Forgetfulness and Memory Loss at Work

Memory loss results from disruption at any of these processes

Forgetfulness and Memory Loss 

Forgetfulness or failure to remember information, is a common complaint. All of us have at some time or the other forgotten to make that important call, to pick up some items from the store, an anniversary or birthday, or a colleague’s name. Students forget what they have “learnt” during exams. We often can’t remember where we have left our car keys, our wallet or that important document. Is it normal? And more importantly; when do we need to seek help?

Forgetfulness or memory loss and difficulty concentrating are common symptoms of mental health disorders. This is specially so in depression, anxiety disorders, ADHD (Attention Deficit Hyperactivity Disorder), and dementias as shown in the examples below.

A young working professional seeks help for increased forgetfulness and poor ability to focus at work. Further probing reveals decreased interest in doing things at work and home. She is also irritable, depressed and her sleep is disturbed. These symptoms of low mood can exist in the background of memory loss and problems with focus.

A student during exams has high anxiety causing memory loss. She cannot recall the answer to a certain question. She gets nervous. This causes her to make mistakes in the next question. She tends to panic; fail to recall what she studied. This vicious cycle is common in anxiety disorders and can manifest as problems with concentration, memory and forgetfulness.

An older person does not just forget the name of his neighbour (something that may happen to any of us); but also who she is. He has problems using money, and with shopping. Difficulties at work manifest towards the end of the career. Dementias affect the aged; cause memory loss and affect the context of the memory. 

A young professional has problems organising and completing projects at work. There may be a history of attention and academic problems in school. Working memory gaps are common in this group. ADHD is a common cause of this problem in adults.

Memory Processing in the Brain

To understand further, it helps to know in brief how memory works. It is a 3 stage process

Encoding

The stage when sounds, images and other sensations are given meaning is called encoding. Sensations are coded electrically for access by other brain areas. (We hear a catchy song from a new movie).

Storage

The process of association or tagging the input with other bits of data to make it persist. The song thus gets stored in our long term memory. Initially, the song remains for a very short while. At this point it is in our working or short term memory. It is encoded. However, we forget the song as the next scene unfolds on screen. The song is repeated at the end of the movie; someone hums the song as we leave the hall. The visuals of the song, and the feelings evoked, the fact that it was a famous actor, then reinforce the memory and makes it persist.

Retrieval

When we need to use this stored data, the brain fishes it out from its long term memory. The more the associations or tags we formed earlier, the more easily the brain can access the information.

Problems in memory can therefore occur at any of these stages. Many of these occur at the stage of encoding because we are simply not paying attention; and many other distractions are vying for our focus at the same time. (e.g checking our FB messages while studying). The brain does not multi-task, it can only do one thing at a time.

Repetition, rehearsal and organisation help in fixing and storage of long term memory. The more widespread and elaborate the connections, and the more data available about an input, the more the connections formed by the brain, and the easier it is for the brain to retrieve the information when required. Many cases of forgetting are due to retrieval failures. The information is there in long term memory but we are unable to access it. This is why we can recall certain things at a later date.

Depression affects memory in many ways. Being unable to concentrate is a symptom of depression. Repeated depressive thoughts also block the learning process through distraction. This affects the stage of encoding. Disturbed sleep which is a common symptom in depression hampers fixing into long term memory.
Forgetfulness is common in ADHD of adults. ADHD lowers the power to focus. The person is easily distracted. The attention span is reduced. This impairs short term or working memory. ADHD persists in up to 40% of aduts.
Anxiety gives rise to pointless thoughts (“my father will be so angry if I don't crack this exam”) which frustrates attempts to retrieve the matter learned. The anxiety provoking thoughts distract from the text which is being studied and impedes the  encoding process.
In dementia there is destruction and loss of brain cells. Dementia blocks all stages of the memory and learning process. The process is not reversible.

Forgetfulness and Memory Loss – when to seek help?

• When it affects our work, or the quality of our work
• When the failure to learn and recall affects our daily activities and functioning
• When there are also problems including sleep, appetite, inter-personal or behaviour changes.
• When it is strange - leaving keys in the fridge 
• When it can harm - often leaving cooking burner on, leaving doors unlocked at night

In normal forgetfulness, the person may recall the memory when some cues are given. The memories were encoded, they just needed some reminder to access them. In clinical disorders resulting in memory loss the memories were never laid down in the first place, or the storage structures in the brain are destroyed. Access to these memories may not be possible. 

References

1. Brydges CR, Ozolnieks KL, Roberts G. Working memory - not processing speed - mediates fluid intelligence deficits associated with attention deficit/hyperactivity disorder symptoms. J Neuropsychol. 2015 Dec 31. doi: 10.1111/jnp.12096. [Epub ahead of print]

OCD – Obsessive Compulsive Disorder

What is OCD?

OCD – Obsessive compulsive disorder – is a severe type of anxiety disorder involving obsessions and compulsions that affects the day-to-day functioning of a person.

What are obsessions?

Obsessions are thoughts, images, or impulses that occur over and over again; cause severe anxiety; feel outside the person’s control and affect the day to day functioning of a person.

What obsessions are not

Most of us know what it is like to be preoccupied with a thought, idea or even a person sometimes. These are not obsessions. They often give pleasure, usually pass off soon and do not affect our daily routine or work. Certain types of personality are also linked to a fastidious concern for details and “correctness”. However, this is not associated with anxiety and hence not an obsession.

What are compulsions?

Compulsions are repetitive behaviours aimed at decreasing the anxiety associated with the obsessions.

What compulsions are not

Not all repetitive behaviours are compulsions. Bedtime rituals, religious practices, learning new skills involve repeating an activity. Behaviours also depend on the condition and situations of a person’s life. Arranging wares back on shelves are a normal part of a shop assistant’s work and are not compulsions.

Types of obsessions and compulsions in OCD

Contamination

Contamination is among the commonest of obsessions. There is a fear of dirt, germs, waste, toxins or body secretions. A person is afraid of getting an illness or spreading it. Sometimes he/she may just have feeling of “not being clean”. Touching an “unclean” object or even being near it may cause extreme anxiety. This is only eased by repeated washing and cleaning. Often the washing has to be done in a particular way or be repeated many times before he/ she feels clean again. The person also goes through great trouble to avoid or prevent contact with the contaminants. In time, they may become house-bound and force family members to also follow these cleaning rituals.

Pathological doubt

A person worries all the time that he will cause some harm to himself, his family or others due to his own carelessness. ‘Did I lock the door?’; ‘Did I switch off the lights?’; ‘Is the gas turned off?’ This constant questioning, doubt and responsibility leads to a compulsion to check and recheck. He may need to check the gas switch and the locks so many times that he gets late for work or is unable to sleep at night. Though he knows that the task is complete, his compulsive, repetitive behaviour continues.

Perfectionism and need for symmetry

A person has a need to do or arrange things “perfectly”. Items on his desk have to be placed in a certain way; or his shoes may need to be stacked in an exact order. He may need to perform certain actions or behaviours a certain number of times or in a precise order to have a sense of ‘completeness’. A child with OCD may worry that his homework is ‘not quite right’ and spend hours checking, erasing and re-doing his work because his T’s are not crossed properly. A person at work may feel that the day will go badly for him if he does not take a certain number of steps (say in multiples of seven) to his desk.

Concern about illness and disease

A person may have an irrational fear of developing a serious or incurable illness-usually HIV, heart disease or cancer. He may consult doctors and visit hospitals repeatedly. Despite normal medical reports and reassurance he will get investigations done again and again.

Distressing sexual thoughts and images

'Sinful' religious images are other common obsessions. This specially occurs near religious places or during religious rites and rituals. He may feel intense guilt and avoid such places or services in the future.

OCD Treatment

Treatment of OCD consists of cognitive behaviour therapy (CBT) and medication. OCD treatment is best done as early as possible, as chronic OCD can affect daily life, work and relationships. CBT is essential for all patients with OCD. CBT tackles the obsessive thoughts [Cognitions-C]; the compulsive behaviours [B] in a methodical way [Therapy-T]. CBT by itself can reduce symptoms and delay or prevent relapses.

OCD medication may be required when symptoms are moderate or severe. Medication for obsessive compulsive disorder is usually combined with CBT. The outcome of therapy also depends on family support; and the patient’s own insight, motivation and readiness for change.

ADHD and Me

Hi. I’m Jai. I’m 8 years old. This is my story. My doctor says I have an illness. I don’t feel sick. But I do know that grown-ups around me are annoyed with me most of the time. I’m constantly being told, “sit still’’, “stop dreaming”, “pay attention”. I can’t seem to be able to do just that.

In class, I seem to lose track of what the teacher says. I try to listen, I really do. I start doing what she says, then I notice the insect fluttering on the window pane, I see the boy in the row ahead tapping his fingers on the desk, the office boy walking down the corridor and the sound of laughter from the next classroom. I don’t realise I have left my seat till teacher tells me “Jai, return to your seat”.

My parents are frequently called to school to meet my class teacher. They are unhappy with my marks. They think I’m careless and lazy because I take all evening to do my homework. I tell my mother that I try hard. I feel sad and frustrated that she doesn’t understand or believe me. Some of the other children make fun of me specially when I can’t answer in class. Mostly, I haven’t heard the question. They don’t like to play with me as I get excited and can’t wait for my turn.

Things changed about 6 months back. My parents took me to a special doctor. The doctor seemed to understand that I was not being naughty or disobedient. He talked to me, looked at my exercise books and listened to my parents. He told my parents that I had an illness, ADHD. I needed medicines for treatment of ADHD to improve my focus and concentration. I also need structure and routine in my life. It was such a relief to know it was not my fault.

A lady at the doctor’s clinic gave me some puzzles and games to do. I liked her; she spoke slowly and clearly. She explained things one at a time and did not mind repeating herself when I did not get her the first time. She helped us draw up a time-table - we had such fun doing that because she made time for everything I want to do. Now I have a study time, a play time, TV time, all clearly written in the big chart I helped to make. It reminds me of what I have to do and gives me enough time to prepare for it. Mother says I sit quietly for longer periods. Teacher says I pay more attention and don’t disturb other kids in class. She is more patient with me too.

Understanding ADHD and Helping Me

Doctor says there are many children like me. Here’s what you can do to help me and others like me.

• Help me focus. Make sure I’ve heard you and understood what you want me to do.
• I sometimes don’t realise I’ve left my seat. Please remind me to stop and think.
• I need structure and routine in my life.
• I need to know what comes next.
• Please give me time to adjust to any changes in my schedule.
• Please let me learn at my own pace, I get confused and make mistakes when you ask me to hurry up.
• Please give me instructions one step at a time. Make me repeat them.
• Please give me short work periods and small goals to start with.
• Please give me immediate feedback; did I do things the right way?
• Do give me praise even if I succeed only partially. Please don’t wait till I’m perfect.
• Don’t always find fault with me. Please praise me and reward me when I do something well.

Thank you for being patient with me.

Dealing with Grief

Dealing with grief is a process of acceptance

Grief is the response to losing someone to death. All of us understand that death and loss of a loved one is a part of life. However, the reality of death often leads to feelings of shock, sadness and confusion. Acute grief occurs in the immediate aftermath of the loss. It is intensely painful characterised by sadness, crying, constant thoughts of the deceased, disturbed sleep, appetite and disinterest in one’s own self and others. In a majority of cases, this is followed by integrated or abiding grief in which memories of the loved one mingle with sadness and longing but it does not persistently occupy the mind or disrupt normal day-to day activities.

“Well, everyone can master a grief but he that has it.”

William Shakespeare. Much Ado About Nothing. III.ii.25

Loss through death affects each of us differently. How one feels depends on the nature and circumstances of the loss, one’s beliefs and religion, age, relationships and one’s own physical and mental health. A sudden or violent death, death of a child or loss of a long-time spouse are always more difficult to accept. If the relationship with the departed person was difficult, the grief is more complicated and may take more time to work through.

Stages of grief

5 stages of the grieving process has been described. The stages do not necessarily come in order, nor are all the stages experienced by every person. One may return or go through one or the other stage several times before acceptance of the loss.Grief is a process and not just a state. During the process of grieving and bereavement a person may experience many emotions during the course of bereavement- helplessness, anger, sadness, denial, despair and yearning are common.

Denial

The first stage is the stage of denial ('It's not true’; ‘There must be some mistake.’) This is a normal defence mechanism which helps to cushion the immediate shock.

Anger

Once the reality sinks in, the pain is often redirected and expressed as anger. ‘Why me?’; ‘Its not fair’; ‘How can this happen to me’; are the common reactions in this phase. Anger may be directed towards objects, strangers, the doctors or family members, God; or even towards the deceased person- ‘How could you leave me alone?’

Bargaining

A promise of good behaviour or an attempt to strike a bargain (‘I will always listen to you’, ‘I will never worry you again,)’ is often the reaction at this stage.

Depression

Sadness and regret are mingled and one may often say ‘There is no point in life; - I may as well die too’.

Acceptance

At this stage emotions are stable and calm.

Strategies for dealing with grief 

Though each one copes differently, the following strategies may help you cope with your feelings and come to terms with your loss.

1. Talking about your loss: It may be difficult for you initially- but in time it helps to talk about your loss and your feelings with a trusted family member or friend or a counsellor.
2. Accepting your feelings : The anger, guilt, helplessness you may feel are normal and part of the grieving process. There is no guilt or shame in accepting them; and it paves the way for healing.
3. Taking care of yourself : Establishing a routine with regular meals, exercise and adequate rest is important for your physical and mental health.
4. Reaching out to others: Working with people less fortunate, or carrying on the legacy of the deceased (teaching, helping in the community) helps to give meaning to life.

When to seek professional help

• Though different people take different times, intense and persistent grief continuing over a period of six months may require professional help.
• Loss due to suicide is among the most difficult to bear. In such cases, counselling during the first weeks is both advisable and beneficial.
• Inability to cope with or resume daily life or work activities, intense sorrow or pain which does not subside with time, inability to maintain or build relationships are indications to consult a mental health specialist.

Recovery from grief is a highly individual process. Each individual works through grief on their own with time, using their own personal ways of coping. Acceptance, rationalisation, humour, distraction, prayer, avoidance of reminders are some of the many ways in which people cope. Social support and healthy habits contribute to recovery which may take a few months or even a year.

Mental Illness Myths and the Media

Media portrayals of mental illness propagate prevailing myths and increase associated stigma.

Media and Stigma

Mass media – TV, cinema and newspaper – are the primary source of mental health information for the general public. The mentally ill are usually shown in poor light; and images of unkempt, violent and dangerous men predominate. This greatly affects the public’s view of the mentally ill, causing them to fear, avoid or discriminate against people with mental illness. This is even true for TV programs and stories for children. From an early age mental illness is seen as less desirable than other illnesses.

Negative images such as these affect those with mental illness, damaging their confidence and self-esteem. It makes them more isolated and withdrawn and they are more likely to stay away from therapy. In one study, as many as 50% of patients reported that a negative media portrayal had a negative impact on their illness, with 34% saying that it directly led to an increase in depression and anxiety.

Government policies are also affected by prejudiced media  portrayals of mental illness. Since people with mental illness are seen as anti-social, prone to violence and a potential danger to society, government policies tend to restrict and isolate instead of being more broad-based.

5 Media Myths on Mental Illness

Myth 1 – People with mental illness are violent and unstable

Almost two-thirds of all stories about the mentally ill in both the news and entertainment media focus on violence. While it can happen, most violent crimes are in fact committed by people without mental illness. But a crime committed by a person with mental illness is blown out of proportion by the media instead of being seen as something rare and out of the ordinary. Studies in fact indicate that the mentally ill are more likely to be victims of violence rather than the offenders.

Myth 2 – They do not get better and treatment is ineffective

The truth is that even severe psychiatric disorders can be treated effectively and people can lead normal lives at work, at home and in the community. While treatment of psychiatric disorders has evolved, the media continues to show outdated practices. This highly inaccurate portrayal often prevents both the mentally ill and their families from seeking treatment.

Myth 3 – Mental health professionals are evil, mentally unstable, or unethical

The diagnosis and treatment of mental health disorders requires patience, skill and comprehensive evaluation. Mental health care professionals spend years in acquiring the qualifications and training required. Yet media portrayals undermine the integrity of these professionals. This further discourages people who are already hesitant to seek treatment.

Myth 4 – Teenagers with mental illness are just going through a phase

This encourages parents of teenagers to ignore symptoms as something that teenagers will outgrow. Movie portrayals of the teenager as a ‘rebellious free spirit’ further glamorises it in the eyes of the teen. The truth is that the onset of many serious psychiatric illnesses is in adolescence or early adulthood and early treatment offers the best outcomes.

Myth 5 – There is a genius behind every mental illness

While some people with mental illness are undoubtedly gifted, a vast majority of people with mental illness are ordinary individuals who want to get on with their lives and work productively. This caution is specially true for parents of children and adolescents; who view the role of the therapist as one who will unlock the hidden genius in their child. These unrealistic expectations put unnecessary pressure on children, often leading to a relapse; or a loss of faith in the treating clinician.

Sympathetic but exaggerated media portrayals may do more harm than good. Simple achievements need to be highlighted just as much. As an example, while the media annually highlights the success of children with physical disabilities in the board exams, yet no story deals with the successes of those with children struggling against schizophrenia and other mental illnesses. Sharing such stories will increase awareness among the public about how regular treatment and supportive therapy can help a child return to normal functioning.

The media’s defence is that the public is not interested in watching something dull and boring, and that they need to dramatize and exaggerate portrayals. However, authentic stories of mental illness have heartbreak, drama, humour and everything in between. Sensitive and accurate portrayals by the media will go a long way in removing the stigma and isolation associated with mental illness, bring the ill into the ambit of treatment, and improve their integration into society. This level of reporting can only be  reached with considerable effort. We need to understand the media are geared towards sensationalism, and the facts regarding mental illness and the people affected by them are more nuanced.

References

1. Dara Roth Edney. Mass media and mental illness: a literature review. Canadian Mental Health Association. 2004. Accessed 21-Sep-2015
2. Murphy NA1, Fatoye F, Wibberley C. The changing face of newspaper representations of the mentally ill. J Ment Health. 2013 Jun;22(3):271-82. doi: 10.3109/09638237.2012.734660. Epub 2013 Jan 16.
   
3. Patrick W Corrigan and Amy C Watson. Understanding the impact of stigma on people with mental illness. World Psychiatry. 2002 Feb; 1(1): 16–20.

Aptitude Testing & Work Choice – evolutionary perspective

Aptitude testing for responsible work choice

Aptitude testing for career guidance has existed only since the 1930s. Aptitude testing was not needed until work choice became freely available about 200 years ago. Before that a person had no choice in his field of work. People trained for whatever their parents did. If they had access to patronage or money they could take up a profession. Now, with the concept of Right to Education, governments seek to extend career choice to all socioeconomic strata. With this new privilege of work choice comes the responsibility of choosing wisely. Aptitude testing takes into account abilities, personality, intelligence and motivation for making a career choice.

Work choice

a brief history

For 10,000 years we did the work our parents did. In the initial millennia of mankind’s existence, work was necessary for survival. Primitive man was a hunter-gatherer to fulfil the biological need for food. As the first human settlements evolved man became a cultivator. He learnt to fashion tools, and make storage vessels. This gave rise to occupations like farming, pottery, and weaving. Densely populated centres evolved, as in Jericho. Families specialised in different trades. Son followed father in the family occupation. Skills were learnt and passed on from one generation to the next. Social hierarchies were formed loosely based on occupation. This often comprised a ruling class of administrators, the merchants, and then the labourers.

In India, occupation formed the initial basis of the caste system. Did an individual have the freedom to choose his profession or trade? The Mahabharat tells us the story of Eklavya, a tribal who wished to become an archer. Drona, the greatest teacher of the time, refuses to take him on. Eklavya through an extraordinary feat of dedication and disciplined study becomes a better archer than Prince Arjuna. However, though he had undoubted skill, aptitude and interest; he was not allowed to transgress the rules of society. Martial art was reserved for the warrior caste – the Kshatriyas – and Ekalavya was punished for aspiring to the same.

5000 years ago the first script evolved. Writing of language in a cuneiform script developed in Mesopotamia (Sumer) in 3200BCE. This heralded a radical change in the way knowledge was communicated and disseminated. Education was imparted informally to groups of children until the age of 13-14yrs. Thereafter these usually followed in the profession of their fathers.

2000 years ago we see the first example of career screening. The Jews selected brighter boys to continue studies as disciples of the rabbi. They would then become masters and rabbis themselves. However, the individual himself had no choice in the matter.

1000 years ago the elite had access to education through universities. The University of al-Qarawiyyin in Fes, Morocco, is the oldest existing, continually operating and the first degree awarding educational institution in the world. An important development in choice of education is the concept of academic freedom. This concept originated in University of Bologna (est 1088 CE, still extant) which was the first to guarantee students freedom in the interests of education. The university also gave students a choice in the curriculum to be studied. However, university education was still for a privileged few and limited to a career in the church or as a professional (law or medicine).

500 years ago formal apprenticeship was first originated. A young person usually between the ages of 10-15yrs was formally bound to a master craftsman for 3-7 years. A supply of labour in a particular trade and a certain standard was thus ensured. In the early 17th century children of paupers and vagrants were put under compulsory apprenticeship – refusal could lead to imprisonment. Later children of the gentry apprenticed to merchants, manufacturers, doctors and lawyers. By the 18th century, apprenticeship existed in every level of society except the highest. However even then, the boy himself had little or no say in his career. Career was dictated by the financial situation of the father and availability of a master. The poor had no choice.

200 years ago educational reforms were initiated when the UK National Education League began its campaign for free, compulsory and non-religious education for all children in the 1870s. Students can now take up any of a whole gamut of ever increasing fields. There is now a surfeit of careers to choose from. Students are now forced to choose between subjects when they transition from secondary school to high school. From an absence of choice they are confronted with an array of career choices. It is now important to choose a career in which the individual has a high chance of success and job satisfaction.

80 years ago aptitude testing for job screening and career guidance was developed by the US Employment Service to improve the fit between the individual and the job. Many other aptitude tests have been developed since. Aptitude tests are used in career guidance to measure different abilities and match them with the requirements of various work fields. Given the importance of work in relation to individual well-being, aptitude testing is now a basic tools in job selection. Aptitude testing combined with assessments of soft skills like personality and work style provides comprehensive data for individual career guidance. However, even today, society at large believes that career decisions happen ‘naturally’. Though so much has changed – higher education is easily available, social and gender restrictions have eased and we can choose to do what we are good at – many of us still follow the path of least resistance and do just as our forefathers did 10,000 years ago.

References

1. Kathleen Mary Kenyon. Encyclopedia Bratannica. Jericho. http://www.britannica.com/EBchecked/topic/302707/Jericho Accessed 21-Apr-2015
2. The History of Education. Ed Robert Guisepi. http://history-world.org/history_of_education.htm Accessed 21-Apr-2015
3. Wikipedia. University of al-Qarawiyyin. http://en.wikipedia.org/wiki/University_of_al-Qarawiyyin . Accessed 02-Apr-2015
4. Wikipedia. University of Bologna. http://en.wikipedia.org/wiki/University_of_Bologna Accessed 06-Apr-15
5. Family Search. Apprenticeship in England. https://familysearch.org/learn/wiki/en/Apprenticeship_in_England Accessed 08-Apr-2015
6. The 1870 Education Act. http://www.parliament.uk/about/living-heritage/transformingsociety/livinglearning/school/overview/1870educationact/ Accessed 09-Apr-2015
7. John F. Reeves. Aptitude Assessment for Career and Educational Guidance. http://www.theworksuite.com/id15.html Accessed 08-Apr-2015

Treat schizophrenia even if your teenager refuses

Treat schizophrenia as you would any other serious medical illness in your teenager

"My 18yr son is aggressive, hearing voices, and not sleeping."

"Since the last two months he is not attending college. He talks to himself in his room and is not going out with his friends."

"He feels he is being tracked through the TV and yesterday assaulted his mother when she put it on."

"We tried taking him to our doctor but he refuses saying there is nothing wrong with him."

This is a common introduction to the more severely ill teenagers presenting at Pathfinder Clinic.

Why teenagers with schizophrenia refuse to see a psychiatrist 

Teenagers refuse to see a psychiatrist for illness related and personal reasons

Illness related factors

Schizophrenia is a brain disease. Your teenager has difficulties recognising his own symptoms. In schizophrenia there are changes in brain structure, chemistry and functioning. The individual is unable to recognise the problems in thinking, and perception. They hear voices threatening harm to themselves and their families. The  same voices command them not to see the doctor. Reality is distorted and they are unable to correct it through feedback from others. Your teenager perceives this distorted internal image of the world as the real one. They attribute their problems to the external environment. Technically this is termed as a lack of insight. The disease process prevents them from seeing these distortions as an illness. Because of the illness they refuse to see the doctor or take medications.

Personal reasons

Many adolescents refuse or drop out of treatment due to stigma of mental illness. They have high levels of self-stigma. They believe that schizophrenia is a result of a laziness, weakness or incompetence. This belief is reinforced by parents, society and friends who give advice like

"You really need to get your act together"

or

"You better snap out of it or people will think you’re crazy."

So in their mind your adolescent rationalises the problems as being outside themselves

 – "You won’t let me do what I want and now you are trying to label me as crazy, you need therapy, you go to the doctor."

Taking medication is seen as an acknowledgement of their own failure. To the teenager denial of illness and rejection of medical care appears more acceptable.

Parents

Parents of an adolescent with schizophrenia are working through their own public stigma. They may see schizophrenia as occurring due to faulty parenting and lack of control. They struggle against the stereotype of their son or daughter as incompetent and requiring supervision. They mistakenly fear they will need to protect the teenager from being labelled and shunned socially. In their mind going to the doctor will accelerate the stigmatising process. So the symptoms are ignored or controlled to the greatest extent possible. This may include keeping the teenager out of school or college for months until the exams are due. When the illness makes life unbearable at home they seek medical help. This is often in an atmosphere of shame and a sense of failure. Many families are unable to overcome these prejudices. They delay treatment for decades until they realise there may be no one to care for their son or daughter when they are gone.

The advisers and 'well wishers' of teenagers and their families are a third set of influencers whose lack of specific knowledge can reinforce self-stigma. Statements like

"Send him to us for a few weeks and he’ll be OK"

and

"Avoid ‘psychiatric’ medications because they are addictive"

or

"Medicines will cause permanent damage"

add further obstacles to the path to standard and adequate treatment.

When the adolescent is functioning well on the medication these misinformed 'well wishers' are the ones who advise

"What do you need the medicine for? I can see nothing wrong with you"

and set the stage for relapse and refusal to meet with the doctor when the illness relapses

 – "Chacha said there is nothing wrong with me, why are you trying to label me?"

What to do?

Refusing help for schizophrenia is not an option.

• We have already seen what can be done to get a reluctant patient to see the psychiatrist. 
• However, for schizophrenia, more urgent measures may be required.  Involuntary admission to a mental health facility for initiation of treatment may be needed. This is especially so when the adolescent is violent, suicidal, using addictive substances, or repeatedly missing from home. Involuntary admission helps in the same way that it helps get your adolescent admitted to hospital if they had dengue fever even if they did not want it. There are provisions in the Mental Health Act to ensure this is done in safety with respect for your adolescent’s rights. After they receive treatment and brain function returns to normal they will thank you. For they will be relieved from the terrors of reality distortions and desperation of suicide thoughts. 
• Once treatment is initiated ensure they take medications every day as prescribed. Don’t take on any other responsibility regarding the medication. Leave that as a dialogue between your teenager and their psychiatrist. Just make sure it continues to happen.

Why teenagers with schizophrenia must get treatment even if  they don't want it

Brain cell death

Schizophrenia is associated with death of brain cells and shrinking of brain volume. The longer the duration of untreated symptoms the greater the toxic “dose” of delusions and hallucinations delivered to the developing adolescent brain. Delusions and hallucinations are merely the tip of the iceberg – underlying brain changes have already set in. When treatments are delayed for more than a week the illness becomes even more severe and impairing. The person is less likely to recover, and is at greater risk for addiction to cannabis and other substances. These negative changes related to delay persist even after a year when treatment is finally started.

Academic impact

Schizophrenia symptoms make it difficult for the teenager to attend school or college. There is difficulty focusing. In the earliest stages there is an accelerated deterioration in academic performance. This usually takes place in late adolescence. Research suggests this may be a marker for schizophrenia onset. Deteriorating academic performance is seen even before social or other symptoms to appear. Unfortunately this is the very stage of life at which academic performance is critical and shapes career choices for adult employment. Many formerly brilliant students are anguished when they are suddenly struggling to even pass their exams. In fact studies have shown schizophrenia is more likely to affect those who excel at academics, making it all the more devastating. Missing or failing in board exams has an adverse impact that timely treatment can obviate.

References

1. Compton MT, Gordon TL, Weiss PS, Walker EF. The "doses" of initial, untreated hallucinations and delusions: a proof-of-concept study of enhanced predictors of first-episode symptomatology and functioning relative to duration of untreated psychosis. J Clin Psychiatry. 2011 Nov;72(11):1487-93. doi: 10.4088/JCP.09m05841yel. Epub 2011 Jan 11.
2. Fung KM, Tsang HW, Corrigan PW. Self-stigma of people with schizophrenia as predictor of their adherence to psychosocial treatment. Psychiatr Rehabil J. 2008 Fall;32(2):95-104. doi: 10.2975/32.2.2008.95.104.
3. Guo X, Li J, Wei Q, Fan X, Kennedy DN, Shen Y, Chen H, Zhao J. Duration of untreated psychosis is associated with temporal and occipitotemporal gray matter volume decrease in treatment naïve schizophrenia. PLoS One. 2013 Dec 31;8(12):e83679. doi: 10.1371/journal.pone.0083679. eCollection 2013.
4. Harrigan SM, McGorry PD, Krstev H. Does treatment delay in first-episode psychosis really matter? Psychol Med. 2003 Jan;33(1):97-110.
5. Karlsson JL. Psychosis and academic performance. Br J Psychiatry. 2004 Apr;184:327-9.
6. Strauss GP1, Allen DN, Miski P, Buchanan RW, Kirkpatrick B, Carpenter WT Jr. Differential patterns of premorbid social and academic deterioration in deficit and nondeficit schizophrenia. Schizophr Res. 2012 Mar;135(1-3):134-8. doi: 10.1016/j.schres.2011.11.007. Epub 2011 Nov 29.
7. Penttilä M, Jääskeläinen E, Haapea M, Tanskanen P, Veijola J, Ridler K, Murray GK, Barnes A, Jones PB, Isohanni M, Koponen H, Miettunen J. Association between duration of untreated psychosis and brain morphology in schizophrenia within the Northern Finland 1966 Birth Cohort.Schizophr Res. 2010 Nov;123(2-3):145-52. doi: 10.1016/j.schres.2010.08.016. Epub 2010 Sep 15.

Want more references? View my collection, "Teenagers with schizophrenia need treatment even if they don't want it" from PubMed

Is your ADHD teenager ready for hostel?

ADHD teens with appropriate life skills can live independently

Does your teenager with ADHD have the life skills to survive in hostel? She did well in her 12th board exams and scored high in the CET. To attend the engineering college of her choice she has to move from home to a hostel in another city. Given her difficulty organising her daily schedule, would she be better off doing the same subjects at the local engineering college? The answer would depend on her personality and the life skills she has acquired.

ADHD teenager personality types

Teenagers with ADHD are of 3 character types: the optimistic, the terrified and the lost. They are placed into these categories depending on their productivity and anxiety (either too much or too little).

• The optimistic teen does not worry. He is excited about the independence that college life will bring, but may not realise that freedom comes with responsibilities (financial, social and personal). If he's still disorganised at home he will be more so in hostel where the distractions are multiple and there is no guiding hand.
• The terrified teen is intensely anxious. She needs reassurance and help in planning the future step by step. If she still waits for you to clear her way round a difficulty she will hesitate to seek help when she is in hostel.
• The lost teen displays a lack of energy and positive view towards life. He is easily depressed and defeated. He has to be repeatedly reminded and encouraged to do what needs to be done. If you still have to push him to get work done he's unlikely to function well from hostel.

Life skills for teenagers with ADHD

ADHD hinders development of the  coping and self-management component of life skills due to inattention and impulsivity. Adolescents with ADHD need to focus on three aspects of this component for transition to independent living away from home.

1. Motivation is first – there has to be the will to achieve. The ADHD teen needs clear goals and has to evaluate them objectively — are they achievable? Clear short-term, mid-term and long term goals are necessary – persistence is required. If a particular course is not available in the local colleges, can he take the initiative to locate an alumnus from school who is pursuing the same elsewhere? He must make a list of pros and cons  – then make a choice – and not procrastinate.
   
2. Time management is a big challenge for most students with ADHD. They should not take on too much initially. ADD adolescents should concentrate on their classes, keep track of assignments, and organize daily notes. They should use a planner to schedule daily activities. A large calendar on the wall for upcoming assignments, project submissions, and exam dates is a big help. The teenager with ADHD needs to get to know her limits, then push them a little at a time to see if more is achievable. She should set some daily routines – get up at the same time everyday, have healthy, regular meals (this is often neglected when staying away from home), and do the laundry.
   Attendance at classes is non-negotiable (all colleges insist on a minimum attendance). The teenager with ADHD must ensure she takes her medication on time and follow-up regularly for refills. When taking a break she should do something that has a limited time span. For example she could read a few pages of a book, watch TV for 15 minutes, or chat with a friend for 10 min.  She must make time for the additional administrative tasks college entails: paying her college fees, creating and sticking to a budget, making time to go to the ATM. These tasks should be entered in the weekly planner.
3. Self-understanding and awareness of strengths and challenges is the key to making intelligent choices. The ADHD adolescent should not hesitate to seek help, from teachers, friends and the counsellor specially if falling back in his schedule. Strategies for learning and study skills training with the counsellor are helpful.

The ADD teenager, like any other adolescent, is transitioning from dependence on the family to increasing adult independence. The life skills he acquires would dictate the ease of this transition. Teenagers with ADHD who have acquired the necessary life skills would be better able to cope with the transition from home to hostel without adversely affecting academic performance.

References

1. Economic and Social Commission for Asia and the Pacific. Life Skills Training Guide for Young People. United Nations. 2003 (Accessed 08-Nov-2014)
2. ADDitude. The Real Whirled: 8 Essential Life Skills for ADHD Teens. Accessed 25-Nov-14.

Work style and employee selection

Use work style assessment to hire the best - and avoid the rest

Work style is a combination of personality traits that are relevant and specific to the workplace. Work style is highly predictive of job performance and employee behaviour. Differences in working style explain how people with similar knowledge, ability, goals, and desire to perform differ in the actual performance of their jobs. In today's complex business environment talent selection is critical and is at the top of a manager's list of priorities. Selecting employees for job-relevant personality traits improves job performance in the organisation.

Work style and job performance

Individuals differ in job performance despite having similar task abilities. The personality traits the individual brings to the organization along with abilities, interests, education, and experience, are responsible for this difference. Personality traits are a major contributor to variations in job performance. The unique personality an individual brings to the workplace is visible as working style - a combination of work habits and self-regulatory ability. Work style has two aspects - work habits and self-regulation.

Work habits are patterns of behavior that people learn over time that can facilitate or interfere with job performance. They include characteristic motivational responses such as choices for the amount, intensity, and duration of effort to expend. They explain why you would give the job to Neha in certain situations and to Riya in some others.  Work habits include characteristic responses that are not necessarily motivational in nature. This is seen when Rahul, your sales representative who has been trained in the best way to deal with an angry customer and has shown the ability to do so,occasionally reverts to pre-training habits of reacting with hostility.

Self-regulation is the thinking process that allocates attention, time, and effort toward attaining a goal. Self-regulation protects an intention from distraction. Priya’s characteristic tendency may be to exert as little effort as possible, but she may choose to go against that tendency in response to the new bonus structure that rewards productivity. Habits influence behavior despite intentions to behave otherwise because they require very little attention. To implement an intention that goes against habitual tendencies and distractions, one must engage self-regulatory or volitional mechanisms. This self-regulatory construct of working style is very important because it is strongly related to personality.

Modern psychometric tools that accurately measure human potential have been proven to

1. enhance overall productivity
2. reduce employee attrition
3. reduce overall hiring costs significantly.

Work style assessment measures traits such as initiative, integrity, persistence, leadership, stress tolerance, analytical thinking, and interpersonal skills. Higher performance can be obtained across all jobs if one hires employees who are highly conscientious and emotionally stable. Other personality traits (Extraversion, Agreeableness, and Openness to Experience) result in higher performance depending on whether these traits are relevant to the actual job activities.  Hiring right mitigates short- and long term damage to the business from a very bad hire. Work style assessment generates a profile of personality traits that can be matched with requirements for successful performance in a particular job.

References

1. Bouton M, Moore M. J Med Pract Manage. The cult of personality testing: why assessments are essential for employee selection. 2011 Nov-Dec;27(3):144-9.
2. Jeff W. Johnson. Toward a Better Understanding of the Relationship Between Personality and Individual Job Performance. In: Personality and work : reconsidering the role of personality in organizations. Murray R. Barrick, Ann Marie Ryan, editors; foreword by Neil Schmitt. John Wiley & Sons, USA. 2003. Pg 83-120

ADHD Diet - practical family meals

Practical ADHD diet for the family

ADHD Diet

A high-protein, low-sugar ADHD diet can help improve ADHD symptoms in children. Parents of children with ADHD are overwhelmed with dietary advice that is often time-consuming and disruptive to the household. However, this need not be so. Research shows it is feasible to incorporate an ADHD diet as part of an ongoing ADHD treatment program. Medication with behaviour modification is the backbone of ADHD treatment. A practical diet can be incorporated into the family routine to supplement ADHD treatment.

High Protein

Foods rich in protein - poultry, fish, eggs, beans, nuts, soy, mutton and low-fat dairy products (milk, paneer, cheese) - may have beneficial effects on ADHD symptoms.

Protein-rich foods are used by the brain to make neurotransmitters, the chemicals released by brain cells to communicate with each other. Protein can prevent surges in blood sugar, which increase hyperactivity. Giving your child protein for breakfast will help his body produce brain-awakening neurotransmitters. Combining protein with complex carbohydrates that are high in fibre and low in sugar will help your child manage ADHD symptoms better during the day.

Low Sugar

Eating simple processed carbohydrates, like white bread and jam, is almost the same as feeding your child sugar! Sugar surges are shown to increase inattention in children with ADHD. The body digests these processed carbohydrates into glucose (sugar) so quickly that the effect is virtually the same as eating sugar from a spoon.

For children with ADHD symptoms serve breakfasts and lunches high in protein, complex carbohydrates, and fibre — like cereals, dalia, upma with vegetables and nuts, and a glass of milk. Peanut butter on a slice of whole grain bread would also be good. The sugars from these carbohydrates are digested more slowly, because protein, fibre, and fat eaten together result in a more gradual and sustained blood sugar release. The result? A child can concentrate and learn better at school.

Supplements

Additive-free and oligoantigenic or elimination diets are time-consuming, disruptive to the household, and impractical. They have no proven role in ADHD treatment. Iron and zinc are best supplemented in children with known deficiencies. Omega-3 fatty acids supplements may be tried in some children with ADHD.

Greater attention to a healthy diet while omitting food that predisposes to ADHD symptoms, is perhaps the most effective and practical ADHD diet.

References

1. Millichap JG1, Yee MM. http://pediatrics.aappublications.org/content/129/2/330.long The diet factor in attention-deficit/hyperactivity disorder. Pediatrics. 2012 Feb;129(2):330-7. doi: 10.1542/peds.2011-2199. Epub 2012 Jan 9.
2. Howard AL, Robinson M, Smith GJ, Ambrosini GL, Piek JP, Oddy WH. http://jad.sagepub.com/content/15/5/403.abstract?ijkey=d7ce9f17e13e896d1e6b00f2684ad29523c1c5a9&keytype2=tf_ipsecsha ADHD is associated with a “Western” dietary pattern in adolescents. J Atten Disord. 2011;15(5):403–411
3. Wender EH, Solanto MV. http://pediatrics.aappublications.org/cgi/ijlink?linkType=ABST&journalCode=pediatrics&resid=88/5/960 Effects of sugar on aggressive and inattentive behavior in children with attention deficit disorder with hyperactivity and normal children. Pediatrics. 1991;88(5):960–966.
4. Yehuda S. http://pediatrics.aappublications.org/external-ref?access_num=3305401&link_type=MED Nutrients, brain biochemistry, and behavior: a possible role for the neuronal membrane. Int J Neurosci. 1987;35(1–2):21–36

Corex cough syrup - no more OTC opioid dependence

Reducing codeine supply forces Corex users to the spiral of change

Corex Cough Syrup opioid dependence

Codeine cough syrup is no longer available over-the-counter (OTC) without a prescription. Record keeping by the dispensing pharmacist is now mandated by a new government notification. This one legislation will aid relapse prevention in abstinent Corex cough syrup addicts. Many former codeine addicts have relapsed after visiting their dispensary for another medication; the pharmacist casually offers opioid containing Corex cough syrup and provides a visual cue to trigger craving and retard their progress through the stages of change.

Codeine cough syrup addiction is fuelled by dispensaries that distribute litres of codeine in the form Corex Cough Syrup and other brands like Mits Linctus. The key ingredient in these ‘cough syrups’, Codeine, is derived from opium and is an addictive substance. Codeine containing cough syrup abuse made its entry to India in the 1990s and since then has contributed to the steadily increasing opioid dependence case-load.The estimated number of opium users in India is well over 5 million with codeine being a major oral source. Opioid dependence in a de-addiction centre increased significantly from 37 to 52% over the last three decades.

Relapse prevention at the pharmacy

Codeine dependent individuals are exposed to visual cues of Corex and other codeine containing cough syrups at every visit to the dispensary. Modification of addictive behaviours involves progression through five stages of change - precontemplation, contemplation, preparation, action, and maintenance. Individuals cycle through these stages many times before termination of the addiction. During relapse individuals regress to an earlier stage of codeine use. Stimulus control - avoiding or countering reminders of codeine use - is a key process for relapse prevention on the spiral of change. Cutting off easy access in the dispensary aids stimulus control and helps prevent relapse to codeine use. The common sight of multiple discarded codeine cough syrup bottle on stairwells would also disappear (see image).

Codeine cough syrup abuse prevention

1. Pharmacy-based approaches help in minimising the harm associated with OTC medicine abuse, and supporting and treating affected individuals.
• Removing products from sight
• Alerting or counselling customers to the abuse potential of products is effective.
• Refusing sales without a prescription
• Suggesting customers contact their doctor
• Supplying only limited amounts.
2. Raising awareness of the addiction potential of codeine cough syrup is necessary for both the public and the prescribers (many doctors are unaware of the ingredients that go into Corex and other cough syrups).
3. Preventing access is the domain of the government.  Regulating and monitoring codeine prescription and dispensing is a welcome step. The finance ministry is now attempting to enable tracing of batches of codeine containing cough syrups  to their suppliers in a bid to control smuggling of Corex and other codeine containing cough syrups.

Nature's vengeance

Unexpected help in relapse prevention by restricting supply has also come in the form of mother nature. Opium growers in Mandsaur, MP are ruing the increasing numbers of nilgai (Boselaphus tragocamelus) that have developed opioid dependence after chance grazing in farms that were once grassland. The nilgai now run amok and destroy swathes of poppy fields in search of their fix.

References

1. Debasish Basu, Munish Aggarwal, Partha Pratim Das, Surendra K. Mattoo, Parmanand Kulhara & Vijoy K. Varma. Changing pattern of substance abuse in patients attending a de-addiction centre in north India (1978-2008). Indian J Med Res 135, June 2012, pp 830-836
2. Richard J. Cooper. J Subst Use. Over-the-counter medicine abuse – a review of the literature. Published online Oct 3, 2011. doi: 10.3109/14659891.2011.615002. Apr 2013; 18(2): 82–107.
3. Gary Reid and Genevieve Costigan. Revisiting ‘The Hidden Epidemic’ A Situation Assessment of Drug Use in Asia in the context of HIV/AIDS. The Centre for Harm Reduction, The Burnet Institute, Australia. 2002. 
4. Prochaska JO, DiClemente CC, Norcross JC. In search of how people change. Applications to addictive behaviors. Am Psychol. 1992 Sep;47(9):1102-14.

Mental Health and Academic Performance in Children

10yr window to treat mental health problems affecting academic performance

Mental health & academic performance

Mental health has a direct impact on academic performance in children. Neglected childhood psychiatric disorders like ADHD and Learning Disorders adversely affect the child’s academic performance and educational attainment. Poor educational outcomes affect the child’s health, employment, and status as an adult. This is especially so for psychiatric conditions that are seen at 7 years and persist beyond 16 years of age.

Mental health disorders in children have a greater impact on academic performance than chronic physical illness. The presence of a single mental condition results in morel board exams failures and backlogs. This association is more than for chronic illnesses of the neurological, lung, heart, or digestive systems. Physical impairments are not associated with exam failures. More than half the teenagers who fail to complete their secondary education have a diagnosable psychiatric disorder. Mental health problems in childhood impede academic performance as the student is unable to take advantage of learning opportunities at school and at home.

Poor academic performance may be a marker for mental health problems in childhood. We screened secondary school students performing poorly at academics for mental health disorders. 2/3 of these children had at least one mental health disability. ADHD and Depression were the most common mental health disorders in this population. One third of the children had more than one mental health disorder. Our study showed that screening children who had poor academic performance would help in the early identification of treatable psychiatric disorders. This in turn would improve academic performance and subsequent adult outcomes.

Mental health problems in children negatively impact physical health, employment and social status as they grow into adults. These adverse health, employment and social status outcomes are especially seen in those children with psychiatric disorders at age 7 that persist to age 16. There is a large window of opportunity between ages 7 to 16 during which psychiatric disorders can be addressed to prevent adverse outcomes in adulthood.

Mental health problems in childhood have a higher impact on academic performance than chronic physical conditions. Psychiatric disorders account for a large chunk of school failures in children. Poor academic performance in children may be a marker for the presence of undetected mental health problems. Treatment of childhood disorders like ADHD improves academic performance. There is a decade window between the ages of 7 and 16 years to prevent adverse impacts on physical health, employment and social status by treatment of mental health problems that are resulting in poor academic performance.

References

1. Case, Anne, Angela Fertig, and Christina Paxson. "The lasting impact of childhood health and circumstance." Journal of Health Economics 24.2 (2005): 365-389. 
2. Stoep VA, Weiss NS, Kuo ES, Cheney D, Cohen P. What Proportion of Failure to Complete Secondary School in the US Population Is Attributable to Adolescent Psychiatric Disorder? Journal of Behavioral Health Services & Research, 2003, 30(1), 119-124.
3. Neville Misquitta, Sayyara Ansari. Prevalence of ADHD, Depression and Dysgraphia in School Children. 15th IACAPAP. New Delhi. 30-Oct-2002

What is normal? Dreams, the tiger and normality

What is normal? A 22-year-old man jumped into the tiger's enclosure at the local zoo on Saturday and was mauled on his back, stomach and thighs. The previous night he had dreamt that he was to free the big cat and that it wouldn't kill him. "See, it didn't kill me," he said. Doctors treating him said, "he has received injuries but he would be well soon ... he was not suicidal."

What is normal?

The concept of normality is at the core of mental health. Without a concept of what is normal one cannot identify the abnormal. In this post we explore the concept of normality from a mental health point of view.

Normality as Health

The WHO has defined health as a complete state of physical, mental and social well-being and not merely the absence of disease or infirmity. Later they added spiritual well-being to the definition. So health is a positive state, not just the absence of disease. This concept looks at normality from a biological or medical point of view.

Suicide attempts are an important marker for mental health illness. However, the mere absence of this particular marker does not rule out mental illness. But the young man’s actions do indicate a lack of judgement - would jumping into the enclosure free the tiger? and after freeing the tiger what next? A display of impaired judgement is often the first visible sign of a mental health problem.

Normality as an Ideal

Normality is a blend of all the elements of the mental apparatus leading to optimal functioning that seeks perfection. However, Sigmund Freud wrote that "A normal ego is like normality in general, an ideal fiction. Every normal person, in fact, is only normal on the average. His ego approximates to that of the psychotic in some part or other and to a greater or lesser extent; and the degree of its remoteness from one end of the series and of its proximity to the other will furnish us with a provisional measure of what we have ...". This psychological interpretation of what is normal was the first to conceive of normality and abnormality as different ends of the same spectrum.

Abnormality

Normality is also defined by the persons internal experience or "personal world" - the way they think or feel. Karl Jaspers, psychiatrist and philosopher, viewed the goal of eliciting signs and symptoms from the patient as an attempt to reach an understanding of their personal experience without any prior assumptions or bias. According to Jaspers, the "personal world" is abnormal when it is based on a disease condition such as schizophrenia, when it alienates the person from others emotionally, or when it does not provide the person with a sense of “spiritual and material” security.

Normality as Average

Normal is also a statistic. The field of psychology contributed further to the concept of normality and mental health by introducing objectivity through measurement. Take intelligence, for example. A graph plotting the distribution of individual intelligence scores (IQ) in the population would follow a bell-shaped curve. The middle range of this curve is considered as normal, and the extremes as significantly low or high intellectual ability. This normal as an average is in the context of the total group. When is it normal to jump into the tiger enclosure?

Normality as Process

Normality is also conceived as being the result of an interacting system. This process-concept emphasises changes over time as against a cross-sectional definition of normality viewed at a particular point of time. The trajectory of development of an infant into an adult is one such process of normal change. When seen against this background an act such as crawling is normal in infancy but would need explanation in adulthood.

Social Normality

Normality is also assessed from a social viewpoint. Is the person normal to others in the same society? Is the person viewed as abnormal by the person's society but normal by others from outside the person's society? Is the person normal in the person's society but abnormal when viewed by persons outside the society? The answers to these questions are directly impact whether the person will be labelled as mentally ill and associated with the stigma of mental illness. The answers are also medically important as they will impact the decision to seek healthcare.

In a world where young people are exhorted to follow their dream one also needs to consider the dream.

References

1. Coelho MT. [Conceptions of normality and mental health among prisoners in a correctional institution in the city of Salvador].Cien Saude Colet. 2009 Mar-Apr;14(2):567-75.[Article in Portuguese]
2. Freud, Sigmund. (1937c). Die endliche und die unendliche Analyse. GW, 16; Analysis terminable and interminable. SE, 23: 209-253.
3. Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/clinical ...By Benjamin J. Sadock, Harold I. Kaplan, Virginia A. Sadock. 9th Edition. Lippincott Williams and Wilkins. Philadelphia. 2003
4. Jaspers, Karl (1997). General Psychopathology - Volumes 1 & 2. translated by J. Hoenig and Marian W. Hamilton. Baltimore and London: Johns Hopkins University Press
5. Sabshin, Melvin. Psychiatric perspectives on normality. Archives of General Psychiatry 17.3 (1967): 258.
6. World Health Organization. WHO definition of Health, Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19–22 June 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948. In Grad, Frank P. (2002). "The Preamble of the Constitution of the World Health Organization". Bulletin of the World Health Organization 80 (12): 982.

Adult ADHD - Attention Deficit Hyperactivity Disorder at work

ADHD (Attention Deficit Hyperactivity Disorder) is thought to be a childhood disorder. However ADHD persists in adults in up to 50% of children diagnosed with the disorder. Hyperactivity, impulsivity and inattention; the hallmark symptoms of Attention Deficit Disorder in childhood have been described earlier. In Adult ADHD, symptoms change to reflect the child's development into adulthood. The symptoms related to hyperactivity gradually disappear by adulthood; however, those related to inattention persist. Adults with attention deficit disorder (ADD) are often distracted, and avoid tasks requiring sustained mental effort. This impairs functioning at home and at work.

Adult ADHD at work

Adults with ADHD experience employment impairments at every level; from the initial job search, to the interview and then during the employment itself. People with Attention Deficit Disorder are more likely to be have poor job performance, lower occupational status, less job stability and absenteeism. Men and women with attention deficit disorder earn less money, and are more likely to be unemployed.

Attention Deficit Disorder (ADD) has at times been portrayed as advantageous from a work perspective, as in the Economist, "in praise of misfits". This may be so in certain sectors where

• Hyperactivity and distractability find an outlet in the need to multi-task with multiple apps at a time.
• Impulsivity manifests as risk taking and an apparent fearlessness. 

This works for Attention Deficit Hyperactivity Disorder adults at the entry level of the IT industry. The physical, social and cultural environment help overcome functional limitations of adult ADD. However, the lack of focus, disorganisation and procrastination become evident when they are promoted in the organisation. It is at this mid-career stage that the adult with Attention Deficit Disorder seeks our help.

ADHD friendly workplace adjustments

Symptom	Adjustment
Inattention and impulsivity	Quieter room/positioning in office Flexi-time arrangement Headphones to reduce distractions Regular supervision to maintain course Buddy system to maintain stimulation
Hyperactivity/ restlessness	Allow productive movements at work Encourage activity Structure breaks in long meetings
Disorganisation, procrastination, and forgetfulness	Provide beepers/alarms, structured notes Regular supervision with feedback, mentoring Delegate tedious tasks Incentive/reward systems Regularly introduce change Break down targets and goals Supplement verbal information with written material

Adult ADHD is a treatable medical condition. Medication to correct the underlying neurochemical imbalance is the cornerstone of treatment for ADHD adults. The adverse impact of adult ADHD is experienced by the employee and the organisation. At the organisational level, workplace adjustments can provide a safe nidus for the ADHD adult to function effectively. At the individual level treatment can help reduce the associated emotional problems and absenteeism of adult ADHD.

References

1. Marios Adamou and colleagues. Occupational issues of ADHD adults. BMC Psychiatry 2013, 13:59 doi:10.1186/1471-244X-13-59
2. Biederman J, Mick E, Faraone SV. Age-dependent decline of symptoms of attention deficit hyperactivity disorder: impact of remission definition and symptom type. Am J Psychiatry. 2000 May;157(5):816-8.
3. de Graaf R, et al: The prevalence and effects of Adult Attention-Deficit/hyperactivity Disorder (ADHD) on the performance of workers: results from the WHO World Mental Health Survey Initiative. Occup Environ Med. 2008.
   
4. Jane L. Ebeje, Sarah E. Medland, Julius van der Werf, Cedric Gondro, Anjali K. Henders, Michael Lynskey, Nicholas G. Martin, and David L. Duffy. Attention Deficit Hyperactivity Disorder in Australian Adults: Prevalence, Persistence, Conduct Problems and Disadvantage. PLoS One. 2012; 7(10): e47404. Published online 2012 October 10. doi: 10.1371/journal.pone.0047404
5. Schultz S, Schkade JK. Occupational adaptation: toward a holistic approach for contemporary practice, Part 2. Am J Occup Ther. 1992 Oct;46(10):917-25.

Irresponsible Drinking & Regulation

Irresponsible drinking requires regulation to modulate its potential for harm. There are specific neurotoxic effects of alcohol drinking. The responsible individual needs to learn personal skills to refuse alcohol drinking when required to do so. The potential harm to society with irresponsible drinking and driving necessitates regulation at a societal level.

Regulating irresponsible drinking

Alcohol drinking and driving in Pune over New  Year's eve was markedly reduced as compared to last year. This year 145 drunk driving arrests were made as against 252 last year. This reduction was despite an increase in the total number of  arrests made in Pune for irresponsible drinking and driving in 2012 as compared to the previous year. The heightened deployment of police personnel manning 30 prominent points of the Pune roads on New Year's eve was apparently deterrent enough.

Alcohol drinking and liquor sales were down by 20-30% in September 2012 following a police raid on an unlicensed rural Pune nightspot. The uproar by its patrons and subsequent police action on liquor retailers and other restaurants resulted in the Pune District Wine Traders Association lamenting the impact of plunging alcohol sales at premium outlets and lounge bars.

Is regulation effective?

The effects of regulating alcohol drinking have been specifically studied.

• In Kentucky — the birthplace of bourbon whiskey and the home of many distilleries — dry districts had less alcohol-related auto accidents and drunk driving arrests. This should cheer the citizens of Chandrapur which will be the third district in Maharashtra state to go dry in a bid to curb irresponsible drinking.
• In Alaska, isolated villages that prohibited alcohol had lower rates of serious injury resulting from assault, and motor vehicle collisions. A local police presence in these dry villages further reduced the incidence of assault

Regulation of alcohol drinking is effective and necessary. It provides a deterrence to irresponsible drinking and illegal distribution of alcohol. Alcoholism treatment financially benefits the family. Regulating alcohol drinking works to benefit society.

References

1. Darryl S. Wood, Paul J. Gruenewal. Local alcohol prohibition, police presence and serious injury in isolated Alaska Native villages. Article first published online: 27 FEB 2006 DOI: 10.1111/j.1360-0443.2006.01347.x
2. Wilson RW, Niva G, Nicholson T. Prohibition revisited: county alcohol control consequences. J Ky Med Assoc. 1993 Jan;91(1):9-12.