Post traumatic stress disorder (PTSD) and its treatment.

                                                     Copyright: ©JKLR - stock.adobe.com

A girl who was sexually abused by her uncle gets very afraid upon seeing any middle aged man with beard. She avoids gathering involving men. She startles as soon as a scene of sexual assault appears on TV, has intense anxiety with tremor, sweating and  emotional numbness. She has been having night mares and have never been able to sleep well for last one month. If you have seen or heard of someone i described before, he/she might be having PTSD.

PTSD is an anxiety disorder following a stressful and traumatic event of an exceptionally threatening nature. It is mainly caused by tragic man made events happening to oneself or seeing it happen to others . Events such as witnessing violent death, being victim of sexual assault, rape,torture,terrorism or wars are by itself so dreadful to anyone but to some individuals, it can have protracted mental disturbances. It can be also caused by natural disaster such as flood or earthquake. It usually occur after 6 months following the traumatic event but might occur later as well. When it occurs, if the symptoms lasts for a month, you might consider seeing a psychiatrist. 

Studies have found that Females have double the risk of getting PTSD than man. And having experienced several stressful events unequivocally predisposes someone to get PTSD. Personality plays a vital role in deciding its incidence. Low self esteemed people are at higher risk. There is a propensity for section of society with low educational background. 

The symptoms of PTSD are as follows :

    1."Flashbacks" - its a recall of the traumatic event. Reconstruction of traumatic memories may be triggered by reminder of the trauma or it may simply be intrusive. 

    2.Avoidance of activities or events the reminisce the trauma. For example a soldier with PTSD might not like to go back to barracks after witnessing torturous death of his comrade. A driver with PTSD might not like to see vehicle of any sort after a road traffic accident. 

    3.Hypervigilence is manifested in then form of unnecessary alertness, exaggerated startle response, irritability and reduced concentration. 

    4.Insomnia due to recurrent nightmares.

It will have huge impact individually and socially. Avoidance of any event or activity which perilously used to excite him/her. Avoidance will deter relationship. Absenteeism from the regular duties is common. Anxiety attack at the workplace brings social stigma. This affects the so much so that some even resort to deliberate self harm. 

How to treat PTSD?

There is no pharmacological treatment but there are psychotherapies which can be arranged after consultation with the psychiatrist. One must visit a psychiatrist if the symptoms mentioned above have been persistent for a month. 

    1. Physchoeducation. The psychiatrist will educate him/her about the disease and counsel how to proceed with the treatment. One might be too protective about the victim and as a preventive measure, might feel the need for psychological reassurance right after any traumatic event. But psychological debriefing immediately after the trauma, is not advised. It's thought to be harmful instead. After all not all traumatic episodes will cause PTSD. More than 80% of people are immune. 

    2.Trauma focused Cognitive Behavioural Therapy (CBT). The therapist will manipulate his/her thoughts about the incident and improve the way he/she behave through counselling, advice and assurance. 

    3.Graded exposure to the avoided situation. The therapist will start with least fearful trigger and gradually increase to the most dreaded one. But the end of the therapy, the patient would have developed resistance to the same trigger which would elicit anxiety before. 

    4.Eye movement desensitization and reprocessing (EMDR) 

EMDR therapy is an eight-phase treatment.  Eye movements (or other bilateral stimulation) are used during one part of the session.  After the clinician has determined which memory to target first, he asks the client to hold different aspects of that event or thought in mind and to use his eyes to track the therapist’s hand as it moves back and forth across the client’s field of vision.  As this happens, for reasons believed by a Harvard researcher to be connected with the biological mechanisms involved in Rapid Eye Movement (REM) sleep, internal associations arise and the clients begin to process the memory and disturbing feelings. In successful EMDR therapy, the meaning of painful events is transformed on an emotional level.  For instance, a rape victim shifts from feeling horror and self-disgust to holding the firm belief that, “I survived it and I am strong.”  Unlike talk therapy, the insights clients gain in EMDR therapy result not so much from clinician interpretation, but from the client’s own accelerated intellectual and emotional processes.  The net effect is that clients conclude EMDR therapy feeling empowered by the very experiences that once debased them.  Their wounds have not just closed, they have transformed. As a natural outcome of the EMDR therapeutic process, the clients’ thoughts, feelings and behavior are all robust indicators of emotional health and resolution—all without speaking in detail or doing homework used in other therapies.(from emdr.com)

The anxiety and sleep disorders can be managed with medicines because they are different psychiatric illness which can be managed by pharmaceutical therapy.

 50% have been found to recover with in a year but 30% will have a chronic course. Good social support and prevention of such traumatic events further has proved to yield better and faster outcomes. 

Jeewan Raj Nirola's Blog: Abortion should be legalized in Bhutan

Jeewan Raj Nirola's Blog: Abortion should be legalized in Bhutan: Should abortion be legalized in Bhutan? Adolescence is a challenging phase. Early adolescence is the transition from childhood to adolescent...

Abortion should be legalized in Bhutan

Should abortion be legalized in Bhutan?

Adolescence is a challenging phase. Early adolescence is the transition from childhood to adolescent and predominantly comprise of puberty. Middle adolescence is about learning to cope with the physical, sexual, social and emotional changes. And having achieved all the developmental milestones, we enter the late adolescence and ultimately adulthood. Sexual maturation is limelight of these phases which give woman capacity to conceive. Reproduction is a primitive instinct and imperative in all aspects including evolution. However, pregnancy becomes beautiful only when mother is ready and contemplating. In rest of the cases, it’s a burden for her. She is not going to welcome the baby at any point of life, intrauterine or post-delivery. She will go for abortion or abandon the child after delivery. 

So far, we have had several cases of infant being abandoned after birth in the capital and in other Dzongkhags as well. Some unfortunately found dead, and some in critical condition. How sad for the baby who had been living in a cozy warm womb for 9 months and first thing he experiences is being wrapped in a plastic and left to die. 

But it wouldn't be fair just to condemn the woman as the only culprit. I attribute this to an abortion act of Bhutan. Section 146 of the Penal Code of Bhutan (PCB), 2004, criminalizes abortion unless the pregnancy poses risk to mother's health physically and mentally or when pregnancy is a result of rape or incest. These prerequisites might have been enough and applicable in good old days but it’s too narrow for today. It doesn’t include the most important need for abortion-mother not wanting to become pregnant. This is a human right violation. By the above law abortion is criminalized in Bhutan. Once a woman is conceived, she has no right over her pregnancy. She has to carry the pregnancy whether she likes or not. She has no choice, doesn't matter if she is a student, unmarried, broke, unemployed, or single. Isn't this unfair? Shouldn't she be allowed to decide on what happens to her body and not the law? Who will be held responsible if she can no longer take it and attempts deliberate self-harm?

Few facts about abortion and the global movement.

Abortion is deliberate termination of pregnancy when mother choose not to continue pregnancy or when she is unfit for pregnancy medically. There are two methods of abortion; medical abortion which uses abortion pills and surgical abortion includes vacuum aspiration and dilation and evacuation method. The choice of methods of abortion depends on factors such as age of the fetus, preference of the women and availability of resources (human and material). But generally medical abortion is induced in first trimester. And surgical abortion in second trimester. The upper legal limit is up to 24 weeks of pregnancy because this gestation reflects the fetal viability. The neural pathways to experience pain are not fully developed in the fetus until 24 weeks. It simply means that up to 24 weeks, the fetus doesn’t qualify to be called a human being. It may also mean that one need not feel guilty of feticide up until this period.

Legalization of abortion has been a controversial topic worldwide. Many nations have come out to consider women’s health over the emotion behind this invasive procedure and legalized abortion. Soviet Union was the first to legalize abortion as early as 1920. Other countries soon followed, including Canada, the United States, Tunisia, Denmark, Austria, France, Sweden, New Zealand, Italy, the Netherlands, and many are considering the approach. Abortion is legal in all U.S. states, and every state has at least one abortion clinic. Since 2000, twenty-nine countries have changed their abortion laws, and all expanded the legal grounds on which women can access abortion services. But most common remains the abortion on women's request.

There is evidence that legalization of abortion does not lead to more abortion. Rather restricting access to abortion simply leads to unsafe abortion with consequent death of mother or land up with complications.

Is it safe? 

Yes, but only if it’s legalized because nothing done in dark is safe. No contraceptive methods work 100% in preventing pregnancy. So there will always be the need for safe abortion. Safe abortion saves mothers lives and prevents severe complications associated with the unsafe abortions. Modern methods of inducing abortion are safer than all common gynecological operations, such as sterilization and hysterectomy and there is lower risk of dying than during child birth according to Gynecology by ten teachers. 

 Both medical and surgical abortion are simple procedure with very low rate of complications. Indeed, the WHO advise that in the first trimester it can be safely performed by a range of health care providers, from specialist obstetrician and gynecologist to a non-specialist doctor or an appropriately trained  nurse. 

Abortion in Bhutan 

The recent news from Bhutan Broadcasting Service (BBS) covering about the increase in number of people looking for abortion pill in pharmacy shops in the capital is shocking. How could people seek for abortion pills in a country where abortion is illegal? This indicates the desperate nature of their situation. People were in dire need. The recent 21 days of nationwide lockdown might have contributed to this. We can call it an index for bonding and intimacy between the partners which is a good thing to witness. But what lies ahead of them is equally painful and troublesome. It's illegal to sell and purchase abortion pills. The hospital has the abortion pills but it is a controlled drug which is prescribed only upon thorough evaluation of the mother by a gynecologist. Thus, all those mothers fail to meet the criteria for the legal abortion in the hospital. This problem existed since a long time. But it was able to catch people’s attention only at this time .This is only because borders are closed following covid outbreak and people can't purchase from India which used to be the common practice earlier. I don't know what has happened to those girls seeking for abortion pills but seriously, they might not be doing well. Once they have decided to abort, I don't think they would give up easily. Some more months later in future we might get a news of abandoned baby again. Those babies will be the result of inaccessible abortion.

By legalizing abortion we are not promoting casual sex among adolescents. But it should be legal and accessible. Whether people opt for it or not should be left upon them. One might presume that it’s only happening among teenagers and spoilt youth but it’s happening at all level within reproductive age. 

Even married couples who are not ready for a baby needs time and space. With conception comes a huge loads of responsibilities and the need for resources. An accidental conception shouldn't deter their lives. A pregnancy is just a phase, but what lies beyond, is difficult to manage for someone who's not contemplating a family.

What will happen if abortion is legalized?

1. A pregnant mother can simply walk in to the OPD, request for an abortion. She would be counseled on her decision and why she needs it. Then she would get herself admitted, undergo a safe abortion by trained health professionals with minimal risks. She will be monitored throughout and may be discharged in few days, as soon as she is declared safe to go.

2. There wouldn't be a fatherless child. Everyone can measure the pain to be a single parent who's unprepared at the same time.

3. Students can continue their education. When a student has to drop the school/college due to pregnancy, both schools and tertiary institutions allow the student to continue her education after giving birth. But this is impractical. Hardly a girl would choose to go to school/college with child crying at home. The embarrassment she faces is a whole different struggle.

4. Getting pregnant before marriage is considered shameful. Acceptance from parents is an issue. Same with the society. It can affect the victim mentally and physically. Law says legal abortion can be availed if the pregnancy poses risk to mother's health physically and mentally. I don't know what kind of mental illness they expect mother to have when she is already under the weather. She would not seek abortion if she was ready to have a baby. So it's pointless to talk about morals here. If she thinks abortion as a disease, treat it like it’s done for mainstream illness and send her home happy. Accessible abortion is a savior of all these problems.

5. We wouldn't see abandoned baby in future. All those babies are the consequence of unwanted pregnancies. Once a mother has decided she doesn't want to become a mother, whatever may be her reason, she is likely to end pregnancy anyway, be it after birth or abandon at any point of time. Studies show that forced pregnancy is one of the causes of post-partum psychosis. Because there's no affection which is only cultivated if mother is fond her child. So it's a wise decision to end suffering for both parties at the root level. 

6. Travelling to India or elsewhere for abortion is costly as well as unsafe. Imagine a situation where a mother undergoes a surgical abortion and next day finds out one of her kidneys is missing. And she can’t claim justice legally because it’s illegal to have abortion. The court might penalize her instead.

7. Imagine waking up in the morning and find out that you are pregnant when you aren’t ready. You are in second year of college and live with distant relatives. You have exams next month. You don’t know the whereabouts of your boyfriend. You call him but he asks you to sort it out yourself. You start to panic. This anxiety attack is for real. You feel guilty. You feel its end of the world. But then you realize abortion is legalized in Bhutan. You go to hospital and request for abortion and sort everything within a week without letting others hear a bit about it. Next week, you are free of tension and you’d start your revision at full swing. It wouldn’t be as simple as this. But imagine if this kind of accessible patient friendly abortion services existed, life would have been far easier.

8. Another case study. A couple has 2 children. Husband has a decent job and wife is a housewife. Both of them are in their early thirties. The first child is 5 years old son and second child is 1 year old daughter. Wife is pregnant again and they don’t want to have third child at any cost. Husband explores possibility of seeking legal abortion but they are not eligible. Married couples who have had already three children are only eligible for abortion. Financially they could afford third child but their first child has some mental issues and second child is too young. The couple are physically and mentally unable to create space for the third child. They start to blame each other for being too careless to the extent of domestic violence. The husband looks for abortion pills in pharmacy shops but nowhere do he finds. He goes to the capital for the same, but return home helpless. The wife looks in internet for natural remedies to induce abortion. She finds out that the raw papaya cause miscarriage so eats several kilograms of papaya but that doesn’t help. The couple uses their contacts to get abortion pills from the government hospitals but all effort goes in vain. They call their parents back in the village to send them herbal medicine. Unfortunately this also does not work. Husband has learned from Google that jumping high will cause miscarriage and forces his wife to do strenuous exercise. All this methods fail. The couple fight everyday about this. They have no choice but to accept their mistake as fate. She is five month pregnant now. But they are worried about all their attempts to terminate pregnancy might have resulted in abnormalities in baby. This is how a simple medical is causing so much trouble in the family. If we go out and ask, most of the mothers have continued the pregnancy because they had no choice.

Decriminalization of abortion is a win win situation for both the parties; mother and the government. It's unfair for the fetus because it would have grown into a beautiful human. But life wouldn’t have been easier for him either.

copyright.cnn.com

Photo of women protesting for lift of abortion ban in 2018 in South Korea

In recent time, South Korea has successfully brought reform to the abortion law after 68 years of ban  of abortion since 1953

Funny memories of school days

 We grow so often. Many things that has happened in our childhood that we considered gruesome were actually interesting. It was our naive nature that stopped us realize that the same thing would make us reminiscent in our adulthood. And every bits of it. Here i unfold some of the many nostalgic school memories. The memories of teachers whom we loved and hated so much hand in hand.

5 funny things your teacher has said to you.

    1.This is the worst class/section. If he's further infuriated, he would go on to say that your class is the worst one he has ever taught in his entire career. But he says this to every class he goes. And students know this. So students don't take it to the level of hurting their sentiment and self esteem. 

    2.When you don't forget to have breakfast how could you forget to write homework? I am sure all of us have heard this cliched rhetorical question from teacher. Common!  do some logical comedy at least. I do not see any logic here. Food and shelter are basic human needs. It's a everyday ritual one has to do even if he's not up to. But is writing homework a basic human need failing in which we risk survival? No!

    3.If you are bad i am worst.  Actually,I feel them. Qualified man teaching stupid kids who neither appreciate teacher's effort nor take them seriously. So teacher getting annoyed is a usual thing to witness. And then this phrase ensues smack on the arse.

    4.If you make too much noise in the class, he would start with "you think you are in fish market?". I understand there is hustle and bustle at the fish market but wouldn't it be same at vegetable market or a toy market?. It could be even worse. Teachers in the staff room make no less noise.

    5.Teachers would say that they have set extremely difficult questions for the year unlike in the past. Hardly few are cruel enough to mark their word. Most do this to scare the students. 

What students cherish but pretend to be sad at;

    1. Maths teacher absent. NO, that is way too much to expect from him. He has a complete calculation of number of instructional hours allocated for mathematics and he knows what being absent for a day would cost. But we were a bunch of positive minds. Even if hes late for few minutes it wouldn't make us less happy.

    2.Teacher deviating from the lesson and sharing about their personal experiences. And we would ask them questions about it to prolong his talk so that no time is left for the lesson.

    3.Staff meeting in the middle of the session. 

    4.Prolonged morning assembly. So that it encroaches the first period. We used to go to the extent of motivating the morning speaker to give lengthy speeches. We least cared about the content of his speech though. First period is supposed to be the most productive for learning. But on the contrary, we hated it the most and least learning happened. It was just enough to recover from the hangover of the previous night's enjoyment, or movie. 

    5.Extra class and remedial class. Students may seem interested but deep inside they might be wishing something urgent come up. So that the teacher needed to leave. 

    6.Substitution teacher. When your fearful teacher is absent, you would dance out of happiness. But mostly this happiness used to short lived by principal sending substitute teacher who is even more ferocious. 

    7.Apprentice teacher to substitute your subject teacher. This is the most awaited moment. They are caring, least deadly, and friendly.

All said and done, i thank my teachers for all the beautiful memories.  They were rough but at least they cared.

Studying medicine in Sri Lanka

 What it is like to study MBBS in Sri Lanka for Bhutanese students ?

MBBS is a dual degree that stands for Bachelor of Medicine, Bachelor of Surgery studied over the span of over 5 years. no wonder it is one of the toughest courses for undergraduates.

Unfortunately Bhutanese medical colleges doesn't have MBBS programme. So the students avail complete or partial scholarship to study abroad, mostly in India, Bangladesh and Sri Lanka. The story is same for self financed students as well.

I had very little knowledge about studying medicine in Sri Lanka prior to choosing university in Sri Lanka. I am pleased to share my thoughts based on facts so that future aspirants can have better understanding before choosing where they are going to spend the next crucial phase of their medical schooling. 

Students have the privilege to choose among four renowned universities of Sri Lanka i.e University of Colombo, University of Peradinya, University of Kelaniya and Kotelawala Defense Academy(KDU) purely based on their merit ranking . Its a common trend for students to choose university in the above order. But again it depends on their preference and how many seats are allocated for each university. Total seats available are divided among these 4 universities. Usually one university is given 5 to 6 seats only. So higher you are on the merit ranking, bigger their choices.

First two years would be exclusively in university. You will be taught  the normal Anatomy +radiology, physiology,  and biochemistry. All the organ systems from head to toe will be taught. There will be lectures in the morning and practicals in the afternoon. So these two years, you will be all time at the faculty. You will not have to go to hospital. 

Phase two starts with 'white coat ceremony' where you will be given clinical lab coat and a stethoscope following a oath taking ceremony. 

For the rest of the two years, you will have to go to hospital and see patients(take history, examine the patients, and observe how the patients are managed in the ward). You will have hospital exposure at the same time lectures in the faculty.The lectures now wouldn't be on normal mechanisms operating in the body. It covers the diseases of all organ systems, its pathophysiology and management.  Pharmacology and forensic science are also taught in this phase. Research and community medicine  are also covered. 

The morning is allocated for clinical rotation in hospital and afternoon is for lectures that would happen in the university. Clinical rotation includes a month of learning each in medical ward, surgical ward, psychiatric ward, pediatric ward and gynecology and obstetric ward. Other minor clinical appointments such as dermatology, rheumatology, pathology, ophthalmology, chest medicine etc are also arranged for practice but it will be for shorter duration. By the end of phase 2 you have completed 4th year of the medical schooling. You would have learned all about  normal body and diseased body. and have seen enough patients in the hospital. This makes you ready to enter the final year. 

This phase is called professorial appointment and it is the last one. It will be completely done in hospital. From morning till evening and occasionally at night, you will be in hospital. This will go on for one complete year. The clinical appointments in different departments will be done in rotation with each appointment lasting for 2 months. Small classes and discussions would all be done in the ward itself. At the end of this phase, you have completed your five long years of medical college. Next you will sit for Final MBBS exam and upon passing the exam, you are very close to getting your most awaited title "Dr".