What's Causing Exam Stress

While we may debate whether examinations in our schools and colleges can ever be defanged of their fear factor, there seems to be growing concern that in the present form they induce considerable stress to students. Increasing media reports of young lives being snuffed out by suicide, and the manifold larger number of unreported scars and traumas produced by this annual event should evoke serious concern in us.

Stress may not always be bad. Without a dash of “positive” stress, we would not be striving to run or climb in life. Without it, I wonder if any of us would have struggled to reach wherever we have. However, with life getting more and more competitive and we getting more and more ambitious, too much is being perceived to be at stake. “Perform or perish” or “do or die” is the attitude that is assuming center stage in the minds of students, claiming the high price of mental and physical health.

Negative stress can be recognized reasonably early and easily. It causes anxiety, nervousness, diarrhoea, nausea, depression and headaches. Inability to concentrate, difficulty to fall asleep, loss of appetite, irritability, anger become common. Chewing the pencil, dressing shabbily, sticking to a small group of friends, not interacting openly with family and neighbours are common observations. Some children start showing cruelty to animals, or hurting their younger sibs. Thrills such a pizza binge, a movie or a hasty trip to a games park provide brief temporary reliefs, and the frown returns quickly. Rather than studying, the student is seen discussing exams on the phone or on the dining table most of the day. Constant worry and fear leads to a stage of emotional exhaustion that is called depression, when negative thoughts begin to play on our minds most of the time. 

If students, especially young ones in school, being the innocent sufferers can hardly be blamed for their stress, then who is /are the real culprits? A study conducted across countries showed that the greatest source of stress was indeed parents, especially in Asia. High parental pressure as the major cause of stress was reported in 60% of Asian (Indian, Chinese and Japanese) students, compared with only 5% of American students. Pressure caused by high expectation from teachers, peers, and in India – neighbours, are the other major contributors.

The reasons for well meaning parents to cause unintentional harm to their children, is intriguing. Struggling parents from “service” backgrounds are the usual culprits, rubbing their own sense of financial insecurity on to their children, often emotionally exhorting them to achieve the impossible as a return for their toil and care. If the poor child then fails to meet his parents’ expectations, he is overwhelmed with gulit and shame!

It should be the collective responsibility of parents and teachers to prepare students to cope with examination stress. Moreover, insecure parents should remind their children and themselves about the several success stories of people such as Bill Gates, Sachin Tendulkar, Micael Phelps, Albert Einstein and Rabindranath Tagore who failed to achieve in examinations, but won in life. How many examination toppers, who have become legends, can you count?

As Published in HT City ( Hindustan Times) dated 21 february , 2010.

Hepatitis C

Hepatitis C, a small RNA virus that causes infection and damage to the liver, had its moment of public recognition when the well-endowed silverscreen celebrity Pamela Anderson of Baywatch fame got diagnosed with it. The way she contracted it was equally sensational: she had shared the needle for a skin tattoo with her boyfriend, Tommy Lee, who carried the infection. The gossipy tale went further to her litigating against him for concealed the information, but as often happens there, they finally united by wedlock!

Hepatitis C infection is indeed more common than most of us probably know. Of all us who consider ourselves perfectly healthy and volunteer to donate blood, 1% harbour the infection. In other words, approximately 10 million people in India have the infection and do not know it.

Hepatitis C virus is a stealthy one that hardly ever produces jaundice, the commonly known symptom of liver disease. It lodges in the liver and nibbles away at its cells over years. During this phase of 10-20 years, the host has hardly any symptom and hence does not seek medical attention. When considerable liver damage has resulted in liver cirrhosis (20%develop it), symptoms begin to appear: lethargy, fatigue, swelling of the feet, abdominal distention or vomiting of blood, drawing attention to this underlying cause. It also increases the risk of developing liver cancer.

There are 2 common scenarios: one is of a person in forties, who, while undergoing blood tests for a visa application or executive checkup finds his liver tests (SGPT) to be abnormal, and further tests reveal the cause to be Hepatitis C; or tests positive during screening for blood donation. Almost invariably, when asked, they recall having had a blood transfusion, surgery or injections with non-disposable needles. These are the lucky ones as their liver disease is usually not advanced, and stand a good chance of cure with anti-viral treatment. The other scenario is of a person, who presents with symptoms of Liver Cirrhosis, having had a blood transfusion from a commercial blood bank 20 or more years ago. They do not tolerate treatment well, their disease progresses relentlessly and find themselves in need of a liver transplanation.

Hepatitis C is the cause of liver cirrhosis in 20 -30%, alcohol and Hepatitis B being the other common ones. Any person who has underone a blood transfusion or surgery should get himself tested for this infection, as should anyone whose liver function test shows derangement. If diagnosed before much liver damge has occured, the infection is curable. Antiviral treatment consists of weekly injections of Interferon and daily tablets of ribavirin for periods of 6 to 12 months. The viral strain common in India (genotype 3) fortunately responds well to treatment, as more than 250 happy patients treated at SGPGI will tell you.

There is unfortunately no vaccine yet for preventing Hepatitis C, unlike Hepatitis B. Hence prevention and early detection assume greater importance. If you have ever received a blood transfusion or undergone a surgery, make sure you have taken the test for Hepatitis C, and have come out negative.

Published in HT City of Hindustan Times Lucknow edition dated 14 February, 2010.

Eating Disorders

A cinical problem of young people that is on the rise these days is Eating Disorders. It is a condition which affects an individual’s eating habits, either as a result of their own doing (self-inflicted), or as a bodily reaction to the consumption of food. Eating disorders can range from mild mental anguish to life-threatening conditions. The two most common varieties of eating disorders that have become well known because of the celebrities afflicted by them are Anorexia nervosa and bulimia nervosa.

Anorexia nervosa, whose sufferers include celebrities such as Victoria Beckham, Kate Winslet and Kareena Kapoor, is a condition in which significant weight is lost deliberately driven by a fear of distorted body image. It is a serious disorder that can lead to death.  The girl has an abnormally low body weight (the suggested guideline ≤ 85% of normal for age and height, or BMI ≤ 17.5), stops having her regular periods, and has an intense fear of gaining weight or becoming fat.She usually has a preoccupation with body  and shape, may be under considerable stress or depressed.

Bulimia nervosa is a cyclical and recurring pattern of binge eating followed by guilt, self-recrimination and overcompensatory behavior such as crash dieting, overexercising and purging to compensate for the excessive caloric intake.One of the celebrities who suffered from this disorder was Princess Diana who confessed "I had bulimia for a number of years. You inflict it upon yourself because your self-esteem is at a low ebb, and you don't think you're worthy or valuable. You fill your stomach up four or five times a day.Then you're disgusted at the bloatedness of your stomach, and then you bring it all up again. And it's a repetitive pattern, which is very destructive to yourself."

Anorexia nervosa and bulimia are ten times more common in women and together affect an estimated 5-7% of females in the United States during their lifetimes. Reports from India suggest that these disorders are on the rise; Dr Mammen from Vellore reported Psychogenic vomiting as the commonest eating disorder in Tamil Nadu.

What causes these problems in the young? Family and friends are very influential when it comes to eating disorders. The media may be a significant influence with its projection of size zero or a skin-and-bones body as being the modern image of beauty, which many young girls want to emulate. They are often associated with dpression or other mental disorders such as Obsessive-Compulsive Disorders. There is considerable ongoing research to show that levels of a hormone called cholecystokinin, which regulates satiety, is low in bulimics. Low levels of this hormone are likely to cause a lack of satiative feedback when eating, which can lead to overeating. Also an imbalance betwen 2 peptide hormones neuropeptide Y and peptide YY  which increase eating and another called leptin, released by fat cells and is known to decrease eating, could play a role.

Early recognition and understanding of these disorders, family support, and timely medical attention can get these young people back to normal fruitful happy lives.

Palliative Care: Adding life to days

While Medical science has significantly increased our life expectancy and made many diseases treatable, it has made our expectations soar to unreasonabe heights and dimished our capacity to accept death due to diseases that defy current treatment. Widespread cancer, dementia and advanced chronic diseases of the heart, lungs or liver are some examples that cause significant pain and suffering, progress relentlessly and render even the relatives helpless and frustrated.

Palliative Medicine (PM) may sound a paradox in modern times, as “it aims to add life or quality to the remaining days, in terminally ill patients”, says Dr Mhoira Leng, a British doctor presently working in Uganda, and a pioneer in this subspeciality, who was in Lucknow recently. “Providing relief of the  distressing and dehumanising pain to patients with terminal cancer can be one of the greatest boons of medical science that is unfortunately not often adequately utilized”, she added.

Experts in PM have to tackle several problems and at various stages. Their work often starts with breaking the bad news and counseling such patients and relatives, who are often in a state of denial or unrealistic expectation. Relatives of most cancer patients in India do not wish the diagnosis to be disclosed to the patient. As the disease progresses and hospital visits get more frequent, the patient usually starts suspecting the diagnosis, but finds himself surrounded by bluffing relatives, with whom he can no longer discuss with frankness his problems, preferences and last wishes. He often feels lonely and emotionally isolated in his last days.

At stake is the “care” that such patients receive. To most relatives (read well earning sons often staying elsewhere), it means taking the ailing parent from one hospital to another, often to another city, putting him through a battery of expensive re-tests, and hooking him on to machines in ICU setups, and keeping him ignorant of his diagnosis and fate. While all this provide some satisfaction to the relatives that they have done all that they possibly could, and mitigates their sense of guilt, it often adds to the patients misery, pain and suffering. Studies have shown that what he needs most is his own bed, his familiar home, loving relatives, and palliation of hid distressing symptoms that make his last phase of life so agonizing.

Relief of pain is crucial to caring for such patients. A recent study has shown that specialists in tertiary care hospitals are often more obsessed with performing one test after another, and paying much less importance to relieving pain. The recently started Pain Clinic and the Palliative Medicine services at SGPGI hope to change that. After assessing the severity of pain, therapy is tailored to the patient’s requirement. Apart from providing relief to the distressed patient and making him comfortable, it often sooths the nerves of bewildered relatives. The major challenge is to take such therapy to the patient’s bedside at home.

Jade Goody, the British TV star, died recently of advanced cervical cancer. Rather than in an alien atmosphere of a hospital surrounded by machines, she lived her last days with dignity at home, and that is where she preferred to die.