What is Dual Diagnosis?

 What is Dual Diagnosis?

Dual diagnosis means that an individual has two separate but very interrelated diagnoses:

1. A psychiatric problem
2. An addiction problem

It is difficult to say which came first. What is important to note is that the person is currently having both problems and both have to be addressed together. A relapse in one of the two areas can trigger a relapse in the other.

Dual Diagnosis profiles may include the following:

1. Severe/major mental illness and a substance disorder(s)
2. Substance disorder(s) and a personality disorder(s)
3. Substance disorder(s), personality disorder(s) and substance induced acute symptoms that may require psychiatric care, i.e., hallucinations, depression, and other symptoms resulting from substance abuse or withdrawal.

How Common Is Dual Diagnosis?

Dual diagnosis is more common than you might imagine.  According to a report published by the Journal of the American Medical Association*:

Thirty-seven percent of alcohol abusers and fifty-three percent of drug abusers also have at least one serious mental illness.

Of all people diagnosed as mentally ill, 29 percent abuse either alcohol or drugs.

What Kind of Mental or Emotional Problems are Seen in People with Dual Diagnosis?

The following psychiatric problems are common to occur in dual diagnosis – i.e., in tandem with alcohol or drug dependency:

• Depressive disorders, such as depression and bipolar disorder
• Anxiety disorders, including generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, and phobias
• Other psychiatric disorders, such as schizophrenia and personality disorders.

Depression

Depression is a serious medical illness that involves the brain. Symptoms can include:

• Sadness
• Loss of interest or pleasure in activities you used to enjoy
• Change in weight
• Difficulty sleeping or oversleeping
• Energy loss
• Feelings of worthlessness
• Thoughts of death or suicide

Depression can run in families, and usually starts between the ages of 15 and 30. It is much more common in women. Women can also get postpartum depression after the birth of a baby. Some people get seasonal affective disorder in the winter. Depression is one part of bipolar disorder.

There are effective treatments for depression, including antidepressants and talk therapy. Most people do best by using both.

Bipolar Disorder

Also called: Manic-depressive illness

Bipolar disorder is a serious mental illness. People who have it experience dramatic mood swings. They may go from overly energetic, “high” and/or irritable, to sad and hopeless, and then back again. They often have normal moods in between. The up feeling is called mania. The down feeling is depression.

Bipolar disorder can run in families. It usually starts in late adolescence or early adulthood. If you think you may have it, tell your health care provider. A medical checkup can rule out other illnesses that might cause your mood changes.

Untreated, bipolar disorder can result in damaged relationships, poor job or school performance, and even suicide. However, there are effective treatments: medicines and “talk therapy”. A combination usually works best.

Anxiety

Fear and anxiety are part of life. You may feel anxious before you take a test or walk down a dark street. This kind of anxiety is useful – it can make you more alert or careful. It usually ends soon after you are out of the situation that caused it. But for millions of people in the United States, the anxiety does not go away, and gets worse over time. They may have chest pains or nightmares. They may even be afraid to leave home. These people have anxiety disorders. Types include

• Panic disorder
• Obsessive-compulsive disorder
• Post-traumatic stress disorder
• Phobias
• Generalized anxiety disorder

Treatment can involve medicines, therapy or both

Schizophrenia

Schizophrenia is a severe, lifelong brain disorder. People who have it may hear voices, see things that aren’t there or believe that others are reading or controlling their minds. In men, symptoms usually start in the late teens and early 20s. They include hallucinations, or seeing things, and delusions such as hearing voices. For women, they start in the mid-20s to early 30s. Other symptoms include

• Unusual thoughts or perceptions
• Disorders of movement
• Difficulty speaking and expressing emotion
• Problems with attention, memory and organization

No one is sure what causes schizophrenia, but your genetic makeup and brain chemistry probably play a role. Medicines can relieve many of the symptoms, but it can take several tries before you find the right drug. You can reduce relapses by staying on your medicine for as long as your doctor recommends. With treatment, many people improve enough to lead satisfying lives.

Personality Disorders

Personality disorders are long-term patterns of thoughts and behaviors that cause serious problems with relationships and work. People with personality disorders have difficulty dealing with everyday stresses and problems. They often have stormy relationships with other people. The exact cause of personality disorders is unknown. However, genes and childhood experiences may play a role.

Symptoms vary widely depending on the specific type of personality disorder. Treatment usually includes talk therapy and sometimes medicine.

Which Develops First – Substance Abuse or the Emotional Problem?

It depends.  Often the psychiatric problem develops first.  In an attempt to feel calmer, peppier, or more cheerful, a person with emotional symptoms may drink or use drugs; doctors call this “self-medication.”  Frequent self-medication may eventually lead to physical or psychological dependency on alcohol or drugs.  If it does, the person then suffers from not just one problem, but two.  In adolescents, however, drug or alcohol abuse may merge and continue into adulthood, which may contribute to the development of emotional difficulties or psychiatric disorders.

In other cases, alcohol or drug dependency is the primary condition.  A person whose substance abuse problem has become severe may develop symptoms of a psychiatric disorder:  perhaps episodes of depression, fits of rage, hallucinations, or suicide attempts.

How Can a Physician Tell Whether the Person’s Primary Problem is Substance Abuse or an Emotional Disorder?

At the initial examination, it may be difficult to tell.  Since many symptoms of severe substance abuse mimic other psychiatric conditions, the person must go through a withdrawal from alcohol and/or drugs before the physician can accurately assess whether there’s an underlying psychiatric problem also.

If a Person Does Have Both an Alcohol/Drug Problem and an Emotional Problem, Which Should Be Treated First?

Ideally, both problems should be treated simultaneously.  When neither illness is treated, one illness can make the other worse. When only one illness is treated, treatment is less likely to be effective. When both illnesses are treated, the chances for a full and lasting recovery are greatly improved, and it is easier to return to a full and productive life.

However, in a controlled therapeutic environment, such as a facility like HOPE, the client is first assessed by a psychiatrist and physician. His psychiatric condition has to be relatively stabilized (with medication within a protocol-oriented setting), so that he is open to other inputs such as psycho-therapy and counseling.

Treatment at AREL HOPE RECOVERY SERVICES

What is the treatment?

Each client has to seen as a unique case, within the broad therapy outlines. The personalized treatment is viewed as long-term and can be begun at whatever stage of recovery the client is in- Empathy, hope and a suitable approach to the problem are at the foundation of integrated treatment.

Treatment at AREL HOPE RECOVERY SERVICES

• For any substance abuser the first step in treatment observed at AREL is detoxification – a period of time during which the body is allowed to cleanse itself of alcohol or drugs. This takes place under medical supervision.  It can take a few days to a week or more, depending on what substances the person abused and for how long.
• Once detoxification is completed, it’s time for dual treatment; rehabilitation for the alcohol or drug problem and treatment for the psychiatric problem.

Rehabilitation for a substance abuse problem usually involves individual and group psychotherapy, education about alcohol and drugs and consequences of addiction, exercise including Yoga, meditation, proper nutrition, and participation in the 12-step recovery program.

The idea is not just to stay off booze and drugs, but to learn to enjoy life without these “crutches.” Clients are placed in recovery groups where theywill learn how others stopped drinking or using, how to cope with cravings and urges to drink or use, and how to live comfortably without the use of alcohol or drugs.

Treatment for a psychiatric problem depends upon the diagnosis.  For most disorders, individual and group therapy as well as medications are recommended.  Expressive therapies and education about the particular psychiatric condition are often useful adjuncts, since insight ensures better compliance with medication.

• Talk therapy (psychotherapy) can help you learn to cope with symptoms of psychiatric illnesses and change the patterns of thinking that may be making them worse. Therapy can also help you look at your drinking/using habits and work on staying clean and sober
• Medication to help with symptoms of illnesses may be prescribed by the physician or psychiatrist. A physician and a Psychiatrist  come in for regular checkup and assessments on the patients/clients

Problems as a result of dual diagnosis

A variety of problems are possible as a result of a dual diagnosis. For example:

• Psychiatric symptoms may be covered up or masked by alcohol or drug use
• Alcohol or drug use or the withdrawal from alcohol or other drugs can mimic or give the appearance of some psychiatric illness
• Untreated chemical dependency can contribute to a reoccurrence of psychiatric symptoms
• Untreated psychiatric illness can contribute to an alcohol or drug relapse
• Family problems or problems in intimate relationships
• Isolation and social withdrawal
• Financial problems
• Employment or school problems
• High risk behavior while driving
• Multiple admission for chemical dependency services due to relapse
• Multiple admissions for psychiatric care
• Increased emergency room admissions
• Homelessness

Recovery depends on treating both the addiction and the mental health problem

Arel Hope recognizes that whether your mental health or substance abuse problem came first, recovery depends on treating both illnesses. The good news is that most people suffering from co-occurring addiction and mental health problems are able to recover, given proper treatment and support.

• It is possible. Recovering from co-occurring disorders takes patience, care and time. It is also important for the correct diagnosis to be made which facilitates recovery. It may take months or even years. But people with substance abuse and mental health problems can and do get better, with proper treatment.
• Arel Hope provides integrated and holistic treatment. The best chance of recovery is through integrated treatment for both the substance abuse and the psychiatric illness. This means getting combined mental health and addiction treatment at one place
• Relapses are part of the recovery process. With every relapse, the chance for recovery is greater. Relapse is a part of recovery and we encourage joining a self-help support group like Alcoholics Anonymous or Narcotics Anonymous where the client is given a chance to share experience and strength and to learn from others’ experiences. Therefore, clients at Arel Hope are sensitized and introduced to AA / NA, while the family is encouraged to attend Al-anon meetings

What is the Role of the Patient’s Family in Treatment?

With both rehabilitation for substance abuse and treatment for a psychiatric problem, education, counseling sessions, and support groups for the patient’s family are important aspects of overall care.  The greater the family’s understanding of the problems, the higher the chances the patient will have a lasting recovery. Arel Hope puts great emphasis on family involvement in the recovery process.

How Can Family and Friends Help with Recovery from the Substance Abuse?

They need to learn to stop ‘enabling’.  Enabling is acting in ways that essentially help or encourage the person to maintain their habit of drinking or getting high.  For instance, a woman whose husband routinely drinks too much might call in sick for him when he is too drunk to go to work.  The family goes on rescuing, protecting and tolerating the addict’s behaviour. That’s enabling.  Likewise, family members or friends might give an addict money which is used to buy drugs, because they’re either sorry for him or afraid of him.  That’s enabling also.

When family and friends participate in the recovery program, they learn how to stop enabling.  If they act on what they’ve learned, the recovering substance abuser is much less likely to relapse into drinking or taking drugs. Moreover, participation in family support groups such as Al-anon initiates a process of healing for the family members.

How Can Family and Friends Help with Recovery from a Psychiatric Condition?

They should be calm and understanding, rather than frightened or critical.  They should be warm and open, rather than cool or cautious.  Although it is fine to ask the person matter-of-factly about the psychiatric treatment, that shouldn’t be the only focus of conversation.

Arel Hope regularly updates family about the client’s progress. However, the family needs to recognize that treatment may take significant time (longer duration than treatment for just addiction problem).

Strategies for Helping Addicts and Alcoholics to Get the Help they Need

Strategies for Helping Addicts and Alcoholics to Get the Help they Need

And, some of these strategies for helping addicts are more about you then they are about the addict themselves. Taking care of yourself, setting a good example of healthy living, and showing basic support is probably nine tenths of the battle. The rest is just details.

But, the details might lead to a breakthrough, so it is worth exploring them. Taking action gives us hope when we are fighting to save our friends or loved ones from this disease.

Here are a few strategies you might try for helping the addict or alcoholic in your life:

• Help them hit bottom faster (do not rescue them)
• Make an ultimatum
• Stop reacting and detach
• Put your own self care and sanity first

There is some overlap here. You might use more than one strategy at a time. Let’s dig deeper and closely examine each one:

Helping them hit bottom faster

“Pain is inevitable, Suffering is optional.” ~ Buddhist proverb

“When I blame someone else for something, I give up my power to them.” ~ Al-Anon Saying

The clear and most direct route to help a struggling addict to hit their bottom faster is to stop enabling them. This is done by setting clear boundaries and sticking to them.

Some people might get the wrong idea here and think that they have to actually take action in order to make the alcoholic’s life worse. This is not really necessary. What has to happen is that you have to remove support from their drinking or drug use. That is all. If they are truly an addict and you are one of the only people enabling them, then this will bring about change very quickly.

Now the problem comes in when the addict or alcoholic has other people who are also enabling them. If this is the case then I would make an argument that you should seek to educate these other people. If you all have a common interest of seeing the addict recover then you should band together and vow never to enable the addict again. Of course, this does not always work because many people do not really think they are enabling, but they believe they are helping instead. Educating them can be done quickly if you can convince them to attend Al-anon groups.

Then there is the question of “outing” the alcoholic or addict. Say they work in a job where they are caring for other people, or they are driving on a regular basis, and you know that they are frequently intoxicated or under the influence. What do you do then? Do you tell their superiors and get them in trouble, and probably fired? Do you do this for their safety? For the safety of others? For both? Or is doing so going to create too much resentment, and basically backfire on you?

Taking drastic action and “outing” someone like this should never be done lightly. In some cases, if someone is truly out of control AND they are endangering other’s lives, then perhaps there are cases where you should make the bold move and involve their superiors or the authorities. But realize what price that comes at. Fierce resentment is really the only possible reaction, at least at first. Perhaps later the addict will realize that you acted in their best interest, but do not expect that type of reasoning when you first call them out and get them into big trouble.

Because the reaction and the level of resentment can be so great, I would not recommend “outing” someone until you have exhausted all options AND discussed the idea with at least 2 other people. If others disagree with the idea then you might seek further counsel. Bring it to an Al-anon meeting, even if you have never been to one. Tell the story, describe your plan, and see what the group thinks. There is much wisdom in a group discussion of that nature, and it could help to steer you towards the right decision.

You may think that you can predict where an addict’s bottom is. In truth, sometimes it is much, much lower than we first suspect. Remember that many who struggle with addiction have to lose pretty much everything before they take action to fix their life. For example, you might think “Ah, now they have lost their job. Surely they will go to rehab now.” In fact, they may be 10 years or more away from giving rehab a shot. You just never know.

In such cases your most powerful weapons are your own personal boundaries. Decide what you will and will not put up with in terms of their addiction, and then stick to it. Focus on your own personal growth and independence, so that you are strong enough to truly take care of yourself if they continue to spiral out of control. Never allow yourself to just hope with all your might that they will change some day, without taking action to protect yourself first.

When you focus on yourself and your own growth, and gain strength, then you have the power to set strict boundaries that actually have a chance at modifying their behavior. Remember, without any consequences, they are not going to change a thing. Become strong enough to set healthy limits, and even walk away from the relationship if need be. That is when they are most likely to hit bottom, when you can fully withdraw all support and focus on your own growth.

The idea is not to punish the alcoholic into getting sober. The idea is to decide what you will not live with, and then build the strength in yourself to follow through with that.

If you are bearing the brunt of an addict’s addiction then you probably have the most power to change it. Not that you have a magic wand, just that you have the power to stop enabling them. In many cases this is going to involve more than the threat of leaving–it may very well involve actually leaving. Most people who are codependent will say that this is impossible for them to do, or they will argue that they could never bring themselves to do it, and so on. But in some cases it might be the best way forward, and it might even lead to a stronger relationship down the road. Hitting bottom rarely happens when your spouse is still standing by your side, doing whatever they can to hold the relationship together. No, hitting bottom happens when your spouse has left, and you have very little left to celebrate. That is the moment of despair that can actually produce real change.

Making an ultimatum

“This too shall pass.” ~ Unknown Persian Sufi poet

“I´m not upset that you lied to me, I´m upset that from now on I can’t believe you.”~ Nietzsche

At some point in your relationship with an addict or alcoholic you might choose to make an ultimatum. Things may have progressed to a point where you are at your wit’s end, and you cannot see yourself continuing to live in this state of chaos any longer. You want relief. You want resolution. You want the madness to stop.

So you might play with the idea of making an ultimatum with the addict or alcoholic in your life. It will almost always take the form of “you quit, or I leave the relationship.” A slight variation on this is “you go to rehab, or I leave the relationship.”

Now one of the problems with making ultimatums is that most people who make them do not intend to follow through with them. It is not so much about what the addict decides to do, it is about you and your own follow through.

Do not make an ultimatum unless you can live with either outcome. Never make a hollow threat with the idea that you might bully someone into taking action.

Ultimatums always work. They always resolve the issue. But this is only true if you actually follow through and stick to your new boundaries. If you are just making a threat to try and get them to stop drinking or using drugs, then the ultimatum will not work.

Ask yourself: “Are you really willing to walk away from this person for good? Are you willing to sever all ties with them, should they choose to continue in their addiction?” If you are not willing to go to that extreme, and really walk away from it all, then do not make an ultimatum. Doing so will likely make things worse in the long run.

The next question is: “Should you make an ultimatum?” I would base this on your level of sanity and peace in your life. How much are you sacrificing due to this other person’s addiction? How much has it compromised your serenity to keep living with the madness of addiction or alcoholism? And most importantly, is there really a compelling reason for the addict to suddenly change their life, especially if you are still supporting them and staying by their side? In other words, is your hope a desperate one? If it is, then an ultimatum might bring you the relief that you deserve.

In many cases, the addict will not be willing to get help if they can maintain the status quo and continue to self medicate while enjoying peace of mind from your relationship with them. So many addicts and alcoholics have to “lose everything” before they are willing to ask for help for their addiction. This frequently means that they need to lose their close relationships, among other things. An ultimatum is a sure way to bring this decision to a head.

You are essentially saying “I am no longer willing to be with you if you are not clean sober. Change now, or I am leaving. Please choose.”

Just don’t say this unless you are truly willing to walk away from it all. That is the key boundary that will make it all work, regardless of what they decide. If you were not really willing to leave, then chances are good that subsequent actions and behaviors (on both of your parts) would lead to a quick relapse anyway.

Stop reacting and detach

“Nothing is good or bad, but thinking makes it so.” ~ Shakespeare

“Resentment is like taking poison and waiting for the other person to die.” ~ Malacky McCourt

“If I am always reacting – I am never free.” ~ Courage to Change

“The 3 C´s: Didn´t cause it, can´t cure it, and can´t control it.” ~ Alanon saying

“How important is it?” ~ Al-Anon slogan

This can be a powerful strategy, especially if you live with the addict or alcoholic in question, and deal with them on a regular basis. The idea is that you should stop reacting to them.

How does this work? The natural inclination is almost always to blow up at the addict when they get into trouble, lose control due to their drug or alcohol use, or just generally screw up and make a fool of themselves. Our natural reaction is to yell, scream, argue, blow up and react to the unacceptable nature of their addiction.

The problem is that if we do not blow up and react to the addict, then we feel like we are condoning the behavior. We feel like if we do not get angry and blow up at their shenanigans, then we are “letting them off the hook.” And we feel that if we do not get angry at them and let them know this, that it will only encourage them to keep using and abusing drugs and alcohol.

But of course this line of thinking is actually a trap. Why?

Because when you blow up at the addict in your life, you are actually giving them an out. You take the focus off of them to an extent and direct it towards yourself. How does this happen? Because when you blow up at them, now they have a target.

YOU are the one who is angry at them. YOU are the one who is yelling at them, and adding to the chaos. Yes, they may have screwed up due to their drug or alcohol use, and they may have created problems for themselves, but now it is YOU who are yelling at them, and this allows them to shift their focus.

The best thing for an addict or alcoholic is to examine their own actions. To see themselves for what they have truly become. If they get a DUI and land in jail, let them sit there, where they are forced to examine their own situation. When you get into a yelling match about their addiction, then it is no longer about their addiction. Now it is about the relationship, it is about the yelling match, it is about anything except their need to self medicate.

So a key strategy is to not react when these critical moments arise. Let the alcoholic turn their rage into self examination. Do not give them an out if they try to drag you into a fight. Stand above the fight, force them to examine their feelings and the core of their addiction.

Not reacting to chaos takes practice. This is not about being a doormat. You still have boundaries, and limits. But the idea is that you will no longer let their addiction turn into a yelling match, one that deflects them from having to look closely at themselves, and their own life, and what a mess it has become.

Rise above the addiction and do not let it affect you. The addict will be surprised when you do not react. They will be confused when they cannot drag your emotions into their chaos and thus shift the focus off of themselves.

Sooner or later, if you do not react to their addiction, then they will have to actually face it for once. And that could produce real change.

Put your own self care and sanity first

“Worry never robs tomorrow of its sorrow; it only robs today of its strength.” ~ A. J. Cronin

“Forgiveness is giving up all hope for a better past.” ~ Jack Kornfield

“Do not worry about what others are doing – each of us should turn the searchlight inward and purify his heart as much as possible.” ~ Gandhi

Perhaps this is the most important strategy, and also the one that is the least intuitive. What does caring for yourself have to do with helping the addict or alcoholic in your life to become clean and sober?

There are a number of benefits to putting your own sanity and personal growth first:

Setting the example - When you put your own health and personal growth first as being the most important thing in your life, then you help to set an example for the alcoholic or the addict that you are trying to influence. Do not make the mistake of thinking that they do not notice your growth, progress, or success.

The addict may feel trapped due to their addiction and secretly think that they could never enjoy a better life like you have, but this can still have an impact on them and could eventually help lead them to change. In other words, it is worth it to try and set a good example, even if the addict does not believe they could ever attain it.

One obvious example of this has to do with drug and alcohol use itself. If you want a friend or loved one to be clean and sober, then you should not use drugs or alcohol yourself around them. Ever. Doing so sets a bad example and “gives them permission” to indulge. Seems obvious enough, but it is amazing how many people miss the boat on this one. They reason that they do not have a problem, the addict does, so why should they have to curtail their drug or alcohol use in order to help someone? Trust me, it makes a huge difference if you are in contact with the addict, and if you are not setting an example of sobriety then you could be part of the problem.

Addicts who hang around with other addicts and alcoholics will eventually believe that chaos and addiction is normal. For every person in their life who lives healthy and sober, it helps to smash this illusion and moves them a bit closer to rationality. A bit indirect but still very important. Be the example of health and stability that you want for the addict in your life.

Achieve emotional balance and stability for yourself – The closer your relationship is with the addict in your life, the more you need to focus on emotional health and stability for yourself. This is especially important if the chaos from their addiction affects you negatively on a regular basis, and causes you great amounts of stress.

You need to find a way to protect yourself from their chaos and become more emotionally healthy. You do this by practicing detachment, becoming a stronger person yourself, and seeking support from others. If you struggle with the emotional aspect of dealing with their addiction then I would strongly recommend that you give Al-anon a try.

Achieving emotional health is important from an indirect standpoint. While not directly causing anyone to get clean sober, being emotionally stable gives you the foundation to better deal with the addict or alcoholic in your life. In addition, you will be happier for yourself in your own personal life if your emotions are on a more even keel. Therefore, you should strive for emotional stability both for yourself, and for dealing with the addict in your life.

Become healthy enough to enforce boundaries – When you become a stronger person in your own path of growth, you get to a point where you can make the types of decisions that may actually have an impact on addiction and alcoholism. For example, if you are codependent with the addict in your life, it is probably the case that you could push them closer to sobriety if you could set healthy boundaries. Doing so requires you to work on yourself, become stronger and more independent, recognize the unhealthy boundaries that you have, and then take action to do something about it.

But the key here is that even if you have an awareness of how you are being codependent, it does no good unless you are healthy enough and strong enough to correct the behavior.

You may identify codependency in counseling, or by sharing in Al-anon meetings, or by talking about your relationship with others. But then you have to take action and fix the problem. You can only do this by making personal growth in your own life first. You can only overcome codependency by becoming healthier and independent yourself.

Becoming strong enough to enforce healthy boundaries does not happen by accident. You will not luck into it. It will take deliberate action on your part, and hard work. But the end result is a healthier you, a healthier relationship, and perhaps the start of pushing an addict towards real change.

Rise above the chaos and live the best life you can, given what you have to work with– If you commit yourself to personal growth and healthier living, then good things will start to happen in your life, regardless of whether or not the addict in your life decides to get help.

If you make detachment and personal growth your priority, then you put yourself in the best position to “weather the storm” if the addict continues in their addiction, but you also put yourself in the best position to help them if they decide to make a change.

Detachment takes practice. Self improvement takes real work and real effort. If this stuff was easy to do then the results would not be worthwhile.

The fact is that this is an opportunity for you to push yourself to become stronger and more healthy. Use it as an opportunity. Dealing with another person’s addiction can become a gift, if you use it as incentive to become stronger. Some day you may look back and say “Look at how much I have grown because I had to learn how to cope with addiction in my life.” It may not be what you asked for in life but you can still make the best of it and become a stronger and healthier person because of it.

Commit to personal growth and a healthier life for yourself.

HOPE TRUST®

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Banjara Hills, Hyderabad 500 034, India

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