Multiple Illnesses and Multiple Prescriptions—Clarify safety with prescribing doctor

People with a serious psychiatric ailment fall ill, just like anyone else does. They develop colds and coughs, fevers and stomach ailments. They may sprain their ankles, have headaches, develop indigestion after having too good a meal, rashes after trying a new cosmetic and food poisoning after eating some unhygienic street food. Like anyone else, they do one of two things: they buy an OTC medicine; or they consult a general physician.

Precautions with other prescriptions

Be careful with OTC preparations. Not all OTC medications are benign or free from side effects. Avoid drug combinations. Cough syrups (even ‘safe’ herbal ones) usually have a combination of many ingredients, including substances which are highly addictive.

It is usually better and safer to go for option two – visit your GP. It is a good idea to establish a trusted professional relationship with one particular GP who knows your medical history thoroughly. However, this may not always be possible.

Very often, the distress of the current ailment takes precedence in the mind of both the patient and the doctor; because of immediate discomfort, pain or distress involved.  It is all too common for a busy GP, to misguidedly tell you to stop your psychiatric medication, attribute your symptoms to your medication or to simply waive the responsibility - ‘tell your psychiatrist to change your medication.’ Also, don't stop any long term medication on the advice of a person who is not a qualified medical practitioner.

Many psychiatric illnesses are serious, long-term, and may be life-threatening; just like chronic medical illnesses like hypertension, diabetes, epilepsy or heart disease are. No doctor will ever ask you to stop the medications for these illnesses abruptly while he treats your fever or loose motions. He will prescribe a medicine which will not react adversely with those you are already taking. Insist that your illness be treated similarly.

Medications for psychiatric illnesses are relatively few, as compared to the number of antibiotics, pain relievers or cough medicines available in the market. They also have to be started at low doses and built up gradually until you have the most benefits with the least side-effects. It is a slow process, for which you have had to follow-up regularly with your psychiatrist usually over months. It is important that this process should not be derailed without due consideration.

Stopping your psychiatric medication abruptly

1. May cause the distressing symptoms to return i.e you may relapse.
2. More seriously, you may find that the original medication, on which you were stable and symptom-free has now become ineffective, and you may require stronger medicines and/or multiple drugs to treat your illness.
3. Even more seriously, you may wrongly attempt to restart your psychiatry medication at its full strength when you recover from your viral fever after a week. Do not do so. Serious side-effects may follow.

What to do when consulting another doctor

• Always take your previous prescription with you when you need to consult another doctor. The prescription from our clinic has the dose and generic name of the medicine you are taking (as best practices worldwide demand and as mandated by the govt).
• Check with your doctor that he has prescribed a medicine which does not react with what you are already taking. Numerous apps are available to check drug interactions, which most doctors are conversant with. It takes only a couple of minutes to do so and prescribe a suitable drug. It can take months to find a new psychiatric medication that suits you and is as effective as the one you are on presently.
• In case, there is still a doubt, ask him to speak to your psychiatrist. Professional courtesy demands so.
• If you have stopped your medication, do not resume it without guidance. Seek an early appointment with your psychiatrist.

World Mental Health Day 2018

World Mental Health Day

World Mental Health Day is observed every year on the 10th of October to take awareness of mental health issues into the community. The theme for 2018 was Young People and Mental Health in a Changing World^[1].

Pathfinder Clinic WMHD2018 Event

On World Mental Health Day 2018 Pathfinder Clinic psychologists manned a desk for the day in the atrium at Magarpatta City, Pune. They used a short mental health quiz to pique the interest of anyone entering the shopping complex and rewarded all participants with an origami patronus! They were also administered a test of their current resilience. Our psychologists engaged in over-the-counter discussions on what constituted mental health issues. People brought out their own family and interpersonal problems, and to many it was an eye-opener that mental health issues could be contributory.

Why focus on young people?

Young people don't vote. They often don't have a voice and depend upon others to champion their right to health justice. The growing prevalence of youth mental health problems is a tsunami, and parents, the community and governments float in a small boat, named “denial”, on the quiet sea^[2]. Most mood and anxiety disorders, and schizophrenia have their onset in this age group[3]. Investing in early intervention programs is not only beneficial for patients, but also cost-effective[4].

What is changing in the young persons world?

The increasing use of online technologies and growing connectivity to virtual networks through the day and night add to pressures faced by adolescents. It is unclear whether some of these changes affect normal aspects of human behavior and cause psychiatric disorders. At the other end of the spectrum are young people caught in humanitarian crises due to conflict and environmental disasters that can overwhelm the coping ability of the individual.

Building resilience in young people

Resilience in young people is determined by their personal and social resources. Engaging young persons in therapy builds resilience through processes of bouncing back and personal growth[5]. Resilience is also built through the process of enhancing immunity to stress by 'innoculation', especially if the prior stress occurs early in life, is mild in its magnitude, and is controllable by the individual[6].

References

1. WHO. World Mental Health Day 2018. Accessed 2018-11-03
   
2. Helen Christensen, 1 Charles F. Reynolds, 3rd, 2 and Pim Cuijpers. Protecting youth mental health, protecting our future. World Psychiatry. 2017 Oct; 16(3): 327–328. Published online 2017 Sep 21. doi: [10.1002/wps.20437]. Accessed 2018-11-03
   
3. Cornelius LR, van der Klink JJ, de Boer MR, Brouwer S, Groothoff JW. High prevalence of early onset mental disorders among long-term disability claimants. Disabil Rehabil. 2016;38(6):520-7. doi: 10.3109/09638288.2015.1046566. Epub 2015 May 14. Accessed 2018-11-05
4. Celso Arango. First-Episode Psychosis Research: Time to Move Forward (by Looking Backwards). Schizophr Bull. 2015 Nov; 41(6): 1205–1206. Published online 2015 Sep 20. doi: [10.1093/schbul/sbv126]. Accessed 2018-11-05
5. Ayed N, Toner S, Priebe S. Psychol Psychother. Conceptualizing resilience in adult mental health literature: A systematic reviewand narrative synthesis. 2018 Jun 11. doi: 10.1111/papt.12185. [Epub ahead of print]. Accessed 2018-11-16.
6. Ashokan A, Sivasubramanian M, Mitra R. Seeding Stress Resilience through Inoculation. Neural Plast. 2016;2016:4928081. doi: 10.1155/2016/4928081. Epub 2016 Jan 5. Accessed 2018-11-16.

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.