Helping People with Psychiatric illness (From www.drmjthomas.com)
This is an educational article for patients and families dealing with psychiatric illness. It is not a scientific article. Reading this article may help patients and families faced with psychiatric illness to understand their illness in lay terms and seek help.
Dr. MJ Thomas, Bangalore, India. (www.drmjthomas.com)
(2) He may suddenly feel his heart is beating very quickly, his breathing becomes very fast and he is afraid for no reason. He is unable to think clearly and does not know what to do. This feeling lasts a short time and returns at any time.
(3) People with psychiatric illness can look very different. Sometimes they do not comb their hair or change their clothes for days. Their facial expressions can change. They can lose a great deal of weight in a short period.
(11) Sometimes when he is very disturbed he may speak strangely, that his family cannot understand what he is saying. The words may be mixed up.
(12) A person who is severely ill will sometimes just stop moving for long periods for no reason and become severely withdrawn.
(13) Some persons may believe that they are someone else.
(14) A person with psychiatric illness may seem like he does not know that anyone else is in the room. However, often he is watching and listening to what is going on around him even though he is withdrawn.
(15) He may think that someone else controls his actions, for example a "voice" tells him that his neighbor wants to steal his things.
(16) Sometimes people with a medical problem also have symptoms like psychiatric illness. A person with a broken back can react to the incident and become depressed when he realizes he will never walk again.A person can also have a medical and a psychiatric illness simultaneously.
(17) Some women become very sad and tearful after the birth of their baby, that precipitates a psychiatric illness. If left alone without help, she may harm herself and the baby.
5. Does psychiatric illness get worse?
There are many kinds of psychiatric illness, which makes the question difficult to answer. Each psychiatric illness has different ways of progressing.
(1) Some people may be ill only once and never have problems again.
(2) Some psychiatric illnesses do not get worse and stay the same way for a long time.
(4) Other people may become worse over weeks or months. They may become severely disturbed.
6. Can psychiatric illness be cured?
There is still a lot to be understood about psychiatric illness. With the right help, in most persons, the problems and strange behavior can be controlled and they can lead a normal life. However, some others may have problems for their whole life.
(2) People with psychiatric illness are often given medicines when their behavior becomes strange. Medicine will not help a person with mental handicap to think or learn.
(3) A mentally handicapped person may also behave in a strange way but that is because he has not learned how to do things correctly. Such people may learn to do certain things with special training.
(4) A person with a mental handicap can also become mentally ill and may need help for the illness.
8. What is it like to have psychiatric illness?
Psychiatric illness disrupts a person's life and the lives of the families and friends. It can cause problems with almost every activity: working, eating, sleeping, speaking to friends and neighbors, and moving around the community. People with psychiatric illness suffer a great deal just as people with physical illnesses do. Their thoughts and feelings can be very frightening to them and the people around them, just as in the case of people with physical illnesses. The family and friends might think that the strange behaviour is causing the problems and forget how badly the person may feel.
9. Warning signs of serious psychiatric illness
Some behaviour that can distress the family is also signs of severe illness:
Not washing himself or changing clothes for long time;
Being active all the time (hyperactivity) with little or no sleep;
Sitting like a statue for hours without moving;
Moving about quickly without any purpose and waving his arms and shouting;
Talking to himself all the time or not allowing others to speak;
Talking without making sense;
Refusing to be with family members and spending most of the time alone;
Eating or drinking too little with a great deal of loss of weight;
Crying for a long time for no reason.
These warning signs tell the family and friends to get help immediately.
Ways to help
There are a number of ways to help a person with psychiatric illness.
1. Medical Treatment: Medication is one of the ways to change strange behavior quickly and correct. Sometimes people need a short stay in hospital.
2. Counselling: Counselling helps the person to talk about his difficulties and to feel that someone else understands and cares for him. It helps a person to overcome interpersonal conflicts and modify his inappropriate behaviour.
3. Routine Activities: Keeps the person involved with his routines and helps him to return to normal behavior early.
Medicines do not "cure" psychiatric illness like antibiotic drugs cure an infection, but it changes thoughts and feelings and can make people function appropriately again. Different medicines are used for different illnesses. Some medicines help make the person with psychiatric illness think normally so they no longer have strange thoughts. Other medicines change feelings and behavior, calm down the overactive person or help a person who does not want to do anything, to start doing his daily activities again. Some medicines take some time to start working, 10 days to 2 weeks. Generally, if the medicine is working, persons with psychiatric illness begin to be easier to talk to, they feel calmer, and their inappropriate behavior decrease though it may not go away completely.
Cunselling is a process that identifies from the affected person his problems, his feelings about those problems and what changes he can make to deal with those problems. Counselling can also educate people with a psychiatric illness to understand why they have an illness and why they need help. It is also a way to support them while they are ill and deal with interpersonal difficulties and inappropriate behaviours associated with the illness. Many persons with a severe psychiatric illness cannot answer questions or their answers do not make any sense. In this case counselling is not useful at that time.
Daily activities at home or at work will help the person with psychiatric illness to get well faster. These activities help the person to pay attention to real, not "crazy" thoughts. They provide a routine for the person's day. The person with psychiatric illness should reminded to bathe and dress appropriately. With encouragement a person with a severe psychiatric illness can begin to assist in simple household activities. The person should be encouraged to do as much as possible even if it takes longer or is not done well. The person with a psychiatric illness may need to take a break while doing an activity because she cannot pay attention for a long time. The time spent each day doing activities by a person with a psychiatric illness should increase. It is much better for him to be busy than doing nothing.
At least 70 percent of all people committing suicide give some clue to their intentions before they make an attempt. Becoming aware of these clues and the severity of the person's problems can help prevent a tragedy. If a person you know is going through a particularly stressful situation, watch for other signs of crisis. Many persons convey their intentions directly with statements such as "I feel like killing myself," or "I don't know how much longer I can take this" (Suicidal thoughts). Others in crisis may hint at a detailed suicide plan with statements such as "I've been saving up my pills in case things get really bad" or "Lately I've been driving my car like I really don't care what happens" (Suicide plans). In general, statements describing feelings of depression, helplessness, extreme loneliness, and/or hopelessness may suggest suicidal thoughts. It is important to listen to these "cries for help" because they are usually desperate attempts to communicate to others the need to be understood and be helped. Often persons thinking about suicide show outward changes in their behaviour. They may prepare for death by giving away prized possessions, making a will, or putting other affairs in order. They may withdraw from those around them, change eating or sleeping patterns, or lose interest in prior activities or relationships.
MYTH: "You have to be psychiatrically ill even to think about suicide".
FACT: Most people have thought of suicide from time to time. Most suicides and suicide attempts are made by intelligent, temporarily confused individuals who are expecting too much of themselves, especially in the midst of a crisis.
MYTH: "Once a person has made a serious suicide attempt, that person is unlikely to make another".
FACT: The opposite is often true. Persons who have made prior suicide attempts are at greater risk of actually committing suicide; for some, suicide attempts may seem easier a second or third time.
MYTH: "If a person is seriously considering suicide, there is nothing you can do”.
FACT: Most suicidal crises are time-limited and based on unclear thinking. Persons attempting suicide want to escape from their problems. Instead, they need to confront their problems directly in order to find other solutions - solutions that can be found with the help of concerned individuals who support them through the crisis period, until they are able to think more clearly.
MYTH: "Talking about suicide may give a person the idea".
FACT: The crisis and resulting emotional distress will already have triggered the thought in a vulnerable person. Your openness and concern in asking about suicide will allow the person experiencing pain to talk about the problem, which may help reduce his or her anxiety. This may also allow the person with suicidal thoughts to feel less lonely or isolated, and perhaps a bit relieved.
Most suicides can be prevented by sensitive responses to the person in crisis. If you think someone you know may be suicidal, you should remain calm. In most instances, there is no rush. Sit and listen to what the person is saying. Give understanding and active emotional support for his or her feelings. Most individuals have mixed feelings about death and dying and are open to help. Don't be afraid to ask or talk directly about suicide. Encourage problem solving and positive actions. Remember that the person involved in emotional crisis is not thinking clearly; encourage him or her to refrain from making any serious, irreversible decisions while in a crisis. Talk about positive alternatives that may establish hope for the future. Although you want to help, do not take full responsibility by trying to be the sole counsel. Seek out resources that can lend qualified help, even if it means breaking a confidence. Let the troubled person know you are concerned, so concerned that you are willing to arrange help beyond that which you can offer.
Obsessive-compulsive disorder (OCD) is an illness that traps people in seemingly endless cycles of repetitive thoughts without being able to stop them (obsessions) and in feelings that they must repeat certain actions over and over (compulsions). The obsessions that intrude uncontrolled into the person’s every day thinking may be frightening, disgusting, painful, or trivial. Most people with OCD realise that their obsessions do not make sense, but they are not able to control or suppress them. They may be able to explain in great detail what their obsessions are, but not why they appear. In most cases, the obsessions cause extreme anxiety. Feelings of discomfort or dread can build up to an unbearable level. To relieve their anxiety, some individuals with OCD feel they have to do something. These feelings that they must repeat certain actions or rituals are their compulsions - the things they feel they have to do to avoid some dreaded event or to prevent or undo some harm to themselves or others, as suggested by their obsessions. Often the rituals have to be performed according to some rules. The rituals may be very simple and hardly noticeable, or they may be very elaborate. Rituals may be time-consuming, sometimes taking hours to finish so that they interfere with the person’s daily routine. Rituals do lessen anxiety, discomfort, or feelings of disgust, but only briefly. The fears and tensions soon return, causing the individuals to start their rituals all over again. People with OCD do not want to have obsessive thoughts, nor do they want to engage in time-consuming rituals. They do not get any pleasure from being the way they are when OCD takes hold of them. Most people with this disorder realise how senseless it all is. Recognising the bizarre nature of their obsessions and compulsions, many conceal their condition from others. Eventually people with OCD may be discovered, or their obsessions and compulsions become so time- consuming that they can no longer function at home, on the job, or without developing conflicts with others.
Most people with OCD can be helped with medication. It allows many people to lead normal lives. People can also be taught to reduce their anxiety from their obsessions. The affected persons are first exposed to the objects or situations that cause them problems. They are then asked to delay performing the rituals they usually use to deal with them, or they are asked to perform the rituals less extensively. OCD is not only distressing to the persons affected, it is also hard on the people who live with them. Family members react to living with a person with OCD in a number of ways. They may demand that the person stop ritualising. They may give continual reassurance. They may even participate in the rituals themselves, to pacify the individual and to avoid arguments. These may seem like the best tactics, but they do not improve OCD. If possible, families should not participate in the person’s rituals.
'Stress' has three different components: The events that start a chain of stressful reactions are called 'stressors', the physical and emotional experiences that follow are 'stress experiences' and the behaviour resulting from these experiences are 'stress responses'. Stressors originate from an "internal disturbance",such as 'psychological illness' or 'physical illness', or an "external disturbance",such as problems in the 'family, society or work place'. All types of stressors result in a common psychological and physiological experience (stress experience). Behaviours resulting from these experiences are called stress responses. Stress responses are behavioural responses resulting from these experiences.
Some degree of stress adds to better performance in life. Excessive stress however may make one agitated. Hence, the goal is not to eliminate stress altogether, but to cope with it and to use it to one's advantage. One needs to find the optimal level of stress that will motivate but not to overwhelm one.
What Is Optimal Stress?
There is no single level of stress that is optimal for all people. What is distressing to one may be a joy to another. If you are experiencing stress symptoms continuously, you have gone beyond your optimal stress level; you need to reduce the stress in your life and/or improve your ability to manage it.
Avoiding stimulants or depressants such as tobacco and alcohol
HOW CAN WE CHANGE MALADJUSTED RESPOSES TO STRESS?
Counselling is used to help manage responses to stressors based on the notion that clear understanding of stressful events and coping play a major role in determining the responses to stress. Counselling aim to help people become more aware of their experiences to stressors, educate them on how stressors negatively influence emotional and behavioural responses, and teach them a variety of effective cognitive and behavioural skills.
How are maladjusted responses corrected during counselling?
By assessing stress producing events and their threat perception
By reducing stress experiences through relaxation exercises and changing automatic negative thoughts into positive ones.
By learning coping skills and avoiding maladjusted responses through behaviour changes
How can you make counselling more effective?
Identify events that cause stress.
Assess if you can change them or avoid them yourself.
Check if they produce any negative thoughts or feelings in you on a consistent basis.
check if these experiences make you consistantly behave in any unacceptable manner.
Check if you really want to change your brhaviour to more acceptable coping behaviour.
What does the counsellor do during counselling?
Focuses on current problem and its future pregression; defines the problem in relation to stressors; relates the problem to current stress experience and maladjusted responses.
Engages the client to develop well-adjusted coping skills.
Changes the client's negative thoughts to positive thoughts by restructuring people's pattern of thoughts.
Creates well adjusted coping skills through training or exp[osure to stressful events.
Medicines are of help for people who struggle with stress related to an illness. In association with counselling, madication can be extremely effective. When a major psychiatric condition like depression is present, clearly the most appropriate management strategy is medication. Even in milder forms of stress, medication can be of help. Unsupervised long term use of medication is not recommended, because it can produce side effects.
Depression and suicide
The product of untreated stress or illness is suicide. Therefore, it is necessary to detect early the distress in people.
Social phobias start in adolescence and are based on a fear of scrutiny by other people, leading to avoidance of social situations. Social phobias can be discreet, for example for public speaking, eating in public or meeting with opposite sex or diffuse, involving all situations outside familiar circles. Direct eye to eye contact may be particularly bothersome in some cases. Social phobias are associated with low self esteem and a fear of criticism. The person with social phobia anticipates and ruminates over the problems that can occur in a social contact, resulting in avoidance of the situation and in extreme cases, social isolation. They experience features of anxiety such as rapid heart beats, trembling, sweating, upset stomach, diarrhoea, muscle tension, blushing and confusion. In some cases these symptoms may be severe enough to take the form of panic attack. Some people with social phobia may use alcohol or drugs as a way to self-medicate to help them get through social situations. Although alcohol or drugs may seem to help initially, they eventually become another problem in the life of the person with social phobia. The consequence of social phobia can be socially and economically devastating. It can result in a person dropping out of school, chronic unemployment and financial dependence, alcohol abuse, suicidal thoughts, and not getting married or having children. Social phobia is related to an imbalance of a chemical that transports signals between nerve cells in the brain. It also runs in families, especially among close relatives like parents and their children. Both medication and cognitive behaviour therapy have proven successful in treating social phobias. Many find that a combination of medication and behavioural therapy is most effective. Cognitive behaviour therapy teaches people with social phobia to react differently and face situations that trigger their anxiety symptoms. Patients learn how to change their negative feelings about social situations so the symptoms begin to lessen. Gradual exposure to an anxiety-provoking situation until the patient learns to identify and modify behaviour that contributes to his or her social phobia is helpful.
Gender identity disorder is used to describe a male or female who feels a strong identification with the opposite sex and feels distressed because of his or her actual sex. They are uncomfortable with their present sexual role and desire to alter their bodies. Cross-gender behavior is tolerated in girls to a far greater degree than it is in boys. Social tolerance of "tomboys" is more than "sissies." Causes of gender identity disorder are not fully known.
Treatment for people with gender identity disorder focuses on treating depression and anxiety, and improving self-esteem. Many people do not see their gender identity disorder symptoms as requiring treatment. People with gender identity disorder request hormone and surgical treatments to suppress their biological sex and acquire those characteristics of opposite sex. Because of the irreversible nature of the surgery, candidates for sex-change surgery are evaluated extensively and are often required to spend a period of time before integrating themselves into the cross-gender role before the procedure begins. Significant social, personal, and occupational issues may result from surgical sex changes, and the patient may require psychotherapy or counseling after the change too.
Many people feel attracted to people of the same sex. For some people these feelings can be very intense. Some people find that these feelings change over time. Some of them are bisexual, meaning they are attracted to both men and women, and have relationships with both. Some people are not attracted to anyone. With time, someone who is homosexual will realize that not only are they sexually attracted to members of the same sex, but that this attraction is not transitional. However, for some people homosexual experiences are part of a transitional or experimental phase in their youth.
There is now growing support for the belief that sexuality is pre-determined, though may change over time. Some people believe homosexuality is an illness and believe it can and should be cured. Available information seems to indicate that reparative therapy is ineffective. Available evidence suggests that the success of these techniques is restricted to three areas:
Convincing bisexuals to limit their sexual activities to members of the opposite sex.
Convincing homosexuals to become celibate.
Convincing homosexual men and women to attempt to maintain heterosexual relationships, while they are forced to retain their homosexual orientation.
Coming to terms with confusion about identity can have both positive and negative effects on many aspects of a person's life, including social relationships, work, and self-esteem. It can take a long time too. Coming to terms is not a single action. It is a process that begins with a feel of being 'different' to other people of the same sex. Sometimes they recognize that they are not very interested in people of the opposite sex but more often they feel they are not really interested in things which are supposed to be appropriate for their sex. Different people cope with the emotional upheaval of identity confusion in different ways. Some people deny it to themselves and try to avoid thoughts and feelings which may confirm they are homosexual. Others persevere with heterosexual relationships to try and 'convert' themselves. In some extreme cases people may try to avoid confronting their feelings by expressing strong homophobia or turning to drink and drugs in order to find temporary relief from them.
Making the decision to tell others that you are homosexual, bisexual or transgender can relieve a great deal of stress and unhappiness and build self-esteem, as well as help improve relationships. However, there are also risks associated with telling others, and it is important to think carefully about how you could cope with the potential consequences before telling others. Friends and family may not react in an understanding way, and relationships can be changed significantly. Having time to fully come to terms before telling others can mean you are more prepared to deal with any misunderstanding or prejudice you may face. Telling others does not mean that you have to tell everybody. Many people chose to tell first to people who they think are more likely to react positively. It not only helps them get an idea of how people may react, but often means that they will have someone to support them when they tell others. Some people may never be able to accept your true gender identity. This is not something that you can change, and it can be very hard to feel rejected by someone you are close to.
There are also many stereotypes surrounding homosexual relationships. As with heterosexual couples, homosexual relationships can also be short-lived or long-term.
Marriage is a social and legal contract between people to create an institution in which interpersonal, emotional and sexual relationships, are acknowledged in a culturally appropriate manner. It includes arranged marriages, marriages out of family obligations, marriages to establish a legal nuclear family, marriages for legal protection of children or public declaration of commitment to each other and so on. Individuals in relationship also come with different value systems. Hence, societal factors like the social, religious, group and other factors that shape a person's behaviour are also considered while counselling. It is advantageous for all in relationships to interact with each other and their society with minimal amounts of conflicts. Many relationships get strained some time during life, resulting in poor functioning and producing self-reinforcing, maladaptive patterns. There are many possible reasons for this, including insecure attachment, ego, arrogance, jealousy, anger, greed, poor communication or poor problem solving skills, ill health, third party influences and so on. Changes in situations like financial state, physical health, and the influence of other family members can also have a profound influence on the actions of the individuals in a relationship. Often, it is the interaction between people, rather than the behaviour of just one person that causes such maladaptive conflicts.
Marriage counselling differ in duration. It is also more 'here and now' and deals with new coping strategies and about seemingly intractable problems within a relationship. These sessions also encourage the client to make steady progress in a caring and supportive manner. During marriage counselling, regardless of the origin of the problem and whether the clients consider it an "individual" or "family" issue, involving all partners in solutions is often beneficial.
A VERY IMPORTANT ASPECT TO BE REMINDED BEFORE ONE STARTS A MARRIAGE COUNSELLING IS TO CONSULT A PSYCHIATRIST, TO RULE OFF ANY POTENTIAL PERSONALITY PROBLEM OR PSYCHIATRIC ILLNESS IN THE PARTNERS THAT CAN BE EASILY TREATED. vERY MANY FAMILIES BREAK UP BECAUSE OF A TREATABLE PROBLEM IN ONE OR BOTH PARTNERS. HENCE BOTH PARTNERS NEED TO ATTEND THE PSYCHIATRIC EVALUATION TOGETHER.
An uderstandable explanation of psychiatric illness
This presentation is primarily to eliminate the mystery associated with psychiatric illnesses. There is far more information available today about the functioning of the brain compared to earlier years. However most people are not aware of these new developments because they are not available to them readily. As a result psychiatric illnesses are considered a mystery even now by most people.
It is important to know that you are not alone with a psychiatric illness. About 1 out of 20 or 5% of the population anywhere in the world will get psychiatric illness during their life, whether they are rich or poor, educated or uneducated, or they live in slums or palaces. In developed countries about 60% of these persons with psychiatric illnesses receive medical treatment. The others do not take treatment because their symptoms do not affect their functioning. In India far less number of people take treatment (7%) because they are ignorant about modern methods of treatment, they do not have the resources, they do not have a psychiatrist in the viscinity or they have a fear of being branded as a 'mental patient'. In India, physicians also find it difficult to diagnose psychiatric illness in the early stages because of their limited training in psychiatry.
Not getting treated early has high costs for the patient and his family. His efficiency is lost resulting in poor productivity, poor earning capacity, loss of job, family disturbances, social inadequacy and branding, finally dragging him and his family down the socio-economic scale and respectability. Beyond all this, there is also higher risk of suicide in untreated patients with psychiatric illness.
The most difficult aspect of understanding a psychiatric illess for a person is to overcome his belief that 'he can control his thoughts'. In reality 'he can control substantially what he thinks, but it is difficult to control How he thinks'. What you think depends mostly on your life experiences, while how you think depends on inherited patterns of thinking. In psychiatric illnesses these patterns of thinking and feeling, are altered into abnormal patterns due to certain chemical abnormalities in the brain. If a person's thoughts suddenly begin to change in it's 'form' into unusual patterns, it is likely that there is a change in the brain functions related to thinking and feeling, and may indicate the onset of a psychiatric illness.
Let us now look at the the common misconceptions about psychiatric illnesses. Firstly, many people believe that psychiatric illnesses occur due to 'External stressful factors'. Available evidence suggests that the most severe form of sadness occurs in normal people due to death of first degree relatives. But he recovers from this severe sadness, usually within 3 months, by talking about the event to his kith and kin, and through culturally accepted modes of mourning ceremonies. He copes up with the loss, leading to well adjusted behavior in 3 months' time. Other low intensity stressors will reult in low intensity and shorter duration reactions. Think of the millions of people who live in slums all over this country. If external factors were to cause psychiatric illness every time, we would have had a psychiatrically sick country !! People who are normal, usually have an inherent capacity to learn how to cope with difficult situations.
Many people also believe that medical illnesses cause psychiatric illnesses. Many medical illnesses cause confusion. However they are only a symptom of the underlying medical illness. For example, a bleed or tumor of the brain can cause some form of behavior abnormalities. However, if the patient is treated for his medical condition he will recover from these behavior abnormalities. These are not primary psychiatric illnesses.
we discussed earlier that a substantial part of behavior is inherited. So one needs to know what is inherited ??? There are two distinctly different sets of behaviors that are inherited, namely 'Personality' and 'Psychiatric illnesses'.
Personality is how you describe 'what kind of a person you are'. A person can be very orderly or disorderly, he can be very quiet or out going, he can be a con man or a gentleman. All these are traits that sum up into 'yourself'. A very quiet person can get trained to become a good sales man for a company. He then meets different people, sells his products quite effectively and comes back to his house to become once again very quiet and introspective person. One can train himself to be like someone else for a period of time. However he cannot change into some other personality in a sustained fashion effectively.' Personality' per se is not a psychiatric illness, and one cannot give medicine to change it. Constant training, advice, counseling etc. may be useful to make some change, more often very temporarily.
Psychiatric illnesses are a set of illnesses caused by abnormal patterns of thinking and feeling, and they are substantially inherited even though the content of thinking and feeling expressed reflect many of the patient's experiences. It is important to know that psychiatric illnesses are inherited very much like Diabetes Mellitus, through gene level inheritance. Hence if a person is loaded with the genes for the illness, he develops it early. Most people develop it in the 20s and 30s. If they have less abnormal genes they develop the illness later in age.
When we do a physical activity like speaking, writing, walking etc., the electrical activity of the brain cells are in action. If somethings go wrong to the electrical activity of the brain cells, a neurologist treats the patient. An EEG is used to identify the problem. If a structural problem occurs in the brain, a scan identifies the structural changes and a neuro-surgeon treats the patient.
When we 'think' and 'feel' it is the chemical activity of the brain cells that are in action. In a psychiatric illness the chemical activity of the brain cells becomes abnormal. It results in abnormal thinking and feeling. Diagnosis of these illnesses are usually made clinically since they are easy to diagnose. Sometimes psychological tests are carried out to make a diagnosis. Medical treatment is then started to correct this abnormality. Different kinds of psychiatric illnesses affect different sets of brain chemicals and alter the patterns of thinking and feeling differently, and they are treated differently.
Now that we know who is psychiatrically ill, the question is ' When should he be treated ?'. The answer to this question is very subjective! It depends on the patient and his significant other people who decide for him. A person is treated when he finds the illness a problem for himself or for other people around him. It is like deciding when to go to a doctor for fever. If it is mild for short duration, you may ignore it. The only exception is when there is a suicidal risk.
The doctor also has to decide about the treatment strategies. Usually most psychiatric treatments take few months to start showing results. However side effects can show up earlier, though they are not common. Hence the doctor monitors the patient periodically to evaluate whether the benefits of the treatment far outweigh the disadvantages. If the disadvantages outweigh the benefits, the treatment may be changed or even stopped.
Till now we were dealing with the changes in the brain during psychiatric illnesses. Let us now see what happens to the body during the illness. The brain is connected to different organs in the body through a set of nerves called 'Autonomic nervous system' (ANS). This is like an electrical main switch connecting to all lights and plugs in a house. The ANS acts by protecting a person from any threat originating from an external or internal source. When there is a threat, the ANS activates different organs in the body to function more energetically. In other words, ANS becomes hyperactive under 'stress'. However, once the stress is relieved the ANS returns to its original level of activity. You may have experienced this phenomenon when you were waiting for an interview or an exam or when you see a snake in front of you. The hyperactivity of the ANS gives the person the extra energy to deal with the stressful situation effectively. During this period the heart beats rapidly, blood pressure goes up, there is sweating, hands become cold and shiver, there is more acid secretion in the stomach, people breathe rapidly and they have to go to the toilet more often. All these are symptoms of 'anxiety' or at times wrongly called by many as 'stress'. They are infact a response to 'stress'. However, if it is prolonged or if it becomes too severe, it damages the organs, just as a machine gets damaged if you run it beyond its capacity.
What happens to ANS in psychiatric illnesses?? During psychiatric illness the brain misinterprets a threat continuously, resulting in continuous ANS hyperactivity. This situation results in organ dysfunction apart from high degree of anxiety. As a result people develop symptoms of organ dysfunction. For example, they feel faster heart beats, palpitation and high blood pressure. Similarly other organs also get affected and they can experience cold extremities and tremors of hands, irritable bowel symptoms, frequent urination, rapid breathing etc. on a continuous basis without any obvious reason.
Unfortunately conventional medicines used in treatment of psychiatric illnesses do not effectively reduce ANS hyperactivity. Hence, people with psychiatric illness need to start some form of 'relaxation exercises' without depending solely on the effectiveness of medicines to relieve their discomfort due to ANS hyperactivity. Walking for an hour is very effective relaxation exercise. Meditation and Yoga are other culturally understood forms of relaxation exercises. Every culture has some form of relaxation exercises with different names. One can choose what is appealing for oneself. This is a lifestyle change one has to adopt to reduce the impact of the illness on the body or any other form of stress on the body. One has to maintain a changed life style all through life too. If you need to know more about 'stress', 'stressors' and 'stress responses', you will find it in the section on "Stress" in this web site.
Till now we discussed about what happens to the brain and the body during psychiatric illness. It is now time to look into the changes in behavior during this period. For most people, it is difficult to understand the changes that occur in the person's brain when he is ill. Similarly the changes in his body and the anxiety he experiences are not visible to others.
However there are many visible changes that occur with the onset of a psychiatric illness. These can be clubbed together and called 'Maladjusted behaviors'. They look different in different people and do not fit into universal patterns. This is because maladjusted behaviors are a result of the attempts by a person to escape from the strange changes he perceives in his body and mind. So he behaves in such a way that he thinks will be most helpful to himself. These behaviors may be quite disturbing for others. On most occasions others do not understand his actions, unless he explains them. Most of the time a patient with psychiatric illness refuses to explain the reasons for his behavior because he gets worried about others misunderstanding him, being teased, abused or scolded. However, his reluctance to explain can result in 'Branding' the person as 'mentally ill', 'eccentric', 'odd', 'crazy', 'mad' and so on, and his treatment gets delayed.
Branding has its own consequences. It has a negative connotation. If the branding lasts for long time the person is stuck with the brand even after he recovers from the illness. This makes it very important for the person to start treatment early in order to avoid permanent branding. Branding also has other consequences. The person is no longer relied on or respected. His employability reduces. His social relationships break down. Finally he slides down the socio-economic ladder.
What can one do to change maladjusted behavior ??? The medicines do not directly change them effectively. Nevertheless one has to change them to 'Well adjusted behaviors'. If a person continues with maladjusted behavior despite recovery from the illness after treatment, the society will reject him. The most effective way to make the change to well adjusted behavior is to educate the person on why he behaves in this fashion. He needs to be educated on why he had his illness, how it has changed his thinking and feeling, why his body functions differently and he behaves as he does now, and what are its consequences. He needs to know how he can be treated and what are the limits of recovery. He needs to also understand how he can change his maladjusted behaviors to well adjusted behaviors by his own efforts.
Counseling is a method of assisting in this process. There are many forms of counseling, practiced by many different groups. The basic principles in counseling are 'Advice', 'Reward' and 'Punishment', very much like how you bring up your children to become adults. The reward and punishment is often experienced from the society's reactions towards the patient. Societal advice is however insufficient, since the society does not understand the patient and his behavior. This is where a counselor can assist, because he is trained or has the experience in dealing with many such people to guide them.
Different counselors have their own methods of counseling, and they come under different schools. But what makes the process successful are the patient's desire to accept the illness, his motivation to change, ability to build a rapport with the counselor and the counselor's desire to achieve results for his client. Many people can also make changes to their maladjusted behavior themselves by reading through materials about the illness like you are doing now, and working to make appropriate changes themselves.
There are of course exceptions to the patterns that I have explained earlier, such as alcoholism and drug dependence, problems of children, problems of the aged, marriage and social problems etc. Many more will be found in the usual lists that are published by different classifying agencies.
However the concepts illustrated in the earlier sections will help many people with psychiatric illnesses to understand their illness in a logical way. This will also help them gain greater confidence and faster recovery.
One has to assimilate this explanation as a simplified concept meant for lay people to understand psychiatric illness without much scientific jargon. In this summary the rough edges of scientific explanations are avoided for readers to understand concepts easily.
Social media is defined as “forms of electronic communication through which users create online communities to share information. First known use of the term was in 2004. About 73% of online adults now use a social networking site of some kind. The top five most popular social networking sites are Facebook, LinkedIn, Pinterest, Twitter, and Instagram. Sixty three percent of Facebook users visit the site at least once a day, with 40% doing so multiple times throughout the day. 300 million Facebook users were mobile-only users. Although social media is accessible to nearly anyone, young adults are the most active users. Eighty four percent of 18-29 year olds are on Facebook in the US.
Motivations for Social Media Use
Recent neuropsychological research shows that the self-disclosure on social media ‘activates the intrinsic reward system’ of the brain, the same way as powerful primary rewards such as food and sex. Self-disclosure was strongly associated with increased activation in mesolimbic dopamine system. A biological reward mechanism happens when people disclose information about themselves. Web users gradually alter prefrontal cortex in this way due to the fast pace of the networking sites rewiring the brain with repeated exposures.
Effects of Social Media Use: Current Research and Speculations
It is no doubt that we are developing a dependence on technological advance that unifies billions of people, but are we addicted. Numerous studies identify connections between social media use and negative outcomes. Greater use of the Internet was associated with more signs of loneliness and depression. When used in moderation, with the right intentions, it can also achieve what it was first set out to do: connect people with similar intentions.
Social Media and Depression
People who spent more time and who performed more image management online showed more symptoms of major depression. More negative and less positive interactions on social networking sites were associated with greater depressive symptoms. Posts on social media present an idealized version of what is happening. Users of social media constantly compare themselves with others and think less of them. If other people are posting happy life accomplishments, then the user feels worse about his lack of having anything good to report. People usually post good things about their lives, rather than the bad things resulting in magnified responses. If things are going well for people in your society and you are having a rough day, it will negatively affect your mood. Negative behaviour occurs because of decline in confidence due to unfair comparisons to others.
Social Media and Narcissism
‘Narcissistic personality disorder’ is marked by a grandiose sense of self-importance, fantasies of unlimited power, self-promotion, vanity, and superficial relationships. Such individuals are driven by responses from others rather than self-assessment of themselves. More time spent on Facebook and a higher frequency of checking Facebook predicted higher narcissism scores. Studies show that social networking sites exacerbate narcissism. Research has shown that young adults with a strong Facebook presence were more likely to exhibit narcissistic behaviour.
Social Media, Anxiety and addiction
People are motivated to use Facebook for two primary reasons: ‘a need to belong to a group’ or ‘a need for self-presentation’. Middle aged and older adults gives greater emphasis on using social media to ‘belong to a group of others’ who have common interests and hobbies. Younger adults below 30years of age connect primarily with those already present in their lives, such as friends and family members for ‘self-presentation’.
There are several studies linking social media to anxiety and compulsive behaviours. Younger generations scored consistently more than older generations on anxiety when they were unable to check their social networks and texts. Two-thirds admitted to having difficultly relaxing when they were not able to use their social media accounts. Many become stressed at the thought of ‘missing out’ on something good posted on the site, a phenomenon known as the “fear of missing out”. “Likes” and comments are positive reinforcement for postings, making it difficult for a person to stop. Quitting Facebook (and Twitter) was more difficult than giving up cigarettes or alcohol. Social media supply a platform to self-disclose to the masses and receive immediate feedback. The immediacy, and the reward associated with social media, is a 'quick hit', and resulted in experiencing 'addiction-like' symptoms. Diagnostic and Statistical Manual of Mental Disorders (DSM) is evaluating "Internet Addiction Disorder" for inclusion. Researchers have created a scale to measure this addiction: The Berge Facebook Addiction Scale.
According to a recent survey of Facebook users between ages 16 to 40, more than half say that seeing pictures of themselves on the site “makes them more conscious about their own body and their weight.” On top of that, 32-percent feel “sad” when comparing photos of themselves to pictures of their friends. A surprising 86 percent felt that such sites hurt their body confidence. Past studies have shown that exposure to fashion magazines, music videos and other mass media can affect body image in both boys and girls — typically causing some girls to strive for a “thin ideal” and some boys to seek an unrealistically muscular physique. Young women and men post photos, count the number of ‘likes’, and feel the pressure to look perfect. Close to 30 percent of girls re-touch or alter their own images via Photoshop or filters before they post them. Some sites ask you to rate people’s appearances. Many of these behaviours finally result in eating disorders.
Social media gives rise to cyberbullying.
Cyberbullying is on the rise. Why does it increase? Some have abused the privileges of social networking. Cyberbullying is an enormous concern for adolescents. Social networking sites facilitate cyberbullying. Forty nine percent of students reported being the victims of bullying online and 33.7% reported committing bullying behaviour online in the US. Schoolchildren who were victims of cyberbullying were almost twice as likely to attempt suicide. Adults can also be victims of cyberbullying.
Social media glamorizes drug and alcohol use.
Seventy percent of teenagers between the ages 12 to 17 who use social media are five times more likely to use tobacco, three times more likely to use alcohol, and twice more likely to use marijuana according to a study in the US. In addition, 40% admitted they had been exposed via social media to pictures of people under the influence. Although a correlation is all it is, it makes sense that social media would increase the amount of peer pressure to which teenagers are exposed. The data may suggest that those who are exposed to pictures of drugs and alcohol are more inclined to seek and experiment with it.
Social media enhances our connectivity.
When used in moderation with the right intentions, it really can achieve what it was first set out for – to enhance connectivity. Social media does not necessarily take us away from real world; instead, it can be used to revive relationships with other people. Even more exciting is that there are an incredible number of like-minded people who can be connected by just one click. Social networking sites allow people to improve their relationships and make new friends. Seventy percent of adult social networking users visit the sites to connect with friends and family. Fifty two percent of teens using social media report that it has helped their relationships with friends, 88% report that social media helps them stay in touch with friends they cannot see regularly, 69% report getting to know students at their school better and 57% make new friends.
Social networking sites help students do better at school. Fifty nine percent of students with access to the Internet report that they use social networking sites to discuss educational topics and 50% use the sites to talk about school assignments. Social media sites help employers find employees and job seekers find work. Sixty four percent of companies are on two or more social networks for recruiting because of the wider pool of applicants and more efficient searching capabilities.
Social networking sites help people who are socially isolated and shy connect with other people. Youth who are "less socially adept" report that social networks give them a place to make friends. Shy adults also cite social media as a comfortable place to interact with others. Studies show that students who experience low self-esteem can use social media to bond them with others. Introverted adolescents can actually gain social skills by using social media.
Social networking sites help senior citizens feel more connected to society. The older age group is the fastest growing demographic on social media sites. Seniors report feeling happier due to online contact with family and access to other information. More recently, people were encouraged to start conversations regarding mental health in a bid to end the discrimination against mental illnesses. This is one instance where social media can be seen as bringing about a positive change in the understanding of mental health. Social media can help disarm social
Social media may also pose a hazard to vulnerable communities.
Social networking sites allow hate groups to recruit members. Children may endanger themselves by not understanding the viral nature of social networking sites. Social networking enables cheating on school assignments with students posting parts of the exam to social media. Social media can facilitate inappropriate student-teacher relationships. Social media allows for unsupervised interactions between students and teachers, which can easily escalate into inappropriate relationships. People say and do things on social media that they would not say and do in person. As a result, a wall has been removed.
Social networking sites encourage amateur advice and self-diagnosis for health problems that can lead to harmful or life-threatening results. Many people use social media for health care information. Many such information posted on social media are harmful and sometimes bizarre.
From social media sites, simple algorithms can determine where you live, sexual orientation, personality traits, signs of depression and alma maters among other information, even if they do not put those data on their profiles. Social media posts cannot be completely deleted and they can have unintended consequences. Postings on social media named as a source of information in one-third of all divorces filed in 2011. Social networking site users are vulnerable to security attacks such as hacking, identity theft, and viruses. Social networks do not scan messages for viruses or phishing scams, leading to large-scale problems.
Help your teen to keep their body image healthy.
• Keep the computer in a common room in the house, so you can monitor their use.
• If you catch your teen rating people’s looks, or counting numbers of likes , gauge how they feel. Ask questions: “Do you know anyone who retouches their photos before they post them?” “What do you think about rating others’ appearances?” “Is it a good idea to focus only on how someone looks?”
• Converse on the non-physical attributes to build up self-esteem … their talents, how hard they study, their patience or generosity. Counter social media images that focus on people’s beauty alone by discussing about others who have achieved distinction through hard work.
• Watch for signs of body image problems and changes in eating habits.
• Set example of healthy body image by not complaining about looks and by stressing exercise and eating well.
• Teach kids to be careful about the comments they post on their own web pages and “unfriend” people who post negative comments about others. Talk to your teens about being careful about sharing pictures. Use social media as a teaching tool and an opportunity for conversation.
Facebook reached one billion monthly users worldwide on October 4, 2012, making it the most popular social networking site with one in seven people on the planet as members. Every day, Facebook manages 4.5 billion "Likes," 4.75 billion content shares, and over 300 million photo uploads. As of Sep. 2014, 51% of US adults use YouTube, 28% use Pinterest, 28% use LinkedIn, 26% use Instagram, and 23% use Twitter.
Primary Eating disorders are psychiatric disordersthat cause voluntarily eating extremely small amounts or severely overeating food, that affects the person's physical and/or mental health.
They include binge eating disorder where people eat a large amount in a short period of time resulting in overweight, anorexia nervosa where people eat very little and thus have a low body weightand bulimia nervosa where people eat a lot and then try to rid themselves of the food, resulting in normal or overweight.
Eating behaviour is a process controlled by the Hypothalamus-pituitary-adrenal-axis (HPA axis). Dysregulation of the HPA axis has been associated with eating disorders. Researchers are still studying questions about behaviour, genetics, and brain function to understand risk factors and develop specific.
characterized by compulsive maintenance of lower than normal body weight and an obsessive fear of gaining weight.
Many people with anorexia nervosa see themselves as overweight, even when they are clearly underweight. Eating, food, and weight control become obsessions. Some people with anorexia nervosa may engage in extreme dieting, excessive exercise, self-induced vomiting, and/or misuse of laxatives, diuretics, or enemas. They have distorted body image, a self-esteem.
Bulimia nervosa (BN), characterized by recurrent compulsive binge eating ollowed by compulsive purging, even though theymaintain normal weight, while some are slightly overweight
Patients with bulimia nervosa have recurrent and frequent episodes of eating large amounts of food and feeling lack of control over these episodes. Binge eating is followed by forced vomiting, excessive use of laxatives, diuretics, fasting, excessive exercise, or a combination of these behaviours.
The notable difference between anorexia nervosa and bulimia nervosa is the body weight of the person. Anorexia nervosa patients are underweight, while those with bulimia nervosa have body weight that falls within the range from normal to obese.
Binge Eating Disorder (BED), characterized by recurring compulsive binge eating at least once a week for over a minimum period of 3 months while experiencing guilt after overeating.
With binge-eating disorder a person loses control over his or her eating. Unlike bulimia nervosa, periods of binge-eating are not followed by purging, excessive exercise, or fasting. As a result, people with binge-eating disorder are over-weight or obese. They also experience guilt, shame, and distress about their binge-eating. Who Is At Risk? Eating disorders frequently appear during the teen years or young adulthood but may also develop during childhood or later in life. Although males with eating disorders exhibit the same signs and symptoms as females, they are less likely to be diagnosed with what is often considered a female disorder. Rates of eating disorders appear to be lower in less developed countries. Reliable statistics regarding eating disorder for India is not available yet. Diagnosis When does severe dieting becomes an eating disorder?
Ø Constant focus on dieting, food and exercise
Ø Insisting dieting meal different from others
Ø Feeling irritable when exercise is not done
Ø Increased social withdrawal
Ø Frequent weighing
Ø Frequent visits to bathroom after meals
Ø Weight loss
Ø Altered eating behaviour
Ø Depressed mood and withdrawal from society
(Use a screening instrument to determine the existence of an eating disorder or other mental health or physical health disorder) Physical examination shows features of malnutrition. Symptoms of eating disorders are actually symptoms
of the starvation itself. Eating disorder shows failure to gain weight rather than weight loss. While diagnostic criteria are a useful guide, one should consider intervention if disordered eating and abnormal behaviours are present, even if the criteria are not met. Investigations
Investigations are to rule off diagnoses other than eating disorders. They are mostly normal in eating disorders. Full blood examination
Ø Mild leukopenia or thrombocytopenia from malnutrition
Ø Anaemia from malnutrition or gastrointestinal losses Urea and electrolytes
Ø Hyponatraemia from excess water intake
Ø Hypocalcaemia from vomiting
Ø Metabolic alkalosis from vomiting Random blood glucose
Ø Rarely low Calcium, phosphate and magnesium
Ø Hypocalcaemia, hypmagnesia, and hypophosphatemia (uncommon) Liver function tests
Ø Slight elevation from malnutrition; albumin normal unless very chronic Follicle stimulating hormone (FSH), luteinising hormone, other vitamins
Ø FSH and LH usually low,
Ø Bone densitometry Scores may be reduced from low hormone levels and malnutrition
Ø Vitamin D Low from malnutrition, Haematinics – iron studies, B12 and folate If indicated – low from malnutrition
Ø Tumours in various regions of the brain.
Ø Brain calcification: of the thalamus.
Ø Addison's Disease
Ø Gastric adenocarcinoma
Ø Helicobacter pylori
Ø hyperthyroidism, hypoparathyroidism and hyperparathyroidism
Ø systemic lupus erythematosus (SLE)
Ø Coeliac disease
Ø Diabetes Treatment
Some who have eating disorder recover with treatment after only one episode. Others get well but have relapses. Still others have a more chronic form of disorder, in which their health declines as they battle the illness.
A combined approach of medical attention and supportive psychotherapy designed specifically for eating disorders is more effective than a single mode of treatment.
1. Role of the Family Physician ( Team leader of the professional Eating disorder care group) is the first point of contact for patients with eating disorders
Early detection and establishment of the seriousness of the condition
Undertake an assessment and provide regular medical monitoring of physical status
Decide if hospitalisation is necessary (Indicators for admission)
Ø Admission criteria for eating disorders
• Bradycardia (resting heart rate <50 bpm)
Orthostatic hypotension (>10 mmHg systolic)
Hypothermia (temp. <35.5oC)
Severe electrolyte disturbances, eg. Hypokalemia (K <3.0 mmol/L)
• Acute dehydration from refusal of all food and fluids
Provide primary care support to outpatient specialist treatment
2. Nutritional counselling is usually necessary. (Dietician/Nutritional counsellors)
Ø Restoring weight through Adequate nutrition, reducing excessive exercise, and stopping purging are the foundations of treatment.
3. Treating the psychological issues (Psychologists)
Ø Issues related to the eating disorder using cognitive behavioural therapy (CBT), that helps the patient learn how to identify distorted or unhelpful thinking patterns, is necessary.
Family therapy and self-help groups are useful adjuncts. Family based therapy requires 6–12 months of outpatient treatment.
Psychiatric management (Psychiatrists)
Ø Medications, such as antidepressants, antipsychotics, or mood stabilizers, are effective in treating patients with eating disorders.
5. Other forms of specialised management (Physician, Endocrinologist, Neurologist, Gastroenterologist, Bariatric surgeon etc).
Outcome estimates are non-uniform for anorexia nervosa, bulimia nervosa, and binge eating disorder, there seems to be general agreement that full recovery rates are in the 50% to 85% range, with larger proportions of people experiencing at least partial remission. 50–75% of patients are weight restored by the end of treatment, with 60–90% fully recovered at 4–5 year follow up.
Dr. MJ Thomas (www,drmjthomas.com) Consultant Psychiatrist