Parenting an Adolescent

Adolescence is a time of transition. Most parents find themselves bewildered by the changes in their previously affectionate and obedient children. Mood changes, withdrawal, monosyllabic answers and arguments find most parents asking, “What have we done wrong?”

Adolescence is marked by profound changes brought about by the hormonal surge at puberty. The physical changes are accompanied by emotional, behavioural and intellectual changes to which the child has to adapt rapidly.

“As their bodies, brains and worlds rearrange themselves, you (parents) will need to do your own reshuffling.”

Changing role of parenting adolescents

The need for autonomy, independence and a search for one’s own unique identity is an essential part of adolescence. Often, this is achieved by questioning and testing existing rules and norms. Make space for this quest. Handle an occasional error of judgement with explanations rather than with accusations and confrontation.

The essentials of parenting at this age are

1. Trust
2. Empathy
3. Respect
4. Support

Trust is important in all relationships. Trust your teen to do what is right. As far as possible, avoid correcting them and pointing out mistakes. Allow them to learn on their own.

Empathise. Your adolescent child is often plagued by self-doubts and insecurities. Remember you were an adolescent once, and do not trivialise their problems.

Respect their need to be away from you, alone or with friends. Listen to their opinions and try not to be dismissive of their views and values.

Support. Assure them of your love and support without being intrusive; this will encourage them to come to you in need.

Parenting styles

An authoritative parenting style provides the adolescent with opportunities to become self-reliant within a set of rules, limits and guidelines appropriate for his/her developmental age. The personality and temperament of the child may also influence your parenting style (a co-operative and responsible teen requiring much less supervision). The environment (e.g an unsafe neighbourhood) can also dictate your parenting style. Privileges and limits may be set with the active participation of the child. It helps to state your expectations without ambiguity (what is acceptable behaviour and what is not), set clear limits and enforce consequences (loss of privileges) when limits are not adhered to.

When parents differ in their parenting styles.

One parent (often a father who is away a great deal) may tend to be permissive in his parenting. Adolescents (and children!) are quick to take advantage of differences between parents. It is important for the parents to arrive at a consensus privately and present a united front when dealing with limits and consequences.

Autonomy vs Monitoring

There are no hard and fast rules. Monitoring does not mean constant surveillance. Safety concerns entail knowing about the whereabouts of the adolescent outside school hours, friends they are with and contact information. A schedule to return home should be worked out. Similar limits should be set for time spent on social media. Be honest in communicating your concerns and avoid doing things behind their backs. It only leads to lack of trust and a tendency to conceal things from you.

Do not seek to control. Often, clashes between parents and adolescent children are about who has control. Adolescents struggle for control over what they feel is their own life, while parents struggle to hold onto the control they had earlier.

Peers

Sometimes, you may be uncomfortable with the company your adolescent keeps. Do not rush into judgements and accusations. Observe for yourself if there is a genuine cause for concern. Teach your adolescents to say ‘no’ to what they feel uncomfortable about. Explain the harmful effects of risky behaviour (alcohol, drugs, sexual activity) at a young age.

When to seek help

Repetitive problem behaviours and high-risk behaviours require professional help and guidance. Aggressive and violent behaviour, progressive academic deterioration, school refusal or truancy, lying or cheating demand immediate attention. Increasing moodiness, lack of communication, inattention to personal hygiene are other warning signs of psychological distress.

Making the Cut—Self-cutting in Adolescents

Self-cutting in adolescents is the strongest predictor for subsequent suicide attempts. It is a clear signal of severe psychological pain being released physically by the act of self-cutting. However, relief is only temporary, and if ignored self-cutting can progress to suicide.

Self-cutting and Suicide

Repeated self-cutting in adolescents is the strongest predictor of attempted suicide. 70% of those who self-cut will attempt suicide at least once. The number of suicide attempts increases with the number of years engaged in self-cutting (Nock 2006). The risk of attempted suicide is higher than with any other psychiatric disorder including depression and borderline personality disorder. Self-cutting may be a uniquely important risk factor for suicide because its presence is associated with both increased desire and capability for suicide (Klonsky 2013).

Ms LM, 15 years old, was brought by her parents for counselling after a suicide attempt. She subsequently revealed repeated self-cutting over the upper, inner thighs after sexual abuse two years previously.

Self-cutting and Psychological Pain

The majority of people who self-cut do so to relieve intense psychological pain. It occurs independently of a diagnosis of borderline personality disorder, or history of sexual abuse in childhood (Klonsky 2014). Self-cutting has a calming effect. (Klonsky 2006). This is much the same way as applying a balm, the superficial irritation suppresses the underlying deep pain. Individuals who self-cut continue to do so because it decreases feelings of anxiety (Haines 1995). Some people self-cut to punish themselves. A small minority self-cut for attention seeking or to escape from responsibilities.

Ms RX, 24 years old: 'When I cut myself  I feel calm, I don't feel the pain'.

Self-cutting Scars

The scars of self-cutting can trigger distressing memories of a time of psychological pain. Seeing self-cutting scars on friends or hearing of self-cutting incidents can induce the urge to self-cut.

Ms KJ, 19 years old, had a history of self-cutting since middle school and was now coping well in a professional course while staying in hostel. She accidently saw self-cutting scars on her room mate. Since then she is anxious and fighting urges to self-cut.

An increasing number of self-cutting scars is associated with presence of suicide ideation and a history of suicide attempts (Taylor 2016). Visible scars on exposed parts of the body can restrict career and social choices. Skin grafting may be required in some cases (Todd 2012)

Mr JS, 21 years old, underwent training and qualified for an initial pilots license. During medical evaluation for a commercial pilots license self-cutting scars were noted on his chest. He was medically disqualified as a hazard to flight safety.

Why do some people self-cut and not others?

Biology may have an answer. A particular gene for serotonin regulation (5-HTTLPR) may be defective. Youths who face severe chronic interpersonal stress and have the defectives gene self-cut more than those with the fully functioning gene (Hankin 2014). Those who self-cut have reduced autonomic and stress responses to anticipation of pain making them less likely to avoid it. They also have increased responses after pain which reduces feelings of numbness and distress, and increases body awareness. This combination serves to reinforce self-cutting behaviour (Koenig 2017).

Self-cutting is a unique physical marker of severe psychiatric problems. Approach a mental-health professional for treatment.

References

1. Rebecca C. Brown and Paul L. Plener. Non-suicidal Self-Injury in Adolescence. Curr Psychiatry Rep. 2017; 19(3): 20. Published online 2017 Mar 17. doi: 10.1007/s11920-017-0767-9. Accessed 2018-09-14.
2. Haines J, Williams CL, Brain KL, Wilson GV. The psychophysiology of self-mutilation. J Abnorm Psychol. 1995 Aug;104(3):471-89.
3. Benjamin L. Hankin, Andrea L. Barrocas, Jami F. Young, Brett Haberstick, and Andrew Smolen. 5-HTTLPR x interpersonal stress interaction and nonsuicidal self-injury in general community sample of youth. Psychiatry Res. 2015 Feb 28; 225(3): 609–612. Published online 2014 Dec 3. doi: 10.1016/j.psychres.2014.11.037. Accessed 2018-09-13
4. Klonsky ED. The functions of deliberate self-injury: a review of the evidence. Clin Psychol Rev. 2007 Mar;27(2):226-39. Epub 2006 Oct 2. Accessed 2018-09-12.
   
5. Klonsky ED, May AM, Glenn CR. The relationship between nonsuicidal self-injury and attempted suicide: converging evidence from four samples. J Abnorm Psychol. 2013 Feb;122(1):231-237. doi: 10.1037/a0030278. Epub 2012 Oct 15. Accessed 2018-09-11
6. E David Klonsky, Sarah E Victor, and Boaz Y Saffer. Nonsuicidal Self-Injury: What We Know, and What We Need to Know. Can J Psychiatry. 2014 Nov; 59(11): 565–568. doi: 10.1177/070674371405901101. Accessed 2018-09-13
7. Julian Koenig, Lena Rinnewitz, Marco Warth,Thomas K. Hillecke, Romuald Brunner, Franz Resch, and Michael Kaess. Psychobiological response to pain in female adolescents with nonsuicidal self-injury. J Psychiatry Neurosci. 2017 May; 42(3): 189–199. Published online 2016 Nov 29. doi: 10.1503/jpn.160074. Accessed 2018-09-13
8. Nock MK, Joiner TE, Gordon KH, et al. Non-suicidal self-injury among adolescents: diagnostic correlates and relation to suicide attempts.  Psychiatry Res. 2006;144(1):65–72. Accessed 2018-09-08
9. Taylor A. Burke, Jessica L. Hamilton, Jonah N. Cohen, Jonathan P. Stange, and Lauren B. Alloy. Identifying a Physical Indicator of Suicide Risk: Non-Suicidal Self-Injury Scars Predict Suicidal Ideation and Suicide Attempts. Compr Psychiatry. 2016 Feb; 65: 79–87. Accessed 2018-09-11
10. Jodi Todd, Sara Ud-Din, and Ardeshir Bayat. Extensive Self-Harm Scarring: Successful Treatment With Simultaneous Use of a Single Layer Skin Substitute and Split-Thickness Skin Graft. Eplasty. 2012; 12: e23. Accessed 2018-09-11

Anger—effect on your child

Effect of Anger on your Child

Anger has a silent but permanent effect on your child. Anger can affect your professional life, harm relationships, and has significant health implications. But quite apart from how it affects you personally, it affects your children. Children of angry adults have been seen to be more aggressive, oppositional and non-compliant. They are also less empathetic; and display poor overall social adjustment. Delinquency and anti-social behaviour are also more common in such children.

Is anger hereditary or learned?

• A child experiences emotions from birth, but how he/she handles emotions is largely determined by learning. While a child may have an irritable temperament, no child is born with temper tantrums. A child learns that throwing a temper tantrum is rewarding (gets attention or gets him what he wants).
• From infancy onward, children learn by imitation. As parents, we are the first role models. Our children watch us; and then model their behaviour on ours. A child will for example; notice that we talk to our elders respectfully, but that we talk brusquely, even rudely to our maids. They will soon behave the same way.So it is with anger. Children observe how we react in difficult situations, how we react to provocation; how we deal with differences. Do we negotiate and listen to the other person’s point of view? Or do we react immediately and aggressively? Do we talk amicably and or do we get what we want by threats and abuses? How we behave and act today is what our children will emulate tomorrow.

What is the effect on a child when adults behave angrily in front of them? It depends a great deal on the age, developmental stage, personality and emotional maturity of the child.

• Young children, particularly, are scared and confused when they see adults who are ‘out of control’. When it happens often, they learn to think of this behaviour as ‘normal’; and they assume that verbal or physical aggression is the ‘normal’ way to deal with differences, to control others, or get what one wants.
• Very often, children are at the receiving end of parental anger. This may be due to unfair and unrealistic expectations that parents have from their children; or misplaced anger that has its basis somewhere else. Fear, insecurity, and poor self-esteem occur almost universally. Withdrawal, anxiety, depression are some of the negative consequences of such anger. This affects optimal performance in school and peer relationships. 
• Alternatively, the child may learn to defend itself by increasingly oppositional behaviour, bullying younger siblings or other children, or engage in other disruptive behaviours –truancy, aggression and violence.
• Parental anger deprives children of the basic need for security and comfort in their own homes. It also perpetuates the legacy of anger and aggression; conflict and fear.

Anger management strategies for interacting with children

• Stay calm when interacting with children. If you are fuming because you were held up in a traffic jam, cool off with a shower before interacting with your child.
• Physical abuse is a strict no.
• Try and understand the underlying issues behind your anger. Is your frustration resulting from an unsatisfactory day at work? Is your disappointment with your child’s academic performance related to your own expectations?
• Learn about your child—his needs, his temperament, learning styles, even the normal development process. This will go a long way in modifying your unreal expectations.

It is possible to break the destructive chain of anger and to create an environment of safety and security in your home for your children. Start today.

Biology of Anger

We all get angry at times. But some of us get angry often and what is worse, we do not seem to be able to control it. We lash out verbally and sometimes physically at objects and people around us. Can we do something about our anger or is it something over which we have no control?

Let us seek to understand the evolutionary basis of anger and what happens inside our brains when we are angry. Anger is usually provoked by a threat; either real or perceived. Our ancestors had to react (and react immediately) to survive; or to protect themselves or their resources. To take time to think would be to lose valuable time. So the brain evolved a mechanism for immediate action.

An almond-shaped area of grey matter deep within our brains - the amygdala perceives threat and generates the emotions of anger and fear. It raises an alarm, and kick-starts the body responses which we collectively know as “arousal”. Our heart beats faster to pump blood to our muscles, the muscles tense for action, breathing becomes faster and shallower, voice becomes shriller. Our face assumes the expression of anger (clenched jaw, lowered brows) as a warning to the adversary; much in the same way that a dog growls and bares its teeth when threatened. All this happens in a matter of seconds.

The frontal cortex, (the part of our brains responsible for conscious decisions) is by now aware of these bodily reactions and the threat perception. It evaluates the situation and the social context. Based on past memory, learning and our individual experience, it decides to respond in a particular way.

So what we have here is an immediate emotional response, and a later conscious response. An example will make things clearer.

• Imagine yourself at a crowded mall. Someone pushes you and moves on un-heeding. You will naturally be annoyed, your face will mirror your displeasure. You are aroused and vigilant - your muscles tense, you breathe faster. This is the immediate response. You realise though after a minute or so that it was probably accidental and think no more about it.
• On the other hand, you may remember that a friend had his wallet stolen in the same way, you may remember reading media reports about pick-pocketing, and you may be having a substantial amount of money in your wallet. Your reactions will be stronger. You may yell at the person, or may even push him in turn. Your conscious mind from past learning and in the present situation causes you to respond differently.

Our emotions; (anger, fear etc) are innate; but our response styles are mostly learnt. We may have seen the same kind of behaviour in our parents (our first role models) in childhood. Or aggression may be our reaction to abuse or bullying. Or we may have observed that anger is the best way to get what we want. Genes, gender (males are known to be more physically aggressive when angry), and our own personality traits also contribute.

Since emotional arousal occurs involuntarily, you may well ask “How can I have any control over my anger?” You can control the behavioural manifestations of anger.

1. Firstly, recognise the signs of anger and arousal. 
2. Then learn to consciously control these processes. Breathe slowly, lower your voice, relax your muscles, stop frowning. 

Does it help? Yes! When we consciously speak slowly and lower our voices, when we relax our tense muscles, when we wipe the frown on our faces and replace it with a smile, we influence activity of the emotional regions of the brain. fMRI scans show less activation in the amygdala. The arousal process is reversed. This is the science behind and the biological basis of anger management. Cognitive Behaviour Therapy further seeks to modify your perceptions – may be what made you angry in the first place, what you perceived to be a threat; was not so at all?

Impulse Control Disorders – Skin Picking, Hair Pulling & More

Skin Picking, Hair Pulling & other Impulse Control Disorders

Impulse control disorders are a treatable group of disorders which share a common feature. This is the failure to resist an impulse or temptation to do something harmful, either to oneself or to others. The person usually senses increasing tension or arousal prior to the act; and pleasure, gratification or relief following the act.

Common Impulse Control Disorders

1. Trichotillomania or Compulsive Hair Pulling
2. Dermatillomania or Skin Picking Disorder
3. Kleptomania
4. Compulsive Buying Disorder
5. Pathological Gambling
6. Internet Addiction

Trichotillomania in simple terms is compulsive hair pulling. There is a recurrent or persistent urge to pull out hair leading to noticeable hair loss – usually from the scalp but sometimes from the eyelashes and eyebrows. It occurs more often in females and starts in adolescence. Sometimes the person may do it consciously, but mostly she is unaware of it, doing it when she is alone; - watching TV, talking on the phone or reading. It may be triggered by stress but may occur even when a person is calm and relaxed. The loss of hair is distressing to the person and she tries to hide the hair loss by using a cap or a scarf. In extreme cases, she may avoid going out and all social situations.

Dermatillomania or skin picking disorder is a similar disorder. A person may constantly pick at real blemishes (acne, scars, moles) causing bleeding, bruises, infections or permanent damage to the skin. Sometimes a person will pick at imagined defects which no-one else can see. The face is the commonest area. It may be a conscious response to anxiety or depression, but is frequently done as an unconscious habit.

Both trichotillomania and dermatillomania can be effectively treated by various forms of CBT such as Habit Reversal Training, Stimulus Control Techniques or Cognitive Restructuring. Compulsive hair pulling may occur in schizophrenia, therefore a psychiatry consultation is advisable. Medications may be required in severe cases.

Kleptomania is probably the best known of the impulse control disorders and has been described from the early 19th century. There is an irresistible urge to steal objects but these are not acquired for personal use or monetary gain. The objects may be discarded, given away or hoarded. There is a sense of tension prior to the act of stealing and a sense of gratification during and following the act.

Compulsive buying disorder, first described in the early years of the 20th century, is a preoccupation with shopping and spending. 80-90% of those affected are women, and it is more common in developed countries where there is a wide availability of items, higher incomes and leisure time. These people tend to share certain characteristics - they frequently shop alone, usually on credit (having many credit cards), buy items they do not need and are often in debt. Buying urges are episodic and can be frequent (daily) or infrequent (less than a month). Four distinct phases have been identified, including

1. Anticipation - in which there are thoughts and urges of shopping or having a specific item
2. Preparation – the stage at which the person plans and decides when and where to shop.
3. Shopping – which is usually described as “intensely exciting”
4. Spending – which is accompanied by a sense of relief but often feelings of disappointment with oneself.

Many of these women have low self-esteem; and the shopping temporarily allows them to feel better about themselves. It also explains why items purchased are mainly clothes, shoes, cosmetics and jewelry.

Pathological gambling: More common in young men, a person suffering from this disorder has an intense urge to gamble despite severe and often devastating personal, family or work-related consequences. He is unable to stop even with an effort of will. He is preoccupied by thoughts and images of gambling. He needs to gamble with increasing amounts of money to achieve the same level of excitement and is restless and irritable when attempting to stop or cut back. These features of tolerance and withdrawal are similar to those seen with alcohol and drug abuse.

Internet addiction or compulsive/problematic internet use: though much highlighted in the media, this requires further study. What is known is that compulsive internet use can interfere with daily life, work and relationships. When a person feels more comfortable with his online friends than his real ones, when he cannot stop himself from playing games, gambling, internet shopping, or compulsively checking his laptop or phone; it is probably time to acknowledge a problem and seek professional help.

Diagnosis

Impulse control disorders share features with obsessive compulsive disorders and with substance abuse. It is important to see a psychiatrist to rule out co-existing or underlying disorders. Impulse control disorders also need to be distinguished from other medical conditions. Milder cases can be treated as outpatients with medication and psychotherapy. Severe cases such as those with pathological gambling often require admission in a rehabilitation centre.

References

1. Black DW. A review of compulsive buying disorder. World Psychiatry. 2007;6(1):14-18. Accessed 09-May-2017
2. Grant JE, Schreiber LR, Odlaug BL.Phenomenology and treatment of Behavioural Addictions. Can J Psychiatry. 2013 May;58(5):252-9. Accessed 10-May-2017
   
3. Trichotillomania – Symptoms and Treatment Accessed 09-May-17
4. Skin Picking Disorder (Dermatillomania) – Symptoms and Treatment Accessed 09-May-2017

Diet & Depression

Diet and Depression

Depression diets were first described in the 2nd millennium BCE. Special diets (including donkey’s milk!) were prescribed in ancient Greece and Rome; and nutritionists have since been looking for possible links between diet and depression. With 350 million sufferers globally; the search for effective treatment and prevention of depression is still on. 

Link between diet and depression

Many people with moderate and severe depression are known to consume food of poor nutritional quality. This is often due to the symptoms of depression itself; such as the loss of appetite; lack of interest in day to day activities; and lack of motivation for self-care. Age, living alone, irregular and hectic work schedules, socio-economic status, cultural and religious taboos may further affect the quality of the diet.

The food we eat is broken down to its simplest forms in the intestines. The nutrients are then used to provide energy for the body and brain; and to synthesize essential compounds. Among them are the hormones and neurotransmitters which act as messengers in the brain. A lack of supply in the diet will therefore certainly affect production of these chemicals.

Bacteria present in our gut help in the breakdown, absorption and even in the synthesis of some of these essential compounds. The type of food we eat, in turn, affects the type of microbes in the gut Thus, there seems to be an important link between what we eat; the microbes in our gut, and all aspects of our health, including mental health.

What are the essential elements of the depression diet?

A diet including whole grains, leafy and colourful vegetables, fruits, nuts and legumes, high quality protein in the form of seafood, chicken and lean meats has been found to be positively correlated to mental health.

• Whole grains contain complex carbohydrates, which are linked to the mood boosting neurotransmitter serotonin. Complex carbohydrates break down slowly in the body, lead to steady levels of glucose in the blood and thus avoid mood fluctuations.
• Proteins of high quality as in egg whites, chicken, fish, milk products, soy products, beans and legumes are the source of the amino acid tryptophan, which is the precursor of serotonin. Trace minerals - selenium, chromium, and zinc, present in beans, legumes, lean meats, dairy products and whole grains are also linked to the brain and mental health.
• Anti-oxidants combat the free radicals which cause cell damage in the brain. Rich sources of anti-oxidants are coloured vegetables such as pumpkin, carrots, spinach(containing beta carotene), citrus fruits, tomato, potato, guava (containing Vit C); nuts, seeds and vegetable oils (having Vit E)
• Omega 3 fatty acids play an important role in mental health and may be used as a supplement in depression. Mammals do not synthesize omega 3 fatty acids and depend on dietary sources which include fatty fish, flaxseeds, and nuts (especially walnuts).

Vitamin D and Depression

Low Vitamin D levels are often seen in depression, but no definite causal association has yet been found. Depression itself may cause low Vitamin D levels, as people with depression are less likely to go outdoors. It would be sensible to correct Vitamin D levels and include fish oils, fish and dairy products in the diet, but use supplements with caution.

In conclusion

Depression cannot be prevented or cured by a special diet. However, a sensible diet including whole grains, proteins, fresh fruits and vegetables will keep you looking and feeling good. Limiting refined starches (the so-called “beige diet” pasta, pizza, bread, baked goods), caffeine, and alcohol also has a beneficial effect on mood. Do not go for any extreme or ‘fad’ diet. It will only add further to your stress and anxiety. A recent study of depression patients shows that diet does not prevent, cure or relieve depression, but diet may have a significant role in recovery and prevention of depression

Diet and dietary supplements are never a substitute for a therapist.

References:

1. Democritus Junior (Robert Burton). Anatomy of Melancholy (1652). Project Gutenberg release date January 13, 2004. Accessed 08-May-2017
   
2. Rashmi Nemade, Natalie Staats Reiss, Mark Dombeck. Historical Understandings Of Depression. Sep 19, 2007. Accessed 08-May-17
3. Rao TSS, Asha MR, Ramesh BN, Rao KSJ. Understanding nutrition, depression and mental illnesses. Indian Journal of Psychiatry. 2008;50(2):77-82. doi:10.4103/0019-5545.42391. Accessed 08-May-2017
4. Drew Ramsey. Prescribing a Diet to Treat Depression. February 03, 2017. Accessed 08-May-2017

Did you know? Many celebrities and historical figures have suffered from depression. Writer JK Rowling, musicians and singers Lady Gaga, Bruce Springstein, Sheryl Crow, actors Robin Williams, Jim Carey, Gwyneth Paltrow, astronaut Edwin ‘Buzz’ Aldrin suffered from depression. Abraham Lincoln, also a sufferer, once said “If what I feel were equally distributed to the whole human family, there would not be one cheerful face on earth.”

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.