Anxiety

https://indianexpress.com/article/express-sunday-eye/waiting-to-exhale-anxiety-depression-mental-health-anushka-sharma-alia-bhatt-panic-disorder-social-phobia-6050314/

Gursimran recently disabled the read receipts facility on WhatsApp. “When you have these blue ticks, which tell that people have seen your messages and have not replied — that makes me very anxious. So, I decided not to care if someone has read my messages or not, or whether I know that or not,” says the 30-year-old, who works at a startup in Delhi.

His struggles with anxiety are as old as his professional career. A few years ago, a sense of being out of control led the IIM-Bangalore graduate to a psychologist. “I thought I was depressed, but the counselling psychologist said what I have is anxiety,” he adds.

Much of his anxiety revolves around the demands of his high-stress workplace. “The world can live with the fact that missing deadlines is normal, but I get anxious. If I am made to commit to a timeframe I know I can’t meet, I get stressed: What if I can’t do it? Does this mean that I am failing?” says Gursimran, who has worked in four companies in the last decade and finds workplaces unequipped to deal with mental health issues.

On a spectrum that ranges from nervousness to pathological and crippling anxiety, Gursimran possibly falls somewhere in the middle. But anxiety, when it manifests as a disorder, can throw life out of gear.

Every time Delhi-based Aparajita Sharma, 24, travels to a new place, whether it is a work trip to Udaipur or a holiday to Europe, she gets a panic attack. “It is not travelling that bothers me, it is being in a new place. It is the inability to trust a new place and its people which makes me anxious,” she says. She describes a panic attack somewhat like this: “There are butterflies in my stomach, then my heart starts racing, there is nausea, and I get breathless. I feel like I am having a heart attack and I will not survive the day. When it happened once, I thought it’s physical, but when it happened whenever I was sent to a new environment, I realised there is a problem,” says Sharma, who is a project manager at Mind Specialists, a platform that works towards de-stigmatising conversations around mental health.

“Anxiety is now the most prevalent psychological disorder in human beings,” says Dr Shwetank Bansal, consulting psychiatrist with Delhi’s BLK Super Speciality Hospital. It manifests as a pervasive sense of lack of control, and a feeling of being overwhelmed by the demands of daily life.

Anxiety now features in more conversations than ever before, with testimonials pushing for an acceptance of what is often not acknowledged enough in modern social systems — that human beings break down, especially when exposed to growing demands of performance and success. “As our encounters with anxiety disorder grow, as more people, including public figures, talk about it and as our understanding of its diagnosis and treatment gets more refined, it is natural for people to want it not to impede their quality of life,” says Dr Bansal.

According to a 2018 American Psychological Association survey, 54 per cent of workers under the age of 23 in the US said they felt anxious or nervous due to stress in the preceding month, and close behind were millennials, with 40 per cent of them reporting anxiety.

The National Mental Health Survey of India 2015-16 found that nearly 10 per cent of the population were affected by common mental disorders, including depression, anxiety disorders and substance use disorders. It quoted a study done in Himachal Pradesh, which revealed that 15.5 per cent of the population in the age group of 15-24 years suffered from anxiety.

It could be that everyday life, too, has morphed strikingly. “We don’t have a 9-5 lifestyle anymore; we certainly don’t have a five-day routine. Because of smartphones, you’re carrying work wherever you are, even before you sleep and after you wake up, so your mind is never switched off. That has increased the anxiety of everyday living manifold,” says Dr Samir Parikh of Fortis Healthcare.

“There is a constant pressure of having a certain kind of job, salary or relationship. The idea that their life should look a certain way is making them anxious. But I think the younger generation has become more accepting of the fact that having a problem is normal and it is okay to seek help,” says Dr Anupriya Sircar, clinical psychologist at Max Healthcare in Delhi.

If you have plugged in to conversations about anxiety, however, you might discern a certain fuzziness to them — when everyday responses to stress also are clubbed with feelings of crippling anxiety. “Anxiety is essential, it facilitates our response to either fight or flee. If someone encounters a lion in a jungle, her anxiety makes her run for her life, till she is safe. But if the person cannot let go of the anxiety even when she is safe, is consistently worried and scared, that is how you understand that an anxiety disorder exists,” says Delhi-based counselling psychologist Manisha A Sharma.

Dr Bansal adds that it is crucial to distinguish between plain nervousness and a disorder. “Failing to do this can result in two problems. One, the medicalisation of the normal human experience of anxiety, and two, the opposite effect of trivialising the anxiety disorder of a person as something ‘that everyone experiences and needs to deal with’,” he says.

“One frustration with anxiety is that it is often hard to find a reason behind it. There may be no visible threat and yet you can feel utterly terrified. It’s all intense suspense, no action. It’s like Jaws without the shark. But often there are sharks. Metaphorical, invisible sharks. Because even when we sometimes feel we are worried for no reason, the reasons are there,” wrote Matt Haig in his book Notes on a Nervous Planet (Canongate, 2019).

One of the first public figures in India to open up about seeking treatment for anxiety was actor Anushka Sharma in 2015. “What’s the need to hide it?” she had said. Actor Alia Bhatt, during promotions for her latest film Kalank, also talked about her experience with anxiety. “I haven’t been depressed but I’ve had bouts of anxiety. It comes and goes… No matter how bad it is, I just let myself feel it. Sometimes, I feel like crying for no reason,” she said.

Earlier this year, Kolkata-based pop duo Parekh & Singh cancelled a music tour after vocalist and musician Nishchay Parekh opened up about dealing with performance anxiety. “I’ve been performing music on some sort of a stage since the age of 16. Even though I’m only 26, that amounts to a decade of performance. There have been extreme highs… However, another common thread has been anxiety, stress, and, recently, depression. I’ve been a natural performer and while I know that many live performers suffer from performance anxiety, mine just seemed to grow as the years went by,” he wrote on Instagram. The prospect of playing “big” shows pushed him over the edge, and he lost the joy and comfort he had once found in music.

Last year, Tanya (name changed), 27, used to be anxious all the time — she could feel her heart racing, she was always tense. She was a lawyer then at a firm in Delhi, after which she moved on to do an MBA from a university in Karnataka. “I was facing a lot of pressure at my work and in my relationship, and to cope, I got into drinking. There was a point when I was either working or drinking. One day, I got extremely violent and angry. That is when I realised there is something wrong and I should seek some help,” she says.

Sometimes, the trigger can be an unanticipated jolt of trauma. Five years ago, for example, Sayoni (who uses one name) was working in the US as a journalist when she replaced by an American hire and given a day’s notice. “That changed everything I had planned. I had a student loan to pay off, I had planned a life and career in the US, but I had to move back to India,” says the Kolkata-based content writer, 30. Soon after, she developed psoriasis, a sudden inflammation of the skin.

“Psoriasis can be psychosomatic with roots in emotional trauma. I think that (firing) is the root of a lot of my anxiety. Since last year, I have started developing more intense symptoms. They particularly come at night, irrespective of how tired I am; my heart will be racing, I’ll break into a sweat, have palpitations and will be unable to fall asleep,“ says Sayoni. Despite that, she has not approached a counsellor or psychiatrist, but has chosen to be treated by a homeopath.

In his book, Haig wrote about his struggle to distract himself. “I was careful about what I ate. I did yoga. I tried to meditate. I lay on the floor and placed my hand on my stomach and inhaled deeply — in, out, in, out — and noticed the stuttery rhythm of my breath. But everything was difficult. Even choosing what to wear in the morning could make me cry,” he wrote.

He also listened to podcasts, watched new Netflix shows, went on social media, tried to get on top of his work by replying to all his emails. “I woke up and clasped my phone, and prayed that whatever I could find there could take me out of myself. But — spoiler alert — it didn’t work. I began to feel worse… I would stare at an unanswered email, with a feeling of dread, and not be able to answer it. Then, on Twitter, my go-to digital distraction of choice, I noticed my anxiety intensify,“ he wrote.

Passively scrolling the timeline felt like exposing a wound. He also read news websites but the knowledge of so much suffering in the world didn’t help put his pain in perspective. “It just made me feel powerless. And pathetic that my invisible woes were so paralysing when there were so many visible woes in the world. My despair intensified,“ he wrote.

In her book, Love and Rage: The Inner Worlds of Children (Yoda Press, 2017), clinical psychologist Nupur D Paiva, based in Delhi, busts the myth that children don’t get anxious, by illustrating the oblique ways in which it affects their behaviour.

Recently, a bright 15-year-old student had come to see her. “She was refusing to go to school as she would get panic attacks. She spent the day at home either sleeping or being on the phone. After seven sessions, we realised that she felt that she should not talk about her emotions or needs with her parents. She felt they were already struggling a lot with their lives and careers, and she must not overburden them,” she says.

Paiva is clear she doesn’t want to label children and teens with disorders while working with them. “For a child, it is an experience. My task is to look for what is making the child anxious,“ she says. “Four-year-olds think about god and death or wonder where babies come from; boys are curious about their penises. Parents tend to shut down those questions, but they don’t go away,” she says.

Peers are also an important aspect of an adolescent’s life, but social media has changed that dynamic. The circle that was previously limited to 10 friends and 30 classmates has now widened to hundreds, adding another reason for anxiety to amplify. “One of the reasons for anxiety is the fear of judgement. People are constantly looking at what you are putting on social media and forming opinions — there is a social media reality and you can choose it. People will like and it will determine how you will feel about yourself,” says Paiva.

But parents are now paying more attention to the emotional needs of their children; in contrast, the previous generation did not acknowledge children’s anxieties as valid and important, says Paiva.

For a culture rooted in relationships, the family remains a source of anxiety as well as solace. “I think the family plays a very important role because if they can give the space to the person where they are able to talk and feel understood, I think half the problem is solved,“ says Dr Sircar.

When Uma (name changed), 70, met counselling psychologist Manisha A Sharma, she had already been taking anti-anxiety medicines, prescribed by her general physician, but they did not help much. “She said she did not have any reasons for anxiety; but nevertheless felt anxious all the time. It was after a number of sessions that we found out that even after his retirement, her husband did not spend enough time with her. She had lived her life expecting that they would be together after he retires. But he was a workaholic, and found some other job to keep himself busy,” says Sharma.

For 52-year-old Anuradha (name changed), an associate professor in University of Delhi, a diagnosis of anxiety led to relief, but also criticism from her husband and friends. “They couldn’t understand my problems and said it happened to everyone… They said there was no need to go to doctors. They thought I was making it up,“ says Anuradha, whose mental health problems exacerbated with menopause.

The first step for family members is to understand when to prod others to seek help. “If you feel there is a drastic change in behaviour, if a very gregarious person now only keeps to himself, it is a cause for concern. If you see irritability or if you see he is getting low or getting angry, if he is anxious and constantly asking for reassurance, these are some signs which can tell you something is wrong,” says Dr Sircar. For those afflicted, her advice is simple: “If your anxiety is affecting your work, or sets your heart racing; if you tend to worry often about catastrophic outcomes, it is time to ask for help,” she says.

It’s taken a while, but Anuradha’s family and friends have come around now; she is on anti-anxiety medication and attends counselling sessions. “The support of my husband has been vital. He is careful about what makes me anxious, and that helps me manage my anxiety,” she says.

“The other day, I had planned to celebrate a friend’s birthday at work, but the teachers got agitated about an issue in the college staff room. I realised that my anxiety could increase, and before it did, I picked up my bags and left for home. The celebration could wait, but my anxiety would not,” she says.

What’s to worry?

Generalised Anxiety Disorder (GAD): The most common form of anxiety, it is an extreme, intense and absurd worry associated with everyday life. You will anticipate disaster about everyday things and experience fatigue, nausea, headaches, restlessness, insomnia and sweating.

Panic Disorder: If you get recurring panic attacks, it is possible that you have a panic disorder. Physical symptoms include rapid heartbeat, perspiration, dizziness, hyperventilation, chest pains and crying.

Social Phobia: Not to be confused with shyness. If you’re scared of being around people altogether, you might be experiencing social phobia, which is an intense fear of being in a social situation and being judged by other people.

Post-Traumatic Stress Disorder (PTSD): If you have experienced something traumatic in the past, and keep revisiting that memory, you might be going through PTSD. It can last for years, with physical effects including severe insomnia and constant fatigue.

Obsessive Compulsive Disorder (OCD): If you tend to have certain thoughts or tend to do certain routines repeatedly and are unable to control them, you might be experiencing OCD. Eating only out of a particular plate may be mild OCD, but refraining from eating if that plate is not available is acute OCD.

Anxiety

https://indianexpress.com/article/express-sunday-eye/living-with-mental-illness-6096400/
I had my first panic attack when I was 18 years old. It was 7.30 am and I was supposed to be up for college. I remember thinking that I couldn’t afford to miss class when I was already falling behind, but for reasons unknown to me, I couldn’t move. A feeling of dread was settling in and it felt like my brain had disconnected from the rest of my body. My vision was blurry, my heart was racing and I was sweating while the air-conditioner was set at 18 degrees Celsius.
The next thing I knew, I was hunched over the toilet pot, throwing up. I ended up passing out in the washroom and skipped the rest of the day. These episodes became so regular that I eventually began therapy, and was later diagnosed with Generalised Anxiety Disorder. Looking back, I wish I could pinpoint exactly when and why anxiety became such a huge part of my life. As a child, I was shy and mostly kept to myself. When we’re little, things like hesitating before placing orders at restaurants or feeling nervous before presentations are common. But children are expected to grow out of that.
I overcame my fear of placing orders at restaurants, but it was replaced by an irrational fear of eating in front of people. One time, a friend stayed at my house for a couple of days, and I was so nervous to eat in front of him that I ended up going mostly hungry for the entire duration of his visit. When I started work for the first time, I was afraid to order food and eat in front of my colleagues because I thought they would judge the food or the way I ate.
Another exhausting aspect of my anxiety is the constant fear that I’m going to lose everyone I’ve ever loved. I have recurring dreams in which I’m burying the bodies of my loved ones. One time, my mother had an incessant bout of hiccups that wouldn’t stop no matter how much water she drank, and I panicked because I couldn’t stop picturing that Grey’s Anatomy episode where Meredith’s stepmother died after she was admitted to the hospital for non-stop hiccups.
My best friend suffers from severe depression, which results in him going off the grid quite often to remain sane . I’ve known him for four years and understand his need for space, but every time he doesn’t respond to my calls or texts for more than a certain number of hours, I can’t help but wonder if he’s finally decided to fling himself off his 17th-floor balcony. When my 11-year-old brother comes home late from football practice, I can’t help but wonder if he’s lying dead somewhere.

Anxiety is so much more than overthinking. It makes you withdrawn, highly irritable and leaves you constantly tired. It fills you with the false belief that worrying means control. And the way the world works is that most times, you don’t control the things that happen to you. It can be exhausting to have your brain constantly analyse every thought, experience, memory and moment. Even the days you spend lying in bed can feel like you’ve just run a marathon. Every little interaction is dissected and scrutinised. You’re always second-guessing everything you’ve ever said or done. It’s hard to be present in a moment when you’re dreading what it’ll be like when it’s over. When good things happen, you’re waiting for the other shoe to drop. When bad things happen, you think it’s because you didn’t worry enough.

People with anxiety are often told to not “think so much”, “calm down”, “go with the flow” and “live in the moment”. In theory, this sounds easy. But living in the moment is a far-fetched concept when every milestone you’ve hit is marred by a crippling sense of fear, worry and apprehension. Anxiety and imposter syndrome often go hand in hand. All your achievements seem like scams or coincidences at best. You feel like a fraud who’s going to be exposed soon. When you’re low, it’s because you deserve it. When you’re riding high, you don’t deserve it. High-functioning anxiety makes you come across as calm, collected and put together on the outside. Internally, though, there seems to be perpetual chaos because you’re constantly overthinking, overanalysing and seeking approval.

The thing about mental illness is that while you can learn to live with it, it doesn’t truly leave you. It might not be as crippling as it used to be, but every now and then, it’ll show up when you least expect it. It’s easy to fall off your wagon when that happens and it’s just as hard to get back on it. It can take a very long time to figure out how to function normally despite your deteriorating mental health.
I think a good way to navigate around mental illnesses is acceptance of the fact that you are, in fact, sick. You wouldn’t ignore a broken leg till it worsened to a point where you had to cut it off. The trick is to be just as kind to yourself when dealing with your mind. Having a good support system in terms of friends and family is essential, but so is the knowledge that ultimately, you’re the only one who has to deal with the mess in your head.

Mental Health

May 23 2012.
Mint news paper

Families find few avenues for care and treatment of the mentally ill


Santosh Kumar Bhowmik, a 67-year-old retired professor, sits erect on a marble bench at a cafeteria at Dilli Haat, an outdoor food plaza and handicrafts bazaar in Delhi, sipping Sprite from a plastic cup while keeping a watchful eye on his son.

At 33, the son conducts himself with the shy deference of an adolescent. At the moment, he is facing a metal pole, muttering quietly under his breath to people no one else can see or hear.

Bhowmik’s son Surjit suffers from schizophrenia, a mental illness that typically makes it difficult for an individual to think logically, have normal emotional responses, and distinguish between real and unreal experiences.

“I do not know what will happen to him after I am no more,” Bhowmik said. “I leave it up to God.”

He is not alone in his anxiety.

The ministry of health and and family welfare estimates that as many as one out of four Indian families will have at least one member diagnosed with some sort of mental illness. At least 7% of the population is estimated by the ministry to suffer from “severe” mental illness.

Yet, with only 37 government institutions to care for the mentally ill in a nation of more than one billion people, there are limited long-term resources for families struggling to look after a relative who needs psychiatric treatment. In northern India, there isn’t a single government-run rehabilitation centre where people with incurable mental ailments can be admitted.

“For 18 years, I have cared for my son at home because I do not have a choice,” said Bhowmik. “It is not enough to give medicine to patients suffering from schizophrenia. They require special care, which we cannot give at home, but I do not have the money to institutionalize him in a private facility. I don’t like to think about what will happen to him after I am gone.”

In the 1980s, the World Health Organization released the startling findings of a two-part study on mental illness: Patients suffering from schizophrenia in developing countries such as India, Nigeria and Colombia had better long-term outcomes than those in developed countries, which included Denmark, the US and Canada.

The culmination of decades of research, the study examined long-term treatment of more than 1,000 schizophrenic patients across 16 countries, concluding the greater levels of acceptance, stronger social ties, and greater family involvement more common in developing companies appeared to be “key positive factors” linked to patient recovery.

While the study’s findings have been criticized on the grounds that it may have ignored patients locked away by families concerned about the social stigma associated with mental illness, it contained important insights into its treatment.

“Social ties are one of the intervening factors that affect patient outcomes. There was another study in the UK which looked at different ethnic groups, and Asian families with stronger social ties showed better recovery and remission rates,” said Manasi Sharma, a research coordinator at Delhi-based Centre for Excellence in Mental Health. “But caution has to be exercised by looking at these studies—it can go both ways. Families have been known to shun patients, too.”

Should the study be conducted in India today, it would likely yield very different results. Economic liberalization and policies successful in lifting millions of people out of poverty have also reshuffled social structures. Large joint families that used to be the norm have given way to the smaller, nuclear families typical of most Western countries.

Nirmala Srinivasan, founder of the Association for Mentally Disabled, a support group for caregivers to the mentally ill in Bangalore, said there is no doubt that the burden of caring for the mentally ill is growing.

The daughter of a woman diagnosed with schizophrenia and the primary caregiver to another close family member struggling with mental illness, Srinivasan has unique insights into how deteriorating social support networks have burdened modern day caregivers.

“I grew up in a large south Indian orthodox Brahmin family, with a lot of widowed aunts. It was a very large joint family, so I never felt the burden of my mother’s care,” said Srinivasan, who fondly recalls a childhood filled with neighbours, festivals and a family that worked together to manage her mother’s illness, to make sure that her mother always felt included and was never alone.

“But now there’s an issue with inadequate family resources, particularly among middle-class families that have migrated to urban centres,” she said. “My father had a tremendous in-house support network. That is completely lacking for caregivers across the country today.”

The growing verticality of cities, which stacks families into isolated apartment units, also serves to isolate them, while exacerbating the stigma associated with mental illness, Srinivasan said.

“They won’t seek help if there’s a crisis unless the (patient) becomes violent. They don’t want to have to explain it to the neighbours the next day,” she explained. “Sometimes I think that the mentally ill in slums may fare better during emergencies than middle-class families, because in slums you can’t hide an emergency. Whether it’s a mental crisis or labour pains, the entire community will rally and bring them to a hospital. And if it’s a village, they’ll put them in a bullock cart.”

Paying for long-term care can also leave families in a financial hole, particularly those who lack insurance.

“I have no options, I cannot even get a loan,” said a woman who’s a full-time caregiver for two family members—a father who suffers from dementia and a brother diagnosed with schizophrenia. “For poor people, there are loan options, but for the middle class, there is nothing. And mental illness affects all income levels, so the issues cut across income levels too.”

Taking on the mantle of the caregiver eventually forced her to quit her full-time job, said the woman, who spoke on condition of anonymity. The scant wages she earns as a freelancer in the social development sector makes hiring any sort of full-time help out of the question.

Finding trained nursing attendants is difficult and costly—a full-time trained nursing attendant costs Rs.35,000-40,000 a month plus food, and adult diapers (now necessary for her father’s care) cost her approximately Rs.300 a day. Even keeping a full-time maid is hard as most don’t stay, unnerved by her brother’s erratic behaviour.

Even while families are increasingly feeling the pinch, state governments are yet to step up to provide viable alternatives. This void is most keenly felt by families living in northern India. As of now, there is not a single government-run rehabilitation centre in the region where patients with incurable mental ailments can be admitted for long-term care.

But the ripple effects of government apathy in the North are also felt in the South, where the few private rehabilitation centres that exist have learned to be wary when approached by northern families.

“After very bitter experiences in the past, we are hesitant to admit patients based in northern India. The likelihood of abandonment is very high and the distances make following up with the families very difficult for us,” said M. Ranganathan, a caregiver at Family Fellowship Society (FFS) in Bangalore.

Ranganathan retired from the National Institute of Mental Health and Neuro Sciences in Bangalore after four decades of work in the area of psychiatric social work. He cited three recent instances when families based in Delhi abandoned the patients at FFS.

“They did not pay the monthly charges and stopped answering our phone calls. Eventually, we had to seek police assistance to get the patients back to their homes, as we cannot take care of patients without financial assistance,” he added.

Bhowmik’s is one of 25-odd families that came together to fill the void for rehabilitation centres in Delhi three years back by forming a social support group of caregivers and mentally ill patients.

Rajeshwari Iyer, one of the founders of the group Roshni, shows through personal example how strong family support can make or break recovery for a person struggling with mental illness. Her daughter Madhu was diagnosed with schizophrenia when she was 16 years old. Now 34, she is working as a receptionist at a doctor’s office and hopes to lead a normal life—perhaps even get married.

Her own recovery has inspired her to help others struggling with mental illness. “In the absence of my mother, I try to help patients and even counsel families based on my experience as a patient,” said Madhu.

Her mother knows all too well what can happen when the primary caregiver passes away, and no long-term care facilities exist. Three months ago, she received a call from the Delhi Police asking that she help with someone they suspected was mentally ill.

Iyer arrived at a dilapidated home that looked abandoned. Living inside, in the dark, was an unshaven man with dreadlocks and an insect-infested beard.

“His legs were gangrenous,” she recalls, shuddering. She learned from neighbours that the man suffered from psychosis and had been cared for by his parents, who passed away several months back. His brothers and sisters all lived in Delhi, but refused to come forward to claim him, saying there was no way they could care for both him and their own families.

Iyer was able to intervene and get the man accepted at a government hospital. But there are many others who are not so fortunate.

“I remember one mentally ill man whose primary caregiver died,” she said. “His brothers would not take him in and put him on the streets. Three days later, he was dead.”

Barring government intervention, the group members have no choice but to take matters into their own hands. “In Delhi, it frustrates me that being the national capital and despite having resources at command, not a single home for mentally ill patients exists,” said Bhowmik. “My request to families in Delhi will be to start a self-help movement, mobilize resources instead of waiting for the government to pitch in.”