The anonymous author of this article is a person in the recovery of Major Depressive Disorder and Borderline Personality Disorder. The views of the author are not those of Promises.
I have struggled with Self-Harm since I was a kid. Most of us are aware of the tantrum’s kids put up when they are upset. They hit others, drop to the floor, scream, and cry. When I felt overwhelmed by certain emotions, in particular anger or sadness, I would use my hands to hit my head. I had trouble identifying and regulating my emotions. My primary school counsellor told me that I have anger management challenges when I shared with her how I find myself unable to control my anger and would hit myself or the well. Little did I know that these behaviours were early signs and symptoms to what would become a diagnosis of Major Depressive Disorder and Borderline Personality Disorder given to me in my 20s.
When the word ‘Self-Harm’ is mentioned, most people think about ‘cutting’. A very common and increasingly concerning the mode of coping for persons in distress, more so for young people, even children. Fortunately, I never turned to ‘cutting’ until I was 23. I was actively suicidal from the stress of battling my illness while also trying to excel in my degree. I began with a penknife and one cut. Soon, that one cut led to many and I found myself with a new problem.
I struggle with Self-Harm till this very day; however, I have come a long way with the help of medications and therapy to reduce the frequency of Self-Harm. I have been trying to replace Self-Harm with healthier coping methods such as exercise.
When I do not wear long sleeves, I end up exposing the scars on my wrists to the world. Generally, I tend to feel ashamed of my scars and it took me some time to embrace them. However, responses from others who have noticed my scars have caused discouragement to me and led me to feel ashamed once again. Ironically, this does not deter me from ‘cutting’; instead, it increases the urge because I develop self-hatred and feel like I deserve to be punished and scarred for my behaviour.
Through this sharing of my experience, I hope to send a message of love to peers who are challenged with Self-Harm, whatever form it might take on. I also want to raise awareness among members of the public on what were some unhelpful words and behaviours people have made towards me, more so out of a lack of awareness rather than a lack of concern. I have learnt to forgive them, and at times have also made the effort to voice my discomfort over their words and actions. Here are five things people have said or done to me that were completely unhelpful, and very likely also to be unhelpful to anyone else challenged with Self-Harm.
1. Touching me without permission I get it, you notice the scars and you get worried. Without thinking, you grab my arm and go “what is this? Did you cut yourself?”. Leaving the question for later, the very act of grabbing my arm to look at my scars without permission is a big ‘NO’. I am hypersensitive to my scars and it takes much courage for me, even till today, to deliberately lift my arm to show my scars. What may surprise you is that, often, this act comes largely from my own parents and also the professionals I see for help. It is good practice to always ask someone for permission if you wish to touch them, even if it means to give a hug. Because some of us who have challenges with trauma and dissociation are hypersensitive to touch. Hence, do be mindful of those around you and remember: If you do not like people grabbing you to see something (on you), it’s the same and perhaps even more, for those of us learning to accept our scars.
2. “Doesn’t it hurt?” No, it doesn’t. This answer may come as a surprise to many, but when I am under extreme stress and emotional distress, the act of physically inflicting hurt on myself gives me relief. The greater the physical “pain” the greater the relief. For me, this goes for any act of self-harm be it ‘cutting’, punching the wall, or knocking my head against the wall until it starts bleeding. I can only compare this to someone who meets with an accident. The body goes into shock to the point the person may have a broken leg; however, he or she is not feeling any pain. I do not have a formal education in psychology or biology, but I believe my brain “shuts down” the part that feels pain which aids me to self-harm without feeling the actual pain.
3. “The scars are so ugly! Why do you enjoy this? Can’t you stop?” This is a three-part question, but it often comes to me in one line of questioning. First, I want to say that I do not enjoy this. Not at all. I would love to have clear and beautiful skin too. Every time I look down at my arm to see the scars, I feel hatred towards myself. “How could I do this to myself? I am a horrible person”. And yet, I find that I cannot stop. A coping method I have turned to, since childhood, to cope with the traumatic experiences and intense emotions is self-harm. It has become the default and almost automatic ‘subconscious’ act whenever I am in distress.
4. “It doesn’t look too bad” I know that this statement is in direct contrast to the one above. But I have had this said to me by peers and sadly, professionals. There is not much need for me to elaborate on this statement as it is obvious that it is unhelpful. This statement makes me feel like a failure and makes me want to hurt myself even more. The ‘Depression voice’ is always on standby, ready to jump in with a “See, you are useless at even trying to hurt yourself? You call that a cut?! You are a coward. Go and do it again”.
5. Taking away or hide the sharp items that I could use to hurt myself This is probably most relatable to parents and caregivers supporting someone who is challenged with self-harm. It is very natural to become protective and do what it takes to stop your loved one from hurting themselves. “If I take away their means to hurt themselves, then they have no choice but to stop, right?” Unless you tag along with your loved one 24/7, it is very easy to drop by the nearest bookstore to buy a new penknife. More importantly, in doing so, you are taking away the one thing that I have which keeps me from jumping out of my window or overdosing on my pills. Until I learn to safely stop self-harming in therapy, to take it away from me by force, will throw me into an emotional turmoil that will only make me feel worse.
So please, next time you notice someone with scars that look like they might be from the act of cutting one-self, please be gentle and kind to the person. Be extremely mindful of what you say. Perhaps, a guiding thought could be: If you cannot entertain the idea of causing pain to yourself, imagine how much pain the person must be in to be able to cause harm to themselves. When I self-harm, it is a desperate means for me to stay alive. It is a cry for help: for attention, for love, care and non-judgemental support.
If you know a loved one who self harms please do gently prod him/her towards seeking help from a trained professional.
Originating from the Greek word ‘wound’, trauma is used to describe the unwelcome recollection of disturbing experiences – those which can cause one to relive horrifying, spine-chilling moments of a disaster or a tragic event which leaves a deep mark on a person’s life.
Flashbacks can be particularly frightening for people with Post-traumatic Stress Disorder (PTSD), which is a delayed stress reaction, where an individual involuntarily re-experiences the mental and physical responses (i.e emotional, cognitive and behavioural aspects) that accompanied the past trauma. Symptoms can be particularly intrusive, presenting themselves in the form of nightmares and emotional distress upon remembering upsetting memories, and even certain physical reactivity after the exposure to traumatic reminders. Additionally, depending on the severity of one’s condition, the negative alterations in mood and behaviours may vary. Alterations may comprise of (non-exhaustive):
Exaggerated self-blame or others for causing the trauma, and a sense of invalidation
Decreased interest in activities
Increased irritability or aggression
Hyper-vigilance, excessive paranoia or heightened startle reaction
Difficulty sleeping or concentrating
Risky or destructive behaviour (can include the development of maladaptive coping strategies such as substance abuse)
A sense of isolation
Avoiding trauma-related stimuli / reminders of the traumatic event (including places, activities, people, thoughts or feelings that may bring back unwanted memories).
Unlike what most would perceive, PTSD does not solely affect individuals who have been through a tragic event personally. Apart from the direct exposure to a trauma, people can also develop PTSD through the witnessing of the event, or upon learning that a close one was exposed to the trauma. The indirect exposure to aversive details of the trauma in the course of professional duties (such as first responders or paramedics) can also make one prone to developing PTSD. With the effects lasting a lifetime for some individuals, PTSD can be debilitating to one’s mental health, robbing one of joy and freedom.
This is where Dialectical Behavioural Therapy (DBT) comes in. DBT is a comprehensive cognitive-behavioural treatment that can provide strong empirical support for individuals struggling with PTSD, Borderline Personality Disorder (BPD), Non-Suicidal Self-Injury (NSSI), and others. Intended to help persons with complex issues that place them at high risks of suicide or other self-destructive behaviours, DBT focuses on imparting the knowledge and skills to cope with PTSD and trauma reminders. Moreover, it also aims to assure the generalisation and application of skills learnt to the environment beyond the treatment setting, as well as to ensure that dysfunctional behaviours are not inadvertently reinforced. DBT consists of four stages, with the first two being the standard, essential stages for all clients.
Stage 1: Aiming to Achieve Better Stability and Behavioural Control
It is safe to say that most of the work is done at stage 1, where clients work hand-in-hand with their therapists to target behavioural dyscontrol and to address the chaos within them. When clients first take on DBT, they are often said to be at their lowest point in their lives. As such, stage 1 focuses on achieving control over life-threatening behaviours, therapy-interfering behaviours, as well as other factors that are causing a decline in their quality of life. At the same time, it will serve to increase one’s behavioural skills which can include mindfulness, interpersonal effectiveness , emotion regulation, distress tolerance and self-management. In short, this helps the individual to stabilise, and to reduce the frequency of impulsive and emotional outbursts.
However, stage 1 alone is insufficient. Although there are reductions in unwanted behaviours arising from the traumatic experience, these people may not have perfect control over their condition yet, and thus may still feel depressed, and anxious along with other PTSD symptoms.
In this stage, trauma-focused treatment is engaged, and past traumatic experiences are safely explored. Therapists will help clients to emotionally process them by approaching (gradually) the avoided trauma-related memories, as well as to help them continue applying the skills learnt in stage 1. With that said, the main objective of stage 2 is to discourage the client from silencing and burying the emotional pain.
Subsequently, this makes it easier for therapists to assess the severity of the problems, the relationships between the issues faced and to determine the hierarchy of needs based on the client’s goals.
Stage 3: Achieving Ordinary Happiness and Tackling Unhappiness
Upon ensuring that the individual is no longer suffocating under the same weight of fear that they once were, stage 3 aims to maintain progress and reasonable goal-setting. This establishes greater stability and addresses any other remaining problems in living. As the clients’ previous undesirable behaviours may have disrupted other aspects of their lives, stage 3 will also focus on improving relationships, and increasing valued daily activities.
Stage 4: Regaining the Capacity for Sustained Joy
Lastly, some people will choose to engage in stage 4 to find comfort in and to work towards spiritual fulfilment. This mainly helps to tackle any feelings of incompleteness as well as to ensure one’s capability to maintain an ongoing capacity for happiness.
DBT is an efficacious prototypic phase-based treatment of PTSD as it is a support-oriented approach to treatment, helping individuals to identify their own strengths and then building upon them to improve the person’s outlook on their life. By improving one’s ability to cultivate emotional regulation, increasing one’s ability to handle challenging emotions, and coping with conflict properly through interpersonal effectiveness, DBT can help traumatised individuals develop invaluable life skills that will allow them to achieve an overall improved quality of life.
Zimbardo, P. G., Johnson, R. L., & McCann, V. (2017). Psychology: Core Concepts (8th ed.). Pearson. (Accessed 22/11/2020)
Wagner, A. (2015). Applications of dialectical behaviour therapy to the treatment of trauma-related problems. Portland DBT Institute. https://adaa.org/sites/default/files/Wagner_MC.pdf (Accessed 22/11/2020)
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.