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.
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.
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.
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.
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.
Principles of Transcranial Magnetic Stimulation (TMS)
In the 1800s, world-renowned English physicist Michael Faraday discovered the principles of electromagnetic induction. Fast forward to the 21st century, Faraday’s discovery was harnessed into the clinical practice of transcranial magnetic stimulation (TMS) for the treatment of mood disorders. Based on Faraday’s Law, TMS can stimulate brain neuronal circuits with tiny electrical currents induced by a changing magnetic field.
In Singapore, the practical application of TMS is employed in the form of repetitive transcranial magnetic stimulation (rTMS). In rTMS, magnetic pulses are delivered in trains at specific frequencies. “Fast” (high frequency e.g. 10Hz) stimulation increases cortical excitability for the treatment of depression. Whereas “slow” (low frequency e.g. 1Hz) stimulation reduces cortical excitability for treating anxiety disorders. Furthermore, TMS can be targeted at focused regions of the cortex for superior precision treatment of specific conditions e.g. rTMS at 1Hz to the right orbitofrontal cortex (OFC) reduces intrusive obsessions in obsessive-compulsive disorder (OCD).
Mood disturbances such as depression are increasingly understood as disorders of connectivity in neural networks linking cortical and subcortical grey structures of the brain. Functional brain imaging has shown dysfunction in cortical regions such as the dorsolateral prefrontal cortex (DLPFC) and anterior cingulate cortex (ACC), as well as deep grey matter structures including the amygdala, nucleus accumbens, hippocampus and hypothalamus. These brain circuits 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, which mediates the body’s response to stress.
Neuroplasticity and TMS
Evidence suggests that TMS induces neuroplastic changes in these circuits. Neuroplasticity is the ability of the brain to reorganize itself by forming new neural connections. TMS helps readjust neurotransmitter (e.g. serotonin and dopamine) levels in a variety of brain regions. TMS also appears to exert a neuroprotective effect on the brain. Research has shown that TMS decreases brain inflammatory factors reducing oxidative stress on the brain. TMS also boosts the levels of brain-derived neurotrophic factor (BDNF), encouraging neuronal growth in regions such as the hippocampus which is vital for learning and memory. It is postulated that the anti-depressant properties of TMS may also help in normalizing the body’s neuroendocrine stress response system.
rTMS has achieved its place on international treatment guidelines as an augmentation treatment modality to be strongly considered in treatment-resistant depression. It is reported that 30-40% of depressed patients may have inadequate responses to anti-depressant medication treatment. The direct neuronal effects of rTMS may explain why rTMS may work for this group of patients.
rTMS for OCD Treatment and other neurological disorders
In May 2022, the U.S. Food and Drug Administration (FDA) approved the use of the NeuroStar TMS system as an adjunct for treating adult patients suffering from OCD. Promising research is ongoing for the clinical application of TMS in treating Post-Traumatic Stress Disorder (PTSD), addictions, chronic pain, insomnia and many other neurological disorders.
TMS and recovery
With further advancements in TMS research and the incorporation of TMS in routine clinical practice, there is strong hope for recovery and the regaining of optimal functioning for patients afflicted by complex neuropsychiatric conditions.
1) Transcranial Magnetic Stimulation
Clinical Applications for Psychiatric Practice
2018 American Psychiatric Association Publishing, First Edition
2) The Science of Transcranial Magnetic Stimulation
William M. Sauvé, MD; and Lawrence J. Crowther, Meng
Psychiatric Annals, Vol44, No.6, 2014
3) Repetitive transcranial magnetic stimulation increases serum brain-derived neurotrophic factor and decreases interleukin-1b and tumour necrosis factor-a in elderly patients with refractory depression