Fear and phobia are mental disorders
Obesity: size really doesnít matter
at birth can help detect fatal disorders
Patient care: Why dissatisfaction?
Fear and phobia are mental disorders
FEAR is a very common human experience. From childhood onwards we are exposed to so many situations where we get terribly frightened. In small children, there is often great fear of darkness or of being left alone or exposed to loud noise. In some other children, it may be the fear of thunder and lightning or fear of violence by bullies in the school and so on.
As adults also, we continue to have many different kinds of fears, and almost each one of us can recall situations where we left intense fear; may it be when caught in a fire or in a traffic accident or when an aeroplane made a dangerous landing, etc. During such a situation all of us experience many bodily sensations along with an intense feeling of fright and the desire to somehow get out of that situation.
Accompanying such feelings are usually rapid and loud heartbeats which one can almost hear, trembling of the body, dryness of the mouth or a choking sensation, rapid breathing, cold sweating, often a desire to go to the bathroom, etc. Such experiences are common to all of us and once the danger passes off, functioning of the body slowly comes back to the normal resting stage.
According to psychologists, the fear response is an attempt by the body to be ready for a "fight or flight" which are the possible two alternatives for an individual to cope with the danger situation. We have rapid heartbeats and quick beating because the heart is pumping more blood to various organs and lungs are working overtime to supply oxygen to the brain and muscles. The body trembles because muscles get ready for action. Medically speaking, there is over-stimulation of the autonomic nervous system, which quickly responds to emotions but is not fully under the control of the conscious brain.
Phobia refers to a medical condition in which a person has an intense fear of a situation which for others may be quite normal. For example, a woman patient tells me that "Doctor Sahib, I am quite normal otherwise, but when I have to get into a lift (elevator) in a building I get very scared. I feel as if I am going to die. My heart is pounding, my temples are throbbing. I am badly sweating. It is such a relief when the lift door opens and I can get out. You know I am so scared now that I avoid lifts altogether. I would climb six storeys of stairs but I would not get into a lift anymore".
Another patient, a well-placed manager of a firm, tells me that "I do not understand what is the reason but I am mortally scared of air travel which I often have to undertake for business reasons. I try to avoid it as much as possible. When the plane door shuts Iget a sinking feeling that I will not get out alive now. I desperately want to get out but there is no way. I am miserable during flight. Many times I have taken a tranquiliser tablet to reduce my tension during travel."
Phobias are not only confined to specific situations but in some persons may be related to specific objects like animals, birds, insects, etc. For example, some patients may be abnormally afraid of dogs or house lizards "chhipkali" or cockroaches or spiders in the kitchen or bathroom. Again though many of us may not like these creatures, we do not run away from them.
In patients of phobias these reactions are very pronounced. For example, a person suffering from dog phobia will avoid visiting houses of friends who keep dogs, or a housewife is unable to work in the kitchen for fear of spiders or house lizards, etc. Still another kind of common fear is social phobia in which a person gets very tense or nervous when at a social gathering or when asked to go on a stage to speak or when appearing in an interview for a job, etc.
One may ask that since most of us are afraid of something or the other in our life, why should we call it disease, or at what point does it become a medical disorder? The answer is that it becomes a medical condition when there is marked personal distress due to these symptoms and when it starts causing marked disruption in social functioning. Ultimately, it is the person or the family who has to decide whether the degree of disturbance is significant enough to require medical help.
Treatment and management
How should one cope with such symptoms of phobia? In my view, first of all we should try to handle it ourselves. The guiding rule is that more you run away from a fear, the stronger the fear gets next time. Therefore, it is better to face the fear ó if not totally then in small increasing steps. For example, if you are afraid of going out in crowd, start going out in the company of someone you trust and first try situations where you are less afraid and then gradually go to situations which make you more afraid.
This is also the principle of what psychologists call "Behaviour Therapy" which is often advised for the treatment of persistent phobias. Relaxation exercises like long walks or yoga or meditation also help. If the problem is severe or persisting, then help can be taken from mental health professionals. Fortunately, during the last 20 years, a number of new medicines have become available for the treatment of phobia with or without panic disorder. The Benzodiazepine group of drugs like Alprazolam or Diazepam are helpful, but the effect is usually temporary. Repeated and prolonged use has the danger of habit forming. The anti-depressant groups of drugs can also be useful and the effect is often more lasting. I would like to repeat once again that anti-anxiety or anti-depressant medicines must be taken only when prescribed by a qualified doctor.
Obesity: size really doesnít matter
IN January 2003, as America prepared to go to war with Iraq, the US Surgeon -General, Richard Carmona, warned the nation that it faced a far more dangerous threat than Saddam Husseinís supposed weapons of mass destruction. Rather than focusing on the danger posed by nuclear, biological and chemical weapons, Carmona told his audience, "Letís look at a threat that is very real, and already here: obesity."
According to the latest BMI (the BMI is a simple mathematical formula that puts people of different heights and weights on a single integrated scale) figures, 64.5 per cent of American adults are either "overweight" (meaning they have a BMI of between 25 and 29.9) or "obese" (defined as a BMI of 30 or higher). Studies have found an association between even mild amounts of "overweight" and a significantly increased risk of premature death.
The proportion of the population that maintains a dangerously high weight continues to climb: obesity in America has increased by more than 50 per cent over the course of the past decade. If the authors of these studies are correct, America is facing a health crisis that, in the words of one anti-fat warrior, will make AIDS look "like a bad case of the flu".
This, then, is the case against fat: America, we are told, is on the verge of eating itself to death. The core belief of those prosecuting this case is that the BMI tables testify to a strong, predictable relationship between increasing weight and increasing mortality. That, after all, is what most people assume when they read that medical and public health authorities have determined a BMI of 25 or above is hazardous to a personís health. This belief, however, is not supported by the available evidence.
A 1996 project undertaken by scientists at the National Centre for Health Statistics and Cornell University analysed the data from dozens of previous studies, involving a total of more than 600,000 subjects with up to a 30-year follow-up. Among non-smoking white men, the lowest mortality rate was found among those with a BMI between 23 and 29, which means that a large majority of the men who lived longest were "overweight" according to government guidelines. The mortality rate for white men in the supposedly ideal range of 19 to 21 was the same as that for those in the 29 to 31 range (most of whom would be defined now as "obese"). In regard to non-smoking white women, the studyís conclusions were even more striking: the BMI range correlating with the lowest mortality rate was extremely broad, from around 18 to 32, meaning a woman of average height could weigh anywhere within an 80-pound range without seeing any statistically significant change in her risk of premature death.
In almost all large-scale epidemiological studies, little or no correlation between weight and health can be found for a large majority of the population ó and indeed what correlation does exist suggests that it is more dangerous to be just a few pounds "underweight" than dozens of pounds "overweight". So, let us look at the most cited studies for the proposition that "overweight" is a deadly epidemic in America today. Anyone who bothers to examine the evidence in the case against fat with a critical eye will be struck by the radical disconnect between the data in these studies and the conclusions their authors reach.
"Overweight, Obesity And Mortality From Cancer", published in the New England Journal of Medicine in April 2003, was the subject of front-page stories in many of the nationís leading newspapers. For example, a Los Angeles Times article reported that the study provided "the first definitive account of the relationship between obesity and cancer". The article went on to quote the studyís authors to the effect that perhaps as many as 90,000 deaths a year from cancer could be avoided if all adults maintained a BMI below 25 throughout their lives. The disjunction between this studyís actual data and the alarmist headlines its authors helped generate is especially remarkable.
Among supposedly "ideal weight" individuals (BMI 18.5 to 24.9), the study observed a mortality rate from cancer of 4.5 deaths for every 1,000 subjects. Among "overweight" individuals (BMI 25 to 29.9 - a category that currently includes about twice as many adult Americans as the "ideal weight" cohort), the cancer mortality rate was 4.4 deaths for every 1,000 subjects. In other words, "overweight" people actually had a lower overall cancer mortality rate than "ideal weight" individuals.
Most Americans, and indeed most doctors, simply assume that the heavier you are, the more likely it is you will suffer from coronary artery disease ó hence the various clich`E9s about "artery-clogging" fast food and the like. Yet several studies have specifically investigated the question of whether a high percentage of body fat correlates with the incidence of coronary artery disease. Answer: no, it does not. Even massively obese men and women do not appear to be more prone to vascular disease than average.
It is true that increasing weight is associated with high blood pressure and certain types of heart disease. But even here there is considerable evidence that this correlation is not necessarily a product of being fat, but rather of losing and then regaining weight. Obese patients who have been put on very low-calorie diets subsequently display much higher rates of congestive heart failure than equally fat people who did not attempt to lose weight in the first place. The biggest evidentiary problem for those who insist there is a strong causal link between increasing weight and heart disease is that deaths from heart disease have been plunging at precisely the same time that obesity rates have been skyrocketing.
Indictments in the case against fat invariably focus on diabetes, because Type 2 diabetes is much more common among heavier-than-average people. It has become routine to claim that America is about to be overwhelmed by a diabetes epidemic, that for the first time Type 2 diabetes is being seen among children, etc, and that the solution to this crisis is to make fat people thin.
Actually, the definition of diabetes has changed (from a fasting blood sugar of 140 to a blood sugar of 126) and many more people have been diagnosed as suffering from the disease. Several recent studies indicate that the key to avoiding Type 2 diabetes is not to try to lose weight (indeed, there is much evidence that dieters are far more prone to the disease than average), but rather to make lifestyle changes in regard to activity levels and dietary content that greatly reduce the risk of contracting the disease, whether or not such changes lead to any weight loss.
If we were to employ the logic of the anti-fat warriors, does this mean that we should be encouraged to gain weight so as to protect ourselves from, among other things, cancer, osteoporosis and most of the major pulmonary diseases?
There are some groups of heavier individuals ó usually those with BMI figures in the mid-30s and above ó who do suffer from worse health than those of "ideal-weight". Yet this does not of itself prove that such peopleís problems are caused by their excess weight. There are many other factors that disproportionately affect the heaviest people in our society, and that also correlate with poor health: most notably a sedentary lifestyle, poor diet, dieting-induced weight fluctuation, diet drug use, poverty, access to and discrimination in health care, and social discrimination generally. None of these factors was taken into account in Annual Deaths Attributable To Obesity In The United States, the Jama study responsible for the "fact" that fat kills 300,000 Americans a year.
Blood test at birth can help detect fatal disorders
WASHINGTON: A simple and inexpensive blood test performed at birth can dramatically increase chances of survival of babies born with potentially fatal disorders such as severe combined immunodeficiency disease (SCID).
Duke University Medical Center physicians have performed stem cell transplants in 136 infants with SCID in the past 22 years.
The survival rate for 38 infants receiving transplants in the first 3.5 months of life is 97 per cent, but the rate drops to 69 per cent for infants who were transplanted after that age, Rebecca Buckley, reports in the April 23 Annual Review of Immunology.
The main cause for the drop in survival rate is serious infections SCID babies develop in the first few months of life.
Infants with SCID have little or no immune system. Without treatment, they die of infection before their first or second birthdays.
But for infants without a known family history of SCID, the average age of referral for immune testing is approximately six months, Buckley said. "The tragedy is that most patients are critically ill by then", she noted.
Buckley believes that
all newborns should be screened for immune deficiency disorders at
birth. "SCID is a paediatric emergency. There is no screening for
any primary immunodeficiency disease at birth or during childhood and
adulthood in any country. óANI
Patient care: Why dissatisfaction?
AS clinicians, our desire is to do what is best for our patients and to provide support during their illness. However, it has become difficult to provide a compassionate care to our patients and their relations. Sometimes the clinicians meet the family for the first time under difficult emotional circumstances.
Before the phenomenal progress in modern medicine, advances in diagnostics and high-tech intensive care unit, seriously ill patients died at home, surrounded by their loved ones, who clearly knew best how to comfort family members in their period of crisis. This situation allowed family members to feel as if they were doing everything or providing the best care possible at home which included touching a loved one or perhaps providing a small amount of food.
The scene has changed now. The simple gestures offered at home have been replaced by the provision of respiratory assistance in the hospital, nutrition by the intravenous route and several other life-saving interventions. The relatives no longer have an active role in the care, thereby exacerbating the sense of helplessness and frustration. The families and friends often request unrealistic therapies.
The worthy goal in the ongoing challenge is to provide optimal care to our patients. The importance of developing and maintaining high-level listening skills need to be emphasised and so is the improved communication with the patient and family members. Patients and their families are suddenly thrust into an atmosphere rife with the emotion of loss and responsibility. They are probably unwilling to accept treatment failure as an outcome. A meaningful presentation of the patientís condition, potential treatment options, and the implications that each choice may have on the future clinical outcome is extremely important.
The discussion needs to include talks about the quality of life as well. Physicians in this way will provide the most compassionate care. It is also valuable in setting realistic expectations for patients and families, and overall increased satisfaction with the care provided. Compassionate understanding at such a time of crisis needs to be recognised in defining new standards of excellence and compassion in the care we provide.
Poor or inconsistent communication between doctors and patients and inadequate pain control have been identified as the major problem areas during the care in the hospital. Patient-specific prognostic reports needs to be delivered/communicated to the patient and the family members. Effective communication is essential to perceiving and facilitating patient and family readiness for healthcare decision-making. It is important that patients and families understood the clinical situation, and felt heard, and understood.
Most families rate, the clinicianís communication skills, along with continuity and accessibility, as more important. Improving communication will improve family satisfaction as well as the quality of care. It is important to communicate uncertainty regarding the patientís diagnosis, prognosis, or treatment options. In difficult situations clinicians should understand that families may not react in the way the clinician expects. It is important to acknowledge strong emotions that come up in a way that allows the person with the emotion talk about why he or she feels that way. Allow a family member to talk about his/her anger.
Building alliances with family members is an effective strategy for delivering a bad news. It is usually best to present a balanced picture of both positive and negative scenarios or by saying that it is a bit too soon to tell, and that I will consult you all along the way hoping for the best, I will do everything in my power to see that the patient remains comfortable.
Good communication is not just language skills. It is a matter of psychological insight and self-awareness on the part of clinicians. Managing a sick person is entirely different from diagnosing an illness and prescribing therapy for it. Listen thoughtfully. Desire for information is high. A patient has the right to enquire about his or her own treatment decisions. A discussion about the risk involved is highly important. Satisfaction is the key to reducing misunderstandings. Satisfaction is based on meeting patient desires and needs. This is relevant to all aspects of the doctor-patient-family interaction in modern times. Perceptive use of eyes, ears, hands and the heart will go a long way in countering dissatisfaction.
The writer is Professor and Head ,Department of General Surgery, PGI, Chandigarh