For individuals that are taking the first step to seek help from mental health professionals, it is natural that they may be concerned with the possibility of a misdiagnosis, or perhaps an overdiagnosis. With the pre-existing stigmatisation of mental health disorders, clients would have needed to pluck up their courage to seek treatment in the first place. A misdiagnosis could not only hinder them from receiving the appropriate treatment for their affliction, but also allows for their distress to grow unchecked as their hope for recovery diminishes. In other words, accuracy in evidence-based mental health diagnosis is crucial, and this article aims to help you better understand how the diagnostic process works.
As the term “Evidence-Based Diagnosis” implies, psychiatrists or clinical psychologists take extra care to ensure that any diagnosis made is accurate, objective, and not subject to any form of personal bias. In some sense, this also means allowing for a safe, non-judgemental and compassionate environment. Primarily, clinicians would have to understand the client’s suffering and situation, before thinking about how that might relate to a possible mental disorder. Perhaps you may be unaware of this – clinicians do not simply jump straight into tying the client down with a specific diagnosis of a mental disorder. Before all else, clinicians have to consider if the client’s symptoms meet the definitions of a mental disorder in the first place. As per the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, the definition of a mental disorder considers these five factors:
A behavioral or psychological syndrome or pattern that occurs in an individual
Reflects an underlying psychobiological dysfunction
The consequences of which are clinically significant distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning)
Must not be merely an expected response to common stressors and losses (i.e.. the loss of a loved one) or a culturally sanctioned response to a particular event (i.e. trance states in religious rituals)
Primarily a result of social deviance or conflicts with society
With reference to the definition of a mental disorder, it is particularly important to note that the consequences of a mental disorder is clinically significant, and causes a weighty amount of disruption to one’s lifestyle and day-to-day activities. For example, it is completely natural for one to feel upset over certain situations, and this does not necessarily mean that you have a case of depression. However, you might need to get it checked out if you find yourself unable to cope with prolonged feelings of sadness which start to interfere with your daily activities, or are causing you to have suicidal thoughts.
Of course, clinicians then assess the syndrome one displays. By “syndrome”, we mean a collection of signs or observable aspects of the client’s suffering (i.e outward expression or behaviour). The main point of this is to identify if the syndrome is clustered in an identifiable pattern that is noted to be severe or pervasive. During the assessment phase, clinicians also try to understand the internal experiences of the client. Besides their outward display of distress, their thoughts and feelings are also important information which counts towards the diagnosis of certain disorders. Upon identifying that the client is indeed suffering from a mental condition, clinicians then try “assigning” the client to a particular category. You can think of it as, “can the syndrome be broadly identified?” There are certain broad categories of disorders, such as anxiety disorders, or psychotic disorders. Needless to say, clinicians have to consider which category the client best fits in.
The last step of the diagnosis process concerns the further narrowing and identification of the specific disorder – branching out from the broader, generalised category and into the specific details. For example, a client could be diagnosed with Obsessive-Compulsive Disorder (OCD), a form of an anxiety disorder. Ideally, a specific disorder is identified during the diagnosis process for various reasons – for the sake of the clients themselves, but also for clearer communication with other mental health professionals (in the case of continuity of care), and even for legal or court matters. Under rare circumstances, some clinicians are able to identify the broad category of the mental disorder, yet are unable to specify the exact condition that the client is suffering from. In cases like these, their disorders will be labelled as “unspecified”, as per the 10th version of the International Classification of Diseases.
As mentioned, evidence-based mental disorder diagnosis is all about diagnosing clients accurately and objectively. To enhance objectivity, some clinicians go the extra mile, stopping to consider if the diagnosis given was biased, or influenced by his or her own culture and history. “Is the syndrome maladaptive?”, “Did I take cultural variables into account?” An objective diagnosis will certainly go a long way in ensuring that the client receives the most appropriate treatment, which will in turn enhance his or her recovery journey.
Overall, it is safe to say that it takes two hands to clap in every treatment process. Clients and clinicians should try as much as possible to work together, be it in the assessment or treatment phase. For an effective treatment, clinicians will do their best to assess the severity and pervasiveness of any syndrome using understandable language such that clients are well aware of their condition. However, clients also need to understand that transparency on their side is pivotal and that it will drastically impact the treatment process, for better or for worse, depending on their cooperativity and how much they choose to reveal.
Dr Robert Shwartz, Ph.D., PCC-S, Evidence-Based Mental Disorder Diagnosis: How to Increase Accountability, Efficiency and Objectivity, video recording, Mental Health Academy
Predictive algorithms, the creation of alternate realities in which we are unlimited by the constraints of the real world we live in – such methods are extensively practiced by the gaming industry to draw players in. Gaming is undeniably a popular and widely-adopted mode of de-stressing, but how much is too much?
In May 2019, the World Health Organisation officially recognised “gaming addiction” as a mental health condition. It is diagnosed when a person displays a gaming behaviour pattern that causes significant disruption to their daily life for a period of 12 months. Meanwhile, a study showed that Singaporeans aged 18 and above spend a weekly average of 7 hours and 26 minutes playing video games, and that approximately 10 percent of Singaporeans game for more than 20 hours per week. This ranks us as the highest in Asia, and third highest in the world, falling only behind Germany and the United States.
What leads these addicted individuals to their compulsive gaming behaviour? Besides the prevalence and ease of access to games on various gaming platforms, video games often act as a form of escapism for many players. As a shining proponent of the alluring, edge-cutting virtuality, games allow for players to throw themselves into a virtual landscape that is contrasted from their – comparatively – mundane everyday lives, and can serve as a distractor from real-life problems that they are unconfident or reluctant to face. Moreover, it can be easy to fall into the trap set by game creators. Game designers construct games in a way that applies principles of behavioural economics as well as psychological mechanisms to explore stages and levelling up processes that trigger the brain’s reward system. In-game statuses matter a lot to gamers – the higher the rank you possess, the more pride and self-esteem you hold, knowing that you can show it off to your friends or gaming counterparts. As a result, individuals are often inclined to continue striving to climb the virtual hierarchy.
Naturally, excessive gaming has its consequences. When an individual develops a gaming disorder, his lifestyles can be disrupted in more ways than one. What is also important to take note of, is that the harmful effects of gaming addiction is not only limited to the individual alone, but could also affect the people in his or her social circle. Some of these adverse effects can include:
Obsessive Behaviour Individuals who are addicted to video games are always anxious to get back to games and will often display irritable, bad-temper aggressive behaviour whenever they are separated from their games unwillingly.
Increased Social Isolation With extended periods of intense gaming, these individuals become more withdrawn and disconnected from family, friends and colleagues, causing them to drift away from their loved ones.
Other Mental Health Conditions Gaming addiction can eventually lead to other issues that include depression or anxiety disorders. Sometimes, depression may follow due to the prolonged social isolation.
Other Physical Health Conditions A gaming addiction can also have a number of physical effects. When one devotes an excessive amount of time to the gaming activity, this can lead to physical conditions such as the carpal tunnel syndrome, migraine, back-aches or eye-strain. Extreme addiction may cause gamers to skip meals and rest, or neglect their personal hygiene as they lose control of themselves and can’t resist the desire to play more and more.
Gaming addiction is a serious matter, and can be degenerative if not addressed in the early stages with the initial symptoms and signs. Habits, including unhealthy gaming habits, can be formed anytime between 1 to 3 months, and it will be significantly easier to curb such self-destructive behaviour the earlier we try to tackle it.
While we are concerned with the various health risks and conditions commonly associated with gaming addiction, we cannot deny that video games are also undoubtedly entertaining and can be a good way to de-stress. However, as the risk of gaming addiction increases with increasing time spent gaming, what we want to advocate is moderation, rather than complete avoidance. With that said, if you are someone who is battling gaming compulsion, try to keep the amount of time spent gaming under control by setting time limits for play and stick to them. If possible, try reducing your playtime gradually by setting a timer on your phone, or use softwares such as ‘Cold Turkey Blocker’ to help you do this by blocking access to websites or applications so that you can get offline when you need to.
Like other forms of addictions, don’t try to go cold turkey at one go. Stopping altogether may cause you to feel as though there is a huge void in your life, hence increasing the likelihood of a relapse instead.
Think of the following scenario: you have friends over at your place and you serve them drinks. Before they can place their cups on your beautiful coffee table, you exclaim and dart out coasters underneath the ice-cold glasses before the first drop of dew can drip on that expensive rosewood. Your lightning-fast reflexes have intercepted what would have been a disaster. Your friends are startled at first, then they laugh and tease you. They say you have OCD – obsessive-compulsive disorder.
This, or a similar instance, may have happened at some point in our lives before. We tidy up a mess in the presence of others, or when our belongings are organised ever so neatly, and we end up joking about OCD.
But in truth, OCD is far from such behaviours that could be written off so light-heartedly.
A person with OCD will have compulsions – they feel the need to perform certain repeated behaviours to reduce emotional distress or to prevent undesirable consequences. These compulsions are so intense that they cannot carry out other daily routines without acting on them. Some common ones include:
Excessive washing or cleaning – They fear contamination and clean or wash themselves or their surroundings many times within a day.
Checking – They repeatedly check things associated with danger, such as ensuring the stove is turned off or the door is locked. They are obsessed with preventing a house fire or someone breaking in.
Hoarding or saving things – They fear that something bad will happen if they throw anything away, so they compulsively keep or hoard things, usually old newspapers or scraps of papers which they do not actually need or use.
Repeating actions – They repetitively engage in the same action many times, such as turning on and off a light switch or shaking their head a numerous number of times, up 20 to 30 times.
Counting and arranging – They are obsessed with order and symmetry, and have superstitions about certain numbers, colours, or arrangements, and seek to put things in a particular pattern, insisting to themselves that the layout must be symmetrical.
When Does OCD Become Chronic and What Should You Do If That Happens?
OCD is a chronic disorder, so it is an illness that one will have to deal with for the rest of his or her life. It is difficult to tell when the disorder becomes chronic, as it presents the individual with long-lasting waxing and waning symptoms. Although most with OCD are usually diagnosed by about age 19, it typically has an earlier age of onset in boys than in girls, but onset after age 35 does occur.
A cognitive model of OCD suggests that obsessions happen when we perceive aspects of our normal thoughts as threatening to ourselves or to others, and we feel responsible to prevent this threat from happening. These misperceptions often develop as a result of early childhood experiences. For example, a child may experience living in a dirty and dusty environment, while being subjected to some form of trauma at the same time. He associates a lack of hygiene with suffering from the trauma. At a later stage in life, he may start to feel threatened upon seeing the unhygienic behaviours of someone he lives with, be it his parents, romantic partner, or flatmates. This leads to the reinforcement of the association and to the development of his beliefs that suffering is inevitable when unhygienic conditions are present, giving him compulsions to improve these unsanitary conditions through washing and cleaning.
If one is affected by OCD to the extent that he or she is unable to hold down a job and to manage household responsibilities, then there is a need for clinical treatment as the symptoms have become severe. Like in the above-mentioned example, recurrent and persistent thoughts of dirt will give the individual compulsions to neutralise these thoughts, resulting in repetitive washing, and checking behaviours. This causes distress and significantly affects one’s functioning.
When OCD has become a chronic illness, through a formulation of intervention strategies, the psychologist should extrapolate the client’s pattern of behaviour and expect a positive prognosis for functional improvement.
How Can OCD Be Treated?
A person diagnosed with OCD may seek treatment through a treatment plan that consists of cognitive strategies. These cognitive strategies involve consciously implementing sets of mental processes in order to control thought processes and content. Through these cognitive strategies, we can examine and restrict the thoughts and interpretations responsible for maintaining OCD symptoms. This is conducted in the initial stages of therapy.
Thereafter, Exposure Response Prevention (ERP) methods are carried out once a client is able to understand and utilise these cognitive strategies. ERP requires the client to list out their obsessive thoughts, identify the triggers that bring about their compulsions and obsessions and rate their levels of distress on each of these. Starting with a situation that causes mild or moderate distress, the client is exposed to their obsessive thoughts and simultaneously tries to resist, engaging in any identified behaviours that they have been using to neutralise these thoughts. The amount of anxiety is tracked each time the process is repeated. When anxiety levels for this particular situation eventually subside, over several repeated processes, and when they no longer feel significant distress over this situation, the same method is repeated for the next obsessive thought with the next level of distress.
A client who is able to demonstrate strength in coping with the symptoms has a better likelihood for sufficient recovery.
OCD is Becoming More Prevalent in Singapore: How has it Been Accepted in Society?
In recent years, OCD has topped the list of mental disorders in Singapore, with the greatest number of people experiencing it in 2018, compared with other mental illnesses.
The disorder has been found to be more prevalent among young adults than those aged 50 and above. In terms of socio-economic status, OCD is more likely to occur amongst those with a monthly household income of less than S$2,000 than those who earn above that amount.
It has also been found that the prevalence of people experiencing OCD at least once in their lifetime is higher in Singapore than in South Korea, Australia and New Zealand.
In addition to becoming more prevalent, people who experience OCD are also becoming increasingly reluctant to seek psychiatric help or counselling, making matters worse. There is some acceptance of the condition as normal and trivial by society, because people who do not understand the disorder well enough misconceive OCD as a quality of being clean and tidy, as being clean and tidy is usually seen as a good thing. This misconstrual by society is dangerous for the undiagnosed, and their condition will further deteriorate if they continue to put off addressing their disorder.
The disorder will get worse if treatment is ignored, and there is a need to realise it in its early stages through observing how one’s life is being disrupted. Awareness about its onset of symptoms is important.
To non-smokers and those who have an occasional cigarette at a party or outside a bar, it is baffling why smokers just can’t simply quit. What’s the big deal?
If you think this, then the conclusion may be: “well they just don’t want to quit”; or “they are uneducated, and don’t know how much damage they’re doing to themselves and those around them”; “they have no conscience” or “they have no self-control”.
The problem with these conclusions is that the scientific evidence doesn’t support them.
70% to 80% of smokers want to quit – and many of them desperately want to quit – and most smokers fail.
A majority have tried to quit multiple times – and about 40% are still drawn to smoking -even after losing fingers and toes to gangrene, or lungs to cancer and COPD, as a result of smoking. Many suffer heart attacks, mouth, throat and colon cancer, or labour under serious diabetes problems; some even lose their close relationships with their families.
They wish that if only they could quit, their lives would be so much better – yet they continue to smoke.
So, there is more to the compulsion to smoking than meets the eye.
Perhaps kindness and compassion for smokers may be a more rational reaction – than dismissal, frustration, irritation, anger or contempt?
There are very good reasons why the chemicals in cigarette smoke are so compelling – and it’s to do with our brains and our bodies. It’s not a mystery.
Although nicotine in the smoke is a comparatively benign substance, and it doesn’t cause the damaging effects of the other harmful substances in the smoke – it is highly addictive. It is the nicotine that causes the addiction – but it is the tar and other substances that cause the damage.
In addition to nicotine, there is another substance, in smoke, that creates a potentially “pleasant” psychoactive effect. It is a monoamine oxidase inhibitor – which results in chemicals in the brain staying longer in the space between neurons and firing those neurons.
And the effect the smoker feels? Well, there can be numerous combinations of “positive” effects.
Those smokers who feel down, moody and unmotivated, may feel a pleasant “lift” or “boost”. Anxious, fearful and nervous smokers, may feel calmer, and more able to think straight. Smokers who are tired, sleepy or lethargic, may be able to focus, concentrate and pull themselves out of their procrastination.
Smoking helps some people become more energetic, have better reactions times and become more effective or efficient. Smoking enables people who are mentally tired with work or constant rumination, to feel like they are taking a break and “relaxing” from their thoughts. They can just let their minds gently wonder. They may even feel that after their “reverie” with a cigarette, they have managed to solve a problem that they have been grappling with.
Some people use smoking as a bonding experience. Ironically, all the community stigma that surrounds smokers makes some feel like a “band of brothers and sisters”, as they stand outside in smoking areas or in smoking rooms. It enables instant connection and the sense of “belonging”.
In short, the effects of smoking depend on how you are feeling in the moment.
Insidiously, mental illness and other addictions result in many becoming vulnerable to smoking – either to cope with: their illness; the difficult side effects of their medication; and the social stigma against mental illness addiction that so oppresses and shames them.
By way of examples, ADHD, schizophrenia, bipolar disorder, anxiety and major depressive disorders, and personality disorders, can all result in life-long suffering – that smoking may appear to “take the edge off”.
There is now persuasive research that some people are more genetically susceptible to being addicted to cigarette smoke. They may get more of a “buzz” from it, they may be more tolerant to its side effects, the effects may wear off faster, and they may feel the withdrawal effects (when not smoking) more keenly. They may have more trouble starting to quit – and staying quit.
There are many other vulnerability factors as well: adverse childhood events (which afflicts 2 out of every 3 Singaporeans); traumas; family and peer modelling; rebelliousness, isolation and loneliness, financial distress, problems in relationships and at work; and many more factors, may all conspire to lead smokers to smoke daily.
Once they smoke enough cigarettes for long enough – the brain changes, it becomes “hijacked” by the smoke.
Smokers experience brain changes as:
Tolerance – the need for more smoking, more often, to get the same effect;
Withdrawals – 45 minutes to two hours after smoking, they may feel the exact opposite of what they felt when they smoked – and therefore need a cigarette to feel “normal”;
Impulsiveness – in the moment (of smoking), they forget about the harms of tobacco and their resolves to quit, and habitually light up;
Smoking triggers – smoking cues are everywhere – and they trigger the urges and cravings – and once these build up, they become overwhelming;
Stress – their stress response slowly but inexorably ratchets upwards, daily – so that even things that used to be experienced as minor, now elicit strong and intolerable emotions. If health, relationships, jobs and self-image are all on the line because of smoking – the stress can be intense.
Luckily – there is a solution. Smokers now have access to psychotherapy, nicotine replacement therapy, quit smoking medication, and any number of other tools to help them on their quit journey. In other countries, new nicotine delivery technologies like e-cigarettes and heat-not-burn are being improved and refined – and they are much safer than smoking.
For someone who struggles with emotional self-regulation, what does having a “breakthrough” mean? A “breakthrough” could mean coming to a point of realisation and acceptance of one’s mental state, and taking a step forward to change his/her seemingly challenging behaviour. To achieve this, we’ll need to learn the art of self-mastery in order to transform our emotions, attitude and most importantly, our behaviour.
Let’s not beat about the bush – the most pivotal factor to attaining self-mastery is for the person in question to understand that he/she needs to take charge of his/her own thoughts, emotions and actions. The model of self-mastery dictates that we should acknowledge and accept that we are the ones who are responsible for changing our own life experiences. It is often said that we are each the author of our own lives, in which we live in whatever we create. At any point in time, we should always be open to learning life skills to deal with whatever life presents us, instead of resisting or reacting against it. We should learn to control what happens to us by exercising creative control over the circumstances that we throw ourselves into. Without the will to take charge and make the relevant changes, this “breakthrough” would, unfortunately, be a tough feat.
There is a difference between control and self-mastery, and it is crucial that we internalise this. Oftentimes, people with mental health conditions tend to display controlling behaviours of themselves or others.To put it succinctly, controlling behaviour arises when we compel others to change their behaviour to cater to our own experiences of life. On the contrary, self-mastery means transforming our own behaviour in order to change our own experiences of life. Practising self-mastery implies that we adapt to what life presents us, instead of quitting or getting emotionally erratic when things become challenging. This involves learning new life skills that we have yet to master in order to carry us through frustrating tough times and eliminate controlling behaviour. Controlling or manipulative behaviour often emerges from within ourselves whenever things don’t go as we expect. We victimise ourselves and push the blame towards others or life in general for what was presented so as to “correct” the situation. The truth is, when you feel that people aren’t showing you the gratitude or appreciation that you deserve, the fault is not with them. In actual fact, you are exhibiting a need to control – to bring your current life experiences to fit your idealised version of it. For individuals with disruptive emotions and impulses, self-mastery may not come easily to them, as a result of the dysfunction of their self-regulation skills. Yet, this doesn’t mean that it is entirely impossible.
Self-mastery means not allowing our past negative experiences to affect our present and future. It is not easy to undo those past experiences, as they are like deep-seated stains on our clothes that cannot be removed. However, we can choose not to wear those clothes again. It is hard to pick up anything new if our hands are full of burdens. Making peace with our past by letting go, forgiving or even forgetting, will give us space for an untarnished and more objective approach to our present and future. Practising self-mastery also includes being mindful of how you interpret an event in a way that reduces the negative thought or completely replacing it with a positive one. This psychological strategy can be understood by looking at a glass and asking yourself whether it is half full or half empty. Instead of focusing on the dark clouds, we should change our interpretative lens to uncover the silver lining. For example, instead of envying your friend’s success, you should see your own failure as a temporary detour and not a dead end.
Being mindful of our actions and reactions helps us see them for what they are so as to reign in any impulsive controlling, or difficult behaviour. Truth be told, we have all displayed difficult behaviour at times, which as a result, might have caused us to burn a bridge or two. However, the display of fluctuating emotions may be a regular occurrence for some individuals who may not know how to work towards a “breakthrough”. In this case, only if we are mindful of our behaviours can we be less reactive and better able to reframe our perception of our current experience in a less emotional and upsetting manner. With practice, we will slowly become better at creating that space which will then allow us to choose our reactions rather than just reacting out of habit or impulse. Of course, this, in turn, leads to happier and healthier relationships, ultimately improving our mental state of health as well.
Last, but not least, a crucial step in developing self-mastery is to start with self-honesty and truthfulness. Do some self-reflection. That is, have an honest assessment of your own strengths and weaknesses, as well as owning up to your problems. When you are able to identify your weaknesses, you will be able to direct yourself better to what needs to be worked on and the relevant life skills you’ll need to master in order to find a breakthrough. In contrast, focusing on your strengths will also help boost your self-confidence, and act as a motivation for you to work towards making the change you need (i.e., self-improvement). If it helps, attend a peer support group. Peer support groups are built on shared personal experiences and empathy – it focuses on one’s strengths and helps you work towards your mental health and happiness goals. At the same time, it comforts you that you aren’t on the road to mental resilience and self-mastery alone and that there are many out there like you. Don’t be afraid to reach out for professional help too, for it could very well be the push you need to help you achieve the breakthrough you desire.