Is it vanity or a serious disease?

What Sachin has is called Body Image Disorder or Body Dysmorphic Disorder [BDD], a mental illness involving obsessive focus on a perceived flaw in appearance. Individuals with BDD worry that their ears are very big, nose is blunt or very sharp or large, head is huge, face has lot of acne and so on.

Body Image Disorder involves behaviours like staring at one’s appearance in the mirror for long periods of time, excessive grooming such as wearing trendy clothes all the time, having fashionable hairstyles, changing one’s style to keep up with the current trends, applying a lot of make-up, constantly comparing one’s appearance to others, trying very hard to hide a defect by wearing loose clothes, make-up and accessories like cap, glares, long boots, scarf, etc.

Such people also try to adjust their body positions so as to keep their ‘defect’ from showing to others. They engage in skin picking, repeated checking of the flawed part, are preoccupied with it during conversations and seek reassurance from others. Emotionally, the person feels hopeless that ‘nothing can be done to improve the situation’, embarrassment and shame, as they believe that they look ugly. Cognitively, they remain preoccupied with thoughts of poor body image and continue to think that this is the worst thing that could happen. They are usually delusional or have poor insight, which means that they are completely or almost convinced that their defects are repulsive or deformed. Individuals with distorted body image tend to have ideas or delusions of reference, that others are looking at, talking about, looking down upon or uncomfortable with their defect.

Mental diseases often co-exist with BDD

Body Dysmorphic Disorder often co-exists with other clinical disorders such as anxiety, other OCDs, eating disorders, substance use disorder and depression. The onset of these symptoms is in adolescence and it causes lifetime impairment if left untreated. It is more commonly diagnosed in females than males; however, it occurs equally in both genders. The symptomatology may be different in both genders. For example, men may obsess over their fitness or being too small or insufficiently muscular while women may focus on their skin and facial appearance. Sometimes, individuals have actual flaws in physical appearance which are apparent to others as well. However, their obsession about it is excessive and causes significant impairment in daily functioning.

Individuals with BDD are highly self-critical, apprehensive, withdrawn, feel unacceptable to themselves and others and have low mood. Thus, they are severely distressed which could lead to increased risk of attempting and committing suicide. Sometimes, individuals who are suffering from BDD come to me at a stage when they have already attempted suicide at least once.

The suicidal ideations reported by them are higher than that in general population and sometimes, even higher than those diagnosed with depression or other mood disorders. Thus, those diagnosed with BDD are likely to have higher rate of suicidal ideation.

Body Image Disorder  is one of the least diagnosed disorders in the clinical setting and it often goes undiagnosed as individuals feel ashamed and like to keep it a secret. They also fear that nobody will understand them. Another reason may be poor insight into their problem. This may again lead to an increased risk of suicide due to untimely intervention. Ideally, treating BDD is easier when diagnosed early, before the thoughts and insecurities become deep-rooted.

Signs and symptoms of Body Dysmorphic Disorder

The following signs and symptoms need to be recognised when dealing with individuals suffering from BDD:

1. BDD is diagnosed if the person is markedly worried about slight physical flaws which can be observed with the individual obsessing about them for at least an hour every day and are very difficult to resist or control. This preoccupation may lead to stress and hamper their everyday functioning.
2. An eating disorder shouldn’t be the precursor for the concerns related to one’s appearance to be diagnosed with Body Dysmorphic Disorder .But, BDD and an eating disorder may occur together. Both diagnoses should be avoided and differences analysed.
3. There are subtle signs such as desire to avoid daylight, finding comfort in dark settings, avoiding social outings altogether and being unusually self-conscious around others.
4. The person with BDD may have keen interest in cosmetic surgeries.

Sometimes, individuals opt for cosmetic surgeries as they believe that their problems will disappear once they correct their flaw(s). However, cases of multiple surgeries are not unheard of and surgeries are not the most effective treatment for Body Dysmorphic Disorder. It may benefit some to improve their confidence and make them feel better about their bodies, thereby leading a routine life. However, more often than not, the individuals still remain unhappy with their appearance after the initial phase of satisfaction and may desire more procedures to improve it further, till the time they believe that they have become perfect. Also, their obsession might move onto another body part, once their previously defected part is treated.

How to treat Body Dysmorphic Disorder

The most effective treatment for Body Dysmorphic Disorder primarily includes pharmacotherapy and cognitive behavioural therapy (CBT).

Medications such as Selective Serotonin Reuptake Inhibitors (SSRIS) are very effective to elevate the mood and reduce the anxiety symptoms. If the individual is delusional, antipsychotics may be recommended.

The component factor in Cognitive Behavioural Therapy for individuals with Body Dysmorphic Disorder involves mirror training where a client learns to observe their entire body and see it in a holistic way which involves focusing on the areas of the body disliked by the individual. Further, the individual may be refrained from excessive mirror checking, mindfulness and habit reversal for skin picking or hair pulling or plucking. They are also taught relaxation exercises to help them deal with their anxiety. Another goal of CBT is to change the irrational ideas/beliefs to rational ones.

Individuals with BDD often have ‘all or none’ thinking, they magnify their perceived flaws, discount the positive attributes and often use ‘labelling’ and ‘emotional reasoning’. During therapy sessions, they learn to identify their irrational thoughts and change them through techniques of cognitive re-structuring and affirmations. Clients with Body Dysmorphic Disorder generally have poor insight, so I recommend not asking them direct questions that involve their views on their appearance because for them, their flaws are realistic and not imaginary.

The treatment plan includes a disciplined regime regulating sleep and eating patterns, and physical activity. The family is educated to help them understand the nature and severity of the problem and to help them cope with the same. The other co-morbid disorders are also treated with medication and therapy. Thus, with a holistic approach, BDD is treatable and the person can recover from it completely. An individual, however, may take time to overcome this problem.

The post Are you suffering from Body Dysmorphic Disorder? appeared first on Complete Wellbeing.

When I left India in 2001, with “just” an MBBS—unfortunately, being a general practitioner can be a challenge if you want to be able to earn enough for three meals a day—the government of India did not recognise an MD from the United States. So, pursuing a speciality in the US and coming back to India to practise was not an option. But since I was going to the US, I decided that I might as well pursue psychiatry, as it was something I had always wanted to do. I graduated from Duke University and I began practising in the US for a while before relocating to India. Thankfully, by the time I was back, the rules had changed and I was allowed to practice after registering with the appropriate authorities.

In for a surprise

I assumed that armed with a degree from a reputed university and four years of psychiatric practice under my belt, I could swoosh in like Zorro and get a job anywhere I wanted. In my practice, I had seen a lot of cases of Post Traumatic Stress Disorder [PTSD], so the altruist in me offered to volunteer with the military services. Unfortunately, the armed forces were not keen on hiring me. So I began thinking about joining a private hospital and contacted a number of them, but without success.

So there I was—a qualified and experienced psychiatrist, in a country with more than a billion people, where 20 – 30 per cent of them suffer from anxiety or depression and yet I could not find a job. My faith in Zorro began to wane. Was I wrong to move back? Should I have stayed in the US? Was I going to stay unemployed for the rest of my life in India? My fears were exhausting. Eventually, I did join a private hospital [where I currently practice], but not before working for three years at The National Institute for Mental Health and Neuro Sciences [NIMHANS]. During my tenure there, I learnt fascinating things about the Indian mindset, aspects that were very different from my experience in the US. I went through a whole new learning process.

There I was—a qualified and experienced psychiatrist, in a country with more than a billion people and yet I could not find a job

Indians don’t like seeing a shrink

I learned what it means to have neither the money nor the access to mental healthcare. I learnt that in India, people with psychiatric issues go through immense and prolonged suffering before they seek help. And once they came to you, they want to be fixed quickly [even though their problem might have started a decade ago]. I learned that even though many people are depressed and even more have all kinds of anxiety disorders, most are not aware of their problem. Others don’t know about treatment options. A significant section of the population cannot afford even basic mental healthcare. The most heartbreaking thing I learned was the stigma associated with mental health due to which most prefer to suffer in silence. I found that literacy does not make it any better. Even educated people hesitate to seek out mental healthcare. People would rather see the heart specialist or the neurologist than a shrink!

It isn’t that people in the US always seek help on time. There are issues even in the developed world but they talk about mental illness a lot more than we do and are generally more accepting of it.

On the brighter side, what uplifted my spirits during my camps was that some of the patients [in spite of not being literate and having very little support] would follow the advise of my team and would see a tangible improvement. The gratitude these people expressed on getting better was overwhelming and motivating—I found myself getting back into the groove, thanks to these patients.

What my patients taught me

I know that I have learnt more from my patients than I could ever learn in my residency or in books and I should acknowledge them. We often get cases that are straight out of a textbook, but no matter what kind of a patient, every “case” is a person who has unique problems and is suffering.

In the US, I met patients who saw me every week for therapy. I call it therapy and so would the patients but a part of me wonders if they came so that we could just talk. I loved hearing about the lives they lead, the houses they live in, their relationships and their heartaches. I heard as they spoke about their holidays and the trips they made with their family. For the one hour I spent with each of my patients, I found myself absorbed into a life that was painful even though it was not mine. Many of them suffered from serious mental illnesses and were disabled as a result. Some of them were old, well into their 60s. A few even told me how they missed being manic, energetic and ecstatic.

The most heartbreaking thing I learned was the stigma associated with mental health due to which most prefer to suffer in silence

But when I started working in India, these stories only got more challenging. The women I met in my rural clinic seemed to have a common theme of an alcoholic husband, 2 – 3 kids, no support and domestic violence. Many of these women worked just to put food on the table and did not rest from the moment they woke up to the time they went to bed. Their resilience astonished me.

A case of attempted suicide

I remember how a mother and a father brought their 20-year-old married daughter who had attempted to kill herself the day before. The whole family was in tears and they talked about how unsupportive the girl’s husband was. He was in another relationship and he provided neither financial nor emotional support to his wife and two children. On finding out about the affair, the young woman attempted to hang herself and was stopped just in time by her mother who happened to walk into the room.

I sat in a crowded noisy OPD [300 patients on any camp day] wondering how I could help this family, especially the young woman even as I struggled to keep myself from breaking down. I counselled her and her parents on that hot sweaty afternoon, over the noise, the din and the curious onlookers. I told her things I would tell a friend who came to me for advice. I counselled her about the power of the soul, the self and reminded her of her love for her children. I hope it helped.

Being a psychiatrist in India is not easy. I see people every day that look like me, dress like me and speak my language, in my accent and have problems that are just like everyone I know in my own life. It is really hard not to get angry at the couple that won’t stop fighting and start loving, it’s even harder not to cry when a son comes into my clinic with his mother and says to me that his mother sees no reason to live anymore because her 22-year-old daughter just died in a road accident because a lorry would not slow down while she crossed the road.

Fixing life is difficult

There are illnesses and then there is life. Mostly what I see in my practice is people whose lives are not what they want it to be. Occasionally, I see an illness too. It’s easy to “fix” the illness but fixing lives—that’s a whole different ballgame.

As I conclude, I am reminded of one professor at Duke University who underscored the power of kindness in transforming lives. In my experience I have found that therapy is about working with gratitude, acceptance and kindness and teaching the same to my patients.

The post Confessions of a psychiatrist in India appeared first on Complete Wellbeing.

Sandhya suffers from hidden depression. Most of us have some idea of the symptoms of depression—those persistent feelings of sadness, loss of interest in people and activities, a negative mindset toward situations, decreased appetite and sudden weight loss. What is less known is that several people suffer from severe depression without showing any of these signs. So, how do we recognize if a loved one is suffering from hidden depression?

How to Recognize If Your Loved One Has Hidden Depression

Here are some characteristic features that could indicate that a person you know and care about needs help:

Enforced Joie-de-Vivre

Like Sandhya, such people always put on a happy face for the world. However, this is a façade. Deep down, they are suffering with feelings of utter desolation, which is so unbearable and unthinkable that they prefer to escape into a world of forced gaiety. If you are perceptive and observant, you will notice fleeting moments when the façade vanishes and you get a glimpse into the dismay that the person may actually be experiencing.

Erratic Sleeping and Eating Patterns

Most people with hidden depression have an odd relationship with food. You will often find them constantly eating, as though trying to fill up the void in their life with food. They will be especially drawn toward cakes, chocolates, or other sugary foods that create a temporary feeling of happiness and wellbeing.

They also suffer from fitful sleep patterns. Most of them are likely to be night owls, staying up till the wee hours and falling asleep with great difficulty. While they function reasonably well in the daytime, they may, on holidays, sleep through the entire day to make up for the lack of sleep.

Super-busy Lifestyle

They are constantly busy doing something. They are often energy powerhouses, flitting from one task to the other with a focus that may seem too intense to others. Keeping busy is a convenient way of keeping your feelings and emotions at bay, and these people have honed this art to perfection. Thus, you may find them taking on excessive responsibilities at work, at home and also having a full social calendar.

Elusive Aches and Pains or Chronic Fatigue

They often complain of vague aches and pains—headaches, backaches and stomach upsets being the most common. Or they may be in a state of perennial exhaustion, ready to crash physically at a moment’s notice.

Reckless Behavior

Play with fire is what people with hidden depression often love to do. They are casual, careless and flippant about their health, their safety and even their life. You may often notice them drinking excessively, clubbing or partying too much, driving too fast, spending too much, and generally treating themselves with a care-damn-attitude.

Uncharacteristic Emotional Outbursts

If your friend is normally a calm and grounded person, and has suddenly started having frequent and intense emotional outbursts, it could be an indicator that he or she is suffering from masked depression. Because these people typically run away from facing their emotions, there is usually an intense build-up of negative emotions, especially sadness and feelings of loneliness and emptiness. They may, at times, burst out at the slightest provocation, usually in the form of tears, or extreme rage and anger.

How to Help Someone Who Is Depressed

What should you do if you suspect someone you know and care about may be suffering from masked depression?

Suggesting to them that they might be suffering from depression may result in an outright denial and a further hardening of the mask. People with masked depression often have a hard time acknowledging their feelings and may be very ambivalent about seeking help or even admitting that they have a problem. In their weak moments, they may break down and admit to feelings of sadness, but in a short while, when the feeling has passed, they revert to the veneer that is so familiar. Let us look at some behaviours, actions and suggestions that you can offer, to help bring these people closer to the truth, and eventually, to getting the help they need:

• Model expression of emotions. Talk about your occasional negative feelings to them, thus silently communicating that it is okay to feel so.
• Whenever you notice the mask slipping, talk about it. If the person talks about something wistfully, encourage him or her to go on talking about what feelings are being experienced.
• Don’t allow them to distract you by their gaiety. If you notice them laughing at themselves, or making fun of themselves, calmly mention that it is not funny, and that there is no reason for them to deride themselves all the time.
• Provide unconditional positive regard and acceptance. This is one of the most fundamental of human needs. Making them feel good about themselves and their lives will go a long way in helping them feel supported.
• If it is a close family member, gently urge them to slow down. Offer to help them with the busy schedules they have created for themselves. Help them create free time in their routine; this will force them to stop and think about where they are headed emotionally.
• Encourage them to take up a hobby. Music, yoga, running, painting… Any of these, if pursued with a passion, are deeply meditative and centring activities, and will help them in a big way to get in touch with their emotions.
• Finally, when they are ready, urge them to seek professional help. Help them to understand that depression is not a sign of weakness; it’s a medical issue that requires intervention. Support them as they take their first steps toward recovery.

As you can see, hidden depression is, in some ways, more challenging than overt depression. Getting the person to acknowledge deep feelings of sadness and emptiness, helping them understand that this is a problem that needs help and getting them the help are issues that can create challenges. Yet, with the right support and encouragement of family, friends and loved ones, this mask can be torn off and the inner demons can be faced, fought and defeated.

The post How to Help a Loved One Suffering From Hidden Depression appeared first on Complete Wellbeing.