Anxiety disorders - Cover story
When fear takes over
Most of us worry about one thing or another. That's normal but if it becomes overwhelming, it may be a symptom of an anxiety disorder
By Poon Chian Hui
The human body is hard-wired to respond to fear. The instant a threat is sensed, the brain automatically switches to defence mode.
Adrenaline is released. Breathing speeds up. The heart beats faster. Muscles tighten as the body is poised to either fight or flee.
But things can get tricky when the fear response, commonly known as 'fight or flight', spins out of control.
Irrational fear can morph into anxiety disorders, such as phobia, obsessive-compulsive disorder (OCD) and panic attack.
'People with anxiety disorders always have a premonition that something will go wrong,' said Dr Tommy Tan, a consultant psychiatrist at Tommy Tan Psychiatric Clinic, Novena Medical Center. 'A key feature of this excessive fear is that they overreact to the situation.'
Anxiety disorders are the most common form of mental illness in Singapore, with about 10 per cent of people here affected, statistics from the Health Promotion Board show. They include phobia, OCD, panic disorder, post-traumatic stress disorder and generalised anxiety disorder. However, there are distinct differences.
A phobia is a morbid fear of an object, situation or activity but it usually causes little real danger, said Dr Lim Yun Chin, a psychiatrist at Raffles Hospital.
'Unlike the brief anxiety that most people feel when they give a speech, for example, a phobia is long-lasting and causes intense distress,' he said.
'If a person fears snakes, even a picture of a snake will trigger an intense reaction,' said Dr Tan.
OCD, on the other hand, is where repetitive, fearful thoughts (obsession) lead to a ritualistic action (compulsion), said Dr Adrian Wang, a consultant psychiatrist at Gleneagles Medical Centre.
'It's extreme perfectionism. Sufferers are compelled to do certain things meticulously; that's why they keep repeating an action,' he said.
Otherwise, they start having catastrophic thoughts, said Dr Tan.
'They think that something bad will happen if they fail to do something thoroughly,' he said.
For example, a person obsessed with cleanliness might imagine getting a disease from germs if he were to stop cleaning. He then imagines spreading the illness to his family and friends, and so on.
Interestingly, sufferers are often aware that their thoughts and actions are illogical. They just cannot help themselves, said Dr Tan.
The lack of control is similar in a panic attack, which is a period of sudden, overwhelming anxiety that occurs without warning, resulting in symptoms like rapid heartbeat, perspiration and dizziness.
Panic attacks are often linked to agoraphobia, the fear of open spaces where escape is difficult, said Dr Lim.
A post-traumatic stress disorder is, as its name suggests, caused by an emotional or life-threatening event. The person later has anxiety symptoms like flashbacks. As for generalised anxiety disorder, it refers to a persistent fear or worry over matters like finances. Sufferers tend to incur health problems from the constant tension.
Although phobias may be more common, partly due to the huge range of possibilities - a person can have a specific phobia of anything ranging from snakes to dentists - OCDs may have a greater impact on a person's life, said Dr Wang.
'Many people live with their phobias by simply avoiding the object of fear,' he said. 'For example, a person who fears snakes can avoid going to the zoo.'
An OCD may, however, disrupt one's life to a greater extent. 'While some may be barely bothered, others spend a lot of time on compulsive actions every day,' said Dr Lim.
Dr Tan agrees. 'The illness itself may not be distressing but the consequences often are,' he said. 'I had a patient who was sacked because he spent hours in the toilet and was always late for work.'
There are five types of OCD sufferers: washers, checkers, orderers, hoarders and obsessionals, based on the different obsessions and accompanying compulsions.
While there are no proven causes, anxiety disorders are believed to be caused by a combination of genetics, brain chemistry and life experiences, said Dr Lim.
For example, phobias may stem from a traumatic incident. DrTan recalled a patient whose coach to Malaysia got into an accident. She later developed a serious phobia of taking buses to Malaysia.
In addition, brain imaging studies have shown that OCD sufferers display patterns of brain activity that differ from those without or have other mental illnesses, said Dr Lim.
In general, anxiety disorders are treated with anti-depressant medication and counselling therapy.
A common method of therapy is exposure therapy, where patients are exposed to the source of anxiety in gradual increments. They build tolerance to the point when they are able to overcome the anxiety.
But how can someone tell if he has an anxiety problem?
If something persistently causes distress to you, it would be wise to seek professional advice, said Dr Tan.
Likewise if you are unable to do daily tasks or work properly due to the anxiety, said Dr Wang.
'Most anxiety disorders can be cured,' he said. 'Some may last for a long time but treatment can improve the current situation significantly.'
Otherwise, an anxiety disorder may lead to other problems, such as depression, said Dr Lim.
Anxiety disorders, the most common form of mental illness in Singapore, affects about 10% of people here
10 COMMON PHOBIAS
A phobia is an irrational fear of an object, situation or activity. These are some of the most common:
Acrophobia: Fear of heights.
Agoraphobia: Fear of situations where escape is difficult, such as crowded areas and open spaces.
Aviophobia: Fear of flying.
Carcinophobia: Fear of cancer. Individuals tend to mistake minor symptoms for a sign of cancer.
Claustrophobia: Fear of enclosed or tight spaces.
Haemophobia: Fear of blood.
Mysophobia: Fear of germs.
Social phobia: Fear of social situations.
Trypanophobia: Fear of injections.
Xenophobia: Fear of strangers and foreigners.
How to spot a phobia
You feel an uncontrollable anxiety when faced with the object or situation of fear.
You cannot function normally due to the anxiety.
You feel that you must do whatever you can to avoid your fear.
You know that your fears are exaggerated but you cannot control your feelings.
Sweating, increased heartbeat and fast breathing.
The thought of the feared object is enough to make you feel anxious.
Can't stop washing and checking
When Lisa (not her real name) returns home from crowded places like a hospital, she goes to the bathroom and washes her hands for up to an hour.
At work, while her colleagues go out for lunch, she stays rooted to her desk, checking and rechecking forms, letters, and other documents.
'I feel so frustrated sometimes,' the soft-spoken technician told Mind Your Body. 'People laugh at me because they don't understand my condition. Only my family understands and helps me.'
Lisa is in her early 50s and is single. She has had an obsessive-compulsive disorder (OCD) for over 20 years. OCD is an anxiety disorder characterised by repetitive, fearful thoughts and one or more corresponding compulsive actions.
Lisa has a combination of two OCD traits: washing and checking.
'I will wash myself over the slightest thing,' she said, adding that she spends at least two hours having a bath every morning.
'If I stop halfway or don't wash for a long enough time, I'll feel that I'm still dirty,' she said. 'I think I'm very scared of germs and of contracting a disease.'
Her inclination to check things repeatedly causes her to be slow in her work. For example, she will read a letter several times, even if she had understood it the first time around.
She also feels compelled to check documents many times, matching names and making sure that numbers tally.
'I spend so much time checking that I go home late,' she said.
However, she is perfectly aware that her thoughts and actions are overboard. 'Yes, I know that it's not normal but I simply cannot help myself. I feel that I must do it,' she said.
When she feels stressed, her compulsions get worse.
'I'll wash more and check things for a longer time,' she said.
While she has coped with the disorder for most of her adult life, she began experiencing more stress at work late last year, which worsened her condition significantly. That was when she decided to seek medical help.
'I sensed that I was almost at breaking point,' she said. 'My condition got so bad that I felt I would collapse one day.'
She has been seeing psychiatrist DrTommy Tan at Tommy Tan Psychiatric Clinic, Novena Medical Center, since last November.
Now, she is no longer as tense as before and it is evident from her relaxed voice as she described her experience with OCD for this interview.
While she still washes and checks things, she spends less time doing so.
'The condition has affected my life for so many years, so I'm glad that it's slowly improving,' she said.
5 COMMON TYPES OF OCD
Obsessive-compulsive disorder (OCD) is an anxiety disorder that centres on repetitive, fearful thoughts, termed as an obsession and a ritualistic, compulsive action.
There are five main types of OCD that commonly appear in sufferers, said Dr Lim Yun Chin, a psychiatrist at Raffles Hospital.
A person may suffer from a combination of traits. Dr Lim explains the five categories.
1: Washers and cleaners
Obsession: A constant fear of contamination and being infected with a disease and infecting others.
Compulsion: Sufferer avoids or removes all possible sources of germs and dirt. Washers may repeatedly wash their hands or take showers, while cleaners may clean their house many times a day as well as clean objects, clothes or surfaces repeatedly.
2: Checkers
Obsession: A fear that forgetting to lock or switch something off will cause harm, for which they will be blamed.
Compulsion: Time-consuming rituals that involve checking and re-checking the objects of their obsession - usually locks and switches in the house or office.
3: Orderers
Obsession: To organise or arrange objects in a specific pattern or order before performing a daily task.
Compulsion: Arranging things in a certain 'correct' way. If someone else touches or moves those objects out of place, they will feel extremely upset.
4: Hoarders
Obsession: Excessive fear of discarding certain objects in the belief that they may be of use in the future.
Compulsion: Keeping or collecting items that are often useless. Even if some are useful, hoarders tend to collect so many items that they are unable to finish using all of them.
5: Obsessionals
Obsession: Unwelcome, horrific thoughts, like violent scenes of injuring a loved one.
Compulsion: Mental rituals like repeated counting or repeating words to take their mind off the disturbing thoughts.
Childbirth fear led to abortion
The thought of giving birth can make most women feel anxious. It may incite dread, alarm and even terror.
However, this fear usually subsides when a woman decides that she is ready to have children.
For some, however, the fear is so serious that they develop a phobia, said Dr Helen Chen, the head and senior consultant of Mental Wellness Service at KK Women's and Children's Hospital (KKH).
'It's possibly universal that most women have some degree of anxiety about labour,' said Dr Chen. 'But there are cases where the fear is so morbid and overwhelming, they become constantly preoccupied with the dread of labour and experience high levels of anxiety.'
This abnormal and persistent fear of childbirth is known as tocophobia. Phobia is an anxiety disorder that describes an exaggerated fear of an object, a situation, or an activity.
Tocophobia can lead to tragic consequences in some cases.
Dr Chen recalled a patient who had planned to get pregnant, but when she did, she harboured such an intense terror of childbirth that she aborted her twin foetuses without informing her husband.
While the causes of tocophobia are not known, Dr Chen said that it usually occurs in women who suffer from antenatal depression.
'The other vulnerable group are women who had experienced past sexual trauma,' she said. 'The notion of giving birth is terrifying because it brings back painful memories.'
Women who experience severe morning sickness may also develop the phobia in the later stages of pregnancy. Also, women with an unwanted pregnancy and who later fail to bond with the foetus or to obtain an abortion may dread the impending birth, she said.
However, there are no fixed rules. Some cases simply do not fit into any specific category.
'I had a patient who saw me for her second pregnancy. She had previously given birth naturally without any problems, but was terrified as it had been 10 years since the birth of her first child,' said Dr Chen.
Treatment involves counselling to address the fears of the patient, relaxation therapy to reduce tension and medication.
'For some women with severe symptoms, labour rehearsal can be helpful,' said Dr Chen. 'We'll walk a patient through the delivery suite and explain to her what to expect at each stage of delivery.'
While some patients may request a caesarean section in place of a normal vaginal delivery, it is important to know the risks involved, said Dr Chee Jing Jye, the head of the peripartum unit at KKH.
'We will counsel them on the risks and advise them against having an elective caesarean section in the absence of other valid medical conditions,' he said.
Instead, patients are encouraged to explore other options.
'As most are afraid of the pain, we may advise them on the use of epidural or other forms of analgesia,' said Dr Chee.
He added: 'In my experience, most women are agreeable to normal vaginal delivery after counselling.'
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