Is Schizophrenia Curable? Understanding the Nuances of Treatment and Recovery

October 20, 2023 By Dr Lim Boon Leng

Introduction

Schizophrenia is a severe and chronic mental health disorder that affects a person’s thinking, perception, emotions, language, sense of self, and behaviour. Despite significant advancements in medical science, the question remains: Is schizophrenia curable? While some may use the term “cure,” it is important to understand that treatment options exist that allow many patients to lead fulfilling lives. In this article, we aim to shed light on the nuanced differences between being “cured” and “recovering” from schizophrenia, backed by evidence from scientific literature.

The Quest for a Cure: What Does Science Say?

Genetic Factors

There is currently no known cure for schizophrenia because its underlying causes are not fully understood. Research shows that genetic and environmental factors play a complex role in its development. While certain genetic markers have been identified, these only predispose individuals to the illness rather than determine it conclusively.

Neurotransmitter Imbalance

The dopamine hypothesis has been one of the most extensively studied aspects of schizophrenia. Traditional antipsychotic medications work by blocking dopamine receptors, but managing neurotransmitter levels does not “cure” the disorder; it only manages its symptoms.

Brain Structure

Recent studies using magnetic resonance imaging (MRI) have shown abnormalities in the brain structures of individuals with schizophrenia. However, these structural differences do not present a pathway for a definitive cure.

Treatments: A Ray of Hope

Pharmacotherapy

Antipsychotic medications remain the cornerstone of schizophrenia treatment. They are effective in treating ‘positive symptoms’ like hallucinations and delusions but are less effective against ‘negative symptoms’ like apathy or withdrawal.

Psychotherapy

Cognitive Behavioral Therapy (CBT) has shown promise in treating the symptoms and improving the quality of life for people with schizophrenia.

Psychosocial Interventions

Programs focusing on vocational and social rehabilitation can significantly improve outcomes, enabling patients to lead more normal lives.

Recovery: A More Realistic Objective

The term “recovery” in the context of schizophrenia is often defined differently than a “cure.” Recovery is a multidimensional concept involving symptom reduction, improved social and vocational functioning, and a higher quality of life.

Remission

A significant proportion of individuals experience periods of remission, where symptoms are minimal or absent. However, remission is not the same as a cure, as symptoms can recur.

Resilience and Coping

Treatment enables many patients to build resilience and coping strategies that allow them to function better, even if they continue to experience some level of symptoms.

Conclusion

While schizophrenia may not be curable in the conventional sense, it is essential to highlight that treatment can allow for substantial recovery. With effective medication, psychotherapy, and psychosocial interventions, many individuals with schizophrenia can lead meaningful, fulfilling lives.

References

Sullivan, P. F., Kendler, K. S., & Neale, M. C. (2003). Schizophrenia as a complex trait: evidence from a meta-analysis of twin studies. Archives of General Psychiatry, 60(12), 1187–1192.

Howes, O. D., & Kapur, S. (2009). The dopamine hypothesis of schizophrenia: version III—the final common pathway. Schizophrenia Bulletin, 35(3), 549–562.

Shenton, M. E., Dickey, C. C., Frumin, M., & McCarley, R. W. (2001). A review of MRI findings in schizophrenia. Schizophrenia Research, 49(1-2), 1–52.

Leucht, S., Cipriani, A., Spineli, L., Mavridis, D., Orey, D., Richter, F., … & Davis, J. M. (2013). Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis. The Lancet, 382(9896), 951–962.

Zimmermann, G., Favrod, J., Trieu, V. H., & Pomini, V. (2005). The effect of cognitive behavioural treatment on the positive symptoms of schizophrenia spectrum disorders: a meta-analysis. Schizophrenia Research, 77(1), 1-9.

Bellack, A. S., Mueser, K. T., Gingerich, S., & Agresta, J. (2004). Social skills training for schizophrenia: A step-by-step guide. Guilford Press.

Liberman, R. P., & Kopelowicz, A. (2005). Recovery from schizophrenia: A concept in search of research. Psychiatric Services, 56(6), 735-742.

Andreasen, N. C., Carpenter Jr, W. T., Kane, J. M., Lasser, R. A., Marder, S. R., & Weinberger, D. R. (2005). Remission in schizophrenia: proposed criteria and rationale for consensus. American Journal of Psychiatry, 162(3), 441-449.

Galderisi, S., Rossi, A., Rocca, P., Bertolino, A., Mucci, A., Bucci, P., … & Maj, M. (2014). The influence of illness-related variables, personal resources and context-related factors on real-life functioning of people with schizophrenia. World Psychiatry, 13(3), 275-287.

Stress in Children and Youths

September 30, 2023 By Dr Lim Boon Leng

During this season of PSLE and national exams, it’s crucial to recognize stress factors in children and youth and offer them support. In this article, we’ll highlight some typical reasons for stress and explore ways to assist our children and youths.

1) What are some of the most common causes of stress in children these days?

Children often experience stress from schoolwork, peer bullying, parental discord, and over-scheduling with extracurricular activities.

2) Are certain types of children more susceptible to stress than others?

It is possible that children who experience ongoing abuse or chronic stress, lack stable family structures or support, and have mental health conditions such as Attention Deficit Hyperactive Disorder or Autistic Spectrum Disorder may be more vulnerable to stress compared to their peers.

3) How can you tell if your kid is stressed? What are the most common symptoms to look for?

It can be difficult for children to express that they are feeling stressed. When experiencing stress, a child may display increased resistance towards completing tasks, become easily anxious, cry more frequently, and exhibit more tantrums. Additionally, they may struggle with falling asleep, have a decreased appetite, appear lethargic, and complain of physical ailments such as headaches or stomachaches.

4) What are the best ways to approach the subject of stress with your children? How do you bring it up to them, especially if they’re tweens or teens and don’t like to share their feelings?

It’s important to recognize that children can experience stress and may become overwhelmed. It shouldn’t be a taboo topic to discuss stress within the family. From a young age, encouraging conversations about stress and ways to cope can be beneficial, rather than dismissing it and expecting the child to tough it out without complaint.

Many tweens and teens may not want to talk to their parents because they feel misunderstood or ignored. Building a respectful relationship with your child and becoming a friend to them can help them feel comfortable coming to you during times of stress. Listening empathetically is key; offering advice from your own experiences or anecdotes can be helpful.

As a parent, it’s important to consider your long-term goals for your child. Do you want them to excel on the next exam or to become a happy and productive adult? By understanding your ultimate objective, setbacks along the way will not seem like permanent failures and will not cause excessive stress. Your child will still be on track for success.

Once you have established your primary goal, it’s crucial to have realistic expectations for your child’s abilities and limitations. You should tailor their schedule and activities accordingly. Some children can handle more demanding schedules, while others may need more time to complete their work. Unrealistic expectations are a major source of stress, while appropriate expectations can be motivating.

Encourage positive values by praising perseverance and placing importance on the process of achieving, rather than solely focusing on results or accomplishments. If your child has done their best, praise their effort instead of stressing over the outcome. This will help them feel good about themselves and maintain a positive outlook.

Adopting good habits, such as getting enough rest, eating a healthy diet, and maintaining a balanced lifestyle with hobbies and enjoyable activities, can help your child stay mentally strong and resilient to stress.

6) Some schools in Singapore have mindfulness programs for their students to help them manage stress. But if you want to teach your kids such concepts at home, how do you go about it?

Engaging in psychological exercises, such as mindfulness training, is similar to physical exercise. Starting at a young age and incorporating them into your child’s routine as a priority can help them develop the necessary discipline to practice them regularly throughout their life.

Numerous apps and online videos exist to guide you and your children in these exercises. It’s recommended to do them together and be a good role model yourself. Attending holiday programs for such exercises can be a great first step in learning them and introducing your child to these practices.

7) How important is a stable family life and good parenting to helping children manage stress?

Having a stable family life and receiving good parenting are crucial for a child’s mental health and resilience when dealing with stress. Parents serve as role models for their children, with their love serving as building blocks for emotional stability and their guidance providing a roadmap to a mature and stable personality. While children can be resilient in the face of mistakes made by parents and other adults, an unstable family environment and toxic parenting, including abuse, can undoubtedly leave a child with low self-esteem, a negative outlook on the world, and an inability to handle life’s stressors.

If you’re looking for valuable insights into student burnout and how parents can identify it, look no further than this informative podcast from 2018. It remains just as relevant today as it was back then, so why not give it a listen?

A Review of Mood-Stabilizing Medications in Pregnancy: Risks, Benefits, and Recommendations

May 17, 2023 By Dr Lim Boon Leng

Bipolar disorder is a chronic condition that requires long-term management, often with mood-stabilizing medications. However, the use of these medications during pregnancy presents a challenge due to the potential risks to the developing fetus.

One such medication, sodium valproate, is associated with a significantly higher risk of neural tube defects (NTDs) and other developmental issues. The baseline risk of NTDs in the general population is approximately 1 in 1000 (0.1%). However, the use of valproate during pregnancy increases this risk significantly, with studies showing that approximately 1 to 2 in 100 babies (1%-2%) born to women taking valproate in pregnancy will have an NTD (Tomson et al., 2018).

Women with bipolar disorder who wish to become pregnant often need to consider alternative medications. Two often-considered alternatives are lamotrigine and lithium.

Lamotrigine (Lamictal)

Lamotrigine has been increasingly used during pregnancy due to its lower teratogenic risk profile compared to other mood stabilizers. However, some studies suggest a small increased risk of oral clefts with lamotrigine exposure in utero. A meta-analysis by Meador et al. (2018) indicated a prevalence rate of oral clefts of 0.27% (27 per 10,000) with lamotrigine use in the first trimester, which is slightly higher than the baseline risk in the general population (about 10 per 10,000).

Despite this small increase, lamotrigine is often considered one of the safer mood-stabilizing drugs for use during pregnancy due to the overall lower risk of major congenital malformations (Meador et al., 2018).

Lithium

Lithium, a first-line treatment for bipolar disorder, is also an option during pregnancy. However, it has been associated with an increased risk of cardiac malformations, specifically Ebstein’s anomaly, a rare heart defect. The baseline risk of Ebstein’s anomaly in the general population is approximately 1 in 20,000 (0.005%) (Medsafe, 2018). Research indicates that lithium exposure during the first trimester may increase this risk to around 1 in 1,000 to 2,000 (0.05%-0.1%) (Medsafe, 2018; Patorno et al., 2017).

While this represents a significant relative increase, the absolute risk remains small. The benefits of lithium, particularly for individuals with a history of severe manic episodes, often outweigh the potential risks.

Antipsychotics

Atypical antipsychotics such as olanzapine, quetiapine, or lurasidone are also considered for use during pregnancy, though their safety profiles are not as well established as those of lamotrigine and lithium (Gentile, 2017).

Efficacy in Treating and Preventing Mania/Hypomania

In addition to the safety profiles of mood stabilizers during pregnancy, it’s also important to consider the efficacy of these medications in managing bipolar disorder and preventing relapses of mania or hypomania.

Sodium Valproate: Valproate is a highly effective mood stabilizer, and it’s particularly potent in treating and preventing manic episodes. However, as previously discussed, its use during pregnancy is associated with significant risks to the fetus, leading many clinicians to avoid its use in women of childbearing age when other effective alternatives are available.

Lamotrigine: Lamotrigine is considered effective in managing bipolar disorder, particularly in the prevention of depressive episodes. Its efficacy in preventing manic episodes is considered less robust than that of lithium or valproate, but it can still be effective, especially in combination with other treatments.

Lithium: Lithium is a first-line treatment for bipolar disorder, and it’s particularly effective at preventing manic relapses. Its use during pregnancy is associated with a small increased risk of cardiac malformations, but for many women, the benefits in terms of mood stabilization may outweigh the risks.

Atypical Antipsychotics: Several atypical antipsychotics, including olanzapine, quetiapine, and lurasidone, have been shown to be effective in treating acute mania and in maintenance treatment to prevent relapse. Their safety profiles during pregnancy are not as well established as those of lamotrigine and lithium, but they can be considered when other treatments are not suitable or effective.

Conclusion

Changing medications should always be done under the close supervision of a psychiatrist, and the patient should be stable on the new medication before attempting to conceive. Additionally, it’s crucial to involve an obstetrician who specializes in high-risk pregnancies. Folic acid supplementation is recommended for all women of childbearing age, but particularly for those on antiepileptic drugs, to reduce the risk of neural tube defects.

While these are general recommendations, each patient’s case is unique and should be managed individually, considering their unique medical history and circumstances.

References

Gentile, S. (2017). Antipsychotic therapy during early and late pregnancy. A systematic review. Schizophrenia bulletin, 43(4), 752-761.

Meador, K. J., Baker, G. A., Browning, N., Clayton-Smith, J., Combs-Cantrell, D. T., Cohen, M., … & Kalayjian, L. A. (2018). Fetal antiepileptic drug exposure and cognitive outcomes at age 6 years (NEAD study): a prospective observational study. The Lancet Neurology, 12(3), 244-252.

Tomson, T., Battino, D., Bonizzoni, E., Craig, J., Lindhout, D., Sabers, A., … & EURAP study group. (2018). Dose-dependent risk of malformations with antiepileptic drugs: an analysis of data from the EURAP epilepsy and pregnancy registry. The Lancet Neurology, 17(6), 530-540.

Medsafe. (2018). Prescriber Update 39(4): 50-56. Retrieved from: https://www.medsafe.govt.nz/profs/PUArticles/December2018/MedicinesUseInPregnancy.htm

Patorno, E., Huybrechts, K. F., Bateman, B. T., Cohen, J. M., Desai, R. J., Mogun, H., … & Hernandez-Diaz, S. (2017). Lithium use in pregnancy and the risk of cardiac malformations. The New England journal of medicine, 376(23), 2245-2254.

Yatham, L. N., Kennedy, S. H., Parikh, S. V., Schaffer, A., Bond, D. J., Frey, B. N., … & Sharma, V. (2018). Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar disorders, 20(2), 97-170.

National Collaborating Centre for Mental Health (UK). (2014). Bipolar disorder: the assessment and management of bipolar disorder in adults, children and young people in primary and secondary care. Leicester (UK): British Psychological Society.

Anxiety vs Anxiety Disorder: When should I seek Help?

March 30, 2023 By Dr Lim Boon Leng

The Difference Between “Anxiety” and Generalised Anxiety Disorder (GAD)

Anxiety is a ubiquitous or common emotion that everyone will feel from time to time. This is a normal human response to stress and when the stressful issue or event is over, the anxiety will go away. Anxiety can be felt i) cognitively, ie worries or fearful thoughts, ii) emotionally, ie nervousness, kan cheong, iii) physically eg heart racing, tremors, butterflies in the tummy.
In normal anxiety, the anxiety is transient, and the individual feels in control. While he or she may be transiently affected, the anxiety is never debilitating and will not cause him or her significant dysfunctions at work or in his or her social life.
Generalised Anxiety Disorder is not just simple anxiety but is a bona fide psychiatric /medical condition. Symptoms of GAD are:
- excessive worry and symptoms of physiological arousal including restlessness, insomnia, and muscle tension.
- The patient must have excessive and difficult to control anxiety about several different events or activities
- In addition to worry, patients must have at least three of the six physiological arousal symptoms:
  - Restlessness or feeling “keyed up” or on edge
  - Being easily fatigued
  - Difficulty concentrating or mind going blank
  - Irritability
  - Muscle tension
  - Sleep disturbance
- In anxiety disorders, removing the stressor or trigger doesn’t always reduce the anxiety.

What is a normal level of anxiety to have? Can anxiety be good for us?
- Anxiety is a normal response to stress, and isn’t always a bad thing.
- Anxiety and stress follow an inverted U model with our functioning or task performance.
- Some anxiety or stress is useful in pushing us into better performance but when there is too much of anxiety, we break down. This is known as the Yerkes-Dodson law.
- However, when anxiety becomes uncontrollable or excessive to the point where it affects our quality of life, an anxiety disorder may have been triggered.

The Difference Between “Anxiety” and Generalised Anxiety Disorder (GAD)

What can cause anxiety? What are the causes of GAD?
- Humans have evolved to react to danger with the fight or flight response and anxiety is part and parcel of the flight response.
- Our mind is constantly looking out for danger as ancient men were hunters and was required to do so to survive. When there is a dangerous situation, men become stressed up and this invokes hormones in our body to be released preparing us to fight or to flight (escape).
- It is of note that the danger can be real or imagined.
- In the modern world while we are not in danger of being attacked or eaten up by a beast, we have associated stress with intense situations in our lives of which we cannot cope with.
- Common stressors in life which induces anxiety are:
  - Stress at work
  - Stress from school
  - Stress in a personal relationship such as marriage
  - Financial stress
  - Stress from global occurrences or political issues
  - Stress from unpredictable or uncertain world events, like a pandemic
  - Stress from an emotional trauma such as the death of a loved one
  - Stress from a serious medical illness
- Like most psychiatric conditions, the causes of GAD are unknown. Today what is largely accepted is that anxiety disorders represent a disruption of monoamine neurotransmitters, namely serotonin, in our brain. It is likely a condition triggered by many factors. Like the Swiss cheese model, when all the holes or factors aligned, severe anxiety which spirals out of control, ie GAD occurs. Risk factors of GAD consist of biological, psychological and social ones and include
  - Genetics or Family history of anxiety
  - Recent or prolonged exposure to stressful situations, including personal or family illnesses and work stress
  - Excessive use of caffeine or tobacco, which can make existing anxiety worse
  - Childhood abuse or bullying
  - Certain health conditions such as thyroid problems or heart arrhythmias

How might both present in my life differently?
- Normal anxiety and anxiety disorders lie on a spectrum and are not categorical.
- Anxiety, symptoms are listed in first question. eg:
  - If you wake up one morning and you know you have a math test later that day, it’s normal to be nervous or anxious about the test.
  - Your heart might pound, and your stomach might churn, and you might be thinking a lot about the test and your possible result. Once the test is over, you’re likely more relaxed, and physically back to normal.
  - Then anxiety is transient and although a nuisance, it does not affect your usual functioning significantly.
- GAD
  - You have been worried excessively about a myriad of issues for the last six months. For example you may worry about losing your job, getting infected with COVID-19 or your children failing their exams.
  - You feel nervous and tensed in the day and you find it harder and harder to control the anxiety and worries.
  - You find it hard to fall asleep at night and have been easily tired.
  - You have been getting more irritable and would lose your temper at your children.
  - Your anxiety has also made it hard for you to make work decisions and you cannot concentrate on your work.
  - (Symptoms of GAD are listed above)

Getting Your Anxiety Better: Tips and Treatment

What are some ways to lower levels of anxiety?
- Having time away from the stressful environment or event is the best way. Unfortunately, stress is everywhere in our small yet competitive island.
- Adequate rest and sleep on a day-to-day basis, and in doing so allow our body and mind to take a break from the stress of the day is of utmost importance.
- It is also important to have hobbies and exercise to take our mind off stress and the anxiety.
- Limit the use of caffeine and cigarettes.
- Cognitively, it is important to moderate our excessive high expectations and need of control. We often quote the serenity prayer: “to accept the things I cannot change, courage to change the things I can, and wisdom to know the difference”

What are the treatments for GAD?
- Medication treatment include using serotonin reuptake inhibitors (like fluoxetine, sertraline, venlafaxine, etc) These help to enhance the serotonin in our synapse which helps the brain to recover from an anxiety disorder. We can use anxiolytic medications like lorazepam or alprazolam in the short term judiciously to provide for immediate relief for severe anxiety.
- Psychological interventions like Cognitive Behavioural Therapy and Mindfulness Therapy are very effective in the treatment of GAD.
- Social interventions can include providing some rest from work in the form of medical leave or asking for a lower workload for the afflicted individual. Beefing and garnering support from patient’s family and loved ones can help improve things.

Anxiety and Anxiety Disorder in Singapore

The Singapore Mental Health Survey 2016 showed an increase in the prevalence of GAD, from 0.9% in 2010 to 1.6% in 2016:

What could be some reasons for this increase?
- In Asian cultures, anxiety is often manifested as poor sleep and physical ailments such as headaches and stomachs, and much less as feelings of anxiety. The increase may signify a shift towards a more Western recognition and presentation of our emotions.
- Anxiety Disorders can often be misconstrued. Many relate abnormal anxiety only to being confronted with huge problems in life, and may feel that they cannot be having an Anxiety Disorder since life is good. However, GAD is essentially overblown worries or anxiety feelings, and it is exactly because you have nothing to worry about and yet you are worried which defines it as a disorder. As such, an improvement in mental health literacy and a better understanding of Anxiety Disorder from public mental health education may have helped more identify that they have an anxiety problem.
- There may be less stigmatization about mental health issues and responders to the survey may have been more likely to answer truthfully.
- The survery in 2016 showed that the increase in the prevalence of GAD in Singapore was observed only in the youngest age group of 18–34 years and not among those of the older age. There are some suspicion that the proliferation of social media and unhealthy social media use habits can be related to the increase in prevalence of GAD, given that many studies have pointed to correlation between social media use and adverse mental health outcomes.

Have Singaporeans become more anxious in the last 10-12 years? What’s the expert take on this?
- Yes, there has been a trend. We do not have actual data but there are some observable trends in people seeking help in my practice. Anxiety towards exams and schoolwork appears to have been increasing as reflected on people enquiring for help for themselves or their children. The number of people seeking help as they are anxious and cannot cope at and around periods where there are major exams have observably increased.
- More people have stepped forward to seek help with regards to their anxiety which often are exacerbated by job stress have also increased. This is encouraging as many are picked up by work place programmes and encouraged by their workplace to seek help. Traditionally, men tends to only seek help when their anxiety are severe but have been doing so in the earlier stages of anxiety disorders in recent years.

ADHD: Are There Alternatives to Stimulant Treatment?

March 16, 2023 By Dr Lim Boon Leng

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterized by symptoms of inattention, impulsivity, and hyperactivity. Evidence-based medication treatment for ADHD in children and adults are as follows:

For children:

Stimulant medications such as methylphenidate and amphetamine are the most commonly used medications for ADHD in children. These medications help improve attention, reduce hyperactivity, and decrease impulsivity.

For adults:

Similar to children, stimulant medications are also used to treat ADHD in adults. In addition, non-stimulant medications such as atomoxetine and guanfacine can also be effective.

When Men Cry: Understanding Common Psychopathology in Men.

March 12, 2023 By Dr Lim Boon Leng

1) What are the most common mental health issues affecting men, and do you have statistics for the percentage of Singaporean men who are affected by these issues?

Common mental health issues for men include Depression, Generalised Anxiety Disorders (GAD), Obsessive Compulsive Disorders (OCD) and Alcohol Use Disorder.

Overall about one in 16 men will experience at least one of this condition in his lifetime.
The lifetime prevalence of depression in men is 4.3%.
The lifetime prevalence of GAD is 1.6%.
That of OCD is 3.6%.
That of alcohol use disorder is 4.1%.

2) What causes these mental health issues?

The actual causes are not known but these mental health issues are related to genetics, childhood trauma, environmental stress, negative personality resulting in negative outlooks, and use of substances and alcohol. These factors can result in aberrations in the neurotransmitters in our brain resulting in mental illnesses.

3) What are some signs and symptoms of these issues?

Depression is characterised by i) depressed mood nearly every day, ii) loss of interest or pleasure in most activities, iii) significant weight loss or weight gain, iv) poor sleep or over sleeping, v) agitation / irritability / restlessness or feeling slowed down vi) feeling tired easily or loss of energy vii) feeling worthless or having excessive guilt, viii) poor concentration, difficulty thinking or forgetfulness and ix) suicidal thoughts, plans or attempts.

GAD is characterised by i) constantly worrying or obsessing about small or large concerns ii) feeling restless, keyed up or on the edge iii)fatigue and easily getting tired iv) difficulty concentrating or mind “going blank” v) irritability and feeling frustrated vi) Muscle tension or muscle aches and vii) trouble sleeping.

OCD is characterized by obsessive thoughts and compulsive behaviours. Obsessive thoughts are experienced by the individual as intrusive and distressing. Common obsessive thoughts include i) fear of contamination by germs or dirt, ii) intrusive thoughts about symmetry and orderliness and iii) obsessive thoughts of checking things.

As a result of the obsessive thoughts, the individual feels that he has to perform a certain act (compulsive behaviours) to undo the obsessions. These include excessive washing and cleaning and/or checking and counting. The compulsions are often performed in a ritualistic manner over a “magical” number of times.

Alcohol use disorders are unhealthy patterns of use of alcohol resulting in harm including binge drinking and addiction to alcohol.

4) Why do so many men avoid seeking professional help for their mental health issues? What is the stigma surrounding this?

Our society expects a man to be strong and to deal with his own problems himself. As a result, Singaporean men often put up a brave front in the face of adversities. This means that men are less likely to acknowledge their emotional problems and will not seek help if they have psychological difficulties as they are afraid that they may be seen as weak.

Many worry that their employers will come to know that they suffer from psychological illnesses and their careers will be affected. And as men are often expected to be the main breadwinner, they are even more afraid of jeopardizing their job.

5) How can such mental health issues affect men if they’re left untreated or undiagnosed?

Often family members would tell the patient suffering from mental illness to just “get out of it” or to “will it away”.

However, psychiatric illnesses are genuine medical illnesses. One cannot simply will it away and will require help and treatment. If left untreated, mental illness can cause problems in relationships and at work.

When unwell, men can be irritable leading to quarrels with spouse, partner and children. Work can be compromised when they have no motivation. poor concentration or are fixated on the difficulties arising from the symptoms.

To relieve their symptoms, men may turn to alcohol, drugs, pornography and gambling.

Most significantly, we know that men are less likely to express or talk about their symptoms but are very much more likely than women to complete suicide.

6) How can men preserve and protect their mental health on a daily basis? Can you talk about good health habits like stress management, a healthy diet, sleep, exercise, opening up to others, etc?

Start with simple practices like keeping to a good routine. Make sure you have adequate rest, sleep enough, have time for meals and toilet breaks.

Either have long easy walks daily, or more intense exercising three times a week for at least 30 mins if physically permitting.

Once you have the basic routines, ensure you look into me time, hobbies and spending time with your spouse.

These and managing your amount of work and hence work stress will help with stress management.

Particularly important for men, be mindful of alcohol use and not be seduced by substance use to numb yourself.

Don’t be afraid of showing your emotions and in fact crying can be cathartic. Also, don’t be afraid to talk to your loved ones about your difficulties, be it stress with work or your symptoms.

7) Many men feel lonely and isolated – how can they overcome these, especially if they are unmarried, have no close family nearby or live alone?

Being isolated increases the risk of mental illnesses and even suicide.

Even if you are unmarried and have no close family nearby, maintain good friendships and engage with the community. You can participate in volunteering, join an interest group or play group sports regularly.

With social media and video conferencing, you can also keep close to your family via technology.

Having a pet like a dog has been shown to be protective for isolated individuals.

Life can still be fulfilling without anyone with you if you engage in meaningful activities and hobbies.

Social Anxiety, When It is not Just Shyness

November 16, 2018 By Dr Lim Boon Leng

1. What are the signs of social anxiety?

Individuals with social anxiety or social phobia will have serious anxiety when having to interact with others, being observed or when performing in front of others.

Kids will try to avoid these situations and may express themselves by crying, tantrums, clinging to their parents, and inability to speak in social situations. The fear typically last for more than six months. It is a huge suffering for these children.

For adults, they may avoid social interactions particularly in big groups and shy away from presentations or public speaking. These can affect their social life as well as limit their career prospects.

2. How is it different from shyness?

In shyness, the anxiety is not so intense and despite initial mild fear, shy individuals often warm up and are able to interact or to perform.

In social anxiety, the fear is out of proportion and extremely intense. Also, shyness does not disrupt the one’s life significantly while those with social anxiety disorder will not be able to function normally in the social situations they fear.

3. What are some causes?

Causes of social anxiety are unfortunately unknown. It is likely due to a combination of genetic and environmental factors.

In individuals with social anxiety, it is believed that there exist an imbalance in the serotonin (a neurotransmitter) levels in the brain.

Environmental stress and negative experiences like bullying and abuses have to found to be associated with social anxiety.

4. Is it more common now than before?

Social Anxiety Disorder is fairly common. As stigmatisation over mental illnesses have improved, many more people are seeking help early. I do believe that seeking help early prevents the anxiety from seeping into the personality and helps avoid chronic anxiety or anxious personality in adulthood.

5. What are some strategies family members can adopt to help patients cope and overcome their anxiety?

Should a child or an adult be diagnosed with social anxiety disorder, a treatment plan will be initiated by the psychiatrist or psychologist. Treatment may include medication and therapy, and loved ones should assist the patients in complying with the treatment plan.

Parents or spouses should avoid being punitive on the patients, and they can help by staying calm themselves when the patients refuse or avoid certain situations due to their fear or anxiety.

A gradual exposure approach will often be adopted and family members will be enlisted to help with exposing the child slowly and gradually to the feared situation.

A Case Illustration

An nineteen year old girl who has always been shy started to refuse to go to school. She feels she is under the spotlight in situations where they are many people, and worries about being judged. She experiences pounding heartbeat and shortness of breath in these situations and cannot talk. Initially, she was unable to present in front of her classmates and would be quiet during group discussions. Her fears and anxiety became worse and she could not attend school assembly or go for recess. Her condition deteriorated and she started becoming anxious about going to school, and refused to do so.

Her school teachers encouraged the family to seek help with professionals. With a combination of medication form her psychiatrist and therapy from a psychologist, she improved and was able to return to school.

Burnout in Medical Professionals

November 6, 2018 By Dr Lim Boon Leng

What is a burnout? What are its symptoms? Is it considered a mental illness?

“Burnout” was coined in the 70s by psychologist, Herbert Freudenberger. To date there is no scientific definition for burnout. It is general description of loss of interest and motivation towards work, following a long period of excessive stress. The sufferer complains of tiredness and lethargy. He or she may feel unappreciated and may be cynical about work and colleagues.

Read about the differences between Burnout and Depression here.

Why are medical professionals more susceptible to suffering from burnout? What do you think are the factors that cause doctors to feel burnt out?

The nature of the work encountered by medical professionals make them more susceptible to burnout. Diseases go on for 24/7 and do not respect office hours. Medical professionals often have to work long hours, rotate through shifts and attend to patients on weekends. Some may continue to worry about the patients they are in charge of even during after hours. Due to the long hours and shifts, they may not have time with their family and friends, to attend to their hobbies, or to even rest.

Medical professionals also have to face crises, deaths and sicknesses all the time. The emotional aspects of the work can be daunting and draining.

Finally, little is done to address burnout in medical professionals within the fraternity. We are expected to be able to handle long work hours and traumatic experiences even as junior doctors. An inability to cope is seen as a weakness and as such medical professionals are often fearful and unwilling to speak up when stressed up or to seek help.

How could burn out affect doctors as well as their work?

As doctors get burnt out, they will start to feel easily exhausted, and start to lose interest and confidence in their work. They may become easily tired and irritable at work. Some may start having anxiety during the weekend about the start of the work week. They may find it hard to drag themselves out of bed each and every day. When the burnout worsens. these difficulties may spread to their social and family life. They may lose their temper easily with their partners, spouses or children. In extreme cases, an anxiety disorder or clinical depression may ensue.

Can you share more about your experience as a doctor? What were some of the difficulties and challenges you faced that were not so apparent to non medical workers or non-doctors?

Doctors are deemed to be in a privileged position by society. In Singapore, the medical fraternity holds it upon ourselves to have high regards to ethics and to our fiduciary duty to our patients and society. In this regard, being a doctor does not end when we leave the hospital or the clinic as one must continue observing the decorum befitting of the profession. We are also very conscious of this in our work and the obsession over being careful all the time can be very tiring.

The doctor patient relationship can also be a tricky one. The doctor-patient relationship is seen to be sacred by us. We have to be personable and approachable but at the same time maintain a boundary with patients. We have to be mindful that our treatment decisions must at the same time be for the patients’ best interest, uphold social justice and evidenced based. Many a times, a recommended treatment may not be what the patient wants and this can often result in unhappy encounters for both sides. For eg. a patient may feel that he deserve a longer medical leave but his condition does not justify it and doing so will be unfair to his company and his colleagues.

While we may work in a team in hospitals, most of the time, we have to make clinical decisions, some of which are life or death situations, independently on our own. Not all good decisions lead to good outcomes but it is still hard to shake the guilt off when outcomes are negative, even when we tried our best.

Have you or any colleagues suffer from burn out? How did you/they cope with it? How can fellow doctors or their loved ones help them?

it is not uncommon to see colleagues suffer from some form of burn out after which they may leave their job or give up some responsibilities. Personally, while I have not experience overt burn out, I have in the past become rather irritable when I am overworked.

It is therefore important for doctors to be aware that we are not infallible and to also be mindful of our psychological wellness or the lack of. Rest is the most effective remedy for burn out and having proper sleep, exercise and hobbies are important. We should ring fence our time and have a break from work, so that we have time to do so.

Doctors do get together in informal support group to rant and ventilate about work. Talking it out helps a lot. Family members and loved ones can also be emphatic, patient and provide listening ears.

When should medical professionals seek treatment for burn out problems?

Prevention is always better than cure. Having adequate rest and a proper work life balance are essential in preventing burn out and making it possible to sustain our work as doctors.

However, when a medical professional start noticing he is having symptoms of burnout and becoming less effective at work, he should start taking steps to slow down his pace. If he notice that he is starting to have excessive anxiety, prolonged low mood, difficulties with sleep and appetite, inability to discharge his duties as a doctor, or even suicidal thoughts, he should seek treatment.

Sleep – A FAQ

September 28, 2018 By Dr Lim Boon Leng

Do we really need to be making sleep such a priority? Is it really all its cracked up to be?

From scientific studies, we know that our body and mind need an average of about seven to eight hours of sleep. However, sleep is not something we can control but good sleep habits or sleep hygiene is something we can cultivate. Ironically, if we were to put sleep as a priority and harp on it all the time, we then become anxious about sleeping and this may in turn result in difficulties initiating sleep.

What is a piece of sleep research the expert finds to be hugely important, and are there any studies that she or he is sceptical about?

Studies have shown that poor sleep leads to poor quality of life (Evaluation of severe insomnia in the general population: results of a European multinational survey. Chevalier H, et al Journal of Psychopharmacol. 1999;13(4 Suppl 1):S21-4.) and can lead to clinical depression (Am J Epidemiol. 1997 Jul 15;146(2):105-14. Insomnia in young men and subsequent depression. The Johns Hopkins Precursors Study. Chang PP1, Ford DE, Mead LA, Cooper-Patrick L, Klag MJ.)

While I am not skeptical about the studies per se, many studies that showed associations between short sleep duration and increased mortality have been misinterpreted in the media as being conclusive evidences. The research in this area is hardly conclusive and should be interpreted carefully. These media reports, particularly those that went viral on social media, has lead to a hysteria of sorts in individuals who may not sleep up to seven hours or have occasional insomnia, causing them to be anxious and resulting in a self fulfilling prophecy leading to more severe insomnia.

What is the science behind a good night’s sleep and why it is so important?

Sleep plays an important part in both our physical and mental well being. Sleeping is first and foremost the most natural and primitive way of resting which helps the restorative processes for our brains and bodies. Certain hormones in the body are secreted only during sleep and our body reacts to certain hormones differently during sleep. These help with a variety of physiological changes and helps with growth in children, regulation of blood sugar level and keeping our immune system healthy.

We have known for a long time that poor sleep leads to daytime sleepiness and poor concentration leading to poor daytime performance. Later studies shows a relationship between poor sleep and increased risk of obesity, heart disease, high blood pressure, diabetes, and stroke. Poor sleep is also associated with poorer learning abilities, irritation and aggression, and depression.

Why is sleep such a big thing all of a sudden in Singapore – is it just a phase, or is there a reason that you know of behind it?

Sleep has been a big issue all along. Many people afflicted with insomnia have suffered in silence for a long time. However, with information becoming more readily available online and news going viral online, the fact that something we do every night has been neglected and can affect our life in such a big way may come as a huge surprise to many. It is important however to be aware that while we should maintain good sleep hygiene, fretting over sleep will just lead to more anxiety and poorer sleep!

Medications for Anxiety Disorders

September 25, 2018 By Dr Lim Boon Leng

Like Depression, Anxiety Disorders occurs commonly in the general population. Studies have shown that as high as one in six people will suffer from an episode of an Anxiety Disorder once in their lifetime.

Anxiety disorder refers to the following psychiatric conditions:

Generalised Anxiety Disorder (GAD)
Panic Disorder
Post Traumatic Stress Disorder
Social Anxiety
Obsessive Compulsive Disorder
Phobias

Patients suffering from Anxiety Disorders who have been started on antidepressant medications often ask me, “Doctor, you prescribed me antidepressants, am I depressed?”

Antidepressants

Whilst many people who suffer from anxiety may concurrently have depression as well, this is not always the case. Antidepressant medications have a wide spectrum of activity and are effective in the treatment of anxiety, pain disorders, ADHD and other psychiatric disorders. These medications are called antidepressants as they were first developed and used in the treatment of depression. Therefore, having been prescribed an antidepressant does not mean that you are suffering from depression in any way.

The classes of antidepressants include:

1) Selective Serotonin Reuptake Inhibitors, eg. Escitalopram, Setraline, Fluoxetine, etc
2) Serotonin and Noradrenaline Reuptake Inhibitors eg. Duloxetine, Venlafaxine
3) Tricyclics Antidepressants, eg. Amitriptylline, Clomipramine

The type of antidepressants used depends on the type of symptoms you are experiencing, previous use of antidepressants and the side effects profile of these medications. Antidepressants can cause side effects in about 5% of people who taken them. These side effects are short term and reversible. I will discuss them in another article as users are often worried about side effects and they warrant a full article to debunk many of the fears related to them.

It is important to note that antidepressants usually take about one to two weeks to start working and their effects are gradual. As such some use of tranquillisers may be needed in the short term.

Tranquillisers

Minor tranquillisers like benzodiazepines (eg. alprazolam and lorazepam) will help to ease anxiety quickly. However, they can potentially cause dependency issues if abused and have to be given judiciously and mostly only during the start of treatment while we are allowing the antidepressants to take effect. Very low doses of major tranquillisers like Quetiapine and Risperidone may be used sometimes to help manage the anxiety. It is important to remember that the mainstay of treatment is still antidepressants and tranquillisers are for short term use.

Safety of Medications

From extensive research and experience, the medications used in anxiety disorders are safe when used as directed. Side effects are short lived and at best troublesome.

Other Treatments

Various forms of therapy are also useful with Anxiety Disorders. They can be considered as first line when the anxiety is mild or they can be used in conjunction with medications. Some patients do find it hard to initiate therapy and to follow through with the home work of challenging their negative thoughts when they are anxious and may need a period of stabilisation with medication before therapy can be commenced.

Duration of Treatment

Many worry that they will need to take medications forever once started. This is a misconception. Many people with anxiety disorder suffers only one episode. The medications will ease the symptoms and with time (depending on their condition) they will come off medications. However, if you have had many episodes of anxiety disorders, if may be beneficial for you to stay on medications on a longer term.