Sexual Dysfunction and Relationships

The Erectile Dysfunction-Relationship Cycle

Erectile and sexual dysfunction in an ongoing relationship usually reflects difficulties between the partners. Relationship problems interfere with sexual feelings and cause or worsen erectile dysfunction.  Any experience that hinders the ability to be intimate, that leads to a feeling of inadequacy or distrust, or that develops a sense of being unloving or unlovable may result in erectile dysfunction.  Successive episodes of impotence are reinforcing. The man becomes increasingly anxious about his next sexual encounter. Erectile dysfunction is worsened by anticipatory anxiety about achieving and maintaining an erection interferes.  Sexual dysfunction interferes with pleasure in sexual contact and reduces ability to respond to sexual stimulation.

Erectile Dysfunction in the relationship cycle

In the early years of the relationship

• Lack of knowledge - there is a refractory period after sex before you can get the next orgasm. This refractory period increases gradually from a few minutes in teenagers to many days  in the elderly. Misguided enthusiasm after a period of separation causes a one-off problem with erection. This  is transient erectile problem is further reinforced by succeeding anxiety.
• Lack of privacy - the young couple moves into the parental home and has minimal access to privacy. Sex is a hurried activity with the focus on orgasm. Intimacy is not fostered. Subsequently there is dissatisfaction and a further build-up of anxiety.
• Stressors - careers with long working hours, night shift work and work from home leaves little time for the emotional intimacy that is requisite for sexual intimacy.

Middle phase

• Lifestyle changes - a sedentary  life style coupled with an indiscriminate diet result in obesity, a leading risk factor for erectile dysfunction. Excessive alcohol intake, and smoking have a direct impact on sexual functioning.
• Infidelity - is a major cause of anxiety and erectile dysfunction in the middle phase of the relationship. This  is especially so when the infidelity arises from insecurity - the man or woman attempting to prove continued youthfulness and desirability outside the relationship.

Later years

• Medical issues - chronic illnesses such as diabetes, and heart disease are commonly associated with erectile dysfunction.

What to do

• Don't panic - anxiety worsens erectile dysfunction. An occasional problem with  erection is not a reflection on your masculinity, and does not necessarily indicate a long term erectile dysfunction. Don't immediately try  to 'prove' yourself. Give it a days break to be safely out of the refractory period. There  will be  no trouble in the  next sexual encounter.
• Communicate - reassure your  partner of your continuing sexual interest in her. Communicate openly about  your condition. Involving your  partner improves the outcome of treatments for erectile dysfunction.
• Quit smoking
• Lose weight, exercise regularly
• Get treatment for alcohol or drug problems
• Work through relationship issues. Consider counseling if unable to work through  problems on your own.
• Depression, anxiety and stress related mental health issues should be addressed. Don't ignore them.

Whom to see for sexual dysfunction

• Consult a qualified psychiatrist. He or she  is the only person with the knowledge, training, and experience to deal with the psychological and medical issues that result in sexual dysfunction. The psychiatrist will also address issues in the relationship that are perpetuating the erectile dysfunction.
• Avoid self-styled sex therapists and sexologists

References:

1. Kubin M, Wagner G, Fugl-Meyer AR. Epidemiology of erectile dysfunction. Int J Impot Res. 2003 Feb;15(1):63-71.
2. McCabe M, Althof SE, Assalian P, Chevret-Measson M, Leiblum SR, Simonelli C, Wylie K. Psychological and interpersonal dimensions of sexual function and dysfunction. J Sex Med. 2010 Jan;7(1 Pt 2):327-36.
3. Metz ME, Epstein N. Assessing the role of relationship conflict in sexual dysfunction. J Sex Marital Ther. 2002 Mar-Apr;28(2):139-64.
4. Nina Bingham. Research Findings on Sexual Dysfunction, Intimacy and Conflict in Heterosexual Couples. Accessed 30-Jun-2012

Cannabis, teenagers and schizophrenia

Cannabis or marijuana use by teenagers and adolescents is highly associated with the onset of psychosis and schizophrenia. Cannabis goes by many names including hash, pot, grass, weed, or ganja. This gateway drug is falsely thought to be innocuous and as having no lasting effects. Cannabis use by teenagers is often not recognised as a problem. Cannabis is cheap and easily accessible in most student populations. Pune is a major hub for the cannabis drug trade. This week a quarter tonnne of ganja was found dumped in a well. Cannabis use is rampant in Pune colleges and hostels, where students assiduosly guard and maintain their 'stash'. During the 57th National School Games the highest number of students testing positive for marijuana came from Maharashtra.

Regular cannabis use increases the risk for schizophrenia and psychosis by upto 4 times. There is increasing evidence that cannabis use can precipitate schizophrenia in vulnerable individuals. This is especially so with early onset use of cannabis. Cannabis also exacerbates symptoms of schizophrenia in those who have already developed the disorder. Psychotic disorders like schizophrenia involve disturbances in the dopamine neurotransmitter systems of the brain. Δ9-tetrahydrocannabinol (THC) - the key neurochemical in cannabis - interacts with dopamine to adversely affect its functioning by multiple mechanisms.

Teenagers are especially vulnnerable to the schizophrenia-inducing effects of cannabis. Cannabis like substances (anandamide) called endocannabinoids, produced by the body, play an important role in several processes of brain maturation. Regular marijuana use affects this process of brain maturation in teenagers. Schizophrenia is also a disorder of brain maturation. Disruption of the endocannabinoid system in the adolescent brain by exposure to cannabis interferes with brain maturation. This provides a mechanism to increase the risk for development of schizophrenia in adolescence.

How to cut down and stop cannabis use

1. Write down a list of reasons for wanting to stop - you will need to review this at times when you are feeling low or experiencing craving.
2. Tell someone you trust that you are quitting
3. Get rid of the paraphernelia for smoking cannabis - the stash, wrappers, lighters, matches. You may be surprised at the number of places where small amounts are hidden. Get rid of it all.
4. Take measures to prevent fresh procurements - avoid places and people associated with replenishments
5. Make a list of things to do to occupy the time freed-up from procuring and using cannabis.
6. Review your list of reasons and things to do when you feel low and when craving is intense.

References

1. Paola Casadioa, Cathy Fernandesb, Robin M. Murray, Marta Di Forti. Cannabis use in young people: The risk for schizophrenia.  Neuroscience & Biobehavioral Reviews. Volume 35, Issue 8, August 2011, Pages 1779–1787. doi:10.1016/j.neubiorev.2011.04.007
2. Degenhardt L, Hall W. Is cannabis use a contributory cause of psychosis? Can J Psychiatry. Aug 2006;51(9):556-65.
3. Deepak Cyril D’Souza,Richard Andrew Sewell,and Mohini Ranganathan. Cannabis and psychosis/schizophrenia: human studies. Eur Arch Psychiatry Clin Neurosci. 2009 October; 259(7): 413–431. Published online 2009 July 16. doi: 10.1007/s00406-009-0024-2

Alcohol and Happiness - do they mix?

Alcohol and happiness don't mix - definitely not when taken in excess, and definitely not in the long term. The relationship between adverse alcohol use and unhappiness is reciprocal - unhappy people tend to drink hazardously, and vice versa. This effect increases over time as demonstrated by a 15-year study that followed-up adult twins in 1975, 1981, and 1990.

Passing out while drinking is significantly more likely in dissatisfied people

Blackouts or passing out while consuming alcohol is an indication of unhappiness.

Dissatisfied people are more likely to have a pattern of binge drinking.

Binge drinkers are more likely to be dissatisfied with life. A pattern of binge drinking on weekends negates any beneficial effects of moderate alcohol use.

Excessive alcohol use increases dissatisfaction and unhappiness. Alcohol, even in moderation does not reinforce feelings of well being, pleasure, happiness or joy. Moderate drinking does not reduce unpleasant feelings.

Don't drink alcohol to regulate your mood, it leads to more grief.

References

1. H. Koivumaa-Honkanen; J. Kaprio; T. Korhonen;, R.J. Honkanen; K. Heikkilä; M. Koskenvuo. Self-reported Life Satisfaction and Alcohol Use: A 15-year Follow-up of Healthy Adult Twins. Alcohol and Alcoholism. 2012;47(2):160-168.
2. R. Curtis Ellison, Marjana Martinic. The Harms and Benefits of Moderate Drinking: Findings of an International Symposium. May 2007 supplement to Annals of Epidemiology.
3. Gustafson R. Does a moderate dose of alcohol reinforce feelings of pleasure, well-being, happiness and joy? A brief communication. Psychol Rep. 1991 Aug;69(1):220-2.

Aggression in children - need for parental intervention

Aggression is uncommon in school children and should be addressed

A Pune teenager was kidnapped and murdered by his school friends a few weeks ago. The victim was deliberately selected and his parents were manipulated for a ransom. Violence, theft and destructiveness are end stage behaviours of conduct problems in children and adolescents.

Trajectories of aggression in children

The commonest path of violence in children is 'adolescence-limited'. The antisocial behaviours usually occur when the adolescents are 'hanging out' in a group.  This type of aggression reflects an anti-authoritarianism. Anti-authoritarianism results from frustration over being denied the benefits of full adult independence despite reaching physical maturity. Adolescent limited aggression is less violent, relies on peer encouragement, and generally diminishes by adulthood  These adolescents are usually able to integrate into society as young adults.

A less common path of violence is 'life-course-persistent'. In this group of antisocial children, problem behaviors unfold in a sequence at home and school

1. Early noncompliance - with excessive arguing and disobedience
2. Poor rule adherence - staying out late, playing in prohibited locations
3. Low frustration tolerance - temper tantrums, abusiveness, aggression

Aggression is common among preschoolers. The prevalence rate of aggression in children reduces dramatically once they enter school. Children whose fighting does not  reduce in the early school years are at high risk for persistent violent behavior. This important subgroup of proactively aggressive youth is profoundly indifferent to the consequences that their misbehavior has upon others. They rarely display genuine remorse. Their personality of 'callous-unemotional traits' is characterised by a lack of empathy, self-centeredness, and shallowness. As youths they are responsible for a large number of violent offenses. Their aggressive behavior is often persistent as features of psychopathic or sociopathic personality.

Parenting can prevent violence

1. Make aggression irrelevant by modifying the setting
Aggression is significantly affected by the parent-child relationship. Children with conduct problems tend to have acrimonious and negative interactions with their parents. The parent is perceived as just an agent of coercion. It is important to change this environment. Positive interactions between the parent and child serves to reinforce the perception of the parent as a source of positive attention, affection, support and encouragement. This makes the child responsive to parents' authority and to the rewards and punsihment that  the parent dispenses.
2. Make aggression ineffective by modifying its consequences
The reactions of others to the aggressive behavior sustains and reinforces it. They may give in to what the child wants, give up trying to get compliance, or even bar the child from school -  which may be exactly what the child wants. To render the aggression ineffective parents/ teachers have to respond by ignoring milder misbehaviour and handing out consequences. These include time outs, loss of privileges (TV, cell phone, Facebook) that the child will want to avoid, and limit setting (curfew times, restricting location).

Parents need to establish  their authority and implement some of these measures in aggressive children. This teaches children that aggression is an ineffective means of fulfilling a particular wish. These lessons are better learned early under caring parents rather than later in a centre for juvenile delinquents.

References
Brennan LM. Toddler-age externalizing behaviors and school-age academic achievement: independent associations and the impact of parental involvement University of Pittsburgh. Thesis presented 27-Aug-2010.

Healthy Baby Contests - judging psychological development objectively

Psychological development is a key aspect of any ‘Healthy Baby Contest”. Pathfinder Clinic judged the psychological development of toddlers participating in one such local event. Healthy baby contests are among the most attractive activities organized by many preschools and communities. Assessment is a sensitive issue at any Healthy Baby competition. Parents of contestants are concerned regarding partiality and subjective errors. Judging a Healthy Baby Contest objectively is crucial to the credibility of the event.

Can psychological development be objectively assessed in 5 minutes?
Psychological assessment can be time consuming and difficult to operationalize. The child’s development is captured in speech, social interaction, and manipulation of every- day objects. Usually a child’s developmental milestones are judged ‘objectively’ based on the parents responses to available screening questionnaires.

We decided to get our knees dirty and go down to toddler level to get a direct assessment of where they were at. The caveat, the organisers wanted us out of the way in two hours. We judged 39 toddlers aged 2 to 4.5yr. We took three hours; less than 5 minutes per child on an average.

Method

The atmosphere around the play rooms was intense -  mainly contributed by parental anxiety. Pre-school coordinators ensured each child walked into the room with their parents. Despite some adult anxieties each family was safely seated at toddler level. Every child was greeted and asked their name. They were then asked to point to and name parts of the body and animal figures;  draw age-appropriate figures; manipulate wooden blocks or coloured beads; and catch a large ball.

Children were assessed on these categories

1. Speech and language
2. Social function
3. Fine motor function
4. Gross motor function
5. Cognitive function

The scores were entered into a proforma and results tabulated

Are healthy baby contests a waste of time?

Of course things didn’t always go smoothly, but under all the levity some serious assessment work was done. We learnt from the kids. Fans and lights are passe as objects to point out - a laptop will always bring out a prompt pointing index finger. The advantages are apparent

• With a reliable scoring system, the results are easy and quick to interpret and more acceptable.
• The results can be explained scientifically
• The protocol can serve as a guideline for educating caregivers and teachers regarding simple criteria for monitoring the child’s health status. These also serve as a checklist for their activities.
• Screening of at risk children - one child screened positive for autism (prevalence rate in the literature is 1 in 110). The parents were advised the need for follow-up.
• Data obtained is used to establish local norms for child development

Healthy Baby Contests can have a positive impact on the community when conducted scientifically. Psychological development of infants and toddlers can be effectively judged through direct observation in a short time-frame.

References

1. Bhat G, Pardeshi S, Kakrani V, Pratinidhi A. Making healthy baby contests more objective. Indian J Med Sci [serial online] 2001 [cited 2012 Mar 23];55:553-8. Available from: http://www.indianjmedsci.org/text.asp?2001/55/10/553/12035
2. M.L. Kulkarni, G.L. Mohan. Healthy Baby Contests-Beyond show, Beyond Objectivity Towards Health Education Indian Pediatrics 1999; 36:417-418 http://www.indianpediatrics.net/apr1999/apr-417-418.htm