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
For many individuals, therapy is a rather intense and personal topic, and it could have taken them a lot of courage to finally seek the help that they need. Keeping this in mind, it is exceptionally crucial that one finds the right therapist, for there’s a pre-existing implicit clinical belief that the level of treatment effectiveness is greatly dependent on the therapist-client fit. Of course, every client would love to be able to – ideally – find that one therapist whom they can fully open up to from the very beginning, but in reality, that may not be the case. At times, it is necessary to assess your relationship with your therapist and evaluate if there’s the good rapport you need for your sessions to be a success. Ultimately, it boils down to whether you feel a steady, reliable and safe connection with the therapist, and whether you are making the progress you hope for.
To give you some background, studies over the years have shown that the more similar the therapist and the client, the higher the rate of recovery. As an example, an assessment instrument entitled the “Structural Profile Inventory(SPI)”, which measures seven “independent yet interactive” variables (behaviours, affects, sensory imagery, cognition, interpersonal, drugs/biological factors or BASIC-ID), showed that client-therapist similarity on the SPI predicted a better psychotherapy outcome for the client as measured by differences pre- and post-treatment on the Brief Symptom Inventory. Moreover, the demographic similarity between therapist and client facilitates positive perceptions of the relationship in the beginning stages of treatment, enhances commitment to remaining in treatment, and at times can accelerate the amount of improvement experienced by clients. More precisely, it can be said that age, ethnicity, and gender similarity have been associated with positive client perceptions of the treatment relationship. With gender and cultural similarities appearing the most strongly preferred among clients, these domains generally enhance clients’ perceptions of their therapists’ level of understanding and empathy, and as a result, sessions are judged to be more advantageous and worthwhile. However, besides these, there are also other means to assess your “fit” with your therapist, and we’re here to discuss just that.
First and foremost, consider if you are seeking help in the right place. Does the therapist you are looking at specialise in the area you are seeking help for? Before we can even touch on the topic of interpersonal therapist-client fit, it is important for you to take the time to do some research on various therapists’ profiles – in other words, to sift through and read up on their respective areas of expertise. Typically, therapists would have their area(s) of specialisation up on their online profile directories. It would be clearly indicated if they specialise in areas such as substance abuse, family therapy, or even anger management. It goes without saying that, for example, it would be inappropriate to consult a psychologist who specialises in child psychology when you’re clearly looking for someone who can help you with your substance-use addiction. With that said, it is to no one’s benefit for you to rush into therapy blindly.
Once you have chosen the potential therapist that you are most likely to want to have see you through your road to recovery, another essential question you should ask yourself is whether you are comfortable with their suggested mode of therapy. During consultations, you will have the opportunity to enquire about their recommended techniques or treatment methods that will be explored during your subsequent sessions. If you are uncomfortable with any particular process, giving honest feedback and exploring other methods is always an option. However, at any point, you also have the right to seek other therapists who may be able to help you in other ways that don’t put you in a tight spot. After all, therapy is all about having a safe and comfortable space for you to sort out your difficulties.
When assessing your interpersonal connection with your therapist, make sure to trust your gut. This way, you’ll also be able to track your progress better and to seek alternative help if required. Some questions you can ask yourself are:
Am I satisfied with the current balance of talking and listening with my therapist?
Is my overall therapy experience safe, warm, and validating?
Am I fully assured that I’m in a non-judgemental space where I can be fully honest?
How much has the therapist helped me to gain greater insight into my own behaviour and thoughts so far?
Am I becoming more capable of coping (independently) with stressful or triggering situations over time?
Am I noticing more positive changes in myself, as compared to when I first started therapy?
As mentioned, a major deciding factor should also be on whether you find yourself noticing positive changes in your thought cycles and behaviour after a couple of sessions. At the end of the day, therapy should be about working towards achieving your desired outcome, and should definitely not be limited to weekly venting sessions. Although venting and letting out hard feelings can provide temporary relief, it fosters a client’s dependence on the therapist over time and further reinforces the client’s problems. Therapy should instead help you to feel more confident that you’ve developed the relevant skill sets in order to cope with whatever emotional challenges that brought you to seek therapy in the first place.
Naturally, there’s no guarantee that we will find chemistry with the first therapist we meet. The chemistry between people varies, and sometimes it’s just not possible for us to force it. Thus, it is important to remember that a lack of fit between therapist and client is no one’s fault. However, remember that the ball is in our court, and it is within our control to start looking in the right place for the sake of our own well-being.
1 Herman, S.M. (1998). The relationship between therapist-client modality similarity and psychotherapy outcome. Journal of Psychotherapy Practice and Research, 1998 Winter; 7(1): 56-64.
2 Luborksky, L., Crits-Christoph, P., Alexander, L., Margolis, M., & Cohen, M. (1983). Two Helping alliance methods for predicting outcomes of psychotherapy: A counting signs vs. a global rating method. Journal of Nervous and Mental Disease, 171, 480-491.
3 Jones, E. E., (1978). Effects of race on psychotherapy process and outcome: An exploratory investigation. Psychotherapy: Theory, Research and Practice, 15, 226-236.
4 Blase, J. J. (1979). A study of the effects of sec of the client and sex of the therapist on clients’ satisfaction with psychotherapy. Dissertation Abstracts International, 39, 6107B-6108B.
Beutler, L.E., Clarkin, J., Crago, M. and Bergan, J., 1991. Client-therapist matching. Pergamon general psychology series, 162, pp.699-716. (Accessed 30/08/2020)
What comes to mind when someone mentions alcohol? For many, alcohol is often associated with the temporary avoidance of daily struggles. Whether or not we have the habit to drink, it is a known fact that people may tend to have “blackouts” whenever they’re really drunk – and are unable to recall anything during these periods of time. As for young adults, perhaps it could also be attributed to their keen desire to look “cool” and to show off their high alcohol tolerance to their friends. However, alcohol can be addictive, and frequent heavy drinkers run the risk of becoming alcohol-dependent and hence developing alcohol use disorders. But what actions can we take if we find ourselves constantly wanting to submit to such an altered state of being, and seeing the appeal in losing control of ourselves as a form of escapism?
What is an Alcohol Use Disorder?
According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.;
DSM–5; American Psychiatric Association, 2013), an alcohol use disorder is essentially characterised by “a problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following, occurring within a 12-month period”:
Alcohol is often taken in larger amounts or over a longer period than was intended.
There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.
Craving, or a strong desire or urge to use alcohol.
Recurrent alcohol use resulting in a failure to fulfil major role obligations at work, school, or home.
Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
Important social, occupational, or recreational activities are given up or reduced because of alcohol use.
Recurrent alcohol use in situations where it is physically dangerous.
Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.
In regards to the disorder’s severity, it is safe to say that an individual categorised under the ‘mild severity’ category would display two to three of the above symptoms, while those under ‘Moderate’ would display four to five. For persons who develop six or more of such symptoms, they would, unfortunately, be diagnosed to be severely alcohol-dependent.
In the development of alcohol abuse, we need to recognise that the physiological and psychological reward system in our brains are what contributes to the clouding of negative consequences and effects associated with alcohol dependence and addiction. In other words, the possibility for change is tough, and the learnt habit can be hard to kick. Positive and negative reinforcements play a major role, especially in the beginning stages of alcohol abuse. Positive reinforcement occurs when the chances of an individual performing an activity (in this case, drinking) is heightened due to his previous experience of feeling rewarded by the “high” he or she obtains when getting drunk. On the contrary, negative reinforcement occurs when the probability of alcohol-seeking behaviour increases upon allowing the drinker to avoid certain situations or negative stimuli. Therefore, it can be said that alcohol abuse is fuelled by the physiological and psychological reward system, thus increasing one’s motivation to consume more alcohol, though sometimes a little too much.
Alcohol addiction can be greatly detrimental to our lifestyles, as well as to our physical and mental health. Known to be a depressant, alcohol can have a significant impact on our brain’s activity. If you’re drinking unhealthy levels of alcohol in an attempt to manage other mental health conditions such as anxiety or depression, stop it immediately! Alcohol affects neurotransmitters in your brain, potentially worsening your pre-existing condition. As such, it is crucial that we help people with alcohol use disorders to move past their addiction to a more fulfilling lifestyle.
What forms of treatment can I consider?
Alcohol abuse can be treated with psychiatric or psychological intervention, sometimes a combination of both.
When it comes to psychiatric medications, psychiatrists may prescribe medications used primarily to treat alcohol withdrawal by targeting the GABA neurotransmitters in the brain, allowing the brain to restore its natural balance when the person abstains from alcohol. Another common medication prescribed mainly affects the individual’s alcohol metabolism. The drug increases the concentration of acetaldehyde, a product formed when alcohol is broken down. The buildup of this acetaldehyde induces undesirable effects such as vomiting, hence holding the person back from consuming large amounts of alcohol. However, despite these drugs being the commonly prescribed medications, it is extremely dangerous for one to source and consume them without first consulting a professional psychiatrist. Everyone’s case is different, and people may have differing medication needs.
Another form of treatment one can consider is Cognitive Behavioural Therapy (CBT). CBT is an effective method which focuses on helping one identify and uproot negative or irrational thoughts and/or behaviours. Being highly solution-focused, such forms of therapy can include trying to help these individuals to recognise situations in which they are inclined to drink, and how they can better repress themselves. As such, the main goal would be for these people to recognise their problematic behaviour, and subsequently cut down on and adhere to healthy alcohol consumption levels. Since the impact of alcohol abuse is usually not limited to the individual, family therapy may also be recommended at times, especially if the individual’s alcoholic behaviour causes others distress.
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.