooked? Youre probably addicted to nicotine. Nicotine is in all tobacco products. It makes you feel calm and satisfied. At the same time, you feel more alert and focused. The more you smoke, the more nicotine you need to feel good. Soon, you dont feel normal without nicotine. It takes time to break free from nicotine addiction. Quitting is also hard because smoking is a big part of your life. You enjoy holding cigarettes and puffing on them. You may smoke when you are stressed, bored or angry. After months and years of lighting up, smoking becomes part of your daily routine. You may light up without even thinking about it. Smoking goes with other things, too. You may light up when you feel a certain way or do certain things. For example: Drinking coffee, beer or hard liquor Talking on the phone Driving Being with other smokers You may even feel uncomfortable not smoking at times or in places where you usually have a cigarette. These times and places are called triggers. Thats because they trigger, or turn on, cigarette cravings. Breaking these habits is the hardest part of quitting for some smokers. Treating the addiction... When you quit smoking, you may feel strange at first. You may feel dull, tense and not yourself. These are signs that your body is getting used to life without nicotine. It usually lasts only a few weeks. Many people just cant handle how they feel after they quit. They start smoking again to feel better. Most people slip up in the first two weeks after quitting. This is when feelings of withdrawal are strongest. There are treatments that can help with feelings of withdrawal: these include nicotine replacement therapy (nicotine gum) and bupropion. Nicotine gum Nicotine gum is available over the counter in 2- and 4-mg strengths. When a person chews nicotine gum and then places the chewed product between the cheek and gum tissue, nicotine is released into the bloodstream through the lining of the mouth. To keep a steady amount of nicotine in the body, a new piece of gum can be chewed every 1 or 2 hours. The gum releases nicotine more effectively when coffee, juice, and other acidic beverages are not consumed at the same time.

Bupropion Bupropion, a prescription medicine available in India, was approved by the USFDA in 1997 to treat nicotine addiction. This drug helps reduce both the nicotine withdrawal symptoms and the urge to smoke. Research has shown that bupropion, under medical supervision, can help double smokers chances of quitting for good. Treatment for Addiction Detoxification (Medical Management), Rehabilitation (Psychosocial management) & Relapse prevention are the three vital programs which are handled by the professionals upon treatment. There are two stages of withdrawal symptoms which may acquire upon the treatment. Acute stage The patient will experience physical withdrawal symptoms which may usually last for few weeks. This usually will get over upon the detoxification period of 21 days which will bring back the patients physical health & routines. It may be different in very few cases as every drug is different, every intake pattern is different and every individual is different. Post Acute withdrawal syndrome (PAWS) At this stage the patient might have a smaller amount of physical withdrawal, but more on emotional & psychological side as the brain chemistry is slowly returning to normal. At this stage brain improves the level of brain chemicals change, as they approach new equilibrium. The rehabilitation process starts upon PAWS to identify their behavioral changes / disorders, which acquired during addiction. Process of Treatment Identification This is the first touch with the Hospital to check whether the admission is necessary or he can be treated as outpatients. It always depends on the pattern of use / abuse. Counselor Intake This happens after the admission where the counselor meets the family alone to collect the historical, physical, psychological, precipitating factors of addiction & social withdrawals etc.. During the session the counselor will educate the family about the disease and the treatment process. Detoxification The Detoxification Process (Medical Management) helps to start the abstinence which is normally 21 days. It is basically referred to acute stage of withdrawal where the patient treated medically for his loss of appetite, sleeping disorder, tremors, loss of weight, weakness & liver disease to bring back the patients physical health & routines. Rehabilitation The Rehabilitation process (Psychological) basically referred to Post Acute withdrawal syndrome (PAWS) which makes the patient to realize and modify his behavioral changes / disorders of decreased efficiency, poor money handling, selfishness, carelessness, ethical break downs , dishonesty, prolonged time in toilets, stealing , carelessness towards Family and Work those were progressive along with his abuse. The rehabilitation process includes psycho therapy, individual counseling, family counseling, family therapy, group therapy, relaxation therapy, relapse prevention therapy & occupational therapy. After Care Services Relapse prevention work out

Relapse prevention is an itinerary not an option. One needs to plan his relapse prevention by learning the prevention techniques and its stages. It can be classified as three different stages such as emotional relapse, mental relapse & physical relapse. Emotional relapse - You are not thinking about using but your behaviors are making you up for a very possible relapse in future. The signs are anxiety, intolerance, anger, defensiveness, mood swings, isolation, not seeking help, avoiding meetings, poor appetite & sleep patterns. Mental relapse - A war inside your mind to use and not to use. In initial phase you are casually thing about using, but in later phase you are positively thinking about using. The signs are lying, remembrance of using places, friends, visualize or fantasize about past use and planning for relapse. Physical relapse - If you dont use the techniques to overcome the emotional & mental relapse it will strongly lead to physical. Support Groups Alcoholic Anonymous - (Known as AA worldwide) It is a fellowship of Men & Women who share their past experience, their strength, hope in order to solve their common problem and help others to recover from Alcoholism. Al Anon - Commonly referred as Family groups. It is a fellowship for Wives / Guardian of Alcoholics who share their past experience, their strength, hope in order to solve their common problems. As they acknowledge it is a family disease and that changed attitudes can support Recovery. Alateen - Alateen is a part of Al Anon, but made for the teenagers from 12 17 year olds as alcoholism is a family disease. It is not for teenage alcoholics, but for those who have been affected by someone else drinking. They also meet and share their past experience with a problem drinker in their lives. They do share, help & support each other and gain knowledge of the disease and sense the benefits of understanding that they are not alone. Narcotic Anonymous - (Known as NA worldwide) It is a fellowship of Men & Women who share their past experience, their strength, hope in order to solve their common problem and help others to recover from substance abuse (drugs) to stay clean. Treatment for Psychiatric Management Our Team treats Mental Illness with commitment, compassion, care, professionalism and with highest standards of health care. Its becoming clear by researches that many of the mental challenges are caused by the combination of Genetic, Biological, Psychological & Social factors and the recovery is not simply a matter of will and self discipline. It MUST be treated by Medical Professionals . Psychiatry Warning Signs (most common) Ethical Breakdown Sad mood Higher excitement Hallucinations False form of belief Irrelevant speech Low self esteem Repeated talk / action Mood swings Poor concentration Lack of interaction

Suicidal ideation Suspicious Grandiosity Lack of sleep Abnormal fear Poor involvement in work Self talk Social avoidance Abuse of drug / alcohol Sexual dysfunction Warning Signs may lead YOU to Bipolar (Mood disorder) Schizophrenia (Thought disorder) Anxiety disorder Personality disorder Obsessive compulsive disorder Panic disorder Psycho Somatic disorder Phobia Attention Deficit Hyperactivity Disorder (ADHD) Substance Abuse & Addiction Our Evaluations Physical examination Mental state examination Neurological examination Psycho Analysis Cognitive test Intelligence test Memory test Neuropsychological test Personality Psychological Psychometrics Learning disability Career Thought Suicidal Ideation Handling Techniques to Family As we are aware that addiction is a family disease which destroys the respective familys happiness, peace, dreams and sleep, now it is very essential to know how you tackle and help the situation which was not invited but being a part of it to overcome. These over all techniques are planned by professionals who work for alcoholics / substance abusers (addicts) according to their experience with patients and families in recovery now. Situation Handling Would you not treat or care if your loved ones were diagnosed with a dangerous illness Encourage, motivate and educate yourself about the disease and recovery. It is a difficult situation for both of you. Create warm environment for sobriety that reduces external & internal triggers.

Avoid giving money instead analyze and procure the needs of them. Please dont name them by Alcoholic or addict which will hurt them and may even worsen the situation. Please have hope on them that they will recover. Avoid false judgments. Please do not enable, cover up or shield the alcoholic / abuser (addict) for the negative results of their addiction as they are more likely to change thru the sufferings. Make them understand about their strengths instead of their addiction. Avoid arguments when they are under their influence and do not over react. Discuss the situation with a professional and go to self support group meetings. (Al Anon) Do make necessary arrangements to arrest the abstinence as early as possible before it could develop various health complications. FAMILY ISSUES THAT MAY INTERFERE WITH THE TREATMENT AND REHABILITATION OF SCHIZOPHRENIA Over the past 10 years, there has been a significant increase in knowledge of effective ways to treat and rehabilitate persons with schizophrenia (1). Concomitantly, approaches to working with families of schizophrenic patients have evolved from earlier emphasis on hypothesized family pathology to a recent focus on family strength and normality (2). During this time frame, we have been working with schizophrenic patients and their families in a multiple family rehabilitation (MFR) group format in which we focus on treatment and rehabilitation as separate, but closely related, activities. We avoid implications that families are disturbed and in need of therapy. Rather, we assert that the brain disease "schizophrenia" is the enemy and we engage both patient and family members in a collaborative "psychoeducational" process. We have reported elsewhere on the specifics of these groups (3) and intend, in this paper, to summarize some of our observations about common family reactions to Schizophrenia that can present barriers to the smooth progression of rehabilitation efforts. Although these issues are commonly seen in the context of the MFR groups, we have also observed them in many other families we have met in the course of our clinical work and through our involvement in Alliance for the Mentally Ill (AMI) meetings. ISSUES Engaging the Patient and Family in a Treatment-Rehabilitation Program -- When contacting family members of a schizophrenic patient we frequently find that they are too busy in their often frenetic daily lives to summon the energy, time and hope to take on yet another commitment, especially one with an uncertain outcome. We therefore often have to "sell" families a treatment and rehabilitation program. We do this by telling them that through rehabilitation we usually can get the member with schizophrenia (who we will refer to as "patient") to work around the house which will result in less work for the parents. We promise them that they will spend less time, less hassle and have less emotional exhaustion because, after a while, their family member will be out of the house every day and will be increasingly useful and cooperative around the home. As his schizophrenia improves and he gains self-confidence, the patient will act more normally, be less of an embarrassment to the family and not require rehospitalizations. We encourage new families to contact other families who have been through a rehabilitation program to see what it is like and we also frequently invite them to observe one of our MFR

groups. This assertive outreach effort is necessary to overcome the hesitation many families have. We do not have data to show how often this approach works, but we know many families have expressed gratitude that we encouraged them to try the program. Problems Resulting from the Deleterious Effects of Prior Experiences with the Mental Health System -- Most families we see have had a long, dismal experience with the mental health system -- both private and public, usually in that order. Such families may be bitter due to the lack of understanding of their problems by mental health professionals and because they were not taught how to manage the patient and his/her illness (6). We hear families complain that "no one told us" about the Alliance for the Mentally Ill, local family education programs, and the many helpful rehabilitation books, articles and pamphlets which are available from local AMI and Mental Health Association chapters. Families frequently feel blamed, rather than helped, by mental health professionals for the unhappy, chaotic condition they are in. They may have depleted finances with a sense of nothing to show for it. The doctor is often not available, or seems hurried or apparently avoids them. They feel excluded from the treatment of their own family member under the guise of "confidentiality," despite the fact that most of the management and treatment of the patient is delegated to the family, often by default, by the mental health system. Families report their dialogue with social workers and case managers is often unsatisfactory because "everything is up to the doctor," they say, rather than, more realistically, a reasonable joint patient-family-mental health professional planning arrangement. "How can a doctor who does not know the home situation prescribe treatment without the knowledge and support of the family?" they ask. Some families complain that mental health personnel are vague and evasive about diagnosis, and that they are conceptually unclear exactly how treatment and rehabilitation work. Families also complain of such diverse problems as: 1) Unrecognized and untreated side effects. 2) Abrupt "dumping," barely improved, of the hospitalized patient back home without reasonable notification. 3) Huge bills mailed by the state mental health system to the family which does not consider itself financially responsible for the adult patient. 4) Having to repeat whole histories with each new facility contact -- wondering why they are not obtainable from other facilities. 5) Difficult in communicating with doctors with poor language skills. 6) Having the patient's medications changed for no apparent reason. We handle these complaints by actively searching them out in order to quickly form a working alliance. We not only sympathize with their legitimate complaints but we also cite other complaints we have heard from other families and we generally try to distance ourselves from prior mental health system experiences. We tell them as accurately as we can what to expect from us, when and how we are available, what we will do differently than what they have previously experienced, and that we will offer education and demonstrate how to persuade their mentally ill family members to implement their rehabilitation program.

Through these tactics we try to translate their bitter, angry, defensive energies into vigorous, positive rehabilitative efforts. Overprotection: "Walking-on-Eggshells" -- Many interested, loving and responsible families are handicapped by their inability to implement necessary rehabilitative measures because of their fears of stressing their schizophrenic member. These fears have apparently been learned from a variety of sources -- mental health professionals, cultural and family attitudes, as well as through their own observation of the negative effects of "stress" on their schizophrenic family member. To counteract these fears, we provide a meticulous education on stress management to both patients (who share these fears) and their families. We vigorously oppose the notion of avoiding all stress. Instead, we cite the importance of stressing oneself through hard (but not overwhelming) work, working up gradually to vigorous, aerobic exercise, proper diet (overweight is depressing!) and plenty of (initially stressful) social life. We teach that normal living is often stressful and our goal is to encourage each schizophrenic person to become as normal as possible in learning to handle life stresses rather than avoiding them. We teach that, generally speaking, most stresses are good, not bad, for schizophrenia. On the other hand, we clearly delineate those stresses which make schizophrenia worse: e.g., alcohol and drugs, lack of sleep, chronic exhaustion, hidden akathisia, incorrect use of medication. We point out how stressful just lying around the house ("toxically horizontal"), lonely and bored, is. We talk about how deleterious to recovery a "toxic" (i.e., frenzied, pressured, hostile, dishonest) family or work atmosphere is. To get good treatment adherence, our list of do's and don'ts is endlessly repeated through the family sessions (see Appendix) (7). To further lessen the fears of stress, we point out the visible benefits of "positive stress" and vigorous hard work gained by other patients who have followed their rehabilitation programs. We present a modified version of the concept of "Tough Love" with fearful families to whom the idea of requiring positive activity from a "sick" person may be viewed as inhumane or even morally wrong. In this effort, we have found it helpful to discuss appropriate use of the "sick role" and "recovery role" (8). This approach requires a careful titration of what the patient is capable of handling. Sometimes we must tell patients and family members to increase their activities and, other times, to slow down. One "rule of thumb" we use is to encourage the patient to make only one change at a time and to let that new behavior become comfortable before taking on a new challenge. Threats, Intimidation and Violence (TIV) -- When any family is frightened of the patient, it cannot take active treatment and rehabilitation measures for fear of retaliation. With the mentally ill person "running the family", so to speak, improvement is not possible, so there is invariably a tense, potentially explosive stalemate in these families -- the family on one side, the schizophrenic member on the other. There are two types of TIV: The first is a real potential of violence. The patient has shown real violence in the past and there is clearly a threat of it in the future (especially when the 5 patient is using drug and alcohol). The other is a much less serious manipulative bullying in which, when confronted, the patient backs down after perhaps trying to treat the event as a joke. The patient often shows a telltale mirthless grin (the "schizophrenic smile") following a confrontation of his intimidating behavior.

We insist that neither state should be tolerated in the home. We teach families that they have rights to live comfortably and that a mental health counselor, lawyer, physician, and so on should be consulted to arrange active treatment for the schizophrenic family member, elsewhere if necessary, to protect both the patient and family. We caution against confrontations when the patient is drinking or drugging, or is clearly actively psychotic. Subrosa, unexpressed threats and intimidation can be as damaging as overt TIV's and need elucidation and clarification because healing of the schizophrenia itself cannot take place in families who are disrupted by fear. To diagnose overt or covert TIV we have found that the family's intuition is usually sufficient to clarify whether the patient is truly potentially violent orl not. That is, we ask, "Is Johnny really violent, yes or no?" On the other hand, the manipulative patient needs confrontation involving negotiation of clear, simple rules of behvior in the home which will insure a pleasant ("nontoxic") atmosphere. We also tell families never to take any patient back from the hospital if they are afraid of him/her. We suggest, instead, a contract prior to the patient leaving the hospital with the patient agreeing to being re-hospitalized or living elsewhere if he exhibits TIV behavior at home. We regularly repeat that "No family should ever have to live with any family member, including the mentally ill, of whom they are afraid!" Drugs and Alcohol -- Lack of fundamental knowledge in the families about the effects of drugs and alcohol on schizophrenia is often a basic problem in itself. For instance, families often do not know that many drugs and alcohol make schizophrenia worse (9). Our observations indicate that both stimulants (in some cases, including caffeine) and depressants may be deleterious in even small amounts, and that, in moderate amounts, they appear to increase the amount of antipsychotic medication required to "cover" their effects (10). Increased side effects, in turn, reinforce a vicious, cycle. We define problem drinking or drug use as repeated us of substances which predictably cause trouble (financial, relationship, physical, mental, etc.). When we encounter a "dual diagnosis" substance abusing group member who is not able to quit drugs and alcohol on his own (most of them will), we try to get him/her to go to NA or AA and their families to Al-Anon, and we educate them on how to use these self-help groups. On the other hand, "social" drinking-and-drugging patients will usually stop drugs and alcohol simply through our persuasion, reinforced by their continuing improvement. As they improve, our schizophrenic patients may return to experiment with drugs and alcohol with a kind of adolescent neet to be "like everybody else." In our experience, although often stormy, this is often a benign and transient process not associated with a major relapse. Even serious relapses, however, can be dealt with positively as valuable (and often expensive) learning opportunities. Family Polarization -- Family polarization over a chronic illness such as childhood asthma, mental retardation and schizophrenia is common (11, 12). Parents often fight an internecine cold war -- the father (usually) focusing on the patient's manipulative style, or other "bad" conduct, attempts disciplinary measures while the mother (but also the father sometimes) is more sensitive to the patient's illness and is predominantly permissive, kind and nurturing. The more each pursues his point of view, the worse the battle gets -- the schizophrenic member usually

attaching to the permissive family member. This polarization tends to extrude the perceived "punishing and cruel" member from the relationship. With time, this family member then becomes characterized by mother and patient as "He doesn't care about us," and "now" says mother, resentfully, "I'm stuck with the full-time care of a schizophrenic patient." The father may then in fact become distant and uninvolved. Most often siblings see the permissive parent as a "sucker" to the patient's manipulations and, not wanting to get caught in the middle, try to duck out of the picture, leaving mother feeling quite alone with no one to support her. To manage this problem, we elucidate it carefully and then persuade all members of the family to back one another up because "they are both right, so to speak." That is, the patient is both sick and behaving badly. Then we turn their energies into focusing only on the treatment and rehabilitation process itself. Much of this problem is worked out ahead of time by our insisting on both parents (or key family members) coming to the sessions. As the schizophrenia improves, even early on, this polarization usually wanes rapidly. In fact, the disappearance of apparent family "pathology," without any attempt to do "family therapy," can be dramatic and extremely gratifying to all concerned. "Lazy, Sick, or Afraid?" -- One problem many patients have is a general lack of interest, energy, motivation and initiative, especially in the area of new activities, that is, towards finding work, social relationships, schooling, and being helpful around the house. Families are puzzled by whether this is simply a result of the schizophrenia itself or whether it represents something more such as a personality defect. We teach patients and families that, because it is a neurological disorder, schizophrenia most often does affect the brain in such a way as to lessen initiative and liveliness ("negative" symptoms). This, in turn, tends to inhibit the already anxious schizophrenic person into not attempting unfamiliar activities or problematic old ones. The vicious cycle continues as the patient loses his confidence and, as a result, tends to act passively and fearfully and tries to be socially "cool" to disguise these fears. Any characterological laziness he may have only adds to his problems. As soon as the patient is relatively free of psychotic symptoms, we teach families not to try to figure out which is which (lazy, sick, or afraid), but rather to encourage positive action against the general syndrome because only assertive, active behavior will help solve all these three in any combination (much as exposure is the best treatment for phobic behavior). We also educate families about these and other so-called negative psychiatric symptoms which are best treated by: 1) Aerobic exercise; 2) Volunteer or paid work; 3) Close friendships; 4) Steady, comfortable, useful activity all day long. Problem Behavior -- Due to Mental Illness or Personality Problem? -- In the same vein as the preceding "lazy--sick--or--afraid" issue, practically every family encounters from its schizophrenic member some type of recurrent, manipulative behavior which they may have assumed was due to the mental illness but which they may have assumed was due to the mental illness but which does not, in fact, disappear as the mental illness improves. The patient may act "spoiled" if he isn't provided with cigarettes or coffee, or he may be angry if "stressed" with a household chore. Pushed even more, he may say his "voices" are coming back.

To help differentiate personality traits from the illness itself, we suggest that schizophrenic symptoms which herald a relapse almost always show a typical sequence and have a serious and more or less ominous "feel" to them. On the other- hand, manipulative symptoms occur in conjunction with things the patient does not want to do (e.g., mot the kitchen floor). Or, maybe he is afraid to do such things as call a friend up or go to the movies. "Personality" versus "illness" behavior can usually be easily distinguished by correctly identifying the underlying motive of the patient, without rancor. That is, "Are you afraid to call Susie up, John," or "Are you trying to get out of mowing the lawn?" This kind of confrontation usually elicits an irritated or defensive reaction, but also is accompanied by the usual, mischievous "schizophrenic smile." An actively psychotic patient, on the other hand, will be serious and respond in his usual psychotic manner. Obviously, the relapsing schizophrenic person needs to stop his alcohol or drug abuse and increase or resume his medications but the manipulative schizophrenic member needs to be "tough-loved" by the family into responsible productive behavior. Emotional Age vs. Chronological Age -- Generally, people who are ill, including schizophrenic people, tend to regress to a less mature state. Because the onset of Schizophrenia usually interrupts accomplishment of the usual developmental tasks of adolescence, many adults with schizophrenia appear developmentally "stuck." During the treatment and rehabilitation of schizophrenia, most families are confronted by the problem of relating to the adult patient as if he were much younger than his chronological age. "Did you take your pills tonight, dear?," sing songs the patient's wife, or, "Remember, only decaffeinated coffee at the social center," says the twenty-five year old patient's mother. As a result, patients view themselves as being infantilized and, like young teenagers, respond resentfully, "Why don't you treat me like an adult? You're always babying me. Why don't you just leave me along?' In some families, this process alone can lead to conflict and tension which may escalate to the point of relapse, or to a stalemate with TIV behavior from the patient and/or the "walking on eggshells" syndrome. After working out reasonably realistic expectations in each of these situations, we teach family members to respond firmly and clearly to such protestations by saying such things as, "As soon as you act like a responsible adult about your recovery program, you'll be treated that way." We also demonstrate the use of specific compliments and praise as positive reinforcers for improved behavior on the part of the patient. Martyring: "Virtue Through Suffering" -- Whether out of love, loyalty or a deep sense of doing what is right as a parent, many families endure bad behavior from their schizophrenic member for months or years in the same way a battered wife takes abuse from her husband. Families may bury or suppress their anger and resentment or live with their schizophrenic member in a "durable-butunsatisfactory" state, usually punctuated with occasional rehospitalizations. We teach these families not only not to take patients back from the hospital unless basic changes will be made, as in the TIV process, but also we attempt to focus on the benign motives and good intentions families usually have in putting up with this behavior. With exploration we often uncover underlying issues, such as fears of appearing selfish (guilty, in their wish to get rid of the schizophrenic member) or disloyal; reinforcement by the extended family and friends of their "courage and stamina" in the face of their adversity; and so on.

We try to persuade families that the schizophrenic member won't improve until their "martyring" disappears. We try to refocus their attention on the greater goal of improvement of the schizophrenia rather than to recite the benefits to the family, because the very basis of the martyring syndrome is usually an idealistic but selfnegating process. CONCLUSION While our emphasis in treatment and rehabilitation is getting the schizophrenia itself better, it is necessary to ameliorate impeding family processes so that the rehabilitation process can proceed. In this paper we have attempted to list some of the most common problems/issues families encounter and to suggest some solutions to them.