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| HEALTH TRIBUNE | Wednesday, April 11, 2001, Chandigarh, India |
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Psychotherapy in India - II Take care if your eyes are ageing HEALTH BULLETIN
Q&A |
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Psychotherapy in India - II THE
late Dr M.V. Govindaswamy, the founder-Director of NIMHANS, Bangalore, often said that the Mahabharata was a great textbook of psychopathology and the Gita was a great treatise in psychotherapy. The Bhagavadgita contains in condensed form all the philosophical and psychological wisdom of the Upanishads which is imparted by Lord Krishna to his dear friend and disciple Arjuna. The Gita is often described as counselling in the battlefield (of life) given to a conflict-ridden individual in stress confronted with a crisis and torn with anxiety, on the brink of giving up and taking flight, but who takes refuge in his Charioteer (the all-time Counseller) who guided him out of his predicament. The Gita is believed to have the power to free one from shame and guilt in its own framework, resolves repression, supplies energy and moral by making one dig deeper into oneself and develop insight into its working. It describes various aspects of psychotherapeutic techniques through 18 chapters of self-knowledge; the yoga of action, the knowledge of renunciation and action, the path of meditation, the knowledge of the Absolute and Eternal, yogic vision, the Yoga of devotion, profound knowledge of the three gunas and the wisdom of renunciation and liberation have been described at length. These lead to personality transformation in Arjuna. In modern psychotherapy, cognitive restructuring is the goal which has been accomplished to a great extent through the Bhagavadgita. Many authors, including Ramachandra Rao, Satyanand and Venkoba Rao have interpreted the gospel of the Gita for the modern Indian and developed educative, preventive and therapeutic techniques based on the dynamic psychology of the great text. Guru-shishya relationship: This, as a therapeutic paradigm, was suggested by Professor Neki in 1973 and appears to be tenable where self-discipline, rather than self expression, is to be inculcated in the patients; where creative harmony is sought between patient and society! More activity and direct guidance and advice by the therapist is adopted in this form of relationship. Therapeutic paradigms aimed at culturally relevant goals:
Psychotherapeutic interventions in economically underprivileged communities should be developed keeping in mind the cost and cultural factors as suggested by Sethi and Trivedi in 1982. They have also stated that a thorough appraisal of the ethnodynamic characteristics of the specific group of patients is essential. In psychotherapy, the use of a clear local language with a medically-oriented concept of illness must be accepted for Indian patients. Psychotherapy will have to be of specific nature, tailored to the needs of the afflicted with a sharp focus on rehabilitation also. The traditional and family support system must be strengthened. This approach becomes more relevant to most of the Third World countries. Specific psychodynamic formulations: Surya in 1966 in his remarkable paper on the "Ego structure in the Hindu joint family", dealt deeply with the ethnodynamics and socio-dynamics that determine the structure of Indian ego, its relatively weak outer boundaries, the degree of responsibility it accepts and the kind of dependency relationship in which it is enveloped. Professor Neki noted that in India parents encourage and foster dependency in their children — a concept which represents the goal of personal development in our culture. Religious psychotherapy as a therapeutic paradigm:
Interestingly, in organising values, modern man still exploits religious texts and systems developed hundreds of years ago, e.g, the Mahabharata, the Ramayana, the Quran, the Bible, etc., which continue to guide and be quoted. A recent trend has been seen in the use in psychotherapy of religious percepts which have existed for many years and embody concepts deeply ingrained in our culture. Such psychotherapy is called religious psychotherapy. For example, for a Muslim, his religious ideology is a way of life which strongly influences activities, like alcohol consumption and sexually deviant behaviour, which are strictly forbidden in the Quran. The understanding of the human psyche in the Vedantic model is more acceptable to Indian patients because of the transfer of attitudes from generation to generation. Anecdotes from the Bhagavadgita as psychotherapy of a dying patient is virtually a tradition in Indian culture. Even now when death is anticipated, the preachings of Lord Krishna stating that thoughts at the time of death determine the species of the next birth help the individual to accept the end in a more gracious manner. Psychotherapy studies in India:
In spite of various comments and reservations often expressed, mostly informally, by Indian psychiatrists and other mental health professionals regarding the place and relevance of psychotherapy in India, factual data concerning the nature and the extent of psychotherapy practised in India are unfortunately, almost non-existent. Varma and Ghosh, in 1976, had conducted a study on the Fellows of the Indian Psychiatric Society practising in India. Females and those from higher socio-economic strata were overrepresented in the total patient sample. The majority of the patients were neurotic (65.2%). Supportive and reductive psychotherapy were the common types practised. The poor responder rate was a serious limitation of this study. Training:
There is a glaring lack of trained professionals in this field. There are few institutes and centres which are known to provide formal training in psychotherapy. The PGI, Chandigarh, NIMHANS, Bangalore, the BM Institute, Ahmedabad, and the Bose Psychoanalytic School, Calcutta, are a few such centres. NIMHANS, Bangalore, did take some initiative in training general medical practitioners in the art and skill of psychotherapy. The probable reason for psychiatrists not showing much enthusiasm in practising psychotherapy in India could be the enormous workload on them, or even the inability of the Indian masses to understand and appreciate psychotherapy as a way of giving medical help. Concluded. Dr Avasthi is a well-known teacher of psychiatry and a reputed clinician based at the PGI, Chandigarh.
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Take care if your eyes are ageing FROM
a physiologic standpoint, ageing is characterised by the progressive constriction of the homoeostatic reserve of every organ system. This decline, often referred to as "homoeostenosis", is evident by the fifth decade and is gradual and progressive. "Normal ageing" can be attenuated by the modification of the risk factors — increased blood pressure, smoking, a sedentary life-style, etc. The appreciation of these facts has definitely led to an increase in life expectancy. The average life expectancy is now 15 years at age 65, 10 years at age 75, five years at age 85 and two years at age 100. As the individuals age, they are more likely to suffer from disease and disability affecting almost all the organ systems in the body, including the eyes. One of the basic human rights is the right to see. The most disastrous morbidity, short of loss of life, is blindness. A simple awareness of the diseases affecting the eyes in late adult life (50-70 years) and elderly (70 and above) can help people in a big way to seek early medical help and prevent serious visual loss. The magnitude of blindness:
At present, an estimated 180 million people worldwide are visually disabled of whom nearly 45 million are blind. India alone has 12 million blind people; this comes to one fourth of the total in the world. Blindness is mainly a problem of old age. According to the "World Health Reports, 1997" about 32% of the world's blind are in the age bracket of 45-59 years, but a big majority, i.e about 58% are over 60 years of age. About 80% of blindness is either treatable or potentially preventable. The structure of the human eye:
The human eye is a round organ approximately 2.4 cm in diameter. Each eyeball acts as a camera. The light rays from a target are focused by two transparent structures-cornea ("putli") and the lens on to the retina ("purda"). The stimulation of the retina by light causes visual sensations which are carried by the optic nerve into the brain where the image is perceived. The eye is filled with a watery fluid (aqueous humour) anterior to the lens and a gel-like substance (vitreous) posteriourly. Physiological eye changes:
A person with normal sight can see not only distant objects, but also near ones. We are accustomed to holding books or newspaper for reading at about 25 cm from the eye in order to have clear and comfortable reading. Starting around 40 years, a person has to hold his book further off, a disability which increases as age advances. This condition is known as "presbyopia", a normal ageing process affecting the ciliary muscle of the eye which becomes weak and is not able to exert its focusing action for the near vision. The condition is easily corrected by prescribing plus glasses (near), which require roughly a 0.5 D change every five years till the age of 60. Eye diseases in the elderly:
In people above 50 years, cataract, glaucoma, diabetes and age-related macular degeneration (AMD) are some of the common eye diseases. Cataract ("chitta motia"):
Any opacity in the lens is called cataract. It is the most common cause of blindness in persons over 50 years accounting for about 80% of the total causes of blindness. About 15% of the blindness is irreversible and correlable to the complications of cataract surgeries performed in the setting of eye camps. The most common factor in the development of cataract is age. There is considerable genetic influence in its incidence. The early symptoms of cataract are: stationary spots before the eyes, doubling or trebling of the object seen, coloured haloes, change in the colour hue, blurred vision and visual deterioration either in sunlight or dimlight. In advanced cases, a marked diminishing of vision occurs. The blindness due to cataract is curable. No medical treatment by drugs has been shown to have any beneficial effect in cataract; the only effective treatment is its operative removal and intraocular lens implantation. The phacoemulsification (sutureless cataract surgery) technique has definite advantages over conventional cataract surgery as visual rehabilitation is faster in the former. Glaucoma ("kala motia"):
It accounts for about 15% of the global blindness and 1.7% of the blindness in India. In this condition, a sustained increase in the intraocular pressure (normal <21 mmHg) due to alterations in aqueous humour dynamics leads to permanent damage of the optic nerve. Two main types of glaucoma are: The closed-angle type characterised by attacks of pain, diminishing vision and coloured haloes; and the open-angle type which causes a slow, quiet and insidious loss of vision over many years. Early diagnosis is the key to the prevention of vision loss. Diabetic blindness:
Diabetes accounts for 10% of all new cases of blindness in the developed world. Nearly 20% of the diabetics have eye changes at the time of diagnosis of diabetes. (To be concluded; “Age-related macular degeneration” next week.) The author is a lecturer and clinician at the Government Medical College and Hospital, Chandigarh. |
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HEALTH BULLETIN THE
knowledge about and the attitude to mental
illnesses and its treatment are still shrouded in myths and
misinformation. People are uncomfortable and unaware of the need to
seek treatment from psychiatrists. New and effective medicines are now
available for treating serious types of mental illnesses. Apart from
medicines, other forms of treatment — i.e electroconvulsive therapy
(ECT), psychotherapy and behaviour therapy — are also effective. In
fact, no other treatment has generated as much fear and prejudice in
the minds of the public as ECT has done. There can be various reasons
for this negative attitude and the lack of proper knowledge about ECT
is the foremost. It is difficult for most of the people to accept that
the passage of electric currents through the brain can cure. Here the
definition of ECT shall be useful. ECT simply defined, as a method of
treatment by which the brain is stimulated with the help of very mild
electric currents. This stimulation leads to changes in the level of
neurochemicals in the brain that help in treating the underlying
illness. People are frightened and worried that the use of an
electric current will cause damage to the brain. But this is not so.
An analogous situation can be the use of the cardiac pacemaker (for
heart ailments), which continuously delivers electric signals to have
a well-functioning heart. The sight of a person receiving ECT and
having body jerks with vigorous movements and loss of consciousness,
as depicted in books or movies also, is frightening to most of us. It
creates fear and bias against ECT. However, now a days, ECT is given
under general anaesthesia (known as modified ECT) under the
supervision of a psychiatrist and an anaesthetist in rooms that are
akin to minor operation theatres in terms of medical facilities.
Following anaesthesia, the patient loses consciousness and develops
deep body relaxation. Thereafter, ECT electrodes are applied to the
temples and the current is passed in a controlled manner. The whole
procedure is ultra-short and the patient regains consciousness
quickly, but is completely unaware that ECT has been
administered.
An ultra-short procedure With modified ECT, the patient may complain of
heaviness in the head, drowsiness, confusion or memory problems and
headache. These effects are occasional, mild, not disabling, transient
and they tend to settle down within a few hours or, say a few days.
Hence, ECT can be administered safely to a patient at regular
intervals. ECT has an important role to play in the treatment of
various mental illnesses. The commonest and prime indication is
depression, which is associated with the best response to ECT.
Generally, severe forms of depression, associated with a suicidal risk
(or attempt) respond very well. Patients with depression require six
to eight ECT treatments on an average. Another indication is mania
where patients who are very violent and unmanageable require 10 to 12
ECT treatments on an average. Patients with schizophrenia displaying
aggression, a suicidal risk or associated depression generally require
10 to 14 ECT treatments. ECT can be used in a variety of other
psychiatric conditions where it may be a method of second choice. ECT
is advantageous in multiple ways. Apart from being safe, it is
relatively cheap compared to the cost incurred medicines. It can be
administered on an outpatient or inpatient basis. It can be combined
with various medicines safely. The onset of action and response is
faster with respect to that of medicines. Therefore, the mental
suffering of the patient and relatives, along with the hospital costs,
can be reduced considerably. ECT has been found to be helpful in
treating those patients in whom medicines have not shown a
satisfactory response or in certain situations where the use of
medicines can be harmful, e.g in pregnancy, or during
breast-feeding. It can be definitely said that the utility and
advantages of ECT outweigh the disadvantages associated with it.
Certainly, ECT should be seen as an effective treatment option for
specific major psychiatric disorders and be equated with any other
medical treatment. |
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Q&A Maj-Gen (Dr) Jaswant Singh answers questions on renal problems. Kidneys can be saved Q What is chronic kidney failure or End Stage Renal Disease (ESRD)? A
When the kidneys — producing urine to keep the blood clear of the waste products of the body — fail in their primary function, the products accumulate in the blood, giving rise to decreased urine output, and a marked rise in blood urea and serum creatinine. We call this chronic kidney failure. Q
What conditions give rise to chronic kidney failure? A Certain important causes like hypertension, diabetes mellitus, chronic glomerulonephritis, kidney infection and some other medical disorders. Q
How do we treat ESRD? A The cause must be treated. At first, the medical regimen is started — a low protein, low-fat and primarily carbohydrate diet with vitamins, then haemodialysis. The patient's blood is passed through a machine which performs the kidney's functions and removes waste products. If the blood urea and serum creatinine are still high (blood urea — 40 mgm; serum creatinine 1.4 mgm;), kidney transplantation is undertaken. Q
What is kidney transplantation? A It is a procedure by which one kidney, which has been tissue -matched and blood-group-matched from a human donor, whose either kidney is normal, is removed and transplanted in a patient. Both donor kidney harvesting and transplanting into the recipient are performed by two teams simultaneously at two different tables in the same operation theatre. Post-operatively, blood transfusion, antibiotics, pain-relievers and immunosuppressives are given. The patient is kept in the transplant ward; the medical and paramedical staff are fully masked. They wear sterile clothes. Q
What is the legal aspect of kidney transplantation? A The Union Ministry of Health brought the Human Organ Transplant Act in 1994 to stop unethical organ-trading. The Organ Retrieving and Banking Organisation (ORBO) is a part of the Act. But now, as per the Act, if the brain is dead even if the heart continues to beat, the person is dead. Doctors, who are not involved in transplants, have to certify the brain dead stage. (More on this topic next week) General Jaswant Singh AVSM is a renowned urologist. After his retirement from a top position in the Army, he has gone into private practice in Chandigarh. |
