All of us have felt anxiety at some point in our lives, whether before a big test, public speaking, or a job interview. Anxiety is a perfectly normal emotion that serves the purpose of motivating us to prepare for a big event or protect ourselves from potentially dangerous situations. However, too much anxiety may put us at the risk of experiencing panic attacks. In this article, we will discuss the symptoms, causes, and strategies for managing panic attacks.
What are panic attacks?
A panic attack is a sudden episode of intense anxiety and fear that triggers strong physiological reactions. These reactions can feel so intense that the individual feels as though they are having a heart attack. Common symptoms of a panic attack include but are not limited to:
It is important to note that panic disorder can develop if an individual starts to fear the panic attack itself (i.e., worrying about when the next panic attack may happen or avoiding situations and places when the panic attack occurred).
What causes panic attacks?
Similar to anxiety, anyone can experience a panic attack. However, some of us may be more prone than others. Several factors play a role in increasing our risk for panic attacks:
Family history: Anxiety often runs in families. If you have a family member who has a diagnosed anxiety disorder or, tends to experience anxiety more intensely and frequently than others, you would be at a higher risk for panic attacks.
Mental health issues: Individuals experiencing burnout, intense anxiety, depression, or any form of mental illness are more prone to panic attacks.
Traumatic experiences: A past or recent experience of trauma can result in our bodies remaining in constant “fight-or-flight” mode—the physiological reaction of anxiety and fear—which may then increase the likelihood of panic attacks.
Substance abuse: Addiction to substances such as alcohol, drugs, and caffeine can put us at a higher risk for panic attacks.
How to manage panic attacks?
If you are experiencing panic attacks at an intensity and frequency that is distressing and debilitating, please seek professional help. Panic attacks can be treated with talk therapy, psychotropic medication, or a combination of both. If not, here are a few ways to manage panic attacks:
Stay calm: It is important to remember that while panic attacks can be scary and extremely uncomfortable, they will not cause you to die. When a panic attack comes, notice and name it as a panic attack, and remind yourself, “It’s just a panic attack, it will pass.” For those of you who are unsure if it may be a medical issue, please see a doctor to rule out such concerns first.
Practice grounding exercises: Grounding is a useful technique that helps us to detach from our anxiety, often with an added calming effect. It works best with regular practice, even when you are not experiencing a panic attack, so that muscle memory can kick in when you most need it. Examples of grounding include:
Notice the environment around you with all your five senses, such as what you can see, hear, touch, smell, and taste. Describe this to yourself, either mentally or quietly out loud.
Carry a grounding object (e.g., a rock, gem, ring, small toy) in your pocket. Hold the object and notice its size, shape, texture, and temperature of it.
Engage in slow, deep 4-2-4 breathing – inhale for four counts, hold your breath for two counts, exhale for four counts. You may also focus on your breath and notice the feel of the air entering your nostrils, the movement of your shoulders, chest, and stomach as you breathe, the feel of the air coming out of your mouth.
Avoid caffeine: Caffeine is a stimulant that can activate your body’s “fight-or-flight” response. Adding caffeine to your anxiety-ridden body would be akin to throwing a lit stick of dynamite into a house on fire.
Overall, please remember that the presence of panic attacks indicates high levels of anxiety. They are our body’s way of telling us that it is at its limit. Should you experience one, it would be helpful for you to reflect on your stress and anxiety levels, identify any triggers and manage them, as well as ensure that you engage in your self-care routine and practice adaptive coping strategies.
Therapy is an indispensable tool to recovery, or in helping one gain deeper insights and achieve self-actualisation. In light of the ongoing COVID-19 pandemic, traditional face-to-face therapy has been forced to take on various forms, including sessions conducted via telephone or through video-calling platforms. Of course, therapy serves the same purpose, regardless of whether it is conducted in person or otherwise. However, there is definitely something restorative about being able to connect with a therapist physically. Humans are innately social creatures after-all, and sometimes when things get tough, a little more human interaction and comfort can go a long way.
Physical presence in therapy certainly provides a deeper sense of connection, in contrast with virtual therapy where one might feel more distant and detached. It may seem bearable at the very beginning, but as you progress through the sessions, having to interact with your therapist through a screen all the time can get frustrating. Similar to how students may have trouble coping with online school and home-based learning, virtual therapy has some form of hindrance when it comes to relationship-building with your therapist. For most psychotherapy methods, it is indeed possible to shift them online. However, for others such as psychodrama, it may not be entirely ideal. How expressive and comfortable can you get, when you’re struggling to follow your therapist’s directives through the small screen and having to deal with technological lags?
Seeing your therapist in person also allows for him/her to detect any subtle body language and somatic movements. These are all non-verbal cues that may be lost through telecommunication. Non-verbal cues are just as important as verbal ones, and can provide your therapist with greater insights. Non-verbal signals can serve to convey your feelings along with what is being said, and can either reinforce or contradict verbal messages. Ignoring them would be very much a failure to be fully engaged in a conversation. Moreover, seeing you in person provides therapists with the ease to identify any form of dissociation. During the session, clients may not necessarily attune well, and may not be fully present in the moment. The client may be engaging with the therapist, but seemingly thinking about something else that is going on in their life at the same time. This does not mean that the session is unhelpful or “boring”. While this could simply be attributed to the lack of presence, it could also point towards other concerns regarding the client’s state of mind. Fragmentation can occur especially when one is recovering from a past trauma and can be brought to the forefront, causing incomprehensive emotional reactions when triggered. Fragments of self are usually suppressed, often attributed to the lack of a sense of safety when it comes to expressing their inner needs or desires. When these feelings start to show during therapy, therapists can identify them through common tell-tale signs such as a switch into dissociation, noticeable body movements (twitching, scrunching of fingers or toes etc.). Body language is not definitive, but can offer clues about one’s thoughts and feelings. With telecommunication, it is more often than not impossible to see the client below shoulder-level, thus making it difficult for therapists to assess any somatic movements that may be occurring.
Another issue with telecommunication is the lack of control over the therapeutic environment. In a traditional face-to-face session, the clinician has considerable control over the environment, and is able to ensure a private, safe and quiet space for the entire duration of the session. This limits the number of distractions and allows for both the therapist and the client to concentrate on psychotherapy. Moreover, in a clinical setting, furniture is often set up in particular ways to facilitate clinician-patient interactions. For instance, seats may be arranged such that the clinician would be facing the client at an angle of 45 to 90 degrees, and approximately 2 to 3 feet away. Facing the client directly can feel somewhat threatening for some, and this angle allows for the client to feel more at ease. Additionally, it allows for both parties to break eye contact naturally (intermittently) without seeming antisocial or distracted by having to do so actively. In contrast, having a session online or through telephone allows for less control over interactions and the client may be more exposed to external distractions or undesirable interruptions. This also leads us to our next point, where teleconsultations also increase the risks of privacy breaches.
Due to the lack of environmental control, having a consultation via telecommunication methods can be a challenge especially for those who do not have access to their own private space. For individuals living with others, there could be situations that compromise client confidentiality, including potential eavesdropping or having others walk in on them. Not only does this make the session extremely disruptive, it can be a huge concern for many considering that mental health concerns are sensitive topics. Clients must make the extra effort to find a suitable place and time for them to speak with their therapists freely and with ease. As such, physical presence in a controlled clinical setting may have the upper hand.
Nevertheless, this article in no way aims at undermining the efficacy of tele-health, nor to allude that tele-therapy is ineffective or pointless. Considering the need for physical distancing during the pandemic, telecommunication is undeniably crucial in limiting the spread of the virus. Putting that aside, traditional in-person therapy can have its barriers too, limiting people from attaining the mental health support they need. Individuals with disabilities may find accessibility to be a significant problem at hand, and find it difficult to travel for therapy without having others to rely on. Others include parents who are unable to find suitable childcare options, all while juggling work and mental health care. For those struggling with social anxiety and agoraphobia, it can also be extremely intimidating and overwhelming for them to step out. In fact, some research has shown that virtual and in-person therapy, depending on the treatment goal, can be equally effective. In adults, cognitive behavioural therapy was shown to be similarly effective both in vivo and virtually (Khatri et al., 2014). There is also evidence that youth with anxiety disorders respond positively via telehealth (Khan et al., 2020). Traditional face-to-face therapy and tele-therapy both have their perks, and we acknowledge that it also boils down to individual preferences. If you’re unsure as to which treatment option to opt for, do feel free to contact us.
Brenes, G. A., Ingram, C. W., & Danhauer, S. C. (2011). Benefits and Challenges of Conducting Psychotherapy by Telephone. Professional psychology, research and practice, 42(6), 543–549. https://doi.org/10.1037/a0026135 (Accessed 06/09/2021)
Khatri N., Marziali E., Tchernikov I., Shepherd N. Comparing telehealth-based and clinic-based group cognitive behavioral therapy for adults with depression and anxiety: A pilot study. Clinical Interventions in Aging. 2014;9:765. (Accessed 09/09/2021)
Khan, A. N., Bilek, E., Tomlinson, R. C., & Becker-Haimes, E. M. (2021). Treating Social Anxiety in an Era of Social Distancing: Adapting Exposure Therapy for Youth During COVID-19. Cognitive and behavioral practice, 10.1016/j.cbpra.2020.12.002. Advance online publication. https://doi.org/10.1016/j.cbpra.2020.12.002 (Accessed 09/09/2021)
For many people, when they hear the word ‘Psychiatrist’, it would instantly conjure up an image of a doctor prescribing medicine for someone with a mental health condition. This is true to the extent that a psychiatrist is a medical doctor who has undergone training to become a mental health specialist. While prescribing medications are indeed part of the treatment process, what really goes on in between – from the first session to the very end?
On your very first session, your psychiatrist will most likely spend 1-1.5 hours with you to gain a better understanding of what you’re coming in for. Mental health conditions can be a touchy subject for many, and it is understandable that you’d feel hesitant to open up to a complete stranger right away. However, trust that your psychiatrist has your best interests in mind, and will do his/her best to provide optimal treatment. Don’t be afraid of being judged for your symptoms, rest assured that the psychiatrist’s office is a safe and non-judgemental space. The psychiatrist will want to know as much as you’re willing to share, and being honest with your psychiatrist will be extremely helpful for an accurate diagnosis and the development of an effective treatment plan. Just as what you’d expect when you seek a General Practitioner for physical conditions, your psychiatrist would start off by asking broader questions such as, “What brings you here today,” or “How can I help you?” For some individuals, especially if it’s their first time at a psychiatrist’s, open-ended questions like these may be nerve-wracking. You may feel a little overwhelmed, not knowing how to start or where to begin. However, there are no hard and fast rules as to how the session should flow. Simply communicating your symptoms and your concerns would be a great start, and your psychiatrist will guide you through the interview.
Your psychiatrist will also run through a history-taking process, paying special attention to your medical history, family history, your current lifestyle habits and general patterns of sleep. It is important to let your psychiatrist know if you’re on certain medications, as some may have side effects that may fuel certain mental health conditions. Avoid downplaying or dismissing any information related to your physical or mental wellbeing, the clue to an accurate diagnosis may very well lie in the details. As such, going for your first session prepared with a complete list of medications, dosages, and your compliance with them can be very beneficial. Many studies have also shown that genetics play a role in mental health disorders. If you have a family member who suffers from a psychiatric issue, be sure to let your psychiatrist know for him to have a clearer idea of the situation. If need be, your psychiatrist may also ask permission to speak with other family members.
Depending on the patient’s circumstance, the psychiatrist may conduct a physical check-up if necessary, or possibly laboratory tests to exclude other possible causes for your condition. These are done to confirm that what you’re experiencing are not due to other medical conditions which may give rise to similar symptoms. Hence, if your psychiatrist asks for these procedures to be carried out, don’t feel too worried! Questionnaires to further assess your symptoms may also be given, so do make sure to answer them as truthfully as possible.
Depending on the complexities of your condition, medication options or other forms of treatment may be prescribed. If you are given medications, the psychiatrist would counsel you on how you can tell if the medications are working. Over the course of your recovery journey, take note of how subtle changes to the medications made by your psychiatrist affects you. Do they stabilise or improve your condition, or do they seem to send you on a downward spiral? How have you been feeling since you started taking them? Whatever the outcome, keep your psychiatrist in the know of how you’re coping. In the same vein, it is very important that you do not adjust your medications on your own without seeking professional advice! Patients may get impatient if they’re not seeing the desired change after a while, but constant and unregulated changes can cause undesirable fluctuations, potentially worsening the situation. We need to understand that there could be catastrophic, life-threatening consequences if we do not take them seriously.
In general, psychiatrists usually work closely with psychologists and therapists, as some mental health conditions are best treated with both neuropharmacological support and psychotherapy. Thus, your psychiatrist may also refer you for psychotherapy if deemed fit. Depending on the level of care required to address the patient’s symptoms, psychiatrists may recommend treatment programmes if more intensive care is needed.
Fear resulting from psychological trauma can be extremely deep-seated. The distress, feelings of helplessness and constant flashback of traumatic events can turn one’s world upside down, causing major problems with daily activities and quality of life. It may be easy for someone to say, “Well, why can’t you just get over it?” But in reality, we need to recognise that it is much easier said than done. In order to help people move past their traumatic experiences, researchers and psychologists have worked tirelessly, creating various therapeutic methods and tweaking them to achieve the optimal recovery outcome. In regards to the treatment of post-traumatic stress disorder (PTSD), you may be familiar with an approach known as Dialectical Behavioural Therapy. In this article, we’ll be introducing you to an alternative psychotherapy technique, also known as Eye Movement Desensitisation and Reprocessing (EMDR).
Developed by Francine Shapiro in 1987, EMDR therapy is an empirically validated treatment for trauma and other negative life experiences. While it is also increasingly applied for the treatment of other mental health conditions such as depression, anxiety or panic attacks, researchers have not found EMDR to be as effective as with trauma-related conditions. As its name suggests, EMDR isn’t all about talk therapy or medications. 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.
What is the Basis of EMDR Therapy?
EMDR is fundamentally based on the Adaptive Information Processing (AIP) Model. A key tenet of this model is that the symptoms of PTSD are manifested due to memories that are dysfunctionally stored or not fully processed. Memories of disturbing experiences often string along negative emotions, thoughts, beliefs and even physical sensations that were associated with them at the time of occurrence. This can bring about a multitude of unpleasant symptoms that can be exceptionally detrimental to one’s mental health.
When one is exposed to stress or trauma, the body’s automatic response would be to activate its Sympathetic Nervous System (SNS). As an adaptive system, it controls our natural fight, flight or freeze instincts, which is critical in ensuring our survival. When the SNS is activated, the individual will undergo physical alterations such as increased heart and breathing rates, decreased blood flow to the digestive system and constricted blood vessels. In addition, hormone levels including those of adrenaline and cortisol will increase dramatically, causing hypervigilance. However, for someone who is under constant stress from traumatic flashbacks, the over-stimulation of the SNS will be greatly damaging to this person’s physical health. As such, EMDR therapy aims to process memories such that the experience is remembered, but the fight, flight or freeze response is eased.
At this juncture, you may be wondering how clinician-directed eye movements could possibly alleviate trauma-induced stress. EMDR therapy involves guiding the client towards reliving triggering experiences in short phases while the clinician directs his eye movements. During the process, the client will be tasked to focus on trauma-related imagery and the relevant sensations. The clinician will then simultaneously move their finger across the client’s field of view, with each phase lasting approximately 20 to 30 seconds. This will then be repeated a couple of times. At some point, other forms of rhythmic left-right stimulation (for example, listening to tones that go back and forth between the left and right sides of your head) will also be incorporated into the therapeutic process. As distressing as it sounds, the process in fact allows for the vividness and emotional triggers of the memory to be reduced over time. When the client’s attention is diverted as they recall the traumatic event, this makes the exposure to negative thoughts and memories less upsetting, hence limiting a strong psychological response. After attending several EMDR therapy sessions (depending on the individual), the impact of the traumatic event is believed to be significantly reduced.
How is EMDR Structured?
Generally speaking, EMDR takes on an eight-phase approach.
Stage 1: History Taking and Treatment Planning
For a start, the clinician will work hand-in-hand with the client to identify the traumatic experiences which require attention. Should the client have a problematic childhood, the initial stage of EMDR may focus on resolving childhood traumas before moving on to resolve adult onset stressors. Identifying targets for EMDR treatment is also crucial – this means looking further into the client’s past memories, their current emotional triggers, as well as what they hope to achieve by the end of the treatment phase.
Stage 2: Preparation
In this phase, the clinician introduces the client to a few emotion-coping strategies to ensure that the client is well able to manage their emotional distress whenever a trigger is brought up. It is important that the client is able to deal with overwhelming emotions even between EMDR sessions in daily life. The clinician may also familiarise the client with the eye movements or bilateral stimulations.
Stage 3: Assessment
The clinician will then identify and assess the specific traumatic memories that need to be tackled. This also involves analysing the associated emotions and sensations triggered by the memories.
Stages 4 to 7: Treatment Process
These intermediate stages focus on the process of desensitisation, installation, a body scan, and seeking closure. The client is asked to concentrate on the trauma-related imagery and memory while engaged in the directed eye movements or other bilateral stimulation. After each set of stimulation, the client will be asked to clear their mind and report what they feel, think, and the sensations they experience. Depending on the individual, the clinician may have the client refocus on the same memory, or move on to another. This process is repeated until the client reports no distress.
Installation is where the clinician works with the client to increase the strength of positive cognition. This means focusing on the preferred positive beliefs, rather than negative ones. For example, an individual dealing with trauma arising from childhood domestic abuse may start off with a negative belief of “I am weak and powerless”. Installation aims to change that belief into one of “I am now in control.” Of course, EMDR does not force one to believe in something that is inappropriate or unsuitable for the situation. In the example brought up, allowing the client to realise that positive belief could mean encouraging them to take on self-defence training, or other skills that can provide them with a greater sense of security and control.
A body scan is used in order to check for any residual somatic response that is linked to event-related tension or stress. Should any undesirable bodily sensations be present, the clinician will then target them specifically in subsequent sets.
Stage 8: Evaluation
The next EMDR session begins with this phase. This stage is mainly for the re-evaluation of the client’s plight. More importantly, this step is to ensure that the necessary progress is made and to review the client’s psychological state. Further review will be carried out, and the relevant changes will be made to provide the optimal treatment effect.
Although EMDR may be a relatively new technique as compared to other forms of therapy, it is nonetheless an extensively researched method proven to alleviate the stress symptoms of trauma survivors and other individuals who have had distressing life experiences. If you think that EMDR therapy is right for you, do seek help from a mental health professional.
Overspending your way into debt? Depending too much on sleeping pills or other sedatives? Snacking non-stop, even when you’re not hungry? Old habits die hard – as personal experience would reflect, we all know that it can be extremely challenging to break a habit, much so to maintain a good one. According to a rather appalling statistic, it was revealed that approximately 9 out of 10 individuals who have undergone heart bypass surgeries as a result of poor health were still unable to change their unhealthy lifestyle habits, even with their lives on the line. Whilst not all habits need to be broken, learning to overcome unproductive ones and replacing them with healthier habits can be vital towards a more fulfilling existence.
As defined in the dictionary, a habit is “an acquired mode of behaviour that has become nearly or completely involuntary”. Some neuroscientists posit that the brain is fundamentally lazy, so where possible, it would program our thoughts, emotions and behaviours into circuits where they would be automated and turned into “shortcuts”. The process of habit formation essentially takes place in the basal ganglia, a group of structures embedded deep within the cerebral hemispheres of the brain. Apart from being responsible for motor control, emotions and behaviours, this region also plays a key role in reward and reinforcement, as well as addictive behaviours.
What occurs in the brain when we try to form a new habit? Habit formation bases itself on neural pathways, involving countless nerve cells connected by extensions known as dendrites to form a larger network. As the frequency of a particular behaviour performed increases, so does the number of dendrites, and the connection between brain cells strengthen. Over time, neural pathways are developed and the messages sent through the same neural pathways are transmitted faster and faster, thus allowing for certain behaviours to become automated with enough repetition. In simpler terms, the more you perform a certain action, the more it gets wired into your brain. This adaptive quality of the brain is also known as neuroplasticity.
On the flip side, when you successfully quit a bad habit, synaptic pruning occurs. Synapses are small pockets of space between the neurons which allow for electrochemical messages to be sent through your neural pathways. Synaptic pruning can be likened to throwing out the old clothes in your closet to make space for new ones. When you no longer perform certain actions, these synaptic connections weaken. At the same time, more resources are allocated towards building the neural pathways of other important or prioritised habits, thereby strengthening them. This means that it is completely possible to rewire your brain to support healthier habits!
How can I develop good habits?
It is not uncommon for people to be ambitious when it comes to seeking positive lifestyle changes. Especially when a new year begins, many of them would have prepared a long list of new year resolutions, such as wanting to make exercise a habit or to meditate on a daily basis. The problem is, how many of them would follow through with it? Enthusiasm is not the issue here, but commitment is. Keep in mind to take things one step at a time. In order to develop a good, sustainable habit, refrain from tiring yourself out even before it takes flight. It can be very effective to focus on just one clear goal at a time and to commit to it every day (or as per your ideal schedule), even if it means only doing it for 10 minutes each time. As you go along, you can then build on your habit according to your pace and your desired end goal.
Another tip is to “stack” your habits. You probably already have a few strong daily habits that you never fail to execute, such as brewing a cup of morning coffee, taking a walk after lunch, or brushing your teeth at night. Leverage these strong connections and use them to your advantage to build on new ones. For example, if you’d like to pick up meditation, tell yourself, “After I brew my morning coffee, I’ll meditate for 5 minutes”. If you aim to cut down on screen time at night before bed for better sleep quality, tell yourself, “I’ll turn off my devices before I brush my teeth”. By creating a link between your new and old habits, you’ll find yourself more likely to stick to new changes and behaviour.
Create frequent reminders of your goal if consistency is something you struggle with, or if you tend to be forgetful. Out of sight usually means out of mind, but that’s natural! You can easily put reminders on your calendars, set alarms on your mobile phones, or even have post-it notes around your house if you will. Sharing your goal with someone else can be an added source of motivation too. Be it a friend or a family member, working together with others who are also striving to pick up on the same habits will act as a catalyst and spur you on. If they aren’t keen on making the commitment, that’s fine too. Instead, let them serve as an accountability partner. Let them in on your goals and progress – when you are accountable to someone for doing what you said you aimed to do, you are more likely to stay committed.
Of course, identifying a goal is easy. But remember to stay mindful and have a clear understanding of what you want to achieve at the end of the day. Apart from asking yourself what you want to achieve, ask yourself how it will look like and how you will feel when you get to the end. Most importantly, remember to set your mind to your goal and take active steps towards it. Instead of merely browsing through tons of self-improvement posts or looking up “quick hacks” for golden tips on Google, focus on the actual tasks that need to be accomplished. It may be a rather mundane, time-tested process at first, but it will eventually bring success and satisfaction.