Anxiety refers to a state of anticipation of alarming future events. Anxiety is usually a normal transient response to stress and may be a necessary cue for adaption and coping, the body’s protective mechanism known as the ‘fight or flight response’.
However, anxiety can become pathologic, where it is excessive and inappropriate to the reality of the current situation. It is often described by many as a distressing experience of dread and foreboding.
Anxiety is manifested in the affective, cognitive behavioural and physical domains. The affective states could range from edginess and unease to terror and panic. Cognitively, the experience is one of worry, apprehension and thoughts concerned with emotional or bodily danger. Behaviourally, anxiety triggers a multitude of responses concerned with diminishing or avoiding the distress.
Physical Manifestations of Anxiety
Stimulating the autonomic nervous system results in an array of bodily perturbations.
Several nervous system structures are involved in fear and pathologic anxiety.
The amygdala is responsible for initiating the fight-or-flight response. When activated, the amygdala triggers a series of changes in brain chemicals and hormones that puts the entire body in anxiety mode.
Left untreated, over time the affected individual’s body physically responds more frequently and intensely to worries. Co-morbid depression often sets in. One’s ability to meaningfully function academically, occupationally and socially gets hampered, leading to a deterioration in the quality of life.
Treatment of Pathologic Anxiety
The first point of contact for many patients would be their general practitioners or even the hospital Accident & Emergency department. It is important to evaluate and rule out underlying medical illnesses that may mimic an anxiety disorder, such as thyroid disorders, heart rhythm disturbances, gastrointestinal diseases or alcohol withdrawal. The doctor may order some basic investigations, such as a thyroid function blood test or an electrocardiogram (to check one’s heart rhythm). Once medical causes have been excluded or identified and treated, persisting anxiety symptoms would warrant a psychiatric consultation.
A prescription of anti-depressants such as Selective Serotonin Re-Uptake Inhibitors (SSRIs) to aid in the balancing of the brain neurotransmitters may be suggested. Anxiolytics such as benzodiazepines e.g. Clonazepam may be used in the initial phase of treatment, and thereafter only short courses are prescribed to reduce the risk of dependency.
Cognitive-Behavioural Therapy (CBT) involves cognitive restructuring and anxiety symptom management. Cognitive interventions are aimed at challenging and correcting the inaccurate and maladaptive thought patterns that maintain anxiety disorders. Symptom management techniques e.g. relaxation and breathing re-training procedures, help to eliminate anxiogenic bodily reactions.
Lifestyle adjustments to one’s hectic pace of life need to be made to break the vicious cycle of stress and worry. Developing a healthy routine with regularly scheduled self-esteem-raising activities, ensuring adequate rest and nutrition as well as maintaining social connections are pivotal for mental wellness.
Massachusetts General Hospital, Handbook of General Hospital Psychiatry, seventh edition, chapter 13: Anxious Patients.
Positive discipline and gentle guidance are concepts which are not given enough recognition. In comparison to corporal punishments and other forms of authoritarian parenting, positive discipline aims to teach by first creating a safe relationship with children, putting connection before correction. According to recent neuroscience research, people learn best when they feel safe and connected to others, in the context of safe relationships. This helps to instil discipline with maximum efficacy in the long run.
What does positive discipline bring to the table? Apart from building trust and strengthening parent-child relationships, it teaches children responsibility, self-discipline, problem-solving skills and cooperation. By ensuring that learning isn’t fear-based – such as in the context of authoritarian parenting – it also helps children build on their self-esteem, develop their sense of significance, as well as manage their emotions effectively. However, it is key to note that gentle guidance may not always yield immediate results. Consistency plays a crucial role, and over time, parents will notice their children actively apply what they have learnt.
Positive Discipline Techniques
This technique involves diverting your child’s attention to other activities when they are acting out, or when you’re trying to guide a child’s behaviour from inappropriate to appropriate. For example, if your child is running around in the kitchen while someone is cooking, stop them and introduce another item or toy that would be of interest to them. Rather than simply saying, “Don’t run in the house,” say, “ “It is not safe to run in the house. Please go outside if you want to run.”
In addition, follow up with questions to confirm that he/she understands the boundaries (i.e what is and isn’t acceptable). Questions can include:
“Is it safe to play in the kitchen while it is in use?”
“Where else could you play instead if you feel like running?”
Such open-ended questions confirming boundaries can also initiate child-led problem-solving.
With positive discipline, it is important that you describe the behaviour you want to see without lecturing, and whenever possible, let your child know what they can do, as opposed to what they cannot do.
Emphasise the positive things your child does. If you only pay attention to negative behaviour, you will end up reinforcing that behaviour. When your child does something worthy of praise, be sure to acknowledge it and give him/her recognition for it. Positive reinforcement is not limited to words of praise for good behaviour. In fact, rewarding your child with natural rewards can be an extremely effective method for encouraging similar behaviour in the future. For instance, if a child asks politely for a cup of juice instead of throwing a full-blown tantrum, consider giving a little more juice or even a nice topping to motivate similar polite requests in the future. Remember to point out what they did right and emphasise how you appreciate their polite behaviour. This kind of praise helps your child maintain a positive self-identity that they will want to live up to as well.
Punishing your child often can turn you into the enemy, fostering an unhealthy parent-child relationship. Many parents tend to punish their children in ways that are unrelated to the offence too, and this can be confusing or simply encourage their children to act in defiance. Where possible, allow the natural consequences of their actions to unfold. For instance, if your child throws a tantrum and refuses to put on a raincoat while it is raining, the natural consequence is that they would get wet. They will be far more likely to acquiesce the next time than if you respond with a time-out when a similar situation arises.
Time-in and Time-out
You may be familiar with the time-out consequence, a common disciplinary technique when a child has done something wrong. Solitary, boring time-outs can be effective when well-executed. However, research has shown that such disciplinary methods are best when occasional time-outs are paired with time-ins. Time-ins encourage good behaviour, and are carried out by having the parent spend quality time with the child after a bout of bad behaviour. Instead of lashing out at the child and sending them away, spend time with them and help them calm down if they are emotionally agitated. Once they’ve calmed down, it would be much easier to discuss better choices for the future, and encourage them to apologise for their bad behaviour.
Paying attention to language use
Language is very important when it comes to disciplining a child. When anger strikes, it’s easy to get caught up in the heat of the moment. Be mindful not to use derogatory language or words of insult, as this can be hurtful and harm the child’s self-esteem. Moreover, try rephrasing your sentences. Instead of saying, “you messed up”, begin sentences with “I” statements. Convey how you felt about their behaviour rather than solely focusing on what the child did. This makes the approach to discussing the situation less critical, and allows the child to calm down and feel less defensive especially if their actions were unintentional.
While gentle parenting is a brilliant method as a whole, it is still important that we do what we need to do if there is danger involved. For instance, if your child is running straight for a busy road, yelling or grabbing at them is completely valid and reasonable.
All in all, remember to focus on encouragement and redirection of bad behaviour to appropriate alternatives. Positive discipline can go a long way, and it will certainly benefit both parent and child.
Senior Clinical Psychologist, Henny Tan, was interviewed by the popular YA YouTube channel, LadiesFirstTv (Titan Digital Media) about the stigma a person might face when being identified as having a mental illness.
Click on the red play button to watch this 13min 24 sec video.
Most of us look forward to the festive season. After all “‘tis the season to be jolly”. It is a time for family and friends to be gathered together, often with the accompaniment of special treats and food. However, this may not always be the case for individuals who struggle with eating disorders.
Across various cultures, food is a unifying cultural thread, and eating is a huge and important part of our social lives. Oftentimes we forget the pervasiveness of food in our everyday lives. Have you ever considered how integral the role of food is in building social connectedness and relationships? We catch up with friends over meals and have informal business meetings over coffee. We also celebrate important occasions and milestones over food. The phenomenon of foodstagramming (a term used to describe the act of taking pictures of one’s food and posting it on social media), or “the camera eats first”, also dominates our social media.
As a result of the emphasis that is being placed on food, individuals with an eating disorder may feel tremendous stress and anxiety partaking in food-focused family traditions and gatherings with friends during the holiday season.
What are eating disorders?
Eating disorders are a category of psychological conditions that manifest themselves in persistent and unhealthy relationships between body image, food, eating and exercise. They usually develop in adolescence and young adulthood and are often associated with a whole host of distressing thoughts and emotions. Eating disorders can affect people of all ages and of any race, gender or body type.
Some types of eating disorders include:
An eating disorder characterised by weight loss (or lack of appropriate weight gain in children), unhealthy eating patterns, intense fear of gaining weight and significant body image concerns. This condition is extremely dangerous as it can lead to malnutrition, starvation, and death.
Bulimia is characterised by a cycle of bingeing and purging, where the individual eats large amounts of food (larger than what most people would eat in a similar period of time) in a way that feels out of their control, and then engages in purging which involves self-induced vomiting, fasting, or excessive exercise, Individuals with Bulimia also tend to have significant body image concerns.
Binge-eating disorder involves periods of consuming unusually large amounts of food in a discrete period of time, accompanied by a sense of loss of control over eating. Binge-eating episodes are commonly associated with difficult emotions such as guilt, disgust and shame.
Struggles Faced During the Holiday Season
A daily struggle for someone with an eating disorder is worrying about what and how much they will eat, how to burn off the calories consumed. When faced with an abundance of food choices and especially food that they do not commonly eat or labelled as “bad”, such worries become exacerbated. For example, someone with binge-eating urges may find it difficult to control their eating during such situations, leading to increased feelings of guilt and shame, as well as negative beliefs about themselves that come with these feelings.
Disruption of Routines
Obligations to attend various parties and gatherings will also likely disrupt everyday routines such as meal timings and exercise. In addition, structured meal plans that may be essential for someone at a specific stage of eating disorder recovery may also be impacted when dining with others.
The holiday season is also a time when we are faced with expectations from family and friends to be happy and relaxed, and to indulge in food. However, for individuals with anorexia nervosa, they may find it extremely difficult to finish their food when family is watching what they eat, or may feel pressured when others are encouraging them to eat larger amounts of food, which can lead to feelings of shame and guilt. Asking someone if they have eaten is often a way of showing we care, but for someone with an eating disorder this could potentially trigger a whole slew of body-image related thoughts. Additionally, stress may also come in the form of worrying about how to manage comments from others about how they look or what they are eating or not eating.
Individuals with eating disorders tend to feel isolated as they may withdraw from social gatherings as a way of coping with the deeply rooted fear of being negatively evaluated by others. During the holiday season where gatherings involve many more people, this fear can become intensified. They often find it hard to express their anxieties and struggles to family and friends, while at the same time feel unable to escape such situations, resulting in them feeling overwhelmed and detached.
How One Can Manage The Struggle
Preventive Measures and Coping
Given the challenges that someone with an eating disorder might face during the festive season, it is important to be proactive and plan ahead to make it easier to transition into the holidays. Friends and family can also be a significant source of support.
Adhere to a meal plan as much as possible to avoid binge or restrictive eating habits.
Identify potential triggers. List them down and try to brainstorm appropriate solutions or coping for each one of them.
List down coping statements that you think might be helpful. Remind yourself the reasons to leave the eating disorder out of this meal.
Plan non-food related activities that are fun and relaxing to recharge or bond with loved ones. You might feel most vulnerable during the first hour after meals, so plan to do activities that may help to distract yourself from the difficult thoughts or urges to binge or purge.
Arrange check-in sessions to review your game plan with your psychologist before the holiday season.
Practise how to politely set boundaries and prepare a list of topics in case you need to change the topic for when someone makes comments about your appearance or eating that make you feel uncomfortable.
Speak with family members or other members of your support system before the holidays to help them understand your needs and potential triggers.
Identify a support person or a “buddy” who can help with sticking to your plans as well as provide emotional support when needed. It might help to arrange a code word or signal to indicate that you are feeling overwhelmed and need additional support.
Be kind to yourself! Acknowledge that you are stepping outside your comfort zone. It is understandable that this might be difficult and challenging for you, but struggling does not mean you are failing.
Set realistic goals and expectations of yourself. Take things one step at a time.
Catch yourself when you criticise yourself again. Recognise that you are doing the best you can.
Give yourself the gift of enjoying the meal. Remove the idea of treating food as a “reward”, and give yourself permission to enjoy the food and company.
How Family and Loved Ones Can Help
Be there for a loved one who is struggling. Listen to their struggles without making any judgments.
Ask them how they feel and try to validate their feelings, even if you may not fully understand what they are going through.
Avoid being the “food police” unless the treatment team has given you a plan to monitor and portion food for your loved one.
Avoid making comments and judgments about calories, eating and physical appearance.
Refrain from making criticisms and instead offer support and words of encouragement.