Discussion Topics

 

Social Media & Mental Health

Social media is defined as “forms of electronic communication through which users create online communities to share information. First, known use of the term was in 2004. About 73% and more of online adults now use a social networking site of some kind. The most popular social networking sites are Facebook, LinkedIn, Pinterest, Twitter, and Instagram. Two third of Facebook users visit the site at least once a day, with about 40% doing so multiple times throughout the day. About 300 million Facebook users were mobile-only users. 

 

Motivations for Social Media Use

Recent neuropsychological research shows that the self-disclosure on social media ‘activates the intrinsic reward system’ of the brain, the same way as powerful primary rewards such as food and sex. Self-disclosure was strongly associated with increased activation in the mesolimbic dopamine system. A biological reward mechanism happens when people disclose information about themselves. Web users gradually alter prefrontal cortex in this way due to the fast pace of the networking sites rewiring the brain with repeated exposures.

 

Effects of Social Media Use: Current Research and Speculations

It is no doubt that we are developing a dependence on the technological advance that unifies billions of people but are we addicted?.  Numerous studies identify connections between social media use and negative outcomes. Greater use of the Internet was associated with more signs of loneliness and depression. When used in moderation, with the right intentions, it can also achieve what it was first set out to do: connect people with similar intentions.

 

Social Media and Depression

People who spent more time and who performed more self image management online showed more symptoms of major depression. More negative and less positive interactions on social networking sites were associated with greater depressive symptoms. Posts on social media present an idealized version of what is happening. Users of social media constantly compare themselves with others and think less of them. If other people are posting happy life accomplishments, then the user feels worse about his lack of having anything good to report. People usually post good things about their lives, rather than the bad things resulting in magnified responses.  If things are going well for people in your society and you are having a rough day, it will negatively affect your mood. Negative behaviour occurs because of a decline in confidence due to unfair comparisons to others.

 

Social Media and Narcissism

‘Narcissistic personality disorder’ is marked by a grandiose sense of self-importance, fantasies of unlimited power, self-promotion, vanity, and superficial relationships. Such individuals are driven by responses from others rather than self-assessment of themselves. More time spent on Facebook and a higher frequency of checking Facebook predicted higher narcissism scores.  Studies show that social networking sites exacerbate narcissism. Research has shown that young adults with a strong Facebook presence were more likely to exhibit narcissistic behaviour.

 

Social Media, Anxiety and addiction

People are motivated to use Facebook for two primary reasons: ‘a need to belong to a group’ or ‘a need for self-presentation’. Middle-aged and older adults give greater emphasis on using social media to ‘belong to a group of others’ who have common interests and hobbies. Younger adults below 30years of age connect primarily with those already present in their lives, such as friends and family members for ‘self-presentation’.

 

There are several studies linking social media to anxiety and compulsive behaviours. Younger generations scored consistently more than older generations on anxiety when they were unable to check their social networks and texts. Two-thirds admitted to having difficulty relaxing when they were not able to use their social media accounts. Many become stressed at the thought of ‘missing out’ on something good posted on the site, a phenomenon known as the “fear of missing out”. “Likes” and comments are positive reinforcement for postings, making it difficult for a person to stop. Quitting Facebook (and Twitter) was more difficult than giving up cigarettes or alcohol. Social media supply a platform to self-disclose to the masses and receive immediate feedback. The immediacy and the reward associated with social media is a 'quick hit' and resulted in experiencing 'addiction-like' symptoms.

 

According to a survey of Facebook users between ages 16 to 40, more than half say that seeing pictures of themselves on the site “makes them more conscious about their own body and their weight.” On top of that, 32-percent feel “sad” when comparing photos of themselves to pictures of their friends. A surprising 86 percent felt that such sites hurt their body confidence. Past studies have shown that exposure to fashion magazines, music videos, and other mass media can affect body image in both boys and girls typically causing some girls to strive for a thin ideal and some boys to seek an unrealistically muscular physique. Young women and men post photos, count the number of likes, and feel the pressure to look perfect. Close to 30 percent of girls retouch or alter their own images via Photoshop or filters before they post them. Some sites ask you to rate peoples appearances. Many of these behaviours finally result in eating disorders.

 

Social media gives rise to cyberbullying.

Cyberbullying is on the rise. Why does it increase? Some have abused the privileges of social networking. Cyberbullying is an enormous concern for adolescents. Social networking sites facilitate cyberbullying. Forty-nine percent of students reported being the victims of bullying online and 33.7% reported committing bullying behaviour online in the US. Schoolchildren who were victims of cyberbullying were almost twice as likely to attempt suicide. Adults can also be victims of cyberbullying.

 

Social media glamorizes drug and alcohol use.

Seventy percent of teenagers between the ages 12 to 17 who use social media are five times more likely to use tobacco, three times more likely to use alcohol, and twice more likely to use marijuana according to a study in the US. In addition, 40% admitted they had been exposed via social media to pictures of people under the influence. Although a correlation is all it is, it makes sense that social media would increase the amount of peer pressure to which teenagers are exposed. The data may suggest that those who are exposed to pictures of drugs and alcohol are more inclined to seek and experiment with it.

 

Social media enhances our connectivity.

When used in moderation with the right intentions, it really can achieve what it was first set out for to enhance connectivity. Social media does not necessarily take us away from the real world; instead, it can be used to revive relationships with other people. Even more exciting is that there is an incredible number of like-minded people who can be connected with just one click. Social networking sites allow people to improve their relationships and make new friends. Seventy percent of adult social networking users visit the sites to connect with friends and family. Fifty-two percent of teens using social media report that it has helped their relationships with friends, 88% report that social media helps them stay in touch with friends they cannot see regularly, 69% report getting to know students at their school better and 57% make new friends.

Fifty-nine percent of students with access to the Internet report that they use social networking sites to discuss educational topics and 50% use the sites to talk about school assignments. Social media sites help employers find employees and job seekers find work. Sixty-four percent of companies are on two or more social networks for recruiting because of the wider pool of applicants and more efficient searching capabilities.

 

Social networking sites help people who are socially isolated and shy connect with other people. Youth who are "less socially adept" report that social networks give them a place to make friends. Shy adults also cite social media as a comfortable place to interact with others.  Studies show that students who experience low self-esteem can use social media to bond them with others. Introverted adolescents can actually gain social skills by using social media.

 

Social networking sites help senior citizens feel more connected to society. The older age group is the fastest growing demographic on social media sites. Seniors report feeling happier due to online contact with family and access to other information. More recently, people were encouraged to start conversations regarding mental health. This is one instance where social media can be seen as bringing about a positive change in the understanding of mental health. Social media can help disarm social stigmas.

Social media may also pose a hazard to vulnerable communities.

 

Social networking sites allow hate groups to recruit members.  Children may endanger themselves by not understanding the viral nature of social networking sites.  Social networking enables cheating on school assignments with students posting parts of the exam to social media. Social media allows for unsupervised interactions between students and teachers, which can easily escalate into inappropriate relationships. People say and do things on social media that they would not say and do in person.  As a result, a wall has been removed.

 

Social networking sites encourage amateur advice and self-diagnosis for health problems that can lead to harmful or life-threatening results. Many people use social media for healthcare information. Much of such information posted on social media is harmful and sometimes bizarre.

 

From social media sites, simple algorithms can determine where you live, sexual orientation, personality traits, signs of depression and alma maters, among other information, even if they do not put those data on their profiles. Social media posts cannot be completely deleted and they can have unintended consequences. Postings on social media are named as a source of information in divorces. Social networking site users are vulnerable to security attacks such as hacking, identity theft, and viruses. Social networks do not scan messages for viruses or phishing scams, leading to large-scale problems.

 

Help your teen to keep their image healthy.

Keep the computer in a common room in the house, so you can monitor their use.

If you catch your teen rating peoples looks or counting numbers of likes, gauge how they feel. Ask questions: Do you know anyone who retouches their photos before they post them? What do you think about rating others appearances? Is it a good idea to focus only on how someone looks?

Converse on the non-physical attributes to build up self-esteem their talents, how hard they study, their patience or generosity. Counter social media images that focus on peoples beauty alone by discussing others who have achieved distinction through hard work.

Watch for signs of body image problems and changes in eating habits. 

Set an example of healthy body image by not complaining about looks and by stressing exercise and eating well.

Teach kids to be careful about the comments they post on their own web pages and “unfriend” people who post negative comments about others. Talk to your teens about being careful about sharing pictures. Use social media as a teaching tool and an opportunity for conversation.

 

SLEEP

 

Sleep disturbance is a common symptom in most cases of medical and psychiatric conditions, apart from conditions caused by external distress. 

 

Let me start with “what is stress”?

  • If one has to understand ‘stress’ he needs to understand the neuro-physiology of stress. Hence let me start with neuro-physiology in lay man’s terms
  • If a person is exposed to ‘threat’, direct or indirect, actual or anticipated, leading to an experience of stress, that threat is called “stressor”.
  • “Stres Experience” is a physical and psychological state that mpairs the adaptive capacity of a person due to the impact from a stressor.
  • There are also other ways one explains stress. “Stress” is the term used for distress caused by subjective perception of distressing events. But, it is important consider that mild stress called “Eustress” actually drives a person to perform better.
  • One may understand it better as a fight-or-flight reaction to a threat that is physiological in nature.  Threat gives rise to autonomic nervous system over activity, preparing the person for fight or flight. Over activity of nervous system in turn creates over activity of all organs in the body including the sleep centres, making it more alert. Hence sleeplessness.
  • Stress is however, not only a response to stressor but also modulated by one’s ability to ‘cope with stress experience’. Stress can be ontrolled by improving coping abilities.

 

Now let me answer the next question of why one sees such high levels of stress today?

  • To understand why people experience stress, it is useful to go through the theory of Abraham Maslov, presented as early as 1943. This theory illustrates the “Hierarchy of needs”.
  • He explains that people always try to achieve higher level of needs. Needs starts in an hierarchy from the basic level of Physiological needs (Food, water, air etc.) to Security needs( shelter), to emotional needs (being loved and belonged), to needs of self-esteem (appreciated by others) to finally self-actualization needs (being content)
  • When a person gets frustrated to achieve the desired need he becomes distressed.
  • The resulting distress leads to stress and stress experience.

Is this decade more stressful than earlier?

  • We need to go into another book written by Alvin Toffler in 1970, called “Future Shock”, to understand this concept. This book was written before internet came to speed up our lives.
  • He presented the idea that ‘change is eternal’. However, the pace of change has increased vastly from the Agrarian era to the Industrial era and to the present Information era
  • In the current ‘Information’ era the pace of change is so rapid that a person goes through number of different cycles of change, unlike the earlier era. Hence the person has to “Learn-Unlearn-Relearn” at a rapid pace, making it difficult for people to reach higher levels of actualization.

How does stress experience present itself in a person?

  • During stress, increased autonomic arousal gives rise to stress experience. This form of exaggerated reaction of different organs of the body, such as the brain, heart, lungs intestines and so on, results in physical and psychological manifestation of stress experience.
  • People undergoing heightened ‘stress experience’, presents with physical changes such as palpitations, rapid pulse, increased blood pressure, air hunger and rapid
    breathing, increased gastric acidity and gastric discomfort, increased bowel motility, sleep disturbance etc.
  • They also manifest psychological changes such as anxiety, panic disorder, and depression.

Does stress and stress experience differ in degrees?

  • Yes. Stress is the threat one perceives from an event that is actual or anticipated. It is obvious that it can vary in degree. Accordingly the stress experience also varies. Stress experience can also vary in degree depending on the coping ability of the person. Coping ability of a person depends on the inborn quality of a person (Nature) and his life experiences (Nurture). It is not constant always and varies from time to time and situation to situation.
  • Mild stress experiences or ‘Eustress’ actually promotes better performance.

What is Anxiety and how does it look like?

  • Earlier I had explained about the physical and psychological manifestation of stress experience. The psychological presentation of stress experience, such as tension, panic attacks; sadness, unremitting preoccupation with the distressing events etc. are commonly termed as ‘anxiety’.
  • However, in many people it is also associated with the physical manifestations. Whenever the physical manifestations are not dominant they are identified as anxiety. While they are mistakenly identified as physical illness if the physical symptoms are prominent.
  • Anxiety occurs in a person irrespective of the form of stress he faces, whether it is internal stress, like in psychiatric or medical illnesses or an external event that creates distress.
  • The severity and the duration of anxiety can vary from person to person and situation to situation.

How does anxiety impact sleep?

  • From the above discussion on anxiety one understands that ‘anxiety’ has two components, a physical and psychological component. The disturbance in ‘sleep’ is the physical component, while the uncontrolled preoccupation with the distressing event is the psychological component. Autonomic arousal in a ‘fight-flight’ reaction activates the sleep centres in the brain to be over vigilant just as it makes all the bodily organs to be overactive.

How does good sleep help people with anxiety?

  • Eight hours sleep is restorative for the brain. An anxious person often finds it difficult to sleep, gets interrupted sleep or wakes up too early, resulting in poor quality and inadequate sleep. His brain becomes poorly rested and anxiety gets prolonged.

How do rhythms play a role in modulating autonomic arousal?

  • I will try to explain it in a lay language. When a person is ‘calm’ the brain activity is generally rhythmic. This activity of the brain becomes irregular and rapid when the person becomes anxious. However the brain has the capability to respond to external rhythmic stimuli and revert back to calmness. This is the principle used in relaxation exercises and also in ritualistic prayers where a prayer bead is rolled rhythmically and they chant continuously. Autonomic arousal subsides with these methods. The result is less anxiety and better sleep.
  • According to me, any rhythmic activity can produce the result. However the efficiency with different methods may vary. I usually suggest one to walk since it activates rhythmic leg movements and circulates blood from the thigh muscles rhythmically. They can chant while walking or listen to rhythmic music to get better results. It is useful to know that some sleep podcasts and relaxation exercises also use rhythmic music as methods to produce calmness.

How do these methods producing sleep beneficial in different kinds of stress?

  • The process of using a rhythmic activity to produce calmness also generates good sleep and less anxiety.
  • Short-term stress leading to anxiety can be reduced substantially with these methods. However, it is only partially beneficial in cases of long term-stress generated due to psychiatric illnesses. These people have a problem controlling their thoughts. While others can voluntarily control what they want to think, psychiatrically ill persons cannot control their thoughts. Thoughts are involuntary and go on and on until it fades away.
  • The combined efforts of relaxation exercises and medicines can however benefit psychiatrically ill persons much better than medicines alone.

There are a large number of people with sleep problems today. What causes these
problems?

  • Sleep problems can occur with many different reasons. Large numbers of people who suffer from problems with sleep suffer due to environmental problems such as work stress to snoring sleeping partner. Then there are people who suffer because they have pain or asthmatic attacks etc. There are also people with primary sleep disorders like sleep apnoea and others. My clients have primary psychiatric illnesses. There are also people who go through post-traumatic psychiatric-disorders who will have sleep disturbances until their distress due to the trauma is resolved.

What are best sleep practices? 

  • Eight hours sleep every day. As far as possible sleep at the same time so that the brain gets habituated to the sleep time and quick onset of sleep. Walk every day for 1 hour.

 

 Future Shock

Future Shock is a book written by Alvin Toffler in 1970. In the book, he defines the term "future shock" as a psychological state of individuals and societies due to the perception of "too much change in too short a period of time". He argued that society is undergoing an enormous change from a slow industrial society to a "super-industrial society". He believed that the accelerated rate of technological and social change left people suffering from "shattering stress and disorientation"future shocked. He believed that the majority of social problems are symptoms of future shock. In his discussion, he popularized the term "information overload."

 

There are three stages in the development of a society: agrarian, industrial and post-industrial. The first stage began when people invented agriculture. The second stage began with the Industrial Revolution. The third stage began when people invented the computer, the internet, and roboticsToffler distinguished between industrial society and post-industrial society. In a post-industrial society, the share of the people occupied in agriculture is only a small percentage while the share of people occupied in the services sector exceeds more than 50%. Thus, the share of the people occupied with brainwork exceeds the share of the people occupied with physical work in post-industrial society.

 

Alvin Toffler's main theory consists of the fact that modern man feels shocked from rapid changes. When a society experiences an increasing number of changes with increasing rapidity, people lose their association with the old institutions such as religion, family, national identity, profession etc. People of post-industrial society have many careers in a lifetime. They look for temporary jobs and become nomads. As a result, relationships tend to be superficial and temporary, instead of being intimate or close that are more stable.

                        

Maslow's hierarchy of needs

Maslow's Hierarchy of needs-Video


EATING DISORDERS

 

Primary Eating disorders are psychiatric disorders that cause voluntarily eating extremely small amounts or severely overeating food, that affects the person's physical and/or mental health. 

They include binge eating disorder where people eat a large amount in a short period of time resulting in overweight, anorexia nervosa where people eat very little and thus have a low body weight and bulimia nervosa where people eat a lot and then try to rid themselves of the food, resulting in normal or overweight.

Causes

Eating behavior is a process controlled by the Hypothalamus-pituitary-adrenal-axis (HPA axis). Dysregulation of the HPA axis has been associated with eating disorders. Researchers are still studying questions about behavior, genetics, and brain function to understand risk factors and develop specific.

Anorexia nervosa

Anorexia nervosa (AN), characterized by compulsive maintenance of lower than normal body weight and an obsessive fear of gaining weight

Many people with anorexia nervosa see themselves as overweight, even when they are clearly underweight. Eating, food and weight control become obsessions. Some people with anorexia nervosa may engage in extreme dieting, excessive exercise, self-induced vomiting, and/or misuse of laxatives, diuretics, or enemas. They have a distorted body image, a self-esteem.

Bulimia nervosa

Bulimia nervosa (BN), characterized by recurrent compulsive binge eating followed by compulsive  purging, even though they maintain a normal weight, while some are slightly overweight

Patients with bulimia nervosa have recurrent and frequent episodes of eating large amounts of food and feeling lack of control over these episodes. Binge eating is followed by forced vomiting, excessive use of laxatives, diuretics, fasting, excessive exercise, or a combination of these behaviors.

The notable difference between anorexia nervosa and bulimia nervosa is the body weight of the person. Anorexia nervosa patients are underweight, while those with bulimia nervosa have a body weight that falls within the range from normal to obese

Binge-eating disorder

Binge Eating Disorder (BED), characterized by recurring compulsive binge eating at least once a week for over a minimum period of 3 months while experiencing guilt after overeating

With binge-eating disorder, a person loses control over his or her eating. Unlike bulimia nervosa, periods of binge-eating are not followed by purging, excessive exercise, or fasting. As a result, people with binge-eating disorder are overweight or obese. They also experience guilt, shame, and distress about their binge-eating.

Who Is At Risk?

Eating disorders frequently appear during the teen years or young adulthood but may also develop during childhood or later in life. Although males with eating disorders exhibit the same signs and symptoms as females, they are less likely to be diagnosed with what is often considered a female disorder. Rates of eating disorders appear to be lower in less developed countries. Reliable statistics regarding eating disorder for India is not available yet.

Diagnosis

When does severe dieting become an eating disorder?

Ø  Constant focus on dieting, food, and exercise

Ø  Insisting dieting meal different from others

Ø  Feeling irritable when exercise is not done

Ø  Increased social withdrawal

Ø  Frequent weighing

Ø  Frequent visits to bathroom after meals

 

Common presentations

 

  • Ø Weight loss
  • Ø  Altered eating behavior
  • Ø  Amenorrhea
  • Ø  Depressed mood and withdrawal from society

 

(Use a screening instrument to determine the existence of an eating disorder or other mental health or physical health disorder)

Physical examination shows features of malnutrition. Symptoms of eating disorders are actually symptoms of the starvation itself. Eating disorder shows a failure to gain weight rather than weight loss. While diagnostic criteria are a useful guide, one should consider intervention if disordered eating and abnormal behaviors are present, even if the criteria are not met.

Investigations

Investigations are to rule off diagnoses other than eating disorders. They are mostly normal in eating disorders.

 Full blood examination

Ø  Mild leukopenia or thrombocytopenia from malnutrition

Ø  Anaemia from malnutrition or gastrointestinal losses

Urea and electrolytes

Ø  Hyponatraemia from excess water intake

Ø  Hypocalcaemia from vomiting

Ø  Metabolic alkalosis from vomiting

 Random blood glucose

Ø  Rarely low

 Calcium, phosphate, and magnesium

Ø  Hypocalcaemia, hypomagnesia, and hypophosphatemia (uncommon)

 Liver function tests

Ø  Slight elevation from malnutrition; albumin normal unless very chronic

 Follicle stimulating hormone (FSH), luteinizing hormone, other vitamins

Ø  FSH and LH usually low,

Ø  Bone densitometry Scores may be reduced from low hormone levels and malnutrition

Ø  Vitamin D Low from malnutrition, Haematinics iron studies, B12 and folate If indicated low from malnutrition

 

Differential diagnoses

One has to exclude other organic and psychiatric disorders that may be confused with an eating disorder.

Psychiatric conditions that present with disturbances in eating

Ø  depression

Ø  obsessive-compulsive disorder

Ø  substance abuse, alcoholism

Ø  anxiety disorders/ phobias

Ø  Schizophrenias

Ø  personality disorders, such as narcissistic personality disorder, obsessive-compulsive disorderborderline personality disorder

Medical conditions that present with disturbances in eating

Ø  Lactose intolerance or irritable bowel syndrome

Ø  Anoxic or traumatic brain injury to the right frontal lobe or temporal lobe

Ø  Neurodegenerative diseases such as Parkinson's disease

Ø  Neurotoxicity such as lead exposure,

Ø  Bacterial infection such as Lyme disease 

Ø  Viral infection such as Toxoplasma gondii 

Ø  Tumours in various regions of the brain.

Ø  Brain calcification: of the thalamus.

Ø  Addison's Disease 

Ø  Gastric adenocarcinoma

Ø  Helicobacter pylori 

Ø  hyperthyroidismhypoparathyroidism and hyperparathyroidism

Ø  systemic lupus erythematosus (SLE)

Ø  Neurosyphilis

Ø  Coeliac disease

Ø  Tuberculosis

Ø  Diabetes

 Treatment

Some who have eating disorder recover with treatment after only one episode. Others get well but have relapses. Still, others have a more chronic form of the disorder, in which their health declines as they battle the illness.

A combined approach of medical attention and supportive psychotherapy designed specifically for eating disorders is more effective than a single mode of treatment.

1.     Role of the Family Physician ( Team leader of the professional Eating disorder care group) is the first point of contact for patients with eating disorders

Ø  Early detection and establishment of the seriousness of the condition

Ø  Undertake an assessment and provide regular medical monitoring of physical status

Ø  Decide if hospitalization is necessary (Indicators for admission)

Ø  Admission criteria for eating disorders

Bradycardia (resting heart rate <50 bpm)

Orthostatic hypotension (>10 mmHg systolic)

Hypothermia (temp. <35.5oC)

Arrhythmia

Severe electrolyte disturbances, eg. Hypokalemia (K <3.0 mmol/L)

Acute dehydration from refusal of all food and fluids

 

  • Provide primary care support to outpatient specialist treatment

 

 

2.     Nutritional counseling is usually necessary. (Dietician/Nutritional counselors)

Ø  Restoring weight through Adequate nutrition, reducing excessive exercise, and stopping purging are the foundations of treatment.

 

3.     Treating the psychological issues (Psychologists)

Ø  Issues related to the eating disorder using cognitive behavioral therapy (CBT), that helps the patient learn how to identify distorted or unhelpful thinking patterns, is necessary.

 

Ø  Family therapy and self-help groups are useful adjuncts. Family-based therapy requires 612 months of outpatient treatment.

 

4.     Psychiatric management (Psychiatrists) 

Ø  Medications, such as antidepressants, antipsychotics, or mood stabilizers, are effective in treating patients with eating disorders.  

 

5.     Other forms of specialized management (Physician, Endocrinologist, Neurologist, Gastroenterologist, Bariatric surgeon etc).

 

Prognosis

 

Outcome estimates are non-uniform for anorexia nervosa, bulimia nervosa, and binge eating disorder, there seems to be general agreement that full recovery rates are in the 50% to 85% range, with larger proportions of people experiencing at least partial remission. 5075% of patients are weight restored by the end of treatment, with 6090% fully recovered at 4 5-year follow-up.