Category Archives: Anxiety Disorder

Anxiety VS Depression

A brief update:

Hui Bee is away for replenishment from 29th Aug to 3rd Oct. When she is back, she will again be very busy preparing for the Stage II of CBH diploma course in BeiJing. After 3 years of regular updates, huibee.com is likely to be quiet for a couple of months. But she promises that she will definitely be back here. 

焦虑 (Anxiety) 和抑郁 (Depression) 的特点

焦虑和抑郁的不同

焦虑和抑郁的相似处

又是我早年制作的表,分辨焦虑和抑郁的相同和不同之处。这只是简略概括来说,每个人的情况症状都不同,绝对不能作为诊断用途。

Trichotillomania

She started picking hair since standard 5 in primary school, and the problems got worse over the years, especially when she was under pressure. She had seen a few counsellors, also skin specialist, and was given injection on the scalp and prescribed medicine. Finally her parents decided to take her to consult psychiatrist, and within two months she got better with some SSRIs and anti-anxiety drugs. She then stopped taking the medicine. Her hair was growing again.

Few days ago the mother called up, saying her problem is back. When she was sweeping her room, she could see hair all over her bed, pillows and on the floor. The mother asked if we could provide phone counselling to help her (without using medication, as it was causing drowsiness).

This kind of request is not untypical here. Asian people (including myself) tend not to take so much western medicine, and avoid it as much as possible. I can understand that. But the girl’s trichotillomania (hair pulling) problem has a biological components.

Most mental or psychiatric illnesses have a biological component, whether it’s depression, anxiety, OCD, psychosis (obvious!) etc. Sometimes it depends on the type of illness, sometimes on the individual, sometimes it depends on which episode (which means for the same individual, she could have a biological trigger last year but this time it’s a pure psychological triggered episode), sometimes it’s a mix of both. For a person who suffers from very bad OCD, medication can probably reduce his symptoms of 30-50%, but still leaving symptoms that would still interfere with his life, so for this part he would need psychological interventions.

So I explained to the mother that she needs medication, pure counselling may relieve her symptoms to an extend, but not all of it. Because when something is wrong biologically, she would need medication to help her, whereas psychological interventions can help her to reduce her anxiety and stress, and to learn to cope with stress, mood swing, etc.

The best treatment for her would be both medication and psychological interventions, and a good combination is in fact the best and most effective treatment for a lot of people and for many mental illness and psychological problems, unfortunately nowadays this is not the kind of service provided anywhere.


拔毛癖

她从小学五年级开始拔头发,多年来问题一直恶化,特别是面对很大压力的时候。她看过几个辅导师,也见过皮肤专科,并接受头皮注射和处方药。最后,她的父母决定带她去咨询精神科医生,吃了一些SSRIs(抗抑郁)和抗焦虑药,在两个月内情况就好转了。然后她就自行停止服药,头发也慢慢长出来了。

前几天,母亲打了个电话来诊所,说她的问题又回来了。当她帮女儿打扫房间的时候,看见床上,枕头,地板上都有头发。母亲问我们是否可以提供电话咨询辅导服务来帮助她(不使用药物,因为药物使她很疲累)。

这种要求在这里绝对不是非典型的(意即典型!)。亚洲人(包括我)普遍不爱吃西药,能免则免。这点我可以理解。但这女生的拔毛癖不是简单的心理问题,她的起因含有生物因素。

大多心理和精神疾病的起因都有生物成分,无论是抑郁症,焦虑症,强迫症,精神病(显然!)等。有时它取决于疾病的类型,有时针对个人,有时取决于哪次病发(就算是同一个人,她去年发病可能是因为生物因素,但这次却是心理引起的),更多时候是两者混合。对于严重的强迫症病患,药物也许可以减轻他的症状的30-50%,但剩余的症状仍然会干扰他的生活,所以对于这部分,他需要心理治疗。

于是我向她母亲解释她需要来见医生和吃药,单纯辅导或心理治疗可以缓解她部分的症状,但不是全部。因为当头脑里的传输物质出错了,她需要药物来帮助她,而心理治疗可以减轻她的焦虑和压力,并学会应对压力和生活的变动,情绪波动等。

最好的治疗方法是结合药物+心理治疗,其实对于很多人和大部分精神疾病,结合治疗都是最好最有效的方法,可惜在现今这却不是多少地方找得到的服务。

The more you worry about having to take medicine, the more you need to take them

Yes, and that’s all the point I want to make in this post.

Recently I spoke to a woman in her late 50s who has problem sleeping. She has been a patient since 15 years ago, but was never regular with medicination.

She has used all possible means to make herself sleep, taking wine, using chinese herbs, exercise etc. She just doesn’t want to depend on medicines. But she always comes back to see doctor and collect medicine when all other methods fail and she really needs some sleep.

So yes, she came back again last week. And since that visit she has called up the clinic several times. Every time asking about

  • When can I stop taking these medicine?
  • Can I start to reduce them now?
  • Will they harm my body?
  • What are the side effects and possible side effects?
  • What’s going to happen in long-term taking these tablets?

These are just some examples, under one topic/question she can ask in so many different ways and for so many times. (Eh? OCD?!)

At the end everyone couldn’t stand answering her questions repeatedly. So I’ve got the job. I told her that through our experience with many patients with either anxiety-related problems or with insomnia, the more she worries about needing to take medicine, the more she has to take it, it’s always like that. I asked her what has the focus of life becomes now?

All kind of worries about taking medicine.

The medicine is not likely to help her much if she continues to worry this way. So she won’t get well, so she’ll have to continue taking them. So she will continue to worry about taking them… … See the vicious cycle here?

So I asked her back why not continue with medicine, but shift her focus of life in something more meaningful, to how to live more healthily and happily? How about developing new interests, learning yoga, going swimming, forming new social relationships, improving familial relationship etc etc.

When she’s able to shift the focus and live more meaningfully and healthily, she may not even need the medicine without herself realising that.

 


越是担心吃药, 越是需要吃药?

当这过去十几年来一向难入眠的女士, 用尽方法却还是不能好好睡一觉, 她就会回来看医生, 通常每一两年至少来一次. 而这次拿了药回去后, 就开始不断地”电话轰炸”诊所, 问什么时候可以停药? 现在就停可以吗? 停了马上复发吗? 这些药有什么副作用? 对身体有什么害处? 一定要吃这些要吗? 等等等等. 每两到三天就来一通电话.

详细解释许多次后, 她却不见得可以明白. 下次打来, 还是问回这些问题.

所以我告诉她, 经验告诉我们, “越是担心吃药的人, 越是需要吃药, 往往也得吃得越久” 想想这么个担心忧虑法, 你的生活中心全是什么? 生活还剩下些什么?

本来吃药可能很快有效, 但是你这么一直担心, 东想西想, 日想夜想, 人可能反而更不舒服更忧虑, 结果要吃更多药, 然后又更担心忧虑, …恶性循环, 对吗?

何不就相信医生, 继续吃药, 同时好好地, 健康地生活, 培养新的兴趣, 做些运动, 建立社交生活, 改善与家人的关系等等, 在这情况些, 也许不知不觉中已经不需要再依赖药物了.

A doctor who can’t doctor

A doctor (noun, a person), who can’t doctor (verb, to treat).

She’s on her 4th year of medical degree when she first came to the clinic with her parents. Once treated for OCD many years ago, she had recovered from it with some medication and never had any problem causing much distress since then.

She is brilliant academically since young, doing so well on most of the papers in the uni now. Now it’s towards the end of her medical degree, the problem rises.

The parents found that she’s always studying, doing revisions – but she’s already done so well and that’s not even the most important things to do now, as they should start with practices, attending to patients on the wards. She slowly disclosed that she is very afraid of meeting people, especially seeing patients. Her mind is occupied with herself misdiagnosing patients and failing to treat patients. So she wants to revise more, learn more about the theories (a good example of safety seeking behaviours – doing something to relieve her fear in the short-term, but in long-term what she does further reinforce what she couldn’t do – seeing patients).

The parents aren’t quite sure what to do. They don’t care if their daughter can never become a doctor, it’s not important, as long as she’s happy. But now her fear is killing her confidence, and they’re still hoping that she can at least complete the degree (and plan what to do subsequently, e.g. teaching, doing research etc). She doesn’t seem to be able to cope to complete her degree.

The parents can give her a gap year, “but the more she rests, does it mean the harder she can ever practice again?”.

“We can push her. But we don’t want her to think we’re forcing her then start to avoid us or lose trust in us.”

The parents were advised that what’s most important now is not whether or not she can become a doctor, whether she can graduate, but whether she can conquer the fear, have the courage and go for her practices despite the obsessional thoughts that she may fail. (Something that Acceptance and Commitment therapy could do, I’m kind of interested to know whether ACT can do better than CBT in this case.)

It is definitely not going to be easy, in fact it could be a long journey till she can manage that, but everything that can make that possible should be done.

Learn about this man’s obsession

WARNING: You may not want to read this while you’re eating.

At first it seems a bit difficult to diagnose what problem he has, other than not being able to sleep well for the past year.

He’s working in KL on his own while all his family are in Penang. He has one daughter and one son, both married with children. He said that he’s in good contact with all the family members, and he goes back to see them often, sometimes they would also come to see him. He is cheerful, and seems very sociable.

Apart from his sleeping problems (the reason he came to our clinic), he also kept mentioning that he has constipation. We’d have thought that this is not directly related to mental health problems, but he said he has had check up, test and scans, and was told that he’s absolutely fine. So why constipation?

When he started to talk about his problems in passing faeces in details, the answer slowly revealed. He said people should at least pass 1 kilogram of faeces every day, not anything less than that, “this morning I passed only 200 grams, that is not good enough, and that would keep me worried all day” (Please don’t ask me how he measures that, I hope he’s just checking his own weight before and after the business. And by the way, how does 1 kg of faeces look?). He does everything he can to improve his bowel movements, but still, he thinks he has constipation.

And it’s kind of difficult for him to have insight about his obsessions. Now he’s being treated for his insomnia, and secretly and hopefully, also for his OCD.

Though we have come across and read about all kind of obsessions, this is still quite distinct and… peculiar.

Placebo effects in psychiatric drugs?

I understand a lot of anti-depressants, anti-anxiety and anti-psychotic drugs that we’re using today have had quite a long history, we’re talking about a few ten years. But is it possible, that what works in some of them, is not the active ingredients in it, but the fact that it’s prescribed and taken, and patient’s belief in the pill(s), so the patient feels better? (If this definition is not clear enough for what placebo effect is, please check google here.)

Recently we have this typical anti-psychotic drugs ran out in the whole of country (i.e. nowhere you can find this drug, unless some expired ones in an old patient’s drawer). So having no choice the psychiatrist has had to replace it with other drugs, drug A, a stimulant that works the same but will be more stimulating (so patients can’t take it at night to avoid sleep disturbances) or drug B, another anti-psychotic that’s more sedative (suitable for patients to take at night).

Most of the patients are fine after the replacement of this old anti-psychotic drug, whether it’s with drug A or B, some with other medicine more applicable and appropriate for their current situations. Except two patients.

They both claimed that after replacing the medicine, they find it difficult to fall asleep (a common symptoms of anxious people: difficulty getting into sleep). When we tried to explain that the old drug is non-sedative (not assisting you to sleep) but also non-stimulating (not making you more awake/alert), and that 95% other patients who’ve had the medicine replaced found no problems, these two patients insisted that they need this old anti-psychotic drug to sleep.

In fact for one of the patients, the psychiatrist has come to realize that she’s no longer present with agitation or any psychotic-related symptoms, and so has replaced it with a tranquiliser, which should in fact be sedative and make her sleep better, as compared to the old anti-psychotic drug. But still, she struggled.

As a psychologist, I’d always observed and noticed the psychological effects of psychiatric drugs. How’d you explain this? Can we start to prescribe some placebo to help patients to sleep better?