Neurotoxic effects of alcohol on the adolescent and young adult brain

(or why the 25 year age-bar on alcohol consumption could be reasonable)

Does alcohol have specific neurotoxic effects on the adolescent or young adult brain? This question is the only important one for deciding whether the 25 year age-bar on alcohol consumption in Maharashtra is justifiable. While the debate rages two students from the premier medical college of India drowned in an alcohol fuelled swimming pool misadventure, and in an unrelated incident on the same night five inebriated youths were arrested for disturbing the peace in a residential area. We have seen how to recognise problem alcohol drinking in teenagers, and how to refuse alcohol. This article probes the specific effects of alcohol on the maturing brain.

Infancy

Alcohol is a neurotoxin. It distorts the normal architecture of the developing brain. This distortion starts during pregnancy when imbibed maternal alcohol crosses the placenta into the foetus. In the foetus alcohol acts on the specially vulnerable immature insulating cells (oligodendroglia) of the brain. The child is born with Fetal Alcohol Syndrome, characterised by irreversible mental retardation, a small head, small stature and facial abnormalities. Because the exact amount of alcohol required and the most vulnerable periods of pregnancy have not been definitively established all pregnant women are advised to abstain from any use of alcohol.

Childhood

By the second year of life the number of connections between brain cells (synapses) are at a maximum. These synapses are gradually reduced to the adult number (synaptic pruning). This process is controlled by immature excitatory (glutamate) receptors in the synapses. These receptors differ from adult ones by allowing quicker and longer excitation. Immature glutamate receptors are vulnerable to the effects of alcohol. Their over-stimulation distorts synaptic pruning (Johnston 1995).

Adolescence

In adolescence there is a rapid growth of gray matter and the formation of new connections (proliferation) in the brain. Elimination of some synaptic connections (pruning) enables the adolescent or young adult brain to change in response to environmental demands. Stability of these connections is enhanced through insulation of neuronal fibres (myelination). Myelination increases the overall speed of information processing within the brain. These maturational processes are critical for cognitive development. They are all adversely affected by alcohol (Guerri 2010).
These adverse effects specifically impact the frontal lobes of the brain and are highly associated with level of intelligence. In addition the brain area essential for working memory (hippocampus) is preferentially damaged by alcohol (De Bellis 2000). Gender effects render female adolescents more vulnerable than males to these alcohol effects.
The reward system of the brain is responsible for motivation and learning. The immature reward system has an adolescent-specific vulnerability for alcohol and drug addiction. Early exposure to alcohol sensitises the brain regions involved in drug addiction and alters gene expression in the brain reward regions (nucleus accumbens).
The pattern of brain electrical activity changes during the transition from adolescence to adulthood. Alcohol also has a premature aging effect on brain electrical activity during wakefulness and sleep. Animal models have shown that even brief exposure to alcohol in adolescence can cause long lasting changes in brain electrical activity. These changes place the adolescent at a high risk for later substance abuse and addiction (Ehlers 2010).

Youth

Alcohol differentially impairs the young persons judgement and motor skills. The evidence for this is so robust that some administrations have placed a lower legal blood alcohol level limit on drivers less than 21 years old (Hingson 1994). This differential susceptibility to alcohol has been shown to persist up to 30 years of age when a specific impact is seen on frontal lobe functions related to driving skills (Domniques 2009).

Whether the authorities considered the neurotoxic effects of alcohol while imposing the 25 year age-ban on alcohol consumption is a moot point. However, educating adolescents and youth regarding these adverse alcohol effects should be the duty of every parent.

References

1. De Bellis MD, Clark DB, Beers SR, Soloff PH, Boring AM, Hall J, Kersh A, Keshavan MS. Hippocampal volume in adolescent-onset alcohol use disorders. Am J Psychiatry. 2000 May;157(5):737-44.
2. Domingues SC, Mendonça JB, Laranjeira R, Nakamura-Palacios EM. Drinking and driving: a decrease in executive frontal functions in young drivers with high blood alcohol concentration. Alcohol. 2009 Dec;43(8):657-64.
3. Ehlers CL, Criado JR. Adolescent ethanol exposure: does it produce long-lasting electrophysiological effects? Alcohol. 2010 Feb;44(1):27-37.
4. Guerri C, Pascual M. Mechanisms involved in the neurotoxic, cognitive, and neurobehavioral effects of alcohol consumption during adolescence. Alcohol. 2010 Feb;44(1):15-26.
5. R Hingson, T Heeren, and M Winter. Lower legal blood alcohol limits for young drivers. Public Health Rep. 1994 Nov-Dec; 109(6): 738–744.
6. Johnston MV. Neurotransmitters and vulnerability of the developing brain. Brain Dev. 1995 Sep-Oct;17(5):301-6.

School bullying

Bullying by children in schools has serious mental health effects on the victim and the bully. Up to 25% of high school students report being victimised by bullies. 13% of victims have considered suicide. In rural India 31% of middle school students report being bullied (Kshirsagar 2007). Bullying is twice more prevalent in coeducational schools than in girl schools. The prevalence of bullying increases from 13% in the 3rd grade to 46% in the 6th grade. Bullying is higher in classes with more retained students.

Bullying occurs in a variety of settings that are an extension of your child's school life. Bullying can occur face to face, by texting or on the web (cyberbullying). Bullying is not a phase of growing up, it is not a joke, and it is not a sign that boys are being boys. Bullying can cause lasting harm - to the victim, the bully and the bully-victim (children who are bullied and also bully other children).

Bullying takes many forms

• Verbal: Name calling, teasing
• Social : Spreading rumours, leaving people out of groups on purpose, breaking up friendships
• Physical : Hitting, punching, shoving (5% in Indian schools)
• Cyberbullying

When is it bullying? It’s bullying when there are three features to the interaction

1. Imbalance of power: People who bully use their power to control or harm. The victims may have a hard time defending themselves.
2. Intent to cause harm: The person bullying intends to harm the victim
3. Repetition: Incidents happen to the same person over and over by the same person or group

It’s not bullying when there are

• Mutual arguments and disagreements
• Single episodes of social rejection or dislike
• Single episode acts of nastiness or spite
• Random acts of aggression or intimidation

Effects of bullying

(www.stopbullying.gov)
Those who are victims are at a high risk for mental health problems

• Higher risk of depression and anxiety with increased thoughts of suicide
• More likely to have health complaints
• Have decreased academic achievement
• More likely to miss or drop out of school
• More likely to retaliate (12/15 shooters have a history of being bullied)

Bullies are more likely to manifest behaivour problems that continue into adulthood when these behaviours manifest as criminality

• Higher rates of alcohol/substance abuse
• More likely to get into fights, vandalise property
• More likely to be abusive towards partners, spouses or children later in life.

Bully-victims are the worst affected. They develop both mental health and behavioural problems

Is your child being bullied?

If your child has any of these features it is very likely they are being bullied in school

• Comes home with torn clothing or missing belongings
• Appears sad, moody, depressed or anxious especially on returning home from school
• Prefers to be alone

These symptoms are also likely in victims of bullying

• Is afraid of going to school
• Vomiting
• Sleep disturbances including insomnia and nightmares

These symptoms are commonest in victims

• Frequently falling sick
• Headaches
• Bodyache is the next most common symptom in female victims. In male victims nightmares are the next most common.

Is your child a bully? Consider these common traits of bullies

• Become violent with others, gets into physical or verbal fights
• Get sent to the Principal’s office often
• Has extra money or new belongings which cannot be explained
• Will not accept responsibility for their actions
• Need to win and be best at everything

Do’s and Don’ts

For parents whose children are victims of bullying (Carr-Gregg 2011)
Do NOT

• Tell the your child to ignore the bullying. This allows the bullying and its impact to become more serious
• Blame your child or assume that they have done something to provoke the bullying
• Encourage retaliation
• Criticise how your child dealt with the bullying
• Contact the bully or parents of the bully

Do

• Communicate with your child
1. Listen carefully. Ask who was involved and what was involved in each episode
2. Empathise and reinforce that you are glad your child has disclosed this
3. Ask your child what they think can be done to help
4. Reassure your child that you will take sensible action
• Contact the teacher and/or principal and take a cooperative approach in finding a solution
• Discuss the matter in a face-to-face meeting. Stay calm. Take along any evidence you may have gathered. Ask three key questions
1. How will this matter be investigated?
2. How long will this investigation take?
3. When will you get a follow up meeting to discuss the results?
• Contact school authorities if bullying persists and escalate your communications up the chain of command. Here’s where your paper trail comes in useful

Every child deserves an education free of fear

References

1. Carr-Gregg M, Manocha R. Bullying - effects, prevalence and strategies for detection. Aust Fam Physician. 2011 Mar;40(3):98-102.
2. V .Y. Kshirsagar, Rajiv Agarwal and Sandeep B Bavdekar. Bullying in Schools: Prevalence and Short-term Impact. Indian Pediatrics 2007; 44:25-28
3. www.stopbullying.gov

Quit Smoking for World No Tobacco Day (31-May)

Fagerstrom Test for Nicotine Dependence

---

Quitting tobacco is the most important thing you can do to protect your health

---

(AHRQ)

Quitting by willpower only

40% of smokers try to quit each year. The success rate of those who quit on their own is about 5% and with self-help books it is about 10%. Most smokers make 5-10 attempts to quit. Unsuccessful attempts to quit are a sign of nicotine dependence.

85% of current daily smokers are nicotine dependent

Signs of nicotine dependence

1. Tolerance - Increasing the number of cigarettes smoked per day (Most smokers escalate to a pack)
2. Withdrawal - Mood changes, irritation, anxiety, insomnia, restlessness when unable to smoke
3. Loss of control - Most smokers do not intend to continue, but 5 years later 70% do
4. Increased time spent using the drug - Leaving office/ work-site to smoke
5. Continued use despite harm - cough, hypertension, heart disease
6. Giving up important activities - air travel

Are you nicotine dependent?

Take the Fagerstrom Test
You can quantify the extent of your dependence by adding your points scored for each question.

• 7-10 points - high level of addiction
• 4-6 points - medium level of addiction
• 0-3 points - low level of addiction

Why does nicotine produce a severe dependence?

• Nicotine has direct effects on concentration and mood
• Nicotine reaches brain in seconds → a rapid effect
• Allows user to titrate the dose by varying puff frequency and depth
• The habit is Intense (>200 puffs/day x 20 years)
• There are many environmental cues (eg, others smoking/ ads)
• Never impairs the user via intoxication

How do I quit?

Make a START

Set a quit date-today! Choose a birthday, wedding anniversary, New Year’s Day
Tell family, friends and co-workers – Enlist their support
Anticipate challenges- Withdrawal symptoms and craving will occur. Tell yourself that you can face the challenges ahead. Behavioural techniques will help you through this phase.
Remove cigarettes and all related products-lighters, matches, ashtrays from your home and workplace
Talk to your doctor – Medication, Behaviour therapy and Nicotine Replacement Therapy are the mainstay of treatment. Your doctor will help you decide what suits you.

After quitting

The habit is still latent after you have quit tobacco smoking. Some vigilance is required to stay quit. However, the longer you stay quit the easier it becomes. Some of the things you could do to reduce the chances of a relapse are as below

Watch out for the triggers

• Habit situations (things you used to do while smoking)
• Stress / -ve moods
• +ve moods/ celebrations
• Alcohol
• Use coping skills to beat the urge and handle craving

Avoid smoking at all costs

• If you do slip
ACT!- QUIT IMMEDIATELY
• Can I have just one cigarette?
You must do everything you can to avoid that first cigarette

---

9 out of 10 people who have that one cigarette after quitting return to regular smoking.

---

Enjoy the rewards of quitting!

• Within 20 minutes Heart rate slows towards normal
• 8 hours Carbon monoxide levels drop to normal
• 2 weeks-3months Heart attack risk lessens, lung function improves
• 1-9mths Coughing and breathlessness reduce
• 1 year - Heart disease risk ½ of chronic smokers
• 5-15 years - Stroke risk = non-smokers
• 10 years - Risk of death due to lung cancer same as that of non-smoker
• 15 years - Coronary heart disease risk same as that of non-smoker

References

1. Agency for Healthcare Research and Quality
2. Centers for Disease Control and Prevention
3. Heatherton T, Kozlowski L, Frecker R, Fagerström K: The Fagerström test for nicotine dependence: A revision of the Fagerström tolerance questionnaire. British J Adict 1991, 86:1119-27.

Police suicides

Five police constables from Pune committed suicide this year. Suicide by police personnel the world over has been extensively reported. It is generally known that the occupation is stressful and associated with psychological stressors that make personnel prone to suicide. However, there is a marked variance in reported rates and stressors. Local factors may overshadow any generalisations even within the country. For instance, in the US/Europe firearms are the most common suicide method used by police (61-77%), but in Pune hanging was the only method used.

Sources of stress in police personnel

There is conflicting evidence as to the extent to which police constitute a high risk group for suicide. A study of well-being in police at Bangalore showed they were were better adjusted and had a better quality of life than comparable middle class urban factory workers (Geetha 1998). However, they had poorer social contact and support beyond the immediate family. This was attributed to their long working hours, requirement to be on duty during holidays, and the prevalent negative attitude of the public towards the police in general. Traffic policemen, personnel with higher education, and freshly recruited personnel were found to be under greater stress.

Police suicides are an interaction of personal vulnerabilities, workplace stressors, and environmental factors as is  seen with other worker groups. Two risk factors have been consistently delineated for suicide by police personnel; workplace trauma that increases vulnerability to posttraumatic stress disorders and organisational stressors that lead to burnout. Mental health interventions and organisational change are usually implemented to mitigate these factors. However, little attention is paid to the third leg of police suicide - personal factors (Stuart 2008). Personal factors had a major role to play in the Pune police suicides.

Suicide rates in police

Data on suicide rates for police in India is not available. However, the suicide rate in Pune is more than the national average. This rate is still increasing and is 17.3/100000 as of 2009.

Suicide rates in police personnel vary depending on geography. They can be higher than the general population as in Germany (25/100000 vs 20/100000), the same as the general population as in the US (14.9/100000) or half that of the comparable general population as in Canada (14.1/100000).

Suicide rates in police personnel also vary when calculated over long or short time frames, indicating the influence of clustering. This underlines the need for using longer time frames while studying this population (Loo 2003). A historical survey of police suicide from 1843-1992 in Queensland showed the rates reduced from 60/100000 to 20/100000 (Cantor 1995).

The accuracy and validity of police suicide rates are controversial. Under reporting of police suicide is significant (Violanti 2010). Up to 17% of police deaths in the US are classified as undetermined as compared to 8% for military deaths. Official police suicide rates are less accurate and less valid than suicide rates published for other working populations (Violanti 1996). We have already discussed the reasons and results of underestimating suicide rates in India.

What needs to be done

1. Personal factors that contribute to suicide need special attention. These factors play alongside the workplace and environmental stressors in police personnel. These include psychiatric illnesses, alcoholism, physical ill health and interpersonal and marital problems. These problems are similar to those of the general population.
2. An early warning system for stressful police events needs to be implemented. The LEOSS (Law Enforcement Officer Stress Survey) is a short 25-item questionnaire specifically designed to evaluate stress in police personnel (Van Hasselt 2003).
3. Police personnel need easy access to mental health services. The barriers are formidable; psychiatric evaluation can result in job sanctions, reassignment, restriction of firearm privileges, missed promotions, and stigmatisation (Mazurk 2002). 

Need for more organisational change?

References

1. Cantor CH, Tyman R, Slater PJ. A historical survey of police suicide in Queensland, Australia, 1843-1992. Suicide Life Threat Behav. 1995 Winter;25(4):499-507.
2. Geetha PR, Subbakrishna DK, Channabasavanna SM. Subjecitive well being among police personnel. Indian J. Psychiat., 1998, 40(2), 172-179
3. Loo R. A meta-analysis of police suicide rates: findings and issues. Suicide Life Threat Behav. 2003 Fall;33(3):313-25.
4. Marzuk PM, Nock MK, Leon AC, Portera L, Tardiff K. Suicide among New York City police officers, 1977-1996. Am J Psychiatry. 2002 Dec;159(12):2069-71.
5. Stuart H. Suicidality among police. Curr Opin Psychiatry. 2008 Sep;21(5):505-9.
6. Van Hasselt VB, Sheehan DC, Sellers AH, Baker MT, Feiner CA. A behavioral-analytic model for assessing stress in police officers: phase I. Development of the Law Enforcement Officer Stress Survey (LEOSS). Int J Emerg Ment Health. 2003 Spring;5(2):77-84.
7. Violanti JM, Vena JE, Marshall JR, Petralia S. A comparative evaluation of police suicide rate validity. Suicide Life Threat Behav. 1996 Spring;26(1):79-85.
8. Violanti JM. Suicide or undetermined? A national assessment of police suicide death classification. Int J Emerg Ment Health. 2010 Spring;12(2):89-94.

Treatment of social anxiety, phobia and self-consciousness

Avoiding social situations because they make you self conscious and anxious? You are likely to have a social phobia or social anxiety disorder. One in 10 persons experiences social phobia between the age of  9-33years. The incidence is highest in adolescence (Beesdo et al 2007). Men and women are equally likely to suffer. However, men are more likely to seek treatment when their performance at work is impaired.

Social anxiety usually begins in childhood or early adolescence. There is often a history of childhood shyness. A stressor or humiliating social experience can precipitate the problem. In fact paediatric social phobia affects 5-10% of children. In children it is often associated with ADHD (Attention Deficit Hyperactivity Disorder), depression or separation anxiety disorder. Longstanding social phobia increases the risk of depression, substance abuse, and alcoholism later in adulthood.

Recognising social phobia

“My mind went blank during the interview. I break into a sweat, my voice changes. I know what is being asked but I am just not able to concentrate and answer with confidence.”

You have social phobia when you feel that everyone is staring at you or judging you during social interactions. There is a persistent and intense fear of being embarrassed and humiliated by your own actions. This especially occurs in public places such as at work, during office 14meetings, while shopping and at social gatherings. The feelings persist even though rationally you know its not true. These fears may become so severe that they interfere with your work, school or college. They make it hard for you to socialise and make or keep friends.

When you decide to confront these fears and join the party or attend a meeting, you are anxious for days beforehand in anticipation of the dreaded situation. Thoughts of a discussion with your boss make you break into a sweat. You may have panic attacks. Your sleep may be increasingly disturbed as the day of the meeting approaches. Reasoning and reassuring yourself as to the non-threatening nature of the situation brings no relief. You are sweating and can feel your heart race during the encounter. After the encounter you worry about how you were judged for hours afterwards. You feel ashamed that you did not perform better. It becomes easier for you to just stay away from social situations and avoid other people altogether.

“I hesitate to enter the room when the group is already seated. When it comes to my turn to speak my mouth goes dry and I feel choked. I don't speak a word during the meeting even when I have something to contribute.”

People with social anxiety can present with different secondary symptoms

• Some people cannot write in public (as on a blackboard), their hand will shake, their cheques bounce
• They experience severe anxiety about eating and drinking in public and often spill food and drop their cutlery
• Others find it a torture to speak in front of people, they just ‘clam up,’ speak in monosyllables or stammer
• One of the worst circumstances is meeting people who are authority figures- bosses, supervisors, interviewers at work; or teachers & examiners at school. A job interview is torture, more so because the person knows that he would be good at the job if only he could get through the interview.

People with social phobia avoid situations in which they feel embarrassment and anxiety. Initially they are comfortable with this avoidance. Later, they see avoidance as an impediment to achieving their full potential in their chosen careers. They see their social lives as stale and restricted. To address these problems people mistakenly enrol for ‘personality development’, meditation and other courses. But this is not the shyness of introversion. This shyness results from overwhelming anxiety and embarrassment. They are frustrated when there is no resolution. The underlying social phobia has not been addressed.

In a child with social phobia this anxiety expresses itself as tantrums, crying or just “freezing up”. In school, the child typically does not participate in classroom activities, is reluctant to stand up and answer, has no friends and frequently misses school with complaints of stomach ache or headache. Outside school these children have few or no friends. They may communicate only with family members.

“My daughter doesn't speak a word when we have visitors. The other children are playing together, she has to be pulled out of her room to join them.”

How is social phobia best treated?

The best treatments of social anxiety include

1. Medication: is usually for a limited period, under supervision. Do not stop taking medication abruptly. Discuss any side effects, if any, with your psychiatrist.
2. Cognitive Behaviour Therapy – CBT: and systematic desensitisation properly administered for 6-12 sessions can produce long lasting, permanent relief. You have to be motivated to persist in the practice of the simple methods and techniques that are explained to you. Do not use any advice available online without due thought and discussion with your psychiatrist

What you can do for a family member with social phobia

• Be supportive. Help the individual seek psychiatric treatment. Many a career has been advanced or saved by a supportive spouse. Family interaction and communication also improves.
• Don’t trivialise (‘its normal to be nervous when you meet new people, you do not have to go for therapy’).
• Don’t perpetuate their symptoms (‘let it be, stay at home if you are not feeling well’).

Family support helps during behavioural desensitisation therapy and decreases the social isolation of the individual. Social phobias and anxieties are treatable conditions. Treatment and therapies are effective and easily accessed.

References

1. Beesdo K, Bittner A, Pine DS, Stein MB, Höfler M, Lieb R, Wittchen HU. Incidence of social anxiety disorder and the consistent risk for secondary depression in the first three decades of life. Arch Gen Psychiatry. 2007 Aug;64(8):903-12.

Sleeplessness, sleep disturbances, insomnia and parasomnias

Sleepless in Pune. Sleeplessness, disturbed sleep, and shift work related sleep problems are interfering with our citizens recovery after a hard days (nights) work. Insomnias and parasomnias are common sleep problems. Once recognised these are treatable.

• Does it take you more than 30 minutes to fall asleep at night?
• Do you wake up too early or frequently at night and have difficulty going back to sleep?
• Do you feel groggy and lethargic when you wake up?
• Do you feel drowsy during the day?
• Do you depend on coffee to get through the day?

If you answer "yes" to any of the above questions; you have a sleep problem. You are not alone. 9-18% of adults suffer from treatable insomnia

What is insomnia?

The inability to fall asleep or remain asleep is insomnia (Latin for ‘no sleep’). In a broader sense insomnia is the inability to get the amount of sleep you need to wake up feeling refreshed.

How much sleep do you need?
As a rule of thumb an adult requires 7-9 hours of sleep. However individual needs differ. You can gauge how much sleep you require by monitoring your own response to different amounts of sleep. Are you productive, healthy and happy on 7 hours sleep or does it require 9 hours of sleep to make you feel good?

What are the effects of chronic insomnia?
Sleeping too little inhibits productivity, ability to remember & consolidate information (cognitive impairment). Chronic insomnia also has serious health consequences and can jeopardize your safety and those of people near you.

Treating insomnia

1. The first step to treating insomnia is to determine whether the insomnia is Primary i.e it is occurring independently from other disorders or Secondary i.e due to other associated medical conditions, (most importantly due to psychiatric disorders such as stress, depression, anxiety and panic disorder). The underlying condition needs to be addressed for the treatment to be effective.
   That is why our assessment includes a medical history, and a physical examination along with your sleep history and daily routine.
2. Behavioural therapy is part of any treatment for insomnia. This includes:
   
   • Stimulus Control Therapy
   • Cognitive therapy
   • Sleep Restriction Therapy
3. Medication most commonly used in treatment for sleep problems. It should be taken under medical supervision, after evaluation, and with appropriate sleep promoting practices.

Self medication and OTC drugs

Why you should avoid them
Medications which help induce and maintain sleep (sedatives and hypnotics) are prescription drugs the world over and for good reason. They can sometimes cause confusion, headaches, memory problems, daytime drowsiness leading to accidents at work and on the road, rebound insomnia when stopped suddenly after continued use. Many have drug interactions and some are addicting. You may develop tolerance and require larger doses.

Don’t let a pharmacist prescribe you a “safe” hypnotic. Consult a doctor who can treat your insomnia and the underlying cause. Follow your doctor’s instructions strictly about drug dosage, timing & duration and follow good sleep practices.

Alcohol and Sleep

Alcohol may help you to relax and thereby decrease the time taken to fall asleep, however sleep later in the night is fragmented and of poor quality. Continued use of alcohol can destroy normal sleep.

Shift work related sleep disorder

Shift work related sleep problems occur due to a lack of synchrony between the individual’s internal biological clock and the desired sleep-wake cycle. Frequently changing shifts, change from night or evening to daytime shifts are associated with greater sleep disorders.

The sleep disorder can vary from excessive sleepiness during the ‘wake’ period, to insomnia during the ‘sleep’ cycle. It is further aggravated by social commitments during weekends. The unsatisfactory quantity, quality and timing of sleep can cause marked distress and interference in daily functioning and living.

Parasomnias (sleep disturbing behaviours)

Nightmares

Repeated awakening from sleep with detailed and vivid recall of intensely frightening dreams. A major stressful life event precedes the onset in 60% of cases.

Sleep terrors

Repeated occasions of awakening from sleep beginning with a cry or scream and signs of extreme fright (sweating, rapid breathing, pounding heart) but with no recall of the content of dreams.

Sleepwalking

Repeated episodes of rising from bed and walking about for several minutes. The child has a blank, staring face, is relatively unresponsive and can be awakened only with considerable difficulty. Upon awakening there is no memory of the event.

Bedwetting or Sleep enuresis

Associated with severe embarrassment, shame and guilt, leading to lifelong psychosocial impairment. More common in children but also seen in 1% of the adult population, properly administered behavioural therapy with judicious medication is effective.

Principles of good sleep practice

You don't need to follow all the points at one shot. Select two or three of them that appeal to you. The first point is essential.

• Set the alarm clock for a particular time and get up no matter how tired you are
• Establish routine times for retiring and waking
• Engage in quiet activities for about an hour or so before bedtime. Follow a relaxing bedtime routine and reduce ambient lighting 1 hour before bedtime
• Avoid engaging in stressful activities or unpleasant tasks near bedtime
• Avoid eating large meals and limit fluid intake immediately before bedtime
• Avoid caffeine for at least 6 hours before bedtime
• Exercise regularly but avoid exercising at least 3 hours before bedtime
• Make your environment right, i.e. your bedroom should be quiet, dark, and at a comfortable temperature.
• Use your bedroom only for sleep and sex, not for work or watching TV
• Avoid daytime naps

Exercise addiction - distorted pursuit of attractiveness?

Overexercising - obsessive weight-lifting or running, compulsive gym routines, or psychological dependence on exercise - is an illness. The health and fitness benefits of exercising are undeniable. However by overexercising the distorted pursuit of attractiveness takes precedence over fitness. Exercise addiction indicates a body image disorder; a distortion of the individual's mental representation of his or her own body. When I first commented on this phenomenon in 2001 body image disorders were a rarity in India (Misquitta 2001).

Pune is fascinated with its physique. Witness the mushrooming gyms and spas in every neighbourhood. Men dissatisfied with their appearance throng them to reduce or gain weight in pursuit of an ideal muscularity depicted on huge sports hoardings. An 18 year old ‘hunk’ is ashamed to wear T-shirts convinced his pectorals are too thin. He has no time to left to socialise at the end of his daily 5-hour workout. Women join gyms to lose weight and attain a waif-like slenderness. A 23 year old is advised by her trainer to cut down on her punishing exercise regimen - she changes her gym and continues to lose further weight. Exercising is no longer about fitness - it's about beauty.

From an evolutionary perspective attractiveness has universal criteria. These serve as cues to a persons reproductive ability. Males and females select partners that will enhance their reproductive success. Body characteristics signal reproductive advantage and render one individual more ‘desirable’ than another

Males desire muscular mesomorphism - the ideal body shape of broad shoulders, a muscular stomach, chest and shoulders, and a thin waist. This usually means about 10kg more muscle and 4kg less fat than their current physique. Positive characteristics of strength, bravery, health, and good looks are associated with this physique. Males also feel that looking fit is essential to career advancement. This discrepancy between actual physique and the desired culturally ‘ideal’ muscular physique is pushed at us from magazine covers, movies, posters, and toys (Todd G 2006).

For women body image is related to weight rather than shape (Viren Swami 2006). Urbanisation has placed unprecedented opportunities and demands on women. Slim women are used by the media to portray desirability. These socio-cultural demands have altered the evolutionary ‘hour-glass’ ideal for women. The emphasis is on slender and glamorously adorned women, striving for career accomplishment while maintaining their attractiveness. Increase in affluence also brings with it an epidemic of obesity that legitimises the pursuit of thinness and fear of fatness. Women exercise to lose body fat and improve muscle tone without increasing muscle mass.

Exercising is distorted into a pursuit of attractiveness for some individuals. These individuals pump iron, creatine, and steroids if they are males; or run and starve themselves if they are females. They lose their sense of perspective. Their bodies turn grotesque or gaunt. But when they look in the mirror they see some more work that requires to be done on some particular body mass.

At this stage they have developed body image distortions. Experiments have consistently shown that high mileage runners have a distorted perception of body size, they overestimate their waist size as compared to recreational runners (Wheeler 1986). Overexercising males who join gyms to increase muscle mass, and underweight females who overexercise are more likely to have body image disorders (Sergia-Garcia 2010). These body image disorders include anorexia nervosa in females and muscle dysmorphia (reverse anorexia or bigorexia) in males.

Muscle dysmorphia in males is the end stage of excessive exercising for muscularity (Pope 1997).

• Preoccupation with the appearance of the body
• Concern with not being sufficiently large or muscular
• Persistent weight lifting and dieting

Anorexia nervosa in females is the result of excessive exercising for slimness.

• Fear of fatness
• Dieting and exercising to maintain low body weight or continue losing body weight
• Underweight at least 15%
• Absence of three consecutive menstrual cycles

When should you suspect a body image disorder in an exercise freak (James E Leone 2005)?

1. Excessive and inordinate time is spent on grooming and appearance. The exercise is done with the aim of enhancing appearance rather than performance. When the person is not exercising he or she spends time being worried, depressed or anxious about appearance
2. Avoidance of social and work obligations either due to a sacrosanct exercise schedule or embarrassment due to perceived deformities in appearance
3. Dieting, supplements and drugs to enhance physical appearance. A large proportion of income could go towards this

What to do for someone who is obsessed with exercising?

• Verify the facts discretely to substantiate warning signs as noted above
• Chose a comfortable setting where you are not going to be disturbed
• Offer some of the information that raised red flags on body image concerns when the person asks what it’s all about.
• Deal with denial which is the first response. You need to listen, acknowledge, and submit your previously gathered observations non-confrontationally
• Suggest psychiatric referral and offer to accompany the individual
• Deal firmly with refusal which is the next response. Show concern that this is a serious disorder and that you would be irresponsible if you didn’t get the individual to consult a psychiatrist.

Exercise for fitness - attractiveness will follow

References

1. James E Leone, Edward J Sedory, and Kimberly A Gray. Recognition and Treatment of Muscle Dysmorphia and Related Body Image Disorders J Athl Train. 2005 Oct–Dec; 40(4): 352–359.
2. Misquitta NF. Anorexia Nervosa : A Caucasian Syndrome Rare in Asia. 2001 Jan; 57(1): 82-3
3. Pope HG Jr, Gruber AJ, Choi P, Olivardia R, Phillips KA. Muscle dysmorphia. An underrecognized form of body dysmorphic disorder. Psychosomatics. 1997 Nov-Dec;38(6):548-57.
4. Segura-García C, Ammendolia A, Procopio L, Papaianni MC, Sinopoli F, Bianco C, De Fazio P, Capranica L. Body uneasiness, eating disorders, and muscle dysmorphia in individuals who overexercise. J Strength Cond Res. 2010 Nov;24(11):3098-104.
5. Viren Swami. The influence of body weight and shape in the determination of female and male physical attractiveness. In: Body Image: New research. Marlene V Kindes Ed. Nova Science Publishers. New York. 2006. pp35-61
6. Todd G Morrison, Melanie A Morrison, Leigh McCann. Striving for Bodily Perfection? An overview of the drive for muscularity. In: Body Image: New research. Marlene V Kindes Ed. Nova Science Publishers. New York. 2006. pp1-34
7. Wheeler GD, Wall SR, Belcastro AN, Conger P, Cumming DC. Are anorexic tendencies prevalent in the habitual runner? Br J Sports Med. 1986 Jun;20(2):77-81.

Relationship conflict and strain in youth

Some relationships are characterised by conflict and strain and this can be detrimental to mental health in youth. Romantic relationships are important for mental health during the transition from adolescence to adulthood. Satisfaction in the relationship is strongly related to regard and empathy with the partner (Cramer 2003). Intimacy increases positive feelings in the relationship. The perceived quality of a relationship depends more on the presence of intimacy than on absence of conflict (Laurenceau 2005).

We have already noted the various the reactions to breakup of relationships. We now take a look at some psychological aspects of conflict and strain in ongoing relationships of young persons.

Gender aspects of ongoing relationships

For a young woman an ongoing and current relationship is associated with feelings of psychological well-being. For her just being in a romantic relationship provides a social identity and increases feelings of self- worth. This need to be in a relationship increases especially when there is gender inequality in the family. After a recent breakup; the altered social identity and reduction of self-worth make her prone to clinical depression.

For young men the quality of the ongoing relationship is more important. Men’s identity and feelings of self-worth are greatly affected by the support or strain they experience from their partner. This is because their romantic partner is their primary source of intimacy. In contrast young women have intimate relationships with family and friends. (Simon & Barrett, 2010). Men benefit more than women from support gained through a relationship; they are also more disturbed than women by strain in an ongoing relationship. When in a strained relationship men are likely to develop substance abuse problems.

Conflict in relationships

The quality of conflict negotiation between the partners in a relationship evolves over time. Initially the romantic bond overshadows the ability to acknowledge and deal with differences. The partners downplay their disagreements and fail to negotiate their differences. Later on, in stable relationships there is an increasing capability to recognize and face disagreements and to negotiate them in a better manner (Shulman 2008).

Personal characteristics and attachment style also play a role. Self-directed and autonomous people are generally less defensive and more understanding in their response to conflict (Knee 2005). Insecure, anxious individuals experience more conflict with their dating partners. Their conflicts tend to escalate in severity. These individuals require daily support to experience satisfaction with the relationship. As perceptions of satisfaction and intimacy change, commitment to the relationship is eroded over time (Campbell 2005). Family background of the partner is also important. The individual's style of handling conflict is learned through interactions with the mother and with siblings. This persists into the romantic relationship (Reese-Weber 2005).

Predictors of break-up

• Breakup of the romance is imminent when the pattern of interaction between partners is characterised by criticism, unrealistic expectations, or withdrawal.
• The best single predictor of impending breakup is contempt. This is especially so when the female partner displays contempt (Gottman 1994).
• Substance abuse problems in any of the partners increases conflict and hostility in the relationship (Floorsheim 2008).
• Adolescents with personality disorders are more likely to have conflict in their relationships (Chen 2004).

References

1. Campbell L, Simpson JA, Boldry J, Kashy DA. Perceptions of conflict and support in romantic relationships: the role of attachment anxiety. J Pers Soc Psychol. 2005 Mar;88(3):510-31.
2. Chen H, Cohen P, Johnson JG, Kasen S, Sneed JR, Crawford TN. Adolescent personality disorders and conflict with romantic partners during the transition to adulthood. J Pers Disord. 2004 Dec;18(6):507-25.
3. Cramer D. Facilitativeness, conflict, demand for approval, self-esteem, and satisfaction with romantic relationships. J Psychol. 2003 Jan;137(1):85-98.
4. Florsheim P, Moore DR. Observing differences between healthy and unhealthy adolescent romantic relationships: substance abuse and interpersonal process. J Adolesc. 2008 Dec;31(6):795-814. Epub 2007 Nov 26.
5. Gottman JM: What Predicts Divorce? The Relationship Between Marital Processes and Marital Outcomes. Erlbaum, Hillsdale, NJ, 1994.
6. Knee CR, Lonsbary C, Canevello A, Patrick H. Self-determination and conflict in romantic relationships. J Pers Soc Psychol. 2005 Dec;89(6):997-1009.
7. Laurenceau JP, Troy AB, Carver CS. Two distinct emotional experiences in romantic relationships: effects of perceptions regarding approach of intimacy and avoidance of conflict. Pers Soc Psychol Bull. 2005 Aug;31(8):1123-33.
8. Reese-Weber M, Kahn JH. Familial predictors of sibling and romantic-partner conflict resolution: comparing late adolescents from intact and divorced families. J Adolesc. 2005 Aug;28(4):479-93.
9. Shulman S, Mayes LC, Cohen TH, Swain JE, Leckman JF. Romantic attraction and conflict negotiation among late adolescent and early adult romantic couples. J Adolesc. 2008 Dec;31(6):729-45. Epub 2008 Oct 4.
10. Robin W. Simon and Anne E. Barrett. Nonmarital Romantic Relationships and Mental Health in Early Adulthood: Does the Association Differ for Women and Men? Journal of Health and Social Behavior 2010:51(2) 168–182 DOI: 10.1177/0022146510372343

Breakup of romantic relationships in youth

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

Reactions to breakup depend on individual attachment style

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

How do individuals react during a breakup?

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

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

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

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

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

What happens after the breakup?

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

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

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

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

High attachment anxiety increases the breakup rate

References

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

Anger management can save your life

Anger induced electrical changes in the heart

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

Why we need the emotion of anger

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

Anger management strategies

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

Focus and mindset strategies

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

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

Strategies for immediate anger control

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

What to do in the long run

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

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

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

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

References

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