Marking the World Mental Health Day which fell on October 10, we spoke to Dr. Mahesh Rajasuriya, Consultant Psychiatrist, National Hospital of Sri Lanka and the Senior Lecturer from the Department of Psychiatry, Faculty of Medicine, University of Colombo who warns that “all frills of digital devices including smart phones come at a huge cost,” impacting our overall mental health and well being.
by Randima Attygalle
The smart phone has come to stay with us and there is no escape. From communicating with people to reading your daily newspaper, the smart phone has become indispensable. More than a mobile phone, it is now a movie theatre, a TV, a radio, a camera, an alarm clock, a diary, a notebook, a flashlight, a navigator, a health checker, a banker, grocer and so much more! It has become the first thing we check in the morning and the last thing before we go to sleep. While leaving home without the phone makes one ‘lost’ for the rest of the day, losing it is a nightmare.
While addiction to our smart phone or other digital devices such as tabs or computers (with access to the internet) is yet to be classified as a ‘mental disorder’, the negative impact of their overuse on our overall health and well being cannot be underpinned says, Dr. Mahesh Rajasuriya, Consultant Psychiatrist, National Hospital of Sri Lanka and the Senior Lecturer of the Department of Psychiatry, Faculty of Medicine, University of Colombo.
“Drunk driving could crash your car and kill another pedestrian and leave you disabled for the rest of your life. But one need not necessary be an alcohol addict to be in this predicament. It is the same with device or screen addiction. There need not be an underlying pathological condition for us to understand the seriousness of addiction to these devices. Your family and work life, education, social connections and even sex life would all be at stake,” says Dr. Rajasuriya.
A mental disorder is diagnosed on acceptable diagnostic guidelines. There are two such internationally renowned guidelines: The International Classification of Diseases (ICD 10, ICD 11) by the World Health Organization (WHO) and Diagnostic and Statistical Manual of Mental Disorders (DSM 5) by the American Psychiatric Association. None of these guidelines still recognize a ‘disorder’ for addiction to screens or electronic devices, yet it recognized internet ‘gaming disorder’ in the section recommending conditions for further research, along with caffeine use disorder and other conditions.
In a move that addresses concerns about the public health implications of excessive use of electronic devices, WHO has included gaming disorder in the 11th Revision of the International Classification of Diseases (ICD-11) which is to come into effect on January 1, 2022. Accordingly, Gaming disorder is defined ‘as a pattern of gaming behavior (“digital-gaming” or “video-gaming”) characterized by impaired control over gaming, increasing priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily activities, and continuation or escalation of gaming despite the occurrence of negative consequences.’ According to the WHO, for gaming disorder to be diagnosed, the behaviour pattern must be of sufficient severity to result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning and would normally have been evident for at least 12 months.
However Dr. Rajasuriya explains that not all people who engage in gaming will develop a gaming disorder. “Studies have shown that gaming disorder only affects a small proportion of people who engage in digital/video-gaming activities.” Evidence-based research findings are yet to emerge on the pathological use of digital devices, yet the obvious harms such excess use can inflict on the user and his family and loved ones which are larger than pathological conditions, cannot be overlooked he says. “It is no rocket science,” reflects the psychiatrist who goes on to say that if the use of digital devices entail any concerns for you, your children and others, certain interventions are necessary. These would include neglect of daily chores, drop in academic performance, strains on family life and cyber/online harassment including sexual harassment.
The physical and mental health cost of device abuse is enormous. An increase in energy intake, sleep disorders, daytime tiredness, the displacement of time available for physical activity and reduction, poor attention and lack of concentration in metabolic rate are among the latest research findings related to physical health impact. Irritability, low mood, impaired cognitive and socio-emotional development and poor educational performance are among the mental health consequences of excessive device dependency. In case of ‘developing minds’, this could be worse, resulting in low IQ levels and poor interpersonal skills in children.
Citing the Screen time Guidelines by the American Association of Paediatrics, Dr. Rajasuriya says that for toddlers under 18 months, no screen time is permitted unless it is to connect with a loved one such as ‘video chatting with grandma.’ While little screen time of ‘high-quality educational content’ is permitted for toddlers between 18 months and two years, according to each age groups up to 13 years, the Guidelines offer advice for parents and care givers.
While letters, post cards and aerogrammes could be ‘ancient communication regalia’ for the present youth, forging a life banishing the latest technological devices would only be unreal. Hence, empowering them to be the master of their smart phone without becoming a slave to it is the way forward, points out Dr. Rajasuriya. “We need to accept that youngsters spend a considerable time on their smart phones, connecting with the world and people. Today WhatsApp groups are popular which could collectively link many people instantly- both students and adults. The instant communication these enable is beneficial, especially in an emergency situation. The COVID pandemic situation further validated the benefits of the digital world.”
In case of social media, while it enables enhanced connectivity, it could also be an intrusion on privacy, calling for ‘smart’ navigation of it. Cyber bullying, online sexual harassment and even digital crimes are rampant today. ‘The projected reality’ created by many digital platforms could lure their users, especially the youngsters, notes Dr. Rajasuriya. “The online social connections foster a false sense of enrichment although in reality the brain is negatively stimulated by them. Such experiences are not deepening or rewarding.”
Identifying early markers of ‘digital device’ addiction could help mitigate its long term cost. “If you or your adolescent child use social media, yet forge real-life social connections with no phobia, socially interact with the extended family, peers and colleagues at the workplace, it does not become a concern, yet if the only social connections are those made on social media, then it becomes a serious concern,” warns the psychiatrist. Inter personal skills, negotiation skills, problem solving, mentoring and even intimacy are all essential elements of human development which could never be replaced by social media, he adds.
Introverts and those with social anxiety find social media and other digital devices as a means of escaping from the reality. “As a result their behaviour doesn’t get corrected but enhanced. In case of depressed people, no real life friend would be there to identify early markers and intervene, the repercussions of which could sometimes be fatal. While some of these introverted people including adolescents may harbour a false sense of achievement and self-esteem in the digital world, in the real world, they would be socially handicapped.” Excessive dependency on these media could even trigger conditions such as depression as a result of an exhausted brain and lack of coping strategies says the Consultant.
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Breast cancer awareness; a simple needle test goes a long way in saving lives
Breast cancer is the most common cancer in women across the globe. National cancer incidence data (Sri Lanka) has shown, a significant increase in the number of breast cancer patients. The peak incidence of breast cancer is between 50 – 58 years of age (can vary from country to country).
1. Age – Peak incidence of breast cancer is between 50 – 58 years of age. The incidence of breast cancer decreases after 60 years. Breast cancer is uncommon in women less than 30 years of age.
2. Family history – Women who have a first-degree relative with breast carcinoma have a two to three times higher risk of getting t
he disease than that of the general population.
3. Genetic mutations – Germline mutations of BRCA1 and BRCA2 genes are associated with an increased risk of having breast cancer.
4. Menstrual and reproductive history – Increased risk is correlated with early menarche (beginning of menstrual cycles), nulliparity, late age at first birth and late menopause.
5. Exogenous oestrogen – Exogenous oestrogen is considered as a risk factor of breast cancer.
6. Ionizing radiation – An increased risk of breast cancer has been documented with exposure to ionizing radiation.
7. Alcohol consumption
8. Cigarette smoking
10. Lack of physical exercise
However, in most cases a definitive cause for breast cancer cannot be identified. It is important to know that you can get breast cancer without having any of the above mentioned risk factors. Why it happened and how it happened may not be clear at all times. Do not blame yourself, it is not due to your fault. It can happen to anyone… rich or poor, big or small, black or white. Do not let breast cancer destroy your life. If you come early the disease can be controlled. Be knowledgeable about the symptoms of breast cancer. If you feel something is not right, without taking it lightly resort to medical advice.
There is a wide range of symptoms that can vary from person to person
Breast lump (usually painless), hardness or thickening
Skin changes that include swelling, redness, pitting (skin of an orange), scaling or any other noticeable change
An increase in the size or change in the shape of the breast
Changes in the appearance of the nipple (s), peeling of skin over the nipple
Discharge from the nipple (other than milk)
Pain in any part of the breast
Lumps/ swelling in the arm pit
However, it is important to understand that early breast cancer may not show any of the above symptoms. You may not feel a lump at all. Only way to detect early cancer is by a screening method and currently the widely acknowledged approach has been screening mammography. By this screening method unsuspected lumps in asymptomatic women can be identified. Breast cancer screening using mammograms is a well- established program in the developed world. Women over 45-50 years of age are recommended for screening. The cut off age for screening can vary from country to country. If there is a strong family history of breast cancer (or any other significant risk factor) screening will be offered at an earlier age. Mammogram exposes the breasts to a small amount of radiation. Benefits of breast screening by mammogram are far too many. We do not have a national breast cancer screening programme yet, but it will come in to place in the near future.
There is a simple needle test (fine needle aspiration cytology technique) that can be done as a first line investigation for breast lumps. It is a minimally invasive procedure with hardly any complications. It is cost effective and the results can be obtained quickly. Needle test can give a clue as to the nature of the lump. Sometimes the needle test results can be inconclusive. In those instances, further investigations will be done to confirm the diagnosis.
A plunge of three decades and more
Sri Lanka Sub Aqua Club credited for producing some of country’s top divers, several of them internationally recognized today, turns 35
by Randima Attygalle
Piling the diving gear into their cars and filling the empty seats with fellow divers, the founder members of the Sri Lanka Sub Aqua Club (SLSAC) in its formative years would head south to Hikkaduwa or Galle. They would fill their cylinders with a compressor, cast their own lead weights from lead pipes bought in Panchikawatte and purchase second-hand equipment whenever they appeared in the market. As the Founder Chairman of the Club, veteran diver, Dr. Malik Fernando recollects more than three decades later, “those who were fortunate enough to travel abroad brought back accessories and sold them at cost and we even serviced our own regulators.”
The Sri Lanka Sub-Aqua Club was formed in 1985 by a group of diving enthusiasts led by the marine biologist, Dr. M.W.R.N de Silva (Dr. Ranjith de Silva). What was envisaged by the Club says Dr. Fernando was to train Sri Lankans in SCUBA diving for both recreation and more importantly, for scientific research. He was supported by Arjan Rajasuriya, presently the Coordinator, Coastal and Marine Programme, International Union for Conservation of Nature (IUCN) Sri Lanka Country Office. The idea of the Club germinated in the mind of the founder, Dr. Ranjith de Silva following his establishment of the Coral Unit at the National Aquatic Resources and Research Agency (NARA). The core group consisted of a few British Sub Aqua (BSAC) qualified divers such as Dr. Fernando, himself and those who have been involved in various diving-related pursuits.
The SLSAC, modelled on the BSAC, had produced several internationally reputed divers along its 35-year journey. The SLSAC-certified divers are today recognized by many local recreational dive stations. “Although we sought to form a branch of the BSAC once we got established, the cost was prohibitive, thus we initiated our independent certification scheme,” notes its founder chairman. The Club’s training courses, Dr. Fernando recollects, were very popular and many divers were trained by senior members. “However, it was eventually recognised that the BSAC curriculum was too comprehensive, too time consuming and too detailed for beginners. With the popularisation of the compact PADI course that a number of us followed, the club curriculum was modified and simplified changing from a BSAC model to a PADI model, with much less theory and drills reduced to basic essentials. The instruction was still by club members, some of whom had BSAC qualification and experience in instructing in their original clubs. We were only able to give a club certification, but after we had established our credentials by producing well trained divers, that certification came to be recognised by some of the recreational dive stations.”
The SLSAC was also one of the chief catalysts in driving the now well-established Maritime Archaelogy Unit (MAU) in Galle, and the contribution made by the Club members towards its expansion is notable. Recovery of several porcelain and glass artefacts by them from the shipwrecks lying in Galle spurred this initiative, says Dr. Fernando. Further, th
e club has also contributed to maritime archaeology and preservation of artefacts by contributing to the establishment of a shipwreck database and actively lobbying against shipwreck salvaging, especially of ancient shipwrecks.
A medical doctor, Fernando attributes his ‘physician gene’ to his illustrious father, Dr. Cyril Fernando and his penchant for nature to his artistic mother. An adventurous family, they would seize every opportunity to travel out of Colombo fuelling the budding physician-cum diver son’s exploring spirits. Taking to water at the age of seven, young Malik’s imagination was fired by the National Geographic Magazine. With a pair of flippers and a second-hand mask he would head towards Mount Lavinia and recollect his earliest experience of Hikkaduwa as “going deep down into an aquarium.” Further inspired by the celebrated diver Rodney Jonklaas, a family acquaintance as well, the freshly graduated doctor would spend more time diving than passing his higher exams in the UK!
“Today the greater accent is on tuition and passing exams with little emphasis on sports and even if children do engage in sports, it is largely for competition. Sadly the value of sports as a leisure activity and a health gain is largely undermined today,” observes Dr. Fernando who urges school authorities to take more interest in water-sports. “Learning to swim and dive is only means to an end. Not only can a person discover new places but he/she can also become a partner is conservation,” says the expert diver who has walked the talk. Encouraging the budding swimmers and divers to become partners of the marine eco-system true to the mandate of the Club, Dr. Fernando urges them to rally around it in a bid to produce ‘responsible’ divers with scientific insights.
“Diving enables connectivity with the entire eco-system from which we are sadly very detached right now. It provides one of the best windows to the polluted environment, for which man is responsible,” reflects Wishwamithra Kadurugamuwa, present President of the Club. The monthly ‘sharing of knowledge’ exercise initiated by the Club facilitates this process, he adds. The experience and stories of the experienced divers shared on this platform inspire the younger members, he says. “For us, diving is much more than sight-seeing, it is about moulding divers who would perceive things scientifically,” says Kadurugamuwa who is a corporate lawyer .
The ‘Citizen Science Project’ which was launched by the Club early this year in collaboration with the IUCN (International Union for Conservation of Nature) is a progressive move which provides the divers a portal to document their dives. The exercise is envisaged to be a vehicle of future research and a facilitator in conservation. “The end purpose of this endeavour is to have a record after each dive as to where the reefs are dying, the extent of the damage, how can they be salvaged etc. To record all this, divers need to perceive through a scientific lens for which training is provided by experts,” said Kadurugamuwa.
The opportunities within the marine eco-system which lay before an island nation such as ours are enormous, yet hardly tapped, he noted. He cites water sports and newer tourism products such as shipwreck tourism in this regard. “Sadly there is not much attention paid to the marine environment in the magnitude it ought to happen,” adding that entangled fishing nets, empty plastic bottles and yoghurt cups floating besides the coral reefs do not support the idyllic picture any underwater explorer would want to see. The Club’s intervention to clean fishing nets entangled on coral reefs and lobbying for legislation against unethical fishing practices are moves towards realizing a sustainable marine environment.
Dynamite fishing and spear-fishing are very destructive forms of fishing and whilst there is active legislation prohibiting dynamite fishing, it is practiced widely and the club has played a very active role in reporting infractions to authorities leading to curtail of such activity. In addition the club was instrumental in bringing about legislation to prohibit spear-fishing in Sri Lanka – again a very destructive practice as spear fishermen in SCUBA gear have caused localized extinction of key species.
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