I met Arjun when he was 20 years old. He had scored an aggregate of 93% in physics, chemistry and mathematics in the 12thgrade exams but had decided to withdraw and rewrite those subjects. He wanted to score a 100%. He submitted his examination forms each time the exams were held since then, but never attempted them. He sat at his books and worried all the time. However, severe anxiety about failing to score 100% immobilized him every time he thought of taking the exams.
Namita was a very tidy youngster who had always been praised for her even handwriting, neat school uniform and well-maintained books. She topped her class till 7th grade. In the 8th grade she found it increasingly hard to cope with academics because her perfectionistic style of learning every lesson by heart no longer served her. She began having panic attacks and had a breakdown before the final exams. She was referred to me by her GP (General Practitioner) after he had calmed her down with a sedative.
Maria brought her 16-year-old son, Sam, for an assessment as he had started checking the latch on the front door six times before going to bed. Once in bed, he would call out to her to check three more times. He had also got into the habit of checking that the car was locked, returning to confirm several times after they had parked and moved away a few steps. He had always been a careful boy, but she could not understand why he had become so insecure lately.
Latika was in boarding school. The warden reported that the girl spent a lot of time in the bathroom. She even went to wash her hands between classes. In the dining room she would wipe her plate and cutlery thoroughly before eating. At first people treated it as a joke. Eventually, her distress at not getting things clean enough and consequently missing classes or reaching the classroom late forced the staff to report this to her parents. She was brought in for a consultation three months ago.
Being conscientious about school work or trying to be clean, tidy or careful as these children were are considered virtues. Wanting to achieve centum in the sciences is a fairly common goal among Indian students. So why were these young people brought by their parents for medical treatment?
The behaviors exhibited by these children are normal behaviors, but overdone. Some parts of their brain are not working as they should, creating a sense of dissatisfaction about cleanliness, tidiness or perfection achieved by an action, making it necessary to repeat the action a number of times.
The cleaning, checking or tidying rituals may be so time-consuming that people who have the need to adhere to them cannot work, sleep or go out. They may become irritable, anxious and angry because nobody understands them or agrees with their reasons for doing what they do.
As actions originate from thoughts, odd behaviors exhibited by people are most likely products of odd thoughts that need correction. Just as spectacles are used to see better and inhalers to breathe better, people sometimes need an aid to think better too. A detailed evaluation by a psychiatrist is necessary to make a diagnosis.
Depending on the diagnosis, psychiatric treatment will usually be an appropriate medicine. If considered necessary, a person may be referred to a psychologist for a specific type of therapy. It is imperative for a doctor to analyse the symptoms and make a provisional diagnosis because the course of the illness cannot be predicted at this age, viz. youth. Taken at face value it may look like irrational anxiety but may follow a course which, unchecked, can lead to something worse. Management depends on the individual case, and all the youngsters in the case vignettes above showed improvement with treatment.
Arjun took his 12th grade exam four months after starting treatment. He did well and joined a well-known Engineering college in Tamilnadu. Over there, he visited a psychiatrist regularly and occasionally called to update me on his progress. The last call I had from him was about seven years ago when he got his first job.
Namita is currently in the 12th grade. In the past five years she has done well in academics and is preparing for various college entrance exams. She is still organized, neat and tidy, but is not a perfectionistic.
Sam has been on treatment for the last eight months. His need to check doors has gradually reduced and he is already about 70% better.
Latika is only 11 years old. I found that she had more symptoms, apart from the ones the school reported, and they took up a lot of her time and energy. She had severe anxiety almost all the time. Medicines have reduced anxiety and the need to clean things excessively, but due to the severity of symptoms she is undergoing therapy as well.
In this series Dr Shyamala Vatsa highlights the fact that teenage changes can mask incipient mental health problems. These articles show how early symptoms of mental disorder can be taken for ordinary teenage behaviour. As illustrated by the stories of young people who have suffered unnecessarily, it is important for friends and family to recognise when a behavior is outside normal limits, and seek help before things spin out of control.
Dr Shyamala Vatsa is a Bangalore-based psychiatrist who has been practicing for over twenty years. If you have any comments or queries you would like to share, please write to her at firstname.lastname@example.org