Timely help from friends and loved ones along with therapy can go a long way in dealing with the emotional trauma that is caused by incidents like these; needless to say, the medical rehab process for victims and families should include counselling and psychiatric help, where needed.

The Home minister banning the media from interviewing victims is a huge positive in this direction; the media in its overzealousness often causes more damage than good.
It is our collective responsibility to do (or not do) whatever we can to help victims and families come to term with their loss and get back to their normal lives.

A classic case which highlights the sorry state of affairs in our country for the mentally unstable and their families; lack of awareness and apathy being the prime suspects.  Most mentally-challenged require special care, medication & treatment and above all, 24/7 supervision, the absence of which threatens the safety of not only the patient but also the people living around him.  In extreme cases, hospitalisation is strongly recommended and cities like Mumbai have facilities where such care is possible.
However, hospitalisation is just the beginning, it is the rehabilitation process which is critical to the successful treatment of the mentally-challenged and the family alone cannot be held accountable for the same; the society in which this individual lives has to show empathy and take responsibility to help such individuals live a respectable life.
Having said that, it is the patient’s family’s responsibility to first ensure the safety of the residents of their neighbourhood before assuming their active participation in the rehab process.
Taking members of the society in which they live into confidence and being transparent about the medical condition of the person in question could perhaps be a start to reaching a common ground – that of successfully rehabilitating the mentally-challenged.

Shunning people who need our help the most is certainly not the humane solution.

Response to stress, for each individual, depends on his/ her personality.

WHAT COMMONLY CAUSES STRESS?

The causes are different at different ages.

-       Adolescents may get stressed due to physical changes (perceived as not proper) and career prospects.

-       Young adults may get stressed due to employment relationship, adjustment in marriage with spouse/ in-laws, tiff with parents or relationship with their own children and a struggle to achieve financial stability.

-       In middle age it could be changing spousal relationships, problems with aging parents and problems of having young adult children who do not see eye to eye or may be having their own stressors.

-       In old age, the main concern is retirement and survival, loss of physical capacity (including sexual), major personal losses, menopause and thought of death with increasing number of deaths in close friends and relations.

Dr C H Asrani

Consequences of Poor Sleep

- Irritability, depression.

- Explosive outbursts & mood swings.

- Increasesd risk of vehicular accidents.

- Poor work performance & memory lapses.

- Problems at work; marital and social problems.

- Increased risk of acidity and heart disease.

by: Dr C H Asrani

How to know that your sleep is INADEQUATE!

- You never wake up with alarm clock or wish to snatch a few extra minutes before getting up.

- You plan to catch up on your sleep on weekends/ holidays.

- Stay awake during long meetings or after a heavy meal is a struggle.

- It takes > 30 minutes to fall asleep/ You wake up repeatedly.

- You’re irritable with co-workers, family and friends.

- You have difficulty concentrating or remembering important issues.

- You wake up groggy and not well rested (Oh! S**T, it is already 7!)

- Your spouse complains about your restless sleeping.

Tips for sleeping well

1. First and foremost, protect your need and right to sleep! Don’t feel guilty if you need to sleep for at least 7 hours (Most adults require 7-8 hours. Youngsters require even more sleep!). Going without sleep is not “macho”; instead, it is self-destructive.

2. Ensure adequate time in bed, free from interruptions and demands. The same applies to night shift workers! They may feel guilty if they do not get up after four hours to perform household chores. But…what would be the response if a day shift worker tries to perform similar chores at 2 a.m.?

3. Night shift duty does not and should not deprive one of basic rights and human necessities.

4. Keep regular sleeping habits! (I sleep when I have time). Regularity makes a tremendous difference. Erratic sleep habits prevent training of centres in our brain that helps control our alertness and ability to sleep.

5. Avoid going to bed after midnight unless you work night shift.

6. Go to bed prepared to sleep! Avoid vigorous exercise shortly before going to bed. It impedes the ability to fall asleep. Exercise at least several hours before going to bed has been shown to be helpful.

7. Avoid late afternoon/evening naps, and do not allow yourself to doze off while reading or watching television prior to bedtime. Even brief episodes of such sleep may interfere with subsequent sleep.

8. Do not allow yourself to lie in bed worrying / planning about problems of the next day. All planning to be done on waking up

9. In most cases, the bed should be used for sleep and sex–and not for reading, watching television, working on a laptop or other activities that keep one awake.

10. Don’t sleep too long – Avoid oversleeping and lying in the bed for prolonged periods after your sleep is completed. Excessive sleep tends to be fragmented, unrefreshing sleep that leaves us feeling worse and may interfere with the following night of sleep.

11. Naps may be beneficial–but for people on a normal day schedule, they are best taken in the early afternoon, and in most cases, should be restricted to less than one hour, no later than 3 p.m.

12. You should wake up refreshed in the morning without the use of an alarm clock and feel energetic all day.

13. Dietary tips

a. Don’t go to bed hungry.

b. Avoid large / heavy meals and excessive fluid intake that provoke poor sleep, indigestion, heartburn or frequent awakenings to urinate.

c. Bedtime snacks should be small and non-spicy foods with sedating potential. Eg dairy products (high in tryptophan promote sleep). Apples taken before bedtime may increase sleepiness and ability to doze off promptly.

d. Caffeine and smoking prior to sleeping can worsen one’s ability to fall asleep and stay asleep.

Still finding it difficult …

14. Warm baths (not showers) prior to bedtime truly can prove helpful!–as can engaging in relaxing, calming and soothing activities.

15. Play soft/ tranquil music.

16. Make sure that your bedroom is conducive to good sleep!

17. Ensure a dark environment, unless you are reassured by having a night light in the room. More so for night shift workers.

18. Ensure a quiet environment. Use measures to block out outside sounds.

19. If necessary and feasible, especially for night shift workers, put off your mobile phone.

20. Ensure a reasonably cool environment. Overly warm bedrooms are not conducive to quality sleep.

21. Be sure that your mattress is adequately firm and comfortable.

22. If you have allergies to dust, dust mites, and other common features of a typical bedroom, take steps to free your room from these; replacement of old pillows, blankets and carpets; keeping pets out of the bedroom, if needed

Sleep Hygiene

1. Don’t stress if you feel you are not getting enough sleep. It will just make matters worse. Know you will sleep eventually.

2. Bedtime routines are helpful for good sleep.

- Avoid looking at the clock if you wake up in the middle of the night. It can cause anxiety

- If you can’t get to sleep for over 30 minutes, get out of bed and do something boring in dim light till you are sleepy

- Know that the “night cap” has a price. Alcohol may help you to get to sleep but it will cause you to wake up throughout the night

- Stick to a schedule, and don’t sleep late on weekends. If you sleep late on Saturday and Sunday morning, you’ll get Sunday night insomnia. Instead, go to bed and get up at about the same time every day

- Taking a hot shower or bath before bed helps bring on sleep because they can relax tense muscles.

- Don’t rely on sleeping pills. Check with your doctor before using sleeping pills. Doctors generally recommend using sleeping pills for up to a week

by: Dr C H Asrani

• Acute stress reaction – a normal reaction to an excessively traumatic event that does not always require medical attention. Few who require medical intervention are said to be suffering from stress disorder. As high as 90% of those involved will experience at least a brief stress shock. Common symptoms of acute stress are confusion, lack of sleep, inability to concentrate, nightmares etc. Common psychological symptoms are fear (of facing the event again); anger (frustration) at perpetrators/ authorities; guilt or shame (feeling of being impotent). Acute stress reaction will slowly pass off (not to say the anger/ fear will disappear but it will not interfere with day-to-day activities.

• Post Traumatic Stress Disorder (PTSD) – As the name suggests, these are problems faced some time (maybe few months) after the actual event. Most of those who get have not even had acute stress reaction. PTSD is the abnormal fear of re-experiencing (recurrence) of the traumatic event. As we know people respond differently to stress situations depending on their personality, PTSD can occur even if event is not very significant or of a giant magnitude. The person getting PTSD may not even have actually faced the threat (viewing it repeatedly on TV is real enough). PTSD results in reduced responsiveness and attempts at avoiding events connected with original stress (like huge drop in air traffic post 9/11 and expected drop in foreigners coming to India and locals partying at star hotels).

How will someone with acute stress reaction present?

It can affect all age groups but if there are kids in the family, it is important to be watching them carefully. An otherwise normal person (child) becomes “hyper” – startles at the slightest stimulus; is lost in thoughts, has sleep problems, has nightmares, dreams about the event and demonstrates over alertness  (viewing all police vehicles with suspicion OR Mom, look that man with cargo pants) are all manifestations of acute stress reaction.

Who should treat this?

First stop is your family doctor, who should decide the further course of action. If there is positive past history of any psychological problem and symptoms are affecting daily routine, then referral to a counselor/ psychiatrist may be required. Most cases can be handled by the family doctor only – as he is an old contact and patient is more likely to trust his word than any new therapist. The family doctor must spend good time with the patient as talking will be more beneficial than drugs.

We should not forget the fact that those involved in rescue operations are also at risk of acute reaction or PTSD especially if they have experienced worst crisis of their career. Group psychological debriefing is suitable for groups who are going to work together in the future, such as rescue and medical personnel. Debriefing contributes towards enhanced future work capacity. Group debriefing is also recommended for people actually involved (in this case staff of Taj/ Oberoi/ Leopold/ Cama hospital/ staff on duty at VT station). Group debriefing does not mean that individual attention is not to be given.

Tips on handling Acute stress reaction

• Avoid watching reruns on TV especially alone; if children are affected, do not allow them to watch the event or aftermath alone on TV. Make sure that at least one parent sits with them to help explain what is happening and anticipate and answer all of their questions.
• Maintaining daily routine is the best way to convince your self that all is fine. If the trouble is away from your locality it is easy but if is too close to home maintaining a routine or at least a semblance of it is important. A regular routine gives a sense of security.
• Keep patience: If exposed to a tragedy, expect that someone in the family will show signs of distress in form of fussiness, fear or nightmares. These are normal reactions and one should be ready to deal with them with understanding and patience. Asking people to ‘…take control of your self’ or ‘…don’t be childish’ may be counter productive as the afflicted will clam up and get long term problems.
• Control emotions: Even young children are acutely aware of the emotional state of their parents. One doesn’t have to hide emotions; It’s fine to let others know that you are upset and sad, but try to be as calm and reassuring as possible.
• If one experiences physical response to the event like palpitations, heaviness in the chest, sweating etc – even though these are usually normal and expectable responses – If one is under treatment for high BP, diabetes or heart disease – visit your doctor immediately.
• Try finding a friend, relative or colleague and talk out, what you feel. This kind of sharing is crucial for you to remain calm.

How would someone with PTSD present?

The diagnosis of PTSD is justifiable when the duration of symptoms exceeds one month but is within 6 months.

Following symptoms after more than 1-3 months would raise the possibility of PTSD.

• Persistent fear of re-experiencing of the traumatic event.

• Recurrent distressing recollections of the event.

• Nightmares of the event.

• Intense distress when exposed to reminders of the traumatic event.

• Difficulty falling or staying asleep.

• Irritability or outbursts of anger (recent development)

• Difficulty in concentration.

• Over alertness.

• Lack of interest in significant activities (studies, marriage in the family etc),
feeling of detachment, restricted range of mood, sense of foreshortened future
(kucch to bahut kharab hone wala hai)

Who should treat this?

Treatment is mainly psychological – Supportive psychotherapy should be carried out by the general practitioner, often combined with drug therapy.

If resistant to management or severe symptoms, prompt referral to a specialist is mandatory.

Important – those with PTSD are very likely to resort to alcohol/ drugs for relief from disturbing symptoms. Care taker(s) should be aware and watchful. An attitude of ‘let him drink, it relaxes him’ can be catastrophic.