Psychiatry Consultations and Counselling Services  in  Goa, India 

To understand the various forms of psychological therapies, including psychotherapies and counseling, one first must be aware of how a psychological problem is actually diagnosed. In most fields of medicine one would diagnose a condition such as diabetes and then advise treatment for it. In Psychological Medicine, however, the process of diagnosis is quite different. According to the Diagnostic and Statistical Manual (DSM IV) of the American Psychiatric Association, a psychiatric diagnosis is made on a multi-axial system consisting of 5 different Axis. Each Axis is designed to look at important yet distinct facets of the individual and his problem.

On Axis I the doctor or therapist records the main psychological disorder such as depression, anxiety disorder, or substance dependence from alcohol or other drugs. If this is the only diagnosis, treatment options would be limited as the information obtained about the person is also limited. The mainstay of therapy for a majority of conditions on Axis I is drug therapy. Even so for conditions such as depression, Cognitive Behavior Therapy ( CBT ), a form of short term psychotherapy, is found to be as useful as antidepressants and both taken together give better results than either of them alone.

Axis II records if the individual is intellectually challenged; has any problematic personality traits, or if a legitimate Personality Disorder exists. Obviously if a person were intellectually challenged, the degree of the disability would greatly influence the treatment approach. Moreover, if any distinct personality traits are present which are considered maladaptive Axis II illustrates that the person is likely to have poor life coping skills. A simple prescription of a medicine such an antidepressant is not going to help such a person completely overcome his psychological difficulties. Such a person would most certainly benefit from psychodynamic psychotherapy.

Axis III records the presence of any medical problems such as diabetes, high blood pressure, asthma etc. The doctor, whether a psychiatrist or not, must then also focus his attention to the adequate treatment of these conditions. He must also consider whether the underlying medical problems are worsened by the psychological disturbance and stress and whether the medical illness is contributing to the psychological difficulties. For example, females being treated for polycystic ovarian diseases are often referred for evaluation for depression after receiving medical treatment for their disease. It would be advisable, however, to screen such patients for depression prior to commencement of medication, as later it becomes unclear as to whether their depression is related to the hormonal preparations they are taking or whether their distress is due to the knowledge of the diagnosis and outcome of the disease itself.

Recent research also shows that psychological difficulties are more common in diabetics. Conversely psychological difficulties are likely to make control of blood sugar difficult in a diabetic as well as aggravate patients with asthma. Patients of hypothyroidism are more prone for depression and a person diagnosed with cancer is likely to suffer from adjustment disorder and depression. What is worse, the main psychological disorder such as depression is very likely to be missed if it is not specifically looked for, thus making the outcome poorer for the patients with physical illnesses.

A recent study by the WHO wherein 245,000 people were interviewed has revealed that depression is a more disabling condition than angina, arthritis, asthma and diabetes. Researchers found that depression had the largest effect on worsening health. Dr. Somnath Chatterjee of the WHO said, “The co-morbid state of depression incrementally worsens health compared with depression alone, with any of the chronic diseases alone, and with any combination of chronic diseases without depression.” Researchers in the Lancet said, “Better treatment for depression would improve people’s overall health.”

Axis IV is used to report any psychosocial and environmental factors which may pose problems to the individual with regards to the diagnoses, treatment, and outcome. Factors under this category include such circumstances as a difficult life event, environmental deficiencies or difficulties, educational problems, housing problems, economic problems, legal problems, a stressor in family or in other relationships, or lack of social support. It is not uncommon that people seek psychiatric evaluation because they are complaining of stress or have been referred by their physicians, yet on assessment the psychiatrist finds that there is no diagnosis on Axis I. The patient is, however, experiencing distress due to external circumstances such as unemployment, defiant adolescents, excessively strict parents, bullying in school, unrealistic educational demands, or a death of family member.  

In some of these instances, counseling, family therapy, or relationship and marital psychotherapy are useful while drug therapy may not be necessary. Social work and assistance from available welfare agencies are useful in cases where a person is unemployed. When a person is unable to do everyday activities such as budgeting, shopping, or paying bills, the services of a support worker who can provide regular home visits to motivate and assist the person would help alleviate their distress significantly. Presently such facilities and therapies are difficult to find in India.

Axis V is used to report the overall level of the individual’s functioning. This is useful in planning treatment, measuring its impact and also in predicting outcome. For example, if a person does not go out at all or stops going to work and does not mix with any one it should be recorded as later an improvement can be easily noticed and conveyed to other therapists specially if more than one therapists or doctors are involved in his treatment.

Therapies which are useful in poor functioning persons are rehabilitation , social work, recreational therapy, and supportive psychotherapy. In patients who have very serious impairments such as not being able to wash ones clothes, have bath, speak and mix with others would require intensive rehabilitation imparted through supported accommodations and half way homes. Such facilities are currently not available in Goa .

Following an assessment if the person has no problems then nothing is recorded  on one or more axis. For example it may so happen that only on axis IV for there is problem such as conflict with office staff or school teacher but  all the other axis are negative and the person is well balanced in which case the person or his parents would merely be counselled how to cope with that situation or remedy it if possible or avoid it.

Some countries have special services for dual diagnoses wherein there are major psychological disorders along with substance abuse related disorders. This dual diagnosis complicates the treatment of both the psychological disorder and the substance abuse disorder. Specialized and exclusive facilities for treatment of dual diagnoses are not presently available in India.

Thus psychological treatment is multifaceted and multimodal and the approach has to be tailor-made to suit the individual.

http://www.goablog.org/posts/an-approach-to-psychological-treatment/

NB: Currently the DSM 5 has replaced the DSM IV

However, awareness regarding psychological disorders as causes of disabilities is low and the negative impact of psychiatric conditions on a child’s normal development is seriously underestimated. Parents, therefore, should be knowledgeable of all conditions which may impact the growth and development of their children. 

The UNICEF report ‘State of World’s Children 2008’ does not contain statistics for India on disability. One reason for this may be that psychological disability is falsely equated with mental retardation. Very often traits such as carelessness, laziness, stubbornness, apathy, unreliability, and disobedience are quite often the symptoms of significant and disabling psychological disorders. 

One such case revealed itself after I advised the principal of a local school to watch the Hindi movie ‘Tare Zameen Par’. After watching the movie, the principal realized that a student, Cynthia, was probably suffering from dyslexia. She referred the case to me complaining that the student was inattentive, badly behaved and did not complete her homework. 

The very concerned mother came to my clinic with 12-year-old Cynthia. Her mother said her daughter didn’t study properly, was very naughty, pinched and pushed her younger sister, and was not interested in studying. The mother was also concerned that Cynthia refused to repeat class VI even though she had scored between only two to six out of 50 in a number of subjects. After a few counseling sessions, Cynthia told me that she felt sad since she was not promoted and felt ashamed of remaining in the same class. She also complained of headaches.

The girl was a fantastic painter and drew spontaneously and enthusiastically. Her craft and puzzle solving skills, as well as her abilities with the mobile phone and the video camera were stunning. Cynthia’s IQ was 106, well within the normal range of 90-110. Yet her academic scores were extremely poor. So what was the problem?

Cynthia had Learning Disability , Attention Deficit Hyperactivity Disorder ( ADHD ) as well as Depression which had developed due to her inability to cope with her disabilities.

In cases of learning disability (dyslexia) and attention deficit hyperactivity disorder (ADHD) the subject finds difficulty in specific areas such as reading, writing, arithmetic and in focusing attention leading to hyperactivity. Quite often these two conditions occur together and are mistaken for truancy, laziness, naughtiness, stubbornness or carelessness. As a result of such disabilities, children may feel despondent and develop secondary problems like low self-esteem or depression. They might also suffer from anxiety problems, which are often manifested with physical complaints such as headache, palpitations and sleep difficulties. Such conditions, when missed in childhood, may lead to poor performance in school and seriously impair the person’s productivity in adulthood. Such was the case of a 37-year-old mother of two who told of not being able to study and concentrate from childhood. She complained bitterly that she had not received any professional help all these years and hence couldn’t achieve much in life despite being intelligent and hard working.

Parents who are aware of the array of psychological disorders leading to disability can make a difference. They will be able to champion this cause. The first step towards this is to mobilize popular opinion and obtain ‘official recognition’. Teacher’s too can certainly pitch in by detecting early that something is amiss and seeking an evaluation of the child if they are trained to recognize the symptoms.

Previously Published as: “Detect disability early to reduce suffering” Publication: Times Of India Date : Jun 16, 2008; Section:TimesCity; Page Number:4 

http://epaper.timesofindia.com/Repository/ml.asp?Ref=VE9JR08vMjAwOC8wNi8xNiNBcjAwNDAw&Mode=HTML&Locale=english-skin-custom

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