ഹോമിയോപ്പതി
1 month ago
Wednesday, January 18, 2012
Sunday, June 21, 2009
I am reproducing another article by Dr K S Jacob from The Hindu dated 20th June. After reading this I have to ask myself "Are doctors promoting health in the community OR Are we just merchants selling health as a commodity ?". Please read on and give your comments
Public health and the clash of cultures
K.S. Jacob
The varied disciplines involved with public health, their divergent frameworks result in different agendas. The public-private partnerships are suggestive of collusion between the stakeholders and actors with the public health agenda hijacked by powerful private players.
Health is now a major priority on the international agenda and is an imperative for development. Despite advances in some developing countries, much still needs to be achieved in many nations.Determinants of health: The relationship between poverty and disease had long been acknowledged by public health reformers. Progressive groups within the movement advocated reform and enlisted many inputs — political, financial, social, cultural, engineering, science, educational, religious, and legal in addition to medical — to be part of efforts to improve the health of populations. The convergence of these disciplines is necessary for improvements in the health of populations. The public health perspective, thus, draws on a variety of disciplines. Consequently, it is not a discipline in the traditional sense.
The different context of public health: The public health movement in India relies on medical models with urgency-driven curative medical solutions which have always been short-term fixes and have resulted in the postponement of permanent public health solutions. The easy availability of antibiotics and medication in the developing world mean that provision of clean water, improvements in sanitation, nutrition and housing, all of which are basic public health approaches, is always on the back burner.
Varied language, framework and cultures: The complex situation has resulted in poor public health systems. The multiple disciplines with their diverse ideology, frameworks and language have muddied the waters and have made progress slow. The medical fraternity and the pharmaceutical industry advocate the biomedical model with its preference for curative treatments. Their language includes symptoms, signs, investigations, diagnosis, medicines and treatment. On the other hand, financial institutions argue for and insist on the capitalistic model, which reflect their own concerns rather than those of population health. They view issues through a different set of idioms including economics, capital, collaterals, loans, interest, repayment schedules and penalties. The social science perspectives, major determinants of health, are often not considered key issues in actual practice and are marginalized. Political leaderships, with their short-term needs, prefer an electoral languag! e and immediate gains, with their focus on retaining power and addressing specific constituencies. Civil servants concentrate on planning, budgets, targets and manpower.The West brought about improvements in population health by providing a minimum standard of living for its citizens and yet insists that India focuses on specific problems rather than in improving the general public health infrastructure. Similarly, many international banks and aid agencies focus on curative heath care and side-step the fact that even minimal improvements in the health of populations are determined by social and economic factors and prefer to support vertical health programmes for particular diseases. Nevertheless, the absence of basic public health measures will ensure the persistence and re-emergence of the very diseases targeted (e.g. malaria, polio and tuberculosis). Politics and finance trump public health every time.
Shared objectives and divergent agendas: While many disciplines have public health as a goal and share public health objectives, their diverse backgrounds and models clearly support their divergent agendas. Financial institutions support initiatives which are profitable. For example, the provision of clean water and sanitation are much less profitable for the various actors involved, compared to the provision of medicines and vaccines. Despite several recent key reports which emphasize the dramatic health (and economic) benefits that can be gained from improvements in water and sanitation, such targets receive low priority in funding. On the other hand, vaccines (e.g. Haemophilus influenza B), which target diseases with much lower prevalence and that have much less impact on the health of populations, receive generous support.
Ownership and ability to deliver: Poor public health standards are a result of major problems related to ownership of the public health goal. The rise of the biomedical viewpoint over the last century has given medicine a much larger role in improving the health of populations than to its ability to deliver. With its focus on biology and drugs, it is not in any position to bring about the public health revolution necessary to have a significant impact on population health whose main determinants are social and economic. The other disciplines necessary to achieve the public health transformation do not take the lead as they lack a sense of ownership of the public health goal. The powerful perceptions and models within the constituent disciplines make public health professionals peripheral players. Public health needs to be a socio-political mass movement if any significant degree of success is to be achieved.
Basis of public health policy: Social justice and an egalitarian society are the essence of public health. The evidence base for medicine and policy are often used selectively to support specific models and frameworks. For example, while evidence is used to defend the introduction of vaccines for disease prevention, it is not employed to argue for interventions which use clean water, sanitation and nutrition which have a much greater impact on the health of populations. Similarly, the estimation of the global burden of disease, on which much of the arguments for funding are based, is controversial and is much less valuable in for use in developing countries as it does not reflect regional priorities.
Health and public health as a human right: The poor health status of populations is related to chronic poverty working through hunger, undernutrition, illiteracy, unsafe drinking water, social discrimination, physical insecurity and political exclusion. The promotion of health, and consequently of social and economic rights of the poor in India, is the most important human rights struggle of our times. While the west continues to focus on human rights in developing countries, the developed world refuses to acknowledge that public health is also a basic right and support its fulfilment. In fact, the failure to meet the public health needs of populations has become normalised across India and on the international stage. However, governments and international agencies often prefer to confine the debate to the issue of resources for medical treatment, as a means of deflecting the debate from the true social and economic causes of ill-health. The public health vision for the 21st! century needs new policies based on a human rights perspective to address the challenges of health needs of populations.
Possible direction: There is a need to differentiate public health as a discipline, a goal, an agenda, and as practice. The abuse of power among the many public health stakeholders and actors and its relationship to their financial clout needs careful review. The current public-private partnerships in public health in developing countries are more suggestive of collusion between the stakeholders and actors with the public health agenda hijacked by the powerful private players. The conflicts of interest and differentials in power within groups working on public health initiatives and their different ideologies, agendas and tensions should be acknowledged.Public health should be located within society and politics rather than within medicine. The majority of the priority health conditions in India require public health solutions (e.g. water, sanitation, nutrition, housing, education, employment, social protection) rather than medical and pharmaceutical interventions. However, the mainstreaming and scaling up of efforts in these areas requires political commitment for inter-sectoral dialogue, an ethical framework which views public health as a human right and resource allocation which examine issues through the public health lens.There is a need for a people’s movement which champions public health issues as basic rights. The current supply-side and top-down approach to public health needs be replaced by a bottom-up approach with community mobilisation for meaningful changes to occur. The challenge is to integrate public health goals into the diverse disciplinary frameworks and models.(Professor K.S. Jacob is on the faculty of the Christian Medical College, Vellore. This article is based on his paper published in a recent issue of the Journal of Epidemiology and Community Health published by the BMJ group.)
Public health and the clash of cultures
K.S. Jacob
The varied disciplines involved with public health, their divergent frameworks result in different agendas. The public-private partnerships are suggestive of collusion between the stakeholders and actors with the public health agenda hijacked by powerful private players.
Health is now a major priority on the international agenda and is an imperative for development. Despite advances in some developing countries, much still needs to be achieved in many nations.Determinants of health: The relationship between poverty and disease had long been acknowledged by public health reformers. Progressive groups within the movement advocated reform and enlisted many inputs — political, financial, social, cultural, engineering, science, educational, religious, and legal in addition to medical — to be part of efforts to improve the health of populations. The convergence of these disciplines is necessary for improvements in the health of populations. The public health perspective, thus, draws on a variety of disciplines. Consequently, it is not a discipline in the traditional sense.
The different context of public health: The public health movement in India relies on medical models with urgency-driven curative medical solutions which have always been short-term fixes and have resulted in the postponement of permanent public health solutions. The easy availability of antibiotics and medication in the developing world mean that provision of clean water, improvements in sanitation, nutrition and housing, all of which are basic public health approaches, is always on the back burner.
Varied language, framework and cultures: The complex situation has resulted in poor public health systems. The multiple disciplines with their diverse ideology, frameworks and language have muddied the waters and have made progress slow. The medical fraternity and the pharmaceutical industry advocate the biomedical model with its preference for curative treatments. Their language includes symptoms, signs, investigations, diagnosis, medicines and treatment. On the other hand, financial institutions argue for and insist on the capitalistic model, which reflect their own concerns rather than those of population health. They view issues through a different set of idioms including economics, capital, collaterals, loans, interest, repayment schedules and penalties. The social science perspectives, major determinants of health, are often not considered key issues in actual practice and are marginalized. Political leaderships, with their short-term needs, prefer an electoral languag! e and immediate gains, with their focus on retaining power and addressing specific constituencies. Civil servants concentrate on planning, budgets, targets and manpower.The West brought about improvements in population health by providing a minimum standard of living for its citizens and yet insists that India focuses on specific problems rather than in improving the general public health infrastructure. Similarly, many international banks and aid agencies focus on curative heath care and side-step the fact that even minimal improvements in the health of populations are determined by social and economic factors and prefer to support vertical health programmes for particular diseases. Nevertheless, the absence of basic public health measures will ensure the persistence and re-emergence of the very diseases targeted (e.g. malaria, polio and tuberculosis). Politics and finance trump public health every time.
Shared objectives and divergent agendas: While many disciplines have public health as a goal and share public health objectives, their diverse backgrounds and models clearly support their divergent agendas. Financial institutions support initiatives which are profitable. For example, the provision of clean water and sanitation are much less profitable for the various actors involved, compared to the provision of medicines and vaccines. Despite several recent key reports which emphasize the dramatic health (and economic) benefits that can be gained from improvements in water and sanitation, such targets receive low priority in funding. On the other hand, vaccines (e.g. Haemophilus influenza B), which target diseases with much lower prevalence and that have much less impact on the health of populations, receive generous support.
Ownership and ability to deliver: Poor public health standards are a result of major problems related to ownership of the public health goal. The rise of the biomedical viewpoint over the last century has given medicine a much larger role in improving the health of populations than to its ability to deliver. With its focus on biology and drugs, it is not in any position to bring about the public health revolution necessary to have a significant impact on population health whose main determinants are social and economic. The other disciplines necessary to achieve the public health transformation do not take the lead as they lack a sense of ownership of the public health goal. The powerful perceptions and models within the constituent disciplines make public health professionals peripheral players. Public health needs to be a socio-political mass movement if any significant degree of success is to be achieved.
Basis of public health policy: Social justice and an egalitarian society are the essence of public health. The evidence base for medicine and policy are often used selectively to support specific models and frameworks. For example, while evidence is used to defend the introduction of vaccines for disease prevention, it is not employed to argue for interventions which use clean water, sanitation and nutrition which have a much greater impact on the health of populations. Similarly, the estimation of the global burden of disease, on which much of the arguments for funding are based, is controversial and is much less valuable in for use in developing countries as it does not reflect regional priorities.
Health and public health as a human right: The poor health status of populations is related to chronic poverty working through hunger, undernutrition, illiteracy, unsafe drinking water, social discrimination, physical insecurity and political exclusion. The promotion of health, and consequently of social and economic rights of the poor in India, is the most important human rights struggle of our times. While the west continues to focus on human rights in developing countries, the developed world refuses to acknowledge that public health is also a basic right and support its fulfilment. In fact, the failure to meet the public health needs of populations has become normalised across India and on the international stage. However, governments and international agencies often prefer to confine the debate to the issue of resources for medical treatment, as a means of deflecting the debate from the true social and economic causes of ill-health. The public health vision for the 21st! century needs new policies based on a human rights perspective to address the challenges of health needs of populations.
Possible direction: There is a need to differentiate public health as a discipline, a goal, an agenda, and as practice. The abuse of power among the many public health stakeholders and actors and its relationship to their financial clout needs careful review. The current public-private partnerships in public health in developing countries are more suggestive of collusion between the stakeholders and actors with the public health agenda hijacked by the powerful private players. The conflicts of interest and differentials in power within groups working on public health initiatives and their different ideologies, agendas and tensions should be acknowledged.Public health should be located within society and politics rather than within medicine. The majority of the priority health conditions in India require public health solutions (e.g. water, sanitation, nutrition, housing, education, employment, social protection) rather than medical and pharmaceutical interventions. However, the mainstreaming and scaling up of efforts in these areas requires political commitment for inter-sectoral dialogue, an ethical framework which views public health as a human right and resource allocation which examine issues through the public health lens.There is a need for a people’s movement which champions public health issues as basic rights. The current supply-side and top-down approach to public health needs be replaced by a bottom-up approach with community mobilisation for meaningful changes to occur. The challenge is to integrate public health goals into the diverse disciplinary frameworks and models.(Professor K.S. Jacob is on the faculty of the Christian Medical College, Vellore. This article is based on his paper published in a recent issue of the Journal of Epidemiology and Community Health published by the BMJ group.)
Tuesday, June 16, 2009
The story of Dr.Vasistha Narayan Singh -
The following story narrated by a fellow psychiatrist may remind us about John Nash - famous after 'A beautiful Mind'. Dr Singh is in many ways an Indian version of Nas, though his tale invokes much more sympathy in us.
Very few people know about Dr.Vasistha Narayan Singh, a world renowned mathematician and an ex-NASA scientist, who has been suffering from schizophrenia since 1976. The mathematician who challenged works of Great Scientist Albert Einstien.Coming from a very poor family, he is the record holder for Matriculation and Intermediate Science Exam. In mathematics conference he had presented a list of 5 most difficult problems. He solved all of them and that too in different ways. Prof Berkley got impressed and requested him to come to USA for further study. Singh did not let down HOD and did his PhD with style and went on to work for NASA. He had nationalistic dreams and thought of doing his India proud rather that stay on in US as his HOD and NASA wanted him to do.He married to an army officer's daughter. Due to reasons unknown, marriage did not work out and his wife left him and never come back. This left him heartbroken and made his condition worse.He returned to India and worked at ISI Cal, IIT Kanpur and TIFR Mumbai. He had a tough time at ISI Cal and was disillusioned at other places also.Soon after that, He lost his mental balance and was admitted to Mental Hospital, Kanke, Ranchi. Mental Authority threw him out of Kanke and his family did not have enough money to support his treatment which made his condition worst. He was treated by NIMHANS but details are not available. It appears that he fled from Merut Mental Hospital and was untraceable for many years until someone from his village saw him as a rag picker in Chapra. Relatives were happy to see him alive but were sad to see his misery.Dr Singh was in Patna (April 2004) to take part in a function organized in his honor by an institute run in his name. Singh looked ruffled, probably unable to catch the lavish praises that were hurled upon him by the speakers present on the occasion. At times, he gave the most loving smile, like a child. However, he looked distracted most of the time, probably lost in his world where there is no scope of anything except maths. He did not seem interested even when his biography was released by former VC.His love for maths was more than visible, even now, when he is said to be mentally challenged. Even while coming to Patna, he had not forgotten to carry with himself his prized possessions (maths books, diaries filled with mathematical theories and formulae etc). He had tied all this in a neat heap and occasionally looking at it.Once when the mike was given to him to say something, he spoke indecipherable words about some mathematical topic. But his sensitivity did not appear lost.Recently, the Bihar government has sent him to New Delhi for treatment (April 2009).John Nash (brilliant mathematician and noble prize winner whose story was portrayed in the movie A Beautiful Mind) made a recovery from the schizophrenia from which he had suffered since 1959 but Dr Singh did not. Why?Some factors supporting recovery in case of Nash could be beneficial to Dr Singh’s case.The relationships Nash had with fellow mathematicians were essential to his eventual recovery, but the single most important factor in Nash's recovery was the bond with his remarkable wife, Alicia. She fed, housed and cared for him even after she divorced him, and never wavered in her devotion to him or her belief in his extraordinary talent.In Nash's case, the Princeton campus functioned as a therapeutic community. His bizarre behavior was mostly tolerated, and he was granted access to lecture halls and libraries and offered human contact without being forced to make it. As his schizophrenia receded, Nash participated in seminars and made friends with a few graduate students. Later he was given unrestricted access to a computer, which he taught himself to use, and began writing intricate programs. A reluctance to give up -- or to accept a prognosis of doom -- can be seen in Nash's story.http://timesofindia .indiatimes. com/articleshow/ 597829.cmshttp://in.answers. yahoo.com/ question/ index?qid= 20090120030204AA xvcnURegardsD N Mendhekar (09868 900 900)Pratap Nagar Metro Pillar 129, Delhi-7
Very few people know about Dr.Vasistha Narayan Singh, a world renowned mathematician and an ex-NASA scientist, who has been suffering from schizophrenia since 1976. The mathematician who challenged works of Great Scientist Albert Einstien.Coming from a very poor family, he is the record holder for Matriculation and Intermediate Science Exam. In mathematics conference he had presented a list of 5 most difficult problems. He solved all of them and that too in different ways. Prof Berkley got impressed and requested him to come to USA for further study. Singh did not let down HOD and did his PhD with style and went on to work for NASA. He had nationalistic dreams and thought of doing his India proud rather that stay on in US as his HOD and NASA wanted him to do.He married to an army officer's daughter. Due to reasons unknown, marriage did not work out and his wife left him and never come back. This left him heartbroken and made his condition worse.He returned to India and worked at ISI Cal, IIT Kanpur and TIFR Mumbai. He had a tough time at ISI Cal and was disillusioned at other places also.Soon after that, He lost his mental balance and was admitted to Mental Hospital, Kanke, Ranchi. Mental Authority threw him out of Kanke and his family did not have enough money to support his treatment which made his condition worst. He was treated by NIMHANS but details are not available. It appears that he fled from Merut Mental Hospital and was untraceable for many years until someone from his village saw him as a rag picker in Chapra. Relatives were happy to see him alive but were sad to see his misery.Dr Singh was in Patna (April 2004) to take part in a function organized in his honor by an institute run in his name. Singh looked ruffled, probably unable to catch the lavish praises that were hurled upon him by the speakers present on the occasion. At times, he gave the most loving smile, like a child. However, he looked distracted most of the time, probably lost in his world where there is no scope of anything except maths. He did not seem interested even when his biography was released by former VC.His love for maths was more than visible, even now, when he is said to be mentally challenged. Even while coming to Patna, he had not forgotten to carry with himself his prized possessions (maths books, diaries filled with mathematical theories and formulae etc). He had tied all this in a neat heap and occasionally looking at it.Once when the mike was given to him to say something, he spoke indecipherable words about some mathematical topic. But his sensitivity did not appear lost.Recently, the Bihar government has sent him to New Delhi for treatment (April 2009).John Nash (brilliant mathematician and noble prize winner whose story was portrayed in the movie A Beautiful Mind) made a recovery from the schizophrenia from which he had suffered since 1959 but Dr Singh did not. Why?Some factors supporting recovery in case of Nash could be beneficial to Dr Singh’s case.The relationships Nash had with fellow mathematicians were essential to his eventual recovery, but the single most important factor in Nash's recovery was the bond with his remarkable wife, Alicia. She fed, housed and cared for him even after she divorced him, and never wavered in her devotion to him or her belief in his extraordinary talent.In Nash's case, the Princeton campus functioned as a therapeutic community. His bizarre behavior was mostly tolerated, and he was granted access to lecture halls and libraries and offered human contact without being forced to make it. As his schizophrenia receded, Nash participated in seminars and made friends with a few graduate students. Later he was given unrestricted access to a computer, which he taught himself to use, and began writing intricate programs. A reluctance to give up -- or to accept a prognosis of doom -- can be seen in Nash's story.http://timesofindia .indiatimes. com/articleshow/ 597829.cmshttp://in.answers. yahoo.com/ question/ index?qid= 20090120030204AA xvcnURegardsD N Mendhekar (09868 900 900)Pratap Nagar Metro Pillar 129, Delhi-7
An article on Psychiatry during medievel Islam period
From the fifth century AD until the past century, Galen's theory about the four humours ruled medicine. Its corollary was that the treatment of disease involved getting the humours back in order; releasing them through bloodletting was the most common procedure, often augmented by other means of freeing bodily fluids (e.g. purgatives and laxatives). For 14 centuries, physicians subscribed to this wondrous biological theory of disease: they bled their patients until they lost their entire blood supply; they forced them to puke and defecate and urinate; they alternated extremely hot showers with extremely frigid ones – all in the name of normalizing those humours . Yet, it all proved to be wrong.Most medieval Christian physicians believed that mental illness was caused by either demonic possession or as punishment from a god, which led to a negative attitude towards mental illness. On the other hand, Islamic ethics and theology held a more sympathetic attitude towards the mentally ill. Muslim physicians relied mostly on clinical observations. The first psychiatric hospitals were built in the medieval Islamic world from the 8th century. The first was built in Baghdad in 705, followed by Fes in the early 8th century, and Cairo in 800. They were the first to provide psychotherapy and moral treatment for mentally ill patients, in addition to other forms of treatment such as baths, drug medication, music therapy and occupational therapy. Such institutions could not exist in Europe at the time, because of European fears of demonic possession. The Persian physician Muhammad ibn Zakarīya Rāzi (Rhazes) (865-925) wrote the landmark texts El-Mansuri and Al-Hawi in the 10th century, which presented definitions, symptoms, and treatments combined psychological methods and physiological explanations to provide treatment to mentally ill patients. Avicenna (980-1037) was an early pioneer of neuropsychiatry, and first to described a number of neuropsychiatric conditions such as hallucination, insomnia, mania, nightmare, melancholia, dementia, epilepsy, paralysis, stroke, vertigo and tremor. Avicenna identified LOVE SICKNESS (Ishq) when he was treating a very ill patient by "feeling the patient's pulse and reciting aloud to him the names of provinces, districts, towns, streets, and people." He noticed how the patient's pulse increased when certain names were mentioned, from which Avicenna deduced that the patient was in love with a girl whose home Avicenna was "able to locate by the digital examination. " Avicenna advised the patient to marry the girl he is in love with, and the patient soon recovered from his illness after his marriage. Avicenna also gave psychological explanations for certain somatic illnesses, and he always linked the physical and psychological illnesses together.Al-Kindi (801–873) was the first to realize the therapeutic value of music. He was the first to experiment with music therapy, and he attempted to cure a quadriplegic boy using this method.Later in the 9th century, al-Farabi also dealt with music therapy in his treatise Meanings of the Intellect, where he discussed the therapeutic effects of music on the soul.Ali ibn Sahl Rabban al-Tabari's Firdous al-Hikmah written in the 9th century was the first work to study 'al-‘ilaj al-nafs (translated as "psychotherapy" from Arabic) in the treatment of patients. His ideas were primarily influenced by early Islamic thought and ancient Indian physicians such as SUSHRUTA and CHARAKA.The Muslim physician Abu Zayd Ahmed ibn Sahl al-Balkhi (850-934) was a pioneer of al-‘ilaj al-nafs, and the first to compare "physical and psychological disorders" and show "their interaction in causing psychosomatic disorders.
http://en.wikipedia .org/wiki/ Islamic_psycholo gyHaque, Amber (2004), "Psychology from Islamic Perspective: Contributions of Early Muslim Scholars and Challenges to Contemporary Muslim Psychologists" , Journal of Religion and Health 43 (4): 357-377.
http://en.wikipedia .org/wiki/ Islamic_psycholo gyHaque, Amber (2004), "Psychology from Islamic Perspective: Contributions of Early Muslim Scholars and Challenges to Contemporary Muslim Psychologists" , Journal of Religion and Health 43 (4): 357-377.
Monday, June 15, 2009
Health, ilness and disease Who is to decide (2)
This is in response to the article 'Bridging the disease-illness divide in medicine' by Dr K S Jacob.(Please see the previous post). The article raises an issue which occasionally confronts many doctors. Patients present to clinicians with various complaints which worry them. Usually they have a real disease which is detectable by objective methods. Sometimes it may be just a doubt whether the symptom has an ominous significance or not. At other times it may be just to seek reassurance that their symptom is of benign nature . Many patients also tend to express emotional distress in the form of bodily complaints. The job of the doctor is to evaluate the symptom and explain the nature of it to the patient in simple layman's language. If it needs some form of medical /physical /psychological treatment he is authorized to administer this by way of his training and license to practice. He may also refer the patient for further evaluation by special tests or by a specialist with better expertise. In the words of Sir William Osler the duty of the doctor is "To cure sometimes, to relieve often and to comfort always". These words still continue to be true, despite all the technological advances in curative medicine, as we are able to offer cure for only a minority of real diseases. When the venue of practice shifts to huge hospitals with profit motive, the priorities change. This escalates the costs of treatment and sometimes leads to iatrogenic complications. Kickbacks from the pharma and lab industry further complicate the situation.The medical training offered to a doctor does not make him always competent to develop the skills needed to evaluate and handle patients without any objective evidence of disease. He is trained to become a practitioner with a license to practise his profession and earn a livelihood out of it. He thinks his duty is to prescribe a pill for every ill that he comes across. Otherwise he may not get paid for his service. The time spend for educating the patient about his own body / health etc is considered a waste. There also time constraints because of huge patient load. He is not given adequate exposure in handling emotional problems or counseling regarding behavioral problems. When the venue of practice shifts to huge hospitals with profit motive, the priorities change. This escalates the costs of treatment and sometimes leads to iatrogenic complications. Kickbacks from the pharma and lab industry further complicate the situation. The whole system of giving medical training has to be revamped for this situation to change. The doctors should be trained to view themselves as counselors and educators of the public on matters relating to health and disease. There should be provision for getting timely, accurate information on one's condition and the remedies available. The system of fixing pay of doctors based on the revenue generated by them will also have to go. Many private / corporate hospitals use this method of paying doctors. Patients with subjective distress / discomfort in the absence of objective signs of disease have to be evaluated by a competent physician with adequate experience and training in bio medicine and psychosocial approaches. Majority of such patients are exploited by quacks, demigods and even by unscrupulous doctors. A recent addition to this group of exploiters are the self proclaimed nutrition and wellness therapists. They charge huge amounts and provide sham therapies which have no proven efficacy. Because these are delivered in posh, luxurious ambience by 'therapists' with good soft skills, the recipient is unaware that he is being duped.
Health, illness and disease - Who is to decide?
The following is an article from The Hindu dated 12th June 2009.
Bridging the disease-illness divide in medicine
K.S. Jacob
The failure to address issues related to the disease-illness dichotomy and the cure-healing divide and to bridge the gap between these part-perceptions is a major cause of patient dissatisfaction.
The increased cost of health care and the urban-centric nature of our health delivery system make it unaffordable and inaccessible to the majority of Indians. The health-hospital, pharmaceutical and medical education industries, which profit from disease and illness, also complicate the situation. These factors have resulted in dissatisfaction with quality of health care for the vast majority of the population and a crisis in health care in India. The problematic conceptualisation of disease and illness which underpins many of these issues is highlighted.
The disease-illness distinction: Disease and illness are commonly used as synonyms and clearly highlight the lack of conceptual clarity. Medical definitions of disease emphasize the pathological process and the deviation from the biological norm. Diseases are pathological entities conceptualised by physicians who offer scientific causal explanations and prescribe treatments with the aim to cure. Illness, on the other hand, is the patient’s experience of ill health, is influenced by culture and focuses on the relief of suffering.While there is an overlap between disease and illness, the divide persists because of the absence of a one-to-one relationship between disease and illness. Similar degrees of pathology generate different amounts of pain and distress. The course of a disease can be different from the trajectory of an illness. In addition, illness can also occur in the absence of disease (for example, medically unexplained physical symptoms causing distress). These result in differences in perspectives about the condition between doctors and their patients.
Modern medicine in perspective: Recent advances in medicine have made curative treatments an attractive option. However, modern medicine has limitations including its narrow focus in making disease more important and interesting than illness and a single-minded pursuit of cure. Physicians often disregard the patient’s interpretation and explanations and discount the human context of illness.Physicians are taught to focus on underlying structural and functional defects and often tend to ignore the impact of the illness on the patient’s life. Partial understanding of conditions (e.g. hypertension), or occasionally complete ignorance (e.g. myalgia, somatisation disorder), results in symptomatic treatment. However, the ubiquitous use of medical jargon suggests that the scientific halo, reserved for the few conditions which we now comprehend reasonably well, is indiscriminately applied to all forms of human distress.Such a divergent focus results in dissonance between doctors and their patients. While doctors highlight naturalistic explanations for a disease (such as abnormality, degeneration, infection, malignant change), patients focus on personalistic beliefs about causation (such as beliefs in karma, sin, punishment, evil spirits, black magic, supernatural explanations). Many patients seem to simultaneously hold naturalistic explanations about disease as well as personalistic perspectives on illness, despite the apparent contradictions. Patients and their relatives also concurrently seek diverse interventions—medical and non-medical. Hospitals which practise modern medicine compete with facilities which offer faith healing and traditional systems of medicine. People with illness who fail to respond to traditional methods of healing visit allopathic centres with reasonable success and vice versa.Diverse systems of medicine and healing flourish in India. While significant technological advances have had a major impact on the health of individuals, many other issues also seem to define health and disease. Financial gain for doctors and hospitals, niche markets for the pharmaceutical industry, insurance reimbursements and opportunities for academics also influence disease categorisation. While there has been much progress, many so-called advances are illusions. Many new disease categories are introduced without adequate scientific evidence. Re-categorisation of existing entities without adequate basis is also common. In addition, expensive new drugs with no real improvement in efficacy give an impression of superior solutions. Although medical advances have resulted in significant improvement in the health of individuals, many indices of the health of populations suggest major unsolved problems (such as malnutrition, shorter life span, infant and maternal mortality ass! ociated with the poorer sections of Indian society).
The success of traditional and folk medicine: Traditional and folk systems of medicine, despite their lack of scientific rigor, continue to enjoy the confidence of the general population. Their success can be attributed to their focus on the illness experience. Their practitioners seem to successfully elicit, offer and negotiate explanations and expectations with their patients. Traditional healers share symbols and metaphors consistent with lay beliefs and their healing rituals are more in tune with the psychosocial context of illness.
The need for a new conceptualisation: Doctors can learn many lessons from traditional healers and indigenous medicine. These include the fact that many patients suffer from no/minor disease. They need to understand that the illness experience dominates patient reality. Consequently, physicians need to appreciate that the sole focus on disease and cure undermines illness experience and the need for healing.While traditional healers are effective in treating illness, they may less frequently influence the course of the disease. On the other hand, modern medicine and physicians can potentially treat both illness and disease. Doctors need to elicit patient perspectives about the illness, its impact on their life and their expectations. They should present biomedical perspectives as an alternate reality without claiming exclusivity. They must negotiate a treatment plan keeping cultural issues in mind. Health care is often less than satisfactory and treatment less effective when only disease is treated rather than when both disease and illness are managed together. Poor compliance, poor clinical care and medico-legal problems are often due to discrepancies between patients’ and doctors’ views of clinical reality.Many problems presenting to doctors are now viewed from a specialist 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 general practitioners and physicians when they are disturbed or distressed, when they are in pain or are worried about the implication of their symptoms. However, the provision of support currently mandates the need for medical models, labels and treatments to justify medical input.The divergent frameworks employed to view the clinical reality of disease or illness artificially forces the divide. There is a need to view disease-illness issues through alternating medical and patient lenses in order to see the full picture. Both the disease and illness perspectives are partial truths and need to be managed simultaneously for cure and/ or for healing. Rapid alternation between the two frameworks and perspectives will result in the delivery of holistic care.Doctors need to accept multiple approaches to restoring health and should encourage the use of diverse strategies to restore health and improve functioning. The disease-cure and the illness-healing models are part-perceptions of the whole and result in a gap in communication between doctors and their patients. This seems to be made worse by medical technology widening the gap between what patients seek and what doctors provide, causing dissatisfaction. Good doctors know the difference between disease, illness, healing and cure. They also know how to manage them.(Professor K.S. Jacob is on the faculty of the Christian Medical College, Vellore.)
Bridging the disease-illness divide in medicine
K.S. Jacob
The failure to address issues related to the disease-illness dichotomy and the cure-healing divide and to bridge the gap between these part-perceptions is a major cause of patient dissatisfaction.
The increased cost of health care and the urban-centric nature of our health delivery system make it unaffordable and inaccessible to the majority of Indians. The health-hospital, pharmaceutical and medical education industries, which profit from disease and illness, also complicate the situation. These factors have resulted in dissatisfaction with quality of health care for the vast majority of the population and a crisis in health care in India. The problematic conceptualisation of disease and illness which underpins many of these issues is highlighted.
The disease-illness distinction: Disease and illness are commonly used as synonyms and clearly highlight the lack of conceptual clarity. Medical definitions of disease emphasize the pathological process and the deviation from the biological norm. Diseases are pathological entities conceptualised by physicians who offer scientific causal explanations and prescribe treatments with the aim to cure. Illness, on the other hand, is the patient’s experience of ill health, is influenced by culture and focuses on the relief of suffering.While there is an overlap between disease and illness, the divide persists because of the absence of a one-to-one relationship between disease and illness. Similar degrees of pathology generate different amounts of pain and distress. The course of a disease can be different from the trajectory of an illness. In addition, illness can also occur in the absence of disease (for example, medically unexplained physical symptoms causing distress). These result in differences in perspectives about the condition between doctors and their patients.
Modern medicine in perspective: Recent advances in medicine have made curative treatments an attractive option. However, modern medicine has limitations including its narrow focus in making disease more important and interesting than illness and a single-minded pursuit of cure. Physicians often disregard the patient’s interpretation and explanations and discount the human context of illness.Physicians are taught to focus on underlying structural and functional defects and often tend to ignore the impact of the illness on the patient’s life. Partial understanding of conditions (e.g. hypertension), or occasionally complete ignorance (e.g. myalgia, somatisation disorder), results in symptomatic treatment. However, the ubiquitous use of medical jargon suggests that the scientific halo, reserved for the few conditions which we now comprehend reasonably well, is indiscriminately applied to all forms of human distress.Such a divergent focus results in dissonance between doctors and their patients. While doctors highlight naturalistic explanations for a disease (such as abnormality, degeneration, infection, malignant change), patients focus on personalistic beliefs about causation (such as beliefs in karma, sin, punishment, evil spirits, black magic, supernatural explanations). Many patients seem to simultaneously hold naturalistic explanations about disease as well as personalistic perspectives on illness, despite the apparent contradictions. Patients and their relatives also concurrently seek diverse interventions—medical and non-medical. Hospitals which practise modern medicine compete with facilities which offer faith healing and traditional systems of medicine. People with illness who fail to respond to traditional methods of healing visit allopathic centres with reasonable success and vice versa.Diverse systems of medicine and healing flourish in India. While significant technological advances have had a major impact on the health of individuals, many other issues also seem to define health and disease. Financial gain for doctors and hospitals, niche markets for the pharmaceutical industry, insurance reimbursements and opportunities for academics also influence disease categorisation. While there has been much progress, many so-called advances are illusions. Many new disease categories are introduced without adequate scientific evidence. Re-categorisation of existing entities without adequate basis is also common. In addition, expensive new drugs with no real improvement in efficacy give an impression of superior solutions. Although medical advances have resulted in significant improvement in the health of individuals, many indices of the health of populations suggest major unsolved problems (such as malnutrition, shorter life span, infant and maternal mortality ass! ociated with the poorer sections of Indian society).
The success of traditional and folk medicine: Traditional and folk systems of medicine, despite their lack of scientific rigor, continue to enjoy the confidence of the general population. Their success can be attributed to their focus on the illness experience. Their practitioners seem to successfully elicit, offer and negotiate explanations and expectations with their patients. Traditional healers share symbols and metaphors consistent with lay beliefs and their healing rituals are more in tune with the psychosocial context of illness.
The need for a new conceptualisation: Doctors can learn many lessons from traditional healers and indigenous medicine. These include the fact that many patients suffer from no/minor disease. They need to understand that the illness experience dominates patient reality. Consequently, physicians need to appreciate that the sole focus on disease and cure undermines illness experience and the need for healing.While traditional healers are effective in treating illness, they may less frequently influence the course of the disease. On the other hand, modern medicine and physicians can potentially treat both illness and disease. Doctors need to elicit patient perspectives about the illness, its impact on their life and their expectations. They should present biomedical perspectives as an alternate reality without claiming exclusivity. They must negotiate a treatment plan keeping cultural issues in mind. Health care is often less than satisfactory and treatment less effective when only disease is treated rather than when both disease and illness are managed together. Poor compliance, poor clinical care and medico-legal problems are often due to discrepancies between patients’ and doctors’ views of clinical reality.Many problems presenting to doctors are now viewed from a specialist 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 general practitioners and physicians when they are disturbed or distressed, when they are in pain or are worried about the implication of their symptoms. However, the provision of support currently mandates the need for medical models, labels and treatments to justify medical input.The divergent frameworks employed to view the clinical reality of disease or illness artificially forces the divide. There is a need to view disease-illness issues through alternating medical and patient lenses in order to see the full picture. Both the disease and illness perspectives are partial truths and need to be managed simultaneously for cure and/ or for healing. Rapid alternation between the two frameworks and perspectives will result in the delivery of holistic care.Doctors need to accept multiple approaches to restoring health and should encourage the use of diverse strategies to restore health and improve functioning. The disease-cure and the illness-healing models are part-perceptions of the whole and result in a gap in communication between doctors and their patients. This seems to be made worse by medical technology widening the gap between what patients seek and what doctors provide, causing dissatisfaction. Good doctors know the difference between disease, illness, healing and cure. They also know how to manage them.(Professor K.S. Jacob is on the faculty of the Christian Medical College, Vellore.)
Tuesday, December 23, 2008
Here is something on your personality type and the music you like
Music exists in different types and forms. We are also of different types. Is there any correlation between our personality type and the kind of music we like? There have been many speculations on this, but very few empirical studies. Here is a study which I came across. But there is a caveat. Do not take it too seriously.
http://www.scribd.com/doc/5573359/Music-tastes-link-to-personality-Press-release
Saturday, November 29, 2008
What motivates the suicide squads?
Hi readers,
Manu has asked "What motivates a terrorist ?" in response to one of my earlier posts. In fact most of us would be having the same thought in our minds, post the recent events in Mumbai. Why do they do this?
Recently there has been reports of youth from even the southern most state of India - Kerala, where nobody speaks Hindi, leave alone Urdu - being recruited for terrorist activities in Kashmir. Most of these were either unemployed youth desperate to get a job or people with past criminal record who came into contact with the recruiting agents. Money would be a very powerful factor to lure such people. Obviously, there is huge money involved in this business. It is not fully convincing to think that Pakistan alone is behind all this. Can the government of a poor nation like Pakistan alone fund such large scale activities? May be, Pakistan is only a transit point in the whole affair. Funding may be being done outside that country by some agency with real money power. Revealing the whole truth needs concerted efforts of all nations. Such issues are not my subject in any case.
Mental health professionals will be more interested in uncovering the factors motivating one to join the ranks of such outifts involved in inhuman activities. It is very difficult to think that a pious person -of any faith - will involve in such activities.
I am quoting from an email send to the e-group of psychiatrists by Dr Abhay Matkar practising psychiatrist at Hubli, Karnataka. He describes findings from his study by interviewing some militants captured by army from Kashmir.
Dr. Matkar writes...."I am reminded of the study which was conducted by me & few others to know the psychodynamics of militancy.I pen down a few thoughts picked during the study on over 500 militants captured by the Indian army: Economic deprivation & deep sense of hurt(alienation) was the major cause of militancy in Kashmir.Coercion was the next major cause to take up to arms.Contrary to the popular belief,religion was not the primary motivational factor for Kashmir militants. What was striking was the strong motivation to sacrifice oneself for Jihad--the holy war.The indoctrination of ethnic & religious identity,political insecurity &deep sense of personal deprivation entrapped the virgin mind into taking to the 'gun culture'.The weak ego,a low self esteem & low frustration made matters worse. Militants seen by me showed no warmth in their relationship with family members nor a keen desire to be reunited with their dear ones.Three-fourths of these are between 15 to 30 years of age;most of them school dropouts.A significant youngsters had painfully tattooed the organisation they belonged to. Militants showed no personal involvement; killing was dehumanised- the victim was faceless,unknown to him.Often the militant was ordered or nominated to carry out the killing-killing was institutionalised. Suicide for a cause was rational & was called martyrdom. A group seen by me reacted with pride when chosen for a 'mission'.Those not selected reacted with bitter & sometimes hysterical resentment.The chosen ones were given a 'dining out' by the Commander.The farewell speech super-charged them mentally. These militants could not be categorised as "fanatics" or "mad men","psychopaths" or "mentally abnormal".They are normal people with a different psycho-logic of their own. It pains to see that time has not removed the veil of cruelty.Political answers are far from soothing. A real introspection & EARLY INTERVENTION are the only way we can have a safe tomorrow. LETS RISE.Regards. Abhay Matkar Hubli"
I am posting this for wider circulation among mental health professionals, other experts, social / political leaders and the public. Comments are welcome.
Bye
Dr Harish M Tharayil
Tuesday, November 25, 2008
Sleep and your mood.
As said earlier mood disorders are closely associated with sleep disturbances.
What is the relationship between sleep and mood?
Studies have shown that transient sleep deprivation can lead to an elevation of mood. A depressed person feels much better after overnight sleep deprivation.
Sleep deprivation can increase the risk of precipitating an attack of mania in a person predisposed to Bipolar disorder. Many persons develop their first manic episodes during festival seasons. They go to the temple yards to watch the late night celebration and fireworks. This is repeated frequently as most of the festivals are clustered in the same period. The resultant sleep deprivation triggers a manic episode.
Another condition that can be worsened by sleep deprivation is epilepsy. Sleep deprivation can precipitate an attack of seizure in a person predispose to it or in whom the disease is under control using drugs.
What is the relationship between sleep and mood?
Studies have shown that transient sleep deprivation can lead to an elevation of mood. A depressed person feels much better after overnight sleep deprivation.
Sleep deprivation can increase the risk of precipitating an attack of mania in a person predisposed to Bipolar disorder. Many persons develop their first manic episodes during festival seasons. They go to the temple yards to watch the late night celebration and fireworks. This is repeated frequently as most of the festivals are clustered in the same period. The resultant sleep deprivation triggers a manic episode.
Another condition that can be worsened by sleep deprivation is epilepsy. Sleep deprivation can precipitate an attack of seizure in a person predispose to it or in whom the disease is under control using drugs.
Management of sleep problems.
Non pharmacological treatment of insomnia
1) Maintain regular hours for going to bed and waking up. Try to wake up at a fixed time every day, even if you find it difficult to fall asleep at a fixed time. Even though you feel sleepy, do not sleep again. Within a few days the time of sleep onset advances to an earlier time.
2) Avoid heavy meals closer to bed time. Early dinner is better, especially if it is heavy.
3) Avoid day time naps.
4) Engage in some physical exercises. Avoid doing it or any other vigorous physical activity during late evenings.
5) Avoid tea, coffee and tobacco at least 6 hours prior to bed time.
6) Avoid bright light before sleep time. It is better for the bedroom to be dimly lit and slightly cool to promote sleep.
7) Clean up your mind before going to sleep. Avoid pondering over issues while lying on the bed. If you suddenly remember something urgent or important, jot it on a piece of paper to look into it next morning.
8) Avoid gazing at the clock repeatedly if you are lying in the bed awake. It is better to sit up and do something that is dull, boring and non stimulating.
9) If you find it difficult to get sleep even after 15 to 20 minutes in bed, get up and sit down. Get something that is not very stimulating or interesting to read. Read it sitting on a chair beside the bed using a reading lamp or in dim light. If you feel sleepy after sometime again try to sleep. Repeat this till you sleep.
10) If you feel tensed up while in bed, engage in deep, slow, abdominal (diaphragmatic) breathing. Take slow deep breaths ensuring that your abdomen lifts up with each breath. Avoid laboring with your chest. When the breath is fully in and your abdomen is protuberant, start slow exhalation by slowing tucking in the abdomen. Repeating this for a few minutes will make you feel relaxed. Thinking some positive thoughts or soothing imagery during this deep breathing may be helpful to some.
11) Use the bed exclusively for sex and sleeping. Avoid reading on the bed even during daytime.
12) Keep away from the tendency to use alcohol as a hypnotic.
These measures can be tried by any one who has difficulty to get sleep. There is no risk involved with any of this.
Insomnia can be transient or continuous.
Transient insomnia is due to mental tension or some minor problems. Continuous insomnia may be due to medical or psychiatric disorders.
Depression, anxiety, psychosis, substance abuse etc are the psychiatric illnesses leading to insomnia.
Using drugs for the treatment of insomnia is not always advocated. First of all the medical and psychiatric disorders have to be ruled out. Next an agent with minimum chances of abuse has to be selected which does not cause daytime sleepiness. Unfortunately, not many drugs are available which satisfies the above criteria. Hence it is better to consult a doctor for choosing a drug and for appropriate instructions.
1) Maintain regular hours for going to bed and waking up. Try to wake up at a fixed time every day, even if you find it difficult to fall asleep at a fixed time. Even though you feel sleepy, do not sleep again. Within a few days the time of sleep onset advances to an earlier time.
2) Avoid heavy meals closer to bed time. Early dinner is better, especially if it is heavy.
3) Avoid day time naps.
4) Engage in some physical exercises. Avoid doing it or any other vigorous physical activity during late evenings.
5) Avoid tea, coffee and tobacco at least 6 hours prior to bed time.
6) Avoid bright light before sleep time. It is better for the bedroom to be dimly lit and slightly cool to promote sleep.
7) Clean up your mind before going to sleep. Avoid pondering over issues while lying on the bed. If you suddenly remember something urgent or important, jot it on a piece of paper to look into it next morning.
8) Avoid gazing at the clock repeatedly if you are lying in the bed awake. It is better to sit up and do something that is dull, boring and non stimulating.
9) If you find it difficult to get sleep even after 15 to 20 minutes in bed, get up and sit down. Get something that is not very stimulating or interesting to read. Read it sitting on a chair beside the bed using a reading lamp or in dim light. If you feel sleepy after sometime again try to sleep. Repeat this till you sleep.
10) If you feel tensed up while in bed, engage in deep, slow, abdominal (diaphragmatic) breathing. Take slow deep breaths ensuring that your abdomen lifts up with each breath. Avoid laboring with your chest. When the breath is fully in and your abdomen is protuberant, start slow exhalation by slowing tucking in the abdomen. Repeating this for a few minutes will make you feel relaxed. Thinking some positive thoughts or soothing imagery during this deep breathing may be helpful to some.
11) Use the bed exclusively for sex and sleeping. Avoid reading on the bed even during daytime.
12) Keep away from the tendency to use alcohol as a hypnotic.
These measures can be tried by any one who has difficulty to get sleep. There is no risk involved with any of this.
Insomnia can be transient or continuous.
Transient insomnia is due to mental tension or some minor problems. Continuous insomnia may be due to medical or psychiatric disorders.
Depression, anxiety, psychosis, substance abuse etc are the psychiatric illnesses leading to insomnia.
Using drugs for the treatment of insomnia is not always advocated. First of all the medical and psychiatric disorders have to be ruled out. Next an agent with minimum chances of abuse has to be selected which does not cause daytime sleepiness. Unfortunately, not many drugs are available which satisfies the above criteria. Hence it is better to consult a doctor for choosing a drug and for appropriate instructions.
Some sleep problems....
Delayed sleep phase syndrome is a mismatch between a person’s sleep-wake cycle to that of the general population. Most of us sleep between 10 pm to 12 midnight and wake up between 5 am to 7am.
But a person with this condition is not able to sleep till 2 am or 3 am. He is awake and mentally active till this time, showing no signs of exhaustion or sleepiness. He is able get up without feeling sleepy only bi 11 am or 12 noon.
There are many explanations for the development of this condition. One is that the sufferer’s brain is unable to respond to the most important regulator of our sleep – wake cycle i.e. light. The brain areas controlling the sleep – wakefulness cycle do not respond to the diminishing daylight to induce sleepiness. In majority of us this is why we feel sleepy when the lights are dimmed.
Need for sleep varies between individuals, and within the individual at different points in life. People with need for longer sleep may be dissatisfied even after sleeping for 9 to 10 hours. People with mood disorders – both unipolar depression and bipolar disorder – show abnormalities of sleep. Many of the bipolar patients in depressed phase, and those with a subtype of unipolar depression called atypical depression sleep for long hours.
But a person with this condition is not able to sleep till 2 am or 3 am. He is awake and mentally active till this time, showing no signs of exhaustion or sleepiness. He is able get up without feeling sleepy only bi 11 am or 12 noon.
There are many explanations for the development of this condition. One is that the sufferer’s brain is unable to respond to the most important regulator of our sleep – wake cycle i.e. light. The brain areas controlling the sleep – wakefulness cycle do not respond to the diminishing daylight to induce sleepiness. In majority of us this is why we feel sleepy when the lights are dimmed.
Need for sleep varies between individuals, and within the individual at different points in life. People with need for longer sleep may be dissatisfied even after sleeping for 9 to 10 hours. People with mood disorders – both unipolar depression and bipolar disorder – show abnormalities of sleep. Many of the bipolar patients in depressed phase, and those with a subtype of unipolar depression called atypical depression sleep for long hours.
Saturday, November 22, 2008
Sleep duration, quality, dreaming......
Misconceptions about many aspects of sleep, including its duration are highly prevalent in the community. Sleeping for lesser duration is equated with evidence of hard work. There is no fact in this. An adolescent aged 14 or 15 years has to sleep at least 9 hours a day according to most experts. But will any child who is to appear for CBSE / SSLC be permitted to sleep this much ?
In reality, there is wide variation in the sleep requirement of individuals. Some can function without any problem even by sleeping for 4 or 5 hours. But generalizing this to the whole population will only lead to unnecessary conflicts. Advancing age reduces the need for sleep as well as results in fragmented and poor quality sleep.
Among the stages of sleep about 25% of time is spent in REM sleep and 75% in Non REM sleep. About 25 to 30% of the Non REM sleep is spent in superficial stages I and II. Usually this portion of sleep can be dispensed off without much adverse consequences. This is what is done by most short sleepers. They enter in to the deeper stages of Non REM III and IV within few minutes of sleep onset. The minimum time of sleep needed may vary from 4.5 to 5.5 hours. This is roughly the time spent in Non REM Stages III, IV and REM together. Reducing the time spent in these stages can lead to sleepiness, poor concentration, impaired work performance, accident proneness etc. If such a deprivation is prolonged mental or physical disorders can occur.
Dreams mostly occur during REM sleep. Dreams may occur in SWS also, but these are less likely to be remembered. It is usual for the sleep to be disturbed by dreams after being deprived of proper sleep the previous night. This is due to rebound of REM sleep. The body tries to compensate for the lost REM sleep by more frequent bursts in the succeeding night.
Dreams were thought to have symbolic meaning. This idea attained maximum scientific attention after Sigmund Freud's book 'The interpretation of dreams'. But now, neuroscientists and psychologists do not give much importance to the content of dreams in understanding the mental life of a person.
In reality, there is wide variation in the sleep requirement of individuals. Some can function without any problem even by sleeping for 4 or 5 hours. But generalizing this to the whole population will only lead to unnecessary conflicts. Advancing age reduces the need for sleep as well as results in fragmented and poor quality sleep.
Among the stages of sleep about 25% of time is spent in REM sleep and 75% in Non REM sleep. About 25 to 30% of the Non REM sleep is spent in superficial stages I and II. Usually this portion of sleep can be dispensed off without much adverse consequences. This is what is done by most short sleepers. They enter in to the deeper stages of Non REM III and IV within few minutes of sleep onset. The minimum time of sleep needed may vary from 4.5 to 5.5 hours. This is roughly the time spent in Non REM Stages III, IV and REM together. Reducing the time spent in these stages can lead to sleepiness, poor concentration, impaired work performance, accident proneness etc. If such a deprivation is prolonged mental or physical disorders can occur.
Dreams mostly occur during REM sleep. Dreams may occur in SWS also, but these are less likely to be remembered. It is usual for the sleep to be disturbed by dreams after being deprived of proper sleep the previous night. This is due to rebound of REM sleep. The body tries to compensate for the lost REM sleep by more frequent bursts in the succeeding night.
Dreams were thought to have symbolic meaning. This idea attained maximum scientific attention after Sigmund Freud's book 'The interpretation of dreams'. But now, neuroscientists and psychologists do not give much importance to the content of dreams in understanding the mental life of a person.
Friday, November 21, 2008
Sleep......
Sleep is a behavior seen in almost all animals. We spend around one third of our life time asleep. Prolonged sleep deprivation can lead to severe mental and physical problems and result in death. Lack of proper sleep can lead to reduced immunity, impairment in memory, reduced alertness and clarity if thinking. Disturbances of sleep are commonly found in majority of psychiatric disorders.
Generally people think of sleep as a uniform state. But studies using electrophysiological equipments have shown that sleep can be divided into distinct stages which occur in a predictable sequence. This pattern is referred to as sleep architecture.
Sleep can be defined as a state of rest with reduced awareness about the environment that is easily reversible. Thus it is different from other superficially similar states like coma.
Human sleep is subdivided into 2 types based on certain electrophysiological parameters and other phenomena. These are the REM (rapid eye movement) and Non REM sleep. REM sleep gets this name as there are rapid movements of the eye balls during this phase. This phase is associated with vivid dreams.
As one falls asleep the first stage occurring is called Stage I of NREM sleep. Then we successively pass through stages II, III and IV. Each stage has characteristic features on the Electro encephalogram (EEG). Slowing of EEG activity is noted from stages I through IV. Stages III and IV are together called Slow wave sleep (SWS) because the EEG record show considerable slowing during these stages. The EEG of REM sleep shows fast activity resembling the waking record.
REM sleep appears in bursts. At the end of approximately 90 to 110 minutes the first burst occurs. By this time the subject would have progressed to the SWS stages.
Subsequently, the subject moves back to SWS in around 20 minutes. Thereafter the sleep alternates between SWS and REM bouts every 60 to 90 minutes. The person enters the stages I and II of NREM only if wakes up again. Otherwise the rest of night is spent in SWS and REM sleep only.
Sleep is essential for growth and repair of the body, consolidation of memory and many other unknown functions. The secretion of growth hormone is maximal during sleep in babies, showing the important role of sleep in their growth.
Generally people think of sleep as a uniform state. But studies using electrophysiological equipments have shown that sleep can be divided into distinct stages which occur in a predictable sequence. This pattern is referred to as sleep architecture.
Sleep can be defined as a state of rest with reduced awareness about the environment that is easily reversible. Thus it is different from other superficially similar states like coma.
Human sleep is subdivided into 2 types based on certain electrophysiological parameters and other phenomena. These are the REM (rapid eye movement) and Non REM sleep. REM sleep gets this name as there are rapid movements of the eye balls during this phase. This phase is associated with vivid dreams.
As one falls asleep the first stage occurring is called Stage I of NREM sleep. Then we successively pass through stages II, III and IV. Each stage has characteristic features on the Electro encephalogram (EEG). Slowing of EEG activity is noted from stages I through IV. Stages III and IV are together called Slow wave sleep (SWS) because the EEG record show considerable slowing during these stages. The EEG of REM sleep shows fast activity resembling the waking record.
REM sleep appears in bursts. At the end of approximately 90 to 110 minutes the first burst occurs. By this time the subject would have progressed to the SWS stages.
Subsequently, the subject moves back to SWS in around 20 minutes. Thereafter the sleep alternates between SWS and REM bouts every 60 to 90 minutes. The person enters the stages I and II of NREM only if wakes up again. Otherwise the rest of night is spent in SWS and REM sleep only.
Sleep is essential for growth and repair of the body, consolidation of memory and many other unknown functions. The secretion of growth hormone is maximal during sleep in babies, showing the important role of sleep in their growth.
Thursday, November 20, 2008
Is addiction a moral weakness?
The only reason to make the distinction [between habit and addiction] is to persecute somebody’ (Szasz, 1973).
The terms addiction, abuse, dependence etc have been used in an imprecise manner by many and this has created some confusion. Lay people still use the term 'addict, addiction' as these are easily understood. But professionals, especially mental health professionals, prefer to avoid these terms for various reasons. One reason is from the angle of political correctness - these terms have pejorative connotations. The other reason is the lack of precise definition, even though these terms have been in use for quite long time. Yet another issue is the trivialized usage. This is when we refer to 'cross word puzzle addicts or exercise addict'. Using the term this way creates a wrong impression that substance use is a problem of similar nature.
Both DSM - TR and ICD - 10 (these are the classification systems used by psychiatrists for diagnosing and classifying mental disorders) use the terms 'substance use disorders' and substance induced disorders'. Substance use disorders include 'substance abuse' and 'substance dependence'. Substance induced disorders include intoxication, withdrawal and other more serious psychiatric conditions.
There are two aspects to dependence - physiological and behavioral. Physiological dependence has two aspects. One is the development of tolerance to the drug necessitating the use of increased quantity over time. The other is the development of a specific withdrawal syndrome on cessation of use.
Behavioral aspects include 1) strong desire or craving for the substance, 2) inability to control the onset, duration, termination or quantity of use, 3) spending lot of time to procure, use or get over from the effects and neglecting other avenues of pleasure due to excessive preoccupation with the substance
and 4) continued despite having adverse consequence (e.g: drinking despite having liver impairment)
It has been argued that it is better to use the term 'neuro adaptation' to the physiological phenomena of tolerance and withdrawal. Therefore, the term dependence is better reserved for the psychological and behavioral consequences.
But this is not strictly adhered to by most authorities. Thus the term 'dependence' continues to include both the physiological phenomena and the behavioral aspects.
The quote given at the beginning is not acceptable to mental health professionals. Dependence is a maladaptive state. It is a significant problem affecting millions all over the world - both the users, their families, employers and the society as a whole. A problem of such magnitude should not be trivialized by comparing with use of common things like food, music, clothes, water or oxygen.
Dependence to substances need not always be thought of from the moralistic angle. A person who is dependent on a psychoactive substance is in a pathological state. It is not like excessive time being spent on music or cross word puzzles. There are no serious physical, mental or social consequences for them. But the serious consequences of substance dependence can be proved with ample evidence. There is no need to be value neutral when one is dealing with a disease condition.
There is definite vulnerability underlying development of dependence. When such a vulnerable person is exposed to the substance, he is at risk for dependence. Social, cultural and psychological factors are also important in shaping the final picture. There may be several others who can have controlled usage. Dependence on substance is not a sign of moral weakness. It is a pathological condition which develops in persons with biological, psychological or social vulnerability, needing proper evaluation and treatment. If untreated, it will lead to serious individual and social consequences. Substance abuse in most cases, is just a prelude to development of dependence. It is always better to intervene at this stage without waiting for development of a full blown dependence syndrome or serious health consequences.
The terms addiction, abuse, dependence etc have been used in an imprecise manner by many and this has created some confusion. Lay people still use the term 'addict, addiction' as these are easily understood. But professionals, especially mental health professionals, prefer to avoid these terms for various reasons. One reason is from the angle of political correctness - these terms have pejorative connotations. The other reason is the lack of precise definition, even though these terms have been in use for quite long time. Yet another issue is the trivialized usage. This is when we refer to 'cross word puzzle addicts or exercise addict'. Using the term this way creates a wrong impression that substance use is a problem of similar nature.
Both DSM - TR and ICD - 10 (these are the classification systems used by psychiatrists for diagnosing and classifying mental disorders) use the terms 'substance use disorders' and substance induced disorders'. Substance use disorders include 'substance abuse' and 'substance dependence'. Substance induced disorders include intoxication, withdrawal and other more serious psychiatric conditions.
There are two aspects to dependence - physiological and behavioral. Physiological dependence has two aspects. One is the development of tolerance to the drug necessitating the use of increased quantity over time. The other is the development of a specific withdrawal syndrome on cessation of use.
Behavioral aspects include 1) strong desire or craving for the substance, 2) inability to control the onset, duration, termination or quantity of use, 3) spending lot of time to procure, use or get over from the effects and neglecting other avenues of pleasure due to excessive preoccupation with the substance
and 4) continued despite having adverse consequence (e.g: drinking despite having liver impairment)
It has been argued that it is better to use the term 'neuro adaptation' to the physiological phenomena of tolerance and withdrawal. Therefore, the term dependence is better reserved for the psychological and behavioral consequences.
But this is not strictly adhered to by most authorities. Thus the term 'dependence' continues to include both the physiological phenomena and the behavioral aspects.
The quote given at the beginning is not acceptable to mental health professionals. Dependence is a maladaptive state. It is a significant problem affecting millions all over the world - both the users, their families, employers and the society as a whole. A problem of such magnitude should not be trivialized by comparing with use of common things like food, music, clothes, water or oxygen.
Dependence to substances need not always be thought of from the moralistic angle. A person who is dependent on a psychoactive substance is in a pathological state. It is not like excessive time being spent on music or cross word puzzles. There are no serious physical, mental or social consequences for them. But the serious consequences of substance dependence can be proved with ample evidence. There is no need to be value neutral when one is dealing with a disease condition.
There is definite vulnerability underlying development of dependence. When such a vulnerable person is exposed to the substance, he is at risk for dependence. Social, cultural and psychological factors are also important in shaping the final picture. There may be several others who can have controlled usage. Dependence on substance is not a sign of moral weakness. It is a pathological condition which develops in persons with biological, psychological or social vulnerability, needing proper evaluation and treatment. If untreated, it will lead to serious individual and social consequences. Substance abuse in most cases, is just a prelude to development of dependence. It is always better to intervene at this stage without waiting for development of a full blown dependence syndrome or serious health consequences.
Tuesday, November 18, 2008
Dr. Vilayanur S Ramachandran talks on the Mind
An excellent talk on 'Brain and Mind' by noted neuroscientist Dr. Vilayanur S Ramachandran is available at this link.
http://www.ted.com/index.php/talks/vilayanur_ramachandran_on_your_mind.html
He disucsses the Capgras delusion, Phantom limb pain and synesthesia in this talk. The 'mirror box' used to relieve phantom limb pain is also shown.
Sunday, November 16, 2008
OCEAN of personality
Study of personality based on psychological traits has a quite interesting history. It started with Gordon Allport and Henry Odbert in 1936 who used a very innovative method. They searched an unabridged dictionary for words that could be used to describe persons. They identified around 35000 words. Further analysis was done to eliminate mere evaluative terms (e.g:awful) resulting in 4000 genuine words that can be called words describing genuine traits.
Raymond Cattell identified 35 personality variables from this list of 4000 words. Further empirical testing and analysis (using statistical technique of factor analysis) resulted in 12 personality factors. He could identify a further 4 factors using self report questionnaire. Thus he came up with the 16 personality factors. He also devised test for measuring these 16 factors (16 PF test).
Later the highly influential British psychologist Eysenck argued that only 2 factors are needed to describe the personality These were extraversion - introversion and neuroticism - emotional stability. Though this was widely accepted, there was a feeling that this is not the whole story.
In 1961, Ernest Tupes and Raymond Christal did studies using the 35 factors of Cattell. They produced evidence that a 5 five factor model could fit in well with empirical data and could explain personality. Thus this model was better than Eysenck's 2 factor model.
The utility of this model was confirmed by Norman and Goldberg 20 years later creating renewed interest in this model.
The 5 factors involved are
Openness to experience, Conscientiousness, Extraversion, Agreeableness and Neuroticism. (can be abbreviated as OCEAN)
Each factor has around 5 or 6 underlying traits. These traits have a strong correlation to the adjectives used to describe a person in the natural languages. Studies have been done in Chinese, hebrew, Filipino and several Indo-European languages.
The personality disorders described in DSM - IV can be understood based on the levels of the underlying traits of these 5 factors.
Raymond Cattell identified 35 personality variables from this list of 4000 words. Further empirical testing and analysis (using statistical technique of factor analysis) resulted in 12 personality factors. He could identify a further 4 factors using self report questionnaire. Thus he came up with the 16 personality factors. He also devised test for measuring these 16 factors (16 PF test).
Later the highly influential British psychologist Eysenck argued that only 2 factors are needed to describe the personality These were extraversion - introversion and neuroticism - emotional stability. Though this was widely accepted, there was a feeling that this is not the whole story.
In 1961, Ernest Tupes and Raymond Christal did studies using the 35 factors of Cattell. They produced evidence that a 5 five factor model could fit in well with empirical data and could explain personality. Thus this model was better than Eysenck's 2 factor model.
The utility of this model was confirmed by Norman and Goldberg 20 years later creating renewed interest in this model.
The 5 factors involved are
Openness to experience, Conscientiousness, Extraversion, Agreeableness and Neuroticism. (can be abbreviated as OCEAN)
Each factor has around 5 or 6 underlying traits. These traits have a strong correlation to the adjectives used to describe a person in the natural languages. Studies have been done in Chinese, hebrew, Filipino and several Indo-European languages.
The personality disorders described in DSM - IV can be understood based on the levels of the underlying traits of these 5 factors.
Wednesday, November 12, 2008
Internet and computer addiction
These are new terms coined to describe 'addiction to internet and computers'. But as expected, there are controversies about these terms and the concepts. Please read the article at the url below for a discussion
http://apt.rcpsych.org/cgi/content/full/13/1/31
There are also reports from China confirming that they have already recognized this as a disorder. They have even started to treat! Read on.....
http://www.wired.com/culture/lifestyle/news/2005/07/68081
http://www.breitbart.com/article.php?id=081110072129.dnm63sjd&show_article=1
The risk factors for developing internet addiction have been studued, The following are some of the important variable
1) Persons who have poor self esteem, especially as children.
2) Anxious, shy individuals
3) Depressed persons.
4) Persons with high degree of impulsivity.
Looks like it is affects people prone to develop other types of addictions as well.
Learning theorists think that the development of addiction is related to reward pathways of the brain.
http://apt.rcpsych.org/cgi/content/full/13/1/31
There are also reports from China confirming that they have already recognized this as a disorder. They have even started to treat! Read on.....
http://www.wired.com/culture/lifestyle/news/2005/07/68081
http://www.breitbart.com/article.php?id=081110072129.dnm63sjd&show_article=1
The risk factors for developing internet addiction have been studued, The following are some of the important variable
1) Persons who have poor self esteem, especially as children.
2) Anxious, shy individuals
3) Depressed persons.
4) Persons with high degree of impulsivity.
Looks like it is affects people prone to develop other types of addictions as well.
Learning theorists think that the development of addiction is related to reward pathways of the brain.
Monday, November 10, 2008
Unholy Alliance
Please read about an instance of the nexus between pharma companies and opinion leaders of the medical profession in this url
http://www.emorywheel.com/detail.php?n=25943
http://www.emorywheel.com/detail.php?n=25943
Friday, November 7, 2008
Who will take over Psychiatry?
I was thinking of writing about the future of Psychiatry. Surprisingly, Ajeesh has raised this issue in his reply to the post on "Many face of love". (It should have been Many faces). He writes that Psyhcology and psychiatry may be taken over by neurology in future. I have heard the same arguments from many other doctors, mostly neurologists and internal medicine specialists. Theoretically it sounds natural as neurology is THE medical speciality dealing with brain. But there are a few issues in practice.
The incidence of major psychiatric disorders are much higher compared to the pure 'neurological' disorders.The most common neurological condition is epilepsy. This is being treated by psychiatrists, internists, pediatricians and the GP without much problem. The skill sets needed to practice hard core neurology is different from those needed to practise psychiatry. In neurology things are more concrete and precise. In the field of mental health, most of the disorder are still vague and abstract. Enormous verbal skills are needed to listen to the patient, and offer psychological treatments. A neurologist may consider all this including the time spent for establishment of rapport as a waste. Of course, a neurologist or any other doctor with the right inclination can practice psychiatry well. Psychiatrists will outnumber neurologists in most countries.
I view things in a different light. The psychotic disorders need mostly drugs, some education about how to handle the illness (for the patient) and education about how to handle the patient (for the relative). To some extent this can be done by any willing doctor with reasonable expertise in psycho pharmacology, if there is a good social worker to help him with the education part. Usually most doctors are uncomfortable with these patients as they are prone to violence and cause disruption in their respectable consultation rooms. This is why they avoid seeing such patients.
The most common mental disorders belong to the category of neurotic disorders (anxiety, somatization and minor depressions). Here more intensive psychotherapy is needed. Hence a mental health professional is needed. My view is that these disorders are best handled by a good G P with adequate training.
If psychiatry is going to be taken over by another speciality, I wish this will be by the speciality of General Practice. This is more beneficial for the persons with the most common forms of mental illnesses. They can approach the GP without fear of stigma. If the GP has some training and is willing to spend some time, he can manage such cases properly. Thus a G P who is willing, can be trained to manage most mental illnesses and reduce the stigma. Only the most difficult cases and those with multiple diagnoses, need to be send to Psychiatrists. In fact this is true of most specialities. A good G P with adequate training can at least rule out serious conditions and refer only those cases needing real specialist care. It is sad that the speciality of G P is not developed in our country. I do not know why this is so. But I am sure this is one important step towards reducing health care costs. The general practitioners should outnumber the total of all the specialists together in a country.
I hope at least some of my friends and colleagues will respond to my arguments.
The incidence of major psychiatric disorders are much higher compared to the pure 'neurological' disorders.The most common neurological condition is epilepsy. This is being treated by psychiatrists, internists, pediatricians and the GP without much problem. The skill sets needed to practice hard core neurology is different from those needed to practise psychiatry. In neurology things are more concrete and precise. In the field of mental health, most of the disorder are still vague and abstract. Enormous verbal skills are needed to listen to the patient, and offer psychological treatments. A neurologist may consider all this including the time spent for establishment of rapport as a waste. Of course, a neurologist or any other doctor with the right inclination can practice psychiatry well. Psychiatrists will outnumber neurologists in most countries.
I view things in a different light. The psychotic disorders need mostly drugs, some education about how to handle the illness (for the patient) and education about how to handle the patient (for the relative). To some extent this can be done by any willing doctor with reasonable expertise in psycho pharmacology, if there is a good social worker to help him with the education part. Usually most doctors are uncomfortable with these patients as they are prone to violence and cause disruption in their respectable consultation rooms. This is why they avoid seeing such patients.
The most common mental disorders belong to the category of neurotic disorders (anxiety, somatization and minor depressions). Here more intensive psychotherapy is needed. Hence a mental health professional is needed. My view is that these disorders are best handled by a good G P with adequate training.
If psychiatry is going to be taken over by another speciality, I wish this will be by the speciality of General Practice. This is more beneficial for the persons with the most common forms of mental illnesses. They can approach the GP without fear of stigma. If the GP has some training and is willing to spend some time, he can manage such cases properly. Thus a G P who is willing, can be trained to manage most mental illnesses and reduce the stigma. Only the most difficult cases and those with multiple diagnoses, need to be send to Psychiatrists. In fact this is true of most specialities. A good G P with adequate training can at least rule out serious conditions and refer only those cases needing real specialist care. It is sad that the speciality of G P is not developed in our country. I do not know why this is so. But I am sure this is one important step towards reducing health care costs. The general practitioners should outnumber the total of all the specialists together in a country.
I hope at least some of my friends and colleagues will respond to my arguments.
Tuesday, November 4, 2008
Many face of love.....
This is a news item reported in the press from Kochi 2 weeks ago. A boy and a girl who were in love got their marriage registered and proceeded to a jeweller to buy ornaments. They quarrelled over the request made by the girl to the salesperson (to give a good purse as compliment). The groom hit the bride on the cheek in public. She ran out lamenting "if you dare to beat me on the day of registration, you may kill me on the day of marriage". (The families had planned a wedding function after a month). The boy was furious and threw the bag containing jewels and cash to the nearby sewage canal. Later some of this were recovered with the help of police.
Many who read this might have wondered 'Were they truly in love?'. I think love is very much misunderstood in our society. Several sex scandals in Kerala started with a boy (who acts as an agent of a sex racket) abducts a girl in the name of love.
I think it is worthwhile to explore the psychological aspects of love. Earlier I had written about love. This time I shall attempt to go a bit deeper. What I write is based on the work of a psychologist called Robert Sternberg. He has divided companionate love into 2 - intimacy and commitment. So we get three dimensions including 'passionate love'(which was discussed in the earlier post).
Sternberg speaks of nine types of love based on the permutations and combinations of these three dimensions.
If passion (erotic or sexual attraction) alone is present it is only infatuation.
If intimacy (warmth, closeness and sharing in a relationship) alone is present it is just called liking.
If both passion and intimacy are present it can be called Romantic love.
Combination of passion and commitment is called fatuous love.
Combination of intimacy and commitment is called companionate love.
If only commitment (intention to maintain a relationship in spite of difficulties and costs that may arise) is there it may be called empty love, devoid of any intimacy and passion.
True or consummate love only occurs if all the three ingredients - passion, intimacy and commitment - are present.
In the early phase of any relationship, it is passion or erotic attraction that dominates. Later on feelings of intimacy and need to be together arises. But it is only after some time the third factor emerges. This is very important for long term stability of the relationship. Of course some level of maturity and interpersonal familiarity is needed to take a decision to stay together forever.
If people who fall in love are willing to take some time to understand these underlying dimensions that can influence their behaviors, many later disappointments can be avoided. Frequently young people equate erotic attraction with consummate love and commit themselves. This can lead to disappointment later. Before proceeding with any relationship some degree of intimacy is needed. This can later pave the way to development of commitment to maintain the relationship. True, satisfying relationships that last can only be built on such firm foundations.
Many who read this might have wondered 'Were they truly in love?'. I think love is very much misunderstood in our society. Several sex scandals in Kerala started with a boy (who acts as an agent of a sex racket) abducts a girl in the name of love.
I think it is worthwhile to explore the psychological aspects of love. Earlier I had written about love. This time I shall attempt to go a bit deeper. What I write is based on the work of a psychologist called Robert Sternberg. He has divided companionate love into 2 - intimacy and commitment. So we get three dimensions including 'passionate love'(which was discussed in the earlier post).
Sternberg speaks of nine types of love based on the permutations and combinations of these three dimensions.
If passion (erotic or sexual attraction) alone is present it is only infatuation.
If intimacy (warmth, closeness and sharing in a relationship) alone is present it is just called liking.
If both passion and intimacy are present it can be called Romantic love.
Combination of passion and commitment is called fatuous love.
Combination of intimacy and commitment is called companionate love.
If only commitment (intention to maintain a relationship in spite of difficulties and costs that may arise) is there it may be called empty love, devoid of any intimacy and passion.
True or consummate love only occurs if all the three ingredients - passion, intimacy and commitment - are present.
In the early phase of any relationship, it is passion or erotic attraction that dominates. Later on feelings of intimacy and need to be together arises. But it is only after some time the third factor emerges. This is very important for long term stability of the relationship. Of course some level of maturity and interpersonal familiarity is needed to take a decision to stay together forever.
If people who fall in love are willing to take some time to understand these underlying dimensions that can influence their behaviors, many later disappointments can be avoided. Frequently young people equate erotic attraction with consummate love and commit themselves. This can lead to disappointment later. Before proceeding with any relationship some degree of intimacy is needed. This can later pave the way to development of commitment to maintain the relationship. True, satisfying relationships that last can only be built on such firm foundations.
Subscribe to:
Posts (Atom)
