Breakup of romantic relationships in youth

Breakups in non-marital relationships are a source of stress in youth. Breakups are a major reason for self-referral at the Clinic. Stress arises from conflict in daily interaction between the couple and peaks at the time of breakup. The individual’s reaction to breakup of the relationship depends on his or her attachment style.

Reactions to breakup depend on individual attachment style

There are four attachment styles displayed in relationships. These attachment styles are delineated based on the individuals capacity for intimacy (interest in and comfort with closeness and interdependence) and independence (less dependence on partner’s approval, and reduced anxiety about abandonment) (Bartholomew and Horowitz, 1991).

How do individuals react during a breakup?

Intense reactions occur in those individuals whose partners terminated the relationship, those who were more emotionally involved in the relationship, and those high in attachment anxiety.

Emotionally secure individuals react to romantic breakup with open, empathic communication with their partner. They try social coping strategies and use friends and family as sources of comfort. They are better able to understand their partner’s point of view regarding the breakup, and are less likely to respond in a histrionic or angry fashion. Secure individuals come in for therapy when they are disturbed by their partner’s reaction to the breakup.

Avoidance prone and dismissing individuals rarely display distress or acting out behaviours. They try to avoid all contact with and reminders of the partner. They also successfully use self-reliant coping strategies. Dismissing individuals use self-medication to suppress attachment-related thoughts and feelings, and this is often the reason for which they come seek help at the Clinic.

Anxious insecure individuals coming to us display three primary dysfunctional reactions (Davis and colleagues, 2003).

• Extreme distress and preoccupation with the lost partner. They neglect work and themselves, waiting all day at the computer desperately hoping to chat with the partner who is trying to terminate the relationship.
• Acting out - strenuous and exaggerated attempts to reestablish the relationship. This is often combined with angry, hostile, vengeful or violent behavior. These reactions include stalking and defaming the former lover by passing on contact numbers and photographs.
• Dysfunctional coping and lack of resolution of the loss including self-destructive strategies such as use of drugs or alcohol. .

What happens after the breakup?

Resolution. Breakup leads to changes in the individual’s perception of himself or herself – the self-concept (Sloter and colleagues, 2010). Relationship anxiety is strongly associated with a lost self-concept without the former partner. The partners renegotiate their sense of self outside the boundaries of relationship. Reduced clarity in the self-concept is associated with post-breakup emotional distress. With time most breakups end in resolution of the associated distress. The individual’s idea of the self and the lost attachment figure are reorganised to allow a changed emotional bond and adjustment to changed circumstances.

Integration. Anxious and avoidant persons may to some extent integrate the ex-partner into their lives in an altered form of attachment, such as friendship or working relationships.

Chronic mourning. Those who are higher in anxiety (more emotionally involved) and those who are more attached to the lost partner (did not initiate the breakup) have greater desire for the lost partner.

Replacement. Insecure individuals high in attachment anxiety are more likely to search immediately for a replacement partner. They feel uncomfortable when not in a romantic relationship. Re-bound relationships formed under these desperate conditions are unusually troubled later on.

High attachment anxiety increases the breakup rate

References

1. Bartholomew K, Horowitz L M. Attachment styles among young adults: A test of a four-category model. Journal of Personality and Social Psychology. 1991: 61, 226-244.
2. Davis D, Shaver PR, Vernon ML. Physical, emotional, and behavioral reactions to breaking up: the roles of gender, age, emotional involvement, and attachment style. Pers Soc Psychol Bull. 2003 Jul;29(7):871-84.
3. Slotter EB, Gardner WL, Finkel EJ. Who am I without you? The influence of romantic breakup on the self-concept. Pers Soc Psychol Bull. 2010 Feb;36(2):147-60. Epub 2009 Dec 15.

Anger management can save your life

Anger induced electrical changes in the heart

Anger management can save your life. Anger can place you at high risk for developing  electrical abnormalities in the heart tissue. These electrical abnormalities are strongly associated with subsequent heart attacks. The chances of surviving an out-of-hospital heart attack are not good. Anger control can save your life by reducing the risk of an out-of-hospital heart attack (Rashba, Lampert 2009).

Why we need the emotion of anger

Charles Darwin was the first to note the universality of anger and other facial expressions of emotion. He viewed this as evidence that emotional signals like anger have been stamped by evolution into the central nervous system. Anger has an essential survival function. Anger needs to be controlled or managed for it to be effective.

Anger management strategies

These are strategies to change your attitude to the expression of anger, as also immediate and long term behaviours to control anger.

Focus and mindset strategies

To control anger one needs to control the scripts that lead up to it

• He's being stupid again. Recognise how easy it is for the best among us to be wrong and make mistakes. Don’t expect life to go on as planned
• It's OK to blow my top once in a while. Talk things over before you reach the explosive stage. Think of how you will regret having been indiscrete and hurting someone. It could work to your disadvantage later. Don’t view an occasional outburst as good for letting off steam. Don’t bottle up your feelings - express them civilly.
• I'll show him who's boss. Remember that your aggression is likely to spark a chain reaction of aggression in others. Losing your temper is not the mark of a strong character who knows his/her mind
• That's my right. There is a difference between feeling indignation and losing your temper because you cannot have things your way. The former leaves room for negotiation, the latter only makes things worse

Strategies for immediate anger control

• Monitoring your feelings  is one of the key skills for anger control. Be aware of your body sensations, such as flushing, muscle tensing, and heart beat as you are getting angry. Take those feelings as a cue to stop and consider what to do next instead of shouting or lashing out.
• Force yourself to keep your voice down. Make a deliberate attempt to speak quietly and slowly
• Take 'time out'. Remove yourself physically by walking away from the place of argument
• Count to ten slowly so the impulse to retort will pass
• Look at your face in the mirror. Now you know why the others are laughing

What to do in the long run

Study your anger. Keep a diary of trigger incidents. Look for the pattern. Avoid precipitating situations as far as possible. Two situations that commonly precipitate anger.

1. Insecurity, which makes you unduly sensitive. Social cues interpreted as hostile may in fact be neutral or friendly
2. Frustration. Learn to accept what can’t be altered. Do your best – do not frustrate yourself over what is not in your control.

Cultivate a sense of perspective. Often the things we lose our temper over seem trivial in hindsight. What really matters to you in life? See things against that background. If its friendship, is it worth losing your friend by losing your temper? Take the perspective of other people. Get a sense of how you are being seen and of what other people might be thinking and feeling in the encounters that make you so angry
Understand people who make you angry. Ask yourself: ‘why do I always get angry with him/her?’ Why do you find them irritating? Enter into their experience – what does it feel like to be them? Others may not accept your point of view all the time. Understand the other person’s point of view. Don't be judgemental.
Relax. Incorporate a relaxation period in your routine – meditation, yoga, music; whatever works for you.
Get direct training in anger control. Many individuals are unhappy that they lose their temper easily. They are receptive to learning how to control it. In the heat of the moment, cool-headed responses such as walking away or counting to ten so the impulse to hit will pass are not automatic. Practice such alternatives in role-playing scenes. Try out friendly responses that preserve dignity while giving an alternative to shouting, hitting, and sulking.

Anger may signal a treatable underlying mood disorder. Treat it. Protect your heart

References

1. Eric J. Rashba . Anger Management May Save Your Life: New Insights Into Emotional Precipitants of Ventricular Arrhythmias. J. Am. Coll. Cardiol. 2009;53;779-781. doi:10.1016/j.jacc.2008.11.023
2. Rachel Lampert, Vladimir Shusterman, Matthew Burg, Craig McPherson, William Batsford, Anna Goldberg,  and Robert Soufer. Anger-Induced T-Wave Alternans Predicts Future Ventricular Arrhythmias in Patients With Implantable Cardioverter-Defibrillators. J Am Coll Cardiol, 2009; 53:774-778, doi:10.1016/j.jacc.2008.10.053

Cross-Dressing - Prevention by Parenting?

Cross-dressing is associated with problems in parenting and may be preventable. Recently a male student in Pune was found dead with a wig and female articles of clothing lying about his room.

Types of cross-dressing

Cross-dressers in society are psychologically indistinguishable from non-cross-dressing men (Brown 1996).

1. Fetishistic transvestism
Almost three percent of men and 0.4% of women have had at least one episode of transvestic fetishism (sexual arousal from cross-dressing) (langstrom 2005). However, these 'nuclear' transvestites are less likely to venture out dressed in public.
2. Transvestism
'Marginal’ transvestites experience non-sexual pleasure from cross-dressing and are more likely to appear in public while cross-dressed. They are probably a separate group and more likely to be homosexual.
3. Transsexualism
Cross-dressers could also be transsexuals who desire surgical sex reassignment. Cross-dressing in Asians is one of the earliest signs of transexualism (Tsoi 1990).

The cross-dresser's childhood

(RL Schott 1995)
Cross-dressers are usually the eldest male child in their family. Most had a very positive relationship with their mothers and a very negative relationship with their fathers.
As children cross-dressing was furtive and secret - the covert group of cross-dressers. In the overt group (up to 20%), cross-dressing was initiated and openly encouraged - up to school age and sometimes beyond - by a mother, sister, or other female extended family member.
Young boys, in contrast to young girls, must struggle to separate psychologically from their mother in order to establish their own gender identity. Identification as a male, as being of the opposite sex from the mother, requires individuation and separation from her. Disturbances in masculinity (cross-dressing) may be an expression of impairments in this process. The eldest male child may be especially vulnerable for lack of a role model or cushion between himself and the mother.

Cross-dressing facts

(Docter 1997)

• Usually starts before the age of 10 years.
• Initially associated with sexual pleasure and orgasm. However, up to 90% of cross-dressers continue to do so for non-orgasmic pleasure.
• The most commonly used articles are female underclothing and wigs.
• Considered as an expression of the feminine part of the self, rather than as just the self with different clothes. Cross-dressing is an expression of consciously felt femininity (Levine 1993). Hence the symbol.
• Cross-dressers prefer complete to partial cross-dressing.
• Cross-dressers are not bold in their public appearances. About a quarter appear cross-dressed in public and a similar number have ever used the lady's restrooms - the final frontier of femininity. With increasing awareness and activism public appearances by this group of people are increasing.
• Transvestism in adulthood is associated with guilt. Most cross-dressers get rid of their feminine clothing at some time due to feelings of shame.
• Most wives are aware of their partners cross-dressing. Up to a quarter of them are completely accepting of the behaviour.

When is cross-dressing normal in children?

Cross-dressing boys are first brought for psychiatric evaluation by their parents when they are discovered in their mother's underclothes. The sexual outcome of early isolated cross-dressing is not predictable.
• It is not uncommon for boys to prefer aesthetic activities like dance or singing to football or wrestling. 
• They occasionally role-play as a girl, play with a doll, or dress up in a girl's or woman's costume.

Cross-dressing is associated with transvestism and transsexualism when there is
1. Stated preference for being a girl and for growing up to become a woman
2. Repeated cross-sex fantasy play
3. Preference for traditionally female-type activities like knitting and baking
4. Female peer group

How to deal with a cross-dressing child

Parents bring their cross-dressing child for psychiatric evaluation when they fear he will become homosexual or transsexual. We have already seen that  parenting style affects the child's social, emotional and behavioural development. At this early stage the focus should be on making the child comfortable with himself or herself and to reduce social stigma (Lev 2005).

Integrate the child into his peer group

This is essential to prevent teasing

• By ages 4-5 boys and girls differ in their manners of walking, running, throwing a ball, and narrating a story. Point out these gestures and mannerisms.

Emphasise a positive father-son experience

Whether the father is distant or the boy is more attuned to his mother - the boy with gender identity disorder typically has a strained relationship with his father.

• The father must compromise his busy work schedule to build a relationship with his son.
• Nonathletic activities can be mutually enjoyable.
• Taking the son to work provides a better image of who father is.
• Board games, video games, and a shared father-son activity, such as model making and visits to the zoo are helpful.

Convey happiness with the sex of the child

The child may believe that the parents wanted a child of the other sex. Sometimes parents did and conveyed the wish to the child.

• Parents must convey the message that they wanted a child of the same sex.
• Convey that they are happy with the sex of their child.

Teach the boy that sex is irreversible

Psychologically children have not achieved gender constancy at ages 4 to 6. They may think that by cross-dressing or changing hair length they change their sex.

• The anatomical differences between the sexes should be made explicit
• Point out that superficial changes will not change their sex.

References

1. Brown GR, Wise TN, Costa PT Jr, Herbst JH, Fagan PJ, Schmidt CW Jr. Personality characteristics and sexual functioning of 188 cross-dressing men. J Nerv Ment Dis. 1996 May;184(5):265-73.
2. Richard F Docter and Virginia Prince. Transvestism: A survey of 1032 cross-dressers. Archives of Sexual Behavior; Dec 1997; 26, 6.
3. Långström N, Zucker KJ. Transvestic fetishism in the general population: prevalence and correlates. J Sex Marital Ther. 2005 Mar-Apr;31(2):87-95.
4. Arlene Istar Lev. Transgender emergence: therapeutic guidelines for working with gender variant people and their families. Haworth Clinical Practice Press. New York. 2005.
5. Levine SB. Gender-disturbed males. J Sex Marital Ther. 1993 Summer;19(2):131-41.
6. Richard L. Schott. The childhood and family dynamics of transvestites. Arch Sex Behav. 1995 Jun;24(3):309-27.
7. Tsoi WF. Developmental profile of 200 male and 100 female transsexuals in Singapore. Arch Sex Behav. 1990 Dec;19(6):595-605.

Whitener Addiction - Death by Inhalant

Whitener (correction fluid) inhalation caused the death of a Pune student recently. Whitener is abused as an inhalant in India. Whitener exerts its effects through trichloroethane, a volatile solvent. Inhalants include other substances such as petrol and toluene. These substances are cheap, accessible and readily available to children and adolescents.

Epidemiology

Solvent abuse is prevalent among street children and working kids. Teenagers start using solvents to gain entry into a gang, and occasionally as experimentation. Its use in a college student is unusual. But this may be a developing pattern indicating spread of the habit into middle class homes. (Kumar S 2008). Most adolescents are one-time or short-term users. Those who abuse inhalants persistently usually have conduct disorders.

Methods of inhalant abuse

1. Sniffing - direct inhalation from a container or piece of clothing sprayed with the substance.
2. Huffing - holding a soaked cloth over the nose or mouth to increase the concentration of vapours.
3. Bagging - breathing from a paper or plastic bag containing the volatile substance to further increase the concentration (Henretig, 1996).

Mechanism of action

Young people abuse volatile solventsby deliberately inhaling available vapours 15–20 times over 10-15 minutes. This results in concentrations of up to 10000ppm as against the industrial standard of 50-100ppm (Bowen et al., 2006).

Inhaled organic solvents like toluene cross from the blood into the brain within minutes. In the brain cells solvents act on specific receptors (NMDA and GABA) to produce effects similar to those of alcohol. Toluene, a common solvent in thinner and paint, increases opiate receptors in the Nucleus Accumbens - a key brain area associated with the reward system and the experience of pleasure. Toluene enhances dopamine release in the Nucleus Accumbens.

Effects on the body

(Lubman 2008)

• At low concentration (500-4000ppm) transient euphoria and disinhibition make abusers prone to risk taking and accidents.
• At higher concentrations (6000-15000ppm) dizziness, sleepiness, slurred speech, blurred vision and headaches appear. Users appear confused, unbalanced, or begin responding to hallucinations.
• Higher doses result in seizures, coma and cardiopulmonary arrest .

Death by inhalant

• Sudden sniffing death is the most common cause. Even first-time experimental users are at risk of sudden sniffing death as a result of heart rhythm abnormalities especially if the user is startled or agitated. 
• Suffocation and burns from exploding solvents
• Accidental injury as a result of impulsive risk taking and impaired motor skills while intoxicated. 
• Suicide accounts for up to 40% of inhalant-related deaths
• First-time users are also likely to die, perhaps because they are inexperienced at this dangerous pastime.

Recognition

Inhalant abuse should be suspected in teenagers showing intermittent intoxication,and signs of recent inhalant abuse including paint or oil stains on clothing or skin, spots or sores around the mouth, red eyes, runny nose, chemical odor on the breath, and a dazed appearance (Anderson, 2003).

Mass screening in schools could be undertaken as part of the annual health check. The mental health component for middle and high schoolers should include the CRAFFT. The CRAFFT is a validated short screening instrument for substance abuse in teenagers.

Laboratory diagnosis is not reliable as these volatile substances

• Do not persist in the body beyond a few hours
• They are undetectable in urine samples because of their volatility
• Hippuric acid, a long lasting toluene metabolite is also produced by foods and  raises the question of false positives. Also, it is usually not available for testing in emergency

Outcome

For most adolescents inhalant use should be regarded as a passing phase or fad. A few persistent users have antisocial personality disorder and abuse other substances. Chronic users develop damage to all organ systems - heart, lungs, brain, kidneys, and liver. The good news (Cairney et al., 2005) -

Damage to the brain is reversible with abstinence

Treatment

There is no specific medication to treat intoxication or for abstinence.

If you suspect a child is intoxicated with an inhalant stay calm and do not alarm him or her. Startling or frightening the child precipitates hallucinations and can also lead to ‘sudden sniffing death’ due to the effect on heart rhythm. Initiate cardio-pulmonary resuscitation (CPR) until help arrives if there is no heart beat or breathing.

When the child or adolescent recovers the incident should be discussed non-confrontationally. Remember, even a single inhalation can kill the child. Also abuse of other substances is frequent with regular whitener abusers. After talking it over commit to seeking psychiatric help. Social, environmental and recreational opportunities need to be addressed.

References

1. Carrie E. Anderson, and Glenn A. Loomis. Recognition and Prevention of Inhalant Abuse. Am Fam Physician. 2003 Sep 1;68(5):869-874. (Also gives good links for information on inhalant abuse and prevention)
2. Bowen SE, Batis JC, Paez-Martinez N, Cruz SL. The last decade of solvent research in animal models of abuse: mechanistic and behavioral studies. Neurotoxicol Teratol. 2006;28:636–647.
3. Cairney S, Maruff P, Burns CB, Currie J, Currie BJ. Neurological and cognitive recovery following abstinence from petrol sniffing. Neuropsychopharmacology. 2005 May;30(5):1019-27.
4. Henretig F. Inhalant abuse in children and adolescents. Pediatr Ann. 1996 Jan;25(1):47-52.
5. Kumar S, Grover S, Kulhara P, Mattoo SK, Basu D, Biswas P, Shah R. Inhalant abuse: A clinic-based study. Indian J Psychiatry. 2008 Apr;50(2):117-20.
6. D I Lubman, M Yücel and A J Lawrence. Inhalant abuse among adolescents: neurobiological considerations. Br J Pharmacol. 2008 May; 154(2): 316–326. Published online 2008 March 10. doi: 10.1038/bjp.2008.76.

Jealousy, rage and murder

In a jealous rage a Pune immigrant murdered his family - wife and two daughters - with an axe. He then attempted suicide. He suspected his wife of infidelity.

Evolution of jealousy

As with socio-sexuality, jealousy has an evolutionary basis that arises out of natural selection (Harris, 2003). Sexual jealousy drives males to guard against cuckoldry thereby ensuring that a rivals genes are not passed on through their mate. Emotional jealousy drives females to ensure her mates continued investment in her own offspring.

Psychodynamics of jealousy, rage and murder

• Freud showed morbid jealousy to be the deepest form of paranoia. His analysis indicated use of the defense mechansims of denial and projection to protect against threatening homosexual impulses - I do not love him—she (a wife, lover) loves him. Othello struggled with jealousy until he murdered Desdemona and then committed suicide.
• Murder or homicide can be understood as rage directed externally while suicide is rage directed inwards. Suicide is thus an inverted homicide (Menninger 1938). This argument is supported by the similarity in characteristics of perpetrators of murder-suicide and those of persons who commit only suicide (Palermo 1997).

Family murder-suicide by males

The jealous male resorts to spouse abuse. The resulting screams are usually ignored by society. If the woman has some independence repeated incidents may result in splitting from her partner. Here again her children may be used as hostages to keep her compliant. It is rare for the morbidly jealous male to be brought for psychiatric evaluation without some external coercion. The tragedy of a family murder-suicide is that its indicators are ignored by the family's society.

• Wife murders are commonly based on jealousy and suspicion of infidelity. Dr O Somasundaram (1970) showed that 30% of ‘The men who kill their wives’ were cases of sexual jealousy and 10% had delusional jealousy.  
• When the children are suspected to be those of the paramour, paternity testing through DNA samples is sought at Hyderabad. Or the children could also be put to death along with their mother. 
• Family murder followed by suicide of the assailant is significantly associated with morbid jealousy in upto a quarter of cases (Goldney 1977, Adinkrah 2008).

How does morbid jealousy manifest in women?

• The newly wed woman who turns jealous is tormented by her suspicions. At this stage the delusion is not yet fixed. The process of paranoia is not entrenched. The woman is aghast at her own attraction towards other males. She struggles to conceal her thoughts and impulses. Freud’s analysis of the process of morbid jealousy is rendered explicit. When she musters the courage to confront him the caring spouse will seek psychiatric consultation if it is available.
• The slightly less caring husband will seek psychiatric consultation for his delusional spouse when it affects his work. She has tried private investigators and other sources to identify the paramour and to check his mobile phone records. At this stage she may also consult with a psychiatrist to recruit his help against her husband. Her husband is alarmed only when his boss or a female colleague is entreated to join cause in the search for his paramour.
• The least caring spouse will try to beat the suspicions out of her. However, by their very nature the delusions are strengthened with each blow. She may then herself seek psychiatric help for her emotional problems or may be referred for the same after treatment for physical abuse. The morbidly jealous woman may also beat her partner.(Stuart, Moore et al., 2006).

Underlying mental illness is apparent before the family murder-suicide

References

1. Adinkrah M. Husbands who kill their wives: an analysis of uxoricides in contemporary Ghana. Int J Offender Ther Comp Criminol. 2008 Jun;52(3):296-310. Epub 2007 Oct 8.
2. Freud S. Psychoanalytic notes upon an autobiographical account of a case of paranoia (dementia paranoides). In Standard Edition of the Complete Work of Sigmund Freud, vol 12. Hogarth Press, London, 1966.
3. Goldney RD. Family murder followed by suicide. Forensic Sci. 1977 May-Jun;9(3):219-28.
4. Harris CR. A review of sex differences in sexual jealousy, including self-report data, psychophysiological responses, interpersonal violence, and morbid jealousy. Pers Soc Psychol Rev. 2003;7(2):102-28. Erratum in: Pers Soc Psychol Rev. 2003;7(4):400. Comment in:Pers Soc Psychol Rev. 2005;9(1):62-75; discussion 76-86.
5. Menninger K. 1938. Man Against Himself. New York: Harcourt, Brace.
6. Palermo GB, Smith MB, Jenzten JM, Henry TE, Konicek PJ, Peterson GF, Singh RP, Witeck MJ. Murder-suicide of the jealous paranoia type: a multicenter statistical pilot study. Am J Forensic Med Pathol. 1997 Dec;18(4):374-83.
7. Somasundaram O. The men who kill their wives. Indian J Psychiatry 1970;12:125.
8. Stuart GL, Moore TM, Gordon KC, Hellmuth JC, Ramsey SE, Kahler CW. Reasons for intimate partner violence perpetration among arrested women. Violence Against Women. 2006 Jul;12(7):609-21.