Did you know that our brains can be rewired? Fairly new psychiatric treatments can encourage what’s known as neuroplasticity – and may help patients overcome severe mood disorders as a result. We asked DR SEAN DAVID from Promises Healthcare to tell us more.
What is neuroplasticity?
Neuroplasticity refers to the brain’s ability to reorganise itself by forming new neural connections to relearn different ways of doing things.
What psychiatric treatments can help rewire the brain?
Medications, psychotherapy and neurostimulation can all induce neuroplastic changes in the brain. Therapy approaches like Cognitive Behavioural Therapy (CBT) and Transcranial Magnetic Stimulation (TMS) can be combined to target the prefrontal cortex for improved cognitive control and emotional adjustment.
TMS can also be combined with other psychotherapeutic practices like mindfulness training. This targets the limbic network for better emotional function. The limbic system controls our behavioural and emotional responses, especially when it comes to those needed for survival – feeding, reproduction, caring for our young, and fight-or-flight responses.
Medications such as antidepressants adjust the levels of monoamine neurotransmitters such as serotonin, dopamine and noradrenaline, to improve synaptic signalling or communication between neurons.
How are neural networks related to mood disturbances?
Mood disturbances are increasingly understood as disorders of connectivity in neural networks linking the superficial to deeper layers of the brain. Functional brain imaging has shown dysfunction in cortical regions and brain circuits that are pivotal for executive functioning, regulation of emotions, reward processing and preservation of memory and cognition. They also link the nervous system to the endocrine system that mediates the body’s response to stress.
What is neurostimulation?
In the practice of psychiatry in Singapore, neurostimulation is the purposeful modulation of the brain’s nervous system using noninvasive measures to aid in the treatment of mental health conditions like mood disorders and psychosis. These therapies include Electroconvulsive Therapy (ECT) and repetitive TMS (rTMS).
How does rTMS work?
Based on Faraday’s Law of electro-magnetic induction, rTMS is able to stimulate brain neuronal circuits with tiny electrical currents induced by a changing magnetic field.
At Promises Healthcare, we use NeuroStar Advanced Therapy. It was the first TMS system to receive US Food and Drug Administration (FDA) approval in 2008 for adults with major depressive disorder. In May 2022, the US FDA approved the use of the NeuroStar TMS system for treating adult patients suffering from obsessive-compulsive disorder (OCD).
How does rTMS affect the brain?
Evidence suggests that it induces neuroplastic changes in these circuits, and helps readjust neurotransmitters like serotonin and dopamine. It also appears to exert a neuroprotective effect on the brain. Research has shown that rTMS decreases oxidative stress on the brain. TMS also boosts the levels of brain-derived neurotrophic factor, an important protein that encourages the growth of neurons in brain regions, improving learning and memory. The antidepressant properties of rTMS may also help in normalising the body’s neuroendocrine stress-response system.
How is it administered?
Magnetic pulses are delivered in “trains” at certain frequencies. “Fast” stimulation at a high frequency of 10Hz is used in the treatment of depression, whereas “slow” stimulation at a lower frequency of 1Hz is used in the treatment of anxiety disorders.
Furthermore, rTMS can be targeted at focused regions of the cortex for superior precision treatment of specific conditions. For example, rTMS at 1Hz to the right orbitofrontal cortex reduces intrusive obsessions in OCD.
How long does a session last and what does it feel like?
The treatment is performed with the patient seated comfortably at an inclined position in a specially designed chair. No anaesthesia is required, and the patient remains alert during the treatment.
Each session lasts for 37 minutes, and a TMS operator will be present throughout the session to ensure the patient is comfortable and safe. Earplugs will be provided. Patients may choose to listen to music or watch TV during the session. Promises clinic has a TMS room with a plasma TV and Netflix subscription!
What does the ideal rTMS treatment programme look like?
Sessions are carried out on weekdays four to five times per week over four to six weeks. A typical course consists of 20 to 30 sessions. Patients with recurrent depressive episodes who respond well may be suitable candidates for maintenance rTMS treatment sessions carried out weekly, fortnightly or even monthly.
Who are the best candidates for neurostimulation?
In particular, rTMS can be used in treatment-resistant depression and OCD. It’s reported that 30 to 40 percent of depressed patients may have inadequate responses to antidepressant medication treatment. The direct neuronal effects of rTMS may explain why it works well for this group of patients.
It’s also suitable for patients who are very sensitive to the side effects of psychotropic medications or who have concerns about ECT.
After commencing rTMS, improvement in mood and cognition may be seen in two to three weeks. Many patients are then able to effectively take part in talk therapy, resulting in their synergistic combination effects on neuroplasticity.
Promising research is ongoing for the clinical application of TMS in the treatment of post-traumatic stress disorder (PTSD), addictions, chronic pain, insomnia and many other neurological disorders.
About the doctor and the clinic
Dr Sean David Vanniasingham is experienced in general psychiatry, addiction medicine and neurostimulation treatment. He is a firm believer in a bio-psycho-social model approach in the holistic and recovery-oriented care of his patients. He’s a fellow at the Academy of Medicine Singapore and is currently serving as an executive committee member of the Singapore Psychiatric Association.
Promises Healthcare is a multidisciplinary mental health and addictions clinic. The team of psychiatrists, psychologists, therapists and executive coaches also includes a rehabilitation physician and nutritionist. Together, they take on a diverse and multidisciplinary approach to treatment. The care and wellbeing of patients is at the heart of the service, and treatments are based on the latest clinically proven protocols in the field of neuroscience and psychology.
Promises Healthcare is at #09-22/23, #09-18 & #11-16 Novena Medical Center, 10 Sinaran Drive. Contact the team at 6397 7309.
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.
References
Massachusetts General Hospital, Handbook of General Hospital Psychiatry, seventh edition, chapter 13: Anxious Patients.
Dr Joseph Leong & Dr Sean David speaks with an editor at Expat Living about Burn out. Read on to find out the details.
We’ve all been there – wired on coffee, exhausted, struggling to keep pace with hurdles and deadlines, before hitting the inevitable brick wall. When can we identify a state of “burnout”, and what does psychology have to say about it? We asked DR JOSEPH LEONG and DR SEAN DAVID from Promises Healthcare about this as current mental health issue.
DR JOSEPH LEONG
What does being “burnout” mean in a clinical context?
Joe: Burnout is an occupational phenomenon. It’s not classified as a medical condition but conceptualised as resulting from chronic workplace stress that has not been successfully managed. It is characterised by feelings of energy depletion or exhaustion; increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and reduced professional efficiency.
While we recognise that students and homemakers can also suffer similar anxieties, burnout refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life. Sean: American social psychologist Christina Maslach, who is well known for her research on occupational burnout, stated: “What started out as important, meaningful and challenging work becomes unpleasant, unfulfilling and meaningless. Energy turns into exhaustion, involvement turns into cynicism, and efficacy turns into ineffectiveness.”
The behavioural manifestations of burnout may be procrastination on tasks; “presenteeism” at work, which is when a person is present at work while they’re disengaged or unwell; sleep and appetite disturbances, or even maladaptive coping methods such as increased smoking and drinking.
If burnout is not addressed early or adequately, it can lead to other mental health issues including major depression, anxiety disorders or even escalate to the severity of suicidality or illicit drug use. This will inadvertently have a profound impact on the afflicted person’s social and family life.
DR SEAN DAVID
Is there treatment for burnout? What “work hygiene” or mental habits can be cultivated to help keep our cogs turning?
Sean: The first step is to recognise when one has reached a stage of burnout, and not brush aside their inability to function due to just “stress”. Increasing awareness of the warning signs of impending burnout and avenues of help internally within one’s company, and externally using community resources or virtual self-help is important. Psycho-education reduces the stigma associated with seeking help for mental health conditions.
The second step is to analyse the specific causes of burnout for that unique person’s life situation. There are systemic and individual factors that can predispose, precipitate and perpetuate burnout.
The third and most crucial step is to take action and make lifestyle changes in accordance with the identified root causes of burnout.
Prescribed medications by doctors to aid sleep or relieve anxiety may also be abused. This can result in addiction. The first step is awareness that this could happen to anyone despite the belief that one knows their limits.
Joe: Some people cope by drinking, smoking or taking some pills to solve their “ills”. These coping strategies may temporarily relieve distress but are not healthy long term and can do more harm than good.
What distinguishes a clearly appropriate medical-use case from an addictive dependency on prescribed medication?
Joe: Chronic distress should be managed in a holistic way rather than self-medicating. Seeing a therapist or a counsellor to learn new skills or change one’s thinking would be helpful.
Appropriate medication use is within the doctor’s prescription weighing the indication, benefits, alternatives and risk of using or not using.
One should be honest with the use of medications and not doctor-hop or collect various medications from different doctors without revealing what was given by another doctor. Bringing all the medications during the consult will help in active use of the medication and reduce the dependency on medications.
How can employers instil and facilitate better mental health practices? How can we negotiate healthier working styles with our bosses and colleagues?
Joe: I recommend a frank discussion about what is working well and what is not. A person will do well with tasks where he or she is strong and interested in doing them, whereas other tasks may cause too much distress and dysfunction.
Sean: Fostering a positive and supportive working environment is encouraged, for example, allowing employees to have autonomy over their job scopes. Trusting them to make appropriate flexible work arrangements, especially if they are parents or care-givers, can ensure better work life balance and happier employees.
Encouraging an open discussion with employers about work strengths and weaknesses can also result in a better allocation of suitable work tasks. Employers can distribute responsibilities fairly at work and put in place multisource feedback channels to keep the effectiveness of work policies in check.
Finally, reminders from company HR for employees to use up their annual leave benefits instead of the repetitive cycle of carrying forward leave may ensure that employees take adequate rest in the work year to recuperate.
Seeking help for “being stressed at work” might seem outlandish to some. What can you share with readers to change their mind?
Joe: Think about it as executive coaching or career counselling. If the job is not a good fit and has caused physical, emotional, psychological and social distress and dysfunction, changing to another department or a better job may be a better outcome in the long term.
Sean: Seeking help is not a sign of mental weakness but instead a bold action taken by you to see a change, and find fruitful meaning in life.
In the words of BKS Iyengar, “Change is not something that we should fear. Rather, it is something that we should welcome. For without change, nothing in this world would ever grow or blossom and no one in this world would ever move forward to become the person they’re meant to be.”
Three Steps Out of Burnout
#1 Recognise when you’ve reached a stage of burnout, instead of brushing aside your inability to function due to just “stress”.
#2 Analyse the specific causes of burnout for your own life situation. There are systemic and individual factors that can predispose, precipitate and perpetuate burnout.
#3 The most crucial step is to take action and make lifestyle changes in accordance with the identified root causes of burnout.
About PROMISES
Promises Healthcare is a multidisciplinary mental health clinic with a team of psychiatrists, psychologists, therapists and executive coaches (and a rehabilitation physician) who take on a diverse and multidisciplinary approach to treatment. Care and wellbeing of patients is at the heart of the service, and treatments are based on the latest clinically proven protocols in the field of neuroscience and psychology.
Dr Joseph Leong believes that recovery is possible for anyone. He looks beyond finding the best combination of medications to recommending talk therapy and psycho-social rehabilitation and community partnerships.
Dr Sean David Vanniasingham is experienced in general psychiatry, addiction medicine, and neurostimulation treatment. He is a firm believer in the biopsycho-social model approach in the holistic and recovery-oriented care of his patients.
Visions by Promises is the addictions treatment arm of Promises Healthcare, providing recuperative care programmes such as one-on-one counselling, group therapy, an intensive outpatient program, specialist groups, family therapy and medical detox.
Promises Healthcare is at #09-23, #09-18 & #11-16 Novena Medical Center, 10 Sinaran Drive. 6397 7309 | promises.com.sg
*This article first appeared in the October 2022 edition of Expat Living and on their website.
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