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.
“While the expat lifestyle can have a glamorous veneer, challenges often lie beneath. The experience of living overseas can be difficult and demanding, adding unique stressors to everyday living,” explains KRISTI MACKINTOSH, psychotherapist at Promises Healthcare, which provides holistic mental health and addiction treatment and recovery services to adults, adolescents and children suffering from all types of disorders. The clinic’s team of multidisciplinary specialists – including psychologists, psychiatrists and therapists, all with different expertise and specialisations – treat both local and expat patients on a daily basis.
In fact, studies show that expats as a group are 40 percent more likely to develop mental health conditions like depression, stress and anxiety, as compared to those who never move abroad.
“The challenging environment and less support than at home often leads to an increase in drinking, smoking, drug abuse – yes, even in Singapore – or self-harm to try and distract from the negative feelings.”
What’s more, the loss of the informal network of support from friends, family and acquaintances back home only compounds the stress and anxiety.
“Expats may often feel like they can’t share their difficulties because it seems like complaining or admitting to a failure. Isolation can lead to depression, and restrictions on travel and socialising because of COVID may have exacerbated feelings of social isolation for many expats.”
How counselling can help – and tips to cope
“It’s important to be aware of the unique set of challenges that come with expat life and ensure you’ve got a good support structure in place,” says Kristi. “One of the most important things you can do is connect. Humans are social beings. While it may require more emotional honesty or reliance on those around you than you might usually be comfortable with, connection and support from others is important.”
Additionally, you can help reduce stress by:
getting enough sleep to help regulate your mental and physical health;
eating a balanced diet to prevent deficiency in minerals that may cause low mood;
trying not to over-drink, over-eat or smoke; and
doing something that brings you joy – from reading a book to trying a new restaurant.
If you feel that you’re not coping or you’d like some extra support with your mental health, reach out to your GP or a professional counsellor or psychologist for therapy in Singapore.
#09-22/23 Novena Medical Centre, 10 Sinaran Drive
6397 7309 | promises.com.sg
Since 2011, Sharmini Winslow has been a pioneer of psychodrama in Singapore and holds sessions with Promises Healthcare. After pursuing a career in dance and choreography, and founding her own Pilates studio, Sharmini discovered her natural affinity for forming connections with people – notably her close bonds with her Pilates students. Facing anxiety and feeling burnt out by the trials of running a business, she took a degree in counselling and eventually discovered the concept of psychodrama, where she found her own inner breakthroughs.
Here we find out more about this unique form of therapy and how it’s helped people with depression, anxiety and other issues.
Can you explain to us what psychodrama is all about?
Psychodrama is not drama therapy. Psychodrama has its own canon of theories and philosophies – it has a very coherent methodology. Jacob L Moreno was the psychiatrist who founded psychodrama and came up with a theory of personality, philosophy and methodology. It’s a very comprehensive way of working with clients that can also be adapted to work with other theories.
Psychodrama is basically taking whatever is in your psyche (“psycho-”) and putting it into action (“drama”) in the therapy room. We use objects and people to represent things or people from your life that you can interact with on the stage. In psychodrama, you can explore issues you want to deal with and the feelings that are coming up.
Can you give an example of what happens in a psychodrama session?
We begin with warm-ups to help participants connect and feel comfortable with each other and the director. A protagonist is chosen either as a volunteer or by the group. The protagonist is the group member who wishes to explore a situation in their life. A scene is set and group members are chosen as auxiliaries to play the roles of people, things, emotions or anything of significance in the story. The psychodramatist, also known as the director of the drama, facilitates the unfolding of the drama on the stage. The stage is the space set apart specifically for the action to take place. The rest of the group act as the audience who witnesses the drama. These are the main elements in a psychodrama.
In a drama, the protagonist might go to a scene from the past, the present or even a desired future. The protagonist usually experiences a new perspective; something in their psyche shifts and they can engage in the present with more energy and life!
In a psychodrama, we have many ways of facilitating healing and closure so we don’t re-traumatise people – that’s why it takes about 800 hours to become a qualified psychodramatist. There are protocols to follow to create safety and confidentiality, which is an important aspect of group therapy.
What do you think the main advantages of psychodrama are?
The main advantage of psychodrama is that it takes less time to get to the heart of the matter. It helps the client cut through the clutter of their intellectualisation and explore new problem-solving skills. It’s also a holistic form of therapy that embraces spontaneity and body awareness.
Psychodrama is relatively new in Singapore; does this cause any challenges? How do you address this?
There are many misconceptions and one of them is that you have to reveal your personal life to a group of strangers. In actual fact, great care is taken to build trust in the group, and if you’re still not warmed up you can participate as an audience member. I offer open sessions that allow people to experience what goes on in psychodrama. This helps to demystify it and make it more accessible. For those that want to dive deeper, I hold Personal Growth Groups that run for six to eight weeks. I believe that if people are willing to try it, they’ll enjoy it. But there’s always a hesitancy and fear about trying something new.
Is psychodrama more effective for certain kinds of people?
Psychodrama works best for people who are willing to be honest and open and want to deal with their issues in more creative ways.
Can it help with anxiety?
It helps with anger issues, depression, anxiety, stress, relationship issues, low self-esteem and even addictions.
What are some of your success stories?
I had a client who was too afraid to speak because of anxiety and his addiction issues. He was put into our group of men with addiction issues, and he was very quiet in this group. We started doing warm-ups and for the first time in his life people were relating to him as an equal, a peer. Nobody was talking down to him because nobody knew about his background except for me. He had become anxious as a result of years of drug use, and had some neurological issues.
After a few weeks, he started talking in short sentences and told us he had gone to a concert. All the guys in the group were slapping him on the back and cheering him on. His family was really grateful. He didn’t even do his own psychodrama, he was just part of the group.
What advice do you have for people who want to become professional psychodramatists?
Be patient! It takes many hours. If you’re committed to it, stay the course and don’t give up. Supervision is part of the learning process as it’s a very powerful method. Don’t neglect this important aspect of your training.
Want to discover psychodrama for yourself?
Sharmini is hosting an open session/introduction to psychodrama on 12 August for Expat Living readers – visit the Psychodrama website to sign up. She also holds training sessions for those interested in taking up psychodrama professionally. Sharmini is a Certified Psychodramatist, accredited by the American Board of Examiners in Psychodrama, Sociometry and Group Psychotherapy
Dinesh is a seasoned writer and editor with seven years of experience covering travel, restaurants and bars. His interests include film photography, cheesy 90s monster flicks, and scouring the island for under-the-radar craft beer bars.
*This article first appeared in the July 2022 edition of Expat Living and on their website.
Post-Traumatic Stress Disorder, or PTSD, is a mental health condition characterised by the failure to recover from exposure to a traumatic event, bringing about intense, disturbing thoughts and feelings related to the experience. Contrary to the widely-held belief, victims of PTSD need not necessarily experience the traumatic event first-hand – PTSD can also arise from witnessing something shocking, terrifying or disturbing. Similarly, PTSD triggers can have a broad spectrum, and the cause differs for everyone. Not everyone has to go through extreme, drastic events such as a war to develop PTSD – the condition can also be brought on by other distressing experiences such as abuse, accidents, assaults, or even adverse health or childbirth-related experiences.
How is PTSD diagnosed?
As with most other mental health disorders, clinicians use the Diagnostic and Statistical Manual of Mental Disorders as a guideline to diagnose PTSD. The diagnostic criteria below are specific to adults, adolescents, and children older than six.
Criterion A: Stressor
The person was exposed to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, in the following way(s):
Witnessing the trauma
Learning that a relative or close friend was exposed to a trauma
Indirect exposure to aversive details of the trauma, usually in the course of professional duties (e.g., first responders, medics)
Criterion B: Intrusion Symptoms
The traumatic event is persistently re-experienced in the following way(s):
Unwanted upsetting memories
Emotional distress after exposure to traumatic reminders
Physical reactivity after exposure to traumatic reminders
Criterion C: Avoidance
Avoidance of trauma-related stimuli after the trauma, in the following way(s):
Trauma-related thoughts or feelings
Trauma-related external reminders
Criterion D: Negative Alterations in Cognitions and Mood
Negative thoughts or feelings that began or worsened after the trauma, in the following way(s):
Inability to recall key features of the trauma
Overly negative thoughts and assumptions about oneself or the world
Exaggerated blame of self or others for causing the trauma
Decreased interest in activities
Difficulty experiencing positive affect
Criterion E: Alterations in Arousal and Reactivity
Trauma-related arousal and reactivity that began or worsened after the trauma, in the following way(s):
Irritability or aggression
Risky or destructive behaviour
Heightened startle reaction
Criterion F: Duration (required)
Symptoms last for more than 1 month.
Criterion G: Functional Significance (required)
Symptoms create distress or functional impairment (e.g., social, occupational).
Criterion H: Exclusion (required)
Symptoms are not due to medication, substance use, or other illness.
In addition to meeting the criteria for diagnosis, an individual experiences high levels of either of the following in reaction to trauma-related stimuli:
Depersonalization: Experience of being an outside observer of or detached from oneself (e.g., feeling as if “this is not happening to me” or one were in a dream).
Derealization: Experience of unreality, distance, or distortion (e.g., “things are not real”).
Delayed Specification. Full diagnostic criteria are not met until at least six months after the trauma(s), although the onset of symptoms may occur immediately.
How PTSD May Go Undetected
Not all individuals will have their condition diagnosed and recorded on paper. The pervasive misconceptions about its complex cluster of symptoms can hinder one from seeking treatment, or simply realising that one may be suffering from PTSD.
In the early onset of the disorder, attempts to weather the storm by turning to short-term coping mechanisms may include binge eating or distracting themselves with their favourite TV shows. However, this is not effective – nor is it healthy – in the long run. In addition, people with comparatively “less traumatising” experiences may feel as though they did not “earn” the diagnosis, considering that others might have gone through worse. This behaviour of downplaying one’s trauma can hold them back from seeking early treatment, as it may seem more convenient to adopt the mindset that they can quickly get over it in due course. With avoidance being the hallmark of PTSD, many victims turn to therapy only after long periods of struggling with the disorder, as if therapy were the last resort. But with delayed treatment, these individuals run the risk of having to navigate symptoms that, with earlier treatment, may never have developed in the first place.
Treatment Options for PTSD
At present, the evidence-based pharmacological treatment for PTSD involves the use of Selective Serotonin Reuptake Inhibitors (SSRIs), which include medications such as Sertraline and Paroxetine. While there are also other medications available, these two are currently the only ones approved by the FDA for PTSD.
SSRIs play a well-recognised role in the management of mood and anxiety disorders. Their mode of action involves raising the levels of Serotonin, a neurotransmitter vital in regulating mood, anxiety, appetite, sleep, and other bodily functions.
Of course, there is no one-size-fits-all. While SSRIs are typically prescribed to treat PTSD, there are exceptions depending on the patient’s medical history. Clinicians will have to consider the patient’s response to the drugs, existing comorbidities, and personal preferences. As such, medications have to be tailored to each individual’s needs.
Cognitive Behavioural Therapy (CBT)
One of the more common forms of psychotherapy, CBT aims to tackle the maladaptive thought processes and emotions associated with one’s trauma. Trauma-focused CBT involves three main categories – exposure procedures, anxiety management procedures, and cognitive therapy. These aim to help individuals understand what they’re afraid of, learn healthy and effective coping mechanisms, and work through dysfunctional thoughts.
Moreover, having a therapist or psychologist that is trauma-informed can be of great benefit. A trauma-informed therapist is knowledgeable about trauma and can understand and empathise with how the traumatic experience could have impacted the patient. Prioritising physical and emotional safety ensures a smoother clinician-client collaboration, which in turn aids in increasing the transparency and efficacy of treatment.
Eye Movement Desensitisation Therapy (EMDR)
Eye Movement Desensitisation Therapy may be less commonly heard, but it is an efficacious, empirically validated treatment for trauma and other adverse life experiences. In a different vein from cognitive behavioural therapy, EMDR doesn’t focus on altering a client’s thought patterns or behaviours. Instead, it relies on one’s own rapid, rhythmic eye movements, allowing the brain to process memories and resume its natural healing process. Simply put, EMDR therapy involves guiding the client towards reliving triggering experiences in short phases while the clinician directs his eye movements. When the client’s attention is diverted as they recall the traumatic event, the exposure to negative thoughts and memories is less upsetting, limiting a strong or negative psychological response.