Edge of reality: T2(The telegraph) article published on 6th Jan'2019

Mrs Sen was admitted to the hospital due to physical concerns. She was very pleasant and warm and the hospital nurses and staff took a liking to her. She laughed and cracked one-liner jokes. Overall, she appeared gentle, sometimes funny, and a slightly eccentric old lady who occasionally displayed odd behaviour but not odd enough to raise an alarm about her mental health. 

The hospital staff let her be on her own until the day she tried to kill herself by hanging with the curtains in the ward. When she was rescued, she was disturbed, angry and agitated, screaming that because of the staff she was not able to meet her people who were the ‘time lords’ and celestial eternal beings, that she was trapped in this body and the only way she could be herself was by leaving this body. 

She was clear that she was not committing suicide; she was, on the contrary, trying to live. Her delusion (abnormal beliefs) was fixed and unshakable; it was not an idea for her but her reality. When she was interviewed by the on-call psychiatrist, she displayed all the diagnostic criteria of psychosis, where she mentioned how she communicated with those celestial beings through TV and telepathy, and how they put thoughts in her head directly (thought broadcasting, thought insertion). 

She also reported that she heard those celestial voices talking about her, discussing her condition and her options, as a running commentary, which no human could hear but she could as she was one of them (auditory hallucination in the third person). She did not have a ‘story’ which could sensibly explain her bizarre beliefs, but she was living in that delusional system where she identified herself as someone non-human in human society.

An Imaginary world!

Psychosis is a condition we know as ‘insanity’ or ‘madness’ where a person loses touch with reality. It is such a scary and taboo topic that the mention of any mental health issue immediately makes us identify it with this condition, and so we shy away from knowing about it or discussing it. We fear psychosis as it doesn’t make sense to us and we don’t acknowledge the person suffering from it as one of our own. 

In full-blown psychosis, people perceive things that are not there (hallucination), and may process information and respond to stimuli from the environment in an abnormal way. They have impossible bizarre beliefs about themselves, the people around them. They lose the ability to interact with reality reasonably or normally. They behave in a chaotic fashion. What they perceive and believe as their reality is so hyper-real for them that it is beyond any logic, reason or argument, unlike normal people where reasonable doubt is part of our everyday experience. 

They are unable to develop an insight into the problem as they experience psychosis intensely and organically. However, at times, people with evolving or remitting psychosis have a limited ability to interact with the world without making their symptoms obvious for brief periods of time, like Mrs Sen.

Psychosis can be seen in people suffering from schizophrenia, schizoaffective disorder, delusional disorders and some mood disorders like depression or mania with psychotic symptoms. There may also be stand-alone brief episodes of psychosis secondary to substance misuse, poisoning or some organic illness without chronic mental health problem.

In spite of some interesting theories suggesting otherwise, at this moment, psychosis can be best explained by the biological model of illness which states that our mind suffers psychosis because of a neurochemical imbalance in our brain and somehow that leads to the disintegration of the psychological faculty. That is exactly why the treatment of psychosis is straightforward with medical intervention. Although psychosis sounds scary and intense, it is treatable with modern medicine and early intervention shows a promising outcome.

We all have some neurotic traits!

Contrary to popular belief, many of the issues in the context of mental health are not related to psychosis. If at one end of the mental disorder/disease spectrum is psychosis, then on the other end there is neurosis. 

Diseases like schizophrenia have a somewhat ‘pure’ psychosis component. Mood affective disorder, which includes depressive illness and bipolar disorder, can display psychotic symptoms as mentioned earlier but can have a strong neurotic factor as well. At the other end are anxiety and stress-related disorders and personality disorders where neurosis takes the centre stage. 

Neurosis is being discussed extensively in psychology for ages. It is an umbrella term that includes anxiety, depression, or other feelings of unhappiness and distress. Unlike psychosis, it is caused by our mind’s complex, paradoxical and often contradictory ways to fulfil our psychological needs such as safety, validation, need to belong, defending self-image, ensure value and worth. 

Our mind tends to quickly assess a stressful situation, correlates it with our past experience and then strategises to protect ourselves even without our awareness. Past trauma, bad experiences, negative core beliefs may engineer a maladaptive coping strategy within us, which at times causes more dysfunction and struggles than the original problem itself. 

However, neurosis may not always be negative; it also serves an essential purpose of keeping our self-image intact. It helps us gather confidence, even if it is false, to go out into the world, interact and experiment. We all have some neurotic patterns or traits in our personalities. We might have pushed away love because we couldn’t handle a potential rejection. We might not have tried out new things as we couldn’t handle the possibility of failure. We might have avoided being alone and sitting with ourselves as we didn’t want to face ourselves and challenge our self-image. 

There are many examples of how our mind is constantly trying to protect and guard us often in a rather myopic way, sacrificing long-term good. Owing to this, at times, our mind may compel us to act, behave and react in a manner which may consistently affect our lives negatively and we may have to struggle to have a functional life.

Matter of motivation!

The treatment of neurosis is not at all straightforward. It requires immense motivation from the sufferer to face themselves, examine their life choices as authentically as possible, recognise and acknowledge their own dysfunctional ways, and take responsibility to change without creating a cycle of self-loathing and self-judgement. 

Medicine has very little role to play in a neurotic struggle as it’s our mind which creates the struggle in the first place. It is imperative to remember that although our mind itself creates the problem, it is not a conscious choice. Much of the strategising happens at a deep unconscious level, hence it is not a drama or conscious manipulation. The struggle and suffering are real and neurosis can seldom be tackled with just ‘snapping out of it’, ‘manning up to it’ or just ‘distracting oneself’ as many of us tend to advise those suffering from it. The recovery and change are rather slow and effortful, with lots of ups and downs and setbacks.

As mentioned earlier, much of the psychiatric illness has a strong neurotic component, which we can actively work upon. A therapist or a counsellor might help one, but the role of a therapist is only to show how one can transparently see oneself,  and if one chooses to, the ways in which to change oneself. 

The most distinctive factor of neurosis is that with genuine effort, we all can gain insight into our own struggles, although we may not be consciously aware of it initially, and identify our own contribution to the problem, hence finding a reasonable way to work with ourselves and become more functional and skilled at navigating life.

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Dr Sangbarta Chattopadhyay and Dr Namita Bhuta are practising psychotherapists. They conduct group therapy and individual sessions.

Age of Innocence: T2 (The Telegraph) article dated 16th Dec'2018

The desire to stay young is there in all of us, and maybe in spirit, we do stay that way. Our physical bodies age nevertheless, which brings with it a host of physical and mental health issues. With increasing lifespans, superior healthcare and nuclear family structures, there’s a variety of health concerns around the elderly. Old age care, particularly cognitive and mental healthcare, remains one of the most neglected health topics in our society. Instead of being in denial about the care needs of the elderly, we need to be aware of what poses a threat and how to address it. 

Cognitive health

Cognition includes various mental processes like learning, memory, language, reasoning and decision making, all of which form what we call our ‘intellectual functions’. There are various presentation of cognitive impairment in the elderly. These range from Mild cognitive impairment to dementia which includes Alzheimer’s disease, and Post Vascular Dementia.

Mild cognitive impairment

Mild cognitive impairment (MCI) is the stage where the cognitive decline is greater than what is seen in normal ageing but less than what is seen in dementia. It can involve problems with memory, language, thinking and judgement that are greater than normal age-related changes. Usually family and friends are the first ones to notice any of these changes.

Symptoms of MCI include:

• Forgetting everyday things more often.
• Forgetting important events such as appointments or social engagements.
• Losing your train of thought or the thread of conversations, books or movies.
• Feeling increasingly overwhelmed, stressed about small things like normal decisions making, planning ,steps to accomplish a task or understanding instructions.
• Having trouble finding your way around familiar environments.
• Becoming more impulsive or showing increasingly poor judgement.
• Depression.
• Irritability and aggression.
• Anxiety.
• Apathy.

Dementia

Dementia is not one specific disease; it refers to a collection of symptoms. It is usually chronic and/or progressive in nature, in which there is deterioration in memory, thinking, behaviour and the ability to perform everyday activities. It mainly affects older people. It is not a normal part of ageing and the clinical picture is more severe than normal expected ageing and Mild Cognitive Impairment. Alzheimer’s disease is the most common cause of progressive dementia in older adults.

Dementia symptoms vary depending on the cause, but common signs and symptoms include:

Cognitive changes

• Memory loss, which is usually noticed by a spouse or someone else.
• Difficulty in communicating or finding words. 
• Difficulty in reasoning or problem-solving.
• Difficulty in handling complex tasks.
• Difficulty with planning and organising.
• Difficulty with coordination and motor functions.
• Confusion and disorientation.

Psychological changes

• Personality changes: A sudden change can be personality is seen. Usually, the person becomes less confident, irritable, unsure and these are often-missed early presentation of dementia. Occasionally people might become the complete opposite of what they usually are. A calm and reserved person can also become talkative chatty and emotionally volatile.
• Depression: Feeling low most of the time, feelings of hopeless and helplessness, inability to find pleasure in anything and low energy can all be a part of the presentation of depression.
• Anxiety: Anxiety alone may not warrant suspicion, however constant worrying and feeling edgy can form a part of the dementia picture.
• Inappropriate behaviour: There might be instances where the person might come out of the bathroom without their clothes on, or do something that’s socially unacceptable or behave in a sexually disinhibited manner. Often this is embarrassing and frustrating for the family and carer, but it is important to remember that these symptoms are part of the disease and not who the person is.
• Paranoia: Paranoia is obsessive suspicion of things and people’s intentions. It can be a predominant part of a changed personality.
• Agitation: Restlessness, agitation and irritability. 
• Hallucinations: Hearing voices and seeing things that are not there are common hallucinations that might also be present in dementia. Visual hallucinations are more common in organic brain disease.

Psychological Health

Depression in Elderly:  

We all tend to associate depression with feeling ‘sad’. However, many depressed older adults do not complain of feeling sad at all. Instead, they complain of not feeling motivated, being low on energy, or other physical problems. Physical complaints are often the principal symptom of depression in the elderly. These can range from arthritic pain and insomnia to worsening headaches.

Factors contributing to depression in older adults

• Health problems: Chronic medical conditions, limited mobility or chronic pain. 
• Loneliness and isolation: Death of the spouse, divorce, death of family and friends. 
• Transitioning from work to retirement.
• Financial hardships.
• Fear of death or dying. 
• Anxiety about health. 
• Prolonged substance abuse. 

Treatment for patients with depression

1. Psychotherapy: Cognitive Behaviour Therapy (CBT) and Interpersonal Therapy are helpful, especially in those people who have experienced major life stressors such as loss of family/friends, major health concerns, home relocations.

2. Engaging in social activities: Becoming a part of a group can make one feel less lonely and isolated. One can join a book club, a hobby class or be part of a discussion forum or spiritual group. Learning something new is proven to better the brain functions as well as mental health.

3. Antidepressants: The newer antidepressants are relatively safe. However, they are less efficacious in older people than in younger people. 

4. Lifestyle changes: Exercising more frequently, eating a balanced diet and on time, cutting down on alcohol and avoiding caffeine late in the day in order to sleep better. 

Things to be aware if you are a carer for patients with cognitive impairment:

It is important to be aware that in many cases, cognitive impairment is a progressive condition with some days better than others. As the disease progresses some functions will be more affected than others. Their ability to understand complex sentences will reduce. Be prepared mentally for them to become aggressive, agitated or irrational at times.  

1. Be aware of your body language and tone. Speak pleasantly and calmly so as to make them feel comfortable. Avoid saying thing like ‘she/he is mad’ or ‘she/he does not understand anything’.

2. When talking to the person, ensure that you have their attention. Switch off the television or radio, keep away your phone and make eye contact; speak slowly. Wait to gauge their response. If they do not seem to follow, rephrase your sentence.

3. Speak in simple sentences. When asking a question, keep it simple. If possible, show them what you are asking. Verbal cues help them understand and respond better. For example, instead of asking ‘Would you like to have egg or fish for lunch’, show the egg and fish to get a better response.

4. Break down tasks and create a routine which they can follow every day for their daily activities.

5. When talking to them, avoid asking questions that rely on short-term memory, like what they had for lunch or what they did during the day. Talk instead of the days in the past. Short-term memory is affected early on, and long-term memory is retained until much later.

Being a carer is not easy. It is equally important that you take care of yourself. Exercise daily, eat healthy, take your medications if you are on them on time and visit your doctor regularly. Be gentle on yourself when you find yourself feeling frustrated and tired. Meet people socially, get adequate sleep and rest. The emotional and physical strain of looking after someone can get a bit much. It is okay to talk to someone professionally if need be. 

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-Dr Sangbarta Chattopadhyay and Dr Namita Bhuta are medical practitioners and practising psychotherapists. They conduct individual and group therapy sessions 

Invisible wounds: PTSD: T2 (The Telegraph India) Article dated 25th Nov'2018

https://epaper.telegraphindia.com/imag

Post-traumatic Stress Disorder (PTSD) is a psychological condition developed after a traumatic event first seen in war veterans but now recognised across all demographic groups. Although trauma can mean a physical injury, in day-to-day use, we often refer to trauma as a psychological wound, hurt or injury, usually with a long-term effect. Unfortunately, life, being a prolonged skill-building exercise, doesn’t allow us to go through it unscratched and cocooned. We all, perhaps, have at least one or two personal experiences of some kind of trauma from the past. 

In the world of mental health, trauma has become a buzzword of late and there are various academic debates over what should be defined as trauma and the rationale behind the definitions. On the one hand, there are psychiatrists and psychologists who advocate sticking to a restrictive definition of trauma, like the American Psychiatric Association’s current definition of PTSD, introduced in 1994. It states that to be diagnosed with PTSD a person must have experienced or witnessed an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others, and which involved fear, helplessness or horror. 

The UK guidelines are even more definitive: “Post-traumatic Stress Disorder (PTSD) develops following a stressful event or situation of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone. PTSD does not, therefore, develop following those upsetting situations that are described as ‘traumatic’ in everyday language, for example, divorce, loss of job, or failing an exam.” 

And yet, there are others who prefer a more person-centric definition of trauma and are willing to look at the definition of ‘trauma’ from a subjective point of view. The American Psychiatric Association’s definition of PTSD and the UK guideline play down the individual’s experience of an event and try to be more definitive about the event itself. Which of course leaves ample opportunity for academics to deliberate on the meaning and interpretation of the words and phrases like ‘exceptionally’ and ‘almost anyone’. 

It is important to consider that personal experience of a psychological trauma is indeed very subjective and it is difficult to devise a universal yardstick to say which events can be called traumatic and which can be discarded as non-traumatic. Similar events can have starkly different enduring effects on different individuals. 

War violence, genocide, sexual abuse with violence, the sudden death of a close one and survival threats are obvious examples of traumatic events. However, rejection, betrayal, social isolation, bullying, loss of a dream, loss of purpose, and also, contrary to the above mentioned guidelines, divorce, loss of job or failing an exam can be very disturbing and distressing, causing a marked change in personality and behaviour. More and more psychologists and psychiatrists are trying to broaden the definition of trauma and be more inclusive towards individual experience of the event.

The newer ideas about complex PTSD, which is a condition described as an effect of sustained and prolonged exposure to trauma in childhood, commonly sexual and emotional abuse as opposed to a singular traumatic event in simple PTSD, are demanding a closer examination of our understanding of various psychiatric conditions and labels including personality disorders like Emotionally Unstable Personality Disorder (EUPD).

Cognitive behavioural therapy pioneer Anke Ehlers described how refugees diagnosed with complex PTSD may not have had early developmental deficits, but may have had equally damaging experiences of relationships with others so as to catastrophically alter their view of themselves, other people and the wider world. (Maercker A., Ehlers A, Boos A. (2000). ‘Post-traumatic stress disorder following political imprisonment: The role of mental defeat, alienation, and perceived permanent change.’ Journal of Abnormal Psychology)

It can be noted that the common presentation of PTSD among war veterans is not restricted to them being victims of violence but paradoxically also as perpetrators of violence. It strengthens the idea that we don’t experience trauma in a linear, black-and-white manner and neither do we cope with stress in similar ways. 

It is perhaps not difficult to imagine how we experience life individually and uniquely and how similar types rof events can shape our personality, our coping mechanisms, our defensive strategies and our behaviours differently.

PTSD symptoms can be described in three broad categories. 

Re-experiencing:  

The sufferer relives the traumatic event repeatedly in the form of…

•  Flashbacks as if the event were happening in real time. 
•  Nightmares, which are common and repetitive made up with metaphors, representation and actual imagery of the traumatic event.
•  Distressing images or other sensory impressions like sound and smell from the event, which intrude during the waking hours. 
•  Reminders of the traumatic event, provoking significant distress.

Avoidance or rumination

In this category, those with PTSD try to avoid reminders of the trauma, such as discussions, people, situations or anything resembling the event or associated with the event. Even a mention of that particular time frame can potentially cause distress. The sufferer often avoids being in such scenarios where they will be reminded of the trauma. They try to suppress memories or avoid thinking about the worst aspects of their traumatic experience. 

Many others ruminate excessively and prevent themselves from coming to terms with the experience. They seem to be trapped in that traumatic time and they cannot live in the present world. They are constantly tormented by…

n Why did it happen to me?

n Could it have been prevented?

n How can I take revenge?

Hyper-arousal or emotional numbing

This may manifest as...

• Persistent perception of current threat, hyper-vigilance, paranoia.
• Exaggerated startle or inappropriate responses to real-time stimulus.
• Irritability.
• Difficulty in focusing and concentrating.
• Sleep problems.
• Difficulty experiencing emotions.
• The feeling of detachment from others.
• Giving up previously significant activities.
• Amnesia or blocking of memory for salient aspects of the trauma.

Complex PTSD 

It can be defined as a condition developed from prolonged and sustained exposure to a stressor event, typically of an extreme nature, in childhood and from which escape is difficult or impossible, such as torture, concentration camps, slavery, genocide or other forms of organised violence, domestic violence and sexual or physical abuse. Often the symptoms present themselves after many years and gradually. As the person interacts with life more,  more effects of the traumatic phase become evident. As it takes years for the symptoms of complex PTSD to be fully manifested, a child’s development, including their behaviour and self-confidence, can be altered as they get older. Adults may have difficulty in trusting people and having meaningful relationships, as an effect of complex PTSD.

Many of the symptoms of complex PTSD are similar to PTSD but they may also include…

• Feelings of shame and guilt.
• Volatile and poor control of emotions with impulsive actions.
• Periods of losing attention and concentration often described as "blanking out" (this is one of the common presentations, known as dissociation. Dissociation can also present itself in many different ways other than blanking out).
• Isolating from family and friends.
• Difficult interpersonal relationships.
• Destructive or risky behaviour.
• Maladaptive coping mechanism, making personal life difficult and complicated.

The symptoms of complex PTSD can be diverse, varied and uniquely expressed in each individual and are difficult to fit into any one diagnostic criterion. 

If we recognise that we are defined by our experiences of life and our response to it, then perhaps we can also identify some ‘traumatic’ events shaping us making who we are today. If we become aware of these unconscious effects of our ‘trauma’, we can perhaps decide not to be defined by those traumas and interact with life more openly. Will it not be interesting to see what we become then?

Addiction:Break The Chain: T2 (The Telegraph) article dated 28th Oct'2018

The urge to escape, the longing to transcend themselves, if only for a few minutes, is and always has been one of the principal appetites for the soul.— Aldous Huxley

We may or may not agree with Aldous Huxley, but in our day-to-day life, we cannot deny the temptation to escape our reality. We all want a quick fix to our problems and miseries. Reality sometimes is overwhelming and our minds seek comfort and pleasure in not facing it. Some of us would rather drug ourselves, or get into a new obsession, or come up with various reasons to stay numb than actively take charge and find a solution to our problems. No wonder, substance addiction is on the rise.
People of all age groups are now susceptible to alcohol or drug addiction, with teenagers and young adults being the most vulnerable. The reasons? Isolation, loneliness, or/ and dysfunctional coping mechanism. The common reasons we give ourselves to use addictive substances are to feel a “high”, to counter boredom, to seek and repeat pleasure, as a form of self-medication for anxiety and insomnia or to escape the emotional turmoil. At times, we con ourselves to believe that we need a chemical crutch to not get disturbed by surroundings and even to be productive.
No matter what be our reason, any kind of addiction — whether a real substance addiction or a compulsive attachment to video games, phone, sex, food, make-up, shopping — is really just a distraction from the real world. It may help us to look away from our problems but doesn’t solve anything. Even legal addictive substances, like tobacco or caffeine, are quite a bit of a health hazard if consumed indiscriminately.
Addiction is a big concern like any other serious disease. If one adds up the risk of injury and damage from chronic alcoholism and substance addiction along with the risk of overdosing and poisoning, addiction definitely is a serious issue.
It destroys one’s physical and mental well-being alongside having severe negative effects on one’s family, employment and society as a whole. The risk of damage depends on the substance used, the dosage and route of administration but, at a varying degree, it involves acute substance toxicity or poisoning, risk-prone behaviour, secondary and chronic medical problems like cirrhosis of the liver in case of alcoholism, secondary psychiatric problem, risk of persistent cognitive impairment, risk of dependency, and other social/occupational negative consequences.

DEPENDENCY SYNDROME

Dependency on a chemical does not happen overnight. It starts at will, with controlled exposure. Nobody starts taking drugs or alcohol to be dependent. However, slowly the body becomes used to the chemical and the substance becomes essential to retain normal functionality.
Dependency Syndrome initially was described (Edward G. and Gross MM 1976: ‘Alcohol dependence: Provisional description of a clinical syndrome’) as provisional alcohol dependency but it is increasingly being applied to describe other drug dependencies as well.
It features a few categories to identify the problem and the extent of it. It might help us to identify where we stand.

• 1. Primacy of drug-seeking behaviour: In this, the substance user’s is always focused on the substance (alcohol or drug) and ways to procure it, which takes priority over everything else. Substance use becomes more important than one’s job, relationships or health. 
• 2. Narrowing of the drug-taking repertoire: The user restricts themselves to a single drug rather than experimenting with many. The route of administration, setting and company become familiar and stereotyped. This means, the user is well past experimentation or trial phase and is slowly becoming dependent on a particular chemical substance.
• 3. Increased tolerance to the effect of drug: The user feels the need to increase the dosage to get the same effect. They might try to use a different route of administration (oral to IV) to get better or faster results.
• 4. Loss of control over consumption: The user feels that they are not able to restrict the quantity of the substance they further consume once they have taken the first dose.
• 5. Withdrawal symptoms: At this stage, even a gap of a few hours of consumption gives rise to withdrawal symptoms, often more evident in the morning. 
• 6. Taking substance to prevent withdrawal: The user knows and anticipates withdrawal symptoms and in order to prevent it, they take measures to have substance handy.
• 7. Continued substance use despite severe negative consequences: Even when threatened by severe consequences, like a marital breakup, job loss or bankruptcy, they continue to use the substance.
• 8. Rapid reinstatement of the previous pattern of drug use after abstinence: Characteristically, when the previously-dependent user relapses after a period of abstinence and rehabilitation, it takes lesser time to again become dependent than the time initially taken. 

Once they are dependent, a user is usually very defensive about their substance misuse. It takes a lot of self-motivation and a strong drive to overcome dependency. Following are the stages one goes through on the path to recovery. It is not unusual to skip one or two stages, but the general progression remains the same unless the movement is halted.

• Pre-contemplation: The user doesn’t recognise the problem although friends and family have already begun to suspect that there is a problem. The user might brush it off or even be surprised if someone points out the possibility of a dependency. A careful non-judgemental chat, a friendly nudge without prodding, might help the user to go to the next stage.
• Contemplation: The user recognises and often acknowledges the problem in a non-judgemental, trusting environment. They might accept that there is a problem and be able to see the negative aspect of continued substance use. Recognising a problem genuinely is half the battle won if one can look for a solution and ask for help.
  As soon as the user recognises the problem, they need to reach out to people who can help. It is important to have a trusted, support group, which may comprise friends, professional caregivers and family members. It might be important to avoid friends who justify drinking and trivialise your insight, even if they are well-meaning.
• Decision: This is a vital and crucial point where the user decides whether to attempt change or continue using the substance. Many times, they might decide to continue until, one day, they change their mind about it. 
• Action: The point of motivation where the user attempts to change. At this turnaround point, it is important to keep the motivation up even if the attempt fails. One needs to be patient and gentle with themselves. Perseverance and determination are key. Family and friends can support a great deal by helping the user to remain goal-oriented, encouraging and celebrating successes and ignoring the ill effects of initial withdrawal symptoms.
• Maintenance: A stage of maintenance sounds easy as the physical dependency is tackled already. Although it’s time to maintain the gain made and focus on rebuilding a life, many times, if the motivation drops, one might relapse. Again, a support group can be a very good resource. It is also important to keep busy and have an active social life. Avoiding ‘risky’ groups who will encourage drinking is crucial. The user might have to rehearse what to say when offered a drink, to deal with awkwardness. 
• Relapse: A return to the previous behaviour doesn’t mean all is lost. There is always a possibility of gaining useful strategies to extend the maintenance period on the user’s next attempt. A relapse is also a stage on the path of recovery if one is aware and motivated. 

De-addiction is quite possible if the user chooses a healthy and safer lifestyle. Like any change, it requires determination, self-compassion and patience. Professional help from a psychiatrist and/or a therapist, to deal with withdrawal symptoms, may be needed on the path to recovery.

----------------------------

-Dr Sangbarta Chattopadhyay and Dr Namita Bhuta

are medical practitioners and practising psychotherapists. They conduct individual and group therapy sessions

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Q n A: Teen Daze: T2 (The telegraph) Article dated 7th Oct'2018

Q. Of late my daughter, who is in Class VIII, has become a compulsive liar. She lies even about basic things, like what she had for lunch. Is this a psychological condition or a passing phase?

Ans:

When a child learns to lie it means they are learning to use their imagination to influence their reality. However, for a girl in Class VIII this is not normal. 

Communication is the key to solving problems, so sit her down and talk to her. Ask her about what’s going on in her life and why she is lying. There may be some stressors that she may have been facing, which is leading her to behave in this manner. Also, is she just lying to you or to everyone? If she is lying to you then you may need to change some aspects of your interaction with her. Explain clearly what is non-negotiable for you. Be firm. Angry outbursts often have a counter-productive effect on children with behavioural problems.

You may need to reiterate that lying is not acceptable. However, when you tell her that lying is not right, you have to be flexible to be able to deal with honesty. You need to be able to acknowledge and reward her each time she chooses to be honest instead of lying. If you think that the problem is getting out of hand, you can also take help of a counsellor. The counsellor should not only be able to help your daughter but will also be able to tell you what’s happening to her and help you interact better with her.

Q.I have a 17-year-old son who dropped out of college. He is now doing his graduation through distance learning. The problem is, he refuses to go out of the house and do anything. There are days when he doesn’t even get up from bed all day. He doesn’t like interacting with anyone. We have not been able to persuade him to see a counsellor. Please suggest what to do. 

Ans:

This indeed is a tricky situation. The whole interaction depends on your shared dynamics. First, what led him to drop out of college? Maybe that is still the reason he is behaving the way he is. Be open and ask him if there is something that is going on and he’d like to share. Explain to him that you are very concerned. 

Encourage him to talk to you without nagging or prodding him. If he trusts you enough, perhaps, he will open up to you eventually. When he does, do not try to tell him what he should do or should not do or offer solutions and advice immediately. Just listen to him and ask him what he would like to do, so that he does not go on feeling the way he is. 

Reaffirm that you want him to enjoy life, go out and socialise and if he doesn’t, it may not be healthy. If he denies there is anything wrong, then encourage him to join in activities with you. Go for walks or to the gym together. If his mood and behaviour stay the same, then take him to a psychiatrist or a psychotherapist saying that as one goes for a medical check-up this is also to be sure that everything is all right with him.  Be firm but don’t lose your cool. You need to be tender yet persuasive to get through his resistance. 

Q.My son is an extrovert, quite a popular child in school. He is 15. Recently I have observed that he is stammering, especially at social gatherings. He is becoming very conscious of it.

Ans:

Stammering can be due to psychological stress or sometimes due to a physical issue. However, since it has just started, it is more likely to have a psychological cause. Talk to him without making him feel judged or weird about himself. Try to find out if there is something that’s bothering him. Has he been anxious of late or has there been some incidence that is bothering him? You can take him to a counsellor if he is not opening up to you. 

At times, even after one deals with the psychological components, one needs to retrain their speech to overcome the impediment. Take him to a speech therapist, who, in this case, is the most qualified to help your son. Be sensitive to what is happening to him and do not keep correcting him when he is speaking.

Q.I’ve come across a stash of ganja in my 16-year-old son’s drawer. I can’t decide if I should confront him or let it be this time and keep an eye out in future? 

Ans:

Ignoring a problem may save you an uncomfortable confrontation but is not helpful in the long run. Letting it be doesn’t address the problem. If it is okay with you, we recommend that you tell him what you’ve found in the drawer and ask him why it was with him. Hear him out patiently. Once you hear what he has to say, let him know that this is not all right with you. However, when you communicate this, do not be overemotional or angry. Communicate with him in a calm but firm manner. 

Children, as part of growing up, will push the boundaries that you have set. They test our threshold and push our limits but as parents, it is our duty to keep defining this boundary. It’s not necessary that they agree with us or see eye to eye with us on every issue but it is important that they learn to respect the limits set by us.

Tell him that if it is the first time and an experiment, you understand but you wouldn’t want this to be repeated. If he tries to argue with logic about how good it is, don’t encourage the discussion. Tell him that it’s not acceptable and as long as he is under your care, this cannot continue. You may also say that you have enough reasons to believe that weed is not good for his physical or mental health and that this is not up for discussion. 

If he says that he’ll not do it again then trust him and give him a chance to follow through on what he is promising. Be aware that in the future he might repeat the same thing and you may have to repeat the same exercise in a firmer way. Setting a boundary is often a long repetitive process, till it becomes apparent and obvious. It is important that you keep an eye on your son.

Q. My 13-year-old daughter still wets her bed at times. She has already started menstruating. How can we help her?

Ans:

Bed-wetting can happen because of various physical and psychological issues. Some children bed-wet occasionally till they are around 12 or until they start menstruating. She is not very far off the normal bell curve as yet. Around the time of menarche, it is also not uncommon to have an uncomfortable feeling around the urinary tract, which can lead to bed-wetting. Sometimes an infection in the urinary tract can cause this type of episodes.

Take her to a paediatrician first and ensure that there is no physical cause for this. If physically she is fine, first, have a friendly chat with her. There can be a lot of anxiety and awkwardness regarding the menstrual cycle, and other pubertal changes. Make her feel normal and comfortable regarding these topics. 

Explore your relationship with her. Could this be a reflection of the anxiety and restlessness she’s feeling? Is she able to express herself and her feelings to either parent without fearing judgement and trivialisation? 

A few other practical things you can try out are as follows: Restrict her fluid intake after 7pm and, throughout the day, ensure she finishes 1.5 to 2 litres of water. Make sure she goes to the washroom just before retiring to bed. It might help to restrict exciting, adrenaline rush-causing films, like horror, suspense and thriller in the evenings. If you have a fairly good idea about which part of the night she is prone to bed-wet, you can wake her up prior to that and get her to go to the toilet, for a couple of months. It might also help her to have her own bed and eventually her own room if possible. A certain degree of autonomy helps them get better autonomy over their body.

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Emotional Eating: T2 (The Telegraph) Article dated 23rd Sep'2018

The festive season is around the corner. Get-togethers and parties with friends and family are in order, and one key ingredient that we cannot ignore in that celebration is food — lots of it. While many of us are looking forward to a good feast over the five days of Durga Puja, some perhaps are already dreading the aftermath of such indulgence. 

The connection between mental health and sleep is obvious; what is not so known is that our relationship with food is linked to our mental health too. When our body is starved or undernourished, it is normal to feel irritated, angry or even depressed. At times overeating can make us feel low about ourselves and take away our usual drive. In the context of mental health, food habit is very important: A balanced diet and healthy fluid intake can help one feel better and grounded.

 

There is another side to the story. Many times we neglect food as we neglect ourselves. This could be out of simple carelessness or a deep-seated self-loathing. We may starve ourselves as punishment and may not even be aware that we are doing so. 

On the other hand, when one is feeling emotionally distressed or feeling stressed, it is also not uncommon to binge-eat. We end up using the normal act of eating food as a way to feel good. In that case, we use food as something known and comforting, something that fills up our psychological void, although for a very short period. 

Eating or staying away from food — both give us a sense of control. Our dynamics with food is far from being simple and linear.

For thousands of years, in fact, for the longest period of human evolution, our most significant survival drive has been to secure our food supply by procuring enough. When we could gather food, we were valued by our community. 

Eating, for evolutionary purposes, has an intrinsic pleasure component attached to it in our mind. We feel good when we eat well. It’s not difficult to understand why food has always been a jubilant way to celebrate and enjoy. However, our expectations and conditioned ideal of ourselves have changed over the years. Being overweight, now, has an added component of shame and injury to self-esteem. So, it is not uncommon to see some of us being in a vicious cycle of craving food in order to feel good but ending up feeling worse after binge-eating. 

Bulimia and anorexia

In the extremes of this complex and layered dynamics with food, there are pathological eating disorders which are under the purview of mental health and psychiatry. 

There is ‘Bulimia nervosa’, which is characterised by repeated episodes of binge-eating with compensatory behaviours. Here one is morbidly afraid of becoming fat, yet at the same time they cannot help but eat more than they ought to. In a typical case, a person is persistently preoccupied with eating or thoughts of eating. They have irresistible cravings followed by binges or episodes of overeating. Often immediately after that, they try to counter the fattening effect of their binges by starving themselves, intentionally inducing vomiting, or misusing over-the-counter purgatives or other drugs to reduce the fattening effect by trying to purge or by increasing body metabolism or by dulling appetite.

 

Another common disorder is ‘Anorexia nervosa’, most commonly seen in young women in which there is a marked distortion of one’s body image in the mind. Even when they are thin, they see themselves as fat and there is a pathological desire for thinness. They try various methods to keep on reducing weight, which severely damages their physical health. Because of their continuous effort to lose weight, they suffer from severe malnourishment, low body weight, anaemia and various hormonal problems. Death due to anorexia nervosa is not uncommon. Often patients resist any attempt of treatment as they lack insight into their physical health condition. 

Regularise your food habit

Both the eating disorders have severe self-image and self-esteem issues associated with them. Like any relationship, our relationship with food vastly depends on how we feel about ourselves. Feeling good about ourselves doesn’t mean that we have to feel we are perfect or that we are infallible or that we can make no mistake. Paradoxically, feeling good about ourselves means we see ourselves as we are, with our flaws and vulnerabilities with honesty but without judgement, and without any need of pretence to hide them. 

Feeling good about ourselves means that we let go of our insecurities, we are ready to improve, open to learn and are not defensive or rigid about ourselves. There is no need to stick to a particular “how I should be” image, but if need be we are ready to work towards a goal. 

We accept ourselves as always learning, growing and changing. If we don’t know how to feel comfortable with ourselves, we will always depend on something external to make us feel good about ourselves. 

Unfortunately, nothing external — whether it is parental approval, peer acceptance, love of life, success, money, fame, respect or, in this case, food — can make us feel good about ourselves. It’s us who need to see ourselves gently, softly and with a little compassion. It is up to us to let go of any conditions or yardstick for accepting and valuing ourselves, and then as a society, we need to learn to let go of this need to constantly measure people by some standards and ideals and impose these ideas. 

So try to regularise your food habit. Watch out for stress eating. Acknowledge your cravings and examine them closely. You may get never-before insights about yourself. Be mindful of the craving for food just as a strategy to feel good about yourself. Put your “I can feel good ONLY IF…” ideas under the scanner and examine those rigid conditions. 

If you want to exercise and lose weight, that is fine. But do it because you want to be healthy, rather than out of pity and shame of being your current self. Remind yourself that it is an informed choice you are making as you want to take care of yourself, nothing more, nothing less. 

Explore your relationship with yourself as you explore your relationship with food. Like every journey of self-exploration, you need to be patient and gentle with yourself.

-Dr Sangbarta Chattopadhyay and Dr Namita Bhuta 

are medical practitioners and practising psychotherapists. 

They conduct individual and group therapy sessions.

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