Lecture

1: Introduction: mental health

One can never satisfy the definition of ‘healthy’ given that it is too perfect and idealistic. One is
never always at a state of complete physical, social and mental well-being.
DEFINING MENTAL HEALTH/ILLNESS
There are varying levels as to how we can define mental health:
Mentally Healthy is a state of well-being in which the
• individual realizes his/her abilities –
• coping with the normal stresses of life such that
• the person can work productively and fruitfully and
• contribute to the community.
• This is common among the general population.
• Being mentally healthy is more than just an absence of mental illnesses.

Those at risk, tend to be
• children from dysfunctional families,
• individuals with multiple medical conditions, as well as the
• elderly living alone

There are also individuals with minor psychiatric morbidity, such as
• adjustment disorders,
• uncomplicated grief, and
• situational reactions.
• Here, the illness still might be progressing, but it is not visible to people that they have an
illness.

Mentally ill refers collectively to all those who have
• disorders associated with the mind
• i.e. health conditions characterized by problems in their
o thinking (cognitive),
o feelings (mood), and
o actions (behavior) –
• individually / in combination association with distress and/or impaired functioning such as
o Psychosis
o Depression
o Anxiety
o Dementia
o Addiction disorders
o Personality disorders.
• It is a medical problem, often arising from brain chemical changes, where
• Symptoms may change over time.
• This affects not only the patient but also the people around them.

• However, people who are mentally ill are no more violent than any other group but rather
– they tend to be victims of violence themselves, more often than not.
• Also, mental illnesses can affect anyone regardless of intelligence, social class or income
level.
• Neither is it a character flaw – it has nothing to do with being weak/lacking will-power.
 o Even in cases like addiction, it is a misconception that people with substance
abuse problems are morally weak. Addiction is a disease that generally results
from changes in brain chemistry.
• These mental illnesses can affect people of all ages – even children & adolescents – and if
untreated, these problems can get worse.
• However, if treated properly with therapy and/or medication, people with mental
illnesses can live full, enjoyable and productive lives.

For more accurate classification of mental illnesses, practitioners often refer to the Diagnostic and
Statistical Manual of Mental Disorders (DSM 5), among others, which provides an international
standardized definition as to what can be considered as e.g. depression.

CAUSES OF MENTAL ILLNESS
More often than not, the cause of mental health disorders, is a combination of
• the brain,
• the environment, as well as
• the genes.

EFFECTS/CONSEQUENCES OF MENTAL ILLNESS
Mental health problems are costly for the patient & family, taking into account the
• direct cost of services & treatment, the
• indirect cost
o on caregivers – within the family & society – that give up time, employment etc.;
as well as, it being a
o trigger for other physical health problems such as chest infections, or excessive
stress linked to heart disease and cancer etc.
• There is also an opportunity cost on the
o Loss of productivity and employment, where for e.g. employees (at 3 major
American companies) with chronic symptoms of depression were twice as likely
to report missed workdays. However, this also,
o Depends on the frequency of the disease too (esp. when comparing across
diseases)

Estimated figures provided by the WHO has shown that in mental health problems have cost
nations like Canada to lose at least $14.4 billion every year, including $8.1 billion in lost
productivity.













 STATS/TRENDS
Adults Children
According to a WHO Burden of Disease Study in Studies have showed that the prevalence of
2001, mental health problems among school children
• Mental illness contributes to 17% of the have been
combined burden of premature deaths • Emotional disorders such as anxiety &
& living with disability in Singapore. depression (12%), and
• Also, more people die from suicides • Behavioral disorders such as attention
than road accidents every year, deficit hyperactivity disorder (ADHD)
according to the Registry of Births and and oppositional defiant disorder (5%)
Deaths
In this case, the child can be seen to display
A 2010 study on Singapore’s burden of disease certain risk factors i.e. the
by Broad Cause Group indicates mental illness • Overall problems common with the
as having a 7% burden of disease within the o Male gender
country, o Low intellectual ability
o Mothers being single, divorced,
Locally in Singapore, the top 3 mental disorders widowed, deceased.
are • Or having emotional disorders
• Major depressive disorder (1 in 17), common with those of
• Alcohol abuse (1 in 32), and o Male gender
• Obsessive compulsive disorder (1 in 33) o Older age
o Low intellectual ability
However, it can take up to 4-13 years on o Mothers being single, divorced,
average, for a person to seek help. Thus we widowed, deceased
now analyse • Or having behavioral disorders
• What kind of help do they seek, or common with
SHOULD they seek and o Fathers who are less educated
• What prevents them from seeking help o Low intellectual ability
earlier

WHO CAN HELP
Support/care can be provided to people with mental illnesses within a 4-prong strategy involving
• the medical sphere for
o early recognition
o information about illnesses and treatment
o medical care
o psychological support
o hospitalization
• the community sphere for
o the avoidance of stigma & discrimination
o full social participation
o human rights
• the rehabilitation sphere for
o social support
o education
o vocational support
o day care
o long term care
o spiritual needs, and
• the family sphere for
 o skills for care
o family cohesion
o networking with family
o crisis support
o financial support, and
o respite care

Psychiatrists are
• Specialist medical doctors
• Trained to specialize in mental illnesses, with
• Sub-specialties in
o Adults,
o Children & adolescents,
o Elderly (Psycho-geriatrics), as well as
o Specific disorders e.g. addiction
• Psychiatrists can diagnose & prescribe treatment such as therapy and medication.

Psychiatrists tend to follow the medical (disease) model to understand why disorders arise,
where they perform
• Diagnoses first, thereafter implementing
• Treatment which is guided by the diagnosis
Aside from this, there are also other models to consider such as the
• Cognitive model (thinking errors),
• Psychodynamic model (unconscious conflicts) and
• Family based model, which look at reinforcing support within this basic unit of society.

Other than psychiatrists, other allied health professionals can also provide support in other areas.
Psychologists can provide
• Psychological therapy such as cognitive behavioral therapy (CBT), whereas an

Occupational therapist can provide
• Occupational therapy or job training for individuals.

A family therapist can also provide support through
• Family therapy

Basically, in psychiatric practice, care is sought and provided by a multi-disciplinary team for an
all-rounded form of support.













 TREATMENT/CARE
At the mentally-well stage, we begin with the
• Universal promotion of wellbeing & prevention so as to
o Create a supportive environment and
o Nurture personal coping skills.

However, if a person is at risk/approaching minor morbidity, we practice
• Targeted prevention & early intervention, seeking out the individual’s
o Significant life events as well as their
o Income & family status

Once a person is identified as mentally ill, we then start
• Standard treatment and
• Continuing care for the patient.

Only when he/she has stabilized to a state of minor morbidity/at risk, will we practice
• Target reintegration & relapse prevention

When the individual is back to a stage of being mentally well, we then implement
• Universal prevention & destigmatisation

Treatment often requires a combination of psychotherapy, medication and socio-occupational
intervention implemented by the multi-disciplinary mental health team comprising
• Psychiatrists
• Nurses
• Psychologists
• Medical social workers
• Occupational therapists
• Art therapists
• Physiotherapists

To counter the direct costs of treatment, Singapore has in place a Chronic Disease Management
Programme (CDMP) involving the
• 3 M’s of medical bill payment, namely
o Medishield Life
o Medisave, and
o Medifund
According to the CDMP, Medisave can now be used for outpatient bill payment for
• 19 medical conditions of which comprises: schizophrenia, depression, bipolar disorder,
dementia, anxiety etc.

Lecture 2: The Family

DEFINITION OF FAMILY
As per the UN, the family is the natural & fundamental group unit of society & is entitled to legal
protection (of rights entitled) by society & the State.

A family is commonly defined as a group consisting of 2 parents and their children living together
as unit. However, this is not a good definition as there are many types of families, such as
• nuclear family (parents + biological children)
• extended family (inclusive of grandparents + blood relatives living together)
• reconstituted/reformed family (remarried parent i.e. not blood parents + members w/o
blood relationship)
• single parent family
• adopted family (child being brought into a family – no blood relation to parents/relative)
• intermarriage family (relative marrying relative – happens within certain cultures à
dangerous as recessive genes may aggregate, causing serious diseases)
• maid in the family

Singapore’s family values
• are pro-family,
• however, they tend to still hold a conservative perspective.
Raising the issue on whether families should
• make children aware or
• protect them from alternative views.
• A case at hand, is the NLB children books promoting homosexual values getting moved to
the adult section.

FAMILY LIFE CYCLE
Each family goes through a life cycle – where at each stage the family goes through different
challenges. The various stages are
• Single adult
• Married couple
o Child bearing family
• Family with preschool children à school children à teenagers
o Home leaving adults
o Middle aged parents
§ Aging family members
MARRIED COUPLE
Happily married couples tend to enjoy better mental & physical health
• Marriage improves healthy lifestyles – one cuts down on unhealthy lifestyles to
accommodate one’s partners
• Healthy people also tend to get married, plus stay married – as on the flipside, unhealthy
individuals have a lower likelihood of finding a mate.

In Singapore, the
• general marriage rate is seeing a declining trend.
• As for the age-specific marriage rate,
o Males tend to get married later, in their somewhat mid 30s, while
 o Women tend to get married around their late 20s – 30s due to their innate
biological clock: fertility. Women who give birth at an older age have a higher risk
of babies with down syndrome.

People get married often for the purposes of
• Reproduction
• Companionship
• Sex
• As a means of escape from poverty/unpleasant circumstances (of which is very common
amongst foreign brides in Singapore)
• Forced marriages – usually for more conservative cultures or perhaps financial purposes
• Having a family.

To make a marriage successful, partners must
• Listen to each other
• Overlook each other’s flaws
• Voice out one’s concerns about issues bothering him/her
• Put in effort to appease the other
o Basically both parties must compromise as it is inevitable to argue in a marriage.
FAMILY WITH YOUNG CHILDREN
Families with young children will then need to
• Adjust their marital system i.e. lifestyles to make space for children whom require
attention and care, at the same time
• Both partners should join in child-rearing, financial and household tasks,
• Realigning with extended family to incorporate parenting & grandparenting roles

As a parent, it is important to
• Provide emotional attachment & bonding with their child by
• Providing a secure setting for their child to grow – given that this is the 1st relationship a
child has. Parents will also need to
• Act as models of behavior and attitudes as children imitate their parents. Parents will also
need to
• Meet a child’s needs for new experiences, as more often than not, it is the parents who
should take charge of their children’s life journey in the initial stages. Parents also serve
• To maintain discipline within a child and
• To learn about communication and relationships at home.
Basically, parents are the security bracket for young children, not only financially, but also to
experiment and develop/shape themselves.
FAMILY WITH ADOLESCENTS
Families with adolescents will need to
• Adjust relationships so that the adolescent can move in/out of the system. At the same
time, parents can
• Refocus on their midlife marital and career issues. Also, there is also a need to
• Start joint caring for the older generation – where their own parents are growing older.
CHILDREN LEAVING HOME
When children start to leave home as adults themselves who have gained independence, very
often, this might result in the onslaught of the
• ‘empty nest’ syndrome which might result in loneliness, or having a lot of time together
with one’s spouse – and perhaps a change in the spouse’s temperament after raising kids.
 • Couples might also need to renegotiate marital system as a dyad (pair) as they are getting
used to life together again as just the 2 individuals, thus priorities might change again.
• Furthermore, there is also the issue of the development of adult-to-adult relations with
grown children, which comes along with the
• Acceptance of in-laws and grandchildren into the family system – which brings along
other commitments
• One would also need to cope with disability and death of elderly parents
LATE LIFE/AGING
At this stage, the couple must
• adjust towards functioning in the face of
o physiological, (worrying about being a burden to children)
o financial, and (financial planning; pensions)
o work role declines
• deal with loss of spouse, siblings and friends
• accept assistance from children and outside agencies, especially when there is a loss of
independence due to being unable to take care of oneself, due to disability etc.

WELL FUNCTIONING FAMILIES
Well functioning families usually have established
• Roles,
• Relationships, and
• Rules which are
o usually unspoken and at times may be
o distorted

This would give rise to family problems such as
• divorce – which tend to be traumatic to children


 FAMILY PROBLEMS
• Divorce
• Child abuse
• Others:
o Chronic illness
o Death of parent/child
o Moving/relocation

DYSFUNCTIONAL FAMILIES
Several predictors of dysfunctional families are
• parental ill health – of which is costly, chronic and disabling – posing not only a financial
strain, but also affects intimacy which is a key factor for a successful relationship
• spousal violence
• addictive behaviors especially towards drugs/alcohol – will result in either party not
investing time and effort in the relationship, giving way for neglect
• parents married early – might reflect immaturity in dealing with situations
• big age gap in parents – where there will be differences in views
• whirlwind marriages – where they do not know each other well enough
• different religions and other incompatible goals esp. for one’s views and lifestyle
• lack of growth in marriage – in terms of relationships and personal growth
• affairs
The more of such factors present, the higher the chances of divorce.

Also, there are many other general areas which lead to marital conflict and a marriage to dissolve.
• Work – esp. when there are long hours and there is not enough time spent together as a
couple
• Stress – that is being displace back on one’s family, can cause conflict, furthermore when
one becomes irritable easily.
• In-laws
• Money – this might be an issue of ego, usually inherent in males, where there is
unhappiness if the female spouse earns more than the other.
• Sex
• Housework
• Baby – esp. when one’s partner does not the share the burden of looking after the
housework / baby (which are the couple’s collective responsibilities), one party will feel
like the other did not contribute any effort into the marriage.
RESOLVING CONFLICT
To resolve conflicts between a family, it is somewhat similar as to making a marriage successful.
Either party should start off with a
• soft (rather than aggressive) approach, where it can be seen that there is a
• motivation to repair the relationship from either party in the family. This would
• regulate emotions, giving way for
• compromise, where it is okay to say sorry and
• tolerance – monitoring oneself to ensure no flare ups.

External support can be found in: see MCYS hand out

UNHEALTHY INVOLVEMENT OF CHILD IN PARENTAL CONFLICT
Whenever one parent is dealing with a conflict between the spouse, it is unhealthy to involve the
child in a manner whereby one
 • asks the child to take sides, esp. when thinking about custody issues, or to
• spy on the other parent, as a result of having suspicion of the other party’s affairs. It is not
right to treat the child as the
• communication channel, acting as a messenger during the ‘cold war’ brewing between
the 2 adults. By
• criticizing the other parent, this also is a form of brain washing the child, and
influencing/turning the child against the other parent. Parents should never
• see their young child as a friend & support – confiding in the child about ones problems.
This would only cause desperation within the child, as his/her young mind cannot handle
such information and emotions, only resulting in increasing fears of abandonment within
the child.
HOW TO INVOLVE THE CHILD APPROPRIATELY
Rather, one should
• not keep a divorce a secret or wait till the last minute before divulging it to one’s child.
• This process of letting the child know, should be done with one’s spouse such that it
becomes an open discussion with no suspicion. Parents should
• Keep things simple and straight-forward, explaining the gist of things, but leaving out
unnecessary information like sexual content which is highly inappropriate. Most
importantly, parents should
• Tell the child that the divorce is not their fault, and reassure their love and care towards
the child, at the same time
• Admitting that this will be sad for everyone.
• Reassuring the child that both parents still love them and will always be their parents is
also a key factor in casting out fear within the child with regard to abandonment issues.
• Parents should also not discuss each other’s faults/problems with the child.

EFFECTS OF DIVORCE ON A CHILD
According to research by Hetherington (1993),
• A majority of children do NOT have problems. However,
• Some have more serious problems,
o Emotionally – in terms of separation anxiety, worries
o Behavioral – in terms of regression, bedwetting, defiance and clinginess – of
which is esp. prevalent amongst younger children and academic problems or
suicidal behavior due to mood problems amongst teenagers

According to Amato and Keith (1991), Amato (2001), studies have shown that divorce causes
children to be worse off
• Academically, plagued with
• More behavioral problems, along with
• Negative self-concepts, which may result in a
• Problem with peers and
• Trouble getting along with parents.

Furthermore, these problems are most likely already present & negatively affecting a child, even
before a divorce (Kelly (2000)), given that it is conflicts within a dysfunctional family that lead up
to divorce.

A 25-year follow up by Wallerstein et al(2001) shows that children who experienced parents
divorcing grew up having difficulties in relationships, where they are
• fearful of marriage, or
 • fearful of becoming parents and this results in
• more marital breakdown for themselves.

HOWEVER, some children are more affected than others depending on the
• resilience of children, the amount of
• stress imposed on them e.g. due to socioeconomic disadvantage, as well as
• parenting quality, where after a divorce they face a
o single parents / new family composition or perhaps their
o parents might become harsher and there is thus a
o greater degree of parental distress inflicted on the child.
• The degree of marital conflict should also be considered, as sometimes the child might be
better off having the parents apart, if e.g. conflict starts to get violent.
Ultimately, divorce causes a child to experience a sense of loss, which might manifest into
• Guilt,
• Shame – where other young children mock them for having an abnormal family,
• Inferiority – where they blame themselves for their parent’s split, and thus develop fears
of abandonment, and
• Distrust towards others, esp. when building a relationship – of which might be an end
result of mixed feelings / anger / frustration / rejection / insecurity.
EFFECTS OF DIVORCE ON PARENT
During/after a divorce, parents face the issue of adjustment, where they might experience
• Life stress in terms of moving/changing schools for their child,
• Parental depression – which often results in irrational decisions being made
• Reduced parenting capacity, due to the absence of one’s partner,
• Economic loss as a result of legal fees, or the fact that they are now a single-income
family, possibly also saddled with existing debts/loans that were taken up during the
marriage, along with
• Custody issues – where a worst case scenario would be when neither parent wants the
child.

GRIEF REACTION TO LOSS
This depends on what kind / how symbolic the loss is to us. Generally, there are 5 stages:
• Denial
• Anger
• Bargaining (hoping things can be reversed)
o E.g. 3 wishes by children: where parents
§ Get back together again, and
§ Life is back to ‘normal’ where
§ Parents are married.
• Depression – once reality finally sinks in within them
• Acceptance


 CHILD ABUSE
Child abuse is defined as any act of omission(neglect) / commission by a parent or guardian which
would
• Endanger/impair the child’s physical/emotional well-being, and is
• Judged by community values & professionals as abusive (MSF, 2012)

Common forms of child abuse are
• Physical abuse – which is the most common in Singapore
• Sexual abuse
• Physical neglect
• Emotional abuse – which is rare and usually comes together with another form of abuse;
among many others.

Several factors are associated with child abuse namely if there is (a)
Child factors:
• Child with disabilities – esp. intellectually, given that they are more naïve/gullible/slower,
and parents often lack the patience to deal with them,
• Premature child – as often they experience more chronic illnesses
• Child with behavioral problems
Parental/family factors
• Domestic violence
• Substance abuse – esp. where parents are intoxicated, making them lose control and thus
possibly having violent tendencies.
• Parental immaturity where the parents cannot control emotions well, and
• Parental expectations inconsistent with child development
• Social isolation – esp. when the family is secretive, with neighbors not knowing much
about them nor are they in contact with relatives.
• Family stress from illness / poor finances / divorce
• Adult caretakers who themselves were abused as children often result in a perpetuation
of abuse.
DISCIPLINE VS ABUSE
See family violence hand out


Lecture 3: Development

It must be recognized that different parents should have a different set of expectations as to how a
child turns out as
• Children have lower cognitive development – i.e. they are not small adults
• Children are still developing, and
• Recognize & express emotions differently, where given that their speech development is not
mature, we very often have to infer their emotions via their behavior. Furthermore,
• Children’s behavior is affected by the interaction between a child and adults.
• Thus, adult’s expectations should complement children’s developmental needs.

Children’s developmental needs fall within the
• Physical
• Spiritual/moral
• Social, and
• Emotional
Which involves developmental assessments done by the doctor in the form of vaccinations, tests
and other cognitive assessments, as well as
• Intellectual – where there are intellectual assessments done to pick up any developmental
delay as early as possibly for earlier intervention and a better outcome.

ERIKSON’S THEORY OF INDIVIDUAL DEVELOPMENT
Albeit dated, this theory helps psychologists understand the various stages of development,
starting with the first 4 stages being the tender years. The first stage of being an
1. Infant
a. Involves learning about Trust vs Mistrust. The child
b. Needs maximum comfort with minimal uncertainty to trust himself/herself,
others, and the environment. Given that this is their very 1st relationship, the child
would be highly dependent & reliant on the caregiver to provide necessities such
as food, comfort and security. This stage is also very important as it is the 1st step
towards trust development for a child to seed future relationships. Next, a
2. Toddler
a. Explores Autonomy (where he/she is able to accomplish certain tasks) vs Shame
and Doubt, at the same time
b. Working to master physical environment while maintaining self-esteem. This
involves a lot of oral exploration and playing around with the environment. Also
this is the start where one’s skills can be an indicator of certain health issues
arising e.g. toilet training – if a child at 11-12 has still NOT mastered it and is
wetting beds daily, this might be the indication of a health issue with the
bladder/kidney. At the
3. Preschooler stage, children learn of
a. Initiative vs Guilt and
b. Begins to initiate, not imitate, activities; developing conscience and sexual
identity. Here, parents should protect (but not over-protect) – giving the child
some freedom within the realms of safety to explore, if not, there is a tendency
for the child to withdraw/become reclusive. A
4. School-Age Child would start to learn about
a. Industry vs Inferiority, and thus
b. Tries to develop a sense of self-worth by refining skills, developing a competitive
spirit. However, inferiority thus emerges and develops when one feels lousier
than others. Thereafter comes the stage of an
 5. Adolescent, where there is
a. Identity vs Role Confusion
b. Tries integrating many roles (child, sibling, student, athlete, worker) into a self-
image under role model and peer pressure. At a
6. Young Adult stage, there is
a. Intimacy vs Isolation. One will then
b. Learns to make personal commitment to another as spouse, parent or partner.
Reaching the
7. Middle-Age Adult stage where one chases fulfilment in life, one will have to balance
a. Generativity vs Stagnation
b. Seeks satisfaction through productivity in career, family, and civic interest. And
lastly, becoming an
8. Older Adult comes with dealing with
a. Integrity vs Despair, where one
b. Reviews life accomplishments, deals with loss and preparation for death.

It should be noted that this is just an estimated sequence, and that some children may skip
particular stages.
DEVELOPMENTAL STAGES THEORY
The basis of this theory is that
• Development starts in the womb, with various
• Milestones in life where anomalies can be defined by areas such as
o Physical development,
§ E.g. certain types of brain tumors secrete liquids that cause a child to be
malnourished or have early sexual signs such as pubic hair,
o Social development,
§ E.g. children who are easily frightened/anxious might be experiencing
stranger anxiety
o Moral development,
o Emotional development,
o Cognitive development and
o Linguistic development
§ Which can be assessed through IQ tests and one’s language abilities
• Children should grow along a certain centile to be considered ‘normal’ and if they fall off
this range, it is an indicator of something wrong, i.e. if the child is of an especially small
size.
• This theory also suggests that the tender years are up to 6 years old, of which is key
• To establish the foundations of development within a child.

EARLY INTERVENTION IN DEVELOPMENT
Early intervention of developmental delays always produces a better outcome in the long run.
This is because the child can be
• Instituted with treatment earlier to
• Reduce the negative consequences, at the same time there can be
• Improvement in support with regard to
• Acceptance vs denial – of which can last a big period of time, esp. if parents deny
treatment in hope of ‘normality’. Whenever, children whom which parents bear their
hopes and dreams are diagnosed/assessed with a problem, parents cannot understand
and take time to accept such a situation. Thus, earlier treatment will have a better
outcome.

 This is commonly provided through
• Support from therapists / pediatricians
• Services e.g. Early Intervention Programme for Infants & Children (EIPIC), along with other
community programmes that offer intensive therapy, and other
• Experiences
To prevent/reduce long term problems.

Thus there is a need to determine
• Who are the children at risk,
• The process of identifying them, and
• Who is responsible.

This can be done through prevention programmes/health promotion to teach young children
‘resilience’. But nevertheless, this requires all-rounded familial & community support, along with
primary healthcare providers such as family doctors/GPs for the early identification of disorders.

FOUNDATIONS OF DEVELOPMENT
These although are differences between each child, help us in establishing normalities.
• Innate(genetic) ability, esp. intellectual
o e.g. IQ tests where a normal IQ ranges within 70-130, of which below 70 might
indicate an intellectual disability
• Temperament – which can change depending on parenting styles and does not equate to
a child growing up the way he/she is when he/she was younger. There are various
degrees of temperament such as the
o Difficult child – whom often has an intense, negative mood that is slow to adapt.
§ Parenting styles here cannot over punish and one must be patient yet
firm with the child. Parents need to be flexible yet also reduce negative
feedback albeit how difficult the child is, as this would only fuel his
negativity.
o Shy child – is often withdrawing with low activity/intensity, thus
§ Parenting styles here have to be patient and repeatedly encouraging for
the child to come out of his/her shell/comfort zone.
o Easy child – is one that often has a positive mood, is approaching and adaptable.
§ Parents should motivate the child to keep up his positive stance, and take
note not to neglect this child who has seemingly developed well.
o Thus, a child’s development of temperament highly also is dependent on the
goodness of fit with parents.
• Environment & support, which is an opportunity to stimulate the child and often requires
motivation by parents
• Motivation & attitude
• Physical health where this can determine if the child picks up certain skills faster or not
• Mental health

ENVIRONMENT – PARENTING
PARENTING STYLES
The best parenting style depends on the child’s age, characteristics and temperament, thus
parents may switch between different styles. However, here we discuss and describe what
predominant parenting style should be implemented.

Parenting styles shape a child’s temperament along with the other foundations of development,
of which the different types are
 • Authoritarian, which involves
o Giving orders,
o Demanding and not being responsive.
• Permissive, which involves
o Giving in
o And is responsive and not demanding.
o Often this is used when handling one’s children whom have already reached the
stage of young adults / adults, rather than young children which would be rather
unhealthy given that kids cannot make good decisions plus the fact that they
might become spoilt and entitled.
• Authoritative which involves a discussion style of
o Giving directions, where although
o Demanding, is however, also responsive – where the child has some input.
o Often this is most effective with the older children.
ENVIRONMENT
Parents should provide an environment where there is time for a child to
• Play – as this allows the child to explore one’s creativity and motor skills etc. Parents
should also provide
• Opportunities for the child to learn, along with
• Rich stimulation at home, rather than leaving the child to sedentary activity i.e. iPhones,
and also
• Engage interested teachers, of which they themselves included
• To build supportive, encouraging relationships between
o Parents and siblings, as well as
o Teachers and students.
ATTITUDE
Given that children are not as emotionally resilient,
• Parental attitude
• Peer attitude, and
• Teachers’ attitude
Towards them is key in a child’s development

Statistics have shown that youth suicide in Singapore has increased to 20-30/year. Thus we look at
society as an indicator to rising problems e.g. from the recent cases of suicide due to stresses
from academic failure and parental expectations.

Expectations of parents have to be reasonable, e.g. when parents themselves do not set
exemplary character – e.g. caning whenever angry, yet it is non excusable for the child when they
themselves cannot control emotions like anger; this requires a reassessment of expectations and
perhaps changing attitudes.
MOTIVATION
Motivation is essential to push a child towards successful development and building of
confidence. This can be done by
• Using rewards – even adults work for a monetary reward that is one’s salary.
• Build on their success – e.g. by complimenting them on their achievements, encouraging
them to try their best
• Develop passion

However, there is a difference between a bribe & a motivational reward, where the former comes
before work, while the latter comes after the work is done.
PHYSICAL HEALTH
 Physical health in these various forms also affects development.
• Physical senses
• Physical needs
• Physical illnesses – esp. might limit opportunities for further development e.g. when they
are home bound, or otherwise as this
o Affects senses
o Illness & treatment effects
o Social & economic issues
o Parental attitudes
o Attitudes of school personnel
o Attitudes of health care team
o Limited school attendance


MENTAL HEALTH DISORDERS
3 main diagnostic groupings:
• Developmental disorders à 25%
o E.g. autism, intellectual disability, learning disorder
• Emotional (internalizing) disorders à 30%
o E.g. anxiety, depression, stress
• Disruptive behavior (externalizing) disorders à 36%
o E.g. ADHD, conduct disorder
DEVELOPMENTAL DISORDERS DEVELOPMENTAL ASSESSMENT
This involves a As a medical service, developmental assessment of children
delayed/disordered development, after birth are often
i.e. • provided by primary care doctors
• Mental • recorded in health booklet
retardation/intellectual • timed with vaccination schedule,
disability • and is an opportunity for early identification, referral
• Learning disorders such for assessment and early intervention
as dyslexia A study at KK Child Development Unit shows that the most
• Attention deficit common concern for referral is speech & language delay à
hyperactivity disorder where the most common developmental disorder was
(ADHD) autism spectrum disorder – which is a condition that carries
• Enuresis a lot of burden & requires lots of support & resources from
• Autism spectrum disorder one’s caregiver.
ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)
This is not a result of bad parenting, but rather is a heterogeneous condition with an unknown
cause, and a worldwide prevalence of around 5%.

Assessment of ADHD is a clinical diagnosis where the gold standard is a thorough examination by
a trained professional i.e. qualified doctor, which involves
• behavioral
• physical and
• psychological examinations. However, there are
• no specific laboratory/psychometric tests to confirm the diagnosis

The symptoms of ADHD are (refer to handout)
• severe inattention, hyperactive-impulsivity (which is inappropriate for normal kids)
• inappropriate (for developmental age)
• persistent e.g. before age 7, more than 6 months occurring
• pervasive in e.g. 2/more settings – not just within school
• impairing as it can affect learning due to one’s
o limited attention span
o weaker working memory, and the presence of
o behavioral problem that come with one’s impulsivity. ADHD is commonly
associated with specific
o learning disabilities i.e. reading disorder/dyslexia in about 20-30% of cases.

Treatment is designed around the needs of each individual child. This can involve medical
treatment through
• stimulants i.e. methylphenidate, which is commonly used during school hours as its
effects can be seen quickly within 30-60 min.
 o However, this can cause reduced anorexia or growth impairment along with other
side effects, thus it should be limited to a necessity during school hours and not at
home, to reduce the total time exposure to medication so as to reduce side
effects. Also,
• Selective Noradrenergic Reuptake inhibitors i.e. atomoxetine – which involves a daily
consumption and is more expensive is another option.
o Furthermore, there are also side effects like nausea and fatigue.
• Antidepressants i.e. imipramine, and
• Anti-psychotic medication
o are both are rarely used.
It must be noted that medications only control symptoms, and does not cure ADHD, thus parents
can only wait for a child to overcome it, through other intervention. There is also a reluctance for
the use of medication due to
• Parental concerns such as the
o Drugged/zombified effects
o Side effects i.e. weight loss, growth retardation
o Addiction
• Child concerns such as
o Thinking they have no health issues and is perfectly normal
o Afraid of being labelled as mentally ill
o Feeling controlled
o Side effects like nausea/sleepiness
Other than medical treatment, there are also Psychosocial interventions involving (refer to
handout)
o school based work – as schools have allied educators & school councilors
o parent training groups – to teach parents how to manage a child at home
§ control the environment
§ develop a routine via guidance & gradually wean off their dependence on
medicine
§ create a quiet environment
o cognitive behavioral therapy (esp. for aggression) as an individual / within a group
o ADHD support group – www.spark.org.sg - which can also help parents of ADHD
kids deal with stress etc.
AUTISM
Autism is a developmental condition with persistent social communication and social interaction
skills deficits. Early signs are late speech development, poor eye gaze, poor interaction with other
children.
Assessment often follows a diagnostic criteria of symptoms present before age of 3: falling under
• Qualitative impairment in social interaction
o e.g. spastic movements/hand gestures in their motor movements, or
o has difficulty starting or responding to social conversation
o lacks initiative to approach or share enjoyment with others
o has difficulty understanding emotions
o often misinterprets social cues
• Qualitative impairment in communication where there is perhaps an
o awkwardness in the pitch of voice, as well as
o impaired understanding – rigid in use of words where they misunderstand
meanings, or
o eye gaze which cannot be maintained
• Restricted repetitive and stereotyped patterns of behavior (where they throw tantrums if
their normal routine is strictly not followed), interests (genius abilities) and activities
 (intense interest in a sole specific topic e.g. dinosaurs, that may exceed the amount of
general knowledge typical for someone that age)
• Delay in speech/language development

Causes of autism tend to be most commonly
• Genetic, where the
o Risk is higher when there is affected family members/relatives.
• Some medical conditions like Tuberous sclerosis
• Brain injury during birth/trauma
o E.g. severe cerebral palsy

Treatment done early is key. (Refer to handout) This can be done through
• Behavioral therapy, which can be
o individualized: where specific strategies vary for each child/family or is simply a
o generalization to everyday life.
• Specific therapies are also involved such as
o speech & language therapy or
o occupational therapy so as to calm them down through sensory therapy e.g. some
of the may be very particular in not liking to wear collared shirts.
• Medication cannot cure, but can control symptoms like e.g. hyperactivity, withdrawal,
stereotypies, self-injury, aggressiveness and sleep disorders.
o Drugs like antipsychotics such as Risperidone are used to reduce aggression

COMMUNAL SUPPORT
Various forms of community support are available. Namely,
SG Enable which manages all the Voluntary Welfare Organizations collectively, who provide
similar services. It provides
• Information and referral services for child and adult disability schemes,
• Support to persons with disabilities and their caregivers
• Improves transition management across different life stages
• Enhances employment for persons with disabilities – as SG Enable provides one outlet to
rally employers & other stakeholders to come together to help/support
• Rally stakeholder support

Other options for
educational services would be the
• Early Intervention Programme for Infants & Children (EIPIC)
• Autism Specific Schools like Pathlight School, or
• Special schools and learning centres e.g. Rainbow centre.
Support services would be
• TOUCH community services
• Movement for the Intellectually Disabled of Singapore (MINDS)
• Autism Association (Singapore)
Other services
• Psychological services
• Speech therapy
• Occupational therapy



Lecture 4: Learning and Mental Health

Learning involves
• Problem solving
• Experience
• Social
• Academics
• Development – pick up skills from the environment
The learning theory is such that we acquire knowledge (factual/experiential) or develop abilities to
perform new behaviors
• A stimulus-response r/s
CLASSICAL CONDITIONING
Classical conditioning involves forming associations between 2 stimuli occurring closely together
in space/time
• Commonly used to understand development of phobias
OPERANT CONDITIONING
Operant conditioning involves the use of reward & punishment to increase/decrease behavior
(ABC model)
• Antecedent(stimulus) à affects behavior à results in intended consequence which will
influence future behavioral response when presented with similar antecedent events
REINFORCEMENT
Reinforcement involves a consequence that causes a behavior to occur with greater frequency.
This can be done through

Positive reinforcement: increasing likelihood of recurring behavior through positive
consequences (rewards)
• Privileges (e.g. more computer time),
• Social (praises, attention, recognition), or
• Star chart/points system (for younger children).
o Behavioral goals set must be specific + achievable (general terms will be
vague/ambiguous – where there is no clear standard set for the child)

Negative reinforcement: increasing likelihood of recurring behavior through removal of
unpleasant consequences
• E.g. parents removing peas from child’s plate whenever child screams à the child will
scream in the future whenever he does not want peas on his plate

Punishment: consequence that causes a behavior to occur with less frequency
• Note: if too severe, this may make the recipient angry, aggressive, or have other negative
emotional responses.
• Thus it is important to let the recipient know which specific behavior they are being
punished for
Increasing behavior (reinforcement) Decreasing behavior (punishment)
Introduce Something child likes (e.g. playtime) Something child dislikes (e.g. chores)
(positive)
Remove Something child dislikes (e.g. chores) Something child likes (e.g. playtime)
(Negative)
• Parents should however be flexible when using this, applying the chart according to the
child’s age by modifying it to their factors and circumstances
• Rewards/punishments should follow behavior
 o Immediately (or as close as possible)
o Consistently (between BOTH parents, as if the child can get away on certain days,
this will cumulate the bad behavior due to inconsistency)
• Rewards should also be valued by the recipient while the
• Punishments should be deemed unpleasant by the recipient

INTELLIGENCE
Intelligence is defined through
• Fluid intelligence – novel problem solving skills / perceptual reasoning
• Crystallised intelligence – accumulated experience / verbal comprehension
• Working memory – executive function
• Processing speed – cognitive efficiency

To estimate the potential of the child to
• Enter special schools (MINDS) or
• Hold simple jobs e.g. be trained to work within a sheltered workshop – packing earphones
for SIA, or
• Require institutionalization or
• Round the clock supervision.
This is dependent on their IQ scores which is an indicator of their intellectual disability and
summary of their overall ability. Those with an IQ score of </=70 are generally determined to have
an intellectual disability – i.e. an impairment in their adaptive functioning.

LEARNING DISORDERS
There are 3 types of learning disorders, namely (see handout)
• Language disorder (written/expressive)
• Reading disorder (dyslexia)
• Math & reasoning disorder (dyscalculia)

To define learning disorder, we first have to assess:
• Whether he received quality pre-school care – such that the child does not achieve at his
expected age & ability levels,
o where his/her achievement is on individually administered, standardized tests in
reading, math, or written expression that is substantially below that expected for
age, schooling, and level of intelligence.
• Only then do we conclude to do the IQ test
• Learning disorders will only be diagnosed after it can be established that the child
o Continues to struggle even after substantial individualized help
o Continuous monitoring of their response to the intervention
§ From tier 1: universal high quality instruction (mainstream)
§ Tier 2: targeted small group instruction (learning support programs)
§ Tier 3: individual intensive intervention
o does not improve with Response to Intervention Strategies
o Postponement of diagnosis till after a proven intervention offered
§ We must consider other factors that might affect the child’s learning i.e.
absenteeism/truancy etc.

Research has shown that people with learning disorders have a higher risk of mental health
disorders such as depression, as these learning disorders can impact a young person’s self-esteem
significantly. Firstly,
 • Mental health disorders lead to learning disorders
o E.g. missing school during critical developmental phases
• Learning disorders leads to mental health disorders because of
o Demoralization, low self-esteem and deficits in social skills which are common.
The fact that individuals experience
o Less success and
o More bullying which leads to
o More stress and frustration is also a major contributing factor
• The etiological factors (causes) for learning disorders and mental health disorders are
similar, being mainly
o Biological & genetic e.g. schizophrenia, ADHD
o Environmental

Assessment for IQ to determine learning disorders, are usually administered by
• MOE educational psychologists
• Psychologists at the
o Child psychiatry clinics (Child guidance clinics @ IMH/NUHS)
o Paediatric clinics (KK / NUHS)
• Educational psychologists at
o Student care services (community services)
o Dyslexia Association of Singapore
• Private psychologists

Interventions for Learning disorders involve
• Highly structured training which involves skills based training e.g. Phonics based
approaches for dyslexia (e.g. DAS) executed by the school or community based teacher
interventions.
• Also, working on other problems e.g. conduct, ADHD, emotional problems etc. is
essential. On the other hand,
• Medications in this case, are not directly useful.

COMMUNAL SUPPORT
People around the individual experiencing a learning disorder, should focus less on his/her
difficulties and disorders, but rather also
• Identify strengths
• Recognize abilities, and
• Nurture early identification of the child’s nature to determine relevant areas for
development to the benefit of the society.
Teachers of students with learning disabilities should (refer to handout)
• Capitalize on student’s strengths,
• Provide clear expectations and structure for them to follow easily. At the same time,
• Use simple sentences and vocabulary. These will
• Provide opportunities for success for individuals. Furthermore, one should
• Allow flexibility in classroom procedures, and
• Use self-correcting materials so as to
• Provide positive reinforcement.

In general, all areas of the community – such as mental health services, educational services, and
pediatric services or NGOs, should be intertwined and work together such that collectively it is
possible to provide better coordinated/seamless care for the individual.

Lecture 5: Adolescence

DEFINITION OF ADOLESCENCE
Adolescence can be defined by
• age – those 13-21 years of age
• legal status – those legally incapable of being considered an adult (consent etc.)
• maturity – but this has no main standard to determine
o physical v mental
o cognitive v emotional
• a transition period between childhood & adulthood – but this depends on which society
you look at, as there are inconsistencies across cultures.

The various stage of adolescence are:
Early adolescence (11-14) – where abilities that develop during this phase are mainly:
• abstract thinking
• critical thinking
• challenging authority
• self-consciousness
• sense of invulnerability
Middle adolescence (15-17) – where the individual starts to experience
• separation – cutting strings from parents as an individual, and
• identity formation – where they question their life choices and might cut out social
interaction due to them undergoing existential crises where they think/question
themselves a lot. This commonly involves
o forging a healthy sexual identify – being comfortable with who you are
o building relationships
§ where they commonly rather be with friends rather than family. Thus
parents must sometimes negotiate out terms with the child.
o developing a moral value system – with regard to conforming or not to peer
pressure
§ More often than not, teens conform to be accepted, yet they might not
be comfortable. Thus, it is key to have a moral compass to guide their
decisions, as well as to balance relationships by saying no, without
offending one’s friends. This is also the stage, where one defines one’s
friends.
o preparing for the future as an independent adult that contributes meaningfully to
society.
Late adolescence (18-21) – where it can be seen as the beginning of wisdom

SUICIDE
Suicide in Singapore has reached a recent high of 27 suicides in 2015, furthermore in comparison
with other countries, given Singapore’s low young population base, in fact the Singapore suicide
rate has increased rather exponentially. Although these rates give an indication, this method of
detection is a late marker, and a looming problem must have gone on for a certain amount of
time already.

To prevent further cases, helplines from various organizations are readily available 24 hours to
provide a listening ear/for advice. (refer to lecture notes)

DELINQUENCY
As much as the number of juveniles arrested has decreased slightly, there are more young
individuals getting into trouble in the online sphere – where the internet creates an illusion of
distance that somewhat translates to them as ‘safety’, unknowing of the dangers of circulation
and the fact that the other party might not be his/her true self too.

The most common crime types in Singapore would be
• shop theft, accounting for 31% of juvenile crimes
• other theft 17% and
• rioting 11% which usually occurs in a group. An example would be the Downtown East
stabbing case where it was the combined action of the entire group that resulted in the
commotion getting out of control even though there were bystanders and observers
around the weapon holding individuals.

The guilt of the child/adolescent caught in the criminal act will be
• determined by the law – making this as legal issue and not a mental health issue directly.
However, when charged in court, the court will
• assess the individual’s mental health, as well as
• ensure that they understand the implications of their actions,
• in order to prevent re-offences.
An example is Michael Fay the young vandal whom the US pleaded Singapore on behalf of to let
him off, but to no avail, such that he suffered caning in Singapore and got deported back to the
USA, only to get into more trouble with the law over there. Thus, it is key for the individual to
understand implications and reassess his actions to prevent re-offences

Causes of juvenile delinquency often is attributed to
• personal factors such as
o temperament – impulsive/violent tendencies
o intelligence, where they think that they can cover their trails, resulting in them
§ getting caught – deterrence
§ getting away – which would encourage them to act, causing
entrenchment of the behavior which makes it harder to treat
o conduct disorder (repeatedly getting into trouble with the law)
• family factors
• social factors
INTERVENTION
The National Committee on Youth Guidance and Rehabilitation has provided a guide to identify
youths-at-risk for early intervention.
• Youths at risk are individuals who have been subjected to a combination of interrelated
biological, psychological, and social factors that result in a greater likelihood for the
development of delinquency, substance abuse, or other related anti-social and self-
destructive behaviors.
Their character traits (individual/interpersonal) are mainly:
• Aggressive
• Impulsive
• High daring
• School failure – this is esp. a high risk factor as the Compulsory Education Act is only up till
the age of 15, thus thereafter, it is easy to drop out, resulting in adolescents developing
o Disruptive behavior,
o Having no discipline, coupled with
o The poor influence of questionable friends i.e. mixing with the wrong crowd and
 o The fact that there is no supervision, contributes greatly to a higher risk of
delinquent behavior.
• Academic difficulties
• Antisocial behavior
• Distant relations with parents/guardians
There are also a landscape of services which provide a multi-pronged approach involving various
stakeholders of society. (see lecture notes)

Lastly, MSF Juvenile Homes such as the SG Boys/Girls Homes are there to
• Cater to juveniles who are at risk / have gotten into trouble with the law, but whose
behavior and circumstances render community-based options inappropriate/unsuitable.
• They offer rehabilitative programmes to help and develop the juveniles so that they can
reintegrate into society as socially responsible persons.
• In general, these homes see a higher admission of boys rather than girls due to perhaps
their more aggressive temperaments.

Children who are deemed beyond parental control will also undergo investigations and
assessments.
• Very often, these are children/young persons below the age of 16 who may be in
persistent conflict with parents/the school/other authorities and who may be displaying
at risk behaviors.
• This may lead to the inability of parents to exercise care & control over the child/young
person, causing the parents to apply to the Juvenile Court for a BPC order.
• As a result, parents and the child may be put through diversionary programmes e.g. the
pre-complaint counselling and Beaconworks programme under the Family Service Centre.
• Also, the child may be remanded for a short period of up to 2 years during court
proceedings/investigation periods to protect the child from getting into increased
trouble/harm.

TEENAGE PREGNANCY
Although teen births have dropped to a 20 year low, as reported in 2015, with more young people
believed to be using contraception, it is still an issue that girls are seen as more vulnerable.
INTERVENTION
Sexuality education has been implemented by
• MOE: within the school education system
o To help students understand physiological, social and emotional changes, and
o Help make wise, informed and responsible decisions on sexuality matters.
o E.g. prevent circulation of pornographic material, esp. with the easy access to the
internet
• MSF: positive adolescent sexuality treatment programme
o Which targets youth offenders
This is essential as nowadays adolescents are empowered with greater access to information,
however the fact that they lack discernment at their age can lead them to be misinformed, and
hence the emergence of
• teenage pregnancies – where each year, there are about 2,000 teenage pregnancies in
Singapore, as well as
• sexual activity that gives rise to Sexually Transmitted Infections/HIV among teens
• suicide when teens cannot handle the stigma, and pressure of another the burden of
another life at such a young age. Other less severe symptoms of such emotional issues are
o cutting themselves
o tattoo
 o plucking one’s own hair to eat
o eating disorders
However, there is also a contentious issue as to who should be the ideal provider of such sexual
education,
• as seen from the prior uproar over sexual education being outsourced to providers like
AWARE whom promoted same-gender orientation (LGBT), of which more conservative
parents are not comfortable with.

LAWS TO BE AWARE OF
Mental Health (Care and Treatment) Act 2008
• regulates involuntary detention in psychiatric institution for treatment of a mental
disorder, or in the interest of the health and safety of the person or the persons around
him.
• This allows officers to compulsorily detain a person if he is capable of hurting
themselves/others i.e. he has a mental illness yet does not want to seek hospital
treatment
Women’s Charter 1997 (Revised 2009)
• Provide for monogamous marriages, solemnization and registration of marriages
• To consolidate law relating to divorce, rights and duties of married persons, protection of
family, maintenance of wives and children, and punishment of offences against women
and girls
• This law is also a form of recognition of the rights of women.
Children and Young Person’s Act 1993 (Revised 2011)
• Provide for welfare, care, protection and rehabilitation of young
• E.g.: When children need protection
o No parent or guardian
o Abandoned child
o Parent or guardian is unfit or unable to care
o Child or young person is at risk
• Regulate Children’s Homes to prevent the child from being e.g. abused at home – esp.
those whom are intellectually disabled
Child protection order
• Applies to Children and Young Persons who are willfully assaulted, ill-treated, abandoned
or exposed in a manner likely to cause unnecessary physical suffering, emotional injury or
injury to health or development comes under the jurisdiction of the Juvenile Court.
• CPO cases may also arise when Children or Young Persons are subject to willful neglect
and not provided adequate food, clothing, medical aid or lodging.
• This order empowers the child protection officer to determine if the child needs to be
taken away & placed at a place of safety.


Lecture 6: Personality and problems

Temperament ¹ Personality
TEMPERAMENT PERSONALITY
Is our early biologically rooted basic Is the sum total and interaction of a person’s physical
personality dimensions that is probably and psychological traits as revealed in his appearance,
genetically coded. However, these thoughts, feelings and behavior.
characteristics changer over time.
Personality is more stable after/by young adulthood –
Overall, temperament is not stable over around the age of 18, one’s personality tends to be
long term, as is more of an association more enduring, although there still might be gradual
during the young period of one’s life. changes.
This is usually influenced by the • E.g. as a person ages, one’s personality tends
environment which molds one’s to become more mellow
temperament
• Some dimensions (e.g., shyness- Personality makes for consistency in our behavior as
sociability, activity) may be well as is responsible for individual differences in
more stable than others behavior.


THEORIES (x)
There is a link between personality & health where
• People with type A personalities run a higher risk of stroke, heart disease & high blood
pressure given that they are high on
o Competitiveness
o Sense of urgency
o Multitasking
o Constant stress,
• as compared to people with type B personalities whom are
o relaxed
o laid back and
o easygoing

To understand one’s personality, we can also take the learning approach, to understand a
person’s prior experiences/consequences so as to assess whether or not it reinforces their current
behavior & personality. This involves
Classical conditioning where
• Behavior is the conditioned stimulus paired with the unconditioned stimulus of
punishment resulting in the conditioned response of fear or anxiety and
Operant conditioning where there is
• Reinforcement & punishment
• For example, one can try to advise parents to slowly mold the behavior of the child.
In this approach, the effects of the environment on behavior is clear, given it explains cross
situational inconsistencies. However, these enduring traits are hard to change

PERSONALITY DISORDER
Personality disorders can be characterized by the possession of one or more abnormal traits so
deviated from the norm that they interfere with his wellbeing and his adjustment to society
(other’s wellbeing) or required medical (psychiatric) attention, given that it puts them at risk for
mental health problems.

 A personality disorder is identified by a pervasive pattern of experience and behavior that is
abnormal with respect to any two of the following:
• Thinking (perception and interpretation of self, others and events),
• Mood,
• personal relations, and
• the control of impulses.

Most personality disorders begin as problems in personal development and character which peak
during adolescence and then are defined as personality disorders (by 18).

Personality disorders are not illnesses in a strict sense as they do not disrupt emotional,
intellectual, or perceptual functioning. However, those with personality disorders suffer a life that
is not positive, proactive, or fulfilling. Not surprisingly, personality disorders are also associated
with failures to reach potential.

TYPES OF PD
The types of personality disorders are the
• 10 disorders in 3 clusters identified in DSM IV TR
• Cluster A (Odd or eccentric group)
o Paranoid PD
o Schizoid PD
o Schizotypal PD
PARANOID PD SCHIZOID PD SCHIZOTYPAL PD
Marked distrust of Primarily characterized by a Peculiarities of thinking, odd beliefs,
others, including the very limited range of and eccentricities of
belief, without reason, emotion, both in expression appearance, behaviour, interpersonal
that others are of and experiencing; style, and thought (e.g., belief in psychic
exploiting, harming, or indifferent to social phenomena and having magical
trying to deceive him or relationships. Tends to be powers).
her; lack of trust; belief monotonous, and prefers
of others' betrayal; being alone. Higher risk to get schizophrenia – of
belief in hidden which does not equate to a PD, even if
meanings; unforgiving Could also be suffering from you have these traits. However, once
and grudge holding. autism & its related social these traits start causing problems, it is
problems due to lack of considered a PD.
communication
• Cluster B (Dramatic, emotional, erratic, difficult group)
o Antisocial PD
o Borderline PD
o Histrionic PD
o Narcissistic PD
ANTISOCIAL PD BORDERLINE PD HISTRONIC PD NARCISSISTIC PD
Lack of regard for the Lack of one's own identity, Exaggerated Behavior or a fantasy
moral or legal standards with rapid changes in mood, and often of grandiosity, a lack
in the local culture, intense unstable inappropriate of empathy, a need
marked inability to get interpersonal relationships, displays of to be admired by
along with others or marked impulsivity, emotional others, an inability to
abide by societal rules. instability in affect and in reactions, see the viewpoints of
Sometimes called self-image. approaching others, and
psychopaths or theatricality, in hypersensitive to the
sociopaths (charming, everyday opinions of others
 smart yet cunning to Characterized by intense behaviour.
con people). emotional crises, with a Sudden and They see themselves
weak sense of self – rapidly shifting as superior beings,
They also tend to get commonly depending on emotion such that they might
into crimes for others’ validation. Thus they expressions. become demanding
disregarding social see things in black & white and entitled.
rights, and also show no e.g. if you don’t do this, you
remorse e.g. abuse don’t love me. Also, this
animals, set fire causes them to be weak in
emotions to the point of
becoming mildly psychotic
• Cluster C (Anxious, fearful group)
o Avoidant PD
o Dependent PD
o Obsessive Compulsive PD
AVOIDANT PD DEPENDENT PD OBSESSIVE COMPULSIVE PD
Marked social Extreme need of other Characterized by perfectionism and
inhibition, feelings of people, to a point inflexibility; preoccupation with
inadequacy, and where the person is uncontrollable patterns of thought and
extremely sensitive to unable to make any action.
criticism/rejection decisions or take an
independent stand on This causes the person to become over-
his or her own. Fear of controlling, needing things to be in the
separation and order he/she wants.
submissive behavior.
Marked lack of We must differentiate when it crosses into
decisiveness and self- OCD/Mental health e.g. when there are very
confidence. specific directions/rules that must be
followed
They face great
difficulty in taking
responsibility for even
small things in life.

CAUSES OF PD
This tends to be due to
Genetic factors – schizotypal, paranoid, psychopathic
Organic factors – brain, infections, epilepsy (rigid, esp. those who have frequent fits & who take
medication for their fits)
Environment – child abuse, trauma

• Genes have been proven to be more influential than the environment, in influencing
personality
• Both factors are important

TREATMENT OF PD
• Psychosocial
• Pharmacological (Medications)
• Combined (Multimodal)
• Must want to change
• Supported by groups

Generally, personalities, are not easy to change.

SELF ESTEEM
Self-esteem is the collection of beliefs or feelings that we have about ourselves, or our ‘self-
perceptions.’ It is how we define ourselves influences our motivations, attitudes, and behaviors
and affects our emotional adjustment.
EATING DISORDERS
A form of low self-esteem is
Anorexia Nervosa which is the
• Intense fear of gaining weight. Individuals have an
• Altered sense of body image: they think one is fat even though underweight by BMI
• Refusal to maintain normal weight
• Females: amenorrhoea (menstruation stops)
• Behaviors: purging (self-induced vomiting), starving, over-exercising, medication (diuretic,
diarrhoea, appetite- suppressant)
• Very often, due to the suppressed appetite and forced diarrhea, one can become
dehydrated and malnourished which leads to heart problems.
Bulimia Nervosa is characterized by
• Binge-eating episodes with efforts to compensate (e.g. purging, medication)
• The onset is usually later in the case of bulimia (young adulthood; even 8-9)
• Bulimics usually normal or over-weight but anorexics underweight
• Develop separately
• Both are more common in females
• Social causative factors are the same – where they fear humiliation, and that they will go
back to being ‘fat’

The causes of eating disorders tend to be
• Psychological mechanisms
o Fear of sexuality and adulthood – trauma from sexual abuse
o Acting out against family/parental control – esp. domineering parents, so as to
punish parents psychologically
o Phobia of food
• Social desirability – society’s ideal body shape
• Medical causes
o Genetic
o Hypothalamic dysfunction

Treatment of eating disorders involves
• Weight gain
• Education and diet management
• Directed towards causes
o Psychotherapy
o Cognitive behavioral therapy
o Family Therapy
So as to help the individual feel normal again.


Lecture 7: Human Sexuality

Sexuality is the quality / state of being sexual, through
• Developing relationships
• Sexual activity
• Sexual identity

Sexuality development ranges from
CHILDHOOD SEXUALITY
Childhood sexuality where they have
• Limited sexual development physically. However,
• their sexuality realization is based on surroundings & influence e.g. girls are supposed to
like pink and wear dresses. These gender specific roles and behavior develop by age 2,
where sex role stereotypes (expectations) and sex type play and behavioral roles set in.
ADOLESCENT SEXUALITY
Adolescent sexuality generally involves
• Puberty – Physical changes, where one’s sexual organs develop causing the emergence of
secondary sexual characteristics e.g. deepening of voice, facial hair, etc. as well as
emotional sexual characteristics such as a surge in sexual hormones causing one to be
more emotional and aggressive (esp. among boys)
• Gender identity – how the youth’s internal perceives gender regardless of genetic or
physical appearances – this being independent of physical development
• Gender roles – i.e. Gender specific (feminine or masculine) behaviors, attitudes and
personality traits that are culturally reinforced and biologically driven. This differs from
society to society, but with the onslaught of globalization, views have become more open
with the push for gender equality.
• Sexual orientation – which is the predominance of erotic feelings, thoughts and fantasies
for one of the same sex. This however can be controversial on the issues on it being on a
o Biological basis,
o Unchanging over time or
o Resistant to conscious control, such that we question genes vs the environment.
Conservative views on one’s biology tends to be ingrained in many parents, whom
might blame the western influence over non-conventional orientations: LGBT.
However, the fluidity of sexual desire, behavior and identity may be a
fundamental characteristic of sexuality during the teenage years.
• Sexual choices – revolving around
o Abstinence – expressing sexuality w/o sexual intercourse
o masturbation – a reportedly common activity that young people commonly
explore during their developmental stage. However, the accessibility to
misleading information might reinforce anxiety e.g. excessive masturbation
causes side effects, which might not be true. Online sources cannot be verified,
thus it is important for parents & schools to properly educate adolescents.
o sexual activity.
SEXUALITY IN EARLY ADULTHOOD
Sexuality in early adulthood focuses on
• Romantic relationships and
• Being able to pro-create, thus
• Gender specific issues like
o Premature ejaculation - where it appears within a short time of initiation of sexual
activity, it creates an unsatisfactory sexual experience, which would in turn affect
a male’s ego as well as the relationship
 o Sexual drive – where there are differences in sexual needs e.g. the husband wants
it but the wife is tired – this may cause a lack of ‘passion’ in the relationship
o Pregnancy – is also a common misconception, as even during this period, a coupl
still can have sex.
SEXUALITY IN MID LIFE
Sexuality in mid-life involves
• Changes in intimacy as a result of issues like
o Mid-life crisis – declining sexual drive along with physical changes
o Erectile dysfunction among the males
o Menopause during the early 50s causing hormonal changes that causes one to
become irritable, private areas becoming dry, and basically a general reduction in
desire
o Andropause – is a result of testosterone production becoming low, resulting in
one getting tired easily.
• A solution to this would be hormonal replacement which is a possibility for BOTH genders
so as to improve their mood, relationship etc.
SEXUALITY IN LATER YEARS
Sexuality in later years generally involves
• Less sexual drive and ability
• Role of medications (e.g Viagra) to improve performance, although Viagra has potential
harmful effects on the heart (one’s cardiovascular health), thus this requires medical
assessment & prescription.
• Affection and intimacy

ABNORMAL SEXUALITY
Abnormal Puberty –
• this is usually medical problem related. It can refer to delayed or early puberty
experienced by e.g. A young child vulnerable to sexual abuse which caused trouble in her
brain such that there is a sexual hormone producing tumour.

Gender Identity Dysphoria (not happy + distressed with gender which does not match physical
traits – society accepted it – no longer a disorder)
• Exists when a boy or girl experiences confusion, vagueness or conflict in their feelings
about their own sexual identity (sees oneself as the opposite gender)
• Struggle between the individual’s anatomical sex gender and subjective feelings about
their sex
• Not due to physical intersex disorders
• Impairs functioning
o Challenges: identity, school, NS, social acceptance, might be teased
• A person who has undergone gender reassignment – ‘transsexual’

Abnormal relationships –
• ethical guidelines are very important esp. where there is an unequal relationship where
one party is more vulnerable e.g. teacher vs student / doctor vs patient

Abnormal sexual activities
• Defining the abnormal through
o Intensity/ severity
o Appropriateness (in privacy? Ok. Public? No.)
o Persistence
 o Pervasiveness (in what situation?)
o Impairment of function (does it prevent/continually distract you i.e. on your mind
the whole day?)
• Illegal
o Penal code 377 criminalizes homosexual activity between males

SEXUAL ABUSE
These incidents usually only get found out and disclosed sometime after as a result of an
unintentional leak.
• For example, adults using children and teens for sexual pleasure.
• These incidents are usually committed by people the child knows and has earned the
child/parent’s trust before moving in and acting on his/her ill intentions.
• Sexual activity with a child is ALWAYS wrong

Short term effects
• Severe: acute stress reactions, PTSD
• Shame, guilt, humiliation and stigmatization – this might be the cause of a family breakup
esp. when the perpetrator is within the family i.e. parent, such that the child then blames
themselves.
• Fear of repeated abuse, threats by perpetrator, STDs and AIDS as well as pregnancy
• Self-blame as well as blaming others esp. when a young person is removed from home i.e.
away from the perpetrator, at times, the child might feel as though they are getting
punished.
• Helplessness and frustration, when people around them do not believe them due to the
perception of such a trusting relationship between the child and his perpetrator.

Medium term effects
• Lowered self esteem
• Prolonged grief on what is lost
• Depression
• If severe, suicide or a suicidal attempt
• Victim may keep secret about the abuse
• Even retract the allegation of abuse in court

Long term effects
• Socially withdrawn
• School refusal and failure
• Sexual difficulties, relationship problems, marital trouble and family life problems
• Mental health problem
o E.g. personality disorder, eating disorder, perpetuator of abuse

Intervention of sexual abuse
• Get help (MSF 1800-7770000)
• Sometimes police report needed so as to instill fear in them not to do it again. However,
some individuals might be more recalcitrant and require more help/more severe
punishments
• Professionals and law enforcement need to
o Understand the family
o Strengths and risks
o Evidence gathering
 Treatment for sexual abuse generally involves the
• Prevention of further abuse
• Reducing the negative effects – e.g. the child protection officer has the power to remove
the child from the family if needed, to protect the child/prevent their exposure to harm,
at the same time
• Meeting the emotional, social and educational needs of the victim e.g. by not divulging
any information to anyone.

SEXUALITY DISORDERS
Basically, sexual disorders are mental health problems leading to sexuality difficulties. This can be
due to
• Mental illness e.g. depression with loss of interest resulting in e.g. reduced libido etc. or
• Medication side effects e.g. anti-depressants may cause erectile dysfunctions.
PARAPHILIA
An example of a sexuality disorder is paraphilia. This does not involve sexual intercourse, but
instead they derive sexual excitement from other perverse means.
• Paraphilia are sexual behaviors in which unusual objects or scenarios are necessary to
achieve sexual excitement. There is a
o Preference for nonhuman objects
o Preference for situations causing suffering
o Preference for non-consenting partners
FETISHISM
This is a case when a person is sexually aroused by a nonliving object which may range from
objects such as
• Panties and bra
• Boots, shoes, textured objects such as silk, velvet
• Body parts (feet, hair, ears etc).
Basically, an orgasm is reached when the person is alone, fondling the object. This happens
commonly among adolescents during masturbation, and is often done in secret, but found out as
a result of them stealing these objects. The fact that this obsession might manifest into other
offences such as housebreaking, leads us to a more severe problem to take into consideration.
SADISM & MASOCHISM
• “Sadist” refers to people who derive sexual pleasure from the pain of others
• “Masochist” applies to those who derive sexual fulfillment from pain inflicted on
themselves
• Both terms usual go hand-in-hand
• This can pose a danger, esp. when one tests the other’s threshold limit, and if unaware,
may result in death or severe debilitating consequences as a result of extreme types of
pain/torture.
EXHIBITIONISM
This involves the exposure of genitals in a public place, with
• 3 stark characteristics:
o Performed for unknown women
o Takes place where sexual intercourse is impossible
o Must be shocking for the unknown woman – this shock on the victim provides the
sexual thrill for the person
• No assault but considered more of a nuisance
• Cases have shown that often this is usually done by a timid male – whom is angry with a
dominant mother possibly and exhibits himself out them in a way to shame females.
VOYEURISM
 Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the act of
observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual
activity
• E.g. taking up-skirt photos
PAEDOPHILIA
Is the Act of deriving sexual pleasure through sexual contact with children (involves intercourse)
• Damage done to children can be severe
• Some pedophiles are known to the child
• Parents usually have no reason to suspect the pedophiles
Given that this offence is on children, usually Interpol is notified and the sentence is more severe.

TREATING SEXUAL DISORDERS
• Reduce deviant behaviour à Punishment
• Increase normal behaviour à Reinforcement
• Supervise and monitor
o This is where parents play a crucial part in balancing between
censorship/vulnerability and skills/support to determine what kind of
graphics/information/videos are exposed to children online.
• Psychosocial factors
• Medications

PREGNANCY
Pregnancy is a special phase in a woman’s life, however this also poses the highest risk of menal
illness in a woman’s life.

Before pregnancy
• Planned vs unplanned – medication may affect the development of baby
• Fertile vs subfertile
• Mental disorders
During pregnancy
• Antenatal depression
• Anxiety disorder
o At this stage it is extremely crucial to watch out for relapses of the above
conditions
After pregnancy
• Postnatal blues – very common, affecting as much as 10% of mothers; characterized by an
excessive worry over their child’s development
• Postnatal depression
• Postnatal psychosis – the danger here lies when mothers feel like killing themselves
together with the baby



Lecture 8: Stress, Emotions and Disorders

DEFINITION OF STRESS
Stress is an event that causes a response from the individual, a situation that causes him to adjust
(depends on the degree of the stress level e.g. war vs increased workload), make changes to his
normal routine. These changes may be physiological, psychological or social and the individual
may be unaware of them.

Types of stress
• Physical stress – linked to environment
• Physiological stress – perspire more etc. when working out
• Psychological stress – mental
o Acute (short term) vs Chronic (long term)

STRESS RESPONSES: GENERAL ADAPTATION SYNDROME
Fight or Flight (Alarm)
• Intense ANS arousal (BP, heart rate, respiration) – to prepare you for action – survival
instinct; heart pumps faster
Resistance
• Prolonged (not sustainable) state of moderately high arousal (heightened stage of alert)
• Resistance saps energy & weakens immune system – may reach stage of exhaustion
Exhaustion
• Vulnerability to illness increases
• Physical illnesses become more common
Stress responses however depend on factors like
• Age – younger: more vulnerable to stress
• Gender – controversial (no evidence as of yet)
• Personality factors
o Those with personality disorders: Cluster C – anxious & avoidant
o Type A goal setters – more @ risk of stress & health effects like high blood
pressure etc.
• Intelligence – 2 extremes
o Intellectuals with jobs that demand a lot – causing stress
o Low achievers whom lose out to friends and hence, experiences stress
• Environment
o Relationships: Home, school, friends – e.g. those who delve in the arts: more in
touch with feelings & temperamental?
• Physical health – chronic issues (mental/physical) e.g. disabilities, stigma etc.

EFFECTS OF STRESS
According to the Yerkes Dodson Relationship,
• Low stress levels result in low productivity, whereas
• mid-high stress levels result in increasing alertness towards one’s optimal level, such that
productivity reaches its peak
• excessively high stress levels however cause increasing anxiety, which results in low
productivity as one cannot make proper judgment
GOOD STRESS BAD STRESS
Also called Eustress (motivated to be Chronic (long-lasting)
productive) • Out of one’s control
• Have positive outcomes
 o Earning a good grade • Intense, e.g. life-threatening, severe
o Graduating consequences (overwhelms our ability
o Working at a new job to cope)
o Making more money • Unexpected – natural disasters / near
o Getting married miss death
o Going on vacation
CAUSES OF STRESS: EXPECTATIONS
Our expectations very often are the main causes of stress. These expectations come
• Internally – Personal, Parental/teachers, Peers
• External –societal
Thus, we should adjust our expectations of ourselves and others to something more reasonable &
realistic.
SIGNS OF BAD STRESS
Cognitive dysfunction
• Impaired concentration, memory
• Poor judgment/decision making
Negative emotions
• Hostility (Anger, Irritability, Frustration, etc.)
• Anxiety
• Depression
• Fear
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
o Family life
o Work life
o Friendships
o Leisure activities
• Distress for the person
• Disruption for others – family may be affected due to increased irritability etc.
MANAGING STRESS
To manage stress, one must
• Understand your own strengths and weaknesses
o Adjust expectations and
o Know when to seek help
• Skills that would be useful are learning to : prioritize, manage time, organization
• Support from: Family, Friends, Fun, Food (nutrition), Faith, Future (optimism) is also impt.

Several coping skills are
• Relaxation
• Building confidence
 • Desensitizing fears – how to face your fears
• Handling worrying thoughts – jot it down, tell someone to share burden
• Reward yourself
• Physical conditioning
• Setting goals: realistic, stepwise

EMOTIONAL DISORDERS
• Common
• Internalizing problems
• Females > Males (Studies have shown – as a result of internalizing one’s problems)
• Anxiety, depression most common
o According to a Singapore Mental Health Study in 2009-2010, among 6616 Adult
SG Residents, the lifetime prevalence of
§ Mental illness 12%
§ Depression 5.8%
§ Generalized anxiety disorder 0.9%
§ Obsessive compulsive disorder 3%
§ Alcohol dependence 0.5%
• Anger is not usually classified as a disorder
ANGER
• Is more of a common emotion
• However, aggression involves harmful, threatening or antagonistic behavior
o Verbal and other forms of communication
o Physical
• Violence denotes the “forceful infliction of physical injury”
• Risk assessment – estimating the danger that one poses to others
Risk Assessment 1 Risk Assessment 2

Severity of Current Aggression Family features
• Serious violence/harm • Parental antisocial personality disorder
• Victim characteristics, e.g. vulnerable – • Domestic violence
might not have provoked him; • Abuse, neglect, rejection
alcoholism; gangsterism Personality features
• Intention and motive – e.g. anti-religious • E.g. anti-social traits
views that triggered Substance use (e.g. alcohol)
• Attitude
• Victim empathy and compassion for
others
Past Aggression
Past Behavioral Problems
• Fire-setting
• Cruelty to animals or people
Similar to treating any mental health problem, e.g. substance use, we must
• Manage the personal factors such as
o Medications
o Counselling/ Psychotherapy
• Manage the social environment
o Family: e.g. repair relationships
o Work/school
o Safety issues
FEAR
• Is a normal response to threat or stressful events
• Usually short-lived and controllable
• Functions as ‘Alarm’ mechanism
• ‘Normal’ developmental fears:
o 6 mths: novel stimuli (e.g. strangers)
o 6-8 mths: height, worse when learning to walk
o 3-5 years: animals, dark, monsters
o 6-11 years: shameful social situations
o Adolescence: death, failure, social gathering

However, we determine when fears become abnormal when there is
• Appropriateness
o Sociocultural
o Developmental
• Intensity/ Severity
• Persistence across time
• Pervasiveness at home/out of home
• Functioning – can one still go to school/work? Have a relationship?
ANXIETY
Signs of anxiety: Thoughts (Cognition)
Emotional • irrational thinking – jumping to conclusions
• irritability or moodiness • poor decision-making
• crying • forgetfulness
• excessive worrying • poor concentration
• panicky, • negative thinking – “What’s the use?”
• jumpy, feeling on edge • helplessness and hopelessness thoughts
• passive or emotional withdrawal • self-blaming – “I’m useless”
• feeling overwhelmed • confused or fuzzy thinking

Physical Behavior / Actions
• palpitations • feeling tired & listless
• muscle aches • restlessness
• stomach upsets, • nervous habits
• diarrhoea or constipation • poor eating habits
• skin rashes • drinking more alcohol
• jaw pain, grinding of teeth • consuming more coffee
• dry throat or lump in throat • smoking more cigarettes
• dizziness • poor sleep
• frequent urination or going to • falling ill – colds, coughs, infections
toilet • sexual problems or lowered sex drive
• sweating • violent outbursts or aggressive actions
ANXIETY DISORDER
Is characterized by excessive & uncontrollable worries and fears. In order to diagnose it as a
problem, individuals usually experience the following symptoms for a period of 6 months or
more, impairing one’s functioning.

Symptoms include:
• restlessness or feeling keyed up or on edge
• being easily fatigued
 • difficulty concentrating or mind going blank
• Irritability
• muscle tension
• sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)
TYPES OF ANXIETY DISORDER
Worries & fears Disorder Age of onset Duration
about:
Separation Separation anxiety Early childhood Brief
disorder
Anything & Generalized Childhood to early >20 years
everything anxiety disorder adulthood
About specific Phobia Early childhood to Brief
situations or people adolescence
About strange Social anxiety Early adolescence >20 years
situations or people disorder
No reason (during Panic disorder 19-30 years >10 years
panic attack, worry
about dying)
Senseless fears (e.g. Obsessive Childhood to adolescence Waxes and wanes
contamination) compulsive
disorder
INTERVENTION OF ANXIETY DISORDER
Treatment of anxiety disorders involves
Biological Individualized, psychological treatment alone is
• medications effective in many cases.
Psychological
• increasing awareness However, more often than not comorbidity occurs
• changing behaviors where there is one or more additional disorders co-
• improve cognitions & skills occurring with anxiety disorder.
• e.g. cognitive behavioral therapy
Social Most important treatment for anxiety disorders, is
• family work & therapy patient motivation, through therapist motivation.
• school/work peers
Managing anxiety begins from fear, where we then choose whether to take a realistic or
unrealistic approach. A realistic approach deals with the danger head on so as to diminish the
fear. On the other hand, the unrealistic approach follows 2 ways; namely the mild approach of
reassurance support which is a gradual way to diminish fear and expose the individual to
desensitization, as well as the severe approach of skills training which tends to be anxiety
provoking, exposing them to extreme measures all at once, to desensitize them at one go, helping
them face their fear. Desensitization very often involves classical conditioning, to remove the
association of the negative connotation with the object.
Medications for anxiety disorder involves 3 groups of drugs:
• Antidepressants which act to increase the
o E.g. Selective serotonin reuptake inhibitor (SSRI). This may take time to
work/build up – 1-2 weeks
• Benzodiazepines (‘sleeping tablets’)
o Addictive, so usually used for short period – so as to tranquilize and bring a
calming effect to the individual
• Antipsychotics are only used for severe cases and is fairly uncommon.
DEPRESSION
Is a reaction to a loss, with the main problem being the suicide risk.

The diagnostic criteria of depression is such that five or more of the following symptoms are
present most of the day, nearly every day, during a period of at least 2 consecutive weeks.

The symptoms must cause clinically significant distress or impairment in social, occupational, or
other important areas of functioning. Of which they are:
1. Depressed mood
2. Loss of interest or pleasure in all, or almost all, usual activities
(at least 1 of the first 2)
(with the bottom having 4-5)
3. Significant weight loss or weight gain
4. Insomnia or hypersomnia
5. Psychomotor agitation or retardation
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive or inappropriate guilt
8. Diminished ability to think or concentrate or indecisiveness
9. Recurrent thoughts of death or suicide
INTERVENTION OF DEPRESSION
Common treatment options are:
Antidepressant medications
• Selective serotonin reuptake inhibitors (SSRIs)
• Other antidepressants (selective norepinephrine reuptake inhibitors [SNRIs], atypicals)
• Tricyclic antidepressants (TCAs) Monoamine oxidase inhibitors (MAOIs)
Psychotherapies
• Cognitive therapy – to correct cognitive errors
o Filtering – filter out the good instead of focusing on the negative
o “Black and White” Thinking – correct the inflexible & extreme thinking
o Overgeneralization e.g. all of my friends hate me
o Jumping to Conclusions
o Catastrophizing
o Personalization
o Control Fallacies
o Fallacy of Fairness
• Behavioral therapy
• Interpersonal therapy
• Psychoanalytically oriented therapy
• Family therapy
Combined medication/psychotherapy / Other
• Electroconvulsive therapy – if the person refuses food/drink
• Phototherapy (light therapy) – usually for those who get depressed during winter
• Hospitalization
SUICIDE
Suicide is an intentional act of self-destruction. Possible causes are
Sociological
• Changes in family structure (families getting smaller)
• Marital breakdown
• Changing cultural values & religious practices
• Unemployment/employment
• Alcohol & substance misuse
• Increased availability of methods of suicide
Psychological
• Mental well-being
• Personality
• Psychosocial
Biological
• Genetics
• Psychiatric illness
• Physical illness

Within Singapore, suicide is most common within the elderly. Those with a high suicide risk
commonly feel
• a sense of hopelessness (negative outlook in life), resulting in their
• suicidal intentions. Furthermore, those with
• recent suicide attempts with planning (tend to have lower risk) as compare to those who
attempt to avoid discovery (which tends to have a higher risk) given their lack of regret.
• The presence of environmental resources for attempt such as high rise buildings or arms
are also contributing factors. Another main factor is the presence of an
• Unstable mental state e.g. being depressed which removes their rationality, coupled with
• Demographic risks
o S: Male sex (males complete suicide, even though more females attempt them)
o A: Older age
o D: Depression
o P: Previous attempt
o E: Ethanol abuse
o R: Rational thinking loss
o S: Social supports lacking
o O: Organized plan
o N: No spouse
o S: Sickness – esp. chronic illness
SUICIDE INTERVENTION
This involves developing rapport
• Time
• Trust (empathy, objective)
• Truth
Helping the Person cope
• Symptom treatment with medications
• Support
• Skills for problem solving

During a crisis, it is important to immediately
• Get support; knowing which numbers to call; at the same time
• Using distractions, communicating hopes and dreams –
• Things the teen still want to do, and making them
• Think of all the important people and how they would react towards their suicide,
perhaps also getting the individual to sign a
• No harm contract and also develop a
• Crisis plan for oneself, after knowing of the child’s attempt. This involves knowing the
o Important numbers: of Doctor, psychiatrist, crisis helplines.
o Knowing who to call first, followed by who if the call cannot through – basically
planning a scenario out to determine what actions to take
 After suicide, it is important that grief work is done, and that there is
• Support for the family, the school as well as individuals whose grief are not properly
resolved and may experience increased risk of depression.
• Responsible sensitive media reporting is also essential





Lecture 9: Addictive Disorders

The issues regarding substances in mental health commonly revolve around
• Substance – drugs, alcohol, smoking,
• Behavioral – gambling, internet gaming
SUBSTANCE ABUSE
Substance abuse – is a pattern of proactive substance use that is causing damage to health
• Problems with the use includes health, psychological, financial, social and legal matters
• 70% of new drug abusers tend to be young, i.e. <30 years old, with the highest figures
being among the more economically active individuals from 20-40 years old.
• This is probably due to the high cost of attaining the drug for consumption.
• Methamphetamine (ice) and Heroin are the most common drugs used by abusers.
SUBSTANCE WITHDRAWAL
Substance withdrawal – can be seen from symptoms associated with cessation/reduction of
prolonged and heavy use, of which may or may not be associated with dependence
• causes significant impairment
• addiction (Esp. to heroine) may arise to relief oneself of the withdrawal effect – that can
be harrowing: common trauma etc.
SUBSTANCE INTOXICATION
Substance intoxication – is the development of substance specific symptoms that are reversible
after ingestion or exposure
• Often results in Maladaptive responses (e.g. mood lability, impaired judgment) but
• The person will recover
• When the substance is in effect = person is intoxicated
SUBSTANCE DEPENDENCE
Substance dependence – is when an individual is taking or has a strong desire to take the
substance (often at a regular schedule), and three or more of the following are experienced or
have been exhibited some time during the previous year (usually prolonged period of use >/=1 yr)
• A strong desire or sense of compulsion to take the substance – strong urge to use it /
planning how to get his/her next fix such that she becomes fidgety/uncomfortable
• Difficulty controlling substance taking – failure of efforts to quit
• Physiological withdrawal state
• Neglect of alternative pleasure or activities – they spend so much time on the substance
that they give up other things like work & relationships resulting in absenteeism which
might lead to financial difficulties etc.
• Persisting with use despite evidence of harmful consequences
• Narrowing of personal repertoire of substance use behaviors (very regular e.g. morning &
evening)
• Evidence of tolerance – take more and more
Tolerance becomes an issue when medication ceases its effects such that there is a need to
increase the dosage for the same effect.
• As drug use increases, the tolerance level develops. This means that larger quantities of a
drug are needed to maintain the same 'high'.
• Soon the addict feels that he cannot survive without the drug as he will have to take the
drug to relieve unbearable pangs of withdrawal.
• This is when the addict's life turns into a vicious cycle of desperate attempts to get drugs
for his next fix to avoid the withdrawal symptoms.
SUBSTANCE INDUCED PSYCHIATRIC DISORDER
Substance induced problems are a result of the substance’s effect on the brain which causes
cognatic problems that induce psychiatric problems
 • E.g. mood disorders
• MDMA (Ecstasy) causes: Confusion, anxiety, sleeplessness, depression, paranoia
(anxiousness, hallucination)
• Inhalants causes one to be: Like on alcohol intoxication, brain toxicity – often, young
people tend to experiment with inhalants
• Steroids cause: Mood swings, psychotic episodes – although steroids are commonly found
in medication, but long term use/abuse will still cause problems.

ALCOHOLISM EFFECTS
To identify a problem with alcohol, one can assess if a request to
• cut down results in
• anger and thereafter
• guilt such that the person receives an
• eye opener.

Medical complications of alcohol dependence are:
• Liver cirrhosis – chronic liver disease resulting in a hard shrunken liver that fails
• Cancers of the oropharynx(mouth), larynx, esophagus, rectum, liver, breast
• High blood pressure
• Stroke
• Cardiac disease
Social complications are:
• Road Traffic Accidents (drink driving)
• Risk of being arrested/victim of violent crime esp. when one passes out/blacks out when
drunk e.g. at a pub – puts oneself vulnerable to theft, rape etc.
• Problems with family/friends/work
• Financial problems – e.g. heroin/alcohol is expensive, and to fund such dependency, one
might turn to loan sharks

CAUSES
The reason why people develop addiction is due to the vulnerability factor inherent in them i.e.
• Genetics
o Acetaldehyde gene (ALDH2) – the gene which metabolism depends on: Asian
genes tend to be less active, hence a lower tolerance where the product gets
broken down slower resulting in greater discomfort e.g. hot flushes which can
also be seen as protective as this will then prevent people from over-consuming
o DRD2 gene
• Brain mechanisms
o Activation of the meso-limbic dopamine system ‘reward circuit’ – experiences
pleasure when the pathway is activated, causing compulsion, which reinforces the
brain’s drug-seeking factor
• Social factors
o such as one’s profession i.e. as a bartender, accessibility, casinos
• Drivers
o People tend to experiment – out of curiosity just to feel what it is like initially.
o Or perhaps it is out of desire for fun and a certain amount of relief.
o Social acceptance is a key factor also as often one is
o Influenced by friends (peer pressure) into taking drugs/consuming alcohol.
 o Another common driver, is to escape from harsh reality and boredom as a result
of marital problems between parents, family tensions, parental neglect, or an
inability to perform in school.
o Most importantly, there is a mistaken belief that occasional abuse will not lead to
addiction – an endless cycle.
PSYCHOLOGICAL CONCEPT OF STAGES OF CHANGE
Can start at any point, is a cycle no definite start point – Does not always follow a constant order.
1. Pre-contemplation – Individuals have yet to consider if they should stop their addiction
2. Contemplation – Individuals start to consider stopping, usually as a result of e.g. the
doctor telling them to stop for health benefits.
3. Determination – Individuals feel motivated and determined on their journey to quit,
usually getting an accountability partner
4. Action – At this point positivity is at its peak, as the individual takes steps to cut back on
addiction.
5. Maintenance – This is a crucial point which determines whether this results in a
permanent exit from addiction. At this point, the individual has put in much effort to stop,
however, some may suffer a relapse.
1. 5A. Permanent exit – Individuals successfully maintain an addict-free life where they are
not bound by their urge to consume the substance on a dependent basis.
2. 5B. Relapse – Individuals return back to point 1 of the cycle, where they are at pre-
contemplation to quit again, as their mind cannot overcome the urge of addiction.
TREATMENT APPROACHES / INTERVENTION
• Abstinence – involves the complete cessation of drug use, such that there is zero
tolerance for the individual. Local treatment commonly undertakes this approach, in
order to let the body adjust immediately to a substance-free system.
• Harm reduction – involves only a partial stoppage so as to reduce harmful consequences.
For example, instead of injecting the drug into the blood stream, alternatives are given
e.g. through sniffing etc. The primary intention is to help individuals avoid using
contaminated equipment especially when sharing, firstly to reduce the dangers of
unhygienic injections are fatal given that they can block up blood vessels, causing body
parts to turn black resulting in amputations. This is especially the case for heroin addicts
who commonly consume the substance intravenously. However, this method is also
contentious as to whether it is a viable treatment, as one is merely providing an
alternative means involving a lower risk of harm to the individual, but not helping the
individual reduce their dependency on the substance.
• Other methods are:
o Motivating the person to change e.g. through motivational interviewing –
§ Using reflective listening – where the doctor listens more than they ask.
This is often more useful as the patient might feel that the doctor cannot
understand how it feels like to be under the control of drugs. Thus, if the
doctor asks, the patient often tends to question the doctor’s experience
under the drug, and tends not to listen to advice.
§ Improve motivation for change
§ Relapse prevention

Medical treatment: Stages
Medical treatment is to help individuals through their withdrawal period safely. Immediate
cessation is not recommended as this can cause a ‘cold turkey’ on the individual i.e. death from
side effects like fits etc.
• Detoxification
 o This usually takes about one week of time, where it is usually used for individuals
with dependence issues. The main aim of detoxification is to safely stop the
substance. This can be done through e.g. replacement therapy with
methadone/buprenorphine, tailing off gradually in a controlled environment; or
through treating withdrawal symptoms e.g. anti-diarrheal, painkillers etc.
o However, there exists the danger of an abuse of replacement therapy, if not
conducted appropriately. E.g. the replacement of heroin consumption with
subutex – which was at a point in time legal for medical use resulted in individuals
reducing their consumption of heroin, but at the same time converting to
substance abuse with subutex. Subutex when combined with sleeping tablets
provided them with a ‘super high’ euphoric feeling that was highly addictive.
However, the danger of sleeping tablets is its inability to dissolve, thus over-
consumption posed the risk of one’s limbs getting amputated. As a result,
Subutex became an illegal controlled drug, resulting in individuals turning back to
heroin which wrote off the sharp decrease in drug abuse trend.
• Rehabilitation
o This usually takes a more extended period of time, ranging from 6 months to
several years depending on the severity affecting the individual. Rehabilitation is
usually done through counselling, hospital based programs, halfway houses or
support groups, such as Narcotics Anonymous or Alcoholic Anonymous. These
forms of support provide structure and support needed to help individuals tide
through long periods of abstinence. An example is the 12-steps of AA which
represents a group effort to reach a common goal together.

Prevention through Public policy
• Through control measures such as
o Legal measures (law enforcement)
o Cost (legal substances) e.g. taxes and
o Limited usage (legal substances), as well as
o Public education – so as to reduce acceptability of such vice activities. E.g. ‘say NO
to drugs campaign’
• Singapore adopts a zero-tolerance on drugs as seen through its legislation where it instills
a death penalty on any drug users or drug traffickers of e.g. heroin and morphine. This is
to set down a stand that prevention is better than cure.

SMOKING
• Smoking albeit less severe than drugs, can cause death among individuals too.
• Half of smokers die as a result of habitual smoking and 1/3 do so before the age of 65.
• Furthermore, there is a common model effect where if someone in the family smokes –
more often than not, the child follows.
• Tobacco/nicotine dependence result in withdrawal syndromes (often 4/more in an
individual):
o Dysphoria o Poor concentration
o Insomnia o Restlessness
o Irritability o Decreased heart rate
o Anxiety o Increased weight gain
TREATMENT / INTERVENTION
• Prevention of commencement is the most effective and primary way to prevent the
development of habitual smoking. Other forms of treatment are by:
 • Helping smokers quit i.e. smoking cessation clinics, health effects images on cigarette
packs – although these efforts have proven to be notoriously ineffective as people tend to
get desensitized to them, becoming ‘contented smokers’
• Less harmful smoking e.g. e-cigarettes
• Encouragement to reduce environmental smoke e.g. through designated smoking areas,
bans, taxes
• Nicotine replacements

BEHAVIOURAL ADDICTIONS
• Non-substance addictions
• Gambling and internet /gaming addictions tend to be the more severe behavioral
addictions in Singapore.
• Other types of addiction are also sex addictions etc.

GAMBLING ADDICTION
The typical profile of a gambler (i.e. with relatively higher gambling rates are):
• Chinese individuals that are
• Male
• Aged 40-59 years’ old
• With an education only reaching up to PSLE standard and a
• Monthly income of $4000 and above.

Gambling participation by type is 4D (38%), TOTO (28%), and Big Sweep (16%)
GAMBLING DISORDERS
Persistent and recurrent problematic gambling behavior leading to significant impairment as
indicated by 4 (or more) of the following:
(1) is preoccupied with gambling (e.g., persistent thoughts about past gambling experiences,
planning the next venture, or thinking of ways to get money with which to gamble)
(2) needs to gamble with increasing amounts of money in order to achieve the desired
excitement
(3) repeated unsuccessful efforts to control, cut back, or stop gambling
(4) is restless or irritable when attempting to cut down or stop gambling
(5) gambles as a way of escaping from problems or of relieving a dysphoric mood (e.g.,
feelings of helplessness, guilt, anxiety, depression)
(6) after losing money gambling, often returns another day to get even ("chasing" one's
losses)
(7) lies to family members, therapist, or others to conceal the extent of involvement with
gambling
(8) has jeopardized or lost a significant relationship, job, or educational or career
opportunity because of gambling
(9) relies on others to provide money to relieve a desperate financial situation caused by
gambling
TREATMENT
• Prevention is better than cure – Thus the government tries to prevent locals from
entering casinos by placing a $100 entry fee
• Gamblers Anonymous – a support group that help gambling addicts with repayment
problems
• Cognitive behavior therapy (depends on motivation) – in order to help individuals during
their relapse back into gambling.
• Treat other problems – depression, suicidality, broken family relationships

INTERNET / GAMING ADDICTION
• Given the nature of this addiction being online, this is harder to detect and prevent, as
compared to i.e. preventing a family member from entering the casino.
• Furthermore, with the many different platforms and media outlets – phone, tablet etc. it
is only defined as a disorder through its (HOW TO IDENTIFY DISORDER)
o Severity
o Pervasiveness
o Persistence
o Appropriateness
o Functioning
INTERNET GAMING DISORDER
Very often it is difficult to use time as a factor alone, à we should base of diagnosis on
consequences.
• Preoccupation with Internet games
• Withdrawal symptoms when Internet gaming removed
• Tolerance: increasing amounts of time spent on Internet gaming
• Unsuccessful attempts to control Internet gaming
• Loss of interest in previous hobbies/recreation as a result of Internet gaming
• Continued excessive Internet gaming despite knowledge of psychosocial problems
• Deceived family members, therapists or others about amount of time spent on Internet
gaming
• Use of Internet gaming to escape or relieve a negative mood
• Jeopardized or lost a significant relationship, job or educational opportunity as a result
PROBLEMS OF THE INTERNET USAGE
As much as the Internet allows for easy information access, learning activities, allowing better
communication and recreation,
• The fact that the communication at times is anonymous throws doubt as to whether this
is truly ‘safe’ e.g. for an individual to share personal information etc. Indeed, it might be
argued that the instantaneous responsive nature which bridges geographical barriers
allows one to attain support from a community without compromising one’s identity,
however, this also results in problems if one is not discerning.
• The Internet facilitates problematic behavior when one engages in malicious/unhealthy
activity e.g. cyber bullying, online gambling – where it is hard to detect online.
• Not only does this perpetuate negative behavior but especially when one lacks
discernment and proper judgment, mis-information is common among internet users and
advice from anonymous support groups or perhaps bullies might at times be questionable
and can result in suicides.
• This accessibility to harmful information like pornography or extremist ideas also results
in online predators e.g. sexual predators, terrorists etc.
o abusing the Internet to woo ignorant and vulnerable individuals like the young or
those with mental health problems – people whom often use the Internet to
relieve deficits i.e. reduce anxiety.
o These people groom victims online making trust and giving treats before acting
upon their ill intentions.
• It should be noted that excessive gaming or Internet usage can also cause mental health
problems like depression/anxiety.

• Physical
o Injuries from overuse
 o Lack of rest/ sleep
o Poor nutrition
• Psychological
o Obsessions
o Compulsions
o Emotional outbursts
• Social
o Reduce peer interactions
o Poor family life
INTERVENTION
• Prevention
o Parental control from young
o Monitor use
o Controls
§ Time control
§ Web safety
o Education: Touch Cyberwellness Programme - a community based programme to
help children to learn controlled computer use (harm reduction approach)
§ Social skills and assertiveness training
§ Problem solving skills
§ Relaxation and stress management training
§ Behaviour Management



Lecture 10: Old age and mental health
Key issues:
• Retirement,
• Dementia (+ depression) – main psychological problem of the elderly
• Problems
TREND
• Females tend to outlive males
• Retirement age in Singapore is increasing as life expectancy increases
CHANGES / DIFFERENTIATING FACTORS
• Entering retirement
• Usually 55-75 years’ old (65)
Growing old is a state of the mind & body, where one will experience
• Physical changes
o Skin
o Hair loss
o Senses (dulled) – reduction in cognitive functions
• Psychological changes
o Memory (poorer)
o Reaction time (slower) – as a result skills tend to deteriorate e.g. driving skills
deteriorate, judgment impaired etc.

• Personality does NOT change as a person ages
• Personality is often quite predictable and hard to change albeit mild changes might occur
e.g.
o Adaptation to stress improves
o Mellowing effect: less bothered by minor stress
o Less emotionally reactive
RETIREMENT
• Seen as a significant life event where there are
o Role changes
o Social relations change
o Economic status change
• To prepare for retirement – one needs to do
o Economic preparation (financial planning) for the period coming where there will
be no constant income from employment
o Social preparation – such that elderly individuals are productively contributing to
society and maintain independence. This commonly involves their
§ Spouse
§ Family
§ Friends / community
§ Volunteerism
o Health
§ Physical: healthy lifestyle – through e.g. resident’s corner etc.
§ Mental: finding interests and hobbies
SLEEP CHANGES (INSOMNIA)
• Elderly in fact need less sleep, thus they find themselves at times sleepless at night.
However, they require power naps during the day.
o It should be noted that this is easily misconstrued by the elderly as insomnia.
o However, we should also not overlook the true presence of depression which is
an insomnia-related problem.
 • Singapore Longitudinal Ageing Studies: insomnia affects 18% elderly
• Insomnia also associated with physical illness and psychiatric illness
• Sleep problems include difficulties falling asleep, frequent awakening and early morning
awakening
TREATMENT / INTERVENTION OF INSOMNIA
• Sleep hygiene
o Avoid stimulants e.g. caffeinated beverages, perhaps only consuming them in the
morning
o Avoid alcohol – which disrupts the quality of one’s sleep (even though on can fall
asleep more easily)
o Less daytime naps
o Regular sleep routines
o Avoid heavy meals – which may cause reflux, making one’s sleep uncomfortable
o Reducing fluids in the evening – which disrupts sleep due to the need to urinate.
This is an especially common problem among males, due to their enlarged
prostate gland which obstructs urinary flow, making their bladders fill up quicker.
• Relaxation exercises
• Medications (last resort) – This is a type of treatment where the elderly must exercise
extra care, given their inactive livers such that medications tend to last longer. Drowsiness
might result in accidents that are fatal i.e. falls which cause broken bones/fractures that
lead to hospitalization and other complications from there.

DEMENTIA
• Is a group of disorders.
• Poor memory does not equate to dementia; it is merely one defining feature.
• Dementia is also not part of ageing, as most elderly do not get it. It simply gets more
common after the age 65.
• Dementia is rather, a loss of cognitive functions that interfere with life, such that
o Higher thinking abilities are declining, same for
o Remembering
o Reasoning/judgment
o Orientation in terms of time, place and person (recognition).
TRENDS
According to the National Mental Health Survey of the Elderly in 2003, albeit this being an old
study, the prevalence of Dementia in Singapore is such that the risk increases with age.
• ≥ 60 years – 5.2%
• ≥ 65 years – 6.0%
• ≥ 75 years – 13.9%
The number of new cases of dementia in Singapore is projected to increase from 22,000 in 2005
to 186,900 by 2050.

A 2015 WISE Study indicated that in Singapore
• 10% of those aged above 60 have dementia.
• As one gets older i.e. above 85, the risk increases to around 20%.
• Furthermore, those who had a stroke before, also have a higher risk of dementia.
• Unemployed individuals or those with lower educational levels also tend to be associated
with having dementia, probably due to reduced engagement where there is lesser mental
stimulation.
Costs on support/caregivers are also fairly significant as
• Half of those with dementia need to be cared for by paid help
 • Caregivers of people with dementia also are significantly more distressed and suffer
psychological problems
o Essentially causes a lot of problems for caregiver
• Ultimately leads to death
o Esp. if with no proper care and nutrition, individuals become bedbound and prone
to infection
SYMPTOMS
These symptoms often need assessment by a professional i.e. doctor. The range of possible
presentations are:
• Impaired memory and thinking (most common) – that affects day to day functioning
• Disorientation and confusion – getting lost esp. in terms of time, place, person
• Misplacing things – as a result of short term memory
• Abstract thinking affected – cannot make conclusions or deductions
• Trouble performing familiar tasks – e.g. forget how to cook / wear clothes (advanced
dementia)
• Changes in personality/mood and behavior – more irritable / quarrelsome
• Poor or decreased judgment – spending excessively (cannot judge value of $)
• Inability to follow directions
• Problems with language and communication – cannot express themselves
• Impaired visual and spatial skills – unaware of things around them e.g. cannot gauge the
space to park etc.
• Loss of motivation or initiative – don’t want to do things
• Loss of normal sleep patterns

Behavioral and psychological symptoms of dementia (BPSD)
• These affect 70-90% of people with dementia
• Behavioural symptoms: restlessness, physical aggression, screaming, agitation,
wandering, culturally inappropriate behaviours, sexual disinhibition (vulgarities),
hoarding, cursing & shadowing.
o Basically, individuals become hard to get along with – leading to psychological
problems as they become suspicious etc.
• Psychological symptoms: Anxiety, depressed mood, hallucinations & delusions (paranoid)
o False beliefs e.g. think people are trying to harm them/steal their things – may
breed into family unhappiness.
CAUSES
There are many different causes of dementia, all of which cause brain degeneration:
• Alzheimer's (commonest)
• Stroke/Vascular (next commonest) – paralysis (damage of the brain leading to brain
death: due to reduced blood supply)
• Dementia with Lewy Bodies
• Head Trauma
• Other medical causes e.g. Creutzfeldt- Jakob Disease, Huntington's Disease, HIV Disease,
Parkinson's Disease, Substance-Induced

Alzheimer’s Disease
• Most common cause of dementia
• About 20,000 Singaporeans - a prevalence rate of 5.7%, suffer from dementia
• Projected to more than double to about 45,000
• Risk factors
 o advancing age, female sex, head trauma, depression, family history (hereditary
esp. with early onset – related to individuals being at higher risk due to the same
gene)
• Protective factors
o higher education, anti-inflammatory medications, and possibly statin medications
• Causes:
o Familial early onset Alzheimer’s Disease
§ Abnormal genes: APP, PSEN1, and PSEN2
§ Can predict this onset, but cannot treat or prevent it
o APO-E, a genetic polymorphism in which the 1 or 2 copies of the e4 allele confer
susceptibility in late onset AD
§ Chromosome 21 contains this gene – thus esp. in individuals with down
syndrome whom have 3 copies of this gene, this puts down syndrome
individuals at a higher risk of early onset of Alzheimer’s disease.
INTERVENTION
Medication Treatment
For dementia (slows progression for about 8-10 years, does not cure – there is no cure)
• Medication treatments
o However, for those with advanced dementia, medication has little value
For mood or behavior problems
• Antipsychotic medication
• Antidepressants
For future stroke prevention (this is preventable unlike Alzheimer’s disease / dementia)
• Medicines for high blood pressure and high cholesterol, etc
• By treating treatable conditions, this can thus prevent stroke i.e. brain damage and thus
prevent dementia.

Other Treatment
• Educational programs offered to family caregivers to
o improve caregiver satisfaction – domestic helpers need to be trained
appropriately. Especially when care involves intimate contact, a person with
dementia might misunderstand one’s intentions
o delay time to nursing home placement
• Behaviour modification, scheduled toileting, and prompted voiding reduce urinary
incontinence
• Functional independence can be increased by graded assistance, skills practice, and
positive reinforcement.
o For example, open window (to orientate them in terms of time of the day), large
fonts and wearing tags etc. can help orientate them with relation to time, place
and person
• Non-drug therapies
o Music therapy
o Art therapy
o Movement therapy
o Reminiscence therapy – more common – involves bringing back
childhood/younger days i.e. fond memories
o Memory training
o Reality orientation
o Validation therapy
o Self-maintenance therapy
o Behaviour therapy
 o Milieu therapy
o Staff training

Prevention
• Starts with helping them stay mentally stimulated.
o Read, write, play cards, crosswords or boards games. Learn a new language or a
musical instrument. Engage with the community @ senior citizen’s corner
• Maintain an active social life.
o Meet up for meals and activities with your family and friends.
o Volunteer, join a club, or participate in community events.
• Eat a healthy diet. (physical health)
o Increase your intake of fruits and vegetables. Take less sugar and salt, and choose
food low in fat and saturated fat.
• Keep physically active. (less home bound – more socially active too)
o Exercise increases blood circulation and may improve brain function. Get active
by brisk walking, dancing, or practicing qigong.

DEPRESSION
Another mental health problem of the elderly – the most common due to higher risk of social
isolation when old i.e. there is a lack of social support when a partner passes on / family leaves to
build their own families etc.
• 7% of the elderly suffer from this based on a survey in Singapore
• Symptoms are similar to depression at any age
o Emotional symptoms
o Physical symptoms
o Psychological symptoms
INTERVENTION
Policies and governmental efforts
• National mental health policy and blueprint
o Initiated in 2007
o The Singapore government has committed $178 million to be spent towards
building an emotionally resilient society with access to good mental health
services.
o Built upon 4 strategic thrusts
§ Mental health promotion
§ Integrated mental health care
§ Developing manpower – healthcare sector and social sector
§ Research and evaluation
• National Dementia Strategy
o Highlight key issues in dementia care – which is an increasingly burdensome
problem esp. with the aging population – as this would then affect young
caregiver’s ability to be productive.
o Identify gaps in the current systems
o Project needs for dementia patients and their families
o Address 4 key focus areas:
§ Primary prevention of dementia (healthy living)
§ Awareness and early detection of dementia (education)
§ Early diagnosis and comprehensive evaluation of dementia
(treatment/detection via AIC which facilitates the linking up of services +
community)
§ Management of dementia
 • Public education
o Advertisements on what is dementia + how to seek help (e.g. Ah Kong by HPB)

Range of services for the elderly – There is shift from hospital based services to community based
services, due to issues like – not enough beds
• Hospital-based
o Geriatric Medicine
o Psychogeriatrics
• Community-based services – main aim to create a sense of familiarity e.g. by reminiscence
therapy
o Home care
o Day care
o Residential
Agency for Integrated care (AIC) – forms the main support/care for individuals with
dementia/depression problems.
• They develop and integrate care services for seniors, collaborating care services together
to provide/oversee all the range of services to support the elderly or individuals with
mental health issues. Thus, serving as a
• One stop for
o Community resources for elderly care
o Financial assistance
o Caregiver education and support
o Professional partnership
o Singapore Silver Line (for elder-care related issues): 1800-650-6060
• For example, under the AIC, there are support groups and caregiver training
o E.g. Alzheimer’s disease association (ADA)
o Provides information about Dementia,
o Caregiver support, counselling, training,
o Dementia Day Care,
o Person Centred Care training

Eldercare services
• Home Care Services – esp. when the patient is too frail to visit the hospital/clinic
o Home-based medical/nursing/therapy services
o This has been increasing in terms of provision by medical practitioners doing
home based care and surveillance.
• Day Centres
o Patients attend during the day and return home in evening (e.g. Dementia Day
Care Centre, Psychiatric Day Rehabilitation Service, Senior Activity Centre)
o Care givers engage individuals during the day. Also they tend to be diagnosis
specific e.g. less cluttered, with more signs to guide and orientate the elderly and
those with dementia.
• Stay-In Facilities (not encouraged, due to high cost and a lack of space – thus the issue of
cross-border nursing homes)
o E.g. Community Hospital, Nursing Home, Psychiatric Nursing Home, Psychiatric
Rehabilitation Home
• Other Services (community services)
o E.g. Befriending Service, Caregiver Support and training, counselling, Meals on
wheels etc.
• A key issue among these is affordability and accessibility

 Community Mental Health teams for the elderly
• Aged Psychiatry Community Assessment and Treatment Teams (APCATS)
o Provided by Institute of Mental Health
o Teams are made up of allied health professionals and doctors who do home visits
to provide treatment
§ Aim is to refer patients for further assistance/early assessment if needed:
at the same time liaise these professional with community services to
support patients staying at home, also helping to train community based
social workers.
• Community Psychogeriatric programme
o Provided by Changi General Hospital
o Focuses on providing care within the community
INTERVENTION CHALLENGES
• Increasing demand and expectations
• Stigma – prevents parties from stepping forward to seek treatment
• Foreign staff and language barrier in a multiracial and multicultural society (as a result of
increasing demands) – but hard to communicate esp. when speaking different languages
– cannot meet the needs of the patient which is ineffective.
o Dialect barrier esp. among young staff
o Translation services might be needed
• More funding for mental health
• Policy changes
o e.g. Medisave can be tapped on for the outpatient treatment of schizophrenia,
dementia, depression and bipolar disorder. (encourage seeking treatment)
o Medishield Life (insurance scheme of co-payment)
o Medifund – hospital based funding based on means testing
• IMH Dementia-friendly ward – potential recognition


Lecture 11: Psychosis
• Schizophrenia
• Bipolar disorder
• Others
PSYCHOSIS
Is a mental condition whereby the patient completely loses touch with reality. It involves a broad
group of disorders which have these conditions/features.
• Defect of insight and reality judgment
o They cannot understand/recognize their own problems and difficulties, when it is
evident to everyone else.
o They also experience repeated misjudgments. This can be told when
• Their way of thinking and behaviour may not be understandable to others
• Opposed to Neurosis (a range of mood & anxiety disorders)
o Morbid subjective experiences not confused with external reality
• Psychosis is primarily described as a loss of contact with reality
• Also has disturbed perceptions, mood, behaviour and communication
• Psychosis results in:
o Delusions
o Hallucinations
o Disordered behaviour
o Disordered thinking
DELUSION
• Is a belief held with unusual conviction, that is
• Not amenable to reason and logic.
• In other words, it is a “False unshakeable belief which arises from internal morbid
processes out of keeping with a person’s educational and cultural background”
• The error is obvious to others.
• However, the issue lies where we cannot determine if it is real or a delusion – esp. when
dealing with religious issues – is it a normal belief?
• Thus, to establish delusion, we first have to identify that the
o Belief is false
o People of the same cultural background do not believe in it.
o Person has a strong/unshakeable conviction or belief.
HALLUCINATIONS
• Is a false perception without external stimuli, as
• Opposed to illusion which is a sensory distortion.
• This is usually experienced where individuals smell/hear/see/feel/taste something, when
there is nothing there at all.
• Commonly, it occurs when one is experiencing
o alcohol withdrawal or
o drug abuse or
o epilepsy.
• Thus, we need to establish whether it is truly psychosis as the root cause, or if it is due to
other factors like the 3 above.
DISORDERED BEHAVIOUR
• This involves Abnormal acts like
o Hoarding rubbish
o Bizarre dressing
o Talking to oneself / gesturing to themselves – i.e. being oblivious to surroundings
• Abnormal motor behaviour
 o Strange gestures
o Catatonia
DISORDERED THINKING
This involves a loss of logical thinking. Individuals have
• Problems in connecting thoughts
o Loosened association
• Problems thinking clearly
• Problems understanding
• Problems making others understand
• Manifestation:
o Neologism – a new word that does not exist in any language pops up in speech
o word salad – jumbled words, words in a sentence that do not make sense
o loosened association – within a few paragraphs, their thought process jumps from
1 idea to another, making it highly confusing. The association from 1 idea to the
next is lost.
o disjointed speech – sentence to sentence do not join.
• This is commonly established through one’s speech – so as to have access to the
individual’s thoughts – which are usually not understandable. However, from the different
levels of understandability, we can determine the severity of the condition and can
distinguish the level of disorganization.

CAUSES OF PSYCHOSIS
• Primary psychosis – we do NOT know what is the direct cause exactly.
• Secondary to medical conditions – indirect causes which result in identifiable symptoms
o Substance abuse
o Brain disorder e.g. tumour, epilepsy
o Another common cause is thyroid problems
• As such, additional tests should be conducted always, so as to NOT miss out on
something that is treatable.
• Also, like for all conditions, early identification is best to control symptoms earlier for
better outcomes.
TYPES OF PSYCHOSIS
The types of psychosis are commonly distinguished by the duration of their symptoms.
• Brief Psychotic Disorder (< 1 month)
• Schizophreniform Disorder (1-5 months)
• Schizophrenia (>/= 6 months)

• Schizoaffective Disorder
• Delusional Disorder
• Psychotic Disorder due to a General Medical Condition, Substance abuse.
• Mood Disorders (Bipolar, Depression)

SCHIZOPHRENIA
This involves an at least 6-month duration of disturbance with two (or more) of the following
symptoms:
Positive symptoms (an addition to what normal people have)
(1) delusions
(2) hallucinations
(3) disorganized speech (e.g., frequent derailment or incoherence)
(4) grossly disorganized or catatonic behavior
 Negative symptoms (a lack of what normal people have)
(5) negative symptoms, i.e., affective flattening, alogia, or avolition – no drive to do things in
life e.g. work, bathe etc. For this it is key to distinguish whether it is truly schizophrenia or
if it is a depress person (not the same)

It generally affects
• Geriatric (12.04%)
• Child and adolescent (0.43%)
• Adult (87.53%)
The peak age is around late adolescence i.e. adult period or NS period where one is vulnerable
and under extreme stress – hence causing symptoms to appear.
EARLY SYMPTOMS
• First noticeable change in behaviour
• Social withdrawal
• Loss of interest
• Deterioration of academic performance – due to loss of logical thinking
• Deterioration in self-care/hygiene
• Change in temperament
• Anxiety, irrational fears, obsessive compulsive and depressive symptoms
EARLY STAGE ‘AT RISK MENTAL STATE’
This is a way to diagnose schizophrenia even earlier, when a person is pre-psychotic, so as to find
out more effective ways to treat them before the full onset of the illness. However, at times the
• Positive Symptoms are
o Too brief or
o Does not meet threshold.
• Although there might be declining function over one year, with positive family
history/schizotypal personality,
• NOT every case progresses to develop schizophrenia (most studies show <50%)

What treatment to offer after identification? – instead of medication which has many side effects
and should not be introduced at such an early stage, engagement of patients is key and can be
considered the most important thing when treating a patient. We must
• Remember that most psychotic children/youths are quite distressed and frightened, due
to fear of being labelled by others.
• Need to spend more time to establish rapport and gain trust in order to educate them.
Thus, the importance of being warm and genuine.
• Acknowledge that his/her feelings.
• Evaluation might require a few sessions.
• Symptoms can change/evolve over time.
PROGRESSION OF SCHIZOPHRENIA
• Negative symptoms (e.g. social withdrawals, loss of drive) are more difficult to treat than
positive symptoms (e.g. hallucinations, delusions). They often do not respond as well to
medication. Thus, given the controversial side effects of medication, we should practice
the rule of thirds, where we extend medication – briefly, in moderation and perhaps for
long term if necessary.
• Ultimately, the Risk of suicide is high, esp. for those with long term symptoms and cannot
perform as well as they used to – causing depression on top of this.

DELUSIONAL DISORDER
 • This involves a person experiencing non-bizarre delusion for at least one month. In other
words, they believe in something that is remotely possible, albeit not true. Usually, the
• Criteria for Schizophrenia is not met.
• Hallucinations may be present, although not prominent.
• Psychosocial functioning may not be impaired. At the early stages, individuals still can
function relatively well. However, as the illness progresses, their functioning might be
impaired.
• Types:
o Erotomanic Type – sufferer is female who thinks that a person of a higher status
is in love with her – might result in stalking behavior
o Grandiose Type – morbid jealousy (more dangerous than erotomanic)
o Jealous Type – this is common with males with long standing history of alcohol
dependence. For example, their erectile dysfunction might affect spousal
relationship, but with the development of delusion overtime, these individuals
project the underperformance on their wife – obsessing over the fact that the
wife is unfaithful to the point where they extort confessions from their partners
through domestic violence – when in fact it is not true.
o Persecutory Type
o Somatic Type – this is common among older people whom experience a
degeneration of body parts e.g. specks in their visual field floating around such
that they think that spiders are in their eyes etc.

MANIA
This is a case when an individual’s mood is elevated and goes high such that they have the
tendency to do extreme and dangerous things.
• Mood: Elevated, elated, expansive (for at least 4 days) – extremely energetic
• Thoughts: Inflated self-esteem – such that they develop poor judgment e.g. believes he
will win gambling debts only to result in consequences thereafter; grandiose, flight of
ideas
• Behavior: More talkative, distractible, increase in goal-directed activity, hyperactive,
psychomotor agitation, excessive involvement in pleasurable activities that have a high
potential for painful consequences, less need for sleep (2-3 hours)
• Psychotic symptoms: might be present

Furthermore, a person with Mania is more at risk of developing depression in some point of their
life as usually they have a bipolar disorder.

BIPOLAR MOOD DISORDERS
This involves 2 types:
• Bipolar I : one or more manic episodes
o +/- one or more major depressive episodes
• Bipolar II : one or more major depressive episodes
o + at least one hypomanic episode
• Prevalence 0.4% to 1.6% in community.
• Treatment is the same for both types of bipolar disorders – through stabilisers
• Increased risk in first-degree relatives for mood disorders (ranges from 1% to 24%).

INTERVENTION
ASSESSMENT
 • Gather information from multiple sources – parents and family members, fellow students
and teachers, fellow workers etc.
• Observe person’s behaviour in various situations and environments (including hospital
ward)
• Review role of family - care giving, social support, expressed emotion and anxiety of
parents and other family members. There is a need to assess what the support is like at
home to determine the success of treatment.
• Impact on studies, work and social interactions
PHYSICAL EXAMINATION
• In addition to psychiatric treatment, this is an essential part of complete psychiatric
assessment.
• Look for signs of medical disorder including confusional state.
• Look for neurological signs, dysmorphic features, cutaneous stigmata of neurocutaneous
syndrome.
• Signs of neglect or abuse or poor self-care. Check weight, height and evidence of injury or
growth failure.
• We always must make sure to identify a treatable medical cause – which must first be
treated – before psychosis can be fully treated.
FAMILY’S EXPLANATORY MODEL + MISCONCEPTION
This should not be dismissed as one might lose the opportunity to treat the person. We should
• Look for the strengths in family and what has been right for child and family.
• Listen to family’s explanatory model. They often have different views from therapist’s
own.
• Knowing their models allow therapist to present views in way most relevant to family.
• Education of the family first is important e.g. muscle spasms, a side effect from
medication – might cause patients to look as though they are possessed. Thus, families
should be educated such that they can distinguish a real medical issue rather than their
draw their own conclusions.

Misconceptions
• Parents and well-meaning relatives often attribute symptoms to spiritual influences.
• Many consult traditional healers, temple mediums and Bomohs.
• This may delay psychiatric treatment.
EARLY RECOGNITION & TREATMENT
• Early intervention is the key to delay and even arrest progression of the illness and its
complications.
• Each subsequent relapse contributes to a worsening of prognosis.
• Better outcome and recovery can be achieved through early and comprehensive
treatment.

Treatment:
• Biological
• Psychological
• Social

• Dopamine hypothesis in psychosis – often related to excessive dopamine activity in the
brain. Dopamine is a type of neuro transmitter which causes a neurological imbalance.
o Thus a form of treatment might be to reduce dopamine activity in the mesolimbic
system is undertaken through medications. Side effects of this is also muscle
spasm – when there is a lack of dopamine in the ventral striatum.

MEDICAL TREATMENT OF ACUTE PSYCHOSIS
o Initiation of treatment
o Choice of antipsychotic
o Route of administration – tablet, liquid, short or long acting injectibles
o Dosages
o Duration of treatment
o Maintenance treatment
DURATION OF TREATMENT
It should be noted that treatment might not be able to fully eradicate the problem. However, if
there is no antipsychotic given – the chances of relapse is higher i.e. there is a lower % of people
who remain well. Thus, we need to consider the
• Side effects of medication – how it affects one’s daily/social life
• How to achieve a balance
• What type of treatment
• How to administer the treatment most appropriately?
• What dosage to give to the patient?
• How long to treat for?
The aim of treatment is basically to optimize a person’s functions not to eradicate the problem, as
this would be impossible.
ANTI-PSYCHOTICS
• ‘Conventional Side effects
o Chlorpromazine (Largactil) • Sedation
o Haloperidol • Weight gain and ‘metabolic’ problems
• New generation o Obesity, raised blood pressure,
o Risperidone raised blood cholesterol and
o Olanzapine glucose
o Quetiapine • Motor side effects, e.g. stiffness, tremors
o Ziprasidone (extrapyramidal side effects)
o Aripiprazole • Restlessness (akathisia) – might result in
suicide due to being highly uncomfortable
PSYCHOSOCIAL TREATMENTS
• Psychoeducation
o Patient
o Family/ caregivers
• Family Interventions
• Psychotherapy
o Supportive
o Cognitive Behavioural
• Social skills training – due to negative symptoms that impair/ make them lose abilities
• Educational & vocational rehabilitation – this is an ongoing process to all stakeholders

EMPLOYMENT IN PSYCHOSIS AND SCHIZOPHRENIA
• 40-50% unemployment in first episode psychosis
• 75-95% unemployment in schizophrenia
SINGAPORE STATISTICS
• Study of 402 patients, aged 15–39 years when first admitted and diagnosed with
schizophrenia
• Outcome classification at 20 years:
o Good: Not receiving treatment, well and working
 o Fair: Not receiving treatment and not working, or receiving out-patient treatment
and working
o Poor: Receiving treatment and not working, or receiving in-patient treatment.
• 2/3 had a good/fair outcome à over an extended period of time, they can maintain some
form of employment J

It should be noted that open employment is a frequently identified long term goal of people with
mental illnesses, and that as much as work is stressful, it is a known stress that is manageable. On
the other hand, unemployment causes more unknown stress which is difficult to manage.
COSTS OF PEOPLE WITH SCHIZOPHRENIA NOT WORKING
Especially amongst the young, schizophrenia robs them of the ability to develop skills.
• Loss of earnings due to illness $487.6M
• Lost income and sales tax $165.7M
• Public cost of carers $88.1M
• Accommodation assistance $16.2M
• Welfare benefits $274M
• Total $1.031 billion (Total cost of illness $1.8b)
o SANE, 2002, based on 2001 data
• US$32 billion of total cost US$61billion (Wu et al., 2005)


Lecture 12: Summary - healing of the mind

PRINCIPLES OF TREATMENT
The broad approach is always taken for all mental illnesses.

Engage the patient/ family
o Build rapport and trust – Be warm and genuine in the relationship
o Be flexible to deal with different cultures and mindsets.
o Address concerns not just symptoms – focus on function, not eradication.
• Informed decision by patient
o Patients and families should know about their medical condition and treatment
options. Thus, professionals should break down their usage of technical jargons
into a more relevant and understandable form to patients and the family e.g.
considering the language too, so that there is a higher possibility of them
complying for treatment.
o Treatment usually involves a multidisciplinary approach with multimodal
treatments:
§ Medications
§ Psychological interventions
§ Social/ Educational interventions
o Providing information improves adherence to treatment
§ Help patients and families understand role of medications and their
effects/side effects, how long to take, etc
§ Help patients and families make informed choices on treatment options
• Consent and concern
o Informed consent should come from patient as the patient holds the choice as to
who & what type of information they want to disclose to.
o Some patients cannot give consent but we should get their assent (if young) or
the agreement of caregivers
o Addressing patient and families‟ concerns about medications
§ Side effects
§ Other’s impression, myths and fears
§ Inconveniences

Multidisciplinary care
• Teamwork among professionals – psychiatric assess + make medical diagnosis – to
determine which other member needs to come in and assist the situation

Think about community support,
• More accessible
• eg. School counselors, Family Service Centre – which is highly important when assisting
caregivers in advice in providing treatment/for early assessment.
CHOICE OF TREATMENT
• Biological treatments
• Psychological treatments
o Specific and focused
o Cognitive and behavioural
o Structured e.g. Manualised
• Social treatment

BIOLOGICAL TREATMENTS
 • Medications – when using this, benefits has to greatly outweigh risk, especially for young
children. Thus, if possible, medication should not be prescribed.
• Diet – common misconceptions should be extinguished through educating individuals that
e.g. reduced sugar intake is recommended to help ADHD individuals, is not proven.
• Electro-convulsive therapy (ECT) – where a current is passed through the brain to induce a
fit. This is usually done under anesthesia for 1-2 min.
• Rest/Sleep – this is especially important in bipolar disorder to create a social rhythm that
helps to train the body to develop a routine.
• Exercise
• Newer treatments (e.g transcranial magnetic stimulation)

Medication Classes:
• Antidepressants (for depression) • Hypnotics
• Antipsychotics (for psychosis) • Autism Supplements
• Stimulants (for ADHD) • Mood Stabilizers (for Bipolar disorder)
• Anti Epileptic Drugs • Antiparkinsonians
• Alpha agonist/ beta blockers • Opiate Blockers
ANTIDEPRESSANTS
Depression, obsessive-compulsive behaviour, and anxiety may be treated using antidepressants.
• reduce the frequency and intensity of repetitive behavior
• decrease irritability, tantrums, and aggression
• improve eye contact and responsiveness
Side effects include headache, insomnia, dizziness, and drowsiness. Fluoxetine (Prozac®)
• Amitriptyline
• Bupropion (Wellbutrin®)
• Clomipramine (Anafranil®)
• Fluvoxamine (Faverin®)
ANTIPSYCHOTICS
Antipsychotic medications Side effects:
• Clozapine • Agitation
• Risperidone • Anxiety
• Olanzapine • Drowsiness
• Quetiapine • Dizziness
• Headache
• Insomnia
• Sedation
STIMULANT MEDICATION
• Mainly for treatment of ADHD Side effects:
• In Singapore, only Methylphenidate is • Abdominal pain
available (controlled drug) • High blood pressure (hypertension)
• Insomnia
• Loss of appetite Nervousness
• Rapid heart rate (tachycardia)
HYPNOTICS
• Mainly used for insomnia, anxiety, Side effects:
tranquilisation • Drowsiness, lethargy, poor muscle
o Benzodiazepine (‘sleeping coordination, dizziness
tablets’) – causes sedation as a • Drowsiness is an issue esp. among the
side effect to help sleep elderly as this increases their
o E.g. Diazepam, Lorazepam susceptibility to falls, resulting in
 • Non-addictive alternatives – Anti- possible fractures and thus bed
histamine medication (cold medicine) – confinements which will result in
sedation as a side effect, but not further conditions like infections,
addictive J muscle relapse etc. due to not being
active.
• There is a high risk of ‘dependence’
with long term use. This addiction
begins when the body gets used to it
i.e. a tolerance develops, such that
higher dosages are required to get the
same intended effect. However, after
long term usage, this would have no
effect.

COUNSELLING
Is the most basic form of psychological treatment. This is different from other types of
psychotherapy, as here the person is aware of his/her problem. Counselling focuses on
• “Resolving conscious conflicts or problems, with the focus on setting goals and problem
solving”. It involves
• A relationship between a client and a counsellor,
• Helping to solve personal and interpersonal issues. This is a
• One to one process, usually through verbal communication
PSYCHOTHERAPY
On the other hand, psychotherapy is to uncover unconscious processes among the individual
whom is not aware of his/her problem. This is
• The treatment of mental or emotional problems by psychological means, which involves
• Regular meetings between a therapist and patient forms a relationship resulting in
transference.
• It often involves identifying and managing unconscious conflicts or thoughts.
• Examples are:
o Behavioural therapy e.g. classical conditioning
o Cognitive therapy – trying to understand thought processes/patterns of thinking
o Cognitive-behavioural therapy – most commonly used in depression
o Psychodynamic therapy – use of free-association – where whatever that comes to
the patient’s mind (when talking freely) is interpreted by therapists to analyse any
repeated patterns/behavior linked with the past.
o Group therapy – often done in addiction i.e. support groups like Alcoholics
Anonymous to help each other in recovery process.
o Family therapy – as family is the primary source of support. This is usually done in
abnormal/dysfunctional families.
BEHAVIORAL THERAPY
Increase desired behaviours
• Reinforcements
• Modelling
• Skills training

Reduce undesired behaviours
• Punishment
• Stimulus change
• Satiation
 • Time out
• Desensitisation
COGNITIVE THERAPY
To identify faulty patterns of thinking. This is very hard to be done with an intellectually disabled
person. More often than not, the
• Person should have capacity for independent thought and action. Also,
• Self-motivation is required.
• Cognitive-behaviour therapy is commonly used to treat depression and anxiety disorders
o Identifying unconscious ‘automatic’ and usually negative thoughts.
o Corrects cognitive errors, e.g. catastrophizing, over-generalization by bringing out
examples and opportunities of success to divert their mindset to a more positive
one.
PSYCHODYNAMIC THERAPY
This lasts for around 1-2 years, involving
• Regular meetings with the therapist that are structured e.g. same place same day same
time of the week. Even if the patient does not turn up, the therapist will then interpret
absenteeism.
o Relationship used to analyse past conflicts with significant people
o Patient develops transference feelings towards therapist and therapist develops
counter-transference feelings
• Reactivate past conflicts and resolve them with therapist
• Interpretation resulting in insight
• Usually long-term
GROUP THERAPY
• Usually specific, e.g. addiction, recovery individuals of specific mental illness
• Open or closed groups – as individuals feels more understood by someone experiencing
the same problem – this way they can also motivate each other.
• Therapeutic factors
o Universality
o Altruism
o Instillation of hope
o Imparting information – models of success (social learning)
o Imitative behaviour
o Cohesiveness
o Catharsis
o Interpersonal learning
o Self-understanding
FAMILY THERAPY
• Family is a system
o Supportive, long-term roles and relationships – communication is very important
o Works with families and couples in intimate relationships to nurture change and
development
o Members influence one another
o Subsystems exist within families
o Rules regulate family systems
o The family develops homeostasis
• Causality is circular

EVIDENCE BASED TREATMENT
• Most clinicians today practise evidence-based medicine
 o Treatment should be shown through research to improve outcome
o Risk-benefit consideration
o Cost consideration: treatment should be cost-effective
• Important for clinicians to keep up with medical literature – e.g. up to date research
papers which must be relevant to your patient / suits your patient the most. Thereafter,
there should be a discussion with the patient on his/her approval.
• Clinical practice guidelines for specific conditions
MENTAL HEALTHCARE COST
To relieve high medical cost burdens,
• Financial assistance available at all public healthcare facilities
o Means-testing
o Subsidies and Medifund – help those who are really strapped financially.
• Medisave can be used for in-patient and outpatient treatment of chronic diseases, e.g.
schizophrenia, depression – this involves using one’s CPF saving to fund medical
treatment i.e. a deducted cost
• Medishield life – nationalized insurance to cover in-patient cost.
PROVIDERS OF MENTAL HEALTHCARE SERVICES
For in-patient treatment, other than private hospitals like Mt Elizabeth hospital,
Under the wing of the Ministry of Health, there are hospitals and institutions like
• IMH
• KK womens and childrens’ hospital
• NUH
• Other restructured hospitals.

Institutions like IMH, KKWCH & NUH also provide outpatient treatment such as
• IMH’s community wellness clinic and child guidance clinic
• Community based services supported by the hospitals – REACH, where together with GPS,
they tie up to support schools and provide intervention.
Schools also have counsellors and allied educators for childrens’ psychological well-being and
learning. Other than these, there are also private psychiatrists at private hospitals.

Most importantly, the Ministry of Social and Family Development also provides the Family Service
Centre which is accessible to all, to provide out-patient care and advice.
IMH
• Inpatient
• Outpatient
o Adult psychiatry
o Child and adolescent psychiatry
o Geriatric psychiatry
o Community psychiatry
o National Addiction Management Service
o Early psychosis (EPIP)

Community based programs
• CHAT (Community Health Assessment Team)
o Drop-in centre for young people
• CMHT (Community Mental Health Team)
o Home-based services
• APCATS (Aged Psychiatry Community Assessment and Treatment Service)
o Home-based service for elderly
 • REACH (Response, Early intervention and Assessment in Community mental Health)
o School-based service for students