Question: Dear Doctor,
I am a 25 year old female medical graduate from XXXXXXX presently preparing for my post graduate entrance exam. I have been a good student all through my career. But over the past few years my academic performance has dipped. Especially now that I have to concentrate on my studies and work hard, I cannot seem to do so. I constantly feel bored and restless. Thinking that the stress of MBBS days is making me feel so, I took a year's break at home. But it hasn't helped.
I have noticed that I have become very moody since past 4-5 years. I have unpredictable mood swings from elated to sudden depression and back again. It does not occur as definite episodes with a well defined trigger that I can try and avoid. I feel as if I am on a roller coaster of emotions most of the time. I was always short tempered but nowadays slightest of the slight or seemingly benign events trigger wild and uncontrollable anger. When I am angry I feel I am justified in screaming or being sarcastic. I sometimes throw and break stuff. But later on I cannot fathom why I reacted so and I feel acutely ashamed and disgusted with myself. I cannot seem to avoid thoughts of how evil I have become at such times and I feel I should be punished but I am not brave enough to contemplate any serious action, though I wish I was dead. I do bang my head or bite or pinch myself sometimes. The pains kind of helps, though I cannot tolerate it for long.
I have shared a few things with my mother who is very understanding usually but when it comes to talks of mental issues she just pacifies me and says I am being overly concerned and am imagining things. I am not sure if she is right. In fact I feel unsure about many things including my future which is scaring me the most. Though doing MBBS was my choice, now the idea of treating patients and sitting in an OPD itself sends me into a state of panic. I had a very hard time during Internship because of this. I cannot overcome the fear that I will hurt patients because of my ignorance. Studying also does not boost my confidence. I feel unworthy. This feeling is worsening. In my MBBS days I had problems with self-confidence and ability to interact with people comfortably. But most of the time I could suppress the uncomfortable feeling and do what was required. I even went for an international conference in Portugal alone. But 2 years later, now I have to drag myself to get out of the house and I feel acutely uncomfortable doing so. I have gained a lot of weight yet I cannot stop myself from binge eating when I feel overwhelmed. I started exercising but cannot stick to it.
My relationship with father has always been strained. He was never present when I or my mom needed him, not even in medical emergencies and no matter what I did I was never good enough for him. I won the silver medal in state maths olympiad in 7th standard and yet he said it's no good as another student got the gold. 1.5 years ago when I cam back home after MBBS he said he was sorry for his callousness and indifference and that time away made him realize his mistakes. He wanted to begin again. I believed him and things got better for a few months but everything is back to what it always was.
He and my mom hate each other. But will never think of separation because of social taboo. Mom suspects his fidelity. I have always known his character was never up to the mark, though he sure appears a perfect gentleman. When I joined the local medical college for internship, I heard unsavory tales about him(he is a doctor too). Their marriage has convinced me of the futility of this whole institution and I never wish to marry. This has caused more problems with father who wants to start looking for a groom.
All these troubles have made me come closer to my mom, though as a child I was extremely attached to father despite all those times when he screamed at me, hit me or wished me dead. Now my emotional dependence on my mother has increased so much that I feel uncomfortable when she leaves for work everyday. She also has commented upon this. The problem does not end here. Though most of the time I idolize her, minor misunderstandings or disagreements with her make me feel lost. I almost hate her then and I fight with her. She forgives me later but I am consumed with guilt. I often cry myself to sleep.
There is also this self doubt which is very troublesome. I often wonder if I am over-reacting and committing a grave mistake by not understanding my father until it will be too late, like he so loves to say. I hate him but a part of me still loves him and craves his love.Yet I am not able to decide who's right and who's wrong. Though my mom has never interfered in my dealings with father, I feel guilty as if I have betrayed her when I feel positive towards him. It was easier when I was away from home. Now when I have to face him daily, it is tearing me in two, especially when he acts like I have wronged him so. Have I? I cannot decide. I have this problem in deciding no matter how big or small the decision might be. All I manage to do is overthink.
Then there is the issue of lying. All through my MBBS days, I told my peers what a wonderful father I had, I invented a doting elder brother (inspired by the elder cousin to whom I was attached as a child but who as we grew up became distant despite all my efforts to the contrary) even though I am a single child. Initially doing so helped me overcome my loneliness and it also gave me something to talk. I was a bookworm, with no exciting experiences, no boyfriends, no idea about the latest happenings to gossip about. But my lies increased and the more I got away with, the more I started lying. I then lied to cover up for my lacunae. For example, when I flunked in an exam, I told everyone who would hear, that my father had a stroke the previous day. I thought that ways people will never know the real reason behind my poor performance, the real problems I was dealing with. I never felt guilty about doing so. I rationalized that those whom I lied to, lied and deceived me when it suited them. They never came to my help, never even asked what was wrong when I dealt with my emotional problems which caused me such distress, even though they did not hesitate asking or accepting help from me for their own issues. I had wanted to develop lasting friendship but could never even trust any one of them. But the lies I told then have become quite troublesome now and I feel very bad about such manipulative behavior. I do not like the kind of person I would become if I continue. So I do not want to lie anymore but if I maintain terms with them I have to cover up and tell more lies or risk exposing myself. So I have cut myself off. I had started saying unintentional small meaningless lies at home too. But I have actively started to try and stop. I have slipped a few times but nothing major for the past couple of months.
Lastly I am scared about what is happening to me and that it will destroy my career and my future. It already has cost me an honors degree in MBBS. But then mom always says I too critical of my own capabilities and that I do to myself what father did once. I am trying to control it. If I don't excel at what I do, I become frustrated and depressed which adversely affects my ability so much so that I almost never perform at par with what I could have easily done.
I can not confide in my mother as most probably she will make light of everything and I will not like it. Or she might become too worried which also I don't want. I have been browsing the net to know more and have stumbled upon some alarming stuff. I know self diagnosis is a mistake. And since I cannot go to any psychiatrist in my small town where my father is a known person, I thought of trying out online consultation. Anonymity is the biggest attraction. But because of my usual distrust of most things, I am quite hesitant. Since I have no other option and I badly want an expert to tell me nothing is wrong or if something is then what it is exactly, I am taking this step. Please doctor, I have read great feed-backs from clients on this website. I hope you will help me make some sense out of everything that I have mentioned here.
Thank you.

The depressive symptoms last for short periods of time, usually a few hours a day. But sometimes when I kind of loose control and give in to verbal fights, I end up crying and feeling depressed for even a whole day. Such full day episodes occur irregularly, around 2-3 times a month. More frequently during times of stress like exam or escalated family tension.I feel an exaggerated sense of hopelessness and helplessness during such times. On relatively normal days I tend to avoid thinking about things that make me feel so and can function almost normally unless there's a trigger.

I have never had a boyfriend. Nor any close friend for long. Like I said before I have trust issues. Usually I attract a lot of friends in a new situation. But I can not retain any bond for more than a few months. I suspect that people have ulterior motives for doing almost everything. You asked about paranoid ideas. I fear I might be betrayed and played by people if it suits them. It is a general thing and not about any person in particular. For example, if a classmate buys me something, I instantly become suspicious and so I have difficulty accepting the gift. I can not tell if I am right in suspecting who are supposed to be my friends. But there have been incidents when I found them lying and deceiving me. For example, my study partner in final year had a habit of making excuses for not studying together. I had asked her if she wanted to discontinue or if she had any problems reading with me, but she always assured me that everything was fine. I was having problems because of this and my studies were suffering. I have difficulty concentrating when I am alone. And then one day after she cancelled our plan saying she was too ill to study, I found her in another girl's room studying. I should have confronted her then but I was too overwhelmed to do anything.

Such incidents when I find my 'friends' are not loyal to me and prefer others over me; make me feel guilty about my habit of lying. After all since I have been deceiving them, I can not expect any thing else. But I hadn't realized that I was deceiving anyone which is ironical, I know. Initially my lies were mostly for wish fulfillment. Like things that i dearly hoped for and couldn't get in reality, I made up stories about those and told others. I used to get lost in the fantastical world that I created. If my mom sent me an earring for my birthday, I used to show it to others saying my elder brother or my father gave it to me. For a little moment, I could delude myself into actually believing that and so feel happy about it. I always wanted such little signs of affection from my dad and the cousin whom I loved like a brother. But I never got it. So a lie like that gave me some solace and I felt I wasn't harming anyone with it. But later on, I started lying for other benefits. I am not sure one can say benefits though. For example, I flunked in my pathology sessional. I now realize it was no big deal. But I had always been a straight A student and felt ashamed for such poor performance and guilty at not having prepared enough. I had been having a hard time dealing with these excess of emotions plus 2nd year MBBS as such was tough and I had taken up the extra work of writing a research article. I could not juggle all of it and the night before the exam I lost it. Having cried through the night, I was exhausted when I sat for the exam and so nervous that I kept trembling. I can still remember that day. Nothing made sense. I turned in an almost blank paper and ran home. The next day I was afraid people will ridicule me for the show and especially when results come out. So before anyone could say or ask anything I just told them that my dad had a stroke the previous night. As expected everyone was sympathetic and none said anything derogatory.Then on-wards whenever, I did badly in a paper or was not enough prepared for a seminar, I found it convenient to make up story than face the real problem. I at-least never skipped what I was supposed to do. Now I am tired of the web of lies I have had to say since then. It had become so difficult keeping up with it. But more importantly, when I look back I feel ashamed. I do not want to become such a weak person, one who has to lie to make up for her own defects. I know I am a perfectionist. Anything less than the best makes me uncomfortable. But lying to justify the lacunae is not the way. Also I was confusing sympathy with concern, pity with love. I don't want to be pitied. I want to be appreciated. Also all these lies are making it difficult for me to now remember the truth. And I don't like it.

Okay about self harm. I have had ideas about it and also suicide when I am at my worst. And I am not proud of it. I dislike that I have had such moments. I have only once acted on such thoughts. I slit my right wrist when I was 18 years old. But thankfully the wound was not deep and I had not damaged anything. I got scared as soon as it started bleeding and all thoughts of self harm fled. I convinced my mom that I accidentally cut myself with a scalpel while searching for a drug in fathers drug cabinet. She believed me with ease and was so worried. Now whenever I start thinking of such thoughts I always remember her face that day and so never proceed. But when I am irritated or angry and alone I often bang my head on the wall or punch things or pinch myself too hard. I don't mean to harm myself though I do sometimes end up with a bruise here and there. I am trying to control such things and do things like counting or deep breathing when needed. But I haven't been much successful.

Pleasure- I like cooking a lot. But there's no one at home who would eat what I cook. Mom is very picky about eating and father, well he eats everything but his comments wash away any pleasure that I got from cooking. So though I do cook often, I end up getting more frustrated than happy after it. I used to like reading novels and poetry. But my interest has diminished quite a lot. Often I feel irritated and give up half way through. Romances feel meaningless though I once loved those. I am too impatient for mystery thrillers. TV and movies- same, my interest has declined. I used to write poetry. I still do but it ends up being overly morose. I often think of trying new things but mostly circumstance are never conducive. I have studies and I am still dependent on my parents. so Have to account for major expenses.I totally do not like shopping or travelling as for both of those I will have to come out of the house and meet people. I can do it when necessary though. One thing I do like is talking about inane things with my mom. She is my best friend and I share a lot of things with her. When father is not home, we often watch movies together, cook or just sit and chat. Those are the things that give me true pleasure. I acutely missed her when I was in hostel and hence fear leaving her in the future once I do get a pg seat.

OPD- I have very low self-confidence. I am afraid I do not know enough to be able to diagnose or treat a patient properly. During internship, I was in a govt college. So there was hardly any supervision. Everyone was overworked. And whatever guidance docs or pgs did give to the interns, was never meant for me. Everyone assumed my father would have taught me the basics. I could never claim otherwise. I felt humiliated. I also never asked father for help. I was never sure if he would. So I relied on copying what I saw others do and used net, books and videos as guide. But I never felt sure. Also I am uncomfortable, shy while dealing with people in general. The openness needed to talk freely with patients is difficult for me, which makes my interactions with them stilted and awkward even as a med student in case taking. Difficulties increased when I realized I am responsible for the well being of a patient. I had to do CPR on a young patient in casualty as I was the only 'doctor' available and the patient eventually died. Though the pgs did say such a thing might have happened to anyone even a specialist but I feel scared when I think of being again responsible or even be partly or however remotely related to a death.

Since I am done with MBBS and have to become a doctor, I would like to specialize in a non or at-least para clinical subject like pathology or microbio or physio. I love teaching. I came to know that in MBBS when I was asked by a prof to stand on stage and teach a small topic. I have no stage fear as I have been taking part in debates and elocution since childhood. I only have trouble talking to a person one on one, where I start fumbling, whether be it a viva or just normal conversation. I feel out of my element then. Also when I got involved in student research I like it a lot. So i would try to be involved in research. But I fear I may have no real talent for any of these things as well. I mean I have never been tested and proved. Also I feel unsure as to how I would achieve these goals. I am not even sure I can get a pg seat. Also I fear if I will not like it when I really start doing it. Father always says I am fickle-minded, that I start many a thing bubbling with enthusiasm but never complete them. I think he might be right. I did join music classes, bought a harmonium but left it half way through. But then I had never had much aptitude for music, I had wanted to learn dance. I also never learnt cycling even though I kept pestering my parents for a cycle for years. But when it was finally bought, I was already wearing chudidars and I felt so awkward trying to learn when mere kids would pedal past me. He says I have excuses for everything and maybe he is right. what if I get into teaching and/or research and then find out I don't like any of it? This scares me and so I try to avoid thinking about the future. But without a clear goal in mind, I don't find enough motivation to struggle daily for studying and so I am lagging behind in preparations.

Thanks a lot doctor. I had been afraid that I might have some serious personality disorder that will ruin my life. Thank you for shedding more light. Having little or almost nil knowledge about psychiatry and psychology, trying to find answers on my own had sure scared me. The way you have depicted it, it gives me hope. A little depression can be dealt with, even without medications, right? I am not willing to immediately consult any psychiatrist in person, at-least not until I am away from my home-town. I can talk to my mother and show her this discussion too if needed. Will that be enough for now especially if I try harder to remain positive?

You have said I should build trust on others? But what if I get deceived in the process? Is it not better to remain aloof? The lesser contact I have with people, the less issues I will have. Was I wrong in cutting off relations with my MBBS classmates? But I don't want them to know the reality.

Next how do I deal with my father? And how do I deal with the insecurities that I might have developed as a result of his constant decrial? How do I try to boost my self esteem and confidence? I guess that should help me get rid of many of my anxieties, uncertainties and fears. Or is it indeed about fickle-mindedness? If it is, is there anything that I can do to modify myself? Also when I feel irritated or anxious, I don't want to lash out at my poor mother. I believe distraction should help. But at that moment I forget about everything, even the need for control and distraction. Can you suggest some method to help me there?

You said my personality is just starting to fix. I don't want to develop a disordered one. Everyone keeps offering free advice about yoga and pranayam. These might be good things but despite how much I try, I can not sit still for long enough to really do it. Are there any alternatives? Should I try reading motivational books? Can you suggest some?

Thank you so much doctor for your help. I will keep in mind all that you have suggested and will surely work on improving things. Thank you.