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.