Rejection sensitivity - rejecting an unwanted lover safely

Rejecting an unwanted lover unceremoniously can be dangerous. Rejection sensitivity and aggression by the scorned male can have disastrous consequences. Last week a college girl was attacked with a sickle for doing so. The demographic profile of students at our clinic is probably a representation of the Pune student population. Many students feel socially and culturally alienated while having to cope on their own with minimal family support. Some have no one to express their feelings or thoughts to. A smile or other facial expressions from a classmate or a single phrase while watching a game are viewed as tokens of intimacy. Subsequent fantasising invests these facial expressions and interactions with an excessive significance. That the girl does not initiate or acknowledge further interaction is rationalised as shyness and considered a virtue, further embedding the myth of intimacy.

The concept of gender equality may be alien in the culture of the student. It comes as a great shock to the lover, when he gathers up his courage to proclaim his love only to find it discarded unceremoniously. His reaction will depend on his attachment style - the behavioural response to separation developed in childhood. Mostly he will withdraw further into his shell, but in some cases, especially when he is high on the personality characteristic of rejection sensitivity and has a fearful attachment style, he will harbour and act out thoughts of revenge.These vengeful thoughts smoulder unrecognised until they burst forth in as dramatic and unexpected action as the initial profession of love.

Rejecting an unwanted lover

Rejection sensitivity is always a concern when rejecting an unwanted lover. The independent modern woman needs to learn how to handle this situation without involving family or other third parties. Rejecting an unwanted lover can be considered as a form of breaking bad news. For this there is no better technique than the SPIKES 6-step protocol which is used to break bad news in medicine.

Setting

Make sure there is privacy. No matter how startled you are by his profession of love, do not blurt out a summary dismissal in front of everyone. Stay in a public place, but take him to one side.

Perception

Ask him to clarify what he has just said, and what lead him to say that. This  will help you to place him, if you haven't already done so.

Invitation

Ask whether you can tell him your point of view on the subject

giving Knowledge

Warning before giving the bad news helps the person process the information imparted without  getting angry or feeling isolated. Start by saying "I am sorry to say that I don't feel that way". Don't be rude or excessively blunt  Responses such as "who do you think you are?",  "why should I have feelings for you?" or laughing contemptuously are bound to turn love into the other end of the stick - hate, especially if he is high on rejection sensitivity. Check his reactions and modify  what you are saying so he can understand.

Empathise

Identify his emotion - sadness, anger, hurt. Closely monitor his facial expressions. Acknowledge it. "I can see that you are feeling hurt. Anyone in your position might feel like that".

Strategy

Discussing what comes next. Start from his Perception of the relationship to help vent his emotions. Deal with these Empathically, again the facial expressions are important. The goal should be to politely but firmly communicate "I don't feel that way" so "we cant take this any further, don't take this personally".

The aim is to stay polite while rejecting an unwanted lover without humiliating him. It should not take more than 5-10 minutes of time spent reading facial expressions and showing concern while firmly putting forward your own lack of 'spark' in the relationship.

Reference

1. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5(4):302-11.

Job Satisfaction & Work Stress in the IT Industry

Work stress and low job satisfaction are the primary drivers for help-seeking in IT professionals. PR a 34-yr old software engineer employed in an IT company came to us for guidance while considering a career change. He felt stressed, and experienced his work as meaningless. He felt alienated from his colleagues and his job dissatisfaction was high.

PR’s is not a one-off case. A PPC Worldwide study reported that 62% of all employees experience work stress. Responses to a poll specifically studying IT related work stress are as depicted in the chart above.

Work stress contributes to job dissatisfaction and increased attrition in the workforce. Most burnout prevention methods focus on personal responsibility for wellness. They require sacrifice of personal time with the perverse goal of being more effective at work. We have already seen what the individual needs to do to manage stress with a health promoting lifestyle,  Even 15 minutes of exercise is effective. We now need to look at the organisational factors resulting in committed employees.

Job satisfaction involves certain obligations that exist in an employment relationship. Pay is largely considered to be the single-most contributor to job satisfaction, and perceptions of fairness in compensation have a direct influence on commitment to the organisation. However, intrinsic motivators contribute greatly to resistance to work stress. These include

Nature of work

Nature of work is an intrinsic motivator measured by an individual’s feeling that their job is meaningful. They feel engagement, and a sense of pride in the job. Humiliation at work does not foster this sense of engagement. For many of our clients humiliation is a prime driver to distress and burnout.

RK came to us when he was thinking of quitting his job. He had been 'de-promoted' into his own team when they were unable to meet a target. His self-esteem was low and he was depressed. He recovered with treatment and counselling. He could then decide his next career move from a position of strength.

Relationship with co-workers

Work plays an important part in fulfilling an individual’s social needs. Co-worker acceptance and a sense of belonging to a group and culture affect job satisfaction. Unfortunately the culture in many IT organisations continues to reflect the ‘in’ and ‘out’ groupings of the college hostels through which their managers have emerged. This only adds to the job dissatisfaction of IT professionals who may be contributing at their jobs but do not feel a part of the organisation.

The motivated and stress tolerant employee shows commitment to the organisation in two ways

1. Emotional
 Job dissatisfaction is inversely associated with emotional commitment. IT professionals who are satisfied feel more emotionally attached to and involved with their organisations.
2. Obligational
Job satisfaction is associated with feeling more obliged to remain with the organisation.
3. Continuance
Continuance commitment (cost associated with leaving the company) is not related to job satisfaction; pay does not matter disproportionately to the IT professional.

Work stress and work pressure are correlated with job dissatisfaction and poor employee engagement. The IT professional’s decision to stay with the company due to feelings of attachment and obligation results from job satisfaction rather than the costs associated with leaving the company. A working atmosphere that validates the individual and their differences will enhance that attachment and commitment to the organisation.

References

1. E.J. Lumley, M. Coetzee, R. Tladinyane, N. Ferreira. Exploring the job satisfaction and organisational commitment of employees in the information technology environment. Southern African Business Review Volume 15 Number 1 2011.
2. Kaluzniacky, Eugene. Stress Management. In: Managing psychological factors in information systems work : an orientation to emotional intelligence. Idea Group. London, 2004. Pg238-245.
3. Psychol Rep. 2009 Dec;105(3 Pt 1):759-70. Employee engagement and job satisfaction in the information technology industry. Kamalanabhan TJ, Sai LP, Mayuri D.
4. Saradha.H. Employee engagement in relation to organizational citizenship behaviour in information technology organizations. Submitted in partial fulfillment of the requirements for the degree of Master of Philosophy. Institute of Management, Christ University, Bangalore. 2010.

Conduct Disorder and Behaviour Problems in Children



 

Conduct disorder and behaviour problems in children make the news when a 5-year old or a grandmother is killed while extorting money. Aggression in children  is just one of the offenses associated with conduct disorders . The seemingly lesser offenses of stealing in thousands from the home, or smoking 'weed' with their friends, pale in contrast. At the lowest end of the spectrum are those children who repeatedly confront authority in school or at home. Dubbed as 'monster kids' these children are viewed indulgently as being mischievous, naughty, 'bad', or 'delinquent'. Very seldom are they seen as having a mental health problem - a conduct disorder.

What is Conduct Disorder?

Behaviour problems that are persistent, violate the rights of others, go against societal norms, and disrupt family life, indicate a conduct disorder and merit psychiatric assessment. Conduct disorder is amongst the commonest childhood disorders seen in our clinic. Every one of us knows or has heard of a child with conduct disorders . Conduct disorder is characterised by the following behaviour problems .

Aggression

This child (maybe a 2 year old preschool cherub) picks fights, bullies, or physically hurts younger siblings at home. He is frequently taken to the principal's office for fighting in school. When this child enters the park the other children get ready to leave. He has often used a weapon (stick, cricket bat, stone or brick) to deliberately assault a person or hurt an animal.

Destruction of property

These children are wilfully destructive. They are the ones who scratch the paint off your new car, slash the seats of parked 2 wheelers, deface the lift, cut up a mothers dress, and tear the library book. More seriously they set fire to clothes and in extreme cases to vehicles.

Lying and deceit

These are children who steal from parents, grandparents, and classmates. They forge their parent's signature on school reports, cheques, and credit cards.They lie,  cheat and pilfer from shops.

Violation of rules

They stay out until late at night against home rules and curfews. They 'bunk' school to hang out with other antisocial friends, and run away from home overnight.

What happens to children with conduct disorder behaviours ?

Most parents feel a child will outgrow behaviour problems and conduct disorders .  However studies show this is not so. If not addressed and treated, children with conduct disorders are suspended from school, and have brushes with the law. Half of these children also have ADHD (Attention Deficit Hyperactivity Disorder) which further impacts their schooling. Broken relationships and marriages, and substance abuse including alcohol and cannabis abuse are common. As adults children with behaviour problems develop antisocial personalities and lead a criminal lifestyle. In the extreme a child with conduct disorder will murder his grandmother or a hapless neighbour's toddler.

Alzheimer's caregiver techniques

Caregivers living with persons having Alzheimer's Disease face specific problem behaviours. These behavioural problems result from memory loss that is the hallmark symptom of Alzheimer's. We have previously discussed resources giving hope for dementia caregivers. Caregiver do's and dont's for mental illnesses in general have also been highlighted. Living with Alzheimer's Disease is the theme for World Alzheimer's Day 2012. In this post we specify methods to help caregivers living with persons having Alzheimer's handle problems related to memory loss and reduce the burden of  care at home.

Caregiver techniques for Alzheimer's

1. Regular routine enables basic activities of daily living for a longer period of time. Make a visual time-table and regularly remind the person with Alzheimers to consult it so it becomes a habit.
2. Keep large clocks in each room and remind them of the time at every opportunity.
3. A personalised calendar with large figures helps plan and anticipate potentially confusing events such as a festival or travel.
4. A room with a window is great for orientation. Natural daylight and dark phases maintain the sleep-wake cycle.
5. Greet at every new meeting with date and time. The date is particularly difficult for a person with Alzheimer's to learn - it changes every day -  hence the disorientation. Repetition will keep the person with Alzheimers disease current with the month and year for longer.
6. Keep familiar objects like photos, phone, books, and decorative pieces in the same place. People with Alzheimer's often have to move from one set of caregivers to another. Placing these objects in the same general positions helps them to avoid confusion and  anxiety.
7. Photographs are important visual memory pegs. Two or three frames with photographs of the caregiver families and old friends reassures the person with Alzheimer's disease and facilitates their smooth transition between caregivers.
8. An identity card is essential for every person with  Alzheimer's. It must contain an address and an emergency contact number. It should be worn at all times, even inside the  house. Your loved one can wander out of an open door and not  be able to find her way back. Reinforce and rehearse showing or consulting the identity card on being asked for address or phone number.
9. Encourage and let them do the  things they can. Don't take over every activity or your caregiver burden will increase. Prompt them when they hesitate or take time. Help them in those activities they are unable to do.

Anti-dementia drugs delay nursing home admissions for upto a year. To make home this stay meaningful and to reduce the burden of care these methods need to be used by caregivers living with Alzheimer's Disease patients.

Alzheimers disease - mild cognitive impairment countdown

Alzheimers dementia is usually diagnosed when memory loss and behavioural symptoms are readily apparent to their caregivers. At this stage the primary concern is to slow further deterioration. Caregivers at the clinic have often wished they could have looked into the future. Many have a history of Alzheimers disease in their elderly and wondered whether there was an earlier way of knowing. New knowledge gives us hope in this direction.

Alzheimers disease before memory loss

We now have the beginnings of a time line in the countdown to dementia. It is now possible to trace the beginnings of Alzheimers Dementia up to 20 years before its manifestation with memory loss and impaired function.

20

Beta-amyloid levels in the cerebrospinal fluid (CSF)  begin to drop 20 years before the onset of dementia. Alzheimer's Disease is characterized by toxic deposition of specific beta-amyloid (Aβ1-42) plaques around the brain cells. In normal aging beta-amyloid continues to increase in the brain fluid. However, in Alzheimers Dementia brain fluid beta-amyloid is markedly reduced.This is due to reduce clearance of beta-amyloid from the brain to the blood and CSF, as well as increased beta-amyloid plaque deposition in the brain.

15

15 years before dementia onset, beta-amyloid deposits can be detected by amyloid imaging PET scans. The best known amyloid PET tracer is Pittsburgh Compound-B (PIB). PIB retention is found in over 90% clinically diagnosed AD patients.
Tau protein accumulation inside the brain cells (neurons) is the second hallmark of Alzheimer's disease.  Microtuble associated protein tau (MAPT) in the brain fluid (CSF) increases with age. In Alzheimer's disease tau levels are markedly increased and reflects damage to the neurons and axons (brain cells). High CSF tau level differentiates mild cognitive impairment (MCI) from that which progresses to Alzheimer's disease.
Shrinkage or atrophy of the brain becomes detectable by MRI. This atrophy is visible in brain structures that are essential for the conscious memory of facts and events. These areas are located in the brain’s medial temporal lobe. This shrinkage is apparent on using a visual rating system which also measures its severity. The more extensive the brain atrophy, the more advanced the clinical stage of Alzheimer’s disease.

10

PET Scan (FDG-PET) changes in the way the brain uses glucose are apparent 10 years before dementia. These PET scan changes correlate with progression of Alzheimers disease.
Episodic memory loss begins at this stage. Episodic memory loss is the inability to learn new information or to recall previously learned information. It manifests as forgetting of recent events and conversations, repetitive questions, repetitive retelling of stories, forgetting the date, forgetting appointments, misplacing objects, losing valuables, and forgetting that food is cooking on the stove. The formation of new episodic memories requires intact medial temporal lobes of the brain; these are progressively destroyed in Alzheimers disease.

5

Mild cognitive impairment (MCI) deveelops 5 years before dementia. People with mild cognitive impairment have problems with thinking and memory loss. Mild cognitive impairment does not interfere with everyday activities. Persons with mild cognitive impairment are often aware of their forgetfulness.
Preventive therapies for Alzheimers disease (AD) require the development of biomarkers that are sensitive to subtle brain changes occurring in the preclinical stage of the disease. Early diagnostics is necessary to identify and treat at risk individuals before irreversible neuronal loss occurs.
Sources

1. Bateman R. The dominantly inherited Alzheimer's network trials: an opportunity to prevent Alzheimer's disease. Program and abstracts of the Alzheimer's Association International Conference 2012; July 14-19, 2012; Vancouver, British Columbia, Canada. Featured research session F3-04
2. Christian Humpel. Identifying and validating biomarkers for Alzheimer's disease. Trends Biotechnol. 2011 January; 29(1): 26–32. doi: 10.1016/j.tibtech.2010.09.007
3. Duara R, Loewenstein DA, Potter E, Appel J, Greig MT, Urs R, Shen Q, Raj A, Small B, Barker W, Schofield E, Wu Y, Potter H. Medial temporal lobe atrophy on MRI scans and the diagnosis of Alzheimer disease. Neurology. 2008 Dec 9;71(24):1986-92.
4. Mosconi L, Berti V, Glodzik L, Pupi A, De Santi S, de Leon MJ. Pre-clinical detection of Alzheimers disease using FDG-PET, with or without amyloid imaging. J Alzheimers Dis. 2010;20(3):843-54.

ADHD treatment improves academic performance

ADHD treatment improves academic performance

ADHD medication enhances academic performance when started early. ADHD drug treatment improves reading ability in children with Attention Deficit Hyperactivity Disorder (ADHD) and Dyslexia. New research shows that drug treatment of ADHD also improves maths ability especially when started early - at least by the 4th standard. Children starting treatment a year or two later show progressively greater declines in academic performance.

ADHD is characterised by inattention and hyperactive-impulsive behaviour. Parents who bring their children to the clinic are focused only on issues arising from the child's hyperactivity. Impairments due to inattention are not immediately apparent in the pre-school years. Depending on the severity of ADHD, inattention is unmasked when the child enters academic life in primary school or during the transitions to middle school, high school, and college. At each  of these stages an increasing demand is placed on the cognitive faculty of attention which the child's brain is not capable of meeting.

Children with ADHD fail to absorb formative academic concepts in primary school. However, rote learning or tutoring by the parents helps the child clear these initial stages. It is only later when the cognitive load exceeds the child's capacity to concentrate that academic problems become manifest. By this time the child's academic progress has already taken a downward trajectory. Reversing this trend and repairing the negative impact on the child's self-esteem entails considerably more effort, time and sustenance at these later stages. The earlier treatment for ADHD is initiated, the better.

Inattention in ADHD is due  to altered brain proteins. These are involved in modulation of the neurochemical - dopamine. This results in reduced dopamine in the synapse (fluid filled space that transmits information from one brain cell to another).  Altered dopamine modulation in the frontal lobe of the brain makes the child impulsive and distractible. ADHD medications act on dopamine and noradrenaline receptors to keep each dopamine molecule longer in the synaptic cleft. Dopamine is then available to stimulate the receptors for longer.

Parental concerns regarding side-effects of ADHD drug treatment on the developing child are largely unfounded. There is now evidence that shows long-term treatment with therapeutic doses of ADHD medication does not affect the developing brain or other standard measures of growth. ADHD drug treatment also does not increase the risk for addiction. As with any other medication side effects can arise at the start of treatment. Adherence to the review schedule will help monitor and mitigate these. All medication is prescribed after carefully weighing the risks and benefits. In the case of ADHD the risks are poor academic functioning and subsequent narrowing of career options at best, to dropping out or expulsion from school and subsequent delinquency at the worst. The benefits of treatment are highlighted in the  report card shown above.

Drug treatment of ADHD enhances academic performance and learning by reducing the inattention and hyperactivity of ADHD. The child with ADHD has attentional and impulse control issues. Inattention and hyperactivity interfere with classroom learning. The earlier ADHD treatment is started the better the outcome in terms of academic achievement. Many children have experienced these benefits.

References

1. Kathryn E Gill, Peter J Pierre, James Daunais, Allyson J Bennett, Susan Martelle, H Donald Gage, James M Swanson, Michael A Nader and Linda J Porrino. Chronic Treatment with Extended Release Methylphenidate Does Not Alter Dopamine Systems or Increase Vulnerability for Cocaine Self-Administration: A Study in Nonhuman Primates. Neuropsychopharmacology , (18 July 2012) | doi:10.1038/npp.2012.117
2. Penny Corkum, Melissa McGonnell and Russell Schachar. Factors affecting academic achievement in children with ADHD. Journal of Applied Research on Learning. Vol. 3, Article 9, 2010.
3. Zoëga, et al. A Population-Based Study of Stimulant Drug Treatment of ADHD and Academic Progress in Children. Pediatrics 2012;130:2011-3493

Sexual Dysfunction and Relationships

The Erectile Dysfunction-Relationship Cycle

Erectile and sexual dysfunction in an ongoing relationship usually reflects difficulties between the partners. Relationship problems interfere with sexual feelings and cause or worsen erectile dysfunction.  Any experience that hinders the ability to be intimate, that leads to a feeling of inadequacy or distrust, or that develops a sense of being unloving or unlovable may result in erectile dysfunction.  Successive episodes of impotence are reinforcing. The man becomes increasingly anxious about his next sexual encounter. Erectile dysfunction is worsened by anticipatory anxiety about achieving and maintaining an erection interferes.  Sexual dysfunction interferes with pleasure in sexual contact and reduces ability to respond to sexual stimulation.

Erectile Dysfunction in the relationship cycle

In the early years of the relationship

• Lack of knowledge - there is a refractory period after sex before you can get the next orgasm. This refractory period increases gradually from a few minutes in teenagers to many days  in the elderly. Misguided enthusiasm after a period of separation causes a one-off problem with erection. This  is transient erectile problem is further reinforced by succeeding anxiety.
• Lack of privacy - the young couple moves into the parental home and has minimal access to privacy. Sex is a hurried activity with the focus on orgasm. Intimacy is not fostered. Subsequently there is dissatisfaction and a further build-up of anxiety.
• Stressors - careers with long working hours, night shift work and work from home leaves little time for the emotional intimacy that is requisite for sexual intimacy.

Middle phase

• Lifestyle changes - a sedentary  life style coupled with an indiscriminate diet result in obesity, a leading risk factor for erectile dysfunction. Excessive alcohol intake, and smoking have a direct impact on sexual functioning.
• Infidelity - is a major cause of anxiety and erectile dysfunction in the middle phase of the relationship. This  is especially so when the infidelity arises from insecurity - the man or woman attempting to prove continued youthfulness and desirability outside the relationship.

Later years

• Medical issues - chronic illnesses such as diabetes, and heart disease are commonly associated with erectile dysfunction.

What to do

• Don't panic - anxiety worsens erectile dysfunction. An occasional problem with  erection is not a reflection on your masculinity, and does not necessarily indicate a long term erectile dysfunction. Don't immediately try  to 'prove' yourself. Give it a days break to be safely out of the refractory period. There  will be  no trouble in the  next sexual encounter.
• Communicate - reassure your  partner of your continuing sexual interest in her. Communicate openly about  your condition. Involving your  partner improves the outcome of treatments for erectile dysfunction.
• Quit smoking
• Lose weight, exercise regularly
• Get treatment for alcohol or drug problems
• Work through relationship issues. Consider counseling if unable to work through  problems on your own.
• Depression, anxiety and stress related mental health issues should be addressed. Don't ignore them.

Whom to see for sexual dysfunction

• Consult a qualified psychiatrist. He or she  is the only person with the knowledge, training, and experience to deal with the psychological and medical issues that result in sexual dysfunction. The psychiatrist will also address issues in the relationship that are perpetuating the erectile dysfunction.
• Avoid self-styled sex therapists and sexologists

References:

1. Kubin M, Wagner G, Fugl-Meyer AR. Epidemiology of erectile dysfunction. Int J Impot Res. 2003 Feb;15(1):63-71.
2. McCabe M, Althof SE, Assalian P, Chevret-Measson M, Leiblum SR, Simonelli C, Wylie K. Psychological and interpersonal dimensions of sexual function and dysfunction. J Sex Med. 2010 Jan;7(1 Pt 2):327-36.
3. Metz ME, Epstein N. Assessing the role of relationship conflict in sexual dysfunction. J Sex Marital Ther. 2002 Mar-Apr;28(2):139-64.
4. Nina Bingham. Research Findings on Sexual Dysfunction, Intimacy and Conflict in Heterosexual Couples. Accessed 30-Jun-2012

Cannabis, teenagers and schizophrenia

Cannabis or marijuana use by teenagers and adolescents is highly associated with the onset of psychosis and schizophrenia. Cannabis goes by many names including hash, pot, grass, weed, or ganja. This gateway drug is falsely thought to be innocuous and as having no lasting effects. Cannabis use by teenagers is often not recognised as a problem. Cannabis is cheap and easily accessible in most student populations. Pune is a major hub for the cannabis drug trade. This week a quarter tonnne of ganja was found dumped in a well. Cannabis use is rampant in Pune colleges and hostels, where students assiduosly guard and maintain their 'stash'. During the 57th National School Games the highest number of students testing positive for marijuana came from Maharashtra.

Regular cannabis use increases the risk for schizophrenia and psychosis by upto 4 times. There is increasing evidence that cannabis use can precipitate schizophrenia in vulnerable individuals. This is especially so with early onset use of cannabis. Cannabis also exacerbates symptoms of schizophrenia in those who have already developed the disorder. Psychotic disorders like schizophrenia involve disturbances in the dopamine neurotransmitter systems of the brain. Δ9-tetrahydrocannabinol (THC) - the key neurochemical in cannabis - interacts with dopamine to adversely affect its functioning by multiple mechanisms.

Teenagers are especially vulnnerable to the schizophrenia-inducing effects of cannabis. Cannabis like substances (anandamide) called endocannabinoids, produced by the body, play an important role in several processes of brain maturation. Regular marijuana use affects this process of brain maturation in teenagers. Schizophrenia is also a disorder of brain maturation. Disruption of the endocannabinoid system in the adolescent brain by exposure to cannabis interferes with brain maturation. This provides a mechanism to increase the risk for development of schizophrenia in adolescence.

How to cut down and stop cannabis use

1. Write down a list of reasons for wanting to stop - you will need to review this at times when you are feeling low or experiencing craving.
2. Tell someone you trust that you are quitting
3. Get rid of the paraphernelia for smoking cannabis - the stash, wrappers, lighters, matches. You may be surprised at the number of places where small amounts are hidden. Get rid of it all.
4. Take measures to prevent fresh procurements - avoid places and people associated with replenishments
5. Make a list of things to do to occupy the time freed-up from procuring and using cannabis.
6. Review your list of reasons and things to do when you feel low and when craving is intense.

References

1. Paola Casadioa, Cathy Fernandesb, Robin M. Murray, Marta Di Forti. Cannabis use in young people: The risk for schizophrenia.  Neuroscience & Biobehavioral Reviews. Volume 35, Issue 8, August 2011, Pages 1779–1787. doi:10.1016/j.neubiorev.2011.04.007
2. Degenhardt L, Hall W. Is cannabis use a contributory cause of psychosis? Can J Psychiatry. Aug 2006;51(9):556-65.
3. Deepak Cyril D’Souza,Richard Andrew Sewell,and Mohini Ranganathan. Cannabis and psychosis/schizophrenia: human studies. Eur Arch Psychiatry Clin Neurosci. 2009 October; 259(7): 413–431. Published online 2009 July 16. doi: 10.1007/s00406-009-0024-2

Alcohol and Happiness - do they mix?

Alcohol and happiness don't mix - definitely not when taken in excess, and definitely not in the long term. The relationship between adverse alcohol use and unhappiness is reciprocal - unhappy people tend to drink hazardously, and vice versa. This effect increases over time as demonstrated by a 15-year study that followed-up adult twins in 1975, 1981, and 1990.

Passing out while drinking is significantly more likely in dissatisfied people

Blackouts or passing out while consuming alcohol is an indication of unhappiness.

Dissatisfied people are more likely to have a pattern of binge drinking.

Binge drinkers are more likely to be dissatisfied with life. A pattern of binge drinking on weekends negates any beneficial effects of moderate alcohol use.

Excessive alcohol use increases dissatisfaction and unhappiness. Alcohol, even in moderation does not reinforce feelings of well being, pleasure, happiness or joy. Moderate drinking does not reduce unpleasant feelings.

Don't drink alcohol to regulate your mood, it leads to more grief.

References

1. H. Koivumaa-Honkanen; J. Kaprio; T. Korhonen;, R.J. Honkanen; K. Heikkilä; M. Koskenvuo. Self-reported Life Satisfaction and Alcohol Use: A 15-year Follow-up of Healthy Adult Twins. Alcohol and Alcoholism. 2012;47(2):160-168.
2. R. Curtis Ellison, Marjana Martinic. The Harms and Benefits of Moderate Drinking: Findings of an International Symposium. May 2007 supplement to Annals of Epidemiology.
3. Gustafson R. Does a moderate dose of alcohol reinforce feelings of pleasure, well-being, happiness and joy? A brief communication. Psychol Rep. 1991 Aug;69(1):220-2.

Aggression in children - need for parental intervention

Aggression is uncommon in school children and should be addressed

A Pune teenager was kidnapped and murdered by his school friends a few weeks ago. The victim was deliberately selected and his parents were manipulated for a ransom. Violence, theft and destructiveness are end stage behaviours of conduct problems in children and adolescents.

Trajectories of aggression in children

The commonest path of violence in children is 'adolescence-limited'. The antisocial behaviours usually occur when the adolescents are 'hanging out' in a group.  This type of aggression reflects an anti-authoritarianism. Anti-authoritarianism results from frustration over being denied the benefits of full adult independence despite reaching physical maturity. Adolescent limited aggression is less violent, relies on peer encouragement, and generally diminishes by adulthood  These adolescents are usually able to integrate into society as young adults.

A less common path of violence is 'life-course-persistent'. In this group of antisocial children, problem behaviors unfold in a sequence at home and school

1. Early noncompliance - with excessive arguing and disobedience
2. Poor rule adherence - staying out late, playing in prohibited locations
3. Low frustration tolerance - temper tantrums, abusiveness, aggression

Aggression is common among preschoolers. The prevalence rate of aggression in children reduces dramatically once they enter school. Children whose fighting does not  reduce in the early school years are at high risk for persistent violent behavior. This important subgroup of proactively aggressive youth is profoundly indifferent to the consequences that their misbehavior has upon others. They rarely display genuine remorse. Their personality of 'callous-unemotional traits' is characterised by a lack of empathy, self-centeredness, and shallowness. As youths they are responsible for a large number of violent offenses. Their aggressive behavior is often persistent as features of psychopathic or sociopathic personality.

Parenting can prevent violence

1. Make aggression irrelevant by modifying the setting
Aggression is significantly affected by the parent-child relationship. Children with conduct problems tend to have acrimonious and negative interactions with their parents. The parent is perceived as just an agent of coercion. It is important to change this environment. Positive interactions between the parent and child serves to reinforce the perception of the parent as a source of positive attention, affection, support and encouragement. This makes the child responsive to parents' authority and to the rewards and punsihment that  the parent dispenses.
2. Make aggression ineffective by modifying its consequences
The reactions of others to the aggressive behavior sustains and reinforces it. They may give in to what the child wants, give up trying to get compliance, or even bar the child from school -  which may be exactly what the child wants. To render the aggression ineffective parents/ teachers have to respond by ignoring milder misbehaviour and handing out consequences. These include time outs, loss of privileges (TV, cell phone, Facebook) that the child will want to avoid, and limit setting (curfew times, restricting location).

Parents need to establish  their authority and implement some of these measures in aggressive children. This teaches children that aggression is an ineffective means of fulfilling a particular wish. These lessons are better learned early under caring parents rather than later in a centre for juvenile delinquents.

References
Brennan LM. Toddler-age externalizing behaviors and school-age academic achievement: independent associations and the impact of parental involvement University of Pittsburgh. Thesis presented 27-Aug-2010.

Healthy Baby Contests - judging psychological development objectively

Psychological development is a key aspect of any ‘Healthy Baby Contest”. Pathfinder Clinic judged the psychological development of toddlers participating in one such local event. Healthy baby contests are among the most attractive activities organized by many preschools and communities. Assessment is a sensitive issue at any Healthy Baby competition. Parents of contestants are concerned regarding partiality and subjective errors. Judging a Healthy Baby Contest objectively is crucial to the credibility of the event.

Can psychological development be objectively assessed in 5 minutes?
Psychological assessment can be time consuming and difficult to operationalize. The child’s development is captured in speech, social interaction, and manipulation of every- day objects. Usually a child’s developmental milestones are judged ‘objectively’ based on the parents responses to available screening questionnaires.

We decided to get our knees dirty and go down to toddler level to get a direct assessment of where they were at. The caveat, the organisers wanted us out of the way in two hours. We judged 39 toddlers aged 2 to 4.5yr. We took three hours; less than 5 minutes per child on an average.

Method

The atmosphere around the play rooms was intense -  mainly contributed by parental anxiety. Pre-school coordinators ensured each child walked into the room with their parents. Despite some adult anxieties each family was safely seated at toddler level. Every child was greeted and asked their name. They were then asked to point to and name parts of the body and animal figures;  draw age-appropriate figures; manipulate wooden blocks or coloured beads; and catch a large ball.

Children were assessed on these categories

1. Speech and language
2. Social function
3. Fine motor function
4. Gross motor function
5. Cognitive function

The scores were entered into a proforma and results tabulated

Are healthy baby contests a waste of time?

Of course things didn’t always go smoothly, but under all the levity some serious assessment work was done. We learnt from the kids. Fans and lights are passe as objects to point out - a laptop will always bring out a prompt pointing index finger. The advantages are apparent

• With a reliable scoring system, the results are easy and quick to interpret and more acceptable.
• The results can be explained scientifically
• The protocol can serve as a guideline for educating caregivers and teachers regarding simple criteria for monitoring the child’s health status. These also serve as a checklist for their activities.
• Screening of at risk children - one child screened positive for autism (prevalence rate in the literature is 1 in 110). The parents were advised the need for follow-up.
• Data obtained is used to establish local norms for child development

Healthy Baby Contests can have a positive impact on the community when conducted scientifically. Psychological development of infants and toddlers can be effectively judged through direct observation in a short time-frame.

References

1. Bhat G, Pardeshi S, Kakrani V, Pratinidhi A. Making healthy baby contests more objective. Indian J Med Sci [serial online] 2001 [cited 2012 Mar 23];55:553-8. Available from: http://www.indianjmedsci.org/text.asp?2001/55/10/553/12035
2. M.L. Kulkarni, G.L. Mohan. Healthy Baby Contests-Beyond show, Beyond Objectivity Towards Health Education Indian Pediatrics 1999; 36:417-418 http://www.indianpediatrics.net/apr1999/apr-417-418.htm

Bipolar disorder and hypomania - irritability and depression

Chronic unstable mood with irritability and superimposed bouts of depression is a common form of bipolar II disorder or hypomania. Persons with this pattern of illness tend to have an unstable course and stormy interpersonal relationships. They also have more irritable and hostile hypomanic episodes. The classical Bipolar II disorder or hypomania of mild elevation of mood, sharpened and positive thinking, and increased energy and activity levels is less disruptive.

Persons with this irritable type of hypomania and bipolar illness have unrealistically high expectactions of those with whom they interact; whether at the workplace, at home, or other casual day-to-day interactions. When these expectations are not met they pass on their irritation and negative mood to unsuspecting others.

There is usually a grain of truth in their version of the incident, but the growing number of incidents with various people at all levels reduces their credibility. At the workplace they are frequently in search of a new job and personally they have problems sustaining meaningful relationships.

Anger management alone is usually not effective. It needs to be combined with specific treatment for the bipolar illness. At the clinic couples and individuals come in for anger and interpersonal issues that are not resolved with counselling.

"I never realised how much my moods controlled my actions"

Treatment for bipolar disorder including hypomania hinges on medication and psychotherapy. Treatment requires patience by all parties in the therapy. Relapses are frequent when medication is stopped.

"I can see the difference when he stops his medication;

help me get him back, doctor"

It takes time for the affected person to accept he or she has hypomania or bipolar illness. The degree of realisation fluctuates during the course of therapy. Regular psychiatric review is essential to prevent relapse in bipolar illness and hypomania

Mental health checklists and screening tests for rampaging bus drivers

Checklists and psychological screening questionnaires for mental illness are effective, easy to use and widely available. Pune was shocked into considering the need for mental health screening of its bus drivers after one of them wilfully killed eight people and injured 32 others. He hijacked a bus at the depot and mowed down victims in broad daylight. Amidst the protests, and outrage the Pune administration has decided that all its bus driver undergo psychological testing.

We have already looked at screening of police personnel for mental health problems, and also screening of teenagers for alcohol and drug abuse. Here we specifically examine the feasibility of regularly screening the 8600 PMPL staff and Pune bus drivers for mental health problems.

Mental illness in bus drivers

• Mental health problems are higher for bus drivers who suffer from back pain, are dissatisfied with their jobs or undertake long-distance driving. This is more so for employees who have worked for >10 years. (Issever et al 2002)
• Aggressive bus drivers have more anxiety, hostility, and anger. They display competitiveness when driving aggressively, and display anger at slow drivers and traffic obstructions (Galovski 2002). Aggressive drivers with Intermittent Explosive Disorder (IED) endorse more assaultiveness and resentment. They display more impatience, hostility and have an angry temperament.
• Bus drivers have higher hospital admissions with diagnoses of mood reactions, paranoia and non-specific psychoses. (Ugesker 1989)

Ideal mental health screen

Easy to administer

it is to be conducted regularly without consuming excessive time

Culturally acceptable

anything stigmatising will be shunned

Sensitive

picks up potentially vulnerable persons

Specific

excludes those who do not have mental health problems

Easy to interpret

results should be available immediately

The aim of mental health screening is to identify individuals who require a more detailed examination. One counsellor will never be able to carry out any evaluation of 8600 staff.

Mental health checklists and screening instruments

There are already valid (test identifies persons mental illness) and reliable (results remain the same when administered by different testers and on re-testing) checklists for mental health screening. Two mental health screening instruments that satisfy many of the ideal criteria are the COOP/WONCA charts and the WHO-5 questionnaire. Both have high diagnostic accuracy for mental disorders. Specificity, sensitivity and positive predictive values range from 0.85 to 0.87 (Anything more than 0.7 is good).

COOP/WONCA

The COOP/WONCA measures six core aspects of functional status: physical fitness, feelings, daily activities, social activities, change in health and overall health through six charts. The charts have been successfully used in illiterate populations, and have guidelines for translation where required. The average time for completion is less than five minutes. One-time assessment with the COOP/WONCA Charts is a valid and feasible option for screening for mental disorders at the primary care level.

WHO-5

The WHO-Five Well-being Index (WHO-5) is a set of 5 questions that can be used when six charts are too much.

A mental health check is most acceptable as part of the regular or annual ‘health check’. Those who score above the cut-off are taken up for detailed assessment by a psychiatrist or other mental health professional. No additional man-power is required. The process will not cost in crores. Our roads will be safer.

We need to use available checklists and screening tests for early detection of mental illness in Pune’s bus drivers.

References

1. Galovski T, Blanchard EB. Psychological characteristics of aggressive drivers with and without intermittent explosive disorder. Behav Res Ther. 2002 Oct;40(10):1157-68. 
2. Issever H, Onen L, Sabuncu HH, Altunkaynak O. Personality characteristics, psychological symptoms and anxiety levels of drivers in charge of urban transportation in Istanbul. Occup Med (Lond). 2002 Sep;52(6):297-303. 
3. Joao Mazzoncini de Azevedo-Marques, MD, PhD1 and Antonio Waldo Zuardi, MD, PhD. COOP/WONCA Charts as a Screen for Mental Disorders in Primary Care.  Annals of Family Medicine 9:359-365 (2011) doi: 10.1370/afm.1267
4. C. van Weel, C. König - Zahn, F.W.M.M. Touw - Otten, N.P. Van Duijn, B. Meyboom - de Jong. Measuring functional status with the COOP/WONCA charts: a manual. Northern Centre of Health Care Research 1990. ISBN 90 72156 33 1 
5. WHO. WHO-Five Well-being Index (WHO-5) Accessed 17-Feb-2011 
6. Ugeskr Laeger. Psychiatric admissions among city bus drivers. A prospective study. Ugeskr Laeger. 1989 Jan 30;151(5):302-5. 

Dyslexia - Difficulty with Reading, Maths & Spelling

Difficulty with reading, spelling and maths is rampant among Indian students. Two recent reports have highlighted this academic underachievement. The academic infrastructure is definitely a major contributor. However, unrecognised dyslexia or other learning disability also needs to be considered by every concerned parent and enlightened teacher. We have already discussed the management of dyslexia. Here we underline the urgent need for action.

India ranked 72nd of 73 countries in a comparative international survey (PISA) of 15-year-old students. All students were assessed on the same test for knowledge and skills in reading, mathematical and scientific literacy. A sample of more than 5000 students from 200 Indian schools were assessed in this program. In none of these categories did more than 17% of Indian students scored above baseline levels as compared to 81% of students from OECD countries (US, UK, Australia etc).

15-year-olds scoring above baseline 

Test	India	China	OECD avg
Reading	11-17 %	95.3%	81%
Mathematics	12-15%	94.5%	75%
Science	11-16%	96.3%	82%

The Annual Status of Education Report (2010) paints an equally dismal picture.
Reading ability

• Only half the students in Class 5 can read the Class 2 text

Maths

• Only a third of Class 1 children can recognise numbers 1-9
• Only a third of Class 3 students can do subtraction in two digits
• Only a third of Class 5 students can do simple division
• A third of Class 8 students could not use a calender

This may be a scathing indictment of our education system, but it also reflects the presence of unrecognised Learning Disorder in our students. Learning Disorder affects 5-10% of students worldwide. Learning Disorder manifests in varying combinations and severity of difficulty with reading, spelling and arithmetic.

If your child has difficulty reading, spelling or in mathematics

• Have them assessed for dyslexia or other learning disability
• The earlier remedial teaching is instituted the more likely the child is to benefit
• Identification of dyslexia or learning disability entitles your child to waivers at the 10th and 12th board exams.

The Right of Children to Free and Compulsory Education Act (RTE) of 2009 lays down the duties of government, local authorities and parents; the responsibilities of schools and teachers; and the norms for schools. These norms include the number of teachers, buildings, minimum teaching hours, teaching aids, library, and recreational equipment. However, the teaching to be done is not mentioned and nor is it monitored. Rote learning is emphasised. Students fail to acquire basic reading, writing and calculation skills that are required to continue learning as adults.

Don't just wait for the government 

Act NOW to secure your child's place in a global future

References:

1. ASER 2010 - Rural. Annual Status of Education Report (Rural)Date of publication: January 14, 2011
2. Maurice Walker. PISA 2009 Plus Results: Performance of 15-year-olds in reading, mathematics and science for 10 additional participants. ACER Press. Victoria. 2011.  ISBN: 978-1-74286-067-1
3. The Right of Children to Free and Compulsory Education Act (RTE). 

Recovery from mental illness

Recovery to meaningful functioning after even severe mental illness is the present standard of care in mental health treatment. Recovery is made possible by medications that are now widely available at a reasonable cost. Planning and persistence with treatment need to be ensured to achieve a quality recovery.

Recovery from mental disorders is a process of change through which individuals

1. improve their health and wellness
2. live a self-directed life
3. strive to reach their full potential

The road to recovery from mental illness has four components that together give meaning to life.

1. Health

Overcoming or managing the disease and living in a physically and emotionally healthy way.

Start with the basics - medication, meals, sleep and exercise. Establishing routines for these basic health tasks are essential for recovery of function. Medication is the corner stone on which recovery is nurtured. In the absence of medication frequent relapses and recurrences disrupt basic functions that protect the individual from the illness producing effects of daily stressors.

2. Home

A stable and safe place to live.

In daily practice we see persons with the most severe mental illnesses putting aside their disturbing thoughts, controlling their behaviours and getting back to school or work; while others with a milder illness are unable to leave their preoccupations and move ahead with life. Trusting relationships are quite often what they lack. Trust makes the home feel safe.

3. Purpose

Meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative endeavors, and the independence, income and resources to participate in society.

A person needs something to recover to. Amazing recovery can be sustained in a supportive job environment. Some bosses give this support naturally. It may be it is in their outlook; they see the illness as just one aspect of the persons identity. Vice versa, others with good symptom recovery without stigmata are unable to function in a hostile work place, and are unable to integrate with society  and lead meaningful lives.

4. Community

Relationships and social networks that provide support, friendship, love, and hope.

From volunteering at the community bookshop to joining a local football team; community interactions bring many otherwise isolated individuals into useful contact with others. These valued interactions are based on a personal identity which is not connected to their mental illness.

Recovery is a process towards achieving ones potential. The first small steps result in giant gains. Without them the individual is unable to reach any level of meaningful recovery. The first step for persons with serious mental illness is medication. Without medication, recovery from serious mental illness is long-drawn, stigmatising, and characterised by frequent relapses. Medication is the pillar around which recovery is fostered. A supportive home, work-place and community further augments this process. Recovery from severe mental illness is a process, it does not happen overnight, but for those who stay the course it brings the meaning back to life.

References

1. SAMHSA’s Definition and Guiding Principles of Recovery – Answering the Call for Feedback
    Accessed 04-Jan-2012