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.
Caregivers with a family member affected by addiction problems are often exhausted, drained dry of their empathy and compassionate capacities.
They recount countless cycles of suspended hope followed by just as many broken promises as they watch the affected person return time and again to their compulsive addiction despite a seemingly obvious trail of destruction behind them.
Caregivers learn to cope with the endless demands on their energies by blending the words uttered by the affected persons as a cocktail of lies, manipulation and attention-seeking antics to get what they want.In time, the cries for help from the affected person turn into cries for help by the boy who cried wolf and eventually fading into indistinguishable white noise.
Professor Lisa Firestone of the Glendon Association observes that there is a natural tendency for caregivers to minimise any suicide expressions in general.Responses such as, “Well, his past attempts weren’t serious.” or “He is just manipulating to get something.” are commonly observed.There is also a general tendency to not want the expressions to be true.In the case of addicts, words such as “I want to die” or “I am going to end my life” no longer convey the same meaning or gravity of their sense of desperation.
Why should we want to pay attention to an addict’s cry for help?
In Singapore, we lose 1.1 lives every day to suicide.It is still the leading cause of death for youths aged 10 to 29.While direct correlation evidence is still being researched on, studies in America have shown that more than 90% of people who kill themselves suffer from depression have a substance abuse disorder or both. Suicidality and addiction share a high concordance relationship.
When we overlay the statistics with a physiological lens, we note that both groups of persons have been observed in studies to have a dysfunctional hypothalamic-pituitary-adrenal (HPA) axis which essentially controls our body’s response to stress.
In a person with a normal functioning HPA axis, on the reception of a stressor, the hypothalamus in our brain instructs the secretion of the corticotropin-releasing factor (CRF) and vasopressin to stimulate our pituitary glands to produce the adrenocorticotropic hormone (ACTH).The ACTH, in turn, stimulates glucocorticoid synthesis and release (commonly referred to as cortisol) from the adrenal glands.This chain reaction provides a person the increased energy to handle the stress event and to do so without suffering from the pain and fatigue.When the stress event is gone, the body produces a negative feedback loop which then brings the body system back to homeostasis.
In a person exposed to a persistent or extreme level of stress, or in a person who frequently activates the HPA axis through substance use, the body starts to blunt the sensitivity of the HPA axis and blunt cell receptivity to cortisol in its efforts to return to and maintain homeostasis.This alteration to the sensitivity of the HPA axis affects our ability to tolerate physical and mental stresses and creates a need for a much bigger stimulus to activate the HPA axis (which may mean higher dosage of substance use); and when the HPA axis does react, produces a much bigger and exaggerated response (which may translate to more aggressive behaviours).
What Does This Mean In Practical Terms?
Many suicidal persons described having a voice in their head which is constantly there; telling them how much they need to seek fulfilment and comfort by reaching for the desired stimulus, whether it be a substance or a behaviour, of which one is killing themselves.Their mind starts to command them to constantly plan, to seek out and to take actions to soothe the unbearable lack that they are feeling.Eventually, the voice in the head goes from coaxing and persuading to being more intensive and aggressive towards the self to take immediate drastic actions.
The relief of death, a final refuge, becomes alluring and pleasurable and the fear of dying eventually transforms into the fear of not dying and becoming the loser, disappointment, and burden that they already believe themselves to be to their caregivers.This dual push towards drastic action and the need for an ever-increasing amount of substance in addicts leads to an increase in the risk level of suicidality.
What Can We Look Out For?
How then does the caregiver separate the wheat from the chaff amid the chaos that addiction has already wrought onto the family system to detect the risks of suicidality?
Below are some, though not exclusive, common markers to look out for. It is particularly useful to note changes in the content of the affected person’s expressions and any escalation or sudden extinction of intensity.
Intense Emotional Outbursts
Extreme Isolation or Withdrawal
The feeling of Being a Misfit in Every Way
Researching or Procuring Means of Suicide.
Self-Harm, Including Risky Substance Use or Behaviours.
Planning of Affairs.
Presence of Trigger Events
Loss of Primary Relationship.
Physical or Mental Health Conditions That Debilitate.
Abuse or Trauma Events.
What Can Caregivers Do On Observing The Signs?
Ask the Suicide Questions:
In the past few weeks, have you ever wished that you were dead?
In the past few weeks, have you felt that you or your family would be better off if you were dead?
In the past week, have you made plans about killing yourself?
Have you tried to kill yourself?
If the answers are yes to any or to all the questions, caregivers are encouraged to take the following first steps:
Be empathetic towards the suicidal wish.
The objective is not to agree with the act of suicide but to understand what has happened to lead the affected person to the conclusion that suicide is the only solution.
Find a genuine connection with the affected person.
However difficult that person might have been in your life, express what this person means to you personally and how the loss of this person would affect you.
Make a safety plan.
Ask the affected person to agree to not take or delay any action to harm themselves until they get to or you get them to professional help.
Professor Lisa Firestone observes that suicidal persons are generally ambivalent: a part of them wants to die but a part of them wants to live as well.There is often a process of the dividing up of the self within the person, between an aspect which is life affirming and engaging with the outer world; and the anti-self, which is self-critical, self-hating and ultimately suicidal.The key to recovery is to connect with and help strengthen that part of them that wants to keep on living.
6 Dazzi, T., Gribble, R., Wessely, S., & Fear, N. (2014). Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence? Psychological Medicine, 44(16), 3361-3363. doi:10.1017/S0033291714001299
We are no strangers to feelings of anxiety – at certain stages of our lives or in particular situations, we would have experienced anxiousness and worry with relation to our careers, studies, relationships and even our environment. However, anxiety levels may go beyond the healthy norm for some people, and may instead develop into anxiety disorders that may have a debilitating effect on their lives. According to the American Psychology Association (APA), an individual who suffers from an anxiety disorder is described to have “recurring intrusive thoughts or concerns”, where the duration and severity in which the individual experiences anxiety could be blown out of proportion to the original stressor, resulting in undesirable tension and other physical alterations. In this article, we will be exploring a few types of anxiety disorders as well as how they can manifest within us.
Generalised Anxiety Disorder (GAD)
Generalised Anxiety Disorder is a psychological issue characterised by persistent and pervasive feelings of anxiety without any known external cause. People who are diagnosed with GAD tend to feel anxious on most days for at least six months, and could be plagued by worry over several factors such as social interactions, personal health and wellbeing, and their everyday routine tasks. For example, an individual with GAD may find himself experiencing headaches, cold sweats, increased irritability and frequent feelings of “free-floating” anxiety. Others may also experience muscle tension, sleep disruptions or having difficulty concentrating. Often, the sense of anxiety may seemingly come from nowhere and last for long periods of time, therefore interfering with daily activities and various life circumstances.
In contrast, Panic Disorders are characterised by the random occurrence of panic attacks that have no obvious connection with events that are co-occurring in the person’s present experience. This means that panic attacks could occur at any time, even when someone is casually enjoying a meal. Of course, panic attacks could also be brought on by a particular trigger in the environment, such as a much-feared object or situation. Some individuals have reported that panic attacks feel frighteningly similar to a heart attack, especially with the rapid increase in heart palpitations, and the accompanying shortness of breath. Other symptoms also include trembling, sweating, and feelings of being out of control. With these panic attacks bringing on sudden periods of intense fear and anxiety, it can be exceptionally terrifying when these attacks reach their peak within mere minutes. However, a notable difference between a panic disorder and GAD is that an individual diagnosed with panic disorder is usually free of anxiety in between panic attacks.
Obsessive-Compulsive Disorder is a disorder marked by patterns of persistent and unwanted thoughts and behaviours. Obsessions are recurrent thoughts, urges or mental images that cause anxiety. On the other hand, compulsions are the repetitive behaviours that a person feels the urge to do in response to an obsessive thought or image. One common example often exhibited in films is where an individual has an obsessive fear of germs. This person may avoid shaking hands with strangers, avoid using public restrooms or feel the urge to wash their hands way too frequently. However, OCD isn’t purely limited to feelings of anxiety due to germs. OCD can manifest in other ways as well, such as wanting things to be symmetrical or in perfect order, repeatedly checking on things (“Did I leave my stove on?”), or the compulsive counting of objects or possessions. While everyone double-checks their things and has their own habits, people with OCD generally cannot control their thoughts and behaviours, even if they are recognised to be rather excessive. They can spend at least 1 hour a day on these thoughts and behaviours, and will only feel the much-needed brief sense of relief from their anxiety when they perform their rituals. As such, OCD can be exceptionally debilitating to one’s mental health.
Social Anxiety Disorder
Persons with Social Anxiety Disorder, or SAD, experience high levels of anxiety and fear under particular or all social situations, depending on the severity of their condition. They are often afraid of being subjected to judgement, humiliation or rejection in public, causing them to feel embarrassed. As such, individuals with SAD may feel extra self-conscious and stressed out, and try to avoid social situations where they might be placed at the centre of attention.
A phobia involves a pathological fear of a specific object or a situation. This means that one may experience intense anxiety upon encountering their fears and will take active steps to avoid the feared object. Phobias may centre on heights(acrophobia), birds (ornithophobia), crowds and open spaces(agoraphobia), and many others. People with agoraphobia, in particular, may struggle to be themselves in public spaces, for they think that it would be difficult to leave in the event they have panic-like reactions or other embarrassing symptoms. In severe cases, agoraphobia can cause one to be housebound.
In Singapore alone, 10% of the population is plagued by anxiety disorders – one of which includes Social Anxiety Disorder, or SAD for short. And on a global scale, approximately 4.5% of the world’s population – 273 million people – are estimated to experience anxiety disorders as of 2010. Commonly misunderstood to be merely an over-exaggerated form of shyness, Social Anxiety Disorder is much more than that. Individuals with SAD experience symptoms of anxiety or fear under particular or all social situations, depending on the severity of their condition. For some, even doing the simplest day-to-day activities in front of others can cause extreme worry of being judged, humiliated or rejected. However, some research has also suggested that SAD may be especially manifested in individuals that have ongoing medical, physical conditions such as Parkinson’s Disease, obesity, facial or bodily disfigurement (including amputees), and any other sort of conditions that may cause one to look different from the norm.
What are the symptoms of SAD?
When people with Social Anxiety Disorder are surrounded by others or have to carry out a particular action around them, they may:
Feel nauseous, experience an increase in heart rate, tremble, blush or sweat profusely.
Be unable to make eye contact with others, move and act rigidly, or speak in an overly soft tone.
Feel extremely self-conscious, as though others are judging their every move.
Easily feel awkward, embarrassed and stressed out in social situations.
Find it extremely difficult to be themselves around others, especially strangers.
Have anxious thoughts such as, “I’m sure they won’t want to talk to me again,” or “Do I look plain stupid right now?”
Apologise excessively, even when there is nothing to apologise for.
Avoid conversations, such as by using their mobile devices or plugging in their headphones.
Avoiding situations where one might be placed at the centre of attention.
The list of symptoms above is not exhaustive, but we need to recognise that they may cause extreme distress to these individuals. For them, it can be tremendously helpful and relieving for them to seek treatment for their condition, more specifically through Cognitive Behavioural Therapy (CBT).
Cognitive Behavioural Therapy is a well-known form of therapy in the mental health profession. Considered to be a form of short-term therapy, CBT is usually delivered in a time-limited manner, often over the course of 8 to 12 sessions (although this may vary from person to person). Once the symptoms are reduced and the individual is well-equipped with the necessary skills to cope with anxiety triggers or social situations in general, treatment can be finalised. As it is not possible to change or alter emotions directly, CBT aims to tackle any maladaptive, limiting thoughts and behaviours that fuel or contribute towards agonising emotions. This, therefore, lowers the extent of anxiety that one goes through and instead, developing a sense of self-efficacy.
First off, CBT encourages individuals to open up and to be truthful regarding their automatic, instinctive (negative) thoughts so that they can work hand-in-hand with therapists to analyse the logic behind them. During the sessions, therapists will work to identify the assumptions (and their validity) that these people hold, which might be causing unnecessary anxiety or fear. Proper reasoning and clearing up of assumptions can be done by asking clients to do some self-assessment and to provide possible reasons as to why they maintain such assumptions. By doing so, therapists can then assess the situation and present evidence contrary to their beliefs.
Another aspect of CBT includes ‘Decatastrophising’. One common thinking pattern found in people who suffer from anxiety issues is ‘Catastrophising’, which is the act of imagining the worst-case scenario and magnifying the bad in any given situation. CBT helps to counter such a mindset by helping these individuals prepare for the feared consequences, as well as to cope with their unhealthy ways of thinking. For example, therapists and clients will go through certain ‘Challenge Questions’, such as:
“Has anything this bad ever happened before? How likely is it to happen now?”
“What makes you confident that your feared outcome will actually come true?”
“What is the best outcome that can happen in this situation?”
These are just a few examples of ‘Challenge Questions’, but they can certainly be beneficial in helping to ease feelings of anxiousness and to calm the individual. In some way, this can also decrease an individual’s inclination to avoid seemingly triggering social situations.
Tying in with ‘Decatastrophising’, another technique introduced during CBT is ‘Reattribution’. ‘Reattribution’ is a method which challenges the negative assumptions held by the individual by considering the possible alternative causes of events. This is particularly advantageous for people who, in most situations, perceive themselves to be the cause of problem events. For example, this can mean having a discussion on the evidence which proves that the individual is/is not the cause of the problem. Eventually, this will help to tackle ‘Automatic Negative Thoughts’, excessive self-blame and worry.
Of course, in order for the treatment process to be carried out more effectively, some therapists do assign “homework” to their clients. This is to say that clients are encouraged to apply CBT principles in between sessions, and are tasked to self-monitor and focus on implementing tips and processes when dealing with actual situations. By monitoring their emotions and making a conscious effort to calm themselves through methods discussed during sessions, these individuals will eventually develop the much-needed skillsets to cope with emotionally-draining social environments.
A combination of cognitive and behavioural therapeutic approaches, CBT has been proven to be an extremely effective treatment method for anxiety disorders, including SAD. In fact, the skills you learn in CBT are practical and highly applicable, and hence can be incorporated into everyday life to help you cope with future stresses more effectively. As such, if you or a loved one is struggling with SAD, do seek treatment as it will ultimately benefit you in the best way possible.
For individuals that are taking the first step to seek help from mental health professionals, it is natural that they may be concerned with the possibility of a misdiagnosis, or perhaps an overdiagnosis. With the pre-existing stigmatisation of mental health disorders, clients would have needed to pluck up their courage to seek treatment in the first place. A misdiagnosis could not only hinder them from receiving the appropriate treatment for their affliction, but also allows for their distress to grow unchecked as their hope for recovery diminishes. In other words, accuracy in evidence-based mental health diagnosis is crucial, and this article aims to help you better understand how the diagnostic process works.
As the term “Evidence-Based Diagnosis” implies, psychiatrists or clinical psychologists take extra care to ensure that any diagnosis made is accurate, objective, and not subject to any form of personal bias. In some sense, this also means allowing for a safe, non-judgemental and compassionate environment. Primarily, clinicians would have to understand the client’s suffering and situation, before thinking about how that might relate to a possible mental disorder. Perhaps you may be unaware of this – clinicians do not simply jump straight into tying the client down with a specific diagnosis of a mental disorder. Before all else, clinicians have to consider if the client’s symptoms meet the definitions of a mental disorder in the first place. As per the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, the definition of a mental disorder considers these five factors:
A behavioral or psychological syndrome or pattern that occurs in an individual
Reflects an underlying psychobiological dysfunction
The consequences of which are clinically significant distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning)
Must not be merely an expected response to common stressors and losses (i.e.. the loss of a loved one) or a culturally sanctioned response to a particular event (i.e. trance states in religious rituals)
Primarily a result of social deviance or conflicts with society
With reference to the definition of a mental disorder, it is particularly important to note that the consequences of a mental disorder is clinically significant, and causes a weighty amount of disruption to one’s lifestyle and day-to-day activities. For example, it is completely natural for one to feel upset over certain situations, and this does not necessarily mean that you have a case of depression. However, you might need to get it checked out if you find yourself unable to cope with prolonged feelings of sadness which start to interfere with your daily activities, or are causing you to have suicidal thoughts.
Of course, clinicians then assess the syndrome one displays. By “syndrome”, we mean a collection of signs or observable aspects of the client’s suffering (i.e outward expression or behaviour). The main point of this is to identify if the syndrome is clustered in an identifiable pattern that is noted to be severe or pervasive. During the assessment phase, clinicians also try to understand the internal experiences of the client. Besides their outward display of distress, their thoughts and feelings are also important information which counts towards the diagnosis of certain disorders. Upon identifying that the client is indeed suffering from a mental condition, clinicians then try “assigning” the client to a particular category. You can think of it as, “can the syndrome be broadly identified?” There are certain broad categories of disorders, such as anxiety disorders, or psychotic disorders. Needless to say, clinicians have to consider which category the client best fits in.
The last step of the diagnosis process concerns the further narrowing and identification of the specific disorder – branching out from the broader, generalised category and into the specific details. For example, a client could be diagnosed with Obsessive-Compulsive Disorder (OCD), a form of an anxiety disorder. Ideally, a specific disorder is identified during the diagnosis process for various reasons – for the sake of the clients themselves, but also for clearer communication with other mental health professionals (in the case of continuity of care), and even for legal or court matters. Under rare circumstances, some clinicians are able to identify the broad category of the mental disorder, yet are unable to specify the exact condition that the client is suffering from. In cases like these, their disorders will be labelled as “unspecified”, as per the 10th version of the International Classification of Diseases.
As mentioned, evidence-based mental disorder diagnosis is all about diagnosing clients accurately and objectively. To enhance objectivity, some clinicians go the extra mile, stopping to consider if the diagnosis given was biased, or influenced by his or her own culture and history. “Is the syndrome maladaptive?”, “Did I take cultural variables into account?” An objective diagnosis will certainly go a long way in ensuring that the client receives the most appropriate treatment, which will in turn enhance his or her recovery journey.
Overall, it is safe to say that it takes two hands to clap in every treatment process. Clients and clinicians should try as much as possible to work together, be it in the assessment or treatment phase. For an effective treatment, clinicians will do their best to assess the severity and pervasiveness of any syndrome using understandable language such that clients are well aware of their condition. However, clients also need to understand that transparency on their side is pivotal and that it will drastically impact the treatment process, for better or for worse, depending on their cooperativity and how much they choose to reveal.
Dr Robert Shwartz, Ph.D., PCC-S, Evidence-Based Mental Disorder Diagnosis: How to Increase Accountability, Efficiency and Objectivity, video recording, Mental Health Academy