Episode 7 of En Ullae S2 is a harrowing tale of Ramesh’ descent into utter despair due to his alcohol addiction. After the lilting trill of a happy alcohol buzz wears off, people in the throes of addiction often experience a sense of bitterness and desolation. It’s an artificial stimulant that when consumed, releases endorphins, neurotransmitters that promote a feeling of euphoria and help reduce stress.
Some instances of alcoholism are undergirded by an anxiety disorder, according to Dr Rajesh Jacob. He posits that people attempt to “treat” symptoms of anxiety by self-medicating with alcohol, ameliorating the discomfort of social situations through chemically induced disinhibition and happiness. They become chattier, and won’t choke during conversations – an alluring prospect for chronically anxious people.
Ramesh, now advanced in age, wistfully recounts how he fell into alcoholism. At 15, he and his friends would entertain themselves with drinks and idle chatter at a ‘kopitiam’, a Singaporean colloquialism for ‘coffee-shop’. Dr Jacob reminds us that despite being a stimulant, long term alcohol abuse invariably leads to depression or anxiety. Alcohol addiction can stem from a variety of factors – from the ‘angry, drunk father’ to early over-exposure to alcohol, and everything in between. Hassan Mansoor, a recovering alcoholic, confesses that his first foray into Bacchanal pleasure was during his secondary school years(junior high) for you Americans). He doesn’t remember the time with rose-tinted glasses, though – his adolescent years were marked by incessant violence, physical altercations and poor academic performance. He’d thought it made him look “cool”. Beer, whiskey, “Boon Kee Low”, “Paddy”, its name derived from its roots as a rice wine, and “Deer”. All of them cheap highs.
We’re then treated to a vignette in which a listless Ramesh, rake thin, gets into an argument with his doe-eyed girlfriend over whether wine should be drunk at lunch. Both of them are adamant that they hold the moral high ground – Ramesh, with his insistence that wine is “not hard liquor”, and Reena, with the awareness that his alcoholism is ruining not only their relationship but himself. We learn that the long-suffering Reena has tolerated Ramesh’s equivocations and excuses for four years, and she’s at the end of her tether.
(Click on the link for a version with English subtitles. Remember to click on the ‘Settings’ button to reveal the English subtitle selection. https://www.mewatch.sg/en/series/en-ullae-s2/ep7/954631 ) Dr Jacob explains that genuine awareness of an alcohol problem can only legitimately come from within, and external criticism is met with a wall of anger and irritation. In the early stages of alcohol addiction, one usually does manage to induce some level of happiness. As the disease progresses, drinking no longer “feels good” and chemical dependence means that consumption is imperative to avoid withdrawals. Alcohol withdrawal symptoms include hand tremors, which can set in as quickly as 4 – 6 hours from the last drink, insomnia, anxiety, psychological cravings, palpitations and sweating. Alcohol addiction is a vicious cycle, according to Dr Jacob.
Most people suffering from alcohol addiction start off with social drinking, which isn’t a problem in itself. However, addiction is a chronic, progressive disease which Dr Jacob measures with three factors of varying severity: drink frequency, duration of drinking, and cravings. Ramesh admits that his family life and relationships suffered. Getting blackout drunk was a nightly affair, which left his wife paranoid of his infidelity, when in fact he was unconscious in a ditch somewhere. He wouldn’t remember the events leading up to the loss of consciousness, a form of anterograde amnesia. Eventually, his wife takes out a Personal Protection Order (PPO) against him, the Singaporean variant of a restraining order.
The spiral into full throttle addiction isn’t a pretty sight. Just being in the presence of his drinking buddies would catalyse a night of binge drinking, invariably followed by a hangover in the morning made all the more unbearable by guilt over the slow rot of his cherished relationships. Work performance suffered, many a medical certificate was sought, culminating in joblessness.
Dr Jacob explains that addiction leads to productivity impairments at work. A sure sign of dependence is the need for a drink in the morning to curb tremors and imbibe him with enough energy to perform as a barely functioning alcoholic. Day drinking and surreptitious alcohol breaks are common. When in active addiction, one’s happiness (in the form of craving relief) takes precedence over that of others, and empathy goes out the window. Ramesh is reduced to a pitiable state, cajoling once close friends to spot him the occasional tenner – in their eyes, he is reduced to a shadow of his former self. Now jobless and without an income, he burdens his children with the restitution of his loans – he is now too functionally impaired to perform any meaningful work. His wife is now the sole breadwinner, and the guilt in his voice is apparent, even today.
Ramesh only manages to stop drinking for some length of time at 48 due to chest pains. After a successful heart bypass, he turns to drink again. Then comes the second bypass, which he sullies with an infection brought on by his inveterate drinking. Alcohol and heart medication should not be taken together, but his addiction blinds him to a sanguine truth. It is only after last-ditch surgery is performed that he cultivates some restraint, managing to abstain from drink when he recuperates for a month in the hospital. He is 68 when he finally gets into recovery.
All manner of physical ailments accompanies alcohol addiction. “From the head to the feet”, Dr Jacob says. The brain is atrophied such that fits, falls, bleeding, subdural hematomas and dementia become common. Liver cirrhosis brings about jaundice and bloody stool. Peripheral neuropathy, a feeling of pins and needles in the hands and feet arises from damage to nerves outside the brain and spinal cord. Even sexual performance suffers. If diabetes is comorbid, the body becomes much poorer at sugar control.
Dr Jacob recommends a ‘biopsychosocial’ model for treating alcohol addiction. “Bio” refers to medical treatment in the form of total abstinence (detoxification) and medication. “Psychosocial” refers to psychological counselling to treat addiction, medication to reduce cravings, and therapy sessions with the family. In short, a treatment model that aims to target likely risk factors for relapse.
Nobody takes their first drink and thinks, “This’ll be the death of me”. Fortunately, if people suffering from alcohol addiction take a step back and consider their mind, their physical body, and their loved ones, and combined with proper support and therapy, recovery is possible.
This episode of En Ullae touches on psychosis. This case study was about a man who had developed schizophrenia and became obsessed with the ‘spiritual safety’ of his partner. The building tension served to demonstrate the dangers of ignoring the symptoms of psychosis, which his partner was predisposed to do, in her untoward position as the long-suffering partner in a dangerously unstable relationship. Dr Rajesh characterised psychosis as rooted in an unshakeable belief in false delusions – people who suffer from the condition are often willfully blind to reason, which he cautions against trying to impose on them when the time is inclement.
Prem, the unfortunate man with all the symptoms of hallucinatory schizophrenia, began to cast an evermore imposing spectre in the relationship, causing much distress to Rani. His delusions began to take such a toll on their relationship, with even the good tidings of a baby in the oven twisted into a string of abortion by Rani, afraid that he would bring harm to her and any prospective child she would bequeath upon them – he professed to see the child as a harbinger of doom, as the embodiment of the devil. Midway through the episode, the viewer is treated to the appearance of two ambiguous personalities – a man and a woman, whose blue lanyard faintly conveyed some sense of authority. We are left uncertain as to their actual responsibilities – they are at times quizzical, unwilling to manifest the “good cop, bad cop” trope. No matter, it is not the point of the episode to further entangle the convoluted plotlines – they serve as plot devices which encourage Prem’s own narrative to unfold – to the end, he remains stolidly convinced that his stabbing of Rani had taken her to a better place, the expression on his face almost beatific at times.
Dr Rajesh, at this point, sees fit to caution the viewer against harshly attributing homicidal tendencies to persons with psychosis. He presents the statistic that even less than 15% of homicides are perpetrated by people mentally unsound. Noting the prevalence of drug use and antisocial tendencies that colour this 15%, he confidently steers the viewer away from making too quick a conclusion – it is in everyone’s best interest to step back and evaluate statistics grounded in good science, instead of leaping to the easy conclusion that Prem was beyond rehabilitation.
1.What kind of mental issues that the elderly can experience during a pandemic like COVID 2019
Physical distancing during this public health crisis is essential in preventing the spread of the virus, but it can come at a high cost to seniors’ mental health and well-being, resulting in loneliness, anxiety, depression, and cognitive problems. Self-isolation will disproportionately affect elderly individuals whose only social contact is out of the home, such as at daycare venues, community centres, and places of worship. Those who do not have close family or friends, and rely on the support of voluntary services or social care, could be placed at additional risk, along with those who are already lonely, isolated, or secluded. It’s hard to escape news updates about coronavirus disease (COVID-19). The constant headlines and media reporting may make some people anxious. In particular, older adults, people with chronic health conditions, and caregivers are likely to be at higher risk for increased stress and anxiety, since they face a higher risk of illness if they contract the virus. Fear and worry about your own health and the health of your loved ones can result in changes in sleeping or eating habits, difficulty sleeping or concentrating, worsening of chronic health problems and increased use of alcohol or tobacco.
2) What are the potential do’s and don’ts that the elderly have to observe during this period of time? (e.g. spreading unverified COVID-19 news via whatsapp)
Maintaining seniors’ connection to their healthcare providers using the telephone or video telehealth platforms is critical and “may be the most important thing we do as mental health professionals.These include greater use of computers or tablets to stay connected to family, loved ones, and friends through video chats and playing online games.Seeing each other’s faces, hearing their voices, and sharing the experience that we’re going through can be therapeutic for everybody.Mindfulness-based interventions and relaxation techniques could also be helpful.There are many computer-based applications for these mindfulness exercises that the elderly folks can try out.
For seniors who are not tech savvy , and have difficulty using smart phones and the internet, just calling their relatives or friends through the phone would be immensely helpful for their mental health and reducing anxiety and fears.
Seniors who are comfortable and confident in using the internet can also sign up to govt websites such as www.gov.sg to obtain correct factual information. Due to widespread internet access, numerous fake messages and videos can be potentially circulated through whatsapp causing increased unnecessary fear and anxiety. This can be avoided by restricting too much exposure to online news and messages and probably watching the news on TV once a day for those who are more prone to anxiety.
GO ON A NEWS DIET
Stay informed, know what’s going on but don’t get locked into endlessly watching “breaking news” on the 24-hour news channels.
3) How can family members in the household assist to ease their worries, concerns and fears?
Children and grandchildren of the elderly who are living alone can also help by being in regular online contact and also calling them on their phones and giving them verified factual information of the COVID outbreak . For family members living in the same household, it is good to regularly update the elderly people about correct factual information about the epidemic. It is also important for the family members to keep the elderly engaged in other activities such as reading, playing indoor board games, chess, and other activities. It is also important for the elderly to avoid going outas they are more vulnerable and family members can help by providing groceries and other household essentials to them.
4) What kind of meaningful activities can the elderly engage at home during this period?
In addition to picking up the telephone, otheroptions that may help seniors stay mentally engaged include practising hobbies or activities such as knitting, crossword puzzles, “or whatever else works for them. Whatever helps them cope and keeps them occupied during self-quarantine should be encouraged. If there is a positive aspect to the COVID-19 pandemic, it’s that it has forced people to slow down and connect with each other. You may not be able to control the virus, but you can help control your emotional reaction to it. Take breaks from watching, reading, or listening to news stories, including on social media. Hearing about the pandemic over and over can be upsetting. Take care of your body. Take deep breaths, stretch, or meditate. Here’s a free guide on how to meditate from Mindful magazine.
Eat healthy, well-balanced meals.
Relax by doing activities you enjoy. Try crossword or jigsaw puzzles, , cook healthy meals and freeze some for later, and seek out TV shows to watch that give you pleasure. Explore your library’s online offerings.
For those who are not tech-savvy, it would be useful to learn the basics of using the internet and also learn to use online tools such as Facebook or zoom, so that they can get in touch virtually with friends and relatives if they are living alone.
5) How can the community play its part in caring for the elderly who have little family/external support and live alone?
It is important for neighbours living on the same floor to look out for the vulnerable elderly living next to them. At times of crisis like this, do people need to get more empathetic and concerned about their fellow human beings? Neighbours can check on their well-being at least twice a day basis, help them to get their groceries and also check on their physical health and get medical help if required.
There are also community agencies run by the government as well as NGO’s that have volunteers who can provide additional support to the elderly living alone or with poor family support.
There are organisations which can provide meals delivered to their houses which will avoid the elderly from leaving their houses unnecessarily.
6) Taking care of elderly patients especially those with conditions like dementia can be challenging for caregivers. How can caregivers ease their tensions, worries and stress while taking care of the elderly at home?
For patients with Alzheimer’s disease or other cognitive problems, maintaining routine is important. Any change in routine can lead to agitation and behavioural issues in these patients. Share simple facts about what is going on and give clear information about how to reduce the risk of infection in older people with cognitive impairment. Repeat the information whenever necessary. Instructions need to be communicated in a clear, concise, respectful and patient way. It may also be helpful for information to be displayed in writing or pictures. It will also be useful for caregivers of patients with dementia to take turns in looking after them to reduce the risk of caregiver stress and caregiver burnout. It will also be useful for caregivers to join online groups where they can share their concerns and other relevant information with similar caregivers looking after people with dementia.
In this episode En Ullae on Postnatal Depression, Dr Jacob Rajesh shed light on what some still view as a taboo reaction to what society views as a blessing – the birth of a child. Postnatal or Postpartum Depression is marked by a dip in mood, emotional turmoil, sleeplessness, and changes in eating habits. It can haunt a mother who has borne her flesh and blood for over a year, or the pall might lift after just two weeks.
This episode started out light and buoyant, with scenes of carefree courtship. But the fortuitous chemistry of an arranged marriage that might have heralded exemplaries of the nuclear family, under different circumstances, was to be tested by the wife’s struggle with Postnatal Depression. The coming child would serve as a lightning rod, bringing strife into the relationship. Even before the little baby girl’s conception, the couple disagreed on whether to have one – but cultural pressures enveloped the mother with a pained acquiescence with living up to the status of an “ideal mother” – at odds with her inner values, although she scarcely knew it. Dr Rajesh noted that the immense pressure of a cultural belief in the Indian community that a child was “God’s gift” would serve only to create uncomfortable dissonance within a mother who is not ready to bear fruit.
At some point during one of their many arguments, the husband even goads his partner with the suggestion of abortion, despite the medical impossibility of aborting a 6-month old fetus in Singapore. The child, inevitably emerging from the womb, healthy, would only highlight the difficulties that the couple would face.
Dr Rajesh was quick to point out the boorish behaviour of the husband, noting that in such situations, the support of family members, especially partners, is crucial in alleviating the symptoms of Postnatal Depression. Dr Rajesh went on to warn potential mothers that past depressions were risk factors and that difficulties during the birthing process that might, for example, warrant emergency Caesarean sections, would prove additional risk factors.
The working mother and father were presented with additional difficulties simply by virtue of the husband and not being able to support the wife when needed. Her slow descent into Postnatal Depression began with the naggings of a vague sense of agitation, exacerbated by tiresome nights and a feeling of malaise. Eventually, she would begin comparing herself to an idealised version of what a Mother should represent, having taken care of relatives’ kids at the age of 13, she felt she had no excuse for her failures. Dr Rajesh noted that the unfortunate situation should serve to highlight the dangers of an internal dissonance that would only elevate the crisis. At her nadir, she even contemplated the act of suicide, pulled back from the edge by her maternal instinct. Her child’s cry saved her.
In these situations, Dr Rajesh made clear that she should ideally have been separated from her child, for the family’s sake and checked in to a mental health clinic for treatment. Luckily for them, her husband initiated contact with his own mother, seeking her assistance in caring for the baby. Taking pressure off the mother in situations such as these is of critical importance, who has to learn that she needs time and space to soothe her own mental health crisis. The health of the family unit is somewhat predicated on the stability of the maternal figure, so such a step makes a whole lot of sense. Much attention needs to be shone on the precariousness of these unfortunate situations, so that other prospective mothers are aware of the risks and the steps they can take to avert such crises.
