THE FIVE ‘I’s OF ANXIETY
Irritability, Insomnia, Impulsivity, Isolation, Impotency
For over two years, it was a constant fight for survival for the 35-year-old banker from Bhubaneshwar. His state of mind was a sense of acute dread without any obvious reasons. Through the long nights, he struggled to get a moment’s sleep and when he got up in the morning, the cycle started all over again. There were times when he actually felt like he was dying. As the condition of Santosh Mishra (name changed) worsened, he sought medical care. He spent time in hospitals to diagnose what was wrong with him. Finally, he was directed to a psychiatrist, who diagnosed him as suffering from an anxiety disorder. After sessions of counselling and medication, things are getting better...
THE WORRY FACTOR: Yale professor of psychology Seymour B. Sarason defines anxiety as a diffuse, vague, very unpleasant feeling of fear or apprehension. Numerical research in India on mental health issues like anxiety is largely inadequate. Mishra is one among the every five Indians who have mental disorders, according to the Massachusetts-based Minds Foundation founded by Dr Raghu Appasani. The Head of the Department of Psychiatry at New Delhi’s G B Pant Hospital R C Jiloha notes that an estimated 1-2 per cent of India’s 100-crore plus population are afflicted with serious mental disorders and about 5 per cent of the population from minor depressive disorders, and for two crore (20 million) Indians with mental illnesses, there are only 3,500 psychiatrists and 1,500 psychiatric nurses. Mental health professionals—India has only around 5,000—especially in urban areas, are treating more and more such cases of anxiety-related disorders and even depression.
“A number of studies have shown that nearly 20-25 per cent of patients attending primary care settings suffer from depression and anxiety disorders,” says Dr Rakesh Chadda, professor of psychiatry, All India Institute of Medical Sciences (AIIMS), New Delhi. While experts say the definitive cause/reason for such illnesses is not known, generally, it’s a combination of genetic as well as environmental factors that makes one vulnerable.
Dr Sameer Malhotra, Director, Mental Health & Behavioural Sciences, Max Hospital, New Delhi, says, “Worldwide, stress levels are at a high and the coping ability of an individual is at stake. The Indian family structure is changing, there’s large-scale migration, our outlook is becoming materialistic, so there’s increased pressure to make more money…rapid population growth also means more people competing for fewer opportunities. All this builds up frustration.”
MODERNITY BACKLASH: According to psychiatrists, the rise in cases of mental illnesses—especially anxiety—is largely a by-product of liberalisation with its job stress, the strain of consumerist aspirations and competitive educational goals. Experts say relationship-related problems are causing stress and anxiety too. “Day-to-day pressures, stress and anxiety of modern living are also responsible for the increasing prevalence of alcohol use and dependence,” adds Dr Chadda. Not just that, more and more people are now turning into social media addicts, measuring self-worth in terms of how many ‘likes’ their latest picture received on Facebook or by the number of followers on Twitter. In a way, these technological tools that were supposed to encourage and make it simpler to remain connected with friends and relatives, are actually causing anxiety in many. Explains consultant psychologist Paromita Mitra Bhaumik, director, Anubhav Positive Psychology Clinic, Kolkata, “When someone praises you, it causes a dopamine surge in the brain, resulting in a ‘high’. The problem starts when you seek and actually expect attention in order to feel good about yourself.” She adds that while such sites are great for building social and professional contacts, it’s important for the user to differentiate between pseudo-support offered by the virtual world and the stability of real relationships.
In India’s vast rural areas, it is even more difficult to audit mental health efforts. In remote villages, mental problems are seen as occult phenomena, where possession by evil spirits and black magic are cited as causes by witchdoctors. As a result, witch hunting has become a savage by-product of fear and ignorance. Last year, this newspaper reported a case in which a teenager decapitated her grandmother who she suspected of sorcery and beheaded her, walking with the severed head to the police station. Dr Anand Balan, a Chennai-based psychiatrist, says, “Broadly, we can understand the reasons for anxiety across three dimensions—biological, psychological and social. Psychosocial usually starts from stress and how we cope with it on a day-to-day basis, which for a vast majority of people is manageable. But in those individuals with vulnerabilities, that same stress becomes extreme and they cannot cope with it. That manifests as anxiety disorder. When we examine the biological aspect, three neurotransmitters in the brain, namely norepinephrine, serotonin and dopamine come into play. When these three do not function in a balanced way, then again it leads to an anxiety problem.”
In case of 15-year-old student Rashmi Dutta (name changed), she says fear has taken over her life. The teenager was good in academics until sometime back, but now dreads the thought of attending school. “I have no friends and I’ve almost given up on everything,” she says. The Class X student has been put under psychiatric care by her parents.
Says Dr Mathew Varghese, Professor & Head, Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, “As per WHO classification, there are over 70-80 disorders. While the common ones account for about 6-7 broad categories, the comparatively less common, but severe mental disorders account for about 3 per cent of the population and comprise 4-5 major disorders, like dementia, schizophrenia, bipolar disorder etc.”
While it may be difficult to pinpoint the exact cause of mental disorders, one thing is certain: it is far more common than what one would want to believe. Says Dr Varghese, “In a study carried out from 2003-06, the prevalence of common mental disorders accounted for about 8 per cent of the population in India.” Obviously, when the total prevalence is considered, the figures are much higher. “According to WHO, the life time prevalence of psychiatric disorders is about 25 per cent (for member countries, including India). This translates into one out of four persons standing a risk of suffering from a mental disorder in a lifetime,” says Dr Chadda.
CHILD VICTIMS: Increasing cases of anxiety and other disorders among women and children worry psychiatrists. The parents of Chennai schoolgirl 10-year-old Priya Raman* (name changed) sensed something was amiss when she started taking a long time to get ready for school; on many days, she even missed school due to this. Then there were other changes: she insisted on drinking only packaged water. It appeared to be an OCD (Obsessive Compulsive Disorder)—while washing her hands, she would turn on the tap only with two fingers of her left hand, then wash the tap thoroughly before washing, and then turn off the tap again with the same two fingers. Before bathing, she would first wash the entire bathroom and would take about 2-3 hours to complete this daily activity. She was scared to drink water from a cup, fearing that she might swallow a centipede. The child, who once used to lovingly hug and kiss her mother before going to school, started avoiding being touched by her. On probing, she said that she felt like vomiting on her mother’s face. Even when she went to school, she would feel uncomfortable the entire day. The consulting psychiatrist put her on medication right away and in 2-3 weeks, Priya’s condition improved.
A study by two Thiruvanathapuram University psychologists—Raakhee AS and Aparna N—found that 56.8 per cent of student population experience one or the other type of anxiety disorder and that girls suffered more than boys from anxiety. The paper states, “The presence of anxiety disorders among adolescents calls the attention of the parents, teachers and educationalists to take action for the improvement of mental health of school children.” The academics categorised anxiety into five sections: generalised anxiety disorder, panic disorder, social anxiety disorder, separation anxiety and school avoidance anxiety. The first is characterised by “long-lasting anxiety that is not focused on any one object or situation, accompanied by persistent fear and worry and concern with everyday matters.” In panic disorder, “brief attacks of intense terror and apprehension, often marked by trembling, shaking, confusion, dizziness, nausea, difficulty in breathing that abruptly arises and peaks in less than 10 minutes, can last for several hours and can be triggered by stress or fear.” Social anxiety disorder (SAD; also known as social phobia) “refers to an intense fear and avoidance of negative public scrutiny, public embarrassment, humiliation, or social interaction—affecting public speaking and in most or all social interactions.” The physical symptoms include blushing, sweating, and difficulty speaking. One suffering from separation anxiety feels “excessive and inappropriate levels of anxiety over being separated from a person or place.” School avoidance anxiety is “most common in kids who are five to six years old, when they are just starting school and in their first year of kindergarten. It is also common in school-age children who are about 10 to 11 years old, toward the end of the last years of elementary school. In addition to temper tantrums and crying when it is time to go to school, symptoms that children may have when they don’t want to go to school may include vague complaints such as stomach ache, headache, nausea, dizziness, chest pain, joint pain etc. School refusal is often the initial presentation of social phobia, particularly in adolescents.”
THE PHOBIA SYNDROME: In fact, it’s the misconception that mental illness means “madness” that prevents people from approaching a psychiatrist or psychologist. “For common cold and cough, people run to a doctor, but choose to suffer in silence when it’s a mental illness. A few of my patients admit (after treatment) that had they approached me earlier, they wouldn’t have had to compromise on the quality of their life,” states Dr Malhotra. He also stresses on the greater role of family members as they, as caregivers, face the main burden. “Mentally-ill patients can exhibit a whole range of symptoms. So, it’s important to recognise them, instead of adjusting and compromising, and seek medical intervention early. Any behaviour that deviates from normal needs to be noted, such as significant mood changes, either withdrawn, avoiding contact with family members (or even over-socialising), irritability, breaking things when angry, change in sleep habits (such as remaining awake at night), loss in appetite or gorging on high-calorie food, unduly suspicious, washing hands repetitively, feeling breathless and unspecific pain in the stomach, head etc, increase in smoking and alcohol consumption, sexual problems...” he lists.
Once the patient is taken to a mental health professional for evaluation, the diagnosis of the specific illness is the next step. Dr Bharat R Shah, professor of psychiatry, K J Somaiya Medical College, and senior consultant psychiatrist, Lilavati Hospital, Mumbai, says, “There are no pathological or radiological tests for diagnosing mental disorders. A detailed family and personal history, combined with the symptoms and psychological testing, help in diagnosing the specific illness.” Bhaumik elaborates, “Psychometric assessment is a standardised test used for diagnosis. As part of the tests, there are scales for measuring anxiety and stress levels. Projective tests, such as the T.A.T (Thematic Apperception Test) help in assessing an individual’s personality, emotions, conflicts etc. These standardised tests are designed to ensure that the subject can’t manipulate his/her responses. In case of young children, who may not be able to verbalise their desires and frustrations, the C.A.T (Children’s Apperception Test) is done.” When a psychologist diagnoses a serious mental disorder, which requires medication, the case is referred to a psychiatrist.
THE CURE CHALLENGE: For the last one year, Bangalore resident Paulina Simon (name changed), a 47-year-old businesswoman, has been occasionally feeling that she is having a cardiac arrest and rushes to the hospital, only to be told that she’s fine. This issue is taking a toll on her family because whenever she gets a panic attack (on a weekly or monthly basis), her family members have to drop everything and rush her to Emergency. So far, medication has not helped improve Paulina’s condition.
When it comes to treatment of mental illnesses, the good news is that most common disorders are completely treatable. Prof Ajaya Kumar Mishra, head of psychiatry at MKCG Medical College and Hospital, Odisha, and member of the State Mental Health Authority, says, “Anxiety disorders are among the most treatable of all psychiatric disorders. Research has proved that Cognitive-Behavioural Therapy (CBT) and new medications have mitigated the disturbing signs and symptoms of anxiety disorder in 60 to 90 per cent of afflicted individuals, allowing them to lead normal lives again.” Doctors also emphasise that the new medications available these days have fewer side-effects, so people should not harbour any wrong notions about their usage. In some disorders, such as depression, while medications may lead to total recovery, in others, they may be able to control only the symptoms. “In cases of severe depression, physical treatments, such as Electroconvulsion Therapy (ECT) or shock therapy is also used sometimes. Though, there’s negative publicity surrounding shock treatment, it’s quite effective,” says Dr Shah. In some patients who are drug-resistant, the Deep Brain Stimulation (DBS) method is also being tried. “DBS is a relatively new science, having been introduced 10-12 years ago and used mainly to treat Parkinson’s or tremors. It is being tried out for depression as well, but it is yet to be FDA approved. In this treatment, an electrode is implanted surgically into the nucleus of the brain and the imbalance between the neurotransmitters is sorted out,” says Dr Ravi Verma, a practising neurosurgeon at MSR Hospital, Bangalore.
UNDERSTANDING ANXIETY: Counselling and psychotherapy (involving techniques such as CBT) are integral to the treatment programme. Says Bhaumik, “Cognitive Behaviour Therapy is a psychological therapy which aims at changing thoughts (cognitions) and our actions (behaviour) so that we become better adjusted and stress-free. The way we think affects how we feel and finally, what we do. As there are both helpful and unhelpful ways of thinking about a situation, CBT involves ‘cognitive restructuring’ of thoughts in a stepwise manner, so that we become aware of the negative automatic thoughts.” CBT involves the analysis of five major areas—the situation (problem or event), thoughts, emotions, physical sensation/feelings and actions. “A variation of CBT, called the Mindfulness-based Cognitive Therapy (MBCT), is also practised which uses the same theory, but the focus is on becoming aware of all thoughts and feelings and accepting them, not attaching ourselves or reacting to them,” explains Bhaumik. With the growing popularity of counselling centres and life coaches in cities, experts say it’s important to find one with the right credentials. Says Dr Shah, “While there’s no harm per se in lay counseling (where one listens to a friend or family member talk about a problem and offers simple solutions), it’s important to remember that being able to diagnose a mental illness requires specialised training.”
Anxiety and depression are ailments that can be beaten if a professional diagnosis is done well. Back in 1981, one of Guwahati-based bank employee Mukul Goswami’s three sisters (a 14-year-old then) started behaving oddly. “Till then, she had been well-adjusted, good natured and doing well in school. Suddenly we noticed that she was barely sleeping at night. She said she could hear voices, had mood swings and spoke bizarrely. In her condition, it became impossible for her to continue studies. The psychiatrist diagnosed the girl’s condition as schizophrenia. “We had absolutely no idea what this illness was,” he says. But, the Goswamis chose to educate themselves. “Once we read up about schizophrenia, we felt empowered.” They decided to inform everyone the girl’s condition. “We told them that her behaviour was not deliberate and that she had no control over it. All this while her treatment continued,” Mukul says. Their open approach paid off and they found unexpected support from people around. “Once I was at work when I got a call that my sister had broken a window of the guesthouse opposite our house. I immediately rushed home, expecting to be met by an angry crowd. But there was no one around. When I approached the caretaker to apologise, he said he understood the situation!” Mukul recalls. Along with her treatment, Mukul’s sister also received vocational training. She got a job in a school of fine arts, where she worked for 17 years till her death in an accident in 2012. “I decided we wanted to work for the rehabilitation of the mentally ill who lack family support. Ashadeep was formed in 1996,” he says. The NGO, apart from counselling, also rehabilitates the homeless. In the ignorance-shot mindscape of India, first attitudes await to be rehabilitated.
Students are Stressed, Senior Citizens Often Depressed
The burden of academics, ever-increasing competition, parental expectations, peer pressure…they face it all, so is it really surprising that the student community is stressed and anxious? Hyderabad-based G Angela David, counselling psychologist at Osmania University’s Sahayam counselling centre, says on an average, she meets three to seven students a week, suffering from anxiety-related problems. “There’s fear, anxiety-related panic attacks, restlessness and insecurity amongst youngsters. We try to explore their thought patterns, beliefs, lifestyle etc and advise them to focus on the best things in life and be grateful, give themselves some space and time, have healthy food on time, live in the present rather than worry about the future,” she says. Sahayam was set up four years ago following rising suicides on the campus. Free counselling is offered to students, a majority of whom hail from rural backgrounds and struggle to adjust. Anita Gracias, a volunteer at Sahai, a suicide prevention helpline says, “At times, I get upto 30 calls a day. During exams, students call up to ask what they should do if they do not get admission to those colleges where their friends will. Parents call too, mainly to ask for reassurance that their kid will make it to college. Other than this, the maximum calls are made by people who are experiencing problems in their relationships. Rifts with parents, spouses, boyfriends or girlfriends are common. We are losing the ability to talk to people as we send a curt message rather than talk.” In younger children, conditions such as anxiety disorders and attention deficit hyperactivity disorder (ADHD) are more common. Says clinical psychologist Paromita Mitra Bhaumik, “We teach kids early on about physical hygiene—how to brush their teeth, bathe and keep themselves clean, but mental hygiene is neglected. It’s essential to teach life skills, anger management, stress management, coping skills etc to enjoy a truly healthy life.”
In the case of senior citizens, depression and dementia are common. “Thanks to better healthcare, people are living longer. But, after retirement, many senior citizens suddenly find themselves idle, without scope of being involved in any constructive activities. Plus, if their children are settled elsewhere, they also have to battle loneliness. All this causes anxiety, insecurity, depression, making them feel suicidal at times. If family members are unavailable, they need to be with people in their own age group, who can understand and share their concerns and experiences,”says Bhaumik.
Self-help for anxiety attacks and anxiety disorders
Challenge negative thoughts
Write down your worries. Keep a pad and pencil on you, or type on a laptop, smartphone, or tablet. When you experience anxiety, write down your worries. Writing down is harder work than simply thinking them, so your negative thoughts are likely to disappear sooner.
Create an anxiety worry period Choose one or two 10 minute “worry periods” each day, time you can devote to anxiety. During your worry period, focus only on negative, anxious thoughts without trying to correct them. The rest of the day, however, is to be designated free of anxiety. When anxious thoughts come into your head during the day, write them down and “postpone” them to your worry period.
Accept uncertainty. Unfortunately, worrying about all the things that could go wrong doesn’t make life any more predictable—it only keeps you from enjoying the good things happening in the present. Learn to accept uncertainty and not require immediate solutions to life’s problems.
Take care of yourself
Practice relaxation techniques When practiced regularly, relaxation techniques such as mindfulness meditation, progressive muscle relaxation, and deep breathing can reduce anxiety symptoms and increase feelings of relaxation and emotional well-being.
Adopt healthy eating habits
Start the day right with breakfast, and continue with frequent small meals throughout the day. Going too long without eating leads to low blood sugar, which can make you feel more anxious.
Reduce alcohol and nicotine
They lead to more anxiety, not less.
Exercise is a natural stress buster and anxiety reliever. To achieve the maximum benefit, aim for at least 30 minutes of aerobic exercise on most days.
Get enough sleep
Lack of sleep can exacerbate anxious thoughts and feelings, so try to get 7 to 9 hours of quality sleep a night.
Mental health professionals in India
There’s an acute shortage of mental health professionals in the country. “With its population of nearly 1.2 billion, our country has nearly 120 million people suffering from mental and neurological problems with about 24 million suffering from severe mental illnesses, who require professional help at any point of time. The country’s budget allocation to health has recently been increased to 2.1% of the GDP, with mental health forming a meagre fraction of the total health budget,” laments Dr Chadda. Dr Varghese adds, “We also have only about 30,000 public hospital beds for mental disorders and about 10,000 in private sector.”
On December 13, 2013, in a written reply to the Lok Sabha, Ghulam Nabi Azad, Union Minister for Health and Family Welfare, mentioned:
As per the National Survey of Mental Health Resources carried out by the Directorate General of Health Services, Ministry of Health & Family Welfare during May and July, 2002, the ideal required number of mental health professionals has been calculated as under:
i. Psychiatrists: 1.0 per 1,00,000 population
ii. Clinical Psychologist: 1.5 per 1,00,000 population
iii. Psychiatric Social Workers: 2.0 per 1,00,000 population
iv. Psychiatric Nurses: 1.0 per 10 psychiatric beds.
Based on the above, the details of present requirement and availability of mental health professionals in the country is as under:
There are three Centrally-run mental health institutes, 40 state-run mental hospitals and 335 departments of psychiatry in various medical colleges (154 in Government and 181 in private) across the country equipped to treat patients suffering from mental illness.
WHEN AN ATTACK COMES ON
■ Surge of overwhelming panic
■ Feeling of losing control or going crazy
■ Heart palpitations or chest pain
■ Feeling like you’re going to pass out
■ Trouble breathing or choking sensation
■ Hot flashes or chills
■ Trembling or shaking
■ Nausea or stomach cramps
■ Feeling detached or unreal
In addition to the primary symptoms of irrational and excessive fear and worry, other common emotional symptoms of anxiety include:
■ Feelings of apprehension or dread
■ Trouble concentrating
■ Feeling tense and jumpy
■ Anticipating the worst
■ Watching for signs of danger
■ Feeling like your mind’s gone blank
Anxiety is more than just a feeling. As a product of the body’s fight-or-flight response, anxiety involves a wide range of physical symptoms. Because of the numerous physical symptoms, anxiety sufferers often mistake their disorder for a medical illness. They may visit many doctors and make numerous trips to the hospital before their anxiety disorder is discovered.
Common physical symptoms of anxiety include:
■ Pounding heart
■ Stomach upset or dizziness
■ Frequent urination or diarrhea
■ Shortness of breath
■ Tremors and twitches
■ Muscle tension