"""
Quick-Reference PDF Guide: Sexual Dysfunctions
Diagnostic Criteria & First-Line Management
Uses reportlab for a clean, clinical-style layout.
"""

from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.units import mm, cm
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.enums import TA_LEFT, TA_CENTER, TA_JUSTIFY
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, KeepTogether, PageBreak
)
from reportlab.platypus.flowables import BalancedColumns
from reportlab.lib.colors import HexColor, white, black
import os

OUTPUT_PATH = "/tmp/workspace/sexual-dysfunction-guide/Sexual_Dysfunction_Quick_Reference.pdf"

# ── Colour palette ──────────────────────────────────────────────────────────
C_NAVY      = HexColor("#1A2E4A")   # header background
C_TEAL      = HexColor("#1B7A8A")   # section headers
C_LIGHT_BLUE= HexColor("#D6EAF0")   # table row alt
C_MINT      = HexColor("#E8F5F2")   # management cell bg
C_AMBER     = HexColor("#FFF3CD")   # DSM criteria cell bg
C_ORANGE    = HexColor("#E07B39")   # accent strip
C_GREY_LIGHT= HexColor("#F4F6F8")
C_GREY      = HexColor("#7F8C8D")
C_RED_SOFT  = HexColor("#F9EBEA")
C_GREEN_SOFT= HexColor("#EAF7F0")

# ── Document setup ───────────────────────────────────────────────────────────
doc = SimpleDocTemplate(
    OUTPUT_PATH,
    pagesize=A4,
    leftMargin=15*mm,
    rightMargin=15*mm,
    topMargin=18*mm,
    bottomMargin=18*mm,
    title="Sexual Dysfunctions – Quick Reference Guide",
    author="Orris Medical Reference",
    subject="Psychiatry – Sexual Dysfunctions"
)

W = A4[0] - 30*mm  # usable page width

# ── Styles ───────────────────────────────────────────────────────────────────
styles = getSampleStyleSheet()

def S(name, **kw):
    return ParagraphStyle(name, **kw)

sTitle    = S("sTitle",    fontName="Helvetica-Bold",   fontSize=20, textColor=white,       alignment=TA_CENTER, spaceAfter=2)
sSubtitle = S("sSubtitle", fontName="Helvetica",        fontSize=10, textColor=HexColor("#BDC8D8"), alignment=TA_CENTER)
sSectionH = S("sSectionH", fontName="Helvetica-Bold",   fontSize=12, textColor=white,       spaceBefore=6, spaceAfter=3)
sDxHead   = S("sDxHead",   fontName="Helvetica-Bold",   fontSize=10, textColor=C_NAVY,      spaceBefore=4, spaceAfter=2)
sBody     = S("sBody",     fontName="Helvetica",        fontSize=8.5,leading=12,            textColor=HexColor("#2C3E50"), spaceAfter=2)
sBold     = S("sBold",     fontName="Helvetica-Bold",   fontSize=8.5,leading=12,            textColor=C_NAVY)
sBullet   = S("sBullet",   fontName="Helvetica",        fontSize=8,  leading=11,            textColor=HexColor("#2C3E50"), leftIndent=8, bulletIndent=0)
sSmall    = S("sSmall",    fontName="Helvetica-Oblique",fontSize=7.5,textColor=C_GREY,      spaceAfter=1)
sLabel    = S("sLabel",    fontName="Helvetica-Bold",   fontSize=7.5,textColor=C_TEAL,      spaceAfter=1)
sFooter   = S("sFooter",   fontName="Helvetica-Oblique",fontSize=7,  textColor=C_GREY,      alignment=TA_CENTER)
sWarning  = S("sWarning",  fontName="Helvetica-Bold",   fontSize=8,  textColor=HexColor("#8B0000"))
sTableHdr = S("sTableHdr", fontName="Helvetica-Bold",   fontSize=8,  textColor=white,       alignment=TA_CENTER)
sTableCell= S("sTableCell",fontName="Helvetica",        fontSize=8,  leading=10,            textColor=HexColor("#2C3E50"))
sTableBold= S("sTableBold",fontName="Helvetica-Bold",   fontSize=8,  leading=10,            textColor=C_NAVY)

def P(text, style=sBody):
    return Paragraph(text, style)

def B(text):
    return P(text, sBold)

def bullet(items, style=sBullet):
    return [P(f"• {i}", style) for i in items]

def HR(color=C_TEAL, thickness=0.8):
    return HRFlowable(width="100%", thickness=thickness, color=color, spaceAfter=4, spaceBefore=2)

def spacer(h=4):
    return Spacer(1, h*mm)

# ── Page header/footer callbacks ─────────────────────────────────────────────
def on_page(canvas, doc):
    canvas.saveState()
    # Footer
    canvas.setFont("Helvetica-Oblique", 7)
    canvas.setFillColor(C_GREY)
    canvas.drawString(15*mm, 10*mm, "Quick-Reference Guide | Sexual Dysfunctions | DSM-5 / IPS CPG 2017")
    canvas.drawRightString(A4[0]-15*mm, 10*mm, f"Page {doc.page}")
    # Thin top rule on pages > 1
    if doc.page > 1:
        canvas.setStrokeColor(C_TEAL)
        canvas.setLineWidth(0.5)
        canvas.line(15*mm, A4[1]-13*mm, A4[0]-15*mm, A4[1]-13*mm)
    canvas.restoreState()

# ═══════════════════════════════════════════════════════════════════════════════
# CONTENT BUILDER
# ═══════════════════════════════════════════════════════════════════════════════

story = []

# ── COVER HEADER BLOCK ────────────────────────────────────────────────────────
cover_data = [[
    P("SEXUAL DYSFUNCTIONS", sTitle),
]]
cover_table = Table([[P("SEXUAL DYSFUNCTIONS", sTitle)]], colWidths=[W])
cover_table.setStyle(TableStyle([
    ("BACKGROUND",  (0,0), (-1,-1), C_NAVY),
    ("ROWPADDING",  (0,0), (-1,-1), 10),
    ("TOPPADDING",  (0,0), (-1,-1), 14),
    ("BOTTOMPADDING",(0,0),(-1,-1),6),
    ("ROUNDEDCORNERS",[4]),
]))
story.append(cover_table)

subtitle_data = [[P("Quick-Reference Guide  |  Diagnostic Criteria & First-Line Management", sSubtitle)]]
sub_table = Table(subtitle_data, colWidths=[W])
sub_table.setStyle(TableStyle([
    ("BACKGROUND",  (0,0),(-1,-1), C_TEAL),
    ("ROWPADDING",  (0,0),(-1,-1), 5),
]))
story.append(sub_table)
story.append(spacer(3))

# Source line
story.append(P("Based on: DSM-5 | ICD-10/11 | Kaplan & Sadock's Comprehensive Textbook of Psychiatry (10th ed.) | IPS Clinical Practice Guidelines 2017 (Avasthi et al.)", sSmall))
story.append(HR(C_ORANGE, 1.2))
story.append(spacer(2))

# ── CLASSIFICATION TABLE ───────────────────────────────────────────────────────
def section_header(text):
    t = Table([[P(f"  {text}", sSectionH)]], colWidths=[W])
    t.setStyle(TableStyle([
        ("BACKGROUND",  (0,0),(-1,-1), C_TEAL),
        ("ROWPADDING",  (0,0),(-1,-1), 5),
        ("ROUNDEDCORNERS",[3]),
    ]))
    return t

story.append(section_header("CLASSIFICATION  (DSM-5)"))
story.append(spacer(2))

cls_headers = ["Phase", "Male", "Female", "Both Sexes"]
cls_data = [
    [P(h, sTableHdr) for h in cls_headers],
    [P("Desire / Interest", sTableBold), P("Male HSDD (MHSDD)", sTableCell),
     P("Female Sexual Interest/Arousal Disorder (FSIAD)", sTableCell), P("—", sTableCell)],
    [P("Arousal / Erection", sTableBold), P("Erectile Disorder (ED)", sTableCell),
     P("(merged into FSIAD in DSM-5)", sTableCell), P("—", sTableCell)],
    [P("Orgasm", sTableBold), P("Delayed Ejaculation (DE)", sTableCell),
     P("Female Orgasmic Disorder (FOD)", sTableCell), P("—", sTableCell)],
    [P("Ejaculation", sTableBold), P("Premature Ejaculation (PE)", sTableCell),
     P("—", sTableCell), P("—", sTableCell)],
    [P("Pain / Penetration", sTableBold), P("—", sTableCell),
     P("Genitopelvic Pain/Penetration Disorder (GPPPD)", sTableCell), P("—", sTableCell)],
    [P("Substance/Med-induced", sTableBold), P("Any phase", sTableCell),
     P("Any phase", sTableCell), P("Substance/Medication-\nInduced SD", sTableCell)],
]
cls_col = [28*mm, 43*mm, 68*mm, 36*mm]
cls_table = Table(cls_data, colWidths=cls_col)
cls_table.setStyle(TableStyle([
    ("BACKGROUND",   (0,0),  (-1,0),  C_NAVY),
    ("BACKGROUND",   (0,1),  (-1,1),  C_LIGHT_BLUE),
    ("BACKGROUND",   (0,2),  (-1,2),  white),
    ("BACKGROUND",   (0,3),  (-1,3),  C_LIGHT_BLUE),
    ("BACKGROUND",   (0,4),  (-1,4),  white),
    ("BACKGROUND",   (0,5),  (-1,5),  C_LIGHT_BLUE),
    ("BACKGROUND",   (0,6),  (-1,6),  white),
    ("GRID",         (0,0),  (-1,-1), 0.5, HexColor("#BBCDD8")),
    ("ROWPADDING",   (0,0),  (-1,-1), 5),
    ("VALIGN",       (0,0),  (-1,-1), "MIDDLE"),
    ("FONTSIZE",     (0,0),  (-1,-1), 8),
]))
story.append(cls_table)
story.append(spacer(2))
story.append(P("Specifiers (all disorders): <b>Lifelong vs. Acquired</b> | <b>Generalized vs. Situational</b> | Severity: Mild / Moderate / Severe | Duration: ≥ 6 months | Distress criterion required", sSmall))
story.append(spacer(4))

# ═══════════════════════════════════════════════════════════════════════════════
# DYSFUNCTION CARDS
# ═══════════════════════════════════════════════════════════════════════════════

def card(
    number, name, code_dsm, code_icd,
    dx_criteria,        # list of strings
    key_features,       # list of strings
    etiology_org,       # list of strings
    etiology_psy,       # list of strings
    first_line_pharm,   # list of (drug, detail) tuples
    first_line_nonpharm,# list of strings
    red_flags=None,     # list of strings or None
    note=None
):
    """Build a KeepTogether card for one dysfunction."""
    elements = []

    # ── Card title bar
    title_row = [[
        P(f"  {number}. {name}", S("ct", fontName="Helvetica-Bold", fontSize=11,
          textColor=white, leading=14)),
        P(f"DSM-5: {code_dsm}  |  ICD-10: {code_icd}",
          S("cc", fontName="Helvetica", fontSize=8, textColor=HexColor("#CCE0E8"),
            alignment=4)),  # RIGHT
    ]]
    title_t = Table(title_row, colWidths=[W*0.62, W*0.38])
    title_t.setStyle(TableStyle([
        ("BACKGROUND", (0,0),(-1,-1), C_NAVY),
        ("ROWPADDING", (0,0),(-1,-1), 6),
        ("TOPPADDING", (0,0),(-1,-1), 8),
        ("BOTTOMPADDING",(0,0),(-1,-1), 8),
        ("VALIGN",     (0,0),(-1,-1), "MIDDLE"),
    ]))
    elements.append(title_t)

    # ── Two-column body: left = DX, right = Management
    # LEFT column content
    left = []
    left.append(P("<b><font color='#1B7A8A'>▸ DIAGNOSTIC CRITERIA (DSM-5)</font></b>", sBody))
    left.append(spacer(1))
    for c in dx_criteria:
        left.append(P(f"<font color='#1A2E4A'>◆</font>  {c}", sBullet))
    left.append(spacer(2))

    left.append(P("<b><font color='#1B7A8A'>▸ KEY CLINICAL FEATURES</font></b>", sBody))
    for f in key_features:
        left.append(P(f"• {f}", sBullet))
    left.append(spacer(2))

    left.append(P("<b><font color='#1B7A8A'>▸ ETIOLOGY</font></b>", sBody))
    left.append(P("<u>Organic:</u>", sLabel))
    for e in etiology_org:
        left.append(P(f"• {e}", sBullet))
    left.append(P("<u>Psychological:</u>", sLabel))
    for e in etiology_psy:
        left.append(P(f"• {e}", sBullet))

    # RIGHT column content
    right = []
    right.append(P("<b><font color='#1B7A8A'>▸ FIRST-LINE PHARMACOTHERAPY</font></b>", sBody))
    right.append(spacer(1))
    for drug, detail in first_line_pharm:
        right.append(P(f"<b>{drug}</b>", sBullet))
        right.append(P(f"  {detail}", S("ind", fontName="Helvetica", fontSize=7.5,
                         leading=10, textColor=C_GREY, leftIndent=14)))
    right.append(spacer(2))

    right.append(P("<b><font color='#1B7A8A'>▸ FIRST-LINE NON-PHARMACOLOGICAL</font></b>", sBody))
    right.append(spacer(1))
    for n in first_line_nonpharm:
        right.append(P(f"• {n}", sBullet))

    if red_flags:
        right.append(spacer(2))
        rf_items = "  ".join([f"⚠ {r}" for r in red_flags])
        right.append(P(f"<b><font color='#C0392B'>RED FLAGS:</font></b> {rf_items}", sWarning))

    if note:
        right.append(spacer(1))
        right.append(P(f"<i>{note}</i>", sSmall))

    # Wrap in left/right tables to equalise padding
    def col_wrap(content, bg):
        t = Table([[c] for c in content],
                  colWidths=[W*0.46 - 6*mm])
        t.setStyle(TableStyle([
            ("BACKGROUND",    (0,0),(-1,-1), bg),
            ("LEFTPADDING",   (0,0),(-1,-1), 5),
            ("RIGHTPADDING",  (0,0),(-1,-1), 5),
            ("TOPPADDING",    (0,0),(-1,-1), 2),
            ("BOTTOMPADDING", (0,0),(-1,-1), 2),
        ]))
        return t

    body_row = [[col_wrap(left, C_AMBER), col_wrap(right, C_MINT)]]
    body_t = Table(body_row, colWidths=[W*0.48, W*0.52])
    body_t.setStyle(TableStyle([
        ("VALIGN",       (0,0),(-1,-1), "TOP"),
        ("LEFTPADDING",  (0,0),(-1,-1), 3),
        ("RIGHTPADDING", (0,0),(-1,-1), 3),
        ("TOPPADDING",   (0,0),(-1,-1), 5),
        ("BOTTOMPADDING",(0,0),(-1,-1), 5),
        ("BOX",          (0,0),(-1,-1), 0.5, HexColor("#BBCDD8")),
        ("LINEABOVE",    (0,0),(-1,0),  1.5, C_TEAL),
    ]))
    elements.append(body_t)
    elements.append(spacer(3))

    return KeepTogether(elements)


# ─────────────────────────────────────────────────────────────────────────────
# CARD 1: Male HSDD
# ─────────────────────────────────────────────────────────────────────────────
story.append(section_header("SEXUAL DYSFUNCTIONS — INDIVIDUAL DISORDER CARDS"))
story.append(spacer(2))

story.append(card(
    number="1",
    name="Male Hypoactive Sexual Desire Disorder (MHSDD)",
    code_dsm="302.71 (F52.0)",
    code_icd="F52.0",
    dx_criteria=[
        "Persistently/recurrently deficient or absent sexual/erotic thoughts, fantasies, and desire for sexual activity",
        "Duration ≥ 6 months",
        "Causes marked distress in individual",
        "Not due to another disorder, medical condition, substance, or relationship problem alone",
    ],
    key_features=[
        "Rarely initiates sex; minimal response to partner's initiation",
        "May still have erections with masturbation (desire absent, function intact)",
        "Often comorbid with depression; bimodal prevalence (young & elderly men)",
        "Distinguish from reduced activity due to partner unavailability (fantasies preserved)",
    ],
    etiology_org=[
        "Testosterone deficiency (hypogonadism)",
        "Hyperprolactinemia (pituitary tumour, antipsychotics)",
        "Thyroid dysfunction, chronic illness, medications (opioids, antidepressants)",
    ],
    etiology_psy=[
        "Depression (dopamine depletion)",
        "Relationship conflict / unexpressed hostility toward partner",
        "History of trauma; fear of intimacy; prolonged abstinence",
        "Comorbid anxiety disorder",
    ],
    first_line_pharm=[
        ("Treat primary disorder first",
         "Treat depression (avoid SSRIs if possible; prefer bupropion) or anxiety"),
        ("Testosterone replacement",
         "Only if biochemically confirmed hypogonadism (total T < threshold); monitor PSA, Hct"),
        ("Cabergoline",
         "If hyperprolactinemia confirmed; dopamine agonist normalises prolactin"),
        ("Bupropion SR (off-label)",
         "Dopamine/norepinephrine reuptake inhibitor; improves desire & arousal"),
    ],
    first_line_nonpharm=[
        "Psychoeducation: address misconceptions, normalise sexual response",
        "Sex education (especially in Indian context – first-line per IPS CPG)",
        "Couples therapy: address relationship dissatisfaction",
        "CBT: challenge avoidance, negative cognitions, low self-esteem",
        "Sensate focus exercises to rebuild sexual connection",
    ],
    red_flags=["New-onset low desire: screen for prolactinoma (check prolactin + MRI)", "Concurrent depression needs independent treatment"],
    note="IPS CPG: Always assess for cultural factors, Dhat beliefs, and sexual knowledge gaps before pharmacotherapy."
))

# ─────────────────────────────────────────────────────────────────────────────
# CARD 2: FSIAD
# ─────────────────────────────────────────────────────────────────────────────
story.append(card(
    number="2",
    name="Female Sexual Interest/Arousal Disorder (FSIAD)",
    code_dsm="302.72 (F52.22)",
    code_icd="F52.0 / F52.2",
    dx_criteria=[
        "≥3 of 6 symptoms for ≥6 months: (1) reduced interest in sex; (2) reduced erotic thoughts/fantasies; (3) reduced initiation/receptiveness; (4) absent/reduced excitement or pleasure during sex; (5) absent/reduced interest in response to erotic cues; (6) absent/reduced genital or non-genital sensations during sex",
        "Causes marked distress",
        "Not better explained by another disorder, medical condition, medication, or severe relationship distress",
    ],
    key_features=[
        "Merges prior HSDD and FSAD (DSM-5): recognises that female desire is often responsive, not spontaneous",
        "Most common female sexual dysfunction; prevalence 17–50%",
        "HSDD with distress ~10% of women; peaks in middle years",
        "Depression positively associated; partner's sexual function highly correlated",
    ],
    etiology_org=[
        "Oestrogen deficiency: peri/post-menopause, surgical menopause, postpartum, lactation",
        "Oral contraceptives: raise SHBG → lower free testosterone",
        "SSRIs/SNRIs (70–80% incidence of sexual side effects)",
        "Antipsychotics (hyperprolactinemia), antihypertensives",
        "Diabetes, vascular disease (impair vaginal engorgement)",
    ],
    etiology_psy=[
        "Depression and anxiety (most common psychological contributors)",
        "Negative body image; history of sexual trauma or abuse",
        "Relationship dissatisfaction, poor communication",
        "Inadequate sexual stimulation (often miscategorised as disorder)",
        "Cultural guilt, religious prohibitions on female sexual pleasure",
    ],
    first_line_pharm=[
        ("Flibanserin 100 mg nocte",
         "5-HT1A agonist / 5-HT2A antagonist; FDA-approved for premenopausal HSDD; separate alcohol by ≥2 h"),
        ("Bremelanotide 1.75 mg SC",
         "MC4 agonist; inject 45 min pre-sex; ≤8×/month; caution in hypertension; main SE: nausea"),
        ("Transdermal testosterone (off-label)",
         "Postmenopausal HSDD; shown to improve all sexual domains; monitor for androgenic SE"),
        ("Bupropion SR (off-label)",
         "Improves arousal, orgasm, and satisfaction in premenopausal women"),
        ("Topical oestrogen (if hypoestrogenic)",
         "Vaginal cream/ring/tablet for atrophy-driven symptoms; minimal systemic absorption"),
    ],
    first_line_nonpharm=[
        "Psychoeducation about responsive vs spontaneous desire in women",
        "Mindfulness-Based Cognitive Therapy (MBCT) – especially post-trauma",
        "Sensate focus (graded touching exercises, removes performance pressure)",
        "Couples therapy: communication skills, partner involvement",
        "CBT for trauma-related cognitions, body image, guilt",
        "Review and switch medications causing sexual side effects",
    ],
    note="IPS CPG: Inadequate stimulation is very common. Rule this out before diagnosing a disorder."
))

# ─────────────────────────────────────────────────────────────────────────────
# CARD 3: Erectile Disorder
# ─────────────────────────────────────────────────────────────────────────────
story.append(card(
    number="3",
    name="Erectile Disorder (ED)",
    code_dsm="302.72 (F52.21)",
    code_icd="F52.2",
    dx_criteria=[
        "≥1 of 3 symptoms on almost all/all (75–100%) occasions, ≥6 months: (1) marked difficulty obtaining an erection; (2) marked difficulty maintaining an erection until completion of activity; (3) marked decrease in erectile rigidity",
        "Causes marked distress",
        "Not better explained by non-sexual mental disorder, severe relationship distress, or other significant stressors, medical condition, or substances",
    ],
    key_features=[
        "Most common male sexual dysfunction; prevalence 52% (Massachusetts Male Aging Study)",
        "Psychogenic: sudden onset, situational, morning erections preserved, younger age",
        "Organic: insidious onset, global (not situational), morning erections absent, cardiovascular risk factors",
        "ED in young men = early cardiovascular sentinel event (often precedes CAD by 3–5 years)",
        "Mixed etiology is very common in clinical practice",
    ],
    etiology_org=[
        "Vasculogenic (most common): atherosclerosis, hypertension, diabetes → endothelial dysfunction",
        "Neurogenic: MS, Parkinson's, spinal cord injury, radical prostatectomy, DM neuropathy",
        "Endocrine: hypogonadism, hyperprolactinemia, thyroid dysfunction",
        "Medications: antihypertensives (thiazides, β-blockers), antidepressants, antipsychotics, opioids",
        "Lifestyle: tobacco (linear dose-response), heavy alcohol, obesity, OSA",
    ],
    etiology_psy=[
        "Performance anxiety with spectatoring (commonest psychological mechanism)",
        "Depression (dopamine depletion) and anxiety (sympathetic override of parasympathetic arousal)",
        "Relationship conflict; fear of intimacy; prior traumatic sexual experience",
        "First organic episode → psychological anxiety → self-perpetuating cycle",
    ],
    first_line_pharm=[
        ("PDE-5 Inhibitors (first-line)",
         "Block PDE-5 enzyme → ↑cGMP → cavernosal smooth muscle relaxation → erection"),
        ("  Sildenafil 25–100 mg PRN",
         "Take 30–60 min before; affected by fatty meals; duration 4–6 h"),
        ("  Tadalafil 10–20 mg PRN / 2.5–5 mg daily",
         "Duration 36 h ('weekend pill'); daily dosing available; not food-affected"),
        ("  Vardenafil 5–20 mg PRN",
         "Onset 30 min; duration 4–5 h"),
        ("  Avanafil 50–200 mg PRN",
         "Fastest onset 15–30 min; duration 6–12 h"),
        ("CI: Organic nitrates (risk of severe hypotension)",
         "Absolute contraindication with any nitrate preparation"),
        ("Testosterone (if hypogonadal)",
         "Restores androgen milieu; PDE-5I often still needed concurrently"),
    ],
    first_line_nonpharm=[
        "Modify cardiovascular risk factors: weight loss, exercise, Mediterranean diet, quit smoking",
        "Review and switch offending medications (e.g., change antihypertensive class)",
        "CPAP for obstructive sleep apnoea (improves erectile function)",
        "Sensate focus: removes spectatoring, rebuilds sexual confidence",
        "CBT for performance anxiety; psychoeducation for couple",
        "Vacuum Erection Device (VED): second-line mechanical option",
        "Penile implant (inflatable prosthesis): third-line surgical option",
    ],
    red_flags=["Absent morning erections in young man: urgent endocrine + vascular workup", "New-onset ED + chest pain: cardiovascular evaluation before PDE-5I"],
    note="IPS CPG: For organic ED, refer to urologist/endocrinologist. Maintain psychiatric liaison for mixed etiology."
))

story.append(PageBreak())

# ─────────────────────────────────────────────────────────────────────────────
# CARD 4: Premature Ejaculation
# ─────────────────────────────────────────────────────────────────────────────
story.append(card(
    number="4",
    name="Premature (Early) Ejaculation (PE)",
    code_dsm="302.75 (F52.4)",
    code_icd="F52.4",
    dx_criteria=[
        "Ejaculation within approximately 1 minute of vaginal penetration and before the person wishes it",
        "Present on almost all/all (75–100%) occasions, ≥6 months",
        "Causes marked distress",
        "Not better explained by non-sexual mental disorder, relationship distress, or medical condition/substance",
        "Three core criteria: (1) brief latency; (2) loss of control; (3) distress to patient/partner",
    ],
    key_features=[
        "Most common male sexual complaint globally (~30%); comorbid in ~1/3 of men with ED",
        "Subtypes: lifelong vs acquired; global vs situational",
        "Many cases represent normal biological variation — psychoeducation and reassurance are highly effective",
        "Lifelong PE: consistent since first sexual experience; likely neurobiological serotonin threshold",
        "Acquired PE: often secondary to ED, thyroid disease, prostatitis, or relationship distress",
    ],
    etiology_org=[
        "Thyroid dysfunction (hyperthyroidism: reversible cause — always check TSH)",
        "Urethritis / prostatitis (acquired PE)",
        "Comorbid ED (anxiety about erection hastens ejaculation)",
        "Penile hypersensitivity (proposed in lifelong PE)",
    ],
    etiology_psy=[
        "Conditioned response: early sexual experiences in high-anxiety/rushed contexts",
        "Performance anxiety; fear of detection; inadequate sexual education",
        "Relationship stress; poor communication with partner",
        "Anxiety disorders (especially generalised anxiety)",
    ],
    first_line_pharm=[
        ("SSRIs — daily (first-line)",
         "Central serotonergic inhibition of ejaculatory reflex; full effect in 2–3 weeks"),
        ("  Paroxetine 10–40 mg/day",
         "Most effective SSRI for PE; delayed ejaculation is a known side effect utilised therapeutically"),
        ("  Sertraline 50–200 mg/day",
         "Well tolerated; alternative first-line"),
        ("  Fluoxetine 20–40 mg/day / Escitalopram 10–20 mg/day",
         "Other options; long half-life of fluoxetine is an advantage"),
        ("Dapoxetine 30–60 mg on-demand",
         "Short-acting SSRI; take 1–3 h before sex; only SSRI specifically approved for PE in many countries"),
        ("Topical lidocaine–prilocaine (EMLA spray/cream)",
         "Apply 20–30 min pre-sex; reduces penile sensitivity; improves latency and control"),
        ("Clomipramine 12.5–50 mg/day",
         "TCA alternative if SSRIs fail; 5-HT reuptake inhibition"),
        ("Tramadol (third-line, off-label)",
         "Opioid + serotonergic mechanisms; risk of dependence — use with caution"),
    ],
    first_line_nonpharm=[
        "Psychoeducation and reassurance (many cases resolve with education alone)",
        "Squeeze technique: stimulate to near-ejaculation, apply pressure at coronal ridge for 30 sec",
        "Stop-Start technique (Semans): pause all stimulation at near-ejaculation; repeat 3× then allow orgasm",
        "Sensate focus: reduces performance anxiety, improves ejaculatory awareness",
        "Couples therapy: PE is a dyadic problem; partner involvement improves outcomes",
        "If PE + ED: treat ED first with PDE-5I; PE may resolve",
    ],
    note="If PE is acquired + associated with hyperthyroidism: treating thyroid disorder resolves PE."
))

# ─────────────────────────────────────────────────────────────────────────────
# CARD 5: Delayed Ejaculation
# ─────────────────────────────────────────────────────────────────────────────
story.append(card(
    number="5",
    name="Delayed Ejaculation (DE)",
    code_dsm="302.74 (F52.32)",
    code_icd="F52.3",
    dx_criteria=[
        "Either (1) marked delay in ejaculation OR (2) marked infrequency/absence of ejaculation, on almost all/all occasions, ≥6 months",
        "Causes marked distress",
        "Not better explained by another disorder, medication, medical condition, or inadequate stimulation",
    ],
    key_features=[
        "Least common male ejaculatory disorder; incidence rising with SSRI use",
        "Classic pattern: can ejaculate with masturbation, cannot intravaginally (situational subtype)",
        "Lifelong DE: often psychosexual — idiosyncratic masturbatory style, rarely attainable with partner",
        "Acquired DE: usually medication-induced (SSRIs, antipsychotics, opioids)",
        "Anejaculation: complete inability to ejaculate (severe form)",
    ],
    etiology_org=[
        "SSRIs / SNRIs (very common cause)",
        "Antipsychotics (alpha-1 blockade impairs emission)",
        "Opioids, excessive alcohol",
        "Spinal cord injury, pelvic surgery, diabetic autonomic neuropathy",
        "Hypogonadism, hypothyroidism",
    ],
    etiology_psy=[
        "Performance anxiety drawing attention away from erotic stimulation",
        "Idiosyncratic masturbatory style (specific fantasy/technique not replicable with partner)",
        "Ambivalence about parenthood (partner trying to conceive)",
        "Fear of loss of control; hostility toward partner",
        "Psychosexual developmental conflicts",
    ],
    first_line_pharm=[
        ("Reduce/withdraw offending drug",
         "If SSRI/antipsychotic is cause: lower dose, switch to non-serotonergic agent (bupropion, mirtazapine)"),
        ("Bupropion (if switching antidepressant)",
         "Dopamine/NE reuptake inhibitor; not associated with ejaculatory delay"),
        ("Cyproheptadine 4–12 mg PRN",
         "5-HT2 antagonist; taken 1–2 h before sex to reverse SSRI-induced DE (short-term)"),
        ("Amantadine 100–200 mg PRN",
         "Dopamine agonist properties; off-label for drug-induced DE"),
        ("Cabergoline / testosterone",
         "If hyperprolactinemia or hypogonadism respectively confirmed"),
    ],
    first_line_nonpharm=[
        "Psychoeducation: explain mechanism, normalise the experience",
        "Graduated extravaginal ejaculation → progressively closer to vaginal entry (bridging technique)",
        "Partner-assisted stimulation to point of near-ejaculation before penetration",
        "Address idiosyncratic masturbatory style: vary technique, reduce frequency before sex",
        "Psychodynamic/CBT therapy for ambivalence, partner hostility, or trauma",
        "Stop-start technique adapted for DE: focus on erotic sensations rather than on achieving orgasm",
    ],
    note="Many DE cases improve when the offending medication is changed. Always review drug list first."
))

story.append(PageBreak())

# ─────────────────────────────────────────────────────────────────────────────
# CARD 6: Female Orgasmic Disorder
# ─────────────────────────────────────────────────────────────────────────────
story.append(card(
    number="6",
    name="Female Orgasmic Disorder (FOD)",
    code_dsm="302.73 (F52.31)",
    code_icd="F52.3",
    dx_criteria=[
        "≥1 of 3 on almost all/all (75–100%) occasions, ≥6 months: (1) marked delay in orgasm; (2) marked infrequency or absence of orgasm; (3) markedly reduced intensity of orgasmic sensations",
        "Causes marked distress",
        "Not better explained by another disorder, medical condition, medications, or inadequate stimulation",
    ],
    key_features=[
        "Primary (lifelong) FOD: has never experienced orgasm by any means",
        "Secondary (acquired) FOD: previously orgasmic; most commonly drug-induced",
        "Situational FOD: orgasmic with masturbation but not with partner (very common, often normal)",
        "Many women require direct clitoral stimulation not provided by coital activity alone",
        "SSRIs are the commonest acquired cause — always take detailed drug history",
    ],
    etiology_org=[
        "SSRIs/SNRIs: most common drug cause (70–80% rate)",
        "Antipsychotics, benzodiazepines",
        "Spinal cord injury, pelvic surgery, MS",
        "Menopause (reduced vaginal blood flow, atrophy)",
        "Diabetes (autonomic neuropathy)",
    ],
    etiology_psy=[
        "Anxiety and fear of 'losing control'",
        "Religious/moral guilt about sexual pleasure",
        "Negative body image and self-consciousness",
        "History of sexual trauma or abuse",
        "Inadequate sexual knowledge or stimulation technique",
        "Partner communication failure",
    ],
    first_line_pharm=[
        ("Switch/reduce SSRI if causative",
         "Switch to bupropion, mirtazapine, vilazodone, or vortioxetine (lower sexual SE profile)"),
        ("Bupropion SR (off-label)",
         "Improves orgasm frequency and intensity; useful add-on or substitute"),
        ("Sildenafil (off-label)",
         "PDE-5I increases clitoral blood flow; evidence for SSRI-induced anorgasmia in women"),
        ("Bremelanotide (off-label)",
         "MC4 receptor agonist; may facilitate orgasm by enhancing arousal"),
        ("EROS device",
         "FDA-approved medical device; small vacuum pump over clitoris increases blood flow → orgasm aid"),
    ],
    first_line_nonpharm=[
        "Directed masturbation program (most evidence-based approach for primary FOD)",
        "Psychoeducation: anatomy (clitoral role), normal variation in orgasmic response",
        "Sensate focus: graduated touching, removes orgasm as goal",
        "Vibrator use: most effective tool for women with primary anorgasmia",
        "CBT: address guilt, shame, trauma-related beliefs, fear of losing control",
        "Communication skills training with partner",
    ],
    note="Situational FOD (orgasmic alone, not with partner) is very common and not always pathological — assess distress carefully."
))

# ─────────────────────────────────────────────────────────────────────────────
# CARD 7: GPPPD (Vaginismus / Dyspareunia)
# ─────────────────────────────────────────────────────────────────────────────
story.append(card(
    number="7",
    name="Genitopelvic Pain/Penetration Disorder (GPPPD)",
    code_dsm="302.76 (F52.6)",
    code_icd="F52.5 / N94.1 / N94.2",
    dx_criteria=[
        "Persistent/recurrent difficulties with ≥1 of 4, ≥6 months:",
        "(1) Difficulty with vaginal penetration during intercourse",
        "(2) Marked vulvovaginal/pelvic pain during intercourse or penetration attempts",
        "(3) Marked fear/anxiety about vulvovaginal/pelvic pain in anticipation of, during, or as a result of vaginal penetration",
        "(4) Marked tensing/tightening of pelvic floor muscles during attempted vaginal penetration",
        "Causes marked distress",
    ],
    key_features=[
        "Merges vaginismus + dyspareunia from DSM-IV (they co-occur and share pathophysiology)",
        "Vaginismus component: involuntary pelvic floor spasm — often a conditioned reflex",
        "Vicious cycle: pain → fear → muscle spasm → more pain → avoidance → worsening anxiety",
        "May prevent pelvic examination and tampon use (not only intercourse)",
        "Dyspareunia: pain localised (superficial = vestibular; deep = endometriosis, PID)",
        "Always rule out organic pelvic pathology before diagnosing psychogenic",
    ],
    etiology_org=[
        "Postmenopausal/surgical menopause: vaginal atrophy, inadequate lubrication",
        "Endometriosis, pelvic inflammatory disease",
        "Vulvodynia / vestibulodynia (chronic vulvar pain without identifiable lesion)",
        "Pelvic adhesions, ovarian cysts, uterine fibroids",
        "Urogenital infections, STIs",
        "Anatomical abnormalities, post-surgical scarring",
    ],
    etiology_psy=[
        "History of sexual trauma, rape, childhood sexual abuse (strongest association with vaginismus)",
        "Conservative upbringing: sex perceived as sinful, dirty, or inevitably painful",
        "Negative first sexual experience",
        "Relationship conflict, fear of pregnancy, fear of intimacy",
        "Conditioned anxiety response (classical conditioning of pain/spasm)",
        "Partner pressure, guilt, performance anxiety",
    ],
    first_line_pharm=[
        ("Topical oestrogen (vaginal cream/ring/tablet)",
         "Postmenopausal atrophic dyspareunia; minimal systemic absorption; highly effective"),
        ("Ospemifene 60 mg daily (oral SERM)",
         "Moderate-severe dyspareunia in postmenopausal women; alternative to topical oestrogen"),
        ("Topical lidocaine 2–4% gel",
         "Vulvodynia/vestibulodynia; apply 20 min before sex; reduces superficial pain"),
        ("Botulinum toxin A injection (specialist)",
         "Refractory vaginismus; injection into levator ani/bulbocavernosus muscles under GA"),
        ("Amitriptyline / gabapentin (low dose)",
         "Neuropathic component of vestibulodynia/vulvodynia; specialist-initiated"),
    ],
    first_line_nonpharm=[
        "Vaginal dilators: graduated sizes (1→5); self-inserted with relaxation; most evidence-based non-pharm Rx",
        "Pelvic floor physiotherapy: biofeedback, myofascial release, Kegel training",
        "CBT: desensitisation of fear/avoidance, cognitive restructuring of pain catastrophising",
        "Sensate focus: ban on penetration; graduated non-genital → genital touching",
        "Systematic desensitisation: paired relaxation with hierarchical exposure to penetration cues",
        "Couples therapy: partner education, communication, guilt-free rebuilding of intimacy",
        "Treat identifiable organic cause (endometriosis → gynaecology referral; atrophy → topical oestrogen)",
    ],
    red_flags=["Deep dyspareunia: refer to gynaecology to exclude endometriosis / PID / ovarian pathology", "Vaginismus preventing pelvic exam: gentle examination under relaxation; avoid forced examination"],
    note="IPS CPG: Vaginismus has excellent prognosis with combined dilator + psychotherapy. Early intervention prevents chronicity."
))

story.append(PageBreak())

# ═══════════════════════════════════════════════════════════════════════════════
# IPS CPG MANAGEMENT ALGORITHM
# ═══════════════════════════════════════════════════════════════════════════════
story.append(section_header("IPS CPG 2017 — MANAGEMENT ALGORITHM (Avasthi et al.)"))
story.append(spacer(2))

algo_text = [
    P("<b>Step 1.</b> Detailed psychosexual history + physical examination + basic investigations (FBS/HbA1c, lipids, testosterone, prolactin, TFTs)", sBody),
    spacer(1),
    P("<b>Step 2.</b> Assess sexual knowledge: Is dysfunction due to poor sexual knowledge or poor relationship quality?", sBody),
    P("    → <b>YES</b>: Sex Education first → Reassess", sBody),
    spacer(1),
    P("<b>Step 3.</b> Ascertain type of dysfunction and probable etiology", sBody),
    spacer(1),
]

algo_table_data = [
    [P("ORGANIC ETIOLOGY", sTableHdr), P("MIXED / PSYCHOGENIC ETIOLOGY", sTableHdr)],
    [
        P("• Refer to relevant specialist (endocrinologist, urologist, gynaecologist)\n• Maintain psychiatric liaison\n• Treat organic cause\n• Identify any additional psychological component", sTableCell),
        P("• Screen for comorbid psychiatric disorder (depression, anxiety)\n  → If present: treat primary disorder first\n• Assess motivation and psychological sophistication\n  → Low motivation: start pharmacotherapy; gradually engage in psychotherapy\n  → High motivation: combined pharmacotherapy + psychotherapy from outset", sTableCell),
    ],
]
algo_t = Table(algo_table_data, colWidths=[W*0.48, W*0.52])
algo_t.setStyle(TableStyle([
    ("BACKGROUND",   (0,0),(0,0), C_TEAL),
    ("BACKGROUND",   (1,0),(1,0), C_NAVY),
    ("BACKGROUND",   (0,1),(0,1), C_RED_SOFT),
    ("BACKGROUND",   (1,1),(1,1), C_GREEN_SOFT),
    ("GRID",         (0,0),(-1,-1), 0.5, HexColor("#BBCDD8")),
    ("VALIGN",       (0,0),(-1,-1), "TOP"),
    ("ROWPADDING",   (0,0),(-1,-1), 7),
    ("FONTSIZE",     (0,0),(-1,-1), 8),
]))
story.append(algo_t)
story.append(spacer(2))

story.append(P("<b>Step 4. Treatment Selection:</b> Explain all available modalities → patient/couple chooses → agree on treatment goals before starting", sBody))
story.append(spacer(1))

tx_cols = [
    [P("<b><font color='#1B7A8A'>GENERAL MEASURES</font></b>", sBody)],
    [P("• Sex education and psychoeducation", sBullet)],
    [P("• Relaxation exercises", sBullet)],
    [P("• Lifestyle modification (exercise, diet, substance cessation)", sBullet)],
    [P("• Screening questionnaires: IIEF-5 (ED), DSDS (female HSDD), SKAQ (Hindi — North Indian)", sBullet)],
]

story.append(P("<b>General Measures (apply to all patients):</b>", sBody))
for row in tx_cols[1:]:
    story.append(row[0])

story.append(spacer(2))
story.append(P("<b>Specific Measures:</b>", sBody))

spec_data = [
    [P("NON-PHARMACOLOGICAL", sTableHdr), P("PHARMACOLOGICAL", sTableHdr)],
    [
        P("Psychodynamic therapy\nCBT (individual)\nCouples / relational therapy\nMasters & Johnson Dual-Sex Therapy\nSensate focus exercises\nSystematic desensitisation\nDirected masturbation (FOD)\nSqueeze/Stop-Start technique (PE)\nVaginal dilators (GPPPD)\nMindfulness-Based Therapy (FSIAD, FOD)\nPelvic floor physiotherapy (GPPPD)\nSex communication skills training", sTableCell),
        P("Erectile Disorder: PDE-5 inhibitors (sildenafil, tadalafil, vardenafil, avanafil)\nPE: SSRIs (paroxetine, sertraline), dapoxetine, topical anaesthetics\nFemale HSDD: flibanserin, bremelanotide, off-label testosterone\nDE: switch/reduce offending drug, cyproheptadine, bupropion\nFOD: switch SSRI, bupropion, sildenafil off-label\nGPPPD: topical oestrogen, ospemifene, topical lidocaine, botox (specialist)\nAll: treat underlying endocrine/vascular cause", sTableCell),
    ],
]
spec_t = Table(spec_data, colWidths=[W*0.46, W*0.54])
spec_t.setStyle(TableStyle([
    ("BACKGROUND",   (0,0),(-1,0), C_NAVY),
    ("BACKGROUND",   (0,1),(0,1), C_MINT),
    ("BACKGROUND",   (1,1),(1,1), C_AMBER),
    ("GRID",         (0,0),(-1,-1), 0.5, HexColor("#BBCDD8")),
    ("VALIGN",       (0,0),(-1,-1), "TOP"),
    ("ROWPADDING",   (0,0),(-1,-1), 7),
    ("FONTSIZE",     (0,0),(-1,-1), 8),
]))
story.append(spec_t)
story.append(spacer(3))

# ═══════════════════════════════════════════════════════════════════════════════
# DRUG-INDUCED SD MANAGEMENT
# ═══════════════════════════════════════════════════════════════════════════════
story.append(section_header("MANAGING PSYCHOTROPIC-INDUCED SEXUAL DYSFUNCTION"))
story.append(spacer(2))

drug_data = [
    [P("STRATEGY", sTableHdr), P("DETAILS", sTableHdr), P("NOTES", sTableHdr)],
    [P("1. Wait & watch", sTableBold), P("Some tolerance develops over 4–8 weeks", sTableCell), P("Only for mild cases", sTableCell)],
    [P("2. Dose reduction", sTableBold), P("Lowest effective dose minimises sexual SE", sTableCell), P("Must balance psychiatric stability", sTableCell)],
    [P("3. Add-on agents", sTableBold), P("Bupropion (most evidence); sildenafil (men AND women); buspirone; amantadine", sTableCell), P("Sildenafil RCT evidence in women on SSRIs", sTableCell)],
    [P("4. Drug holiday", sTableBold), P("Brief planned discontinuation before sex (only short half-life agents: paroxetine)", sTableCell), P("Risk: discontinuation SE, relapse — use cautiously", sTableCell)],
    [P("5. Switch to non-offending agent", sTableBold), P("Bupropion / mirtazapine / vilazodone / vortioxetine (low dose) / moclobemide", sTableCell), P("Most effective long-term strategy", sTableCell)],
    [P("Antipsychotic-induced:", sTableBold), P("Switch to aripiprazole or quetiapine (lower prolactin effect); or add aripiprazole to reduce hyperprolactinemia", sTableCell), P("Prolactin level guides decision", sTableCell)],
]

drug_t = Table(drug_data, colWidths=[W*0.22, W*0.48, W*0.30])
drug_t.setStyle(TableStyle([
    ("BACKGROUND",   (0,0),(-1,0), C_NAVY),
    ("BACKGROUND",   (0,1),(-1,1), C_GREY_LIGHT),
    ("BACKGROUND",   (0,2),(-1,2), white),
    ("BACKGROUND",   (0,3),(-1,3), C_GREY_LIGHT),
    ("BACKGROUND",   (0,4),(-1,4), white),
    ("BACKGROUND",   (0,5),(-1,5), C_GREY_LIGHT),
    ("BACKGROUND",   (0,6),(-1,6), C_RED_SOFT),
    ("GRID",         (0,0),(-1,-1), 0.5, HexColor("#BBCDD8")),
    ("ROWPADDING",   (0,0),(-1,-1), 5),
    ("VALIGN",       (0,0),(-1,-1), "MIDDLE"),
    ("FONTSIZE",     (0,0),(-1,-1), 8),
]))
story.append(drug_t)
story.append(spacer(2))

antidepressant_note = (
    "<b>SSRI Sexual SE rates:</b> Sertraline, venlafaxine, citalopram, paroxetine, fluoxetine → 70–80% | "
    "Imipramine, phenelzine, duloxetine, fluvoxamine → 25–45% | "
    "<b>No significant difference from placebo:</b> Bupropion, vilazodone, vortioxetine"
)
story.append(P(antidepressant_note, sSmall))

story.append(spacer(4))

# ═══════════════════════════════════════════════════════════════════════════════
# QUICK-REFERENCE SUMMARY TABLE
# ═══════════════════════════════════════════════════════════════════════════════
story.append(section_header("AT-A-GLANCE SUMMARY"))
story.append(spacer(2))

sum_data = [
    [P(h, sTableHdr) for h in ["Dysfunction", "Duration", "Prevalence", "Key Organic Cause", "Key Psychological Cause", "First-Line Pharm", "First-Line Non-Pharm"]],
    [P("MHSDD", sTableBold), P("≥6 mo", sTableCell), P("2% (young); 40% (>65 yr)", sTableCell), P("Low T, hyperprolactin", sTableCell), P("Depression, relationship conflict", sTableCell), P("Testosterone (if deficient); bupropion", sTableCell), P("Sex education; couples therapy", sTableCell)],
    [P("FSIAD", sTableBold), P("≥6 mo", sTableCell), P("17–50%", sTableCell), P("Estrogen deficiency; OCP; SSRIs", sTableCell), P("Depression; trauma; inadequate stimulation", sTableCell), P("Flibanserin; bremelanotide", sTableCell), P("Mindfulness; sensate focus", sTableCell)],
    [P("ED", sTableBold), P("≥6 mo", sTableCell), P("52% (all ages)", sTableCell), P("Vasculogenic (most common)", sTableCell), P("Performance anxiety; spectatoring", sTableCell), P("PDE-5 inhibitors (sildenafil, tadalafil)", sTableCell), P("CVD risk factor modification; sensate focus", sTableCell)],
    [P("PE", sTableBold), P("≥6 mo", sTableCell), P("~30% men", sTableCell), P("Hyperthyroidism; urethritis", sTableCell), P("Conditioned anxiety; rushed early sex", sTableCell), P("Paroxetine/SSRIs daily; dapoxetine PRN; topical EMLA", sTableCell), P("Squeeze/stop-start technique", sTableCell)],
    [P("DE", sTableBold), P("≥6 mo", sTableCell), P("Increasing (SSRI era)", sTableCell), P("SSRIs; pelvic surgery; DM neuropathy", sTableCell), P("Idiosyncratic masturbation; ambivalence", sTableCell), P("Switch to bupropion; cyproheptadine PRN", sTableCell), P("Extravaginal bridging; psychotherapy", sTableCell)],
    [P("FOD", sTableBold), P("≥6 mo", sTableCell), P("5–10%", sTableCell), P("SSRIs; pelvic surgery; menopause", sTableCell), P("Guilt; fear of losing control; trauma", sTableCell), P("Switch SSRI; bupropion; sildenafil off-label", sTableCell), P("Directed masturbation; vibrator; CBT", sTableCell)],
    [P("GPPPD", sTableBold), P("≥6 mo", sTableCell), P("Variable", sTableCell), P("Vaginal atrophy; endometriosis; vulvodynia", sTableCell), P("Trauma; conditioned pain fear; guilt", sTableCell), P("Topical estrogen; ospemifene; topical lidocaine", sTableCell), P("Vaginal dilators; pelvic floor PT; CBT", sTableCell)],
]

col_w = [W*0.09, W*0.06, W*0.10, W*0.15, W*0.17, W*0.23, W*0.20]
sum_t = Table(sum_data, colWidths=col_w)
sum_t.setStyle(TableStyle([
    ("BACKGROUND",   (0,0),(-1,0), C_NAVY),
    ("BACKGROUND",   (0,1),(-1,1), C_LIGHT_BLUE),
    ("BACKGROUND",   (0,2),(-1,2), white),
    ("BACKGROUND",   (0,3),(-1,3), C_LIGHT_BLUE),
    ("BACKGROUND",   (0,4),(-1,4), white),
    ("BACKGROUND",   (0,5),(-1,5), C_LIGHT_BLUE),
    ("BACKGROUND",   (0,6),(-1,6), white),
    ("BACKGROUND",   (0,7),(-1,7), C_LIGHT_BLUE),
    ("GRID",         (0,0),(-1,-1), 0.5, HexColor("#BBCDD8")),
    ("ROWPADDING",   (0,0),(-1,-1), 4),
    ("VALIGN",       (0,0),(-1,-1), "TOP"),
    ("FONTSIZE",     (0,0),(-1,-1), 7.5),
]))
story.append(sum_t)
story.append(spacer(3))

# ─────────────────────────────────────────────────────────────────────────────
# REFERENCES FOOTER
# ─────────────────────────────────────────────────────────────────────────────
story.append(HR(C_ORANGE, 1.5))
story.append(spacer(1))
refs = [
    "1. Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 10th ed. — Chapter 33.17c (Ponce Martinez, El Haddad, Clayton). Wolters Kluwer.",
    "2. Kaplan & Sadock's Synopsis of Psychiatry, 12th ed. — Chapter 16. Wolters Kluwer.",
    "3. Avasthi A, Grover S, Sathyanarayana Rao TS. Clinical Practice Guidelines for Management of Sexual Dysfunction. Indian J Psychiatry. 2017;59(Suppl 1):S91–S115.",
    "4. Salonia A et al. EAU Guidelines on Sexual and Reproductive Health: Male Sexual Dysfunction 2021. Eur Urol. 2021;80(3):333–357. [PMID 34183196]",
    "5. Sathyanarayana Rao TS et al. IPS CPG for Sexual Disorders in Elderly. Indian J Psychiatry. 2018;60(Suppl 3):S398–S402.",
    "6. Zulfikaroglu E. Vaginismus treatment: systematic review and meta-analysis. J Sex Med. 2026. [PMID 41148166]",
]
for r in refs:
    story.append(P(r, sFooter))

# ─────────────────────────────────────────────────────────────────────────────
# BUILD
# ─────────────────────────────────────────────────────────────────────────────
doc.build(story, onFirstPage=on_page, onLaterPages=on_page)
print(f"PDF created: {OUTPUT_PATH}")
print(f"Size: {os.path.getsize(OUTPUT_PATH):,} bytes")