Category Archives: Treatment Approaches

Neutral Pure-O

Most people know that Exposure Response Prevention (ERP) is the main intervention used for Obsessive Compulsive Disorder (OCD). So the rationale is pretty simple here, say we have a patient who is afraid of contamination (obsession) and wash his hands excessively (compulsion), we do some preparation work and can then start the ERP by exposing him to dirt without letting him to wash his hands (response prevention). This is normally done on a very gradual manner (with the patient’s consent and enough preparation work beforehand, so it is definitely not forcefully done to him). And of course in reality the OCD cases are barely as straightforward and simple as this, but this is the general principle.

With pure obsession, i.e. those without any compulsive behaviour, it’s all in their minds, things can get a bit harder, but still, it’s possible. Some commonly seen pure-O are (1) relationship obsessions (discussed in my blog else where as “morbid jealousy” which might or might not be the same condition), (2) sexual obsessions, (3) religious obsessions, (4) violent obsessions, (5) neutral obsessions.

So let’s take a recently seen man as an example here. It started once when he drove past a church, and somehow a sexual related thought popped out in his mind, he couldn’t bear himself having such “dirty” thought in a holy place, and since then, whenever he goes passed any holy places, he will suppress his mind from coming out with any “dirty thoughts”. And as we all know that our minds don’t work this way, the more you try to push some thoughts away, the more they bounce back and pop up.

ERP is possible for such pure-O cases. After the initial preparation work including psychoeducation, motivation building and mindfulness training, they are exposed to those thoughts that they have been avoiding, in those places (based on the items in the hierarchy). So it works similarly for all different types of pure obsessions, be it relationship, violent, religious or sexual (in certain cases where direct exposure is not possible, it will have to be done in imagination, and by watching videos etc).

However, how about neutral obsessions? What the patient has could be some really simple, random thoughts, which might be inconsistent, but they might be spending hours and hours thinking about these random stuff. Like a young man I saw couple months ago, who reacts to any thought his mind comes up with, e.g. “why does the universe work this way?”, “how do my ears listen and my brain comprehend what others say?” etc. I couldn’t really carry out typical ERP to him, since those are really random topics and they can be completely different every time. So I needed him to start thought defusion exercises, mindfulness meditation (then he dropped out…). I believe this is the best way for neutral pure-O, though I understand how difficult it’s to increase their motivation to keep practicing until they see the effects (did have patients in the past who were surprised by how quiet their minds can be after such exercises – and this is just a bonus, as it’s not the intention or purpose of such practices).

Do enlighten me if you have better psychological intervention for neutral pure-O. And I hope all the OCD sufferers out there will not give in to the illness!

CBT & Bipolar Disorder

認知行為療法 (CBT) 如何幫助躁鬱症(雙極症, bipolar disorder)?




  1. 接受“躁鬱症”這個診斷。首先第一步就是明白和理解這個可以對你的症狀做出解釋的疾病。對很多躁鬱症患者來說,這往往很難接受,所以讓他們學會關於躁鬱症的信號、症狀、起因、病程等是很重要的。這讓患者能去尋求幫助,而且也知道他們其實並不孤單。
  2. 監控情緒。這通常是用工作表或日記來紀錄。目的在於更加能夠覺察情緒的導引和改變。
  3. 進行認知重建。這過程專注于通過學習如何更好的識別想法對情緒扮演的角色、如何識別有問題的想法、和如何改變或糾正它們來改變思維的習慣。(有些時候接受該想法,再與想法產生距離化可能比挑戰和改變想法有幫助-似情況而定)。
  4. 頻密進行問題解決。其中的步驟包括如何識別問題,產生可能的解決方案,選擇適合的方案,嘗試它,和評估其結果。問題解決療法可以應用在生活的任何領域,不管是兩性關係、失業、或卡債等。這所有壓力的根源,如果沒有被好好處理解決,都會帶來復發。
  5. 增強社交技巧。有些躁鬱症的患者缺乏社交技巧,這讓他們覺得自己沒辦法控制生活的其中一些部份。學習自信心訓練等技術能幫助處理與他人的關係。
  6. 穩定日常節奏。給生活建立一個規律的日常活動和節奏,這有助于穩定情緒。


Non-blind Placebo

Placebo is sometimes called a sugar pill, indicating that it is medically ineffectual, yet a person given such ineffectual treatment will often have an actual improvement in their condition. 

One key thing with the use of placebo, is that it involves deceiving the person receiving it. For example, before many drugs get into the market, they would surely have to be tested against placebo. And people who are being tested, all would think that they are receiving the drug, though some do not know that they are actually taking a placebo, are serving as the “control group”.

So what’s this “non-blind placebo”? In the 1960s, two researchers published an unusual article “Nonblind Placebo Trial: An exploration of neurotic patients.” Non-blind, i.e. the neurotic patients were told that what they were to take are sugar pills, with no active ingredients in it. Fifteen neurotic participants from a psychiatric clinic were selected, and they each read the following script:

“Mr Doe, at the intake conference we discussed your problems and it was decided to consider further the possibility and the need of treatment for you before we make a final recommendation next week. Meanwhile, we have a week between now and our next appointment, and we would like to do something to give you some relief from your symptoms. Many different kinds of tranquilisers and similar pills have been used for condition such as yours, and many of them have helped. Many people with your kind of condition have also been helped by what are sometimes called ‘sugar pills’, and we feel that so-called sugar pill may help you, too. Do you know what a sugar pill is? A sugar pill is a pill with no medicine in it at all. I think this pill will help you as it has helped so many others. Are you willing to try this pill?” (Park & Covi, 1965)

One of the 15 patients refused to take part. Of the remaining 14 patients, 13 showed signs of significant improvement across different measures. The researchers note that the improvement of 41% found here was greater than the improvement found in previous studies of real drugs, using the same measures.

It might sound ludicrous but this is what has been found. (Definitely have to replicate this study when I get the opportunity). What do you think about this research finding?

It’s all about one’s expectation, this is what I think – what you believe and expect is going to happen. You can be given a sugar pill believing that it will do you good and expecting to get better, or you can be given a world most advanced and expensive pill thinking that it is useless and expecting to get worse. So, no matter what kind of treatment you are receiving, be it drug or psychotherapy or hypnotherapy or counselling, have the belief that you will get better, expect that you will get better – these will definitely help! (Self-fulfilling prophecy!)

What is most important to get better from mental illness?

Sometimes people ask me what I think is the most important “thing” that can help the patient to recover from mental illness. Many would guess it is the patient’s compliance to treatment, support and love from family members, getting help from the right person/place etc. Yes these are all quite important.

But no, I think it’s the patient’s insight to his/her problems, that’s the most important factor.

First you need to be able to recognise that you have a problem. And then you seek help, and then you comply to the treatment, and then maybe your family support you throughout, and then you learn about your illness and how to prevent relapses. Without insight, none of this is possible.

Yes I have mentioned before that for some patients with no insights to their problems, sometimes family members can put medicine into their food/drink. But do you think family member can consistently and successfully put the medicine each and every time? Do you think they can fully recover after a period of time?  Do you think next time they have a relapse the patient can spot the early warning signs themselves? Do you think family members can be there all the time? Do you think about the consequences if and when the patient finds out?

Many people don’t recognise their problem as a problem, and allow it to worsen. It’s a bit like liver cancer, you don’t feel pain, you don’t see any symptoms, by the time it’s discovered, the cancer could have spreaded quite badly. But what we are talking about here is worse than liver cancer, some people with clinical depression don’t recognise it even until the time they jump down from the building and end their lives – they still think it’s their problems that they can’t cope, can’t face and manage adversity in life. They didn’t see that it could be their hormones, their brain circuits, and that maybe they need help (not on adversity in life), on their mood disorder (and perhaps learning some coping skills and become more resilient), and then they can face all the challenges by themselves again.

One’s insight to their problem affects all stages of treatment. Recognising symptoms of hearing voices as mental illness, recognising the need to seek help, recognising the need to be compliant to treatment, recognising how the illness functions, recognising how to prevent relapses, recognising when to see doctor whenever needed.

So sometimes I’ll tell people, it’s good enough that you recognise it as a problem and that you need help. Quite often this is to people with bipolar disorder (don’t recognise the manic phase as problem, as they enjoy it!), morbid jealousy (insist that it’s the partner that’s unfaithful, not their excessive jealousy and suspicion as the problems), schizophrenia (thinking the voices are real, they are not problems to them), depression (genuinely believing that they are useless, they can’t cope, they are stupid etc instead of seeing those as just negative automated thoughts) etc. Don’t worry too much once you have got the insights, there will be people trying to help you along the way. All you need to do first of all, is to reach out, really.

Medicine side effects vs the illness itself – Which is worse?

The illness itself, or the medication side effects – which is worse? Perhaps people who are taking medication can share their experience?

I’d always thought it’s the illness. Of course, it’s something that you don’t get to choose and can’t control. To many people, it just happened, then their lives changed.

So whenever people complained about side effects of medication (e.g. many anti-psychotics cause so much drowsiness that patient can sleep all day; or some antidepressants cause dry mouth, constipation etc), I’d tell them the gains are much greater than the losses, or that you get more advantages than disadvantages out of it. So tolerate with it, and it’s going to fade away anyway  (when patient gets better the dosage can be reduced, or maybe when their body get used to the drug then the side effects diminish!)

Till this morning when I saw this young girl. She was completely disorientated, perplexed, restless, with limited response, almost zero eye contacts and tremor hands when I held her. It’s not possible to hold a brief conversation with her, leave alone doing psychotherapy. I knew it’s a psychosis case, but in my mind i kept wondering why her presentation was like that. It’s hard to believe she was once a happy and easy going girl, doing well in the schools, despite her kind of difficult family background.

Then I recalled what her auntie told me in the emails – the medicine she was taking from the hospital following the first onset and admission couple of weeks ago. Suddenly it became much clearer. I have seen this quite many times, most of them are patients who were already taking medicine when they first came to us. It’s not the presentation of the illness itself. It is the side effects of the medication (you can perhaps email me to ask what drug it is; I think to many people, the answer is obvious) given by the GH.

If this were one of my family members, I wouldn’t want it. I’d rather to have her having difficulty sleeping, some hallucinations and being a bit paranoid – ok, this might be equally bad I can’t deny it. But It’s really difficult. Isn’t it?

What would you choose? Do you have any experience tolerating side effects of medicine that you take?

N.B. Don’t get me wrong, I’m not asking everyone to stop their medication due to the side effects. Most of the time I still think that medication would be beneficial and helpful despite the side effects. However, if you suffer from intolerable side effects (another common one from anti-depressants – sexual dysfunction, ranging from changes in drive, arousal, erectile/orgasm problems, satisfaction), do speak to your consultant, quite often there are substitutes.

Introducing “Listening to Prozac”

By Peter D. Kramer

By Peter D. Kramer MD

Last year I bought this book for RM5 from the Popular RM5 book fiesta (by now you probably have realized that I bought a lot of books there, and yes you’re right, I do spend time to go through those non-fictions and try to pick some treasure!). It is written by an American psychiatrist.

This is really a book that I’d strongly recommend, to … certain people, like me – who know quite a bit about psychopharmacology, but not enough, not much about their history – who have seen how all those drugs are used practically and in day to day life, but not read much about the facts and dark stories behind them. It is an old book I have to say, but I learnt so much about the older generation anti-depressants (tricyclic like Imipramine, Monoamine Oxidase Inhibitors which is not so common these days) and those that I’m so familiar with, i.e. the SSRIs (e.g. Prozac (Fluoxetine)!).

It made me think a lot about how those so-called legal drugs are prescribed, used and misused, how it can change a person from the inside (personality! how they see themselves all their lives simply changed after they started the medicine!), how vague the definitions of psychiatric diagnosis are, how tiny the difference between well and unwell could be etc etc. It may not be a book for everyone, I’m sure some might fall asleep reading it, but it’s probably the first time I’m reading such old book (published in 1993 -before I attended elementary school :P , some updates in early 21st centuries at the back) but still get so astonished and learnt so much!