Shrink's Views

ramblings of an unknown psychiatrist

Archive for the ‘depression’ Category

Hell’s View on Mind, Mentally Ill and Mental Illness: Satan writes to Screwtape

Posted by Dheeraj Kattula on August 31, 2010

Prologue:

The Screwtape Letters is a Christian apologetics novel written in epistolary style by C. S. Lewis, first published in book form in February 1942. The story takes the form of a series of letters from a senior demon, Screwtape, to his nephew, a junior tempter named Wormwood, so as to advise him on methods of securing the damnation of a British man, known only as “the Patient”.

One must know this background to understand the following post. The following is a letter written to Screwtape by the father below Satan himself. It addresses issues of the mental illness and mind.

Letter:

Depths of Hell

21st Century. Year of the Enemy

Dear Screwtape,

I bring greetings from the depths of our eternal home. I have heard of your progress from your junior aid Wormwood. He gave me the news that you have been active in trying to understand and use the interface of spiritual and mental realms for our purpose.

I must warn you of the dire consequences of making yourself too obvious. Our success lies in our subtlety. You know it clearly that the ones who are obsessed with us and the ones who do not even believe in our existence are not our threat. In fact they are safe in our hands. I use the word safe only for sarcasm. You know the truth that they are actually unsafe in our hands 🙂

Many of our Enemy’s children are slowly coming into our camp. They are quite obsessed with us. Many of them do not even realize it. They know us. They can drive us out of our subjects with the authority of the Enemy. What is good for us is that they see us in everything. What our Enemy intended for them is to know Him more deeply. We can keep them preoccupied with us and distract them from Him. We can make them hate us more, thus filling their heart with more hatred. This distracts them from showing love for their brothers through their actions.

I see you have done a good job in the area of mental ill-health. Of course, I cannot credit you with making people mentally ill. I know some of this is beyond our capacity. We can only hurt those subjects as much as we are allowed by the enemy. You have quite nicely convinced many that mental illness is caused by us. It is a great lie. I love it. It is useful in quite a number of ways.

One, it keeps people in search of a magical-spiritual cure, which we can use for drawing them closer to us by involving them in rituals that are not pleasing to Him. Secondly, this preoccupation helps them keep away from medical attention. This makes the subject live in a psychotic state, away from reality. This makes him lose contact with the world that the enemy has created and makes them live in a world of lies. Remember our job is to steal, kill and destroy. We steal, kill and destroy the time of our subjects through this.

When we encounter any illness, we can use it for our purpose. We can use mental illness, even more. Our weapon of lies is very powerful. You are using it well. People fear mentally ill. They think that mentally ill subjects are violent and dangerous. Those of them who fear us also think we are causing these patients to do their behaviors. What a joke! We can laugh at this even in hell! The subjects who seem to be walking around normally and living their life successfully could probably be much more in our control. In fact they could be much more dangerous than subjects with mental illness.

We must realize that every bad thing that happens to His children is a good thing-gone wrong. For example when a man works hard in his business, he is doing what our enemy intended him to do i.e. to provide for his family and share with others. This good can be made to be bad when he works hard to make more and more money to the point of neglecting his family. It can be made to be bad in another way, when he earns for his family only and does not give out to anybody else. I am sure you have been using these distraction tactics to deviate our Enemy’s children.

Basically evil is qualitatively only slightly different from what is good. It is at times quantitatively only a changed proportion. Now why do I say this, we cannot take credit for the evil in the world too. We have not created it from anything. Evil is only the deviation from what our enemy meant in this world. We love it though.

If a person takes cocaine, he will get a high. Cocaine works in his brain and alters the chemicals in different areas. If a person takes Diazepam, he will get sleep, as Diazepam acts on certain areas in the brain which induce sleep. Did you or I create these substances? No! Can you or I control that effect? No! It is bound to happen in a world created by our enemy. In fact all of the day to day functions are regulated by chemicals in the body.

Our enemy has created certain chemicals, when present in right quantities make subjects happy. If these are not present in right quantities or if their proportions deviate then the subject loses his happiness and become depressed. If this is severe he may become suicidal and may even end his life. We love imbalance. We want his subjects to die if they are depressed. We can rejoice in death of a human subject, but we do not earn points. What extra have we done? It may be more like a person with cardiac failure dying with a cardiac arrest. Would I give you any points for it? Absolutely not!

These guys with mental illness lose capacity. Even the earthly Courts of Law give them some immunity by considering them not criminally responsible if they were to do a murder under specific circumstances. Our Enemy loves them much more. How much more he would be gracious towards these mentally ill on the day of judgment!  These people might get away with much of what they do due to their illness. Remember to not take credit for what bad happens to them and do not feel happy when they do something bad.

Mind is a good playground for us to demonstrate our skills. You and I cannot know exactly what our subjects are thinking in their mind, but we can input thoughts in their mind. I am not speaking of the thought insertion seen in what the humans call Schizophrenia or the intrusive thoughts seen in what they call Obsessive Compulsive Disorder. These phenomena as I said earlier are not out doing. If I hear of you take any credit for this kind of phenomena seen in your assigned subjects, you would be demoted in the hierarchy of Hell.

What you would be given credit for is, when you can instill a normal human with automatic negative thoughts. By this you trigger a volley of negative thoughts. These affect the subject’s mood making him anxious, angry, bitter or depressed. I agree that this is more pronounced when he is mentally ill. You would get no points for that. You would score if you use this on normal people, happy people, loving people, and obedient people and successfully make them lose contact with what our enemy intended them to keep in touch with, by painting a darker picture of reality even if it lasts for a short while. I would be happy if you could do this long enough to make thought patterns freeze. They should ultimately submit and react to thoughts that arise in the minds without questioning it rationally. This would ensure the subject’s drift away from the Enemy.

By the way I liked your letters to Wormwood. I have asked new recruits and slow learners to read the letters to improve their performance. Wishing you all the very best in accomplishing our task.

Hail Me!

Your Father below,

Satan

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Posted in christian, depression, fiction, humour, OCD, philosophy, psychiatry, religion, schizophrenia, science, spiritual, stigma | Tagged: , , , , , , , , | 15 Comments »

The Cultures of Depression

Posted by Dheeraj Kattula on October 21, 2009

Here is an article written by my teacher Prof KS Jacob. It is a well articulated argument for need for a wider perspective on depressive illness.This article appeared in newspaper “The Hindu” on the 18th of October 2009.Here is the link and the article follows:-

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Diverse models of depression have been proposed and debated. Much of the confusion that exists in this area is because of disputes about the nature of mental illness. The confusion is compounded by the fact that core depressive symptoms, such as sadness and feelings of hopelessness and helplessness, are also found in medical diseases, as reactions to stress and as part of normal mood.

Medical model: The medical model considers psychiatric disorders as diseases, supposes brain pathology, documents signs and symptoms and recommends treatments. The disease halo reserved for the more severe forms of depression is also conferred on people with depressive symptoms secondary to stress and poor coping skills. The focus for diagnosis of depression centres on symptom counts without assessment of context, stress and coping skills. The provision of support by health professionals mandates the need for medical models, labels and treatments to justify their input. Insurance reimbursement also necessitates the use of disease labels. Consequently, psychiatric culture now tends to view all depression and distress through the disease/medical lens.

Perceptions in primary care: Patients visit general practitioners (GPs) when they are disturbed or distressed, when they are in pain or are worried about the implication of their symptoms. Bereavement, marital discord, inability to cope at work and financial problems also lead people to seek help from their doctors. In this context, the major challenge is to distinguish between distress and depression. Depression in patients encountered by GPs is often viewed as a result of personal and social stress, lifestyle choices or a product of habitual maladaptive patterns of behaviour. Consequently, GPs often subscribe to psychological and social models of depression.

Population perspectives: Social adversity is often seen as a cause of depression by the general population. Under such circumstances, people are reluctant to consult their GPs, counseling is the preferred treatment and antidepressants are viewed with suspicion by patients as they are considered addictive. Religious models are also popular. The general population seems to simultaneously hold multiple (and often contradictory) models of illness. They seek diverse treatments from assorted centres offering healing. The protracted course of depression secondary to chronic stress, lifestyle and poor coping results in people shopping for varied solutions.

Pharmaceutical approach: The pharmaceutical industry has espoused the cause of the medical model for depression. It has aided and abetted the medicalisation of personal and social distress to its advantage. Sponsoring educational activities and professional psychiatric and user meetings and conferences have helped shape medical and patient opinions. While pharmaceutical companies play a major role in the development and testing of new treatments firmly rooted in the medical model, in actual practice theirs is a culture driven by profit rather than by science.

Competing cultures: The medical model is defended by the powerful biological psychiatry movement within the specialty of psychiatry and by the pharmaceutical industry. But the other models and cultures of depression emphasising psychological and social issues are equally valid in the contexts of primary care and the community, but lack the academic clout and financial resources to present their points of view. The different ‘cultures of depression’ and the pressures from these divergent perspectives need to be acknowledged.

The issues which need to be re-examined include: (i) the heterogeneity of the concept of depression, (ii) the (in)adequacy of a single label of depression, relying solely on symptoms counts, to describe the diverse human context of distress, (iii) the need for clinical formulations which clearly state the context, personality factors, presence or absence of acute and chronic stress and extent of coping, (iv) the fact that antidepressant medication is not the solution to mild and moderate depression and should be reserved for severe forms of the condition, (v) re-emphasising the need to manage stress and alter coping strategies, using psychological treatment for people with such presentations, (vi) de-emphasising medicalisation of personal and social distress and, (vii) focusing on other underlying causes of human misery including poverty, unmet needs and lack of rights.

Clinical presentations: The syndrome of depression includes depressed mood, loss of pleasure in almost all activities, poor concentration, fatigue, medically unexplained symptoms, insomnia, guilt and suicidal ideation. Three categories of depression can be identified from a clinical and treatment point of view. The first, called adjustment disorder, is a normal reaction to acute and severe stress in people with a past record of good coping. The magnitude of the stress would temporarily destabilise many people with good coping strategies. By definition, the condition is time-limited and people usually settle back to normal lives within a few weeks or months. There is an absence of a family history of depression or suicide. The self-limiting nature of the condition means that support is all that is usually required and results in good outcome.

The second type of depression is characterised by its chronic nature (called dysthymia). Stressors, usually mild and multiple, precipitate, exacerbate and maintain the symptoms. The onset of such depression is usually in early adult life and such people usually have a long history of depressive symptoms. Their moods fluctuate and are usually responsive to changes in the environment. They also have a history of maladjustment and poor coping in response to past stress. The mainstay of treatment is psychological interventions which focus on improved coping, changes in personality, attitude, philosophy and life style.

The third category is called melancholia. In addition to the basic syndrome of depression, symptoms of melancholia include a pervasive depressed mood with minimal response to environmental change, global insomnia, early morning awakening with low mood worse in the mornings, significant loss of weight and restlessness, agitation or slowed movements. Melancholia usually occurs later in life and there may be a family history of similar depression or suicide. Such presentations may be also part of a bipolar disorder (manic depression), which has extreme mood swings, or may be due to medical, neurological and endocrine disease. The treatment of choice is antidepressant medication, management of the underlying medical causes and hospitalisation.

Management: Clinicians and psychiatrists managing patients with depression should be able to hold multiple models of depression. They should be able to appreciate the diverse cultures of depression and choose appropriate treatment strategies. Clinically, there is a need to look beyond symptoms and explore personality, situational difficulties and coping strategies in order to comprehensively evaluate biological vulnerability, personality factors and stress. The treatment package for such presentations should include psychological support, general stress reduction strategies (for example, yoga, meditation, physical exercise, leisure, hobbies) and problem-solving techniques (for example, cognitive therapy) for subjects presenting with ‘depression’. Antidepressant medication should be reserved for the severe forms of depression with hospitalisation and electroconvulsive therapy for those with high risk of harm to themselves and to others. People can present with a mixture of clinical presentations requiring a combination of approaches. A psychosocial formulation of the clinical presentation, background and context will put issues in perspective.

The progressive medicalisation of distress has lowered thresholds for the tolerance of mild symptoms and for seeking medical attention for such complaints. Patients visit physicians when they are disturbed or distressed. Grief at loss, frustration at failure, the apathy of disillusionment, the demoralisation of long suffering and the cynical outlook of pessimism usually resolve spontaneously without specific psychiatric intervention. Distress and emotions should not be mistaken for pathology; fear and apprehension should not be labeled as anxiety, or sadness as depression.

The failure of individual models and cultures to explain all aspects of depression seen in diverse settings has led to the development and use of multiple models, which argue for the need to accept the many perceptions as partial truths. These models should be viewed as complementary rather than competitive, with some being more valid in a specific context than others. Patients present to physicians with their illnesses while doctors diagnose and manage disease concepts. The failure to bridge the gap between disease and illness and healing and cure is a major cause for the contemporary confusion in the diagnosis and management of depression. There is a need for more pragmatic approaches which move beyond the specific models of depression and narrow ‘cultural’ perspectives.

( K.S. Jacob is Professor of Psychiatry at the Christian Medical College, Vellore.)

Posted in adjustment disorder, depression, Diagnosis, mood disorders, psychiatry, psychotherapy, religion, social, suicide | Tagged: , , , , , , , | 2 Comments »

Religion,Depression and Suicide:an Observation

Posted by Dheeraj Kattula on July 26, 2009

Kandhamal district of Orissa is stunningly beautiful. In the peak of winter there is a place here where it snows. It is surrounded by mountains and is covered with thick forests. The air is pleasantly cold. The canvas of it’s beauty was marred by violence that struck its heart in August 2008.You may read about what happened here.

It is sad that I have not seen Kandhamal in its best of times. I have been there on two occasions.Once it was as a Medical Officer from Red Cross to look into health issues in Nuagam Relief Camp in November 2008. Recently I went with a team of other doctors and conducted camps in four different sites in the district.

A carpenter looks for nails everywhere. I, a novice carpenter of the mind looked for stress related mental disorders. I expected to see PTSD, Severe Depression, Anxiety disorders, Insomnias, complicated grief and suicidal ideation. What else do we expect in a group of people who have lost all their assets and have no clue what the future had in store for them?

I was wrong.I did not find even one PTSD case in about 1000 consultations that I had in the Relief Camp. Of course people were concerned about their future and were sad about the persecution they faced,but they had enormous faith in their God,who they felt allows suffering but is in control. I found that they had tent prayers everyday.

Situations have changed. The situation now is not at all as bloody as it had been. There may be tensions. There may be animosity, but the situation is now in control.The Governments are trying their best. In this state of peace, I recently went to Kandhamal again.

In this visit I  saw about 250-300 patients. I did find people with depression. I found a couple of them quite severely depressed. When we mental health workers probe about very personal thoughts and behaviors, we usually ask open ended broad questions and slowly zero-into specific areas.

In case of depression,we usually enquire if the patient feels himself to be useless & worthless, then ask if he feels lonely and helpless, then ask if he thinks that things are going to improve in future. If he says yes to these then we tell him,”when life feels so difficult many people feel it is better to die,have you ever felt like that?” If patient says yes, then we ask regarding suicidal intent,which will have a bearing on how we would manage the patient by asking ” Have you ever felt like killing yourself?”

I have seen a many people in Tamil Nadu, easily consider the thought of killing themselves when overwhelmed with stress. In a study in Vellore,the average annual suicide rate was 95 per 100 000 for the years 1994-99. The rates in adolescent males and females and those over 55 years were 148, 58 and 189 per 100 000 respectively.(The British Journal of Psychiatry (2006) 188: 86.)

In Kandhamal I had a shock.I did not find even one person consider suicide despite overwhelming adverse life events and financial distress.Individual cases were depressed clinically, but they were not feeling ‘hopeless’.Many reflected their view to be like,”Yes I feel bad.I have nothing left.I do not know what I will happen tomorrow.I wish to go back to my village to start a new life.I hope they allow me to start again.I feel sad,but I know God is there.He has helped us till now.If it were not him,I would not be here today.He will continue to take care of me and my family.Why would I kill myself and hurt God?Things will improve.We are praying.”

The pattern forced me to think if indeed religion and faith protected people from suicide and mental illness in general. Why is it that I did not find a single case of PTSD in a relief camp after a spate of bloody violence?What makes them stronger than American war veterans from Vietnam!!?

Harold G Koenig’s review in Candian Journal of Psychiatry 2009;54(5): 283–291  concludes stating that “In general, studies of subjects in different settings (such as medical, psychiatric, and the general population), from different ethnic backgrounds (such as Caucasian, African American, Hispanic, and Native American), in different age groups (young, middle-aged, and elderly), and in different locations (such as the United States and Canada, Europe, and countries in the East) find that religious involvement is related to better coping with stress and less depression, suicide, anxiety, and substance abuse.”

Considering suicidality in specific, an article in Journal of Affective Disorders reports that its results suggest that religious attendance is associated with decreased suicide attempts in the general population and in those with a mental illness independent of the effects of social supports.

Indeed, research validates my observation that religion does help in coping stress and prevent mental illness and decrease suicidality.

References:

1.In the name of God.

(http://www.tehelka.comstory_main40.asp?filename=Ne130908CoverStory.asp)

2. Manoranjitham et al.Suicide in India.

(http://bjp.rcpsych.org/cgi/content/full/188/1/86)

3.Harold G.Koenig.Research on Religion, Spirituality, and Mental Health:
A Review

(http://publications.cpa-apc.org/media.php?mid=793&xwm=true)

4.Daniel T.Rasic et al.Spirituality,religion and suicidal behaviour in a nationally representative sample.

(http://www.jad-journal.com/article/S0165-0327(08)00344-3/abstract)

Posted in anxiety, depression, distress, grief, mood disorders, philosophy, psychiatry, religion, spiritual, substance abuse, suicide, Uncategorized | 3 Comments »

psychotherapy beyond boundaries

Posted by Dheeraj Kattula on April 28, 2009

He was allotted to me as I could speak Bengali. He was slow in his movements and in speech. He used words which I did not understand and spoke with a accent difficult for me to comprehend. I had many cases to see that day and I had reasons to feel irritated. I listened to him. He was depressed. He had seen psychiatrists in Europe, Bangladesh and in India. He had received many drugs from many people. He had lost hope in everything.

He should be admitted as an in-patient with the level of hopelessness and suicidal ideation. One cannot be admitted into the Mental Health Center, Vellore without a accompanying relative. So, If I wanted to help him I would have to treat him on an OP basis. I had many OP psychotherapy appointments and I had my hands full with full quota of IP patients too. I gave him a time slot for an afternoon session with him. That day I saw him sitting in front of my room right in the morning. He greeted me humbly, understanding my busyness, not expecting to be seen immediately.

I liked this guy’s commitment to therapy. I decided to give my my best. His visa was for 30 days and few days are already gone. I had to hurry. I squeezed in some time even during my duty days to see him on a regular basis. I remember I had a session with him between 9.00 and 10.00 pm! I struggled to communicate with him. He understood that I was struggling. He tried to be helpful ! I started him on a rapid modified Cognitive Behavioral Therapy (CBT). I failed miserably to even communicate what an automatic negative thought was. So I focused on behavioral issues.

His diagnosis was Dysthymia with Depression. We had also started him on an antidepressant called Imipramine. As he and I struggled together, I remember on one occasion I shouted so much at him that it was audible outside my consultation room. This was because he was nodding in that session as if he was understanding so as to not displease me! But to me the time was FULLY wasted, a reason to feel displeasure.

My therapy was primarily supportive, as my glorious plan of CBT failed. There were many issues he discussed with me. His anger over his brother, who had cheated him of all his savings for 5 years, his sexual problem after being married thinking marriage would lift him out of depression, his poor supports in Europe, treatment failures everywhere and many other things.

I was listening patiently. In a sense, buying time for the time tested Imipramine to work. He was on a pretty good dose of 175 mg.The time for his going was nearing. I took an opportunity to ask if it was possible for him to forgive his brother unilaterally. He said it was impossible. I prayed with him once. I gave him a exercise for my last session. He had to make a ‘mixture’ using puffed rice, onions, tomatoes, some sweets and boondi.

I will never forget the last meeting. He came in unexpected on a day I had to leave to another campus to see patients. Every minute with him would crunch my lunch time. The expression on his face made me skip lunch. I ate the ‘mixture’ he had bought. Told him that it was very good. I took him to my supervisor and told of his improvements. I wrote letters to the psychiatrists, who might have to follow him up. I gave my personal email ID and mobile number. This is usually not done in our set up. I did it as I felt he might not be able to send a email himself but if he ever required help I could offer it over telephone.

A year later I received a phone call from him. I was having my final PG exams. I could not give him much time. I told him ‘DO NOT STOP medicines. Show my letters to psychiatrists there and follow their advice.’ I had written long term treatment plans in the letter.

I received another call 6 months later. I was in Baripada. My Tamilnadu mobile is roaming. I use it for sms only. I picked it as it was an international call thinking it was my aunt calling. He told me that 6 months ago when he had cal led had  I told  him to follow up locally. They had changed the   medicine. The changed Imipramine to a newer drug. He slowly slipped into depression again. He had stopped work. He wanted to come, wherever I was for getting treated! I gave him my address.

Lo Behold ! In a month’s time he was in Baripada. He shocked our staff and our town people, who heard this. He got admitted. I restarted him on Imipramine. He improved in 2 weeks and went back. Last month he called from Europe. He told me that he is doing well and has also got a promotion. I congratulated him. I was happy for him and for myself too !

I was wondering what is it that has brought him from thousands of miles to get treated from a young psychiatrist like me? It would have lessons for me to learn and be consistent about. It was :-

1. Willingness to take up extra work despite a lot of busyness, if that is the only way another person can be helped.

2.Willingness to invest time and energy, without looking for rewards.

3.Looking at a person as a whole not as a label.

4.Being really committed to well being of a person, even if minor departure from protocol.

5.Using time tested medicines.

6.Being available.

It was not that the doctors, who saw him were incompetent. They could not give him hope at a personal level. To them he was a case, who was treatment resistant. To me he was MY patient who has problems. I do not deny that failures on his part would not have affected me, with this sort of an attachment, but at times it is that attachment only that holds a person who is sinking.

There was two things that he told me in this Baripada admission that I would never forget.

‘Sir, I have forgiven my brother fully. I hugged him and cried. My relationship with him has been restored, but this depression has not left me.’ He need not tell this as I had never pushed him to it. I had just suggested it. Traditionally psychiatry is neutral regarding forgiveness etc, but I sense some of those things matter a lot to people.

‘Sir, If you had not given me an appointment soon after you saw me to explain me the treatment plan and the time required to improve, I would have gone and slept  on a railway track in Vellore itself.’

I realize there are many opportunities which come our way to make a difference in people’s lives, if we are patient enough to respond.

May God give us such patience at all times.

Posted in depression, drug therapy, psychotherapy, suicide | 3 Comments »