THE LOUDSPEAKER - FEARS & ANXIETIES

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Fears & AnxietIES Exam Anxiety:

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How to Handle 27 Facing their Anxieties

Helping Other People Manage Anxiety 20

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Shyness and Social Anxiety

The Management of

Insomnia

Coping with the Loss of a Partner

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NIMHANS Center for Well-Being A Center for Mental Health Promotion

#1/B, 9th main, 1st Phase, 1st Stage, BTM Layout, Bengaluru– 76.

Phone: 080-26685948 / 9480829670 email: nimhans.wellbeing@gmail.com www.facebook.com/nimhanscentreforwellbeing

Mental health for persons with medical illnesses Marital enrichment services Stress management Trauma recovery Brief psychotherapies & counseling services Enhancing positive mental health Family counseling Parents support group

Services Offered

Support in intimate partner violence Prevention & early treatment for addiction Enhancing parenting skills & child mental health Services for healthy use of technology Workshops & training programs in mental health Elderly helpline & mental health helpline Youth Well-Being 2

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Editor Dr. Prabha S. Chandra Professor of Psychiatry Coordinator NIMHANS Centre for Well-Being

Chief Editor:

Dr. Prabha S Chandra Editorial Team:

Dr. Prasanthi Nattala, Mrs. D. Padmavathy, Dr. Meena.K.S. Mr. Manoj Chandran, Mr. Prabhudev.

Editor’s Note

T

he month of July augurs rain, thunderstorms and the fear of floods and traffic jams. It brings back memories that may be filled with panic and worries. Anxiety as an emotion has been experienced since time immemorial. In fact anxiety is usually a useful emotion and helps in enhancing preparation and performance. It is when it becomes excessive and unmanageable that it becomes a clinical condition. However, it is important for us to learn to manage our anxieties and fears in a manner that they work for us rather than against us. This issue of Loudspeaker deals with a range of conditions in the realm of anxieties and fears.

We at the Editorial Board of the Loudspeaker try to make the magazine relevant to the information needs of the public in the context of mental health. Most people are resilient and have enough internal resources to handle even the toughest of life’s problems. Sometimes just understanding that you are on the right path or getting a few helpful tips helps in dampening the intensity of the problem and prevents a symptom from becoming a disorder.

This is our fifth issue and we are pleased that the magazine finds place in all City Central libraries across our state. We would like it to be available to many more people and with our digital edition we hope that more people will have access to it.

We are grateful to the R.N. Moorthy Foundation for continuing to fund the next few issues. This support for mental health information delivered by experts in a distilled and simple form is a step forward in the promotion of mental health.

Printing of the Magazine funded by: Dr. Ramachandra N Moorthy Foundation for Mental Health and Neurological Sciences

Sub Editors Dr. Prasanthi Nattala Associate Professor of Nursing NIMHANS

Smt. D. Padmavathy In-charge Staff Nurse NIMHANS Centre for Well-Being

Editorial Board Mr. Manoj Chandran Mr. Prabhu Dev

Conceptualized and produced by NIMHANS Center for Well-Being Cover photos: NIMHANS Center for Well-Being

Photo Credits:

National Institute of Mental The Health & Neuro Sciences

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Contents

Health Anxiety Dr. Sundarnag Ganjekar Dr. Geetha Desai

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Certain tips to handle health anxiety, a condition in which individuals experience excessive concerns and worries about health.

Exam Anxiety: How to handle it?

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Dr. M Manjula Handy tips for managing the stress and anxiety related to exams.

Are you overly anxious? How can you manage it?

Dr. N. Manjunatha Insights into Generalized Anxiety Disorder and its management.

14 Shyness and social anxiety Ms. Systla Rukmini Dr. Paulomi M. Sudhir Distinction between shyness and Social Anxiety Disorder; ways to manage.

16 Specific phobias and how to deal with them?

Ms. Systla Rukmini Dr. Paulomi M. Sudhir Specific phobias (intense fear related to a specific situation/ object) and their management.

Living with someone who has Obsessive-Compulsive Disorder Dr. Sabina Rao Insights into Obsessive-Compulsive Disorder (a condition where a person experiences uncontrollable, recurring thoughts and behaviors); tips for family members.

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20 The Management of Insomnia Dr. Ajit Bhalchandra Dahale Insomnia (not getting enough sleep or good quality sleep): ways of handling, Sleep Hygiene Rules.

Facing their anxieties - Helping other people manage their anxiety Mr. Sanjay Patnaik Understanding and accepting individual differences in the ability to handle life stresses; helping others to handle their anxieties and stressful situations.

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First aid for Mental Health Problems Dr. K.S Meena Basic intervention measures to help people in mental health crisis.

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Childhood Fear Ms. Chaithra Holla

You have Panic attack, Not a heart attack Dr. N. Manjunatha

Insights into handling fears and anxieties in children.

Distinction between panic attack and heart attack; ways of handling panic attacks.

Coping with the Loss of a Partner

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War with my thoughts Dr. Veena A.S

Mr. Pradeep Jakka

Coming to terms with the loss of a loved one, a reality all will face at some point in life.

The story of one of our young clients who is in a journey to conquer his illness - hear his story, in his own words.

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Health Anxiety Case Example Prasanna, a 35 year old autorickshaw driver has been an anxious person since his childhood. He had difficulty in learning to ride the autorickshaw.

His trainer used to make fun of him as he would apply brakes very often as he was worried about head on collision. He used to be anxious to drop passengers to destinations far from his area. He used to get thoughts “what if I lose my way back” , “what if I met with an accident away from my area and nobody came to my rescue? . One of his best friends died of a heart attack while at work, and since that day he has started having palpitations, tremors of hand, perspiration and impending doom whenever he starts his autorickshaw. Recently when he was riding his autorickshaw through the crowded market he suddenly felt uneasy with palpitations, tremors, cold sensations in his limbs.

He immediately abandoned his auto and ran to his

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house. From then onwards he has not been able to leave home by himself. He has visited multiple specialists and has undergone many investigations.

The specialists have ruled out any heart problems.

However, Prasanna continues to be excessively concerned about his health.

The above descriptions highlight excessive concerns about health.

Detailed evaluation of his anxiety was done. His symptoms were validated. He was started on antianxiety medication. Relaxation techniques were taught to him and he was asked to practice it daily along with medication. He underwent cognitive behavioral therapy along with medication for 6 weeks with which he reported significant improvement in his symptoms. He has been able to venture out alone and ride his autorickshaw to different destinations away from his home.

What is health anxiety?

Health anxiety is a clinical condition where the individual is preoccupied with an idea or the thought that he/she is experiencing a physical illness. Most commonly people suffering from health anxiety are preoccupied about having serious illnesses such as cancer, HIV, AIDS, heart attack, etc. This anxiety can become overwhelming, cause significant distress, and affect every day functioning. Men and women may be equally affected.

Factors that may trigger health anxiety: • Having a family member or friend with serious illness • Death of close relative/friend with serious illness • Suffering from obsessive-compulsive disorder/ other anxiety disorder • Having a belief that healthy persons should not experience any physical symptoms at all • Having close family members who themselves have health anxiety.

What are the symptoms of health anxiety?

• The person experiencing health anxiety often attributes his/ her bodily symptoms to life threatening conditions, e.g. the person may interpret his/ her headache as a sign of brain tumor. He/ she may also attribute nonphysical symptoms such as poor concentration or sleep disturbance to a major illness.

• Persons suffering from health anxiety have repeated thoughts about the illness and constantly check for signs of any illness. They also seek information about the illness from various sources such as newspapers, health magazines and health sites on the internet.

The anxiety may often be precipitated by some information about an illness (e.g. obtained from a newspaper or other media).

• Persons with health anxiety might subject themselves to investigations repeatedly, and consult multiple health professionals, often spending large amounts of money and time to do so. Often, lack of diagnosis is attributed to poor medical care or unqualified doctors.

Conversely, there may also be avoidance of consultations and hospitals for fear that a serious illness might be detected.

How can you recognize health anxiety?

You may be suffering from health anxiety if: • You have been preoccupied for many weeks with the thought that you may be having a serious illness • If this preoccupation is causing you significant distress • If it is affecting your work, family life or sleep • If you feel the need to seek constant reassurance from the doctors, family, friends about your health.

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How and what help can you get?

If you feel you are suffering from health anxiety, consult a mental health professional. The following are simple techniques adopted by the health professional to help you to overcome your health anxiety: 1. Understanding your health anxiety and its impact on you 2. Reducing your focus on health symptoms and worries 3. Re-evaluating thinking

excessive

health

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4. Teaching you techniques to reduce checking and reassurance seeking 5. Helping you to overcome avoidance and safety behaviors. Safety behaviors include immediately seeking help from a doctor, asking various people for reassurance or getting investigations done. Unfortunately, safety behaviors only offer immediate relief but ultimately worsen the anxiety.

What can you do ?

• Discuss your concerns about your health with a family member • Gather health information from reliable sources • Reduce the time spent on reading about illnesses on the internet

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• Keep a check on excessive thoughts about your health and learn to say “stop” to the thoughts • Remember that your thoughts, feelings and behaviors are interconnected. If you are worried about having an illness, you are more likely to perceive the normal bodily sensations as abnormal or signs of an illness which might make you more anxious. Try distracting yourself form these thoughts • You can try relaxation exercise under supervision • It is essential to have a regular healthy diet and exercise • It is important to be aware of any sudden or persistent changes in your health status and seek timely help.

Dr. Sundarnag Ganjekar Assistant Professor Department of Psychiatry NIMHANS, Bengaluru Dr. Geetha Desai Associate Professor Department of Psychiatry NIMHANS, Bengaluru

Exam Anxiety: How to Handle?

Exam anxiety is a feeling of fear, nervousness, uneasiness and stress before or during an exam. It interferes with learning, reduces memory, increases mistakes and lowers test performance. Everyone feels nervous and experiences some anxiety before an exam; however about 20-35% students suffer from exam anxiety that interferes with performance.

Factors contributing to exam anxiety: Exam anxiety may result from any of the following factors: • Excessive competition for getting their desired course/seat in desired college/school • Lack of preparation and fear of failure • Fear of not achieving their goals and the perceived ridicule from significant others • Fear of not meeting expectations of parents and self, which is perceived as failure •

Worrying nature of the individual and a tendency to anticipate negative outcomes such as failure, forgetting answers, difficult exam, etc.

Symptoms of exam anxiety Exam anxiety may manifest through bodily symptoms, behaviors, cognitions and psychological symptoms.

The bodily symptoms include rapid heartbeat, headache, dry mouth, stomach problems, loss of appetite, sleep problems, bodily aches and pains or falling sick. Cognitively they may have difficulty in concentration and recall, in understanding and remembering, may go blank during the exam, forget answers because of excessive anxiety. Psychological symptoms include negative thoughts, lack of confidence, pessimism, hopelessness, anxiety, panic and sadness. To handle the anxiety students may involve in avoidance behaviors (such as avoiding studies, exams), become restless and irritable, or resort to use of substances such as alcohol, smoking or excessive coffee/tea intake.

How can exam anxiety be handled?

Healthy lifestyle practices: Adopting healthy lifestyle practices such as eating healthy food, adequate sleep, physical activities, balanced time schedule allowing for study, recreation and sleep, goes a long way in preventing exam related stress and anxiety.

Practice of relaxation methods such as deep breathing/pranayama, meditation, deep muscle relaxation, mindfulness exercises, positive imagery helps in reducing physiological symptoms of anxiety as well as worrisome thoughts and feelings.

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and ultimately your performance in the exam. It is also important for you to have realistic expectations and set realistic goals. Remember that ‘you are not just your grades’, there are many aspects to you as a person, exams are just a part of learning and there is always more than one option in life. It is most important to be open to all options, have a never-say die attitude, and believe in yourself.

In case you are not able to handle the negative thinking and worries by yourself, it is beneficial to consult a psychologist.

Good study habits: There is no short cut to hard work and good preparation! Thus if one plans studies from the beginning of the year and covers the syllabus systematically, anxiety is less. Though preparing from the beginning is ideal, pressure is more as the exams draw near, thus preparation during the months before exam becomes crucial. For utilizing the time adequately it is important to assess one’s assets and difficulties, level of preparation, and make a realistic timetable for studies. It is equally important that your timetable should allot sufficient time for revision, otherwise it may be still difficult to remember the study material during exams.

Eliminate all distractions during studies, stay focused and use study methods which work best for you, depending on the subject (e.g. writing, making charts, reading aloud, group study and discussion, etc.).

On the day of the examination: Have a good breakfast, reach the place early, try and relax before going into the exam hall. Keep repeating self-statements that you are going to do well, you are going to remember all answers, you will pass the exam.

After the exam starts: Stay calm, read the question paper thoroughly, and make sure you have understood the questions properly. Allocate time for each section, thereby ensuring that you answer all questions as well as you can. First select the order of answering the questions – for instance, you may want to start by answering the easier questions first.

Also, highlight points, use graphs and figures to enhance the quality of the answers. Make sure you have at least 5-10 minutes to spare before the exam ends, so that you can go through your answers and tie up any loose ends.

Role of positive thinking and having realistic expectations: In general, cultivate positive thinking, which improves memory, concentration

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Role of parents: Role of parents is very crucial during the stressful periods in their children’s lives – examinations, in this context. Parents need to work on their own anxieties and be supportive, so that they can help their children to stay focused and relaxed. It is also important for parents to not see their children as extensions of themselves and expect them to achieve what they (viz. the parents), could not achieve in their own lives. Although they may be your children, you, as parents, need to remember that your children are individuals in their own right.

They need to be respected and encouraged to do their best, regardless of the result. The bigger picture would be to mold them into honest citizens, than just toppers in an exam or acquirers of seats in coveted educational courses.

Dr. M Manjula Associate Professor Department of Clinical Psychology NIMHANS, Bengaluru

Are you Overly Anxious? How can you Manage it?

Anxiety is a feeling of worry, nervousness, or unease about something which the individual feels may have a negative outcome. Anxiety is a fundamental and universal emotion of human beings. A certain level of anxiety is adaptive and survival oriented, and facilitates  adjustment with the environment.

However, anxiety is abnormal when it fails to perform this adaptive function, causes the person

to become dysfunctional, and in short, causes more harm than good, to the individual.

Let us see whether you have a problem with anxiety.

Please tick your answer for the following questions and calculate total score. Over the past two weeks, how often have you been bothered by the following problems?

No

Item

Not at all Several days More than half the days Nearly every day

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Feeling nervous, anxious or on edge?

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Not being able to stop or control worrying

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A score of 3 or more in above questions indicates that you see a doctor / psychiatrist since you may be having an anxiety disorder, called as “Generalized Anxiety Disorder (GAD). A survey by the World Health Organization reports that GAD is the

commonest anxiety disorder in the world. So please remember that you are not alone, and read on, as we provide you with some information about GAD, which can help you to understand this condition better and obtain help.

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 The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

GAD may also present with physical symptoms such as shortness of breath, rapid heart rate, dry mouth, trembling, headache, nausea, muscle tension, cold hands and dizziness. Since these symptoms overlap with other medical illness such as hypothyroidism, cardiac problems, these medical conditions should be assessed with a complete physical examination and if needed, laboratory investigations.

1. What is Generalized Anxiety Disorder (GAD)?

Excessive anxiety and worry are the main symptoms of GAD. This affects many aspects of daily life of individuals from family/social life to occupational function.

In general, everyone usually worries about their family, job, and health, but people with GAD have unrealistic, excessive fears and worries.

They often feel overwhelmed and live their lives anticipating disaster. This worry is generally out of proportionate with reality, so that they are unable to relax, concentrate, or sleep. If diagnosed and treated early, suffering will come down and quality of life can improve significantly.

2. Who are commonly affected?

People of all races and cultures are equally affected.

However, women tend to suffer more with GAD. GAD tends to begin in the early 20’s, and has a longstanding course.

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What are the signs and symptoms of GAD?

A diagnosis of GAD is generally made when:  Excessive anxiety and worry (apprehensive expectation) occurs for at least 6 months about several events or activities  There is difficulty controlling the worry  Anxiety and worry are associated with 3 (or more) of the following most of the time, for at least 6 months: restlessness or feeling on edge, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance  Anxiety and worry are not due to substance abuse or another medical or mental disorder

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4. What are the causes of GAD? The exact cause of GAD is unknown till date.

However, biological, environmental, and psychological factors are thought to contribute to the development of GAD. The general understanding is that psychological factors interact with biological and environmental factors in leading to the development and maintenance of GAD. 5. What treatments are available for GAD? Effective treatments are available to control the symptoms of GAD and promote recovery. Early and effective treatment is necessary to prevent the emergence of another more serious anxiety disorder or depression.

GAD is primarily treated with medications and / or with psychotherapy. In our country, traditional healing practices are also available for treatment such as yoga, relaxation exercises or meditation, acupuncture, relaxation exercises, meditation, acupuncture.

One effective therapy commonly used for GAD is Cognitive-Behavioral Therapy (CBT). This helps patients to develop healthier thought patterns, and helps to teach them new ways of handling anxietyproducing situations. CBT is generally carried out in a session of 30-40 minutes once or twice a week for approximately 12 weeks.

Commonly prescribed medications are antidepressants and anti-anxiety medications.

Antidepressants commonly used to treat GAD are Selective Serotonin Reuptake Inhibitors (SSRIs) such as fluoxetine, escitalopram, sertraline, etc. Relief from symptoms is usually obtained within 3 to 4 weeks, and the individual may have to continue the medicines for one year.

Anti-anxiety medications called benzodiazepines, provide immediate relief from anxiety symptoms, but continued use may be addictive / habit-forming.

Hence, these medications should only be used for an initial short period of time. and exactly according to prescription.

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What are the complications of GAD in the long run?

There are other mental disorders that can co-occur with anxiety such as depression, other anxiety disorders (e.g. social phobia, panic disorder, posttraumatic stress disorder, and obsessive compulsive disorder), and substance abuse and dependence.

When these set in, diagnosing may be complex since symptoms often overlap with GAD. Often, people with GAD are found to ‘self-medicate’ with addictive substances such as alcohol, tobacco, caffeine, etc. to get relief from symptoms. Without proper treatment, people can continue to be disabled, with poor quality of life.

7. How long can GAD persist?

In general, GAD is a long standing illness with multiple relapses and remissions. The challenge is

that GAD more often is undiagnosed and untreated for quite long. If diagnosed early, with available treatments, suffering can be reduced to a large extent and quality of life can be improved.

8. What is role of family and friends in GAD? Support from families and friends of individuals with GAD is crucial in promoting a quicker recovery from GAD. Family members and friends should understand that GAD is a real, serious, but treatable medical condition. It is important not to downplay the seriousness of the symptoms by saying that they will get better on their own.

Family and friends can be helpful by listening without judging, providing helpful suggestions and encouraging positive coping skills, bringing them for treatment at the earliest, and by being flexible and supportive during stressful periods.

Dr. N. Manjunatha Assistant Professor Department of Psychiatry NIMHANS, Bengaluru

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Shyness and Social Anxiety Social Anxiety disorder (SAD) or Social Phobia gained recognition as a clinical disorder by the American Psychiatric Association in 1980. However its definition has undergone many revisions since then, including raising questions about differentiating between a person who is shy and one who has SAD. Does being a shy person mean that one has Social Anxiety Disorder? In order to understand these two seemingly overlapping constructs, it is important to understand how they have both been described: • Shyness is defined as feeling anxious and inhibited in many social situations such as meeting new people or making a presentation.

• Social Anxiety Disorder (SAD) is defined as the experience of significant fear, embarrassment or humiliation in social situations, to the point that the person avoids these situations, or faces them with a high level of distress. Persons with SAD also fear negative evaluations and are highly sensitive to interpersonal judgment and criticism.

Since the term social anxiety was introduced, there have been differing viewpoints, with some stating that it is a normal part of personality, while others have felt that shyness is the same as social anxiety albeit in a less severe form. Research on young children has highlighted differences between shyness and social anxiety. As seen below, these two are different, and yet overlapping concepts:

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Shyness • Personality trait • Doesn’t always cause distress • No avoidance

Social Anxiety Disoder • Anxiety at least present for 6 months • Causing difficulties in work, interpersonal relationships

Distinguishing between shyness and social anxiety Shyness is part of a person’s personality which means it is present since an early age and across many different situations. Even though a person feels nervous or anxious when giving a speech or meeting new people, this does not stop him/ her from entering into that situation or talking to others.

The anxiety is also manageable and can reduce as

a person becomes engrossed in talking to others. A shy person is not excessively worried about being embarrassed or ridiculed by others and so does not avoid social situations. Being shy is also not seen as a negative trait or weakness, on the contrary it can be seen positively. Shyness also does not hinder people from fulfilling their life goals as they are able to face and negotiate with situations when required.

On the other hand, Social Anxiety Disorder (SAD) is not considered a normal or positive part of people’s lives or personality. Shyness is diagnosed because the people affected by it are enduring fear, anxiety, stress, embarrassment, and humiliation on a daily basis and are greatly distressed by it. The severity of SAD hinders people from meeting their life goals and this furthers their distress. Many times social anxiety can start during adolescence or in early twenties which can lead to loss of valuable years of their life.

Shyness does not lead to SAD nor does it necessarily mean having SAD. It is not just a less severe form of SAD as many people with SAD do not report being shy. Extroverts also face difficulties when in social situations if they have worries about being embarrassed or ridiculed.

Early identification of SAD and ways to overcome

On the other hand, SAD needs to be treated, as it causes significant distress, as well as interferes with the achievement of life goals. SAD can be effectively managed using various treatment modalities such as medications and psychological interventions, primarily Cognitive-Behavioral Therapy (CBT). CBT aims at modifying the factors which maintain anxiety such as negative thoughts or beliefs and reducing avoidance. Therapy can also involve teaching people skills to interact in anxiety-producing situations and learning to manage anxiety through relaxation techniques.

In summary, shyness is not the same as social anxiety disorder nor is it a less severe form of it. Both of them can cause unique difficulties which can be overcome either through individual efforts or various effective forms of therapy.

Ms. Systla Rukmini PhD Scholar Department of Clinical Psychology NIMHANS, Bengaluru

Dr. Paulomi M. Sudhir Additional Professor Department of Clinical Psychology NIMHANS, Bengaluru

There is a crucial need to understand the differences between shyness and SAD since mistaking SAD for mere shyness can lead to delay in seeking treatment.

People who consider themselves to be shy are often able to manage social interactions and demands when they have to. However in order to be able to further overcome shyness, one could try to interact with others in social situations more often, particularly those which have been previously avoided - for example, starting a conversation in a get together or making inquiries at stores.

These initiatives will gradually help individuals to overcome their anxiety and face these situations with confidence.

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Specific Phobias and How to Deal with Them?

Case Example Sheela is a 35 year old lady who is working in a school.

As a child Sheela was an outgoing person, with lots of friends. During one summer holiday, while playing a game called dark room, Sheela’s cousins locked her up in the basement and the door got jammed, leaving her stuck for a long time. After this incident, Sheela started becoming uneasy every time she had to be in dark places, such as lifts, theaters and closed spaces.

At home she has to leave all the lights on when alone and finds it difficult to travel or visit places due to this and cannot work in buildings that have only lifts.

Her family has also been affected by Sheela’s fears as she insists on leaving lights on in rooms and must have someone with her at all times and she refuses to go to movies, unless the seats are near the exit.

As her fears have increasingly affected her life over the last few years, Sheela decided to seek professional help, and was diagnosed to have specific to have specific phobia for closed spaces.

Many situations or objects in the modern world can be dangerous to one’s well-being such as loose electrical wires, stray dogs, or an old lift. When one experiences fear which is proportional to the danger these objects present, anxiety can be helpful and of survival value. However, the anxiety which Sheela experiences for closed spaces is excessive as it is present even when there is little danger, and irrational because there is no logical reason for being afraid of that object or situation. Her fears have limited her career growth and also affected her ability to interact with others. This type of anxiety which is disproportionate to the danger presented by that situation or object is called “phobia”.

Specific phobia which is excessive or irrational fear of a specific object, animal or situation, can disrupt daily routine, limit work efficiency, reduce self-esteem, and strain relationships. However despite realizing that one does not need to be afraid the person cannot control his/ her anxiety. Some of the commonly reported phobias are listed in the below table:

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Animals • Snakes • Spiders • Dogs

Natural Environment • Heights • Water • Darkness

Signs and symptoms The intense arousal experienced either when facing the phobic object or in anticipation of facing it is also called the fight-or flight-reaction. People may experience all or some of the following symptoms: • Feeling of impending doom or danger, need to escape • Increased heart rate, breathing difficulties • Sweating, trembling • Uneasiness in the stomach • Headache ,nausea, feeling dizzy • A sense of things being unreal or being outside of the body • Feelings of losing control or going “crazy”.

Who develops phobias and how?

About 5 – 10% of the population experience specific phobias. Phobias may develop due to a genetic vulnerability (blood-injection-injury subtype), strong negative experiences associated with the object, or vicariously by seeing others go through a negative or aversive experience.

Management of specific phobia The two main treatments available for phobias include pharmacotherapy and psychological interventions. Medications are often used in a combination with psychological interventions such as behavioral and Cognitive Behavior Therapy (CBT) and help in reducing arousal.

CBT is aimed at reduction of physiological symptoms, avoidance of the feared situation that often maintains fears and prevents alternate learning, graduated exposure to the feared situation, identifying and modifying irrational thinking responsible for maintaining anxiety.

Graded exposure (GE) is the most effective technique for overcoming phobia. It is based on learning theories which explain that the development of phobia is through a process of learning negative associations or conditioning towards the feared object. GE aims to weaken these negative associations by gradually exposing the person to the cues associated with the fear, while preventing avoidance. Exposure is carried out systematically, using a list of feared situations, arranged in an ascending order (least to most feared ones). While facing these situations the person is instructed not to avoid, or use any other means of distraction, allowing

Situation • Elevator • Air travel • Closed spaces

Blood-injectioninjury* • Seeing blood or injury • Exposure to treatment for injures • Injections

for habituation of fear and eventually extinction of the fear. Through exposure the person also gains a greater sense of self-efficacy and confidence in facing the phobic object/ situation. Family members may be a part of the therapeutic program.

Systematic desensitization (SD) is another therapeutic approach, which combines relaxation response to imaginal exposure to a feared object, thereby causing the relaxation to block or inhibit anxiety. The key differences between graded exposure and SD is that in SD there is imaginal exposure, anxiety is paired systematically with relaxation, while in GE there is real life exposure (In vivo) to the feared object without use of any relaxation training.

Applied relaxation is yet another method by which phobia can be overcome. This involves teaching the person to use relaxation as a coping skill when having to face the feared situation. The person is trained in various steps of relaxation, eventually reducing time taken to relax to a mere 30 seconds. The person is then asked to apply this relaxation at earliest sign of anxiety, while continuing to face the feared situation (application phase). It must be ensured that applied relaxation is not to be used to distract oneself from the experience of anxiety and works well only when used to counter the earliest sign of anxiety.

In summary, specific phobia is a condition where the person experiences intense fear to a specific situation/ object based on past learning, characterized by avoidance and impairment. There are effective treatments available for overcoming phobias and include behavioral and cognitive techniques such as graded exposure, applied relaxation, systematic desensitization and cognitive restructuring..

Ms. Systla Rukmini PhD Scholar Department of Clinical Psychology NIMHANS, Bengaluru

Dr. Paulomi M. Sudhir Additional Professor Department of Clinical Psychology NIMHANS, Bengaluru

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Living With Someone Who Has Obsessive-Compulsive Disorder “This is exhausting, can you just stop doing it!!!!�

Mr. Kumar went with his wife to the clinic on her insistence. She was tired of seeing him repeatedly switch on and switch off his vehicle for several minutes before leaving for work, go through some elaborate rituals before sleep and constantly checking things around the house.

She heard from a friend that there was a psychiatrist who practiced very close to where they lived.

Mrs. Kumar told the doctor that ever since she was married to him, her husband would do several things before going to bed, such as tapping on the floor, getting into bed, getting out of bed, again tapping the floor with his fingers, sometimes 2-3 hours at a time. What made her bring him to the doctor was that he was starting and stopping the engine of his car so many times before leaving for work

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that he was constantly late to work. She was afraid he would lose his job. Since she was not working and they had 2 small kids, she was worried about the financial consequences of her husband losing his job.

The above vignette typically illustrates what is known as Obsessive-Compulsive Disorder (OCD).

What is Obsessive-Compulsive Disorder (OCD)?

OCD is a disorder in which a person has uncontrollable, re-occurring thoughts (obsessions) and behaviors (compulsions) that he or she feels the urge to repeat over and over. People with this illness can have obsessions, compulsions or both. The obsessions and compulsions affect all aspects of the individual’s life.

Additionally, the obsessions and compulsions can interfere with the life of the whole family.

instance, saying “This must be so hard for you” will be better than “Can you stop it!” or “Get over it!”

Talk to your doctor about how you can set limits on your loved one’s compulsions. The limits might include things such as the time spent in reassurance, the time spent on participating in the compulsions, etc. The idea is to “normalize” family life as much as possible.

This is harder than the marriage itself!

Having a partner with OCD can be exhausting and many times frustrating. It can feel like the partner’s ritualistic behaviours control the relationship. One can get easily sucked into the rituals.

For example, the loved one might start spending a lot of time of in the bathroom, take an extraordinarily long time to get dressed, appear more irritable and anxious, do things repeatedly which might appear very odd to you. He or she might repeatedly ask you for reassurance. Sleep can become disturbed while your loved one is completing “tasks”, eating habits might change. For example, your wife might spend hours cleaning the kitchen at the end of the day, to a point that you notice she is not finished even at 1 AM.

You also need to remember to be patient, as the illness tends to run a prolonged, fluctuating course.

Your expectations might have to change from hoping for leaps and bounds of rapid improvement to small improvements and relapses.

Dr. Sabina Rao, MD Consultant Psychiatrist Sakra World Hospital Bengaluru

What does it feel like to have OCD and how can I help?

A lot of the improvement in OCD depends on taking prescribed medications regularly. Be sure to support your relative in this regard, in terms of taking his/ her medication, and making sure he/ she adheres to follow-up appointments with the doctor.

For the most part, people with OCD know what they are doing or repeatedly thinking is illogical and irrational. A small percentage is unable to identify the strangeness of these thoughts and behaviors.

For those persons with OCD who have some insight into their behavior, the thoughts and behaviours can be exhausting and frustrating, yet not thinking in a particular way or doing things in a specific way can create immense anxiety.

Telling your loved one with OCD that what they are doing is bizarre or illogical or blaming them for it, will not help. It will only increase the levels of anxiety which will in turn increase the symptoms of OCD. Instead, acknowledge the difficulties faced by the person with OCD. You can be a partner in the fight against the symptoms of this illness. For

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The Management of Insomnia Providence has given us hope and sleep as a compensation for the many cares of life - Voltaire.

As noted above by the French philosopher-writer, sleep is a gift given to us by nature to deal with the worries of life. Yet, some people believe that it may be just a waste of time spent doing nothing. Is it really so? Science has shown us that sleep is a necessity in our daily life and has multiple functions. Sleep has a role in restoration of body and mind after a day’s wakeful state, forming and organizing memories, brain development and immunity. Several people are affected by different types of sleep related problems of which ‘insomnia’ is the commonest.

Insomnia can be termed as `not getting enough sleep or not getting good quality and refreshing sleep’. It can be occasional or chronic. In fact it has been found that insomnia affects around one-third of the world population occasionally and one-tenth of it on a long term basis (for more than six months).

Insomnia may occur due to many reasons such as- preoccupation with sleep and its effects, poor sleeping habits, use of addictive substances and excessive use of caffeine, change of place, stressful events, shift-work, frequent air-travel, presence of medical problems causing significant discomfort or pain and psychiatric problems like depression or anxiety. Some people may have insomnia without any of the above reasons, which is then called idiopathic insomnia. Women and the elderly are known to have higher risk for developing insomnia.

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Why we should bother about having less sleep?

Can we not use the extra time to work, enjoy or relax more? The answer is No. Research shows that inadequate sleep or poor quality sleep results in many problems such as - day-time sleepiness, poor attention and concentration (which can lead to accidents), poor judgment and memory, fatigue, anger, nervousness and depression. In severe cases, hallucinations, suspiciousness and impaired disorientation can also occur. Sleep problems can affect our physical health as well. Hence, insomnia knowingly or unknowingly hits us hard. Insomnia is assessed clinically by taking a detailed sleep history and maintaining a sleep diary. Sleep diary consists of systematic recordings using a standard format of sleep pattern and related events in a book.

Further assessment includes physical examination to rule out any contributing factor like obesity or cardiac, neurological or respiratory problem.

Psychological examination is also done to rule out stress, anxiety or depression as well as to assess the psychological effects of insomnia. Investigations like polysomnography where an all night sleep recording is done to assess the pattern of sleep may also be needed in some people.

Treatment of insomnia depends on its cause or contributing factors, for e.g if a person is not getting proper sleep due to pain, treating the pain will help the person sleep better. If somebody is not able to sleep because of working on shifts, changing to daytime shift/work would help overcome the problem.

Medications and psychological therapy are the common treatments for insomnia. Medications are not the first choice of treatment and sleeping pills are used only for a few weeks and then tapered slowly.

They can sometimes cause imbalance and respiratory difficulties specially in the elderly and have to be used with caution. Modifying environmental factors and sleep related habits are `easy to do’ interventions and useful in most situations. Changes like a stable diet and exercise schedule, avoiding excess coffee or tea, avoiding day-time sleep, not using the bed for work or watching TV, doing moderate exercise in the evening, and maintaining a peaceful environment are helpful.

Psychological interventions are also available, of which most studied is cognitive behaviour therapy, where sleep related unhelpful thoughts

and behaviours are analyzed and resolved in a systematic way. Other psychological interventions include thought suppression (specially worrying thoughts), and relaxation training. Whenever it appears that sleep problems are not coming down in a few days, we should check for the above mentioned causes and sleep related behaviors and try to modify them. If the problem still persists then we can consult a doctor. We should all take care of our sleep… and sleep will take care of our happiness and dreams.

Dr. Ajit Bhalchandra Dahale Assistant Professor Department of Psychiatry NIMHANS, Bengaluru

Sleep Hygiene Rules Rule 1: Do not drink beverages like caffeine or tea at least 2-3 hours prior to bedtime.

Rule 2: Do not smoke within several hours prior to bedtime.

Rule 3: Establish a regular exercise pattern. However, avoid strenuous exertion after 6 p.m.

Rule 4: Use common sense measures to make your environment most conducive to sleep (comfortable room, dim lighting, no noise etc).

Rule 5: Avoid excessive fluids before bedtime, so that you don’t have to awaken in the middle of the night to use the toilet.

Rule 6: Do not go to bed until you are really sleepy.

Rule 7: Have a regular sleep schedule. Get up at approximately the same time each morning, including weekends.

Rule 8: Do not take naps during day-time.

Rule 9: Do not use your bed or bedroom for any activities other than sleep. For instance, you should not read, write, or eat in bed. Teaching your body that the bed is for sleeping, and not for worrying, tossing and turning, is probably the most important rule to follow.

Rule 10: Establish regular pre-sleep routines which signal that bedtime approaches. For e.g, lock the door, set the alarm for the next morning, and any other activities that make sense for this time of night.

Rule 11: Once you get into bed, if you find that you cannot fall asleep after a few minutes, get up and go into another room. Engage in some quiet activity until you begin to feel drowsy and then come back to your bed.

Rule 12: If you still do not fall asleep within a brief time, repeat rule 11. Repeat this process as often as needed, and also if you wake up in the middle of the night and are unable to return to sleep within about 10 minutes.

Rule 13: Put worrying thoughts out of your mind. Anxiety is the most common cause of insomnia. Write down everything that is worrying you and promise yourself that you will deal with it in the morning.

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All the above rules may not work for all individuals.

One should choose what best suits him/ her. All said and done, it is important to take care of our sleep pattern, and ensure we get adequate amount of sleep, for good health, happiness, and longevity.

Source: Prasanthi Nattala, Pratima Murthy, Nagarajaiah. (2013). Relapse Prevention in Alcohol Dependence: A family-based approach - Treatment Provider’s Manual. Helping persons with addiction Manual Series 3. Bangalore: Center for Addiction Medicine, National Institute of Mental Health and Neuro Sciences, Publication No. 87, ISBN 81-8643600-X.

You Have a ‘Panic Attack’, Not a ‘Heart Attack’!!!

A 35-year married lady was rushed at midnight to the Emergency of a nearby nursing home with complaints of sudden chest discomfort, difficulty breathing, dizziness, sweating, shaking of body, and fast heart beat lasting a couple of minutes. Doctors examined her, did an ECG

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and sent for some blood tests which were all normal.

Meanwhile, the patient became calm, but she feared that she had experienced a ‘heart attack’. The doctor informed her that she was perfectly normal and the problem might have been due to ‘tension’.

A month later she had another similar attack and she started worrying that she was having a serious heart problem. She even went to a cardiologist for a heart checkup and was found to be normal. She was asked to meet a psychiatrist who treated her and she improved within a month.

Did the above lady suffer from a heart attack or something else?

No, the lady definitely did NOT suffer from a heart attack. She suffered from another medical condition called a ‘panic attack’. A panic attack is experienced like a heart attack; both are medical emergencies.

However, while a heart attack can have serious consequences, a panic attack is a not a serious medical condition. However, it can make people feel extremely scared and often apprehensive of another attack.

What is the difference between a panic attack and a heart attack?

In simpler words, ‘heart attack’ originates in the ‘heart’, whereas, ‘panic attack’ comes from the ‘mind’ How common is panic attack/disorder?

This lady is not alone. Around 5-6% of population around us may be suffering from this condition.

During the same attack, people may also experience any of the following psychological symptoms:  feeling of being out of control or ‘goning mad’  feeling that things are not real  thoughts such as - like ‘I am going to die right now’.

Often people focus only on physical symptoms which makes them very scared that they are having a heart attack.

What is the difference between panic attack and panic disorder?

This difference is very important since a large number of people experience one panic attack in their lifetime without recurrence. Some people also experience panic attacks at predictable situations and with warning signs, which may not be a panic disorder. This predictable panic attack could be a sign of other illness such as depression, other anxiety disorder. On the other hand, when panic attacks occur repeatedly and unexpectedly without any warning signs and in an unpredictable way, it qualifies for the illness “Panic Disorder”.

What to do when a panic attack occurs?

When does panic disorder start?

It often begins in the late 20s or early 30s, and is more common in women.

Why does panic attack occur?

The exact cause is not known, however, research shows that imbalance of biochemical parameters in the brain is one of the important causes. To a certain extent, hereditary predisposition and stress can also be the reason for panic disorder. Treatment is thus targeted at balancing this biochemical imbalance in the brain.

•

First, stay calm.

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Second, tell yourself that it is not a heart attack, and there is nothing wrong with your heart.

Instead, it is coming from the mind.

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Third, tell yourself that this attack will fade away on its own in a couple of minutes.

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Finally, meet a doctor/psychiatrist at the earliest for further advice and treatment.

Symptoms of panic attack: A panic attack starts suddenly and comes down on its own, usually in 10 to 20 minutes.

People experience the following physical symptoms during a panic attack:  fast heart beat  sweating  weakness, faintness, or dizziness  feeling a hot flush or a cold chill  tingly or numb hands  chest pain  feeling nauseous or stomach pain  shaking of the whole body.

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How is panic disorder diagnosed?

Panic disorders are diagnosed by interviewing the individual in detail about his/ her symptoms. .

There are no specific laboratory tests to diagnose panic disorder. However, physical examination and diagnostic tests (e.g. thyroid function test, ECG) may be required to exclude other medical conditions which may be causing the symptoms.

Is panic disorder curable?

At present, there is no complete cure for panic disorder. However, it is a ‘controllable’ medical illness similar to other chronic illnesses like blood pressure, diabetes or arthritis. Early treatment is advantageous to enjoy your life and to prevent complications such as addiction to sleeping pills, and to reduce difficulties in personal and professional life.

What kind of treatment is available for panic disorder?

This condition is treated with medications, psychological treatment , or both. Anti-depressants are the preferred medicines to treat panic disorder.

Treatment should be continued for at least 6-9 months after the attacks stop completely. Since the benefits of these medications take 2 to 4 weeks to

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begin, in this interim period doctors often prescribe a mild anti-anxiety medication.

Psychological treatment focuses on teaching new skills including education about the illness, changing the thought process specially at the time of the attack and building confidence to handle the panic attack.

If the person avoids situations such as bein alone or going out, gradual exposure with relaxation is taught to enhance the feeling of confidence and safety. Psychotherapy is usually carried out in 1220 sessions, each session lasting 30-45 minutes each.

What is the benefit of early treatment?

Early diagnosis and treatment have several advantages. First, the suffering and fear come down which saves unnecessary time and costs related to multiple visits to doctors. Secondly, addiction to `sleeping pills’ is avoided and finally, individuals can enjoy their lives without the disruption caused by panic disorder.

Dr. N. Manjunatha Assistant Professor Department of Psychiatry NIMHANS, Bengaluru

Coping with the Loss of a Partner Losing a loved one through death is extremely painful and overwhelming. As told by Gautama Buddha, all of us will experience this at some point in our life. Coping with the loss of a loved one, in this case, a spouse or partner, can be particularly traumatic if the death was sudden and untimely, as in the case of a young man or lady succumbing to a road traffic accident or suicide. Typical stages of emotional reactions experienced in this scenario include: shock- upon hearing about the sudden demise of one’s spouse; denial- that one’s spouse is no more; anger- towards anyone (including themselves and even God!) who they think was directly or indirectly responsible for their spouse’s death; sadness-profound grief about the loss, and finally; acceptance of the loss.

is when one spouse survives in the road traffic accident while the other succumbs to death. The survivor is left feeling that they could have done something to avert the tragedy. The feeling is worse if the survivor was riding the bike and the deceased was a pillion rider.

Coping with the loss of a spouse or partner can also be difficult if the surviving spouse experiences “survivor guilt”. A scenario where this may happen

The nature of grief experienced is therefore a function of many factors: the context in which death occurred-- sudden Vs. prolonged illness and

Among the elderly who experience the loss of a spouse, the experience is particularly painful as they may have spent several years together. Loss in this context is typically a consequence of the aging process itself and/or illness. The surviving spouse may experience a deep sense of loneliness, particularly if he/ she has to live alone away from children or is now physically and emotionally dependent on children for care and support.

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suffering; the survivor’s personality—sociable Vs. Reserved, independent Vs. dependent on the deceased; and the survivor’s relationship with the deceased—intimate Vs. conflictual.

Different people cope with their loss in different ways. While the old adage holds true, that “time is the best healer”, the survivor can take the following proactive steps to cope with their loss more effectively. a. Mourning: Participating in religious ceremonies and rituals to mourn the deceased facilitates emotional healing and therefore it is important to get involved in these activities. b. Expressing your grief: Talking to your close friends and relatives about your loss, your memories of the deceased is another important way to overcome grief. c. Stay connected with friends and family: Being around people who care about you is known to help during times like these. Do NOT keep yourself away from people or be isolated. d. Self-care: Ensure that you are eating well, getting adequate rest and exercise. Older survivors who have health problems should ensure that they are taking medication regularly like before. e. Have a routine: Try to get back to your previous routine to the extent possible. Having activities to do keeps you active although for you to feel interested in these activities will take time. f. Pursue your interests and hobbies: Try to revive your interest in hobbies that you can pursue.

Doing activities that you like or enjoy will help you overcome negative emotions. g. Grieving takes time, don’t be in a hurry to makes changes or bounce back: In today’s fast paced life, people are in a hurry to bounce back and

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restore a normal routine too soon. While it is important to do as much as you are able to, don’t be too harsh on yourself or push yourself more than you should. Important decisions can wait. h. Children may be grieving too: Crises such as these affects the whole family. Others in your family will also be grieving and so may sometimes NOT be able to give you the attention you need. Do NOT take it personally. i. Plan for your future: It is important to plan for your future (without your partner)- who you will stay with, managing finances, handling any unfinished business, etc. j. Finding meaning /Religious and Spiritual practices: Try to find meaning in the loss.

Spiritual practices are known to help you reach a state of acceptance. Offering prayers, reading spiritual texts, meditation are some useful practices. k. Don’t be afraid to seek professional help: Remember that help is available and that it is alright to seek help when you are in need. This may include taking medication for symptoms you may have and/or seeing a counsellor who can facilitate the grieving process for you. Talk to someone who may be able to direct you/ escort you to a professional.

Coming to terms with the loss of a loved one is a reality we all will face at some point in our life.

Although there is no such thing as being ‘fully prepared’ for it, we can take a few steps to help ourselves and those around us to adapt to the loss in a way that is effective.

Dr. Veena A.S Assistant Professor Department of Clinical Psychology NIMHANS, Bengaluru

Facing their Anxieties – Helping Other People Manage Anxiety Arvind had been struggling with thoughts of the impending board examination. Although he was a bright student, the fear of disappointing his family had started to take a toll on him. “He’s going to ace these exams; top of his class!” his parents would proudly tell anyone they came across.

Arvind had always been a little nervous before important events such as exams, debates and sports events. These board exams, however, were different. “You make it in this exam, you are set for life,” is what he had grown used to hearing; but each time it induced a sense of panic.His worry had become so intense that he found it impossible to think about anything else. He wasn’t eating well and looked extremely tired but his parents put it down to him working hard on his exam preparation. In the past few days he had tried to talk to his mother about these heightened worries. “It’s your board exam, of course you will be nervous,” she said, the first couple of times. But when his complaints persisted, she too began to worry. “You don’t

know what you are feeling. Don’t say anything to your father, he will be very disappointed. Everything will be okay, you just concentrate on your revision.” Now, with three days left for his first exam, Arvind sat to attempt a mock test, and he drew a complete blank. Overcome by panic, he suffered a complete breakdown.

Good anxiety Vs bad anxiety Anxiety is our brain’s natural response to a stressful situation, such as an examination, a job interview, or a big match. Some anxiety is good, as it makes us more alert and helps us perform better. However, for some people anxiety can become overwhelming and cause them to panic. This hinders their ability to perform regular functions because they experience a loss of control. The sense of doom can become severely debilitating and the person can feel extremely lonely.

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How others react to anxiety How do we react when someone around us is worried? Typically there are three types of behavior that a person would exhibit towards someone who is extremely worried: • Avoiding the panicky person because “it’s not my problem,” or “you are just creating a scene.”

• Underplaying the person’s worry because “everyone has problems in life,” and “there is no need for you to overreact.”

• Trying to comfort the person with reassurance.

The first two reactions result from a general lack of awareness about anxiety and how severe it can be, and a lack of empathy. Many people are able to cope with their worries, irrespective of whether it’s a small matter or something extremely serious and hence maybe ignorant of the fact that anxiety can be a severe condition that can hamper daily function.

To such people, someone’s inability to cope with their anxieties or worries may come across as a sign of weakness. This in turn may prevent them from empathizing with an anxious person; they don’t find it worthwhile to try and understand what the person is going through.

There are yet another set of people who project their own anxieties onto someone who is experiencing panic. For instance, a person who is extremely worried about some poor financial investments, confides in his colleague about his worries. Rather than reassure this person that it will be okay or that it’s not such a huge loss, the colleague starts talking about the alarming rate at which the cost of living is increasing or the losses that he has had. This only fuels the person’s anxiety further.

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So why is knowledge so crucial in such a scenario?

Without an understanding of what another person is experiencing, it is close to impossible to help them, no matter what the cause of their distress. Empathy alone is not enough; in fact empathy without knowledge can be damaging in some cases. Take Arvind’s case for example. His mother obviously cares about him and wants him to do well. But in her lifetime she may have found many ways to cope with her own anxieties, so she is unaware of the effects that severe anxiety can have on her son.

While her intentions are good, she is unable to help Arvind because she doesn’t know what he is experiencing. Moreover, she projects her anxieties upon him unknowingly, when she asks him not to talk to his father. This makes Arvind feel even more isolated and increases his distress further.

How can we help people help others with anxiety?

It is safe to assume, that if Arvind’s mother was aware of anxiety disorders, her approach would have been different. This highlights the fact that the right knowledge would better enable us to be empathetic towards others.

It is important for people to know what anxiety is and how it can lead to distress and poor performance; they also need to be aware that telling people to stop worrying or change their mind-set. Understanding and accepting that different people maybe anxious about different aspects of their life enables us not just to be empathetic but also to help the person find solutions. Solutions may include simple relaxation techniques, diverting oneself from worrying thoughts, brainstorming with well-wishers for productive solutions for problems, etc. In some cases, one may need to direct the person for professional assistance.

Helping someone who is extremely anxious • Remain calm: It is important that you remain calm and patient so that you can provide reassurance to the person.

Sanjay works at White Swan Foundation, a not-forprofit providing knowledge services in the area of mental health. For more information, visit www.whiteswanfoundation.org

• Speak to the person in short and simple sentences.

• Help the person to slow his/ her breathing slow their breathing: Anxiety causes an elevated heart rate and rapid breathing, Help the person slow down his/ her breathing: if necessary, demonstrate slow and deep breathing.

Mr. Sanjay Patnaik

• Try and move the person to a calm place.

• Stay with the person till he or she feels less anxious.

First Aid for Mental Health Problems When we see a person suffering a cardiac arrest or snake bite, we may have some awareness about what to do as basic first aid. But are we skilled enough to provide the same when we see a person extremely anxious, tensed, sad or depressed?

Often the response is to ask the person to snap out

of it or tell him/ her that things will get better.

However, such emotional states, especially if severe or prolonged, are signs of mental health crisis, and warrant attention and basic intervention measures, which may be referred to as ‘Mental Health First Aid’.

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are facing. If left without active intervention, these problems can escalate to diagnosable mental health disorders. Thus, it is of utmost importance to find ways of improving the general public’s knowledge and skills to provide first hand support to people with mental health problems.

Who can be a Mental Health First Aider?

Anybody who is interested in connecting with people, and wants to reach out when a person is in distress, can be a Mental Health First Aider.

How can I go about it?

1. Identify the signs of mental health problems and intervene As a Mental Health First Aider, it is very important to identify the early signs of a mental health problem.

The possible signs could be:

Why Mental Health First Aid? Myths and misconceptions are widely prevalent about mental health and mental illness. This might prevent people from talking about any mental health issues they may be experiencing, with family, friends or others. This can even cause a delay in seeking professional help. Thus, many individuals continue to suffer silently. All of us face problems in our day to day life. However, while some of us are able to cope effectively, some of us are not. When we are not able to cope, it can manifest as various negative emotional states like anger, irritability, and fear, to name a few. Such negative emotions, particularly when intense and prolonged, often stem from various issues such as being victims of bullying or domestic violence, going through critical stages of the life cycle such as old age, major life events such as, job loss, failure in academics, loss of loved ones, migration, etc. .

Friends and family members can have difficulty in identifying a person who is undergoing a mental health problem. They might be aware that something is going wrong with their dear ones, but feel helpless in providing aid. It may be often due to lack of awareness of mental health problems and what needs to be done. Availing mental health services may not be considered as the first option, and delay in recognition and treatment could lead to worsening of the mental health problem.

As a society, we are, and continue to be ignorant, of the mental health problems that the members

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- - - - - - - - -

Looking dull and listless Looking sad Lack of interest in surroundings Crying spells Talking of death and dying or suicidal behavior Irritability Withdrawal from social gatherings Anger outbursts or aggression Unusual and unexpected behavior

If you notice any of the above signs, approach the person with empathy and try to establish rapport.

Once established, try to engage the person in talking about what could be bothering him/ her and ask if he/ she would be willing to talk about it. Make the person feel comfortable that he/ she can confide in you. Provide room for the person to decide how much he/ she would like to share with you.

However, remember that the person may take time to confide in you. In many instances, just sitting with the person, and letting him/ her know that you are available, can gradually help the person to trust you and talk about any mental health problems he/ she may be facing.

2. Avoid being judgmental At times, in trying to help others, we let our own views dominate our communication, which can be detrimental. We may judge the person based on our views with respect to people or their problems. It is important to recognize this and learn to put our own opinions and values on hold, while helping people in need of our support. For instance, avoid making moral statements such as “This is not the age for

you to fall in love” or “you need to realize that it is not right to think like that”, etc. Refrain from asking too many probing questions. The person may not be ready to answer to you initially and can withdraw from talking. Instead, engage more in listening, which will allow the person to ventilate the issues that may be bothering him/ her. Try summarizing at the end to make sure you have understood what the main problem areas are.

3. Encourage professional help Once you are sure that the person is experiencing mental health problems, probe gently whether he/ she would like to get help. At times, the person affected may not be aware that help may exist for the kind of problems he/ she is facing. If he/ she appears keen, provide information as to where such help can be obtained, e.g. a psychiatrist/ psychologist/ counselor. Assure them that it’s perfectly acceptable for them to seek professional help. Instil hope that things will get better and problems will be professionally addressed.

4. Build up coping strategies Apart from medicines and psychotherapy sessions, encourage the person to enhance his/ her coping skills by expanding social network, developing new hobbies, reading books, volunteering for a social cause, and so on. Strengthening coping skills can

help individuals in defending themselves against crisis situations that may come their way. Also provide information about local support groups with which he/ she can connect, , participate and share his/ her problems.

5. Follow up It would also help the person if you connect with him/ her occasionally to find out how he/ she is doing and ask if any further assistance is required.

In conclusion, you can play a crucial role in identifying and intervening with mental health problems, and making prompt referrals as needed.

Such strategies will go a long way in preventing the problems from turning into a mental disorder.

Mental Health First Aid is also simple, which anyone interested in helping can learn and practice, and make a difference in the lives of people.

The Department of Mental Health Education, NIMHANS, initiated training in First Aid for Mental Health Problems in April 2016.

Dr. K.S Meena Assistant Professor Department of Mental Health Education NIMHANS, Bengaluru

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Childhood Fear 3 year old Vikram’s mother was shouting at him Mom: Come and poo in the potty Vikky (Whining): No… Mom: You will soil your pant if you don’t go now.

Vikky: No mommy, I’m scared to sit on the potty.

Mom: What are you afraid of ?

Vikky: I’m afraid that I would fall in.

objects/situations when he or she sees his or her parent being anxious about the same. E.g., a vigilant mother may scream or shout when she loses the child in a social gathering/crowd and she may cry after finding the child.

When does a child feel fear?

There are various situations when a child can feel fear:

What is fear?

Fear is a normal part of child development. It helps children to avoid taking risks and hence ensures safety. For example, the child avoids going near a snake, when he/she is scared of it. However, the parents have to consider fear as serious when it interferes with the child’s daily activities, friendships and school. For instance, the child avoids attending the school frequently because he/she is scared of the teacher.

“It is very scary in the dark”.

“The devil will come and eat me alive. So I can’t go to that dark room.”

“Mommy, what if I get hurt in your absence?”

“Where are you going, leaving me alone?”

“The strange and crazy looking masks are frightening.”

“I don’t want to see a doctor because he hurt me with a needle last time I met him.”

“I am scared of cockroaches because they might eat me.”

How does fear develop in a child?

Some children develop fear from their personal experiences, e.g., a dog attack; however, in others, there may not be any events which triggered fear in them. Children also develop fear by observing other children, for example, when a child is punished by the teacher or when they observe others expressing fear of monsters. Children also learn such behaviors at home observing their parents. A child believes a particular thing is unsafe and develops fear towards

How to identify fear?

Children might have difficulty in talking about their fear. Instead, a child is likely to express fear through behaviors like crying, clinging, avoidance, discomfort and physical complaints such as stomach ache, headache, sweaty palms or trembling. Often, parents and others may feel that the child is behaving this way to avoid school or other similar to school.

But in reality, children could be genuinely afraid of something.

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Help children to manage their fear •

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The first step in addressing their fear is to understand that it is very normal for a child to face fears for his/her age. The parents need not expect the child to act brave and show appropriate behavior. The parent has to understand that the child might be fearful when he/she cries and not necessarily disobedient.

Hence, showing a genuine acknowledgement of understanding and listening to the child would help him/her.

Keep reassuring the child that he/ she is safe.

For instance, parents can say, “I know it is scary in the dark. So let’s do one thing. Let’s switch on the lights around the house when it is dark and I’ll also make sure that you’ll have a bed lamp at night in your room.” If the child continues to express fear, just tell him/her, “I’ve just explained it to you”, and leave it at that, there’s no need to repeat the same over and over.

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In certain situations, you may need to model appropriate behavior to the child.

For instance, it is very normal for a child to be scared of strangers, so let the child take time to feel comfortable with an unfamiliar person.

Meanwhile, stand beside the child and show friendly behavior yourself. Also, instead of shouting at the child after finding him/her in a huge crowd (when they thought they had lost the child), say “It is confusing for me to search for you in the crowd. Hence, you need to inform me before leaving my hand and meeting your friend.”

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Never force a child to encounter a situation all of a sudden. But gradually expose the child to fearful situations. For example, making the child to touch a dog if he/she is scared of dogs would only worsen the situation. Instead initiate a discussion about dogs which could be in the form of stories or one’s own good memories associated with dogs. Gradually, the parent can introduce dog’s images, then show a dog in a video, and later show a dog from a distance, once the child is comfortable. Later the child can be taken near a dog. The whole process of exposing the child to a dog should be done in a gradual manner and it requires constant appreciation, encouragement and reward from the parents.

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Provide support to the child. This doesn’t mean that the parents have to be overprotective. It wouldn’t help the child if the parents keep the child completely out of fearful situations. For instance, it will not help the child if he/she is never sent to nearby shops because he/she is scared of crossing the road. Instead, the parents can initially assist the child to cross the road and help him to go to the shops.

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In specific situations, the parents may need to engage in overcorrection. For instance, if the child soils clothes because he/ she is afraid to go use the toilet, the parents can get him/ her to clean his/ her clothes, and the , place where he/ she poops.

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Too much attention given by the parents can maintain the fearful behavior in the child. This is because avoiding the fearful situation can bring in other privileges which may be adverse for his/her development. For example, when a child is kept from going to school, it may reduce his/her anxiety related to the teacher, but at the same time, he would also get exempted from home-work and other school-related activities necessary for his growth. Therefore, parents need to be understanding of the child, and yet firm, and gently persuade the child to attend school regularly. In instances where the child displays extreme fear and anxiety, parents may need to address the root of the problem. For example, they may need to find out if the teacher is engaging in harsh behavior towards the child, painful physical punishment, mental humiliation of the child, etc. In such cases, the parents may need to approach the school authorities or take other practical steps as relevant.

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Other practical measures include physical activities which can help to reduce stress in children and also help them sleep well at night. Stories at bedtime or when children are anxious, can help to reduce their fear.

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In instances where nothing seems to be helping and the children continue to be fearful or avoid situations, consult a professional at the earliest.

Ms. Chaithra Holla Research Assistant, Project BCHADS, NIMHANS, Bengaluru

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War with My Thoughts “Thoughts are powerful servants, but terrible masters.” - Vedas My life is a war with my thoughts. The war started at the age of 17 years when I was studying Intermediate in Narayana Junior college, Kurnool, Andhra Pradesh, in the year 2004. The enemy in my thoughts, waging a war, was schizophrenia. The allies of my enemy were hallucinations, delusions, negative thinking, and anger. It took eleven years for me to conquer my enemies completely. Now I am doing Ph.D in Psychology from Sri Venkateshwara University, Tirupati. I also qualified in National Eligibility Test (NET), conducted by University Grants Commission (UGC), on December 28, 2014, and State Eligibility Test (SET) conducted by Osmania University on February 15, 2015. I have written two self-help books in Telugu language titled “Jeevana Parishkaralu” and “Ee kshanam Dhyanam” (translated as ‘Life Solutions’, and ‘The Meditation of this Moment’, respectively) My third book “Chaduvu Kuntunnama..? Chaduvu Kontunnama..?” (which translates as “Are We Studying, or Buying Education?”) is also under publication.

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Why do I call it a War with My Thoughts?

“Thoughts are like open ocean, they can either move you forward within its waves, or sink you under its abyss.” - Anthony Liccione It is indeed a war with my thoughts. I am calling this as a war because Schizophrenia is a thought disorder.

This thought disorder is because of certain neuro transmitters in the brain that become unbalanced.

Awareness of the war with your thoughts is the first step to cure yourself.

5 ‘E’ formula to Win War with the Thoughts: 1) ENDURANCE: “What cannot be cured, has to be endured.” Most psychological problems cannot be cured. But with endurance, we can minimize the losses created by it. The determination of the patient to fight with his own thoughts, emotions, and behavior is crucial. Accepting the fact that I am the problem is the first step to win in a war like Schizophrenia. I was admitted as an in-patient and I was treated for three weeks. I dropped out of college twice in my pursuit to study engineering.

I was unable to continue my education because of my problems related to Schizophrenia. Voices in my head, telling me that I am not a male, and voices coming from T.V. pictures and commenting on my daily routine persisted till 2012.

Later, I decided to pursue distance education and joined Bachelor of Arts (B.A), and M.Sc Psychology from S.V. University, Tirupati. It never was an easy ride; even there I had to battle poor concentration, and was unable to read my text-books or write for a long time. I failed a few times, but somehow, with the help of my Dad and brother, I crossed this hurdle. I worked as an Academic Consultant in Psychology at Yogi Vemana University, Kadapa, for six months. I heard about NET and SET exams for the first time from my colleagues while at this university. I decided to take a shot at it in order to pursue a career in teaching, and finally succeeded after 5 attempts.

What particularly helped me was that I was a voracious reader, and read a lot of self-help books.

Also, the practice of Kriya Yoga for one year helped me to improve my concentration and win the war with my thoughts. “some people see hopeless end, others see endless hope.” - E.B.Norton 2) ENCOURAGEMENT: My father Sri J.Venkata Swamy, and my mother Smt. J. Radhika, are a big support to me in every aspect of my life. They are the pillars of my success. Frankly speaking, I had even beaten my mother once in 2004. Yet, they tolerated my anger, and showed unlimited compassion and love. They never discouraged me and never criticized me saying that I am mad and can’t achieve anything. They adjusted their attitude according to my health condition and fully cooperated and supported me. My brother also loves me so much. I also thank my publisher and Professors for supporting me in my academics.

“Love all. Serve all. Help ever. Hurt never.” - Sathya Sai Baba 3) EFFICIENT DOCTORS: Efficient doctors have been treating me from a long time. It is extremely important to take medications and go for checkups regularly, in order to experience maximum recovery. Medication helps to maintain chemical balance in the brain. They also help the patient by

calming his mind and enabling him/ her to sleep well. When I was studying my Intermediate, I couldn’t sleep at nights due to undesirable thoughts going through my mind and making me restless. But, after taking medication I found it easy to have a good night’s sleep.

“Right thought plus right people in the right environment at the right time for the right reason is equal to right result.” - John C. Maxwell 4) EFFECTIVE COUNSELING: A psychologist in Tirupati gave me a lot of emotional support, so that I was able to face my thought disorder courageously. This contributed to my speedy recovery. In his magazine Jeevana Vikasam, my articles were published for two years. He is the one who had encouraged me initially to write self-help articles and later I wrote books, learning some basics from him. He has also encouraged me to give training programs in Sri Venkateshwara Employee Training Academy (SVETA) for Tirupati Tirumala Devestanam (TTD) employees.

I have given twenty training classes. I have learnt from him that a counselor should also act as a friend, motivator and a compassionate family member, if necessary.

“The value of life lies not in the length of days but in the use we make of them. A man may live long but yet live very little.” - Montaigne 5) EXERCISES: Daily physical activities, doing exercises help to maintain fitness levels of the patient. It helps to reduce obesity, because one of the side effects of the medication is overweight.

Exercises also reduce anxiety, help in getting a good night’s sleep, maintain good mood, and reduce depression. So regular exercise and practice of Yoga is a great recipe for sound mental and physical health.

Yes I agree that schizophrenia is a deadly disorder.

But it is possible to overcome it. The above 5 E’s are extremely helpful for the patient to win the odds against Schizophrenia. It is important to understand and encourage the people suffering from schizophrenia.

Mr. J Pradeep M.B.A;M.Sc(psychology); P.G.D.G.C;NET;SET;(Ph.D)

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Mental Health for Everyday Life Public Lecture series at the NIMHANS Centre for Well-Being, BTM Layout The NIMHANS Centre for Well-Being is starting a regular series of public lectures on mental health issues that we face every day. These topics aim to de-mystify mental health issues and create a bridge between experts and the community. There will be thought provoking talks by prominent mental health professionals from NIMHANS. The lecture will be held for a small and intimate audience of 40-50 people to encourage interaction.

Public lectures planned in the next six months include topics such as Parenting; Alcohol use; Creating a mentally healthy workplace; Handling emotional situations in relationships; Making aging an easier experience and Technology addiction.

Lectures will be held every Third Saturday at the NIMHANS Centre for Well-Being between 5 and 6 pm. All lectures will be available for later viewing.

Venue NIMHANS Centre for Well-Being 1/B, 9th Main, Ist Stage, Ist Phase, BTM Layout, Bengaluru-560076

To Register Contact: 080-26685948 or 9480829670

Printing of the Magazine funded by: Dr. Ramachandra N Moorthy Foundation for Mental Health and Neurological Sciences 36

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