Clarifying Psychiatric Illness

CLARIFYING THE CONFUSION ABOUT PSYCHIATRIC ILLNESS

Dr. M.J Thomas (www.drmjthomas.com)

What is psychiatric illness?

If you ask hundred people around you, whether they are sad or tense, twenty of them will say ‘yes ‘for every hundred people you ask. If you go further to ask why they are sad or tense, fifteen of them will give the reason and attribute the cause of their misery to an event that has happened or to an event that could trouble them in the future.

If you were to attend a funeral, you will find people crying to express their sadness in relation to their loss. If you were to visit these people three months later, you will find them back to their normal life and not sad anymore. Human beings have an inherent capability to cope up with stress. Hence, given a little time they cope up by talking to significant others in their society and return to normal life. This behaviour after a stressful event and the return to normalcy by coping up with the stress are called ‘Post traumatic stress disorder’ (PTSD). Normally professional intervention is not required for them unless it leads to dangerous situations like attempt to commit suicide or homicide. However, people confuse these stressful reactions with other primary psychiatric illnesses. The lesson to learn here is that stressful events are inevitable in life and most people can cope up with them using the available resources in their society.

I have talked till now only about fifteen people out of the twenty who said, ‘yes’ to your question ‘whether they are sad or tense’. What about the five others? If you ask them what caused their sadness or tension, they find it difficult to determine the cause, and often relate it to random stressful events in their life that can be an acceptable condition to others. They are the people who suffer from ‘Primary’ psychiatric illnesses. Hence you can safely assume that one out of twenty people in the society may experience some form of psychiatric illness sometime in their life and they suffer for longer time than those who go through inevitable life stresses. Very often they have no answer why they suffer emotionally and are not able to get out the emotional turmoil despite all their efforts.

Why does this happen in these five people? Psychiatric illnesses are primarily inherited. What the genes change is the ‘manner’ in which you think. However, ‘what’ you think depends on your culture, society, education etc. Some of the thoughts may be socio-culturally appropriate while others may be inappropriate. All of us are in control of our thoughts if we are not ill. For example, if we get a thought that the world is going to end in the next minute, we will rationally analyse it, decide it is a silly thought, and discard it immediately. In ordinary understandable terms, we have a ‘Switch’ to switch off unwanted thoughts and continue to think only what we want to think. However, when someone gets a psychiatric illness, this ‘switch’ disappears and the person is not able to switch off the thoughts that come to his mind, irrespective of whether they are appropriate or inappropriate, or these thoughts are welcome or unwelcome.

Why does this happen? The abnormal genes interfere with the brain functioning by altering the brain chemicals. These changes in the brain make the ‘switch’ dysfunctional. Hence a thought that comes to the foreground in the brain cannot be switched off even if you want to do so. They have to go on and on, until they fade off naturally. Many times, these thoughts can disturb the individual. It can be frightening and because they come repeatedly, without an end, the person can get extremely sad, sometime resulting in suicide.

Why do these peculiar thoughts come to your mind? From anywhere around five years of your life and even earlier, the brain stores in it, all your experiences, like the google stores all that you do. Normally only a fraction of these stored experiences is brought to the foreground at any given time. However, when the ‘switch’ becomes dysfunctional, these stored experiences come to the foreground at random and often without a logic, just as you find your computer behaving while it gets infected with a virus.

What kind of thoughts come to the foreground when the ‘switch’ becomes dysfunctional? Brain stores every kind of experiences in life. We call them memories. We also associate an emotion to these memories. We assign a symbolic language to these memories. Hence when the switch becomes dysfunctional these thoughts come to the foreground at random, sometimes illogical, in the form of a language, associated with an emotion and sometimes experienced as a voice.

How does one experience these changes? Firstly, it is important to recognise that there are many forms of psychiatric illnesses. Some illnesses are ‘Episodic.’ They come on and disappear for a while and return. Others are ‘Continuous.’ Some illnesses show significant expression of mood changes with related changes in thoughts. They can experience episodic or continuous mood changes towards ‘depressed mood’ or ‘happy mood.’ Yet others can switch between excessive depressed mood to excessive happy mood with free intervals of normal mood in between. In some other illnesses people experience hearing ‘voices’ of others as you would hear voices from a mobile phone. Yet others become ‘suspicious’ and get convinced about their illogical experiences. There are also many other forms of expressions in psychiatric illnesses and only the most common expressions are explained above.

Do these experiences have names? When you call an illness ‘Typhoid’ or ‘Malaria’ you communicate that the patient’s experience, irrespective of what it is, is caused by the respective ‘Organism.’ However, when you call a psychiatric illness ‘X’, you communicate that ‘symptoms’ such as ‘a,b,c,d’, in my opinion is called ‘X’. Opinions may differ between doctors; names may differ in different countries and different classification tables. Sometimes your experience may not fit into any of the names.

How do you then treat the psychiatric illness? One must understand that there is no ‘cure’ for psychiatric illness till now. You can ‘control’ psychiatric illness like you control fever with paracetamol or diabetes with antidiabetic medicines. These medicines are to suppress symptoms if they exist. If there is a mood change, one takes medicines to normalise the mood, if one hears voices, he takes medicines to suppress it and so on.

Do you take medicines in the same dose continuously? No. Treating psychiatric illness is highly technical. Hence you need to consult a psychiatrist for deciding about your medicines. The general principle is to use medicines appropriately, which means the lowest effective dose of medicines to control the illness without side effects.

Is psychiatric illness restricted to only your brain? Does it affect other organs? Psychiatric illness affects every organ in the body, directly or indirectly. An explanation about it will be available in the subsequent sections. An explanation about how to control the consequence of psychiatric illness also will be available in the other sections.

Does this explanation fit with all psychiatric illnesses? No. Children’s psychiatric illnesses are very different. An addiction to alcohol and addictive drugs needs different explanation. Personality disorders are different. This explanation is to provide an understanding of the common forms of psychiatric illnesses only.

BODY AND MIND RELATIONSHIPS

Dr M.J Thomas (www.drmjthomas.com)

Is there a relationship between the body and mind?

In the last section we learned that five people out of hundred developed some form of psychiatric illness in their life. When they develop psychiatric illness, they lose control of their thoughts and feelings, and it happens due to genetically influenced chemical abnormalities of the brain cells. The next question is whether these changes in the brain can in some way affect the body and whether some manipulations of the body can make changes in the brain to alter thinking and feeling. Typically, humans are characterized as having both mind (nonphysical) and body (physical) components. Your mind and body are powerful allies. How you think can affect how you feel, and how you feel can affect your thinking. When you face any distressing event or object, or you expect to face them, the brain gets alerted. The reaction of the brain to these distressing events is by alerting all the bodily organs to function in an exaggerated manner. This reaction is known as ‘Fight-Flight reaction’ or technically explained as ‘Autonomic arousal.’

This situation makes you distressed and you require to escape from this situation either by running away from it, for example a snake or killing it. However, you require extra energy to conduct any of these alternatives. In this situation the brain sends a message to all bodily organs to function more actively. Your heart overreacts by increased blood pressure, pulse rate and you may feel palpitations. You may get air hunger, blood glucose rises, your stomach secretes more acid altering your appetite and your intestinal and bladder motility increases. Your hands shake and sweat more. You also require being alert since the snake is in front of you, resulting in sleep disturbance. You become anxious since you are continuously focussing on the snake that is ready to bite you. The snake in this situation is called ‘Stressor,’ that is, any object or event that causes distress in you at present or expected to cause distress in the future. The mental feelings are called ‘Stress’ and the bodily changes resulting from this are called ‘Stress experience.’

Medical illnesses as well as psychiatric illnesses can function as ‘Stressors’ and they cause ‘Stress’ and ‘Stress experience’. But these features are not limited to only diseases. They occur due to distressing life events too. During a period of ‘Stress’ one finds that the electrical activity of the brain changes from slow rhythmic activity in general to rapid irregular activity.

To reduce ‘Stress’ and bring back the brain electrical activity back to normal, professionals suggest ‘Relaxation exercises.’ If you search for ‘Relaxation exercises’ in google you will find many forms of exercises, called by different names. However, all of them make use of similar process of introducing a rhythmic stimulus to the brain, using any of your sensory organs. Chanting silently or loudly, listening to rhythmic music, rolling beads using your hands, walking for an hour every day, using certain rhythmic muscle movements, rhythmic deep breathing and others are diverse ways of doing ‘Relaxation exercises.

All of them will reduce ‘Stress’ and ‘Stress experience.’ However, none of them will control the psychiatric illness due to the changes in the brain cells. The thoughts continue to emerge constantly, even though the resultant ‘Stress’ or anxiety is reduced. After a while, the level of anxiety or ‘Stress’ returns. The changes in the brain due to the chemical abnormality of the brain cells need to be treated using appropriate medicines. However, many forms of Post Traumatic Disorders may only require ‘Relaxation exercises’ for control.

From this explanation you will understand that mind controls the body and body controls mind. In case of psychiatric illnesses, one can use simultaneous interventions targeted at the brain/mind, such as medicines to correct changes in the brain, as well as ‘Relaxation exercises’ that reduces anxiety/stress, for better results.

BEHAVIOURAL CHANGES IN PSYCHIATRIC ILLNESS

Dr M.J Thomas (www.drmjthomas.com)

Will changes in mind and body influence your behaviour?

If you observe people with a physical disability, you will notice some of them will adapt and cope with the disability well and become comfortable, while others become frustrated and infuriated. If one gets paralysis of the right arm; he may learn to write with the left or become frustrated and angry, resulting in dependency on others. Every person who faces some form of distress will have unique reactions to it, affecting his mind, body and will have changed behaviour. Doctors, family, friends, peers, and members of his society, constantly observe these changes to come to a conclusion. If this behaviour is inappropriate to their culture, the person gets ‘branded.’

In case of psychiatric illness, the person has an abnormality of his thought process along with resultant bodily changes, producing behavioural changes. If these behaviours are inappropriate and they are noticed early, he gets branded. However, not all behavioural changes are due to psychiatric illnesses. It can also be due to a physical illness or a conscious, selfish, manipulative intentional behaviour. This makes it difficult for observers to conclude the origin of the altered behaviour. This is the reason psychiatrists observe verbal and non-verbal communications before they conclude.

These changes in behaviour are important in many ways for the patient with psychiatric illness. Firstly, they can get branded and excluded from the society, resulting in poor peer relationship and ability for self-dependence. Many such people can become dependent on others for life, unproductive and discarded by the caregivers. Some of them can end their life. Secondly, despite the treatment of psychiatric illness these behaviours may persist for long time since they have become a habit. Hence it is important to correct them. Thirdly, the caregivers may doubt the intention of these behaviours, suspect these behaviours are intentional and punish the patient. Lot of people who are psychiatrically ill can correct inappropriate behaviours by themselves or with the help of their dear and near ones, who can identify these behaviours. Intelligent and introspective people with psychiatric illness tend to recognise the behavioural inappropriateness in them as they improve with medical treatment and relaxation exercises. They can then correct these behaviours by themselves.

Others who find it difficult to identify their inappropriate behaviours, require help from counsellors for correction. This is of particular importance in chronic patients who have developed habits that are inappropriate and for patients and families where caregivers become punitive due to their own frustration.

After reading these sections, it is expected that the reader understands that treatment of psychiatric illness is much more complex affair than taking medicines or getting counselled. It is a more complex, long-term plan, to bring a person who has impaired mind, body, and behaviour, back to normal status of functioning over time, despite the lack of available curative interventions or medicines.

MYTHS AND FACTS ABOUT PSYCHIATRIC ILLNESS

Dr M.J Thomas (www.drmjthomas.com)

Psychiatrically disturbed patients and those who are going through traumatic stress, often think about suicide, plan for it and sometimes attempt suicide. Some of them die in the process. Most people cry for help before they find that everyone avoids discussing this topic. Caregivers are usually frightened to ask the patient if they get suicidal thoughts, assuming that it will increase the chances of suicide. Contrary to the caregiver’s belief, if they ask the distressed person whether they have suicidal thoughts, it can give an opportunity to the person to talk about their problem and be able to prevent an attempted suicide and death. People attempt suicide when they find no options to live or when they want to threaten someone with it. It is possible for remedial actions if you know about the context.

Many people believe that sleeplessness causes psychiatric illness. To get better sleep, they take alcohol, sleeping tablets or other addictive substances. Alcohol, sleeping tablets and addictive drugs damage brain cells, and psychiatric illness becomes worse in time. They are also, addictive and changes brain cell configuration. Tolerance develops in time and doses are increased to get the same effects. Of serious psychiatric illness

Some behaviours that can distress the family are also signs of severe illness. They are as follows: Not washing or changing clothes for a long time; being active all the time (hyperactivity) with little or no sleep; sitting like a statue for hours without moving; moving about quickly without any purpose and waving his arms and shouting; talking to himself all the time or not allowing others to speak; talking without making sense; refusing to be with family members and spending most of the time alone; eating or drinking too little with a great deal of loss of weight or crying for a long time for no reason. These warning signs that tell the family and friends to get help immediately.

How are people with psychiatric illness different from others?

Family is usually the first to notice a change in people who act differently from the usual.

A person becomes worried, cannot sleep, or stop worrying, no matter what others say.
Some feel heart beats fast; breathing becomes fast and afraid for no reason. He is unable to think clearly and does not know what to do.
Some do not comb their hair or change their clothes for days. Their facial expressions can change, and they can lose a great deal of weight in a brief period.
Some complain of pain, and pain moves around various parts of the body, or they have headaches. Even if the doctor finds nothing wrong, they continue to worry and believe in something being wrong.
Some persons cannot sit still because he is worrying about silly things. Others may be unusually happy (so happy in fact), making strange, unrealistic plans.
Some lose interest in life, may sit alone at home, and not see others. Sometimes, they do not want to eat or talk to anyone.
Some say strange things and make strange decisions that no one can understand.
Some become suspicious for no reason and think others are talking about him. Sometimes they believe others want to hurt them. It is hard to convince them.
Some falsely believe things that everyone knows are not true and tell others about it.
In severe illness some hear things that are not there; as a result, he may talk to himself.
When he is very disturbed, he speaks strangely, others cannot understand his talk. The words may be mixed up.

HOW DO CAREGIVERS DEAL WITH PERSONS WITH PSYCHIATRIC ILLNESS?

Dr M.J Thomas (www.drmjthomas.com)

What should caregivers do when they deal with their loved ones?

If you have a person with psychiatric illness in your family or amongst your friends, you need to take care of them. Unlike caring for patients with cancer or paralysis, caring for psychiatrically ill persons can be testing for caregivers. In most circumstances, caregivers do not understand what is expressed by the patient during the illness. At the same time, the patient does not understand the caregiver too. The logic that the patient uses to communicate his feelings and observations can be quite different from the caregiver’s logic. Patients describe events around him based on their illogical thoughts while they are ill, while the caregiver understands them based on the real situation on the ground. There can be gross disparity in understanding of the same subject between these two individuals.

Very often caregivers aggressively correct patients from his thoughts and behaviours. Consider you have a severe abdominal pain, and then you may not go for work, eat well, take bath or do any serious productive work. You may also become restless and irritable. If the caregiver does not recognise his pain, and forces him to do the chores, he reacts angrily. As time go by, the abdominal pain reduces, and he conducts his daily chores without force. Later, when he is completely pain free, he involves in his creative work as earlier.

The stages of recovery in psychiatric illnesses are similar. As the patient improves, he can conduct daily chores spontaneously. However, his thoughts remain illogical. It will be difficult to correct him from these thoughts since his logic is still irrational. Daily chores correct first and logical thinking later. Patients who have become ill recently recover in this order. Those with longstanding illnesses, however, learn certain inappropriate ‘habits’ during the illness and do not change their habits easily.

Caregivers need to think like the patient. They must encourage the ill person to return to normal functioning, but not force. At the same time, inappropriate habits in patients with longstanding illnesses need to be forcefully corrected.

The reasoning described above is true for most psychiatric illnesses. But there are exceptions. People with problem of addictions are usually managed with punishment and reward paradigm. For inappropriate behaviour some form punishment or denial of reward is organised, while appropriate behaviour leads to rewards. These are usually conducted in professional rehabilitation centres. Certain people have personality types that are different from others. There are attention seekers. When they become ill, they exaggerate the symptoms. If they receive continuous sympathetic attention from caregivers, they perpetuate the symptoms and gain from it.

There are also very stubborn, obsessive people. They may require medicines to control the stubbornness when they become ill. Some people are manipulative and selfish. They can manipulate the caregivers and split them apart, during their illness. The care givers of these patients need to be always careful and be united in their actions.

https://www.youtube.com/watch?v=r93avRTi8mw This video gives you substantial information on how to deal with psychiatrically ill people, explained by a young person who has gone through it all.

QUICK REFERENCE TO HELP A VERY ILL PERSON

The information below gives some ways to help people who show exceedingly difficult behaviour.

The first thing to do is to find a doctor.

Unfriendly and suspicious patients who think others want to harm him and are overly watchful of things going on around him. His ideas are unreal.

Do not argue with the person about their ideas or thoughts or try to prove them wrong.
Change to a concrete topic that is not related to suspicions.
Be friendly and accepting. Do not get angry with the person.
Do not whisper or talk secretly when the person is in the same room or nearby.
Do not talk or do things behind the person’s back.

Restless, constantly walking back and forth or overly excited, moving around without a reason.

Do not try to hold on or restrict the person.
Talk to him and get his attention.
Firmly but without anger, ask him to come to you and do what you say.
Tell him his behaviour is disturbing you and you would like him to stop.

Avoids people and will not let others come near

Approach the person slowly and friendly. Stop in front beyond his reach to avoid aggression and greet him in the usual way.
Talk to him about things you both can see and discuss. For example: Is that chair comfortable?
If he answers, continue with small talk.
If he stops talking, try again to get him to answer. If he becomes restless, thank him and leave.
Repeat this small talk many times until he allows you to come near and talks to you about how he is feeling.
Have the family members continue their activities near the person so that they can watch him.
Family members should continue to talk to the person even if he does not answer.

Aggressive behaviour and suddenly strikes out

Stay calm and do not show that you are frightened but quickly go for help.
Speak in a firm loud and commanding voice: “I would like you to stop this behaviour”.
Remember that the person does not always know what he is saying or doing.
Give the person an activity which requires him to use his energy and get distracted.
Do not let him use objects that are sharp or that can be used as a club.
Instruct other persons not to argue with the person and to stay away until he calms down.
Talk to him about his behaviour when the person is calm. Make suggestions about other activities he can do that will help the anger disappear.

HOW DO YOU TREAT PATIENTS WITH PSYCHIATRIC ILLNESS?

Dr M.J Thomas (www.drmjthomas.com)

How do I prepare to meet a psychiatrist?

Meeting a psychiatrist is like meeting any other doctor. You may contact him online or face to face. Each doctor will have a set of rules to regulate the appointments. Once you have decided on your doctor you need to check on the rules of his practice and enrol for appointment. In countries where online consultations are legalised, one can also choose this mode of consultation. It reduces the cost of travel to meet the doctor and provides you a facility to consult from the comfort of your home. Meeting the psychiatrist online or face to face is no different from each other in effectiveness.

Before you contact a psychiatrist, make sure that you have your entire past medical history with you, which includes past investigations for all medical illnesses you have had. Many medical illnesses present with psychiatric symptoms and if you do not present their history the psychiatrist can make gross mistakes or require reinvestigating you again to rule off those illnesses. This may cost you much more, as it is expensive to repeat the investigations.

Start telling him about symptoms that are most distressing for you and how long you have noticed them. Your doctor may interrupt you and ask clarifying questions. Once you have finished with the present problems and the doctor have clarified them, you may go into your past, which you think are relevant for your illness. If they are not relevant your doctor will tell you so and you can go to the next point. It is not necessary that you list out everything in a paper before you go to your doctor. It is much better to be spontaneous since your doctor needs to observe you for your verbal and nonverbal communications and interrupt you in between to focus on relevant information. While you are expressing your problems, your doctor’s mind is logically analysing them. He observes your verbal and nonverbal expressions of mood and logical thoughts, apart from the content of your reported symptoms. Most illnesses show up with certain patterns of symptoms and does not present as random symptoms. Your doctor is fitting them into patterns. If it fits well, your diagnosis is clear, if not, he asks you more questions or investigates you.

To start with he may consider whether your problems are due to psychiatric illness, medical illness, personality disorder, post-traumatic stress disorder, addictions, or any others. Once this stage is over he analyses and assigns the problems to a specific group of illness. Next step is to decide whether to investigate or to confirm diagnosis during follow up visits. After this he plans for a treatment programme for the person. He will explain this programme to you and seek your permission. Some of the problems may be solved with medical interventions, others with counselling or both, yet others with referral to other specialists. Sometimes all these interventions may be required since your doctor is treating you as a whole person and not as a compartment called ‘mind.’ He will then fix the time for review and send you off, to follow the instructions responsibly and carefully.

Treatment is always need based. No two persons have the same needs or same treatment in ideal situation. Medicines in psychiatric treatment are given to control the symptoms. They take time to reach the brain and results take time to be visible. Reviews are required to identify side effects, responses and decide on the ideal dosages if medical treatment is planned. Medicines are calibrated by the doctor to the lowest effective dose without side effects. Medicines are not given in a static protocol, and you may expect changes in them every time you go for a review. If a person must undergo counselling, reviews are fixed according to the need of that person. You may expect more frequent reviews to start with. As you improve and your need comes down, the reviews become less frequent.

You may also expect treatment plans to be different for different persons, and different doctors also make different plans for the same person, depending on the doctor’s skill and his familiarity with these plans.

Psychiatric illnesses are mostly long-term illnesses. Hence it is better to consistently follow up with your doctor rather than keep changing doctors unless it is specifically instructed to do so. Treatment for psychiatric illnesses may be lifelong or for a brief period. The aim is to bring the person back his normal productive life.