We are no strangers to feelings of anxiety – at certain stages of our lives or in particular situations, we would have experienced anxiousness and worry with relation to our careers, studies, relationships and even our environment. However, anxiety levels may go beyond the healthy norm for some people, and may instead develop into anxiety disorders that may have a debilitating effect on their lives. According to the American Psychology Association (APA), an individual who suffers from an anxiety disorder is described to have “recurring intrusive thoughts or concerns”, where the duration and severity in which the individual experiences anxiety could be blown out of proportion to the original stressor, resulting in undesirable tension and other physical alterations. In this article, we will be exploring a few types of anxiety disorders as well as how they can manifest within us.
Generalised Anxiety Disorder (GAD)
Generalised Anxiety Disorder is a psychological issue characterised by persistent and pervasive feelings of anxiety without any known external cause. People who are diagnosed with GAD tend to feel anxious on most days for at least six months, and could be plagued by worry over several factors such as social interactions, personal health and wellbeing, and their everyday routine tasks. For example, an individual with GAD may find himself experiencing headaches, cold sweats, increased irritability and frequent feelings of “free-floating” anxiety. Others may also experience muscle tension, sleep disruptions or having difficulty concentrating. Often, the sense of anxiety may seemingly come from nowhere and last for long periods of time, therefore interfering with daily activities and various life circumstances.
In contrast, Panic Disorders are characterised by the random occurrence of panic attacks that have no obvious connection with events that are co-occurring in the person’s present experience. This means that panic attacks could occur at any time, even when someone is casually enjoying a meal. Of course, panic attacks could also be brought on by a particular trigger in the environment, such as a much-feared object or situation. Some individuals have reported that panic attacks feel frighteningly similar to a heart attack, especially with the rapid increase in heart palpitations, and the accompanying shortness of breath. Other symptoms also include trembling, sweating, and feelings of being out of control. With these panic attacks bringing on sudden periods of intense fear and anxiety, it can be exceptionally terrifying when these attacks reach their peak within mere minutes. However, a notable difference between a panic disorder and GAD is that an individual diagnosed with panic disorder is usually free of anxiety in between panic attacks.
Obsessive-Compulsive Disorder is a disorder marked by patterns of persistent and unwanted thoughts and behaviours. Obsessions are recurrent thoughts, urges or mental images that cause anxiety. On the other hand, compulsions are the repetitive behaviours that a person feels the urge to do in response to an obsessive thought or image. One common example often exhibited in films is where an individual has an obsessive fear of germs. This person may avoid shaking hands with strangers, avoid using public restrooms or feel the urge to wash their hands way too frequently. However, OCD isn’t purely limited to feelings of anxiety due to germs. OCD can manifest in other ways as well, such as wanting things to be symmetrical or in perfect order, repeatedly checking on things (“Did I leave my stove on?”), or the compulsive counting of objects or possessions. While everyone double-checks their things and has their own habits, people with OCD generally cannot control their thoughts and behaviours, even if they are recognised to be rather excessive. They can spend at least 1 hour a day on these thoughts and behaviours, and will only feel the much-needed brief sense of relief from their anxiety when they perform their rituals. As such, OCD can be exceptionally debilitating to one’s mental health.
Social Anxiety Disorder
Persons with Social Anxiety Disorder, or SAD, experience high levels of anxiety and fear under particular or all social situations, depending on the severity of their condition. They are often afraid of being subjected to judgement, humiliation or rejection in public, causing them to feel embarrassed. As such, individuals with SAD may feel extra self-conscious and stressed out, and try to avoid social situations where they might be placed at the centre of attention.
A phobia involves a pathological fear of a specific object or a situation. This means that one may experience intense anxiety upon encountering their fears and will take active steps to avoid the feared object. Phobias may centre on heights(acrophobia), birds (ornithophobia), crowds and open spaces(agoraphobia), and many others. People with agoraphobia, in particular, may struggle to be themselves in public spaces, for they think that it would be difficult to leave in the event they have panic-like reactions or other embarrassing symptoms. In severe cases, agoraphobia can cause one to be housebound.
In Singapore alone, 10% of the population is plagued by anxiety disorders – one of which includes Social Anxiety Disorder, or SAD for short. And on a global scale, approximately 4.5% of the world’s population – 273 million people – are estimated to experience anxiety disorders as of 2010. Commonly misunderstood to be merely an over-exaggerated form of shyness, Social Anxiety Disorder is much more than that. Individuals with SAD experience symptoms of anxiety or fear under particular or all social situations, depending on the severity of their condition. For some, even doing the simplest day-to-day activities in front of others can cause extreme worry of being judged, humiliated or rejected. However, some research has also suggested that SAD may be especially manifested in individuals that have ongoing medical, physical conditions such as Parkinson’s Disease, obesity, facial or bodily disfigurement (including amputees), and any other sort of conditions that may cause one to look different from the norm.
What are the symptoms of SAD?
When people with Social Anxiety Disorder are surrounded by others or have to carry out a particular action around them, they may:
Feel nauseous, experience an increase in heart rate, tremble, blush or sweat profusely.
Be unable to make eye contact with others, move and act rigidly, or speak in an overly soft tone.
Feel extremely self-conscious, as though others are judging their every move.
Easily feel awkward, embarrassed and stressed out in social situations.
Find it extremely difficult to be themselves around others, especially strangers.
Have anxious thoughts such as, “I’m sure they won’t want to talk to me again,” or “Do I look plain stupid right now?”
Apologise excessively, even when there is nothing to apologise for.
Avoid conversations, such as by using their mobile devices or plugging in their headphones.
Avoiding situations where one might be placed at the centre of attention.
The list of symptoms above is not exhaustive, but we need to recognise that they may cause extreme distress to these individuals. For them, it can be tremendously helpful and relieving for them to seek treatment for their condition, more specifically through Cognitive Behavioural Therapy (CBT).
Cognitive Behavioural Therapy is a well-known form of therapy in the mental health profession. Considered to be a form of short-term therapy, CBT is usually delivered in a time-limited manner, often over the course of 8 to 12 sessions (although this may vary from person to person). Once the symptoms are reduced and the individual is well-equipped with the necessary skills to cope with anxiety triggers or social situations in general, treatment can be finalised. As it is not possible to change or alter emotions directly, CBT aims to tackle any maladaptive, limiting thoughts and behaviours that fuel or contribute towards agonising emotions. This, therefore, lowers the extent of anxiety that one goes through and instead, developing a sense of self-efficacy.
First off, CBT encourages individuals to open up and to be truthful regarding their automatic, instinctive (negative) thoughts so that they can work hand-in-hand with therapists to analyse the logic behind them. During the sessions, therapists will work to identify the assumptions (and their validity) that these people hold, which might be causing unnecessary anxiety or fear. Proper reasoning and clearing up of assumptions can be done by asking clients to do some self-assessment and to provide possible reasons as to why they maintain such assumptions. By doing so, therapists can then assess the situation and present evidence contrary to their beliefs.
Another aspect of CBT includes ‘Decatastrophising’. One common thinking pattern found in people who suffer from anxiety issues is ‘Catastrophising’, which is the act of imagining the worst-case scenario and magnifying the bad in any given situation. CBT helps to counter such a mindset by helping these individuals prepare for the feared consequences, as well as to cope with their unhealthy ways of thinking. For example, therapists and clients will go through certain ‘Challenge Questions’, such as:
“Has anything this bad ever happened before? How likely is it to happen now?”
“What makes you confident that your feared outcome will actually come true?”
“What is the best outcome that can happen in this situation?”
These are just a few examples of ‘Challenge Questions’, but they can certainly be beneficial in helping to ease feelings of anxiousness and to calm the individual. In some way, this can also decrease an individual’s inclination to avoid seemingly triggering social situations.
Tying in with ‘Decatastrophising’, another technique introduced during CBT is ‘Reattribution’. ‘Reattribution’ is a method which challenges the negative assumptions held by the individual by considering the possible alternative causes of events. This is particularly advantageous for people who, in most situations, perceive themselves to be the cause of problem events. For example, this can mean having a discussion on the evidence which proves that the individual is/is not the cause of the problem. Eventually, this will help to tackle ‘Automatic Negative Thoughts’, excessive self-blame and worry.
Of course, in order for the treatment process to be carried out more effectively, some therapists do assign “homework” to their clients. This is to say that clients are encouraged to apply CBT principles in between sessions, and are tasked to self-monitor and focus on implementing tips and processes when dealing with actual situations. By monitoring their emotions and making a conscious effort to calm themselves through methods discussed during sessions, these individuals will eventually develop the much-needed skillsets to cope with emotionally-draining social environments.
A combination of cognitive and behavioural therapeutic approaches, CBT has been proven to be an extremely effective treatment method for anxiety disorders, including SAD. In fact, the skills you learn in CBT are practical and highly applicable, and hence can be incorporated into everyday life to help you cope with future stresses more effectively. As such, if you or a loved one is struggling with SAD, do seek treatment as it will ultimately benefit you in the best way possible.
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
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.
Depression has been portrayed extensively in pop culture and media, from R.E.M.’s hit song “Everybody Hurts”, to the television series “13 Reasons Why”. The phrase “I’m so depressed” is thrown around casually when someone has had a bad day or when they can’t get their favourite brand of ice-cream. But what is depression, really? How does it affect us, and can it be treated?
If someone was recently fired or lost a loved one, it would be natural to feel grief at such events. However, grief is not depression. Depression is classified as a mood disorder that causes unusually low moods for an extended period of time and may impair one’s ability to function at work and at home. Grief or other stressful situations may sometimes trigger depression, but unlike grief, there is often no discernible cause for the hopelessness and despair a depressed individual feels. Depression affects everyone differently, and factors such as one’s family background, environment, or physical state can impact their chances of developing depression, and how severely it impacts them.
Depression has a variety of symptoms that can vary in intensity, including;
Loss of interest in typically pleasurable activities;
There are several different types of depression, with the most common being Major Depressive Disorder (MDD). According to a study conducted by the Institute of Mental Health (IMH), 1 in 16 people in Singapore have experienced MDD in their lifetime. Major depressive episodes last about eight months and have a 70% chance of recurring within five years, though this varies with each individual.
There is also Persistent Depressive Disorder (PDD), also known as dysthymia. This type of depression can last for several years, with symptoms receding for no more than two months at a time. PDD is much harder to spot, as the symptoms are often not as severe as MDD. Due to the length in which PDD affects individuals, friends and family may eventually brush it off as part of their personality. Others may think that they are just naturally “gloomy”, or “introverted” and “withdrawn”. Some individuals may also experience major depressive episodes while in the midst of PDD. This is known as double depression.
If any of the above sounds like they might apply to you or someone you know, you may be wondering “what can I do?”. The first step would be to speak to a mental health professional, who can properly assess the situation and make a diagnosis if necessary. They can then recommend a form of treatment. However, there is no “one size fits all” treatment. It may take many tries to find one that works for you. To help find that, here are some proven methods of treatment.
Antidepressants prescribed by psychiatrists help to stabilise one’s mood by adjusting specific parts of their brain chemistry. SSRIs are the most commonly prescribed class of antidepressants and help to boost the effects of serotonin in the brain. Antidepressants take time to produce full effects so don’t be discouraged if you don’t experience any effects immediately. However, if the antidepressants do not work after an extended period of time, or produce unpleasant side effects, speak to your psychiatrist about changing medications. When taking antidepressants, be sure to adhere to the prescribed dosage in order to see the best results. There is a common misconception that if someone feels better after taking antidepressants for a while, they can stop taking it immediately. This is not the case, and can instead cause their mood to suddenly crash back down again. If you are feeling better after taking antidepressants, speak to your psychiatrists, and together you can work out a plan to reduce the dosage of antidepressants.
Unfortunately, even with the wide variety of treatments available, the majority of people suffering from depression do not actually seek professional help. In many cases, this is due to the stigma associated with mental illness and the fear of what others may say. People with depression are often told “just stop being sad”, or “you should be happy, you have so many things to be thankful for”. So they hide it. They struggle each and every day and they hope that they’ll just get better on their own. But that makes the process so much harder. Support from friends and family is crucial in the recovery process.
Depression is a disease that can happen to anyone. It could happen to the quiet kid that sits in the corner. Or to your best friend who’s always been bubbly and lively, and now seems like someone else that you can barely recognise. But just like other diseases, it is possible to recover from depression with the right support from friends, family, and therapists. So be kind to one another, love one another, and when things get tough, be there for one another.