Mental Health Care

Some people feel extremely anxious in social settings. They feel they might be under scrutiny and their actions might embarrass or humiliate them. Although the fear is all in the head, it becomes so intense and persistent that they begin to shiver at the thought of facing up to such a situation and do their best to avoid it. The fear may become so pervasive that it might interfere with their daily routine, occupation or social life. Social phobias can relate to several situations. The more common examples include the fear of public speaking or stage performance, fear of eating in a restaurant and fear of using a public restroom. The whole thing can turn into a vicious cycle. The anxiety associated with the disorder may actually mar performance and worsen the phobia.

People who suffer from social phobia are often hypersensitive to criticism, negative evaluation, or rejection by others. They find it difficult to be assertive and suffer from low self-esteem. They may not be able to achieve as much as they are capable of at work. The anxiety in speaking to a group or to authority figures and colleagues further lets them down.

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Techniques such as meditation, yoga, muscle relaxation, guided imagery, and slow breathing can help you relax. Your goal is to lower your heart rate and blood pressure while reducing muscle tension.

Meditation. The relaxation response can be achieved just by following four simple steps: assume a comfortable position, close your eyes, concentrate on a single word, sound or phrase, and cast off all other thoughts. This can have many physiological benefits, including decreased heart rate, lower blood pressure and reduced oxygen consumption. It is a mechanism that is the opposite of the fight-or-flee response. Practise it for 10 to 20 minutes daily, and being a natural antidote to stress, it would ease your nerves.

Yoga. Yoga is a way of life prescribed and practised by our forefathers for almost 6,000 years. Seeking perfect health and inner harmony through a unique lifestyle, yoga, unlike Western medicine, seeks holistic solutions. Regular practice of yogic breathing (pranayama), yogic postures (asanas), and meditation can help reduce anxiety, slow down breathing, lower blood pressure, alter brain waves, and make your heart work more efficiently. On top of all that, it just makes you feel good.

But before you sign up for the nearest yoga class, you need to know that yoga is not easy. It demands discipline and concentration. The good news is you can do yoga almost anywhere and you can get its benefits in just 20 minutes, practising it once daily. If you want to give yoga a try, your must find a good instructor to teach you yogic breathing and poses. Doing it incorrectly or going beyond your limits can cause injury. Make sure your instructor can adapt poses for different levels of flexibility. Also, tell him or her about any physical limitations you have, and ask whether there are postures you should avoid.

Other techniques. The techniques of progressive muscle relaxation, visual imagery and relaxed breathing have been discussed. Practise them to prevail over stress and a range of stress-related disorders, including hypertension, migraine and tension headaches, and chronic pain.

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Phobias can be successfully treated. Pharmacological treatments offer quick relief, but their benefit is short lived. On the other hand, behaviour therapy can eliminate the phobia altogether, but the treatment is more intensive.

Medications

Several anxiety-quelling medicines come in handy in the treatment of phobias. They block the anxiety response aroused by the phobic object or situation. Benzodiazepines, like alprazolam; beta-blockers, like propranolol, and antidepressant medicines can help check the symptoms of phobia, and can be used before a public performance by those having social phobia. The benefit lasts till the medication is taken.

Behaviour therapy

Behaviour therapy is the most effective treatment for phobias. It holds the promise of a definite cure. A number of techniques are in vogue, and the most popular is the systematic desensitization. In this method, the phobic person is exposed to the anxiety-provoking object or situation in a gradual graded manner. The first step focuses on allaying the person’s anxiety. For this, he or she is given anxiety­relieving medication and lessons on how to relax in the face of anxiety­provoking stimulus. Once he or she is sufficiently equipped to handle the situation, they are confronted with the object or situation that is increasingly similar to the feared one. Gradually, the person learns to overcome fear. In this way, the strong associative links between the feared situation, the experience of anxiety, and subsequent avoidance of that situation are broken. The following case history illustrates the usefulness of the technique.

Therapists have also found other behavioural techniques useful in the treatment of phobias. Thus, in the flooding technique, the therapist encourages the person to actually face up to the feared situation. Gradually, they reach the point when they no longer dread the object or event. The implosion technique, similarly, tries to demolish the fear by training the individual to confront the feared object or situation in their imagination.

Visual imagery, deep breathing and other relaxation techniques are also useful in overcoming social phobia. Yoga, particularly pranayama (conscious breathing) and meditation can also help with their calming effect on the mind.

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Most people who suffer from alcohol dependence or alcohol abuse are reluctant to take any treatment. In fact, most of them deny the problem. Since alcohol has serious health and social consequences, there is a definite need for them to be pressured to give up drinking. Some habitual drinkers seek treatment when they run into health or legal problems. If you are concerned about a friend or family member, go ahead and take a pro-active role and discuss the possibilities with a physician who specializes in de-addiction therapy.

There is a wide range of treatments available and they need to be tailored to the needs of the individual. The treatment must begin with a total evaluation, estimation of the severity of the dependence, counselling and management as an outpatient, or a residential inpatient stay.

The first step is to try and determine the extent of the problem. If a person has not lost control over the use of alcohol, the treatment may involve simply motivating the person to stop. This can be achieved with the help of counselling or a brief intervention. Effective treatment is impossible unless the person accepts that he or she is addicted and is unable to control drinking. The intervention usually involves alcohol-abuse specialists who can establish a specific treatment plan. Interventions may include goal setting, behavioural modification techniques, use of self-help manuals, individual and group therapy, participation in self-help groups, educational lectures, family involvement, activity therapy, counselling, and follow-up care at a treatment centre.

If the person has lost control and has turned into an alcoholic, the above listed steps alone are generally not sufficient and the beginning of a successful abstinence programme requires active surveillance under a specialized residential treatment facility or a separate unit within a general or psychiatric hospital. The treatment begins with detoxification. This usually takes up to a week, and the patient may need medications, such as diazepam to prevent delirium tremens and to treat other withdrawal symptoms. At the same time, steps are taken to provide the patient with adequate nutrition and rest. The patient often needs good amounts of multiple B vitamins. Each patient also requires a complete health check up. Chronic alcoholics are known to develop high blood pressure, increased blood sugar and liver and heart disease, and need active treatment.

Once the patient recovers from acute withdrawal symptoms, the process of rehabilitation must begin. Group and individual counselling, and psychological support can keep the motivation level high and reinforce the resolve to abstain. The family and friends also need to know that they must stop protecting the patient from the problems caused by alcohol. Those who are weak-willed; but have a desire to stop may take help of medications. An alcohol­sensitizing medication called disulfiram (Antabuse) may be useful. If a person drinks alcohol, the medication produces a severe physical reaction that includes flushing, nausea, vomiting and headaches. Disulfiram will not cure alcoholism nor can it remove the compulsion to drink. But it can be a strong deterrent. Naltrexone, a medication long known to block the narcotic high, can also reduce the urge to drink. It may, however, lead to serious side effects, including liver damage. These medications cannot be given to a person who is not willing to stop.

While the person makes a recovery, they must also return to useful and active life. This may require vocational rehabilitation, family support and sexual counselling. Positive life enforcement can go a long way in keeping the person from returning to the old ways. They need constructive engagements such that it is easier to deal with free time without alcohol, develop a non-drinking social circle, and handle stresses on the job and at home without alcohol. Whether the treatment begins in an inpatient or an outpatient setting, the patient needs to stay in touch with the treating physician for at least six months.

Self help groups, such as Alcoholics Anonymous (AA), established in the US in 1935 and now with branches all over the world, offer continuing support and help in abstinence from alcohol, managing any relapses and begin life anew. The organization functions through local groups that have no constitutions, officers, or fees. Anyone who has a drinking problem may become a member.

A large number of alcoholics are able to win the battle. The path to success is self-determination.

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Stress management simply aims at training your thoughts and actions and being in control of your self A positive mindset, perseverance and self-belief are the first pre­requisites to overcome stress, but the game plan also includes developing a social support group, using appropriate behavioural and mental techniques to relax, and turning to time ­tested formula of exercise, balanced diet, sleep, regular dose of humour, and recreation sports to dissipate stress. Let us see how:

Develop Positive Mental Coping Mechanisms

A positive mental and emotional approach towards life situations can help you cope with stress. You just have got to believe in self and hold that you can control much of all that happens to you. Researchers have found that people who hold a positive attitude about their abilities, do not get easily frustrated, remain optimistic, and persevere. They tend to cope well with stress. On the other hand, negative personality traits, such as low self-esteem and an outlook of gloom and negativity can trip people even if they have everything working in their favour. Bolster your psychological defence by equipping your self with the following mental strategies:

Think positive. For long, it has been asserted in Vedanta that our thoughts become reality. We are what we think. It is simple. If we think gloomy and negative thoughts, we feel miserable and unhappy. If we think anxious thoughts, we become tense and nervous. Conversely; if we think healthy thoughts, we feel happy. A positive self-talk that focuses on our capabilities and inner strengths eases stress, while a negative self-talk can push back even geniuses.

Set realistic goals. Setting our goals unrealistically high invites failure. Take a reality check. Assess your strengths, abilities and resources before deciding on the goals. Think big, but be pragmatic. Overstepping your limits can only lead to disappointment, frustration, and stress.

Prepare adequately. Plan your work in a step-by-step manner. Specify your target and work out all the details. Rehearse in your mind what the job will require of you. Then divide the target into small accomplishable tasks. While finalizing the plan, also keep an allowance for some extra time and expense. Events beyond your control will happen and jeopardise your planning, and if you account for them, it is easy on the nerves.

Prioritize. Concentrate on what’s important. Decide on your priorities and concentrate on the things most important to you. If more jobs come your way, do not take them unless you are comfortable.

A polite regret sometimes works better. A polite ‘no’ is much better than failing to deliver later. If you have too many things on your hands, do not add to your stress by accepting another job. It is wrong to think that another person will feel offended if you are honest.

A wishy-washy attitude gets you nowhere. Psychologists have found that people use two broad types of coping behaviours to triumph over stress: problem-focused coping and emotion-focused coping. The goal of both is to control stress level. In problem-focused coping, people try to short-circuit negative emotions by taking some action to modify, avoid, or minimize the threatening situation. They adapt themselves to deal with the stressful situation. In emotion-focused coping, people try to moderate or eliminate unpleasant emotions through mechanisms that may not be ideal. For example, faced with a difficult situation you might prepare yourself and deal with it or conversely, indulge in wishful thinking and deny the situation. Both approaches may ease your immediate stress, but relief is temporary if you adopt the latter strategy.

To understand these responses, consider the example of a biochemistry student who is due to appear for his final examinations. He knows he must get top grades in order to have a chance at acceptance to the PhD programme. This situation is a potential source of stress. To cope, he could devote himself fully to master the course materials systematically (problem-focused coping). Or he may take a wishy­washy attitude and watch television for hours on end to prevent having to think about or study for the exams (emotion-focused coping).

Dissipate your anger healthily. If you experience anger, it needs to be expressed, but carefully. Count to 10, compose yourself and respond in an effective manner. Give the provoker the benefit of the doubt, and if you still feel aggrieved, make it known without attacking the other person. Let him know about your disagreement with tact and positive communication skills.

At the same time, also learn the art of forgiving. It has a positive psychological value for you. It makes your inner self glow, lowers your blood pressure and heart rate, and your breathing calms.

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You could try several age-old simple recipes to knock off the tensions of life. Regular doses of humour, adequate sleep, a healthy balanced diet, exercise, recreation and sports, soaking in a warm tub, massage, and timely vacation can treat anxiety and stress.

Add laughter to life

A chuckle a day keeps the doctor away. This philosophy has been prevalent in yoga down the ages. The therapeutic powers of ‘hasya yoga’ or laughter are a legend. It relaxes mind, eases stress and anxieties, improves circulation and breathing, lowers blood pressure, and is a wonderful tonic both for the body and mind. Modern researchers investigating into the healing powers of laughter have found that humour also activates the natural stress-relieving chemicals in the brain and improves the defence system of the body. So, it may be a good idea to keep a collection of amusing books, comics and videos at your bedside and take a regular dose of humour before going to sleep.

Sleep well

Sleep is a healer both for the body and mind. It refreshes us, resolves emotional conflicts, helps us think clearly, and promotes positive mental health. Take regular six to eight hours sleep during the night and, if possible, a short post-lunch nap. Indulging frequent late nights and then cutting on sleep hours are the sure way to court stress.

Some people just cannot get sound sleep. The best way out is to maintain a regular sleep routine. Switch off the television and PC at least one hour before the bedtime. Light relaxing music, a bath, pleasant conversation and a gentle massage are some sure recipes to keep away from sleeping tablets.

Take a balanced diet

Do not neglect meals. Eat on time, even if you are under a time pressure. If you fast for long hours, the blood sugar is lowered, and you may feel easily fatigued. The second commandment is, eat light and enjoy a balanced diet. Take plenty of fresh fruits, salad and vegetables. They neutralize stress. On the other hand, too much carbohydrate in desi-videshi junk and fast food items, like pizza, aaloo ki tikki, samosas, chhole-bhature, French fries and hamburgers tend to adversely affect your think tank.

Do not indulge in self-abuse

Alcohol, cigarettes, and cups and cups of caffeine are not the solution to stress. Such substances only mask the problem and can make the situation worse. Their abuse stresses the body and the mind.

Exercise regularly

Start the day with a 30-45 minute brisk walk. Aerobic exercise ­such as running, walking, biking and swimming-can help keep stress levels down. It also increases the endurance of the heart and lungs. A physically fit individual has a lower heart rate and lower blood pressure, less reactivity to stress, and quicker recovery from stress. In addition, studies show that people who exercise regularly have higher self-esteem and suffer less from anxiety and depression than comparable people who are not aerobically fit.

Water is a wonderful energizer

Drink plenty of water every day. It makes more than 70 per cent of the human body. But splash in it also, whenever you can. A soak in the bathtub can wipe you clean of fatigue. A good swim, Jacuzzi, or sauna bath also make an excellent remedy for stress.

Massage is good

Touch is a newborn’s first contact with the world. As babies, we all snuggle up to our mothers for warmth, comfort and security. A warm rub by a loved one can bring back the same sense of comfort and care to your world.

Even an impersonal massage by a masseur has many virtues. It releases tension from aching muscles, stimulates blood flow, eases the mind and body, and fosters a sense of well-being.

Take out time for relaxation

Even though satisfying work is a great tonic, taking time out for recreation is also a must. You can do anything that you like. Read a book, play a game of chess; bridge, carom, or rummy, or take your family out for a picnic. Going for nature walks, enjoying a movie or play, visiting an art gallery, or partying with friends and family-all can help in a big way. Even helping your child do a school project or cooking a dish in the kitchen may work out to be an excellent rejuvenator.

Listen to music

Good music-music that you enjoy-is a wonderful remedy to overcome stress and fatigue. Tune in and soothe your self.

Take a vacation

A relaxing, fun-filled holiday is a perfect recipe for good health. It casts a magic effect on your physiological and psychological health and is one sure way to recharge your batteries, cleanse your mind and body and humour your soul. The best way is to simply rest and relax. Remember, the word ‘vacation’ is coined from vacate, which means ‘to leave’ or ‘go away’. Go away you must-not just physically, but mentally as well. A sedentary desk-bound person may wish to go out and stretch his muscles a bit, but a physically active worker may wish to take a quiet vacation. Let the vacation be a complete change from the routine.

Seek help

If you cannot devise a solution and find that stress is building up or you are not functioning well, contact your physician.

The key to handling stress is to keep it on your side. Some of it is necessary to keep you sufficiently motivated. Moderate stress fuels creativity and also enhances our performance. The joy lies in listening to the perfect twangs from your soul machine. If you let the strings too loose, they won’t just play. Tighten them too hard, and they may break.

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The illness usually develops slowly over months or years, and can surface at any time. In some people the symptoms may only last for a brief period, disappear, and then appear again in a cyclical fashion for a few years. The illness may then stop recurring and leave no residual effect. This is called the schizophreniform disorder. In most people the disease runs a long and continuous course. The severity of symptoms and the functioning of a person may however wax and wane. The disease may erupt and become severe, but may again become placid. Some people, as they grow older, are fortunate to experience a gradual decline in symptoms. About 25 per cent people with schizophrenia become symptom-free in their later lives.

The illness is marked by a variety of symptoms. The most prominent features are: disordered thinking-thinking becomes incoherent, disjointed and rambling; emotions get unrelated to the situation, actions and utterances become impulsive, and hallucinations overtake-the person begins to hear voices, often of unfriendly kind, or see objects that do not exist. Bizarre delusions is another common feature. The movements may become strange. Most people with schizophrenia cannot recognize that their mental functioning is disturbed or that they need help. They often do not understand that medication is a necessity for them and this worsens their suffering.

To develop a clearer understanding of the illness, let us take a closer look at its characteristic symptoms:

Delusions. Delusions are false ideas or beliefs that obviously appear untrue to other people. People with schizophrenia experience delusions of many kinds and are unable to appreciate why their ideas are unacceptable to those around them. Sometimes, these delusions are extremely grandiose. A person with schizophrenia thus may believe that he is the king, prime minister, or president of a country! Often, the delusions are persecutory in nature. He may believe that people are plotting against him, and are out to get him, or that he is being spied on. This condition is known as paranoia. The delusions may also be bizarre. A person with schizophrenia may thus believe that a stranger has removed his internal organs and has replaced them with someone else’s organs without leaving any wounds or scars. He may also believe that aliens are controlling his thoughts or that his own thoughts are being broadcast to the world so that other people can hear them.

Hallucinations. People with schizophrenia may also experience hallucinations (false sensory perceptions), and may see, hear, smell, feel, or taste things that are not really there. Auditory hallucinations, such as hearing voices when no one else is around, are especially common in schizophrenia. These. hallucinations may include two or more voices conversing with each other, voices that continually comment on the person’s thoughts or behaviour, or voices that command the person to do something. These are fairly characteristic of the illness. These hallucinations must occur when the person is clearly awake and not at the time when he is about to fall asleep or is waking up.

Disorganized Thinking and Speech. Since the thought process gets disorganized in people with schizophrenia, they may talk in an incoherent or nonsensical way and may jump from topic to topic or string together loosely associated phrases. They may also combine words and phrases in meaningless ways or make up new words. In addition, they may show ‘poverty’ of speech, in which they talk less and more slowly than other people, fail to answer questions or reply only briefly, or suddenly stop talking in the middle of a conversation.

Bizarre Behaviour. A person with schizophrenia may behave bizarrely. He may appear markedly dishevelled, may dress in an unusual manner (for example, wear multiple shirts, coats, scarves and gloves or use inappropriate makeup), may talk to himself, may shout or swear without provocation, may walk backward, laugh suddenly without explanation, make funny faces, or may display clearly inappropriate sexual behaviour. In rare cases, he may maintain a rigid, bizarre pose for hours on end, or may engage in constant random or repetitive movements.

Social Withdrawal. A person with schizophrenia may experience several negative symptoms, the most characteristic of them being social withdrawal. The person may thus begin to avoid others or act as though others do not exist. He may show decreased emotional expressiveness, and may talk in a low, monotonous voice, avoid eye contact with others, and display a blank facial expression. He may also have difficulty in experiencing pleasure and may not feel up to taking part in any work or social activities. This lack of volition stops him from initiating and pursuing goal-directed activities.

Other Symptoms. People with schizophrenia may face difficulties with memory, attention span, abstract thinking, and planning ahead. They commonly suffer from anxiety, depression, and suicidal thoughts.

They may experience physical tiredness for no valid reason, may oversleep or find difficulty in sleeping, suffer a loss of sexual interest, become overly dependant, and face problems in money management.

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Man’s rendezvous with fear must date back to the beginning of life itself. The moment Adam and Eve took their first steps on this planet, they must have bumped into fear. The ‘terrible’ elements of nature-including storms, lightning, dizzy heights, water bodies, fierce and powerful animals, and caves and hidden crevices-must have filled them with trepidation. This natural instinct of self-protective fear still dwells within us after thousands of years of evolution. If we were in a jungle, with no arms and ammunition for safety, and a tiger were to suddenly spring on us, most of us would be petrified. A severe earthquake, tornado, or storm would evoke the same emotion.

This natural fear, in the face of danger, is an in-built mechanism within all human beings. Sometimes, however, some people begin to fear a specific object, situation, or activity, without any logic or justification. This pathological fear, which is persistent, intense, and has no relationship to the real situation, is termed phobia.

People who have phobia realize that their fear is unreasonable. Yet, faced with a feared object or situation, they lose control over themselves, are stricken by terror and go through acute bodily changes. The heart begins to race and thump against the ribs. The skin turns cold and deathly pale and breaks out in cold sweat. The hair stands on end. The eyes and the mouth are open wide. The pupils dilate. The breathing becomes hard and laboured. The mouth turns dry. The lips tremble. The voice becomes indistinct or husky or fails. The bowels and the bladder may move. The muscles become tense. All in readiness to flee or fight.

Most people, who suffer from phobia, try to sidestep their illness. They learn to avoid the object or situation that causes the fear, even if it cripples their freedom. This avoidant behaviour may hamper their daily routine, compromise their social life and rob them of career prospects. For example, a sales manager who develops a phobia of flying might avoid travel, fail to meet his sale targets and be thrown out of his job. Yes, phobia can make life most difficult!

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Sudden withdrawal of alcohol from a person who has developed physical dependence on it can lead to a number of symptoms. The picture can vary between individuals, and may include shaky or jittery hands, increase in heart rate, breathing rate and body temperature, sleeplessness often accompanied by bad dreams, irritability and stomach upset. These symptoms begin within five to ten hours of last dose, peak in severity on day two or three, and improve by day four or five. Anxiety, sleeplessness and other mild symptoms may persist for six months or more and may contribute to return to drinking. About five per cent habitual drinkers show severe withdrawal symptoms. They suffer from confusion, and hear voices, see horrifying images or feel objects that do not exist. It takes several days before theses symptoms disappear and the mental state becomes clearer. A small number may suffer from generalized convulsions, called rum fits, within 48 hours of stopping drinking. In some cases, they may experience delirium tremens, which produces confusion, severe agitation, terrifying hallucinations, and sleeplessness. As this delirium progresses, the hands develop a persistent and uncontrollable shaking that may extend to the head and body.

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With the predominant symptoms at the core, schizophrenia has been categorized into five subtypes: paranoid, disorganized (hebe­phrenic), catatonic, undifferentiated, and residual. The first is the paranoid type. Its essential feature is the presence of prominent delusions or auditory hallucinations. Delusions are typically persecutory or grandiose, and hallucinations may also revolve around similar themes. Associated features include anxiety, anger, aloofness and argumentativeness. The person can benefit from treatment and lead an independent life.

The disorganized type is the most severe. It is characterized by silly speech and misplaced laughter, distuption in the ability to perform daily activities, and oddities of behaviour, such as grimacing and other strange mannerisms. The illness has a continuous course without significant letups.

Catatonic illness is marked by waxy flexibility, extreme negativism, rigid or bizarre posturing, parrot-like apparently senseless repetition of a word or phrase just spoken by another person and repetitive imitation of another person’s movements (echopraxia). People with this illness are faced with the risk of becoming malnourished and they may inflict injury on themselves.

The undifferentiated illness features delusions, hallucinations, incoherent speech, disorganized behaviour, or negative symptoms of muted emotion, absence of logic and lack of will to work.

The residual type is characterized by eccentric behaviour, odd beliefs, and mildly disorganized speech. Delusions and hallucinations do not occur or, if present, are mild.

This classification helps in decision-making at the time of treatment and prognosis, but it is not a rigid one. If there is major change in the clinical picture, which happens frequently, the subtype also changes.

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