Psychiatry and Society in Pune

Saturday, November 12, 2011

Talk - not TV - for your toddler

Turn off the television and speak to your toddler. Talking is the best thing you could do today for your child’s psychological development. Talking is an interactive process in which your child exercises a core feature of being human - communicating through speech. Your child's vocabulary is directly proportional to the amount of time you spend talking.

Talking primes your child for independence. Speech evolves through attempts to communicate needs and feelings. Infants and toddlers are driven by evolution to master this complex process. You, the parent, play a key role in this two-way interaction. Infancy and toddler-hood are stages for developing secure bonding and attachment. The child is primed to bond with the mother or caregiver. The initial bond is secured by direct contact with the caregiver - through warmth, touch and voice. A secure attachment bond enables the infant seeks to explore the environment by attempts to crawl and later walk. The exploring toddler returns often to the parent to re-experience attachment security. It is here that talking plays a crucial role in maintaining the attachment bond at a distance. The child is then able to explore the environment away from direct contact with the parent.

Your one-year-old is psychologically unable to follow or learn from video. Some parents are convinced that certain TV channels are ‘educational’ for their toddler. The ability to comprehend video arises between 18 to 24 months of age (Pempek 2010). Prior to 2 years of age TV has little or no educational impact on the child, whatever the claims by media groups vying for their ‘eyeballs’. TV programming meant for 2-year-olds delays language and vocabulary development (AAP 2011, Zimmerman 2007).

Television is not a substitute for parenting. Parents leave the TV on to distract the child while they are engaged otherwise. Television holds the toddlers attention through its series of changing visual stimuli. This visual stimulus is powerful and distracting. While interacting with parents with the TV on in the background, the toddler is forced to shift attention to the TV once every 20 seconds. Even in adolescents, background TV adversely affects mental processing, memory and comprehension. Having the TV always on in the toddlers home interferes with unstructured play time that is critical to developing problem-solving skills and creativity. Repeated research has shown no developmental benefits for television exposure in infancy (Schmidt 2009, ).

Talk to and play with your children. Television is a medium that encourages passivity. TV delays vocabulary growth and language development in toddlers. Turn off the TV.

References

Academy of Pediatrics. Policy Statement. Media Use by Children Younger Than 2 Years. Council on Communications and Media. PEDIATRICS Vol. 128 No. 5November 1, 2011. pp. 1040 -1045 (doi: 10.1542/peds.2011-1753)
Pempek TA, Kirkorian HL, Richards JE, Anderson DR, Lund AF, Stevens M. Video comprehensibility and attention in very young children. Dev Psychol. 2010 Sep;46(5):1283-93.
Schmidt ME, Rich M, Rifas-Shiman SL, Oken E, Taveras EM. Television viewing in infancy and child cognition at 3 years of age in a US cohort. Pediatrics. 2009 Mar;123(3):e370-5.
Zimmerman FJ, Christakis DA, Meltzoff AN. Associations between media viewing and language development in children under age 2 years. J Pediatr. 2007 Oct;151(4):364-8. Epub 2007 Aug 7.

Thursday, November 3, 2011

Diet and mental health

Mental health and diet quality are closely linked. The food choices you made as a teenager affect the development of conduct and emotional problems that continue into adulthood. Lifestyle diseases such as heart disease, diabetes and obesity are attributed to changes in diet and exercise habits. Recently there is increasing evidence that diet and exercise also have a major influence on mental health. Dieting peaks after the festival season. This post will help you avoid the 'isms' and fads and point you in the direction indicated by current research.

A good quality diet predicts better mental health

Evaluating the quality of the complete diet provides a better and more consistent picture of nutrition status than focusing on individual nutrients like magnesium or food groups like various fatty acids (omega, polyunsaturated). A traditional diet of vegetables, fruit, meat, fish, and whole grains is associated with lower risk for depression and for anxiety disorders as compared to a "western" diet of processed or fried foods, refined grains, sugary products, and beer (Jacka 2010).

Switching to a high quality diet improves mental health

Switching to a healthy diet improves mental health. Unhealthy diets are associated with lower scores on mental health tests. The best part is that improvements in diet quality are mirrored by improvements in mental health (Jacka 2011). Also the reverse, when diet quality deteriorates psychological functioning is adversely affected.

What constitutes a high quality diet?

The quality of diet is assessed using food frequency questionnaires. Points are allotted for each type and frequency of food consumed. For example one point is allotted for each of at least two fruit servings per day, at least four vegetable servings per day; using reduced fat or skimmed milk, using soy milk, consuming at least 500mL of milk per day; using high fibre, wholemeal, rye or multigrain breads; having at least four slices of bread per day; using polyunsaturated or monounsaturated spreads or no fat spread; having one or two eggs per week, using cottage cheese, using low fat cheese. Out of a maximum possible score of 74, the average is about 33.0 (+9.0).You can get some idea of your diet quality score from this chart (Collins 2008).

Preventive psychiatry

Improving diet quality improves mental health outcomes. Especially for adolescents this is an important preventive intervention. Three quarters of all long term psychiatric illness manifest during adolescence and early adulthood (Kessler 2005) . These illness are among the most disabling. They occur with a high enough frequency to contribute a major portion of life years lost due to disability. Mental health illnesses cause long-term problems at work and at home. They usually persist over the lifetime and require medication and support at various stages. Adopting a high quality diet is an important primary preventive intervention for improved mental health - easy to implement and proven to be effective.

References

Collins CE, Young AF, Hodge A (2008). Diet quality is associated with higher nutrient intake and self-rated health in mid-aged women. J Am Coll Nutr 27: 146–157.
Jacka FN, Pasco JA, Mykletun A, Williams LJ, Hodge AM, O'Reilly SL, Nicholson GC, Kotowicz MA, Berk M. Association of Western and traditional diets with depression and anxiety in women. Am J Psychiatry. 2010 Mar;167(3):305-11. Epub 2010 Jan 4.
Jacka FN, Kremer PJ, Berk M, de Silva-Sanigorski AM, Moodie M, Leslie ER, Pasco JA, Swinburn BA.A prospective study of diet quality and mental health in adolescents. PLoS One. 2011;6(9):e24805. Epub 2011 Sep 21.
Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, et al. (2005) Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 62: 593–602.

Sunday, October 23, 2011

Tattoos - true love will never fade

What is the motivation or psychology behind obtaining a tattoo? Tattooing as a form of decorative body art has moved out of the realm of cults and organisations into mainstream society. It is increasingly common to see patients sporting a new tattoo. "Just like that, doctor. My friends were getting one". The Pune magazines reflect this new found art form through full page articles every other week. Driving through the some parts of Pune takes you past at least three studios specialising in the art of tattooing.

Here we are concerned with the psychological aspects of tattooing. As compared to body-piercing, a tattoo is relatively permanent and more deliberate operation. For the moment set aside doubts over hygiene, HIV, and hepatitis.

10 reasons people get a tattoo

Beauty, art, and fashion. Tattoos are a means of decorating the body with a permanent fashion accessory. Many tattooed individuals refer to their tattoos as a piece of art.
Individuality. A tattoo fulfils the desire to create a distinct self-identity. The symbols or words embellishing the skin creates a special message that distinguishes the person from others. The individual gains a sense of control over their appearance and identity. We see this especially in teenagers brought in by their parents.
Personal narrative. Women recovering from abuse create a new understanding of the injured part of the body. They reclaim possession through the deliberate and painful procedure of body modification. Tattoos have a self-healing effect in this reclamation of the body.
Physical endurance. For some tattoos are a statement about testing their threshold for pain endurance.
Group affiliations and commitment. Body ornaments are a permanent sign of love and commitment. The wish to belong to a certain community or to show affiliation to a particular group is a common reason for getting a tattoo.
Resistance. Tattoos are a provocative protest against parents and society, especially in college students. Body modification has long been associated with subcultural movements and criminal tendencies. Until recently most studies on tattooing were done on prison populations.
Spirituality and cultural tradition. Body modifications emphasise personal affiliation to cultures and their spirituality. Esoteric symbols that convey special meaning are tattooed as a permanent reminder.
Addiction. Tattoos and piercings possess an addictive character through the release of endorphins. These substances are released in brain areas in association with painful penetration of the body.
Sexual motivation. Tattooing is a form of expressing sexual affectations and of emphasising ones own sexuality.
No specific reason. A tattoo may be obtained impulsively on the spur of the moment. Some individuals may be under the influence of alcohol or drugs while acquiring their piece of body art.

Reasons people have a tattoo removed

People are mostly satisfied with the actual design of their tattoo.

Most want their tattoo removed for personal reasons. This occurs when the quest for uniqueness turns into stigma, negative comments, and clothes problems. Poor decision making and subsequent personal regret seem to be frequent motivations for tattoo removal.

An improved sense of self and maturity is another factor. Especially for those who obtained their tattoos for internal expectations of self-identity at an early age. Many are still trying to dissociate from the past and improve self-identity. More than 40% of persons who choose a tattoo to feel unique are disillusioned when their unique product loses its luster and excitement.

Professional/social reasons account for another third of those motivated for tattoo removal. A new job or career is a major motivation. Negative workplace attitudes toward tattoos and perceived interference for a tattooed individual’s achievement is common. There is a perception of lowered credibility, competence, and sociability that diminishes the image of tattoo wearer in the workplace.

The possession risks are more for women than for men. More than two thirds of those seeking tattoo removal are women. Society support for women with tattoos is not as strong as for men. Strong tattoo support from significant others and friends is counterbalanced by negative remarks about the tattoos from fathers, physicians, and the public. Negative responses are also documented among career-oriented women with tattoos. Women still need to deliberately think about controlling the body placement of their tattoos to avoid the possession risks and to increase their own psychological comfort.

References

Armstrong ML, Roberts AE, Koch JR, Saunders JC, Owen DC, Anderson RR. Motivation for contemporary tattoo removal: a shift in identity. Arch Dermatol. 2008 Jul;144(7):879-84.
Silke Wohlrab, Jutta Stahl, Peter M. Kappeler. Modifying the body: Motivations for getting tattooed and pierced. Body Image 4 (2007) 87–95.

Tuesday, October 11, 2011

Learning Disability - academic underachievement

Impaired spelling and arithmetic in Standard 3 boy with Learning Disorder

Learning Disorder (LD) is characterised by impaired acquisition of academic skills. This impairment in scholastic skills is not due to intellectual disability, physical disorders, emotional disturbances, or environmental, cultural, or economic disadvantage.

There is a gap between ability and application. The child may know what is asked, is able to explain it verbally, but is unable to put it down in writing. Learning Disorder could affect any of the three scholastic Rs – Reading, wRiting or aRithmetic.

Types of Learning Disability

Dyslexia – is the commonest learning disability (80%). It is marked by impairment of the ability to recognize and understand written words.
Dyscalculia – problems with doing math, understanding time, using money.
Dysgraphia – problems with handwriting, spelling.
Dyspraxia – problems with hand-eye coordination and balance, difficulties with fine motor skills.

Signs and Symptoms

Most children with a Learning Disability are not diagnosed until they are in Standard 2-3 or 7-8 years of age. Remarks like ‘can do better’ or ‘handwriting needs to improve’ are often the first warning signs to appear in the report card. Many of these children would have been the stars of their nursery or kindergarten class. The transition to assessment of written output in primary school is what unmasks the disorder. The aware teacher is able to help the parents understand and put the parents on the path to remedial teaching.

Parents should watch out for

Reading may be slow or there is repeated rereading or skipping of an entire section. In the lower classes the child learns to memorise and reproduce entire chapters. Later the child is unable to hold the increasing amounts of material in memory, grades plummet, and confused parents are left searching for answers.
Problems in copying from the blackboard or a book. This is a frequent complaint of the teacher. Classwork is left incomplete. The child tries to copy from their partner and is punished for distracting the class.
Poor handwriting or drawing – their exercise books are messy, with frequent scratching out and erasing. This is especially so when the child writes on blank paper. It is also a reason why the child performs poorly in exams – they just cannot write quickly enough. They run out of time before they reach the last few questions.
Other signs in more severe conditions

Reversing numbers and letters while reading or writing - For example, confusing ‘b’ and ‘d’
Mixing the order of letters or numbers. Writing ‘twon’ instead of ‘town’.
Skipping letters in spelling. The child says ‘grass’ but writes ‘gas’.
Forgetting words they know well.
Weakness in mathematics.

Conquering Learning Disorder

Approach a centre undertaking diagnosis of learning disabilities.
A complete history of the child’s birth, milestones, health and academic record
Physical exam to exclude problems related to vision and hearing
Psychometry - to demonstrate specific academic problems that are not associated intellectual disability
Psychiatric assessment - to address associated anxiety, phobias and depression that arise out of repeated academic failures.
Psychiatric assessment - to exclude or address Attention Deficit Hyperactivity Disorder (ADHD) a common comorbidity. 15-40% of children with ADHD also have dyslexia.
Remedial teaching is essential to overcome learning problems

Drug treatment for dyslexia?

There is a growing body of research to show that at least in children who have both ADHD and dyslexia there are significant improvements in reading ability with ADHD medication. These improvements in reading ability are not related merely to improvements in attention. The brain systems responsible for therapeutic improvement in children with ADHD + dyslexia are probably different from those in children with ADHD alone. The finding that selective areas of working memory can be enhanced by these medications is important, as poor working memory function appears to be a mental constraint on academic learning.

References

Schulte-Körne G. The Prevention, Diagnosis, and Treatment of Dyslexia. Dtsch Arztebl Int. 2010 Oct;107(41):718-26; quiz 27. Epub 2010 Oct 15
Sumner CR, Gathercole S, Greenbaum M, Rubin R, Williams D, Hollandbeck M, Wietecha L. Atomoxetine for the treatment of attention-deficit/hyperactivity disorder (ADHD) in children with ADHD and dyslexia. Child Adolesc Psychiatry Ment Health. 2009 Dec 15;3:40..

Thursday, September 22, 2011

Stress in the festival season

Festivals as a source of stress? Festivals are meant to be a time of happiness, enjoyment and family togetherness. However for some it can be time of great stress and can adversely affect mental health. The extended festival season starts around Independence Day (15th Aug) and extends right up to New Year including Ganesh Chathurti, Dusshera, and Diwali. Vacations have a positive effect on well-being. However, these effects fade soon after resumption of work (de Bloom 2009). These four months of celebration are associated with psychological distress and mental health problems for many individuals and their families.

Festival distress

(Harion 2009)
Expectations take their toll on the family. Festivals are a prime time for couples to come in for counselling with relationship problems, problems with in-laws, siblings and their children. 'Don't we get to celebrate at least once in our own home?". They end up celebrating each in their own parental homes at Pune and Ahmedabad.

For those in the workforce it means negotiating and competing with everyone else for leave or being the only one left in the office. No one at home understands why you cannot get leave. No one understands why work-pressures and deadlines increase in the time leading up to the holiday. Financial stress also comes into the picture; cool electronics, gifts, partying and vacation trips cost.

For people with mental health problems festivals are another source of stress. Well intentioned, though ill informed relatives prevail on them to stop their medications 'they are addicting', 'why do you need to take them if you're allright?' Many are coaxed into stopping medications entirely.They relapse some time after they return to work, when the social supports are at a minimum and the beneficial effects of the vacation begin to wear off. That is also the time when they have to start paying out the EMIs. This time lag to relapse after stopping psychotropic medication is a prominent factor in non-adherence. 'But he was allright at home. It's the job that is causing stress; we are thinking of relocating'.

Fasting and sleep deprivation are associated in the run up to the festivities. In vulnerable people, especially those with mental health problems, these can play havoc with the body rhythm and with medication regimens leading to a relapse. Every religion excuses ill followers the rigours of these rituals, yet the very people who should be supporting moderation often goad their vulnerable members to comply. 'I thought he was just being lazy'.

Alcoholism is another problem that is likely to recur. It starts insidiously at the beginning of the festival season. By the time the season ends its time for another stint of 'deaddiction'. Binge drinking at parties is just another problem that requires to be addressed recurrently.

Violence and injuries in the home occur through the combination of excitement, stress, tiredness and alcohol. Pressures lead to conflict and then violence. Domestic abuse is about one-third more likely on the day of the festival than the daily average. Homicide rates are generally higher on all major holidays.

Loneliness and isolation are particular issues at festivals. The holiday season is the time of the year when our desire for social contact is most likely to outstrip what our circumstances will allow; it is into this gap that loneliness creeps (Lancet 2010). As festivals are associated with friends and family, it can be difficult for those on their own to avoid feeling lonely at this time. This is especially so for older people living alone who may have no one to spend the festive season with. The loneliness felt on the festival day is often the worst. Festivals can be a sad and nostalgic time, when the loss of a family member may become especially painful. It is often a difficult time for bereaved people. The rates of suicide are known to increase especially on New Years Day (Bridges 2004).

What to do?

Prior to the festival

Communicate. Make your festival plans keeping your spouse in mind. If there were problems last year don't expect them to disappear. ' I thought we agreed on that last year'. Putting off the discussion could ruin your festivities.
Collaborate. Work together to find a solution that satisfies the needs of all parties. You may not get everything you want, but you get enough of what you want to feel satisfied. Colaboration requires respect for the needs of the other party, communication skills, patience, and creativity. Parties usually do better when they collaborate than when they compete.
Watch the finances. Budget for the expenses and keep a track.

During the festival

Limit your alcohol. Don't drink if you don't want to.
Keep to your normal sleep-wake schedule as far as practicable. When it is disrupted return to your normal schedule at the earliest. Take some time out for exercise.
Take some time off for just yourself and your family. A walk, movie or meal away from the others will contribute to a few more days of harmony.
Your medication is sacrosanct. Don't negotiate on this.

Strategies for loneliness
(Masi 2010)

Improve social skills: After relying on a partner to share experiences and thoughts a separation, breakup or bereavement requires relearning of skills needed to build new relationships and participate in community functions.
Enhance social support: Find a listening ear – people who are lonely can find it helpful to speak to a counsellor or someone removed from their situation.
Increase opportunities for social contact: Be a volunteer – many charities and organisations need help at festivals and you could spend a few hours working as a volunteer. The absence of close family need not be the end of companionship.
Address maladaptive social cognition: Loneliness can also be tackled by helping people to feel happier in their own company.

'Everyone else is having a good time'. Keep busy – try to stop the festival taking over your life. Make time for enjoyable activities, such as reading, walks, joining a social club or going for a movie.
'What's the point, I'm just not up to it'. Take some physical exercise – this reduces stress and enhances mood. Just getting off the sofa and getting outside should improve mood.

Visit an older neighbour who lives alone if you have a little spare time on your hands over the holidays; it might be just what they need to make their holiday a happy one.