Are You OK?

Mental Health in Singapore:

Stress and Anxiety
Disorders

Dr Lim Choon Guan

Psychiatrist
Objectives

 Definition of stress
 Signs, Sources and Management of
stress
 Normal emotions

 Anxiety and disorders

 Knowing Stress

LIFEIS INHERENTLY
STRESSFUL
 Stress (in Life)
 Stress is an event that causes a response from the
individual, a situation that causes him to adjust, make
changes to his normal routine. These changes may be
physiological, psychological or social and the individual
may be unaware of them.
 Physiology of Stress
 2 systems
 Nervous System
(Fast)
 Endocrine System
(Delayed)
Stress Response:
General Adaptation Syndrome
 Fight or Flight (Alarm)
 Intense ANS arousal (BP, heart rate, respiration)
 Resistance
 Prolonged state of moderately high arousal
 Resistance saps energy & weakens immune
system
 Exhaustion
 Vulnerability to illness increases
 Physical illnesses become more common
How Do You Measure
Stress?
 Physiological Response
 Heart rate, skin conductance
 Surrogate Measures
 Socialproblems
 Mental health problems
 Suicide rates
 Life event Life change units

Death of a spouse 100

Divorce 73
Imprisonment 63
Death of a close family member 63
Personal injury or illness 53
Marriage 50
Dismissal from work 47
Retirement 45
Pregnancy 40
Sexual difficulties 39
Gain a new family member 39
Change in financial state 38
Death of a close friend 37
Child leaving home 29
Trouble with in-laws 29
Outstanding personal achievement 28
Vacation 13
Christmas 12
Yerkes Dodson Relationship

Yerkes, R.M. & Dodson, J.D.

"The Relationship of Strength of Stimulus to Rapidity of Habit Formation.

Journal of Comparative Neurology and Psychology. 1908, 18, 459-482.

Bad Stress

 Usually situations/events associated

with these characteristics:
 Chronic (long-lasting)
 Out of one’s control
 Intense, e.g. life-threatening, severe
consequences
 Unexpected
Good Stress
 Also called Eustress
 Usually more likely to lead to positive
outcomes
 Earning a good grade
 Graduating
 Working at a new job
 Getting married
 Going on vacation
Stress Responses
Depends on
 Age
 Gender

 Personality factors
 E.g. association between type A
personality and cardiovascular
diseases
 Intelligence
 Environment
Environment
 Relationships
 Home
 School
 Friends

 Physical health
Expectations
Internal

Personal Parental


 Peers External

Societal
Signs of Bad Stress
 Cognitive dysfunction
 Impaired concentration, memory
 Poor judgment/decision making
 Negative emotions
 Hostility (Anger, Irritability, Frustration, etc.)
 Anxiety
 Depression
 Fear
Signs of Bad Stress
 Physical dysfunction
 Immune system dysfunction
 Insomnia
 Cardiovascular system dysfunction
 Pain (Neck Pain Back Pain, Headaches
 Gastrointestinal problems (Ulcers, Irritable bowel)
 Behavioral consequences
 Substance abuse
 Poor work
 Absenteeism
Impact of Stress
 Social impairment
 Family life
 Work life
 Friendships
 Leisure activities
 Distress for the person
 Disruption for others
Stress Management

• Understanding yourself
• Strengths and weaknesses
• Prioritizing
• Time management
• Organization
• Support
• Family, friends, fun, future, faith
• Coping skills
 Coping Skills

 Relaxation
 Building confidence
 Desensitising fears
 Handling worrying
thoughts
 Reward yourself
 Physical conditioning
 Emotions

Emotions are feelings

Young children  Behaviours
Infancy  Generalised distress
 Specific expression
Toddler
 Simple language of
Preschool children
broader emotions
Childhood  More qualitative
differences
Adolescence  Like adults

Cultural differences
Emotional Disorders

 Common
 Females > Males

 Includes Anxiety disorder

and depression
 Anger is not usually
classified as a disorder
Fear
 Is a normal response to threat or stressful
events
 Usually short-lived and controllable
 Functions as ‘Alarm’ mechanism
 Some fears are normal during
development:6 mths: novel stimuli (e.g.
strangers)
 6-8 mths: height, worse when learning to
walk
 3-5 years: animals, dark, monsters
 6-11 years: shameful social situations
 Adolescence: death, failure, social gathering
 Anxiety: fear of future threat
Signs of Anxiety
 Emotional
 irritability or moodiness
 crying
 excessive worrying
 panicky,
 jumpy, feeling on edge
 passive or emotional
withdrawal
 feeling overwhelmed
 Thoughts (Cognition)
 irrational thinking –
jumping to conclusions
 poor decision-making
 forgetfulness
 poor concentration
 negative thinking –
“What’s the use?”
 helplessness and
hopelessness thoughts
 self-blaming – “I’m
useless”
 confused or fuzzy
thinking
Signs of Anxiety
 Physical  Behaviour / Actions
 palpitations  feeling tired & listless
 muscle aches  restlessness
 stomach upsets,  nervous habits
 diarrhoea or  poor eating habits
constipation  drinking more alcohol
 skin rashes  consuming more coffee
 jaw pain, grinding of  smoking more cigarettes
teeth  poor sleep
 dry throat or lump in  falling ill – colds,
throat coughs, infections
 dizziness  sexual problems or
 frequent urination or lowered sex drive
going to toilet  violent outbursts or
 sweating aggressive actions
Singapore Mental Health Study
Dec 2009 – Dec 2010
 6616 Adult Singapore Residents (including
Singapore Citizens and Permanent
Residents) aged 18 years and above

 Lifetime prevalence
 Mental illness: 12.0%
 Depression: 5.8%
 Generalised anxiety disorder: 0.9%
 Obsessive compulsive disorder (OCD): 3.0%
 Alcohol dependence: 0.5%
Anxiety Disorder: Features
 Worries and Fears
 Excessive
 Uncontrollable
 Symptoms include
(1) restlessness or feeling keyed up or on edge
(2) being easily fatigued
(3) difficulty concentrating or mind going blank
(4) Irritability
(5) muscle tension
(6) sleep disturbance (difficulty falling or staying
asleep, or restless unsatisfying sleep)
 Persists over 6 months or more
 Impairs functioning
Types of Anxiety Disorder
Worries and Disorder Age of onset
Fears about:
Separation Separation Anxiety Disorder Early Childhood

Anything and Generalised Anxiety Childhood to early

everything Disorder adulthood

About specific Phobia Early childhood to

situations or objects adolescence

About strange Social Anxiety Disorder Early adolescence

situations or people

No reason (during Panic Disorder 19-30 years

panic attack, worry
about dying)
Senseless fears (eg Obsessive Compulsive Childhood to
contamination) Disorder adolescence
Separation Anxiety Disorder
 Usually in young children
 Symptoms persist over time (e.g. more than 4
weeks)
 Developmentally inappropriate
 Excessive anxiety about separation from home or
from parents/caregivers such as:
 Excessive distress/cries when separated
 Worries about getting lost/kidnapped
 Worries about losing, or possible harm to parents
 School refusal
 May have bodily symptoms such as stomachache
Generalized Anxiety Disorder
 Excessive uncontrollable worry about many
events or activities (e.g. work, school,
health, being late, etc) for at least 6 months

 Hard to control worries

 Feelings of restlessness or on edge,

fatigue, poor concentration or mind going
blank, muscle tension, insomnia etc
Social Anxiety Disorder
(Social Phobia)
 Marked fear or fear about social situation in which
an individual is exposed to possible scrutiny by
others
 E.g. meeting people, being observed (eating,
drinking), speaking or performing in front of others
 Fear of acting in a way that will be humiliating or
embarrassing
 Exposure to the feared social situation provokes
anxiety symptoms, may have avoidance
Specific Phobia
 Marked anxiety or fear about object or
situation, that is excessive and out of proportion
(e.g. insects, height, blood)
 Usually associated with avoidance behaviour
 Anxiety or avoidance interferes with
occupational and or social functioning
significantly
 Panic Disorder
 Recurrent panic attacks with no obvious trigger:
 Discrete period of intense fear with heart
palpitations, sweating, trembling, shortness of
breath and intense fearing of dying, having heart
attack or going crazy
 Persistent worry about future attacks
 Consequent maladaptive or avoidance behaviour
Agoraphobia

 Marked anxiety or fear about using

public transport, open/enclosed
spaces, in crowd or outside alone
 Fear that escape is difficult ot help
unavailable if one has anxiety
symptoms
 May lead to avoidance
 Obsessive-Compulsive
Disorder (OCD)
A) Recurrent Obsessions and/or Compulsions:
Obsessions as defined by:
1) Recurrent and persistent thoughts, urges, or images that
are intrusive, unwanted and cause marked anxiety.
2) They are not simply excessive worries about real-life
problems.
3) The person attempts to ignore or suppress such thoughts
or neutralize them with another thought of action
(compulsion)
Common themes: contamination, symmetry, doubt, sexual
 OCD (Cont.)
Compulsions as defined by:
1) Repetitive behaviors (hand washing, ordering,
checking) or mental acts (counting, repeating words)
that the person feels driven to perform in response
to an obsession
- usually done according to some rigid rules.
2) The behaviors or mental acts are aimed at
preventing distress or some dreaded event but are
not connected in a realistic way or are clearly
excessive.
 Post-Traumatic Stress
Disorder(PTSD)
 Exposure to actual or threatened trauma (death, serious
injury or sexual violence) a traumatic event
 Re-experience through recurrent and intrusive thoughts,
dreams or flashbacks (or feeling as if the event were
recurring)
 Avoidance of cues associated with event and intense
psychological distress at exposure to internal or external cues
that resemble event.
 Increased arousal: easily startling, irritable, insomnia, poor
concentration
 Symptoms persist more than a month after event
Selective Mutism

 Persistent failure to speak in social

situations e.g. school
 Affects educational achievement or
social communication
 Child usually speaks at home

 Usually related to anxiety

 Need to exclude other reasons e.g.

language or learning problem
Treatment of Anxiety Disorders

Psychological
Biological Increasing awareness
Medications Changing behaviours
Improve cognitions and skills
e.g. cognitive-behavioural therapy

Social
Family work and therapy  Individualized
School/ Work  Psychological treatment alone effective

Peers in many cases

 Comorbidity

 Patient motivation

 Therapist motivation
Managing Anxiety
Fear
Realistic Unrealistic

Mild Severe
Deal with
danger Reassurance
Skills Training
Support

Fear Exposure
diminishes
Desensitisation
Flooding
Psychological Therapy
 Relaxation therapy
 Breathing exercises, muscle relaxation
 Exposure therapy
 Exposure to fears until anxiety habituates
 Systematic desensitization
 Relaxation followed by exposure to hierarchy
of fears
 Response prevention
 To reduce compulsions, used together with
exposure therapy for OCD
Medications for Anxiety
Disorder
 2 main groups of drugs
 Antidepressants/Anti-anxiety
medication
• E.g. Selective serotonin reuptake inhibitor
(SSRI)
 Benzodiazepines (‘sleeping tablets’)
• Addictive, so usually used for short period
• Usually for discrete period of severe
anxiety, e.g. panic attack
 References

http://iacapap.org/wp-content/uploads/E.4-
SUICIDE-072012.pdf

http://iacapap.org/wp-content/uploads/F.1-
ANXIETY-DISORDERS-072012.pdf

Samaritans of Singapore webpage

 https://www.sos.org.sg