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.
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.
This is an important concept that helps to explain certain interactions within relationships better. Relational patterns and rules between family members within the family system dominate how individuals interact and engage with one another. These rules are often silent, unconscious or multi-generational in nature. Within this system, the family operates according to some ‘thermostat’ which sets the ‘desired setting’ for how each member is expected or required to function. The functioning applies to how situations or people are viewed, how much self-disclosure is welcomed or permitted, how personal or interpersonal difficulties are addressed or not, how disagreements or secrets are to be dealt with, or what relational values are being promoted. Families in different cultures may operate with certain predictable rules or patterns, eg. within families sensitive to shame, avoidance or non-verbal disclosure, communication is often practised. Tapping into the honest emotions of members over time tends to reveal the ‘temperature’ within the family system.
Families nurture the psychological ‘birth’ of the sense of self within children during their childhood. In the process, parents shape within their children how young children will engage themselves (intra-personal relationship) to function in later childhood and adulthood (inter-personal relationships). Healthy relational patterns and appropriate rules are important to foster healthy emotional development towards an important psychological milestone for children: healthy identity formation. Because these patterns and rules are so fundamental in the shaping process, it is important for parents to understand how they can shape their children towards this healthy identity. If not, the child could begin a life-long struggle from having accepted an identity that is diffused, confused or distorted in nature. This is usually accompanied by secondary effects of this outcome, eg. a pattern of difficult or troubled relationships with others. This usually adds additional distress to the sufferer and to those who relate to them.
Instead of understanding interactions within relationships along a linear continuum where there is a definitive start and end, circular causality opens up to appreciating the relational context where interactions can be examined between two events in more useful detail. With an understanding of circular causality, understanding the interactions between two or more individuals can better reveal where an interaction can get stuck. This pattern occurs in all relationships but it is especially within ongoing relationships where being stuck in a negative cycle can lead to particular disappointments, hurt and pain. For children, unhealthy patterns and rules within families can undermine the child’s emotional development over time.
Circular causality is particularly useful to explain conflicts between family members which can become persistent and damaging. Persistent hurts can undermine relationships and lead to how negative expectations of each person are viewed and engaged with over time. They are a concern because of the prospect of children’s sense-of-self being hurt or damaged within certain family systems. Therefore, careful attention is usually necessary in understanding the attribution of cause-and-effect of what is problematic between family members.
Individuals attribute cause and effect or causation in situations and within relationships. Linear cause and effect of A 🡪 B 🡪 C are defined by a specific start and end point. Individuals who operate from understanding relationships based on linear causality tend to assume that problems are caused and maintained by the other individual’s beliefs, biology, emotions or other abnormal factors within the individual, i.e., they are self-generated. Therefore, solutions are found when the individual in question changes their beliefs or emotions within them to respond differently to the situation.
In contrast, circular causality refers to the reciprocal relationship between two events. Family members influence each other in a continuous process within a feedback loop. A vicious cycle is often present when two or more family members have relied on unchecked assumptions to carry out their attributions of cause-and-effect in the situation. The perspective of reciprocal relationships stems from the foundations of cybernetics, which refers to the regulatory action where one part of the system impacts another. Events usually do not happen in isolation. There is a feedback loop which tend to result in a new equilibrium. It is more that A 🡪 B 🡪 A.
Susan refuses to go to school and goes into her room. Mom and Dad raise their voices and lecture her. When they raise their voices, Susan isolates. Mom and Dad’s frustrations or anger heighten Susan’s need for isolation, and Susan’s isolation heighten Mom and Dad’s anxiety, and therefore their escalation.
For parents who operate on assumptions of linear causality, their perception can easily overlook other reasons to explain the child’s original presenting problem, eg. Susan may be bullied at school, she has an unhappy relationship with her teacher, or she may be afraid of facing exams but is afraid to tell anyone. Parents who operate based on linear causality tend to see their child as the source of the problem, and to overlook their contribution or other reasons leading to the child’s presenting problem.
Instead of being quick to judge the situation as the child choosing to misbehave, parents should focus first on establishing a safe, trusting relationship with their daughter before their intervention. They can raise concerns about what their child may be fearful of with empathy. The following statement could be as follows, “Hey Susan. You usually would enjoy attending school. But something unpleasant or uncomfortable may have happened to make you afraid of returning to school. I remember that when I went to school, I have at times been uncomfortable going to school because I was afraid of meeting someone I did not like, or having to face an exam I was not prepared for, or having to face a teacher who was mean. Can you tell me what is going on for you at school that you are uncomfortable facing? I will like to help you.”
John struggles in completing his homework and his poor grades. The father Mr. Lim responds to him with harsh criticism. Hurt and demoralized by his father’s criticism, John does not put in his best effort at school. His father’s criticism then intensifies and John puts in even less effort to learn.
Family difficulties are often not rooted by a simple mistake made by the child (mistakes are common for children and instrumental for how they learn). In this scenario, the father’s response to John may be reflective of how Mr. Lim was regarded as a child himself by his own parents when he was growing up. Criticism then is an extension of how he was treated as problematic as a child (to regard himself as stupid, inadequate, irresponsible) so as to repeat the cycle here. Without knowing all this history, John becomes hurt and angry against his father’s accusation. He can try to defend himself and retaliate with, “I am not useless. You are.” Mr. Lim who is outraged by John’s apparently disrespectful reply can bear down on John for what he considers to be John’s defiance to intensify his attack: “You are not only useless but disrespectful.” This pattern can then set up a loop that becomes self-perpetuating or self-reinforcing based on their view of each other. John is seen by his father not only as stupid or irresponsible, he is also viewed as disrespectful and defiant. In turn, John sees his father as unloving and hurtful whom he needs to distance himself from. If they had a positive relationship earlier in John’s life, this relationship can deteriorate over time if the underlying issues are not addressed.
In reciprocal relationships, circular causality is often revealed in the course of the interplay between emotional experiences, false or valid expectations and eventually how we experience each other. It often reveals how one or both parties perceive and interpret their individual world, and there is usually a historical reason behind their perception. Our current experiences, perspectives and approach to relationships are often already influenced or shaped by our previous significant relationships with our family-or-origin and culture.
[ In this situation, Mr. Lim should be advised to consult a child clinical psychologist when he sees no improvement with his son’s behavior. He needs to be alerted to the importance and quality of the parent-child relationship in impacting the child’s self-esteem, emotional conditions for what children need to thrive and the nature of the unconscious. If Mr. Lim was armed with the appropriate knowledge and possibly obtain personal help to address his relationship with himself as defective or inadequate, he could approach his son with, “Hey son. Studying in Singapore can be challenging or difficult. The workload can be heavy and the material can be difficult. I struggled with it too when I was a student. What struggles are you facing at the moment?” ]
In the midst of ongoing conflicts between parents, their child Ben develops anxiety because the two people he loves appear to be hurting each other. Ben acts out with anxiety and/or depression, eg. temper tantrums, excessive withdrawal from school or play, trouble at school. This draws the attention of his parents who attend to him. In the process, their own conflict decreases. From this, Ben learns that he can influence his parents’ conflict through his anxiety.
Circular causality helps to explain why family members may be stuck arguing about the same subject every time through communication traps or failures. Understanding cause & effect on a linear perspective in relationships can result in an artificial understanding: one cause & one effect or multiple causes & the same effect. In this scenario, Ben’s parents may wish to see Ben as having difficulties coping with school. Their solution may be to improve Ben’s responses to become more resilient. But if Ben attempted to communicate his difficulties with his parents’ conflict, they may not wish to believe that they contribute to his struggles. In so doing, they fail to capture the root of the problem for what it is. A child’s struggles may be defined by their parents because the child’s limitations reflects the parents’ limited emotional insights on themselves or their children. This lack of emotional insight and understanding is often expressed through circular causality to reveal that children can be misunderstood often and that the parent-child relationships can often be negatively impacted. The parents’ own limitations are often overlooked in the situation.
Repeated over time, the negative rituals expressed in circular causality can be locked in place by ignorance, emotional hypersensitivity, defensiveness, contempt for one or more family members, hopelessness, hurt, anger, blame, fear and avoidance or stonewalling. Emotional cut-offs may be used frequently. If this happens, the effects of circular causality in an unhealthy family system can be experienced as intolerable. If there was previously a positive bond that bound the relationship, it can now be worn down by pain and the relationship may become damaged.
In this situation, the parents should consult a clinical psychologist familiar with children and family issues when they notice their child struggling with school or presents with anxiety in the midst of their conflict.
How To Break The Cycle
Raising healthy children require establishing healthy relationships and healthy boundaries. Because the goal of raising healthy children is so worthwhile and essential to their future growth and success, parents need to be concerned that their relationship with their children are not defined by misunderstandings and conflict which are painful. To foster family unity and raise healthy children, three important values and practices are essential to promote certain patterns and rules in the family system:
Parents need to learn about child development. They should also remember that children function at a disadvantage because they tend to lack the emotional insight to explain their fears, their confusion, and what they need. Subsequently, children often have difficulty articulating what they feel or need. They need parental help to develop their emotional insight and offer them a broad emotional vocabulary to learn to express and communicate themselves clearly and honestly. When this is offered by parents who are emotionally mature and aware, intentional to raise children in their best interests, and when these parents are trusted by their children, the groundwork is being laid for the healthy formation and development of the child’s emerging identity.
Parents need to develop the courage to have honest conversations with each other and their children. This courage needs to be accompanied by the believe that each member has important value so that each person is treated with respect. With courage and respect, each person can be approached with caution about making inaccurate or false assumptions of each other, and engaging in a self-serving bias. Being honest and courageous is important to clarify if inaccurate attributions are being made. Being ready to listen without judgment prior to making honest inquiries would further help to avoid misunderstandings or address misunderstandings when they occur.
The willingness to develop healthy emotional intimacy promotes the value of sharing for each family member to know one another and to being known by the others in the family. This offers the basis for bonding and closeness. When communication is constructive, affirming and respectful, it can establish the sense of security within children and trust between family members. For children, this is particularly important since secure attachments contribute significantly to the child’s emotional development and mental health. This in turn offers a basis for them to acquire a healthy approach to future relationships and healthy functioning. To promote relationships which are safe and nurturing, words are powerful to convey that each family member is highly valued. They should be deliberately selected to promote each other’s well-being. Having a pattern of honest and constructive communication with healthy rules where individuals are affirmed and supported help to promote a family system where each member can safely practice saying what they mean and mean what they say. Misunderstandings are not left to stay but are promptly corrected. This offers the most fertile ground for healthy personal and interpersonal growth to happen. When parents notice they have difficulty delivering these practices, they should consult a clinical psychologist.
American Psychological Association. (n.d.). Apa Dictionary of Psychology. American Psychological Association. Retrieved October 22, 2022, from https://dictionary.apa.org/circular-causality
Kerr, M. E., & Bowen, M. (1988). Family evaluation: An approach based on Bowen theory. W W Norton & Co.
Expat life and moving around the world places a great deal of stress on children. DR REBECCA GIESS and DR MARK TOH from Promises Healthcare share how parents can help them adapt to new environments and people.
What issues do children deal with when adjusting to expat life?
Rebecca: They suffer mostly from homesickness, and grief from losing friends, extended family and familiar places. In a new country, they find it difficult to fit in and feel a sense of belonging. They have a fear of missing out (FOMO) on life back home.
Mark: They perceive a threat in relocating. Extended family and friends represent the emotional resources the child depended on, and the disruption in daily routine affects their emotional security and stability. This is an important and largely overlooked stressor. How children experience this, and how prepared they are for the change, is based on their relationship with their parents.
What are the red flags?
Rebecca: It can be difficult for children to know how they are feeling or how to express it. They may exhibit anti-social behaviours by breaking the rules or defying expectations. Tune into your child to uncover the underlying emotional triggers, and what they might need emotionally from you.
Mark: For children under the age of eight, there may be more crying, moodiness and irritability, complaining about school, expressing worry, or becoming withdrawn and clingy. There may also be regressions such as thumb-sucking, temper tantrums or toilet accidents, despite being potty-trained.
Children aged seven to 10 may worry about their health or family and express anger and irritability. They may also pin negative labels on themselves. Some of these behaviours may manifest at school more than at home.
Preteens may be more reactive to the demands and stress of the new school, complaining about the different system or classmates. They could become withdrawn, have more incompleted homework, or have declining grades.
How can we help teenagers adjust?
Mark: Teenagers will miss their friends, prom, graduation and sports pursuits – the rites of passage – and they may feel their sense of identity being stripped away. They may display depression, anxiety, irritability, apathy and withdrawal, which increases their sense of isolation.
Those who feel ready to be independent may feel trapped with their family. They blame their feelings on the relocation and start to resent the family for it.
If the teenager is close to completing Grade 12, consider allowing them to graduate before they relocate.
How can parents navigate their child’s emotions?
Rebecca: Create space and guidance for their emotional experiences. Parents can validate and normalise their emotions by saying things like: “It makes sense.” Or: “It’s normal to feel sad or stressed.”
Don’t place any expectations on how your child “should be feeling”. They feel what they feel. Parents can help them label their emotions and work out how best to manage them.
Talk to your child about becoming a “third culture kid” – someone who spends a portion of their developmental years in another country. There are several benefits and challenges worth understanding and planning for.
I recommend parents read Third Culture Kids: The Experience Of Growing Up Among Worlds (Pollock, Van Reken & Pollock 2017).
What is most important to the child?
Mark: Children are looking for safety and security. With younger children especially, this depends on how close they are to their parents. Pay more attention to any work or social activity that might threaten this bond. Parents must remain accessible to the child, meeting regularly, exploring and discovering the country together and having fun in the process.
They should also assess how they themselves are coping, and if they might be unintentionally neglecting their child’s needs.
What can parents do at home?
Mark: Help children to set up their room. They are more likely to embrace their new home when they know that their needs are being met predictably. Parents should be ready to share their personal feelings and discoveries to encourage their children to communicate as well.
Create routines that bring everyone together. Playing games encourages bonding. Team games, where discoveries can be made individually and shared collectively, are particularly useful. In the process, the family learns about each member together.
How can a therapist help?
Rebecca: Therapists are trained to work with children experiencing anxiety and depressive symptoms due to adjustment difficulties. Children are rarely completely open with their parents and may do better in a non-judgmental safe space.
Mark: A therapist looks at both the child and family’s wellbeing. How is each person in the family coping? If there are individual or collective difficulties uncovered, the therapist could help them get unstuck.
About Dr Giess & Dr Toh
Dr Giess has extensive experience in working with teenagers and parents. She also helps adults address severe and chronic mental and physical health issues, and is trained in couples relationship counselling.
Dr Toh treats troubled children and their families and helps them to address their challenges. Helping parents to parent well is also a concern for him. He also works with couples and individual adults, as well as individuals with personality disorders.
Promises Healthcare is at #09-22/23 Novena Medical Center, 10 Sinaran Drive. Contact the team at 6397 7309.