Monday, March 14, 2011

Whitener Addiction - Death by Inhalant

whitener correction fluid
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 YĆ¼cel 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.



Monday, March 7, 2011

Jealousy, rage and murder

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.



Monday, February 28, 2011

Narcoanalysis - spies, lies and truth serum

narcoanalysis - the 'truth' might set us free
The 'truth' might set us free
Permission for narcoanalysis on a spy was refused by the Pune courts a few days ago. The investigating authorities have perceived this as a setback in arriving at the ‘truth’.

Method

In a clinical settting narocoanalysis and narcotherapy are conducted in a treatment room. The patient lies quietly with an iv line in place. While the psychiatrist recapitulates the patients history in a low monotone a nursing assistant injects thiopentone sodium to terse instructions of “push 50” or “25 slow”. Thiopentone sodium is no rare drug. It is used everyday to induce general anaesthesia. At lower doses in willing patients it produces a state of relaxation. You have to be careful the patient does not doze off or start slurring in speech. At the start of the narcoanalysis attention has to be paid to the patient's posture and eye movement. Horizontal eye movements indicate a state of sufficient relaxation to proceed with the deeper probing interview. Subsequent aliquots are adjusted with the aim of maintaining this state during the rest of the interview.

Psychiatric indications

  • The aim of narcoanalysis is to produce an abreaction in hysteria and other disorders in which there is an element of dissociation. During abreaction the patient recalls traumatic experiences and, by talking about them, discharges associated disturbing emotions. Abreaction facilitates subsequent and sometimes dramatic recovery (Breuer & Freud 1957). However, there are only anecdotal - though fascinating and highly readable - reports for the effectiveness of narcotherapy (Miller 1954, Denson 2009). The theory is based on the unconscious suppression of emotion through use of psychological defense mechanisms. It may not apply when suppression is done consciously as in most forensic cases .
  • Narcotherapy is effective in relieving catatonic mutism (McCall et al 1992).

Drawbacks

(Jesani 2008)
  1. Narcoanalysis was never considered as a method to get at the ‘truth’. It was just the patients perception of whatever he or she believed at that time. A similiar process occurs every night in the bar when a garrulous, intoxicated person talks about whatever is bothering him or her.
  2. A person can consciously lie during the procedure and get away with it.
  3. At times it is difficult to separate actual events from fantasy.
  4. You can even plant an idea into a persons mind through leading questions and later they would have no doubt it was their own.

Present status

A PubMed search using the MeSH term ‘narcotherapy’ gives just two articles in the last ten years. There are no randomised control studies - the scientific standard - to demonstrate the reproducibility of results obtained by narcoanalysis for information gathering, abreaction, or lie detection. Randomised control studies would give us an idea of the procedures sensitivity - the number of actual cases that would not be detected; and its specificity - the number of innocents who would be implicated. Presently all we have to go on are anecdotal reports of narcoanalysis practitioners . Not enough evidence to rely on narcoanalysis for deciding the fate of an unwilling subject. Not even for spies caught in Pune. Even the judiciary is sceptical of narcoanalysis..

References
  1. Breuer, J. Freud, S. 1957. Studies on Hysteria. New York: Basic Books.
  2. Denson R. Narcotherapy in the treatment of post-traumatic stress disorders: a report of two cases. J Psychoactive Drugs. 2009 Jun;41(2):199-202.
  3. Jesani A. Willing participants and tolerant profession: medical ethics and human rights in narco-analysis. Indian J Med Ethics. 2008 Jul-Sep;5(3):130-5. PubMed
  4. WV McCall, FE Shelp and WM McDonald. Controlled investigation of the amobarbital interview for catatonic mutism. Am J Psychiatry 1992; 149:202-206.
  5. Michael M. Miller. Certain Factors Pertaining to the Value of Narcoanalysis in Securing Testimony. J Natl Med Assoc. 1954 July; 46(4): 238–241. PMC
  6. PubMed. PubMed MeSH search for 'narcotherapy'. Accessed 27-Feb-2011.

Thursday, February 24, 2011

Academic stress in youth

stressed youths
Stressed youths relaxing
Academic stress is a significant aspect of youth. Youth is the developmental phase between puberty and working adulthood. It is a period of continuing student-hood. This is a distinctive feature of youth - it exists only for those who undergo post-secondary education. This is for the privileged few who do not join the workforce full-time after schooling.

Youth is a valuable time for serious experimentation. The young person is not fettered by long-term commitments. In contrast to adolescence, youth is a period of independence - the peer group is no longer a dominant influence. There is greater freedom to develop as an individual. The young person evolves a personal perspective on life and develops a sense of direction before tackling the duties of adulthood.

However this stage of life is by no means stress-free. By definition youth is associated with academics. Academic demands are perceived as significant stressors by youths (Rao 2000, Goff 2011). These demands include workload and time constraints (Jungbluth and colleagues 2011). On entering college the youth is suddenly exposed to an unsupervised life of parties, college events, projects, and an intense curriculum, all of which make demands on time.

Why do academic stressors acquire such significance in youth? Why do students who have done well in their 12th and got into good courses find it difficult to cope with the academics? Well, until high school the student has a limited syllabus. Students in good schools rely almost entirely on the notes dictated by their teachers. Also the exam system is designed so that most students can achieve high scores with minimal time spent on study. All this changes in college. When the youth enters college, he or she is confronted with the entire gamut of knowledge in a particular field. Without the skills to filter, assimilate and reproduce information in context the youth experiences stress.

There is also the problem of youths whose career path was chosen by their parents despite their protests or otherwise. These youth may find themselves completely out of their depth in a course for which they have little interest or aptitude.

Students cope with academic stressors using a combination of emotion-focused strategies like self-blame, or bunking, and problem-focused strategies like reading guide books, and cheating. Study skills training and the acquisition of good learning habits are essential life-skills for students. We have already shown that study skills are effective and can be successfully acquired.
Study skills training should be a part of every freshers curriculum.

References
  1. Jungbluth C, Macfarlane IM, Veach PM, Leroy BS.Why is Everyone So Anxious?: An Exploration of Stress and Anxiety in Genetic Counseling Graduate Students. J Genet Couns. 2011 Jan 25. [Epub ahead of print]. PubMed
  2. Goff AM. Stressors, academic performance, and learned resourcefulness in baccalaureate nursing students. Int J Nurs Educ Scholarsh. 2011;8(1):Article1. Epub 2011 Jan 24.
  3. Rao K; Moudud S; Subbakrishna DK. Appraisal of stress and coping behaviour in college students . Journal of Indian Academy of Applied Psychology. 2000 Jan- Jul; 26(1-2):5-13



Sunday, February 20, 2011

Study skills - effective learning habits for students

study skills
Effective study skills are essential learning habits for students. Some students have a knack of learning much in a short time. Others study for hours without much progress. An important differentiating factor is the method of study. Effective study habits can be learned (Barry L. Richardson and Murray Saffran 1985, D F Alexander 1985). The good student must not rely on “study drugs” as these are associated with addiction, panic reactions, confusion, and medical complications including heart attack and stroke (Steve Sussman and colleagues, 2006).

Habit No 1: Apply book learning to daily life

Those who learn rapidly apply their imagination freely to their studies. They see that every subject of study deals with something vital in the affairs of the world, and probably of personal relevance.
Allow the knowledge you are acquiring to become an active part of your daily life, with some bearing on normal activities. Thinking about studies in this way will help build greater interest and also help you to understand and remember things better.

Habit No 2: Think of the long term reasons for studying

Imagine yourself as the CEO in a multinational company; as an internationally acclaimed designer; as an architect creating the perfect city, as the next software entrepreneur, or picture yourself as the valued management expert. Hold that image in your mind and add some detail to it every day.
Visualising these ultimate goals, will give you fresh energy to keep going, because whatever your dreams; your studies are a necessary step towards achieving them.
Many students don’t know what they want to do after their board or other graduation exams. I’ve found Aptitude Testing to be a great way to get them thinking and motivate them to study. Parents usually get this done after the exams. Aptitude assessment before the exams has the added advantages of motivation for study, as also reducing anxiety related to making career choices.

Habit No 3: Organise your work

Successful study is largely a matter of good organisation.
  • Establish a regular routine. As far as possible study at the same time and place each day. A quiet, well-lit room, free from distractions is best.
  • Work out a daily timetable, to guide your activities. Do not be over ambitious with your timetable. Keep it flexible and do not try to learn more than you can comfortably manage.
  • Begin your major assignments well in advance of the required finishing dates to avoid having to complete them in a rush.

Habit No 4: Follow good study technique

Effective learning habits also minimise test anxiety.
Make notes and underline key sentences. Notes should be brief and to the point. Let notes assist your memory, not replace it.
Concentration is a necessary study habit. Resolve, for instance, to study ten pages without a break and then relax. Break up the learning of a lengthy item into sections, concentrating on each separately.
Start at the appointed time everyday. Do not make excuses – ‘I have to get into the right mood’; ‘I’ll just watch TV for 5 more minutes’. Just plunge into your work.

Habit No 5: Enhance your Memory

Memory depends on association, attention and repetition.
  1. Association can be developed by deliberately setting out to form associations or links with given words or facts.
  2. Attention is necessary for registration in the mind. Attention comes from interest in the subject, exercising the brain on it, and by focusing on one’s work in as much detail as possible.
  3. Interest can be inculcated. The more you know about something, the more interesting it becomes.
  4. Develop understanding. It is easier to remember something that is clearly understood. Aids to understanding include a wide vocabulary, good command of language, wide reading and plenty of discussion.
  5. Repetition helps in fixing memory. It is most effective if interest and understanding are involved.

Habit No 6: Build a positive attitude

Think positively. Do not picture defeat, or failure. Use your imagination to dwell upon the positive aspects of life - happiness, hard work, success, health.
People who succeed in examinations begin by believing that they will succeed. Keep telling yourself you are certain to be successful when you do the required work.
Examinations are designed for the average student to pass and the outstanding student to get a distinction.
What thousands of ordinary people have done, YOU can certainly do.
References
  1. Barry L. Richardson and Murray Saffran. Effects of a Summer Preview Program of Study Skills and Basic Science Topics on the Academic Performance of Minority Students. J Natl Med Assoc. 1985 June; 77(6): 465–471. PMC
  2. D F Alexander. The effect of study skill training on learning disabled students' retelling of expository material. J Appl Behav Anal. 1985 Fall; 18(3): 263–267. doi: 10.1901/jaba.1985.18-263.PMC
  3. Steve Sussman, Mary Ann Pentz, Donna Spruijt-Metz, and Toby Miller. Misuse of "study drugs:" prevalence, consequences, and implications for policy. Subst Abuse Treat Prev Policy. 2006; 1: 15. Published online 2006 June 9. doi: 10.1186/1747-597X-1-15 PMC.



Teaching, Learning, Aptitude, student