HEALTHYMINDS

Adolescent Conflicts: How to deal with them?

2011-07-31T20:56:00.000+05:30

This piece of information may be helpful for the parents and families where the children are approaching adolescence. Problems in these areas mostly lands the families in trouble.

The home should be a safe base

Adolescent children are exploring life, but need a base to come back to. Home should be the place where they feel safe, protected cared and will be taken seriously. A safe place is usually a peaceful one.

Mutual support

Parents need to agree between themselves about their basic values and rules, and be supportive and unambiguous in applying them.

It's difficult for a teenager to respect parents who are always at each other's throats or undermining each other. A common problem is for one parent to ally with their child against the other parent. This usually leads to constant family trouble.

Listening Really

Parents are a source of advice, sympathy and comfort, if they listen to the youngsters. A teenager needs to know that his or her parents will not automatically pass a judgement and criticise. They will be forthcoming with their problems, rather than raise a tantrum. Patient listening is important.

Rules

It is reasonable that parents should decide what the ground rules are. Whilst adolescents may protest, sensible rules can be the basis for security and agreement. They must be:

Clear, so everybody knows where they stand.
Where possible, they should be agreed with the children.
Consistent, so everyone sticks to them.
Reasonable.
Less restrictive as children become more responsible.

You can't (and shouldn't) have rules for everything. While some issues will not be negotiable, there should be room for bargaining on others.
Punishments, such as loss of pocket money, will only work if they are established in advance. Don't threaten these if you are not willing to carry them out.

Rewards for behaving well are just as important - probably more important, in fact.

In case of disagreements

Involve your children in making family rules - like all of us, they are more likely to stick to rules if they can see some logic to them and have helped to make them. If a teenager is reluctant to discuss rules for him or herself, they may still do this if they can see that it might be helpful for younger brothers or sisters.

A lot of things adolescents do may be irritating to parents (as parents probably irritate them), but not all are worth an argument. It's usually better to spend time on praising good decisions or behaviour. Many annoying habits will burn themselves out once parents stop reacting to them.

Don't compete with them

Adolescents are growing and gaining strengths, and having a lot of opportunities and may be very busy, making the parents feel older for the first time. At times jealousy can be the underlying reason for all sorts of arguments and trouble.

Physical punishment

Although it is now viewed as unhelpful, many people still occasionally smack younger children. It create’s the impression that violence is an acceptable way to solve difficulties. This means that they are more likely to grow up to use violence as adults. It can create a cycle of violence

Parents are the prime example

Although they are becoming more independent, the children will still learn a lot about how to behave from the parents. If you don't want them to swear, don't swear yourself. If you don't want them to get drunk, don't get drunk yourself. If you don't want them to be violent, don't use violence yourself. If you want them to be kind and generous to other people ….. try to be like this yourself. “Do as I say, not as I do” just won't work.

Thankless Teenagers

Don't worry if your children aren't as grateful as you' like. It's great if they are, but they may not be until they have children of their own and realise how demanding it can be.

When to seek help

Sometimes, all of this may not be enough and you (or your child) may be unable to cope. Worries about the physical changes of adolescence can be discussed with the family doctor
If there is violence in your family - parents hitting one another, children hitting each other, parents hitting children or children hitting parents - ask for help.
When problems arise at school, school refusal or decline in grades are there.
Psychological help may be needed if relationships are the issue.
Adolescents who experience turmoil or distress for more than a few months - persistent depression, anxiety, serious eating disorders or difficult behaviour - generally require professional help.
Specialist help can help the whole family.

Unravelling Adolescence Conflicts: Few Facts

2011-07-26T08:42:00.001+05:30

The Growing Years

The teenage years can be a source of emotional trauma for whole of the family. A void can grow between parents and their children during adolescence. Why should many of the families land into trouble?

It's a time of rapid physical development and deep emotional changes. These are exciting, but can also be confusing and uncomfortable for child and parent alike.
The process of rapid physical changes in adolescence is called puberty. The hormone changes responsible actually begin some years earlier and may produce periods of moodiness and restlessness.
Besides rapid physical growth and these changes include
For girls: menstrual periods, breast development, growth of under-arm, body and pubic hair.
For boys: voice becoming deeper, growth of body and pubic hair, facial hair, erections and nocturnal emissions.
Teenagers may sleep more as growth and development uses a lot of energy
Parents become less important in their children's eyes as their life outside the family develops.
Parents often feel rejected, and in a sense they are. But this is often necessary for young people to develop their own identity. In spite of the differences and arguments the children will usually think a lot of the parents.

Behavioural Problems in Adolescence
Teenagers and their parents complain about each other's behaviour. Parents often feel they have lost any sort of control or influence over their child.

Adolescents want their parents to be clear and consistent about rules and boundaries, but at the same time may resent any restrictions on their growing freedom and ability to decide for themselves.

Young people can crave excitement in a way that most adults find difficult to understand - and exciting activities may be dangerous.

Disagreements are common and normal, but when to conserned? As a general rule, the chances of children being at risk of getting into trouble are more if their parents don't know where they are. So, try to keep a track of what the children want and where they are going to spend their time

School Refusal can be due to:

difficulties in separating from parents
being perfectionist, and becoming depressed because they can't do as well as they would want to disturbed family life, with early separation from or death of parent.
an established pattern which may have started at primary school. Such children often have physical symptoms, such as headache or stomach-ache.
Bullying can also cause all of the above. Most young people do not break the law, but those who do are usually boys.

Many adolescents diet. Fortunately, few will develop serious eating disorders like anorexia or bulimia. However, these are more likely to occur in those who take up serious dieting, think very little of themselves, are under stress and who have been over-weight as a child.

Many teenagers experiment with alcohol and illegal drugs. Regular use of drugs or alcohol is much less common.

Adolescence has often been projected as bad time. However, the scenario is not as bad and most teenagers actually like their parents and feel that they get on well with them.

It is a time when the process of growing up can help people to make positive changes, and to put the problems of the past behind them.

It is not just a difficult stage, although it can feel very much like it at times. The anxiety experienced by parents is not one sided. Periods of uncertainty, turmoil and unhappiness are also experienced by the adolescent.

Difficult times come and go, but most adolescents don't develop serious problems. It's worth remembering this when things are difficult.

Parents may sometimes start to feel that they have failed. But still they continue to play a crucial part in their children's lives. Helping the children grow through adolescence can be profoundly satisfying.

Marital Therapy

2011-05-30T17:43:00.001+05:30

Marriage is one of the biggest gambles of life. If the gamble works, adjustment and compromise becomes the life mantra and if it doesn’t work then divorce or extramarital affairs are the outcome. If the marriage works, it doesn’t mean it is perfect. Perfect marriage is an illusion. It happens only in Mills and Boons novels. Once the honeymoon period is over, the curtain from the eyes is lifted and a clearer picture emerges. The same spouse who seemed to be carved out with utmost perfection becomes a bundle of imperfections. Fights, arguments, negative feelings & cribbing become a rule rather than an exception. If you feel that now nothing can happen and separation is the answer, think again. If love and motivation to stay together exists and no present extra marital affairs and violence or gross untreatable mental illness exists in either of the partner hope exists.

Marital therapy is the treatment of choice when such a problem becomes difficult to solve. The problem is approached in a step wise manner through a series of sessions. These are paced as per the problems in a professional and scientific manner. Few tips are given below.

No one is 100% bad or good. If there are lacunae within your partner, there must be something good as well. You can keep concentrating on the negatives and keep feeling worse but if there is anything positive, think about it which will give at least a ray of hope to move on.

Whenever feeling low, think of all the happy memories and the good times you spent together which will not only lift away the despair but also will help you in thinking clearly.

Years of marriage results in blame game whereby responsibility for anything that has gone wrong is passed on to the other partner. Shedding away the responsibility is the easiest thing to do and takes the guilt away as well. Think again. Attacking your partner will always result in defensive reaction by the other partner, the result of which will always be a fight.

Discuss issues with your partner, things that make you happy or sad, what are your expectations, how can this alliance be improved. Communication very important; which should be done in the right fashion. If you don’t talk; you can’t talk your way out.

Realise your own mistakes and how you rectify them. Change has to be brought in both the partners so why not start from your own self. Write down your positives and negatives and do the same for your partner as well.

Imagine how it would be like to be married to your own self. Then you might be able to understand the position of your spouse better. It would also help you in understanding your own self.

Long term marriages work on strengths and not weaknesses. Concentrate on the strengths of your partner and build upon it. Concentrate your energies in constructive things around you which give you happiness.

Depressed? Dont be.

2011-05-29T17:23:00.002+05:30

We all at some point in life we all have had periods of feeling blue. The feeling persists till the time the desired goal is not achieved or some compromise is done. Depression is a feeling state which persists over a long period of time causing disturbance in thinking, behaviour, feeling, biological functions, interpersonal relations and psychosocial functioning.

Depression is such a common problem that sometimes it is referred to as common cold of psychiatry. The depression may be unipolar or bipolar. It may be endogenous or exogenous. The cause may be either internal or external. There is imbalance of neurotransmitters in the brain. Sometimes the environmental conditions may be so harsh that inability to cope up may result in depression. The range of severity may differ from mild, moderate to severe. There may be prolonged periods of feeling sad, loss of interest in the self, world and the environment. There may be severe loss of energy and initiative taking. The guilt feelings can be extreme. The perception of the world becomes negative. Biological functions like sleep, appetite and sexual performance may deteriorate and in the extreme state, suicide may be sought. In psychotic depression, there may be extreme immobility and the patients may experience hallucinations and delusions as well. The contact with reality may be lost.

The treatment depends upon the severity of the condition. There are a lot of misconceptions ignorance and regarding treatment leading to a lot of unnecessary suffering and loss of productive time. Depression is not because of lack of effort from the patient. Don’t get angry if the person cannot be positive despite ‘instructions’.

In mild or moderate depression, the patient is managed either with Medications or Psychotherapies, with medications becoming more important as the severity increases. In severe depression, hospitalisation may be required whereby the patient is managed with medications. The medications given are very safe and effective if taken under proper supervision. These do not cause dullness and do not make a person lethargic. These are also not addicting or causing dependence. And the treatment results are most encouraging.

Anger Management

2011-05-21T07:20:00.003+05:30

Anger is an emotion related to one's psychological interpretation of having been offended, wronged or denied and a tendency to undo that by retaliation.

Being angry is not always bad. Anger is a normal human emotion, which prepares a person for dealing with the anticipated threat. Anger becomes a problem when due to various factors it becomes excessive, persistent, poorly controlled and starts interfering a person’s usual routine or social life.

Anger Management Therapies are tailor made as per the requirements of the clients. The personality, psychological mindedness of the clients, perspective on life and how the client has led one’s life is all crucial for determining the progress of therapeutic intervention. The number of sessions depends upon the severity of the problem. It can range from 5-10 sessions with adequate spacing in between.

Cognitive Restructuring is the treatment of choice. It is the process of guided self- discovery whereby the client realises that anger is just one of the many responses that can be given to any dissatisfying situation. Anger is felt when some goal is not achieved, things do not function the way they are planned or when dissatisfaction is felt over one’s life. The result is frustration and subsequently anger is felt. In Cognitive restructuring the clients are made to see the power of cognition as to how it can affect behaviour either positively/negatively which thereby determines the consequence. Cognitions are nothing but the belief system of the client. The situation is not held responsible for the action but the thoughts and beliefs are. One experiences anger and expresses it because there is fear of loss of control over the situation. This inability within oneself to tackle the situation fruitfully is hidden behind the facade of getting anger and hiding the insecure selves. So belief is generated within oneself and the clients are made to realise that they are not passive recipient of the harsh environmental forces but with ones beliefs, can change the consequences. Clients are made to realise with the help of techniques of Reflective listening, Motivational interviewing, Socratic questioning and empathetic understanding that anger at some point can serve some functional utility but if crosses the threshold then can be self destructive and debilitating. Other better options also exist which the clients fail to see which are then made more visible therapeutically. If one changes the belief regarding a situation and doesn’t feel threatened, then the consequences can also change.

A-B-C Model of anger management works by the understanding that the anger is a behaviour which has antecedents (i.e. the situations and conditions leading to Behaviour of being angry) and consequences (i.e. the after-effects of anger, e.g. being angry repeatedly can further sour a strained relationship, increasing chances of being angry). By manipulation of these antecedents (e.g. by trying to repair a strained relation) and consequences(e.g. delaying an angry response) in such a way that decreases the likelihood of thebehaviour of being angry.

Stress Inoculation Therapy is an option too, where the clients are inoculated against stress and trained to deal with stress effectively as the need arises. Anger is just one of the responses to frustration.

Mindfulness training where clients are trained towards self awareness and understanding that both good and bad are parts of the big picture and not isolated phenomena, leading to less violent reactions.

Metacognitive therapy is a higher order form of therapy where clients are trained to think about one’s own thoughts and to develop discrepancy between self owned thoughts. The clients can see, as a result, the fallacies in one’s own thinking process.

Other techniques are also taught which helps the clients to channelize their anger more productively. When in anger, analogy is given of a traffic signal. The clients are encouraged to “stop, look, think and act” which when followed can save oneself from accidents. Withholding ones immediate response can give some time to think and this can save oneself from impulsive decisions. One can drink a glass of water or box out ones anger on the bed are probably withdraw from the situation which can at least bring some momentary relief.

ANGER is only one letter short of DANGER

Weight loss: The Psychological Aspect

2011-05-12T00:11:00.000+05:30

Dealing with weight gain is one of the most difficult psychological tasks. Many people might not agree with this but having consensus on this issue is not the aim. The intention with which this piece is written is just to inculcate hope and motivation regarding one’s ability in dealing with their own body.

There are a lot of issues associated with weight gain which is why loosing weight is regarded as a psychological battle rather than a physical one.

Self image which is derived primarily from body image is an important facet associated with person perception which our opinion is regarding our own self. How others perceive us also forms an important part of self image which largely determines our self esteem. Having an appropriate body weight is considered attractive. The day you look good is the day you feel good. If you feel good, self confidence shoots up and vice versa. Slow weight gain is like slowly losing control over one’s body and involuntarily surrendering oneself. Slowly we sit in silent and magical anticipation that a day will come when we will be able to fit ourselves in the old jeans. But obviously that day never comes. Sizes sought after are mostly L or XL with just cold sighs towards the S or M range. Dining outside is always associated with severe guilt which is compensated for by missing the next day breakfast or lunch and suffering perennially from hunger pangs. The taste of biryani is forgotten, cold drinks and meethi lassis are replaced by cold water. Mangoes and bananas are replaced by water melons, oranges or grapes. Wardrobe slowly is overflowed with baggy like clothes and good fitting clothes are said bye-bye to. One avoids fridge as if it contains some infectious microbes which will contaminate you permanently .The routes are changed so that the favourite sweet shop or junk food outlet is not crossed. One remains always hungry and frustrated. The results are either bulimic munching or anorexic dieting. Eventually long term outcome is loss not of those extra kilos but of self esteem, self confidence and happiness .

But the belief in oneself that one has control over one self is like half the battle won. The golden rule behind weight loss is not exercise primarily but PERSEVERENCE and MOTIVATION. These important traits are responsible for any act whereby long term goal is expected. Shedding those extra kilos is not impossible task nor does it require the help of those weight loss pills or slimming centres which claim weight loss of 3-5kgs in a short time. It results in more harm than good. If one is motivated enough to realise ones goals, there is no stopping. Motivation to shed those extra kilos will act as a fuel to the fire and if it is backed by perseverance then the aim is not far reaching any more. Usually time is taken out for all the important tasks except exercise. Remember that you are important, all the work and the world can take a back seat. If you can’t love or take care of your own self, how can you love or take care of others. Respect your own self first. Give yourself priority. In 24hrs, take out at least ½ hr for exercise. You can dance, do aerobics, cycle, treadmill or walk, do yoga or whatever form of exercise you prefer. Fix this time. Use music to make it enjoyable. Every mobile phone has got this option. Whatever you do, just do it regularly. Sunday can be an off day.

PATIENCE and HARD WORK is the key to success. Just give yourself a time frame and aim at loosing 5-6kgs. It is not a question of a month or two; it might take a year, so just keep going on. Something which you have nurtured over all these years like your own baby will take some time to shed away. Do not weigh yourself every day. Just hide the machine and weigh yourself once a month. It is very much acceptable that you do not loose even an inch in two months. Every machine takes some time to pick up momentum. Our body is the most astounding god made machine. The resistant extra kilos which have accumulated over all these years will take some time to go. When you invest your money, the long term investment pays higher dividends. Similarly you are investing time in your body, returns will take some time. After first three months of regular and rigorous exercise, returns will be visible. The body will be more toned up, mood will be fresh, and probably one or two kgs are lost. From there on, aim at loosing 1 kg per month. If the weight loss is slow, weight gain will also be slow. But never over do. Listen to your body.

Accompanying this is the right kind of DIETARY HABITS. Do not avoid healthy food like rice, roti, fruits, vegetables or non veg. The amount needs to be monitored. One can avoid excess oil, unsaturated fats, red meat, artificial beverages etc. People often stay hungry while dieting which should not be done. Where will you get the energy from to exercise? You should be found on the treadmill or park and not on the hospital bed. Eat everything but in moderation. Never skip breakfast, that’s the most important meal of the day. Avoid paranthas, eat roti instead or brown bread. Never push out anything completely from your diet like sugar or rice or meat etc. When you restart all these things, you gain more rapidly. Our body requires all these things including fats. You can even treat yourself to your favourite sweet or dish or can dine outside after a week. Eat small portions more frequently rather than following thrice a day meal plan. Eating in short intervals will kill the hunger pangs and the amount of food intake for the next meal will be reduced. The cravings will also reduce. Along with your body one has to take care of one’s face as well. Do not loose the lustre of your face in the race to shed off those extra kgs. Facial will improve only outside skin. If the skin is healthy it will show.

Be REALISTIC in your aim. One has to decide how much is extra and this goal has to be realistic. Every body’s body chemistry is variable and therefore the response to exercise differs. Be realistic in the amount of weight you want to loose. Do not expect drastic results. Do not aim at size zero as well. Every body’s tendency to loose or gain kgs is variable. Stop comparing yourself to your friend who has followed the same diet plan as yours and doing the same set of exercise yet has shown better results than you. Whenever your hope start diminishing or motivation starts dwindling, thing of what you will look like after 6-7 months, the feeling of getting back into your old jeans or eating as much as you want, is motivating enough.

“Every time I feel like exercising, I lie down till the feeling passes”, if your life mantra is this.....then you do not need anything but motivation.

Child Psychology: Behavioural Management of problem behaviours in Children

2011-03-06T13:19:00.000+05:30

The following is the out line of modules used to manage manage Problem behaviors in Children. It is not an exclusive list and is intended only for education of Parents and Caregivers. These are highly effective and proven measures of intervention.
The strategies are arranged as to be least intrusive to most intrusive. Therapist should be clear and confident about specific strategies. Parental consent is a must for using these strategies.

Depending on the degree of the problem, the strategies are used at several levels.

Level I: It includes manipulation of the antecedents that trigger the problem behaviours.
Eg. If a child is engaging himself in thumb sucking behaviour whenever he is free this behaviours can be reduced by keeping him busy in some adaptive manual activities like, counting objects, finger painting etc.

Level II: Strategies of differential reinforcement, where Differential Reinforcement refers to the process in which desirable behaviours are reinforced and undesirable behaviours are not reinforced.
Types:
1. Differential reinforcement of low rate behaviors (DRL).
2. Differential reinforcement of other behaviours (DRO)
3. Differential reinforcement of incompatible behaviours (DRI)
4. Differential reinforcement of alternative behaviours (DRA)

DRL: It is used when the primary focus is to reduce the behaviour but not to eliminate the behaviour.
Eg: If child has habit of shouting we can’t expect him to totally stop talking but he will be rewarded when he speaks at normal voice.

DRO: When a target problem behaviour has not occurred/ or been postponed for a specific period of time, then the reinforcement is provided.
Eg: If a child has a habit of getting up from seat frequently, he would be reinforced when he remains in seat for a specific period of time.

DRA: Here reinforcement is provided on occurrence of alternative desirable behaviours.
Eg: In a specific interval, if the child asks permission to go out rather than running away, he will be rewarded for asking permission (i.e. alternative behaviour).

DRI: In this module, reinforcement is provided on occurrence of the behaviour that is physically incompatible to the problem behaviour.
Eg: If child has the habit of thumb sucking, he will be engaged in some manual activity so that his hand will not be free for sucking. And reinforcement is given when he engages in that particular manual activity.

Level III:
Extinction: It simply means terminating reinforcing event that maintains problem behaviour.
Eg: If a child cries only to get the attention of adults that can be safely ignored.

Extinction is mainly used for attention seeking behaviours or if, the function is clearly measurable.
It should not be used if the function of behaviour is escape or self stimulatory.

Level IV: Removal of undesirable behaviour stimuli. It includes 2 techniques:

Response cost: If a child shows a particular target behaviour he will be made to pay cost for it.
Eg: Tokens or rewards may be withdrawn when a child breaks an object. But, this technique is possible only when the child has some token/rewards and does not run out of them to pay as cost.

Time-out: It means, removal of reward from the child or the child from reinforcing situation.
Eg.: While everybody is playing, if a child is disturbing others with a toy, the toy will be taken away from him or he will be removed from the situation for a specific period of time.
In case, if time-out room is used, the child should not be secluded for more than 1 to 5 minutes. And there should not be any recreational or potentially dangerous articles in the time- out room.
This strategy should not be used with very young children, or if they have associated medical problems like seizures etc. or if the function of behaviour is “escape” or “self-stimulatory”.

Level V: Presentation of aversive stimuli.

Unconditioned aversive stimuli: It includes the use of stimuli like water spray directly on face or mild tick or pungent odors. But this strategy is very rarely used. It is proved to be successful in managing stereotypical behaviours.

Conditioned aversive stimulus: As in conveying verbal displeasure (Like, an emphatic ‘No’)

Over-correction: It is considered to be educative. The purpose of overcorrection is to teach student to take responsibility for their problem behaviour and teach them desirable behaviors. It involves two methods.
a. Bringing the situation back to normalcy (Restitution)
b. Teaching appropriate behaviour (Positive practice)
Eg: If a child spits on the floor, he will be made to wipe the place (Restitution) and also taught where to spit, like in a wash-basin. (Positive- practice).

Sexual Disorders: Premature Ejaculation

2011-02-06T12:30:00.000+05:30

According to the tenth revision of International Statistical Classification of Diseases and Related Health Problems (ICD-10, WHO), sexual dysfunction refers to a person's inability to “participate in a sexual relationship as he or she would wish.” The dysfunction is expressed as a lack of desire or of pleasure or as a physiological inability to begin, maintain, or complete sexual interaction.”
They can be lifelong or acquired, generalized or situational, and due to psychological factors, physiological factors, or combined factors. They can be attributable entirely or partially to a medical condition, drug/alcohol use, or adverse effects of medication.

PREMATURE EJACULATION (PME)
From an evolutionary point of view, a rapid completion of coitus is more adaptive in situations where predators are at large, but then we have moved out of jungles a long time back.
In PME, the man repeatedly reaches orgasm and ejaculation occurs before he desires to do so...and before there is full satisfaction in the sexual act. There is no definite time frame within which to define the dysfunction. The diagnosis is made when the man regularly ejaculates before or immediately after entering the vagina or after minimal sexual stimulation. Sometimes 15 seconds taken as the upper time limit, at other times when a man could not control ejaculation long enough during intravaginal containment to satisfy his partner in at least half of their episodes of coitus).

Duration = ?

The factors that affect duration of the excitement phase, such as age, novelty of the sexual partner, and the frequency and duration of coitus should also be considered before making a diagnosis.

Difficulty in ejaculatory control is sometimes associated with anxiety regarding the sexual act. Both anxiety and ejaculation are mediated by the sympathetic nervous system. Other psychological factors that can contribute are sexual guilt, a history of parent–child conflict, interpersonal hypersensitivity, and perfectionism or unrealistic expectations about sexual performance.

Few men are more vulnerable to sympathetic stimulation, hence, they ejaculate rapidly. Others have found a shorter bulbocavernosus reflex nerve latency time in men with lifelong premature ejaculation than in men who had acquired the dysfunction.

Premature ejaculation also may result from negative conditioning. The man who has most of his early sexual contacts in situations in which discovery would be embarrassing, such as there is lack of privacy or with has had prior intercourses with prostitutes who demand that the sex act proceed quickly, become conditioned to achieving orgasm rapidly.
A stressful marriage exacerbates the disorder.

The problem is quiet common, but under reported due to obvious reasons. About that 30 percent of the male population are reported to suffer, and approximately 40 percent of men treated for sexual disorders have premature ejaculation as the chief complaint.

Sex therapy

This shoud be done under supervision of an expert only. In cases of premature ejaculation, an exercise known as the squeeze technique is used for the purpose of raising the threshold of penile excitability. In this exercise, the man or the woman stimulates the erect penis until the earliest sensations of impending orgasm and ejaculation are felt. Penile stimulation is then abruptly stopped, and the coronal ridge of the penis is squeezed for several seconds. The technique is repeated several times.

Another variation is the stop–start technique, in which stimulation is interrupted for several seconds but no squeeze is applied. The man is encouraged to focus on sensations of excitement rather than distract himself from them. This makes him more familiar with his excitement pattern and lets him feel in control rather than overwhelmed by sensations of arousal. Communication between the partners is improved because the man must let his partner know his level of sexual excitement so that she can squeeze the penis before the ejaculatory process has started. Sex therapy has been successful with some premature ejaculators; however, a subgroup of dysfunctional men may need pharmacotherapy as well.

Medications

Delayed orgasm is a peculiar side effect of Selective Serotonergic Reuptake Inhibitors type of antidepressants, and this aspect has been used to prolong the sexual response in patients with premature ejaculation. This approach is particularly useful in patients refractory to behavioral techniques or who may have physiologically determined premature ejaculation.
Dapoxetine is a new, short acting SSRI specifically developed to treat premature ejaculation.
Other on demand treatment for premature ejaculation is topical anaesthetic such as lidocaine cream or spray in mild strength, which is applied to the glans of the penis.

Again all these approaches are to be used only under medical supervision.

Drug use in Pregnancy- FDA Categories

2010-12-21T23:39:00.001+05:30

In view of such events as the thalidomide crisis in the 1960’s when in-utero exposure lead to Phocomelia, and the teratogenic effects of diethylstilbestrol in 1979 US Food and Drug Administration developed strict guidelines regarding drug labeling, use of medications in pregnancy with safety parameters before it was marketed.
FDA classifies various drugs used in pregnancy into five categories, categories A, B, C, D and X. Category A is considered the safest while category X is absolutely contraindicated in pregnancy.

Pregnancy Category A
Adequate and well-controlled human studies have failed to demonstrate a risk to the fetus in the first trimester of pregnancy (and there is no evidence of risk in later trimesters).

Pregnancy Category B
Animal reproduction studies have failed to demonstrate a risk to the fetus and there are no adequate and well-controlled studies in pregnant women OR Animal studies have shown an adverse effect, but adequate and well-controlled studies in pregnant women have failed to demonstrate a risk to the fetus in any trimester.
Pregnancy Category C
Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.
Pregnancy Category D
There is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.
Pregnancy Category X
Studies in animals or humans have demonstrated fetal abnormalities and/or there is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience, and the risks involved in use of the drug in pregnant women clearly outweigh potential benefits.
Source

Journal Impact Factor

2010-12-19T09:22:00.003+05:30

The best evaluation system for the quality of a Journal would involve actually reading all its articles but then the amount of information available is too much, and expanding for this sort of evaluation to carry on.

Here comes the role of Journal Impact Factor.

The Impact factor was devised by Eugene Garfield, the founder of the Institute for Scientific Information, now part of Thomson, a large worldwide US-based publisher.

It is not a perfect tool but is generally considered a good technique for scientific evaluation. For those who have some experience in research publications will know that it is difficult to get an article published in the best of journals, which incidentally also have the highest impact factors.

CALCULATION

The impact factor for a journal is calculated based on a three-year period. It can be viewed as an approximation of the average number of citations in a year, given to those papers in a journal that were published during the two preceding years. For example, the 2003 impact factor for a journal would be calculated as follows:

A = the number of times articles published in 2001-2 were cited in indexed journals during 2003

B = the number of "citable items" (usually articles, reviews, proceedings or notes; not editorials and letters-to-the-Editor) published in 2001-2

2003 impact factor = A/B

(note that the 2003 impact factor was actually published in 2004, because it could not be calculated until all of the 2003 publications had been received.)

A convenient way of thinking about it is that if a journal is cited once for each article published it will have an Impact Factor(IF) of ‘1’ in the expression above.

In the field of psychiatry... Archives of General Psychiatry is the Highest rated in terms of IF. The impact factor of Indian Journal of Psychiatry cannot be calculated as of now as it has been indexed for less than an year.

Sci-Bytes provides ranking and impact factor for selective journals. The list is located here:

http://www.sciencegateway.org/rank/index.html

COGNITIVE BEHAVIOURAL THERAPY

2010-11-06T23:16:00.005+05:30

 

Even if you take a pill for every ill, medications can't do everything.

 So the next step is COGNITIVE BEHAVIOURAL THERAPY. Few facts below.

IS IT USEFUL?
CBT is one of the established methods of treatment of mental health problems.
It is one of the most effective treatments for conditions where anxiety or depression is the main problem
It is the most effective psychological treatment for moderate and severe depression
It is as effective as antidepressants for many types of depression

WHERE DOES IT HELP?
It can help people suffering from Anxiety, depression, panic, phobias (including agoraphobia and social phobia), poor stress coping, eating disorders, obsessive compulsive disorder, post-traumatic stress disorder.
Those with anger outbursts, or with a low opinion of self or chronic physical health problems, like pain or fatigue, can also benefit a lot.

HOW DOES IT WORK?

It is a way of talking about:
How you think about yourself, the world and other people?
How what you do affects your thoughts and feelings?
CBT can help you to change how you think ("Cognitive") and what you do ("Behaviour)".
These changes can help you to feel better.
There is focus on the "here and now" problems and difficulties instead of focussing on the causes of distress in the past.

Problems can be overwhelming... but by breaking them down into smaller parts... makes it easier to see how they are connected and how they affect you.

In a test situation (e.g.a problem, event or difficult situation), there can follow: Thoughts + Emotions + Physical feelings + Action.

Each of these areas can affect the others.

The key point is How you think about a problem... it can affect how you feel physically and emotionally. It can also alter what you do about it.

AN EXAMPLE
Situation: After a bad day in office, feeling tired, you drag yourself for shopping and while coming back, your neighbour walks by you, apparently, ignores you.
REACTION 1: Unhelpful

Thoughts: He/she ignored me – it means they don't like me
Emotional Feelings: Low, sad and rejected
Physical: Stomach cramps, low energy, feel sick
Action: $##@*@#$, Go home and avoid them

REACTION 2: Helpful

Thoughts He/she looks a bit wrapped up in themselves - I wonder if there's something wrong?
Emotional Feelings: Concerned for the other person
Physical: None - feel comfortable
Action: Get in touch to make sure they're OK

There are helpful and unhelpful ways of reacting to most situations, depending on how you think about them.
When we are distressed, we are more likely to jump to conclusions and to interpret things in extreme and unhelpful ways.
CBT can help you to break this vicious circle of altered thinking, feelings and behaviour.

When you see the parts of the sequence clearly, you can change them - and so change the way you feel.

CBT aims to get you to a point where you can "do it yourself", and work out your own ways of tackling these problems.

DIFFICULTIES WITH CBT
CBT is not a quick fix. It takes time and effort both from the patient and the therapist.
The therapist advises and encourages - but cannot 'do' it for the patient. If someone is feeling low, it can be difficult to concentrate and get motivated.
To overcome anxiety, it has to be confronted. This may lead you to feel more anxious for a short time.

Smile, it's free therapy

Anxiety: Normal to Disorder

2010-08-31T22:17:00.005+05:30

What is anxiety?

It’s a vague unpleasant emotion that is experienced in anticipation of some future misfortune
A state of apprehension, uncertainty or fear, resulting from the anticipation of a realistic or imaginary threatening event or situation
May have emotional, behavioural, cognitive and physical components

Anxiety is commonly experienced by virtually all living beings including humans. It is an alerting signal and warns of threat, both internal and external, and is the first line of defense.
When the body prepares to deal with a threat: blood pressure and heart rate are increased, sweating is increased, blood flow to the muscles is increased, and other functions are inhibited (the fight or flight response) causing what we call the manifestations of anxiety.
It prepares us for the situations, and its consequences. It is beneficial to an individual and is NORMAL.

Anxiety and Performance
An increase in the anxiety to some extent helps a person grow and improve his performance.
In very low level of anxiety, performance is very low, as the anxiety increases the performance increases. A phase comes when performance is at its peak any increase in anxiety does not increase performance. At this stage any anxiety leads to discomfort. Now the anxiety symptoms will appear and any increase will reduce the performance and may lead to deterioration.
The complete absence of anxiety is as pathological as excessive anxiety.

Anxiety Disorders
When anxiety becomes excessive, and being detrimental rather than adaptive, then it fall's under the classification of an anxiety disorder. There are several specific forms of the disorder as per the current classificatory systems. Some of these are: Agoraphobia, Social phobias, Specific (isolated) phobias, Panic disorder, Generalized anxiety disorder, Mixed anxiety and depressive disorder, Anxiety disorder- unspecified.

Anxiety can also be a symptom of any other underlying medical condition such as mitral valve prolapse, hypoglycemia, pheochomcytoma, hyperthyroidism, hyper parathyroid, cardiac arrhythmias, seizures, chronic obstructive pulmonary disease (COPD), heart failure; or as a part of drug abuse and withdrawls.

Identify the Anxiety Symptoms
1- Physiological

Palpitations or thumping of heart.
Tremors
Tightness of chest and choking sensation
Difficulty in breathing
Hyperventilation
Sweating
Dizziness
Tingling
Urinary frequency
Increased motility of GI tract
Restlessness
Insomnia
Pupillary dilatation
Light headedness

2-Psychological

Diffuse,vague, unpleasant sense of apprehension, fearfulness,
Nervousness, irritability
Inability to relax,
Poor concentration
Inability to think clearly
Derealisation, depersonalization
Feeling of impending doom / disaster, the perception of danger is very real, as if he or she is about to die or pass out.

“There are more things to alarm us than to harm us, and we suffer more often in apprehension than reality.”

International Day against Drug Abuse and Illicit Trafficking (26 June, 2010)

2010-06-13T09:18:00.002+05:30

Health is the theme of this year's world drug campaign, to be launched on International Day against Drug Abuse and Illicit Trafficking (26 June, 2010).

The United Nations Office on Drugs and Crime (UNODC) is leading the international campaign to raise awareness about the major challenge that illicit drugs represent to society as a whole, and especially to the young.

The goal of the campaign "Think health - not drugs" is to mobilize support and to inspire people to act against drug abuse. The campaign encourages young people to put their health first and not to take drugs.

Drugs have the power both to improve and to damage health, depending on the type of drugs used, the quantity consumed and the purpose for which they are taken. For example, while morphine can relieve pain, heroin can be highly addictive. Such examples illustrate the need to control drugs.

Drugs under international control include amphetamine-type stimulants, cannabis, coca/cocaine, hallucinogens, opiates and hypnotic sedatives, all of which have immediate physical effects. While some of the physical effects might sound pleasant, they do not last long. Drugs can also severely hinder psychological and emotional development, particularly in young people. In addition, some users risk addiction.

Drug use is preventable. UNODC has developed prevention activities that provide the public, particularly young people, with the information, skills and opportunities they need to make healthy choices, including the choice to avoid using harmful drugs.

The world drug campaign calls on young people, who are twice as likely as adults to take drugs, to protect their health.

Parents, teachers and other interested individuals can also join the campaign. There are a number of ways to get involved, including providing information, by spreading the word about the campaign and organizing outreach or institutional events to mark International Day against Drug Abuse and Illicit Trafficking on 26 June.

We can all play a role in promoting health in our communities.

Signs of drug use

Although there are certain emotional and physical symptoms of substance use, do not immediately assume that the person is on drugs. There could be other reasons why he or she behaves unusually.

Emotional and social signs
• Moodiness, excitement, anger, hostility, depression
• Constant lying and stealing
• Refusing to admit to the harmful effects of drugs
• Avoiding old friends or people who could confront them about behaviour changes
• Being secretive about phone calls
• Having friends they do not want you to meet or talk about
• Being evasive about their whereabouts
• Loss of motivation
• No interest in everyday life
• Playing truant from school

Physical signs
• Drowsiness
• Trembling
• Red eyes, dilated pupils
• Lack of interest in personal hygiene and appearance
• Slurred speech
• Loss of, or increase in appetite
• Uncoordinated movements
• Circles under the eyes
• Irregular sleeping habits
• Frequent colds and coughs
• Weight loss

(source: www.unodc.org)

The Human Clock: CHRONOBIOLOGY

2010-06-09T12:37:00.005+05:30

It seems natural but why in a 24 hours day do we sleep at night and work in day, and why does ‘shit happens’ mostly in the mornings? Our biological routines are mostly time bound…and that too round the clock.
A clock can be defined as an instrument used to indicate, keep, and co-ordinate time. Clocks have advanced from being the sun dials of ancient times to the ultra modern atomic clocks.

But there is another clock, besides the one hanging on the wall… inside our body. It is fitted in our brain. It determines the rhythmicity of our biological routines like being alert in day, sleepy at night. And the study of “biological time” or biological rhythmicity is called Chronobiology.

Among biological rhythms, circadian (in Latin: circa= about; dies= day) rhythms are the most extensively studied. The activity–rest (i.e. wake-sleep) cycle is the most apparent of all circadian rhythms.

There are various less overt phenomena going on inside our body which depend on this clock, such as many hormones are released in a pulasatile manner, heart attacks are more common in early mornings, the blood pressure varies at different times of day- being maximum in evenings, the normal body temperature is maximum in the evenings and lowest in early morning before dawn. The fever of tuberculosis also has an evening rise; the alertness in daytime also varies in between the day, being most alert in the forenoon. Although there can be exceptions… these processes are more or less time bound.

This human ‘clock’ resides in an area of brain- the anterior hypothalamus and is called suprachiasmatic nucleus (SCN) by the scholars. And it does not agree with the wall clock.

The mean circadian period generated by the human clock (or SCN) is approximately 24.18 hours. The wall clock completes an astronomical day/cycle in 24 hrs. So the human watch ticks 10 minutes and 48 seconds too slowly per day. Therefore, a circadian/human clock must be reset on a regular basis to be effective at maintaining the proper phase relationships of behavioral and physiological processes within the context of the 24-hour day. If not done, an individual will gradually come out of synchrony with the astronomical day. In slightly more than 3 months, a normally diurnal human would be in opposite phase to the day–night cycle and thus would become transiently nocturnal i.e. wakeful at night and sleeping in day.
Best wishes for your Time Check.

New Year Resolutions: A Blank Board?

2010-01-03T02:39:00.004+05:30

Good resolutions are simply checks that men draw on a bank where they have no account...Oscar Wilde

New Year's is a harmless annual institution, of no particular use to anybody. Along with the provision of nice parties, it has become customary to make a nice wish list also called NEW YEARS RESOLUTIONS. These range from promising to exercise regularly and loose weight, to being honest, be good to others, quit smoking/drinking, work harder, relax more etc. Many will vouch for change in the arriving year but how many of them do actually keep their promise?

The responsibility and capability for change lie within the person. The fact of the matter is that reward/hope of a positive outcome should be ingrained within the act that one is trying to achieve, i.e. the changed state brings pleasure or makes one feel significant. The motive for change should come from within. If external factors are the driving force, it doesnt last too long. The promise for change should be to ourselves and not to the new years! This is simply a slippery seduction. The key element of transformation is a clear and firm decision to change.There is truth to the saying that we can "talk ourselves into" a change. If I say it, and no one has forced me to say it, then I must believe it! And the way to get started is to quit claiming and begin doing.

May all your troubles last as long as your New Year's resolutions!

Punishment for children – Is it judicious or ridiculous?

2009-12-27T21:37:00.012+05:30

Many parents come for help reporting that…‘Mine is a problem child’, ‘can’t manage the tantrums’, ‘disobedient’, ‘too demanding’, ‘disrespectful’ ‘can’t control him/her’, and a lot of other problems.

So what is the role of punishment in bringing up a child?

Punishment should be used sparingly, and as a last resort on children. It should not become a way of taking revenge, insulting or humiliating the child. It should be administered with the aim of helping the child develop an internal control over self for the bad habits.

Technically it can be defined as presenting an aversive stimulus contingent on the target behaviour for the purpose of decreasing the target behaviour.

The first strategy should always involve “positive strategies” such as

• Rewarding for good behaviour (just praising verbally is usually more than sufficient, more elaborate schemes may include gifts, picnic/party or whatever suits your scene).

• Not meeting the demands of the 'bad behaviour' in the initiation only (so as to avoid setting up of an unhealthy pattern; an unrewarding act is likely to get extinguished on its own).

• Withdrawing some privileges (e.g. I will not play with you today) as you did this bad behaviour.

Explain to the child what wrong he/she has done, and that it is undesirable, and that you are reacting to it, and that you would not do it if the ‘bad behaviour’ was not there. You should be sure of what you are doing, and be consistent with it.

Excessive use of punishment only decreases its efficacy, and in the long run causes strained relations between parent and child, and if you are very unlucky, the child learns to deceive you by lying and hiding mistakes for the fear of punishment. Beating up the child is usually undesirable; it is mostly the result of parent anger rather than purpose of helping the child… and the child can also learn from Your aggressive behaviour. Punishment may be called the lowest form of education.

Spend time with your child, it will help avoid development of problem behaviours, and you will know what causes bad behaviour when it is there.

The Paa Problem... PROGERIA

2009-12-09T18:40:00.019+05:30

Auro is suffering from 'Progeria'.

The word Progeria is derived from the Greek progeros meaning 'prematurely old'. The Greek word pro means 'before', while the word geras means 'old age'. It is an extremely rare, fatal genetic condition.Progeria affects children and gives them an appearance of accelerated aging.

Progeria Factfile

About 100 cases (only!) have been formally recorded in medical history till date.
There is a 1 in 8 million chance of having it!
Children with Progeria are born looking healthy.
Features of aging that should start in 60s, start to appear as the child ages past infancy.
Growth failure, Loss of body fat, Loss of hair, and a distinctive facial appearance (small face and jaw, pinched nose) are all characteristic of progeria.
They will have small, fragile bodies, like those of elderly people.
Later, the condition causes wrinkled skin, atherosclerosis, and cardiovascular problems.
Progeria patients generally die in early teens.
Most die from cardiovascular complications.
Patients with Progeria have a mutation on the gene that encodes a protein “Lamin A” whose fuction is to hold the nucleus of the cell together.
The defective Lamin A protein makes the nucleus unstable, which leads to the process of premature aging.
This is a rare gene change which happens purely by chance, and not inherited.
For treatment few anti cancer drugs (eg Lonafarnib- a type of Farnesyltransferase inhibitor) are being tried but with minimal success.
Mainstay of management is symptomatic and supportive medical care for complications; supportive psychotherapy for patient as well as care givers.
Any research into finding a cure for Progeria would probably have results which would benefit adults with diseases linked to aging.

Reference

Scaffidi P, Gordon L, Misteli T (2005) The Cell Nucleus and Aging: Tantalizing Clues and Hopeful Promises. PLoS Biol 3(11): e395. doi:10.1371/journal.pbio.0030395

Why SHOUT?

2009-08-22T23:34:00.006+05:30

A saint asked his disciples, 'Why do we shout in anger? Why do people shout at each other when they are upset?'

Disciples thought for a while, one of them said, 'Because we lose our calm, we shout for that.''
But, why to shout when the other person is just next to you?' asked the saint. 'Isn't it possible to speak to him or her with a soft voice? Why do you shout at a person when you're angry?'

Disciples gave some other answers but none satisfied the saint.
Finally he explained, 'When two people are angry at each other, their hearts distance a lot. To cover that distance they must shout to be able to hear each other. The angrier they are, the stronger they will have to shout to hear each other through that great distance.'

Then the saint asked, 'What happens when two people fall in love? They don't shout at each other but talk softly, why? Because their hearts are very close. The distance between them is very small...'

The saint continued, 'When they love each other even more, what happens? They do not speak, only whisper and they get even closer to each other in their love. Finally they even need not whisper, they only look at each other and that's all.
That is how close two people are when they love each other.'

Happy ............ day!

2009-08-09T22:55:00.011+05:30

Birthdays make us feel special, and anniversaries bring back the joy (or the sorrows) of our past. Parties are good fun to have, socialize and diversify.
But for this, why the need of some specific excuse which really serves as no better than a nomenclature of sorts. What of the rest of 364 days?
I have always been wondering, what is the importance of so called “special” days in our life? In fact I find myself in minority when I say all days are equal for me, I don’t want birthdays or anniversaries to be celebrated. Consider exchanging gifts on one day (anniversary) and brickbats most of the year. Celebrating a theme for a day and then forgetting it (or putting on reminder for next year) seems a show off, plastic and banal (retarded at times!). Each theme is for every day to enjoy, rather than to compartmentalise it to “those” days.
So enjoy every moment. And HappyEveryday!

Schizophrenia... Disorganised Thoughts

2009-08-01T22:26:00.025+05:30

Given below is the actual account given by one of my patients. Please read till end to understand what gross problems he had in his thinking processes.

He was asked wether he knew Mahatma Gandhi, to which he told yes and described Him as follows....

The above speech sample demonstrates a type disorganisation of thought that is technically called by psychiatrists as 'loosening of associations'.

It is a pattern of spontaneous speech in which the ideas slip off the track onto another one which is clearly but obliquely related, or onto one which is completely unrelated. This pattern of speech is often characterized as sounding "disjointed.’ There is a slow, steady slippage, with no single derailment being particularly severe, so that the speaker gets farther and farther off the track with each derailment, without showing any awareness that his reply no longer has any connection with the question which was asked. This abnormality is often characterized by lack of cohesion between clauses and sentences and by unclear pronoun referents.
Termed simply... there is lack of cohesion leading to disintegration of core of self, and relationship to reality.

It is one of the impotant symptoms of illness called Schizophrenia, which has many other aspects like hallucinations and delusions, along with socio-occupational dysfunction.

The above person was diagnosed as suffering from Schizophrenia and showed good improvent with medications and occupational therapy. He is now back with his family and has started working at his brothers shop.

(Patients Identity witheld on ethical grounds)

Understanding Emotions

2009-07-26T08:05:00.037+05:30

'तेरा इमोशनल अत्याचार'.... taking cues from this popular song,lets give a few thoughts about emotions.

Emotion is a mental state involving a distinctive feeling tone. It is defined as “a moved or stirred-up state of an organism caused by physiological changes occurring as a response to some event and which tends to maintain or abolish the causative event.”

Emotion includes a wide range of observable behaviors, expressed feelings, and changes in the body state. This diversity in intended meanings of the word emotion makes it hard to understand and study. For many of us emotions are very personal states, difficult to define or to identify except in the most obvious instances. Moreover, many aspects of emotion seem unconscious to us. Even simple emotional states appear to be much more complicated than states as hunger and thirst. The expression of emotion is also an effective means of communication.
There are four basic components of emotions:

1. The physiological aspect, which involves active changes in the body physically, e.g., tachycardia (rapid heart rate), tachypnoea (fast breathing), dilated pupils etc. For example, try to recall the pounding heart and dry mouth, just before looking at the notice board for the annual exam results.

2. The cognitive component, which emphasizes the importance of thoughts, beliefs, and expectations in determining the type and intensity of emotional response. For example, if we look back and think about our friends/relatives, we do recall that ‘sensitivity’ was inbuilt in some.

3. The behavioural component, which involves the various forms of expressions that emotions may take , e.g., facial expressions, bodily postures, gestures, and tone of voice which changes with anger, joy, fear, sorrow, etc. Some ‘express’ more, others less. As in, in our culture girls have a much free hand at crying, if they cry it’s ok, and when boys do that, they are ‘sissy’.

4. The subjective experience, which includes elements of pleasure, or displeasure, intensity of feeling, etc. what one individual experiences as intensely as pleasurable may be boring for another. So, remember the best and worst moment of your life for five minutes each, and try to recognise what is the difference while you were reliving those states.
(References available on request)

Normal Thinking: A Psychiatrist's Perspective

2009-06-28T17:52:00.028+05:30

“We are what we think. All that we are arises with our thoughts. With our thoughts, we make the world” Gautam Buddha.

It is hard not to think. During most of our waking hours and even when we are asleep and dreaming we are thinking. Thinking consists of cognitive rearrangement or manipulation of both information from the environment and the symbols stored in long term memory. It is the form of information processing that goes on during the period between a stimulus event and response to it.
Normal ThinkingThinking refers to the ideational components of mental activity, processes used to imagine, appraise, evaluate, forecast, plan, create, and will. Most thought involves complex rules that are probably best currently approximated (albeit inexactly) by fuzzy-logic decision-making algorithms that use neural net technology, increasingly applied by scientists and engineers in vague situations in which all-or-none, black-or-white thinking does not apply but in which multifaceted, contradictory, and competing possibilities and biases are the rule. Most of what is known about thinking derives from the study of language as the product (and reflection) of thought, yet a great deal of thinking takes place preverbally and nonverbally. Thinking occurs in images, music, and kinesthetic sensations and in symbols other than linguistic ones.

Ideas are the contents of the stream of thought. They may arise on the basis of a percept, may follow a memory, may arise out of a mood state or atmosphere, or may occur de novo. Those that are consistent with one's sense of self, compatible with the individual's self-image, are called ego-syntonic. Other thoughts that conflict with one's central values are called ego-alien or ego-dystonic.

Normal beliefs and valuesPhilosophers have for many years distinguished beliefs and values and debated the relationship between the two. A belief (or an inference) is something thought to be true because of observation or evidence. It can often be subjected to empirical testing or logic to derive facts, which tend to be objective and universally agreed. By contrast, a value is something thought to be good or important to an individual. Hence strongly held values are the principles on which one will not yield and are not subject to empirical testing. Normal values may be divided between those that are terminal (e.g. the importance of happiness) and those that are instrumental (e.g. the importance of being honest). Values (like beliefs) are on a continuum in terms of the degree of importance attached. Some values might be viewed as extreme (e.g. those values held by a racist organisation or an orthodox religious group) but they are not classified as a mental disorder. Evaluations (or attitudes) are associated with values. They are a rating of an event or person on a scale of good and bad. In comparison to beliefs, values or evaluations are not subject to empirical testing. They are more difficult to measure or challenge because they are subjective and personal. Sometimes beliefs are influenced by a value. For example, beliefs about the risk of HIV and sexual behaviours are influenced by values regarding excitement and stimulation. The reverse may also occur, in which values are influenced by beliefs. For example, a belief that there has been an increase in the incidence or severity of HIV infection may increase values about the importance of caution, restraint or self-discipline. The division between beliefs and values is often blurred. They are like two sides of a coin.

Belief systems are the scaffolding of thought, chains of impressions, and expectations around which plans and behaviours are organized. Belief systems may be attitudinal, setting general expectations and biases about the world that inform how incoming information is processed; examples are optimism, pessimism, and paranoia. Some beliefs are effervescent and fleeting, whereas others are pervasive, tenacious, enduring, and influential. The enduring belief systems are associated with behaviours consistent with the belief, at times dominating interpersonal relationships and lifestyles. Some beliefs are unique and private, whereas many are shared by others.

Abstract thinking is the ability to assume a mental set, to keep simultaneously in mind all of the aspects of a complex situation, to move from feature to feature as indicated by the situation, and to abstract common properties. Complex thinking also concerns the ability to simultaneously consider many different, vague, and subtle aspects of situations; to appreciate differing and contradictory points of view; and to integrate these multiple dimensions to form opinions that are marked by differentiatedness and nuance.

Concrete thinking is a disturbance in the ability to form abstract concepts, generally illustrated by literal mindedness and the inability to abstract the commonality of members of a group, for example, the fact that a flea and a tree are similar in that they are both living things. Concrete thinkers seem unable to free themselves from the literal or superficial meanings of words. Concrete thinkers may be more prone to prejudice and stereotypical thinking and more likely to manifest unidimensional or “all-or-none” reactions to complex situations. Concrete thinking can be seen in individuals with lower intelligence, organic mental disorders, and schizophrenia.

Freud considered division of thought into primary and secondary process-
Primary process thinking, the more primitive type, includes thinking that is dereistic, illogical, magical; normally found in dreams, abnormally in psychosis. This type of thinking disregards logic, permits contradictions to exist simultaneously, disregards the linear notion of time, and is dominated by wish and fantasy. It uses symbol, metaphor, imagery, condensation, displacement, and concretism in its organization, creating the jumbled and incoherent style of thinking characteristic of dreams and has been associated with visual images and creative thought.
Secondary process thinking is characterized by logic. In contrast to primary process thinking, the secondary process uses linear notions of time, clearly delineated abstract categories, and deductive rules of logic. The abilities to think abstractly and to think in detail about future plans are characteristic of secondary process thinking. Normal secondary process thinking is also characterized by predictability, coherence, and redundancy. Words, vocal inflections, and gestures provide important contextual cues and create a sense of overall coherence to the communication. Ideas follow one another in a sequence that is understandable to the listener.

Later Conceptualisations of Types of thinking
The process resulting in a thought can vary with regard to the degree to which external reality and goal-directness are taken into account. In this perspective three types of thinking can be distinguished which represent a continuum without sharp boundaries and are intertwined in everyday life: fantasy thinking, imaginative thinking, and rational thinking. Since each of these types can become dominant under some conditions, this distinction is useful to aid understanding of certain abnormal phenomena. The characteristics of the three types can best be illustrated by considering the differences between fantasy thinking and rational thinking.
Fantasy thinking (also called dereistic or autistic thinking) produces ideas which have no external reality. This process can be completely non-goal-directed, even if the subject is to some extent aware of the mood, affect, or drive which motivates it. In other cases fantasy thinking serves to exclude reality because it requires actions that the subject does not want to accomplish. This second kind of fantasy thinking is not undirected. Its goal is not to solve a problem but to avoid it via neglect, denial, or distortion of reality. Normal subjects use fantasy thinking deliberately and sporadically. However, if its content becomes subjectively accepted as a real fact, it becomes abnormal. This pathological exclusion of reality can remain limited in extent (e.g. in hysterical conversion and dissociation, pseudologia phantastica, and some delusions) or it may be manifested as complete autistic withdrawal from the real world. Bleuler believed that excessive ‘autistic’ thinking in schizophrenia was partly the result of formal thought disorder.
Rational (conceptual) thinking attempts to resolve a problem through the use of logic, excluding fantasy. The accuracy of this endeavour depends on the person's intelligence, which can be affected by various disturbances of the different components involved in understanding and reasoning.
Imaginative thinking can be located between the fantasy thinking and rational thinking. It is a process of forming a representation of an object or a situation using fantasy but without going beyond the rational and possible. This thinking is goal directed but frequently leads to more general plans than the solution of immediate problems. The essential difference between imaginative and rational thinking is that the former neglects the notion that each theoretical assumption should be accompanied by an attempt to falsify or refute it. Imaginative thinking becomes pathological if the person attaches more weight to his representation of events than to other objectively equally possible interpretations. In overvalued ideas, the imagined interpretation surpasses other interpretations in strength; in delusions, all other possibilities are excluded.

(References available on request)