Wednesday, 18 November 2015

Question of the week (19 November 2015)

"I have trouble falling asleep at night and as a result I feel tired in the mornings. This leaves me feeling sluggish and unproductive during the day. What can I do?"

Many do not realise that waking up well is as important as falling asleep to prevent insomnia. If you allow a lousy night of sleep to upset you the next morning such that you stay in bed, refuse to exercise and give yourself an excuse to be sluggish, a negative vicious cycle will be ensue, which results in the poor sleep perpetuating the next night. However, if you wake up well, exercise and be active upon waking, your brain will know it is the morning and it will signal to you when it is night and this results in a healthy circadian rhythm and better sleep.

1) Improve your sleep quality by observing good sleep hygiene:
-Go to bed and get out of bed the same time all the time.  
-Have a soothing pre-sleep routine
-Avoid doing things in bed except sleep and sex to prevent feeling alert in bed all the time
-Avoid tossing and turning in bed for more than 15 minutes if you cannot fall asleep as you will get anxious. Go to another room and read a book and try to sleep again when tired.

2) Establish a good exercise schedule. Try and do so in the morning so as to wake the mind up and do not let one night of poor sleep stop you from exercising. The best way to stop that sluggish feeling is to stay active and activated by fun activities!

Sunday, 15 November 2015

FAQ: Physical Punishment in Children

What age is deemed appropriate when it comes to disciplining a child (toddlers included)?

Discipline should start as early as 8 months. This can be a simple "no" for example when the baby plays with the remote control. However, the baby should also be praised if he obeys the instructions.

Are there any benefits to using physical punishment (caning or a smack on the bottom/Palm) on a child? What about parents who incorporate this punishment at an early age?

Whether physical punishment is appropriate boils down to the cultural  background and values of the family. Most western studies have shown that physical punishment is detrimental to the child. I would suggest minimising using physical punishments as parents may then only focus on punishment and not on teaching or educating the child. Nevertheless, physical punishment, when incorporated with consistency and non punitively, can be a quick and effective way of disciplining the child. 

What consequences might a child have if he is reprimanded or caned at an early age? 

If a child is fairly and appropriately reprimanded or even caned, and the reasons why these punishments meted out are carefully explained, I do not think that the child will have any consequence. However, if a parent metes out punishments, especially physical ones, as he or she is frustrated, this can lead the child to learn to react violently when distressed. If the physical punishments escalates inappropriately, it may become physical abuse and may scar the child permanently leading to long term psychological difficulties. 

Could this lead to a more disciplined child? Or might it have possible negative effects?

As mentioned above, it depends largely of the punishment is meted out appropriately. A parent must never can or hit the child out of frustration. The punishment must be predetermined and meted out consistently, and proportionate to the age of the child and the bad behavior. A good amount of teaching and education must follow suit. If so, the child understand why he is punished and learn from it leading to better discipline. 

At what age would physical punishment (caning or a smack on the bottom/palm) be deemed ok for a child? Why?

Physical punishment, if at all used, should only be used when the child can understand the correlation between his actions and consequences. This would be at the earliest 3-4 year old. 

What is the best way to properly discipline a child? 

A positive approach is often best. Therefore encouraging good behaviour with use of techniques such as star chart / reward chart will be desirable. Using methods such as time out when a child is throwing tantrum or misbehaving is also useful. 

Most importantly, it is most important to be consistent and firm in disciplining the child. Do not be punitive and do not shame the child. 

Thursday, 12 November 2015

Fears in Children: 4 Questions Answered

Q: How should a parent help a child cope with his/her fear of the dark, bad dreams, clowns and strangers?

Generally mild fears and simple phobias can be ignored if they are not affecting the life of the child to a huge extent. They are usually a passing phase and the child will slowly get better as he matures. Parents should remain calm and not be frustrated with these. Most importantly, do not be punitive and start calling the child names, as this will cause further low self esteem.

Q: How can a parent help the child get over the fear?

If for some reasons, the child's fear and phobia is affecting his life, he can be gradually exposed to the feared object. Parents can start by telling positive stories of these feared objects. For eg. adventures in the dark or a friendly helpful clown. They can also share their own experiences with their fears when they were young. Subsequently they can increase the degree of exposure slowly. If serious, it is best to get professional guidance.

Q: Are there any "don'ts" when trying to help a child get over the fear?

i) Don't push the child, give him time.
ii) Don't criticise the child as this makes him more fearful.
iii) Don't bother with the fear or phobia, if it is not really affecting the child's life.
iv) Don't ignore working on your own anxiety and fears, as the child may have learnt it from the parents.

Q: What's the likelihood of the fear being brought over to the child's adulthood?

Most children have fears as they continue to have magical thinking and believe in their fantasies, for eg. monsters. However, as we grow older, we lose these magical thinking and the fears mostly go away as well.

Tuesday, 31 March 2015

Four Differences Between Depression and Burnout

Many a times, clinical depression can be triggered by stresses at work. It is no wonder that people often wonder what the differences are between depression and burnout from work.

1. Depression, A Diagnosis. Burnout, A Description

The greatest difference is that clinical depression / major depressive disorder is a formal psychiatric diagnosis whilst burnout is a description of one's feelings towards work. To be diagnosed with clinical depression, the sufferer has to have several symptoms of depression and for a duration of at least 2 weeks. You can read this page to find out more about clinical depression.

"Burnout" was coined in the 70s by psychologist, Herbert Freudenberger. To date there is no scientific definition for burnout. It generally describes a lost of interest and motivation towards work following a long period of excessive stress. The sufferer complains of tiredness and lethargy. He or she may feel unappreciated and may be cynical about work and colleagues.

2. Pervasiveness

If an individual is just burnt out from work and has not developed clinical depression, the difficult mood and lack of motivation is generally limited to work and work related events. He will feel fine when he is at home or when doing his hobbies. A tell tale sign that this is just burnout and not depression is if the individual feels alright during weekends and starts to worry and brood about work on Sunday night. In depression, not only will the individual have a sense of negativity towards work, the negativity spreads to life in general as well.

3. Severity of Symptoms

Compared to just burnout where physical exhaustion, feeling low about work and poor work performance are typical symptoms, the symptoms of clinical depression can be a lot more serious and include:

i)   Hopelessness and Despair
ii)  Low Self Esteem and Loss of Confidence
iii) Suicidal Thoughts and Suicidal Attempts

4. Treatment Recommendations

For pure burnout, removing the source of stress will lead to rapid improvement of symptoms. Quitting or changing one's job will help to rid one of the feelings of burnout. However, in clinical depression, the sufferer will persist in feeling negative about his new circumstances or new job. In fact, losing one's job may aggravate the depression! As such, allowing the depressed individual to have some rest from work and to only make a decision AFTER the depression has been adequately treated is important.

When Burnout is Depression and Vice Versa....

The relationship between burnout and depression is a complex one with numerous overlap in symptoms and a bi-directional influence. It is easy to see why a burnout individual who is unhappy at work is at risk of developing depression. Clinical depression can bring about a loss of motivation and lethargy which can worsen work burnout as well. When this happens, the sufferer becomes trapped in a negative vicious cycle.

Regardless of the terminology, there are solutions and treatment for both work burnout and clinical depression. Identifying and delineating the two with careful assessment and investigations will help the clinician / psychiatrist provide the best and optimum treatment for the patient.  

Monday, 10 November 2014

Bulimia Nervosa FAQ

Bulimia nervosa is an eating disorder characterized by cycles of binge eating and purging, or consuming a large amount of food in a short amount of time followed by an attempt to rid oneself of the food consumed (purging), typically by vomiting, taking a laxativediuretic, or stimulant, and/or excessive exercise, because of an extensive concern for body weight.

What are the common reasons for bulimia?  

The way media portrays and idealizes a slim physique has often been found to be the main culprit. This in turn leads to peer pressure in teenage girls and youths to stay thin and results in distortion of body image. There can also be a biological or genetic predisposition.

What are the warning signs of the disease, if I were a parent, how can I detect it?

If the child starts becoming secretive about her meals, parents need to start taking note. Parents may notice that they try to restrict their diet and then loses control and binge eat at other times. They may disappear or spend a lot of time in the toilet, often to purge or vomit the food out.

What are the dangers of bulimia? Are they the same as anorexia, or more dangerous? (will the stomach acid harm the throat walls, other complications e.g?)

Bulimia and Anorexia are really two sides of the same coin. From a physical point of view, Anorexia and restricting one's diet is more dangerous. However,Bulimia can also cause a myriad of physical problems such as electrolyte imbalance, cardiovascular problems like irregular rhythm, digestive issues and throat and mouth problems. Having Bulimia is likely to predispose one to Anorexia as well.

How different are the profiles of patients of bulimia and anorexia? (since maybe bulimia is a more active way of coping, while anorexia seems passive?)

I believe they are the same illness presenting differently and at different times. Many anorexic patients go on to binge and develop bulimia after the anorexia episode. As such the profile is very much the same. In young adolescent girls exposed to a culture which emphasises a slim physique.
 How is the treatment for bulimia? is it the same as anorexia?

As with anorexia, the first step is to recognise the problem and to seek help. The need for hospitalisation is often lower in Bulimia as compared to Anorexia where low body weight can sometimes be a medical emergency and refeeding needs to be carried out quickly and safely in the hospital. Unlike in Anorexia, medication like antidepressant plays a role in helping with the urge of binging and purging. Psychotherapy is an important component of treatment in both.

Tuesday, 13 May 2014

Attention Deficit Hyper Activity Disorder (ADHD / ADD) Medications Cheatsheet

The use of medications revolutionised the treatment of ADHD /ADD. Today, international consensus often recommends medication as the first line of treatment for ADHD / ADD in patients above the age of 6 years of age. You can visit the following sites for more details:

Medications for ADHD / ADD can be categorised as:

1) Stimulants
2) Non stimulants
3) Antidepressants
4) Supplements

1) Stimulants

Stimulant medications have the best evidence in the treatment of ADHD for children and Adult ADD. As such it is often recommended as the medication of choice to start for both child and adult patients with ADHD. In Singapore, only methylphenidate based medications are available. They may come in short acting forms (lasting 3-4 hours) and long acting forms (lasting 8-10 hours).

Common brand names: Ritalin, Concerta

Advantage: i) Most likely to be effective, ii) works almost immediately, iii) can be taken only when necessary
Disadvantage: i) Can be potentially abused, ii) effects does not last the whole day

Common side effects: Headache, insomnia, poor appetite

2) Non stimulants

Atomoxetine is a selective noradrenaline reuptake inhibitor indicated for the treatment of ADHD /ADD. Unlike stimulants which has immediate effects, the benefits of atomoxetine is gradual and subtle, and its effect is only apparent usually after two weeks. For it to be effective, Atomoxetine has to be taken daily.

Common brand names: Strattera

Advantage: i) No abuse potential, ii) if effective, will last 24/7, iii) may be effective for concomitant depression
Disadvantage: i) Has to be taken daily, ii) only works after two to four weeks, iii) probably less likely to be effective than stimulants

Common side effects: Nausea, headache, insomnia

3) Antidepressants

Bupropion, an antidepressant, used in the treatment of depression and smoking cessation has been shown in some studies to help with the symptoms in ADHD / ADD. However, comparatively, the evidence for Bupropion is not as robust as stimulants and atomoxetine. As such, guidelines often recommends antidepressants as the third line of treatment, after stimulants and atomoxetine.

Advantage: i) No abuse potential, ii) if effective, will last 24/7, iii) effective for concomitant depression
Disadvantage: i) Has to be taken daily, ii) only works after two to four weeks iii) probably less likely to be effective than stimulants and atomoxetine

Common side effects: Headache, insomnia, anxiety

4) Supplements

There has recently been some research which suggests a decrease level of Omega-3 fatty acids (fish oils) may be associated with ADHD and taking Omega-3 supplements can help in controlling ADHD symptoms. Parents who may not be ready to medicate their children can consider this option as Omega-3 is a natural supplement. A recent product Lipirinen which contains phosphatidylserine-omega 3, EPA enriched, has shown effectiveness in studies, improving symptoms. Omega-3 can be used to supplement current treatment with other medications as well.

Advantage: i) Natural product, ii) no abuse potential, ii) if effective, will last 24/7
Disadvantage: i) Has to be taken daily, ii) only works after at least four weeks iii) probably less likely to be effective than stimulants, atomoxetine and antidepressants

Common side effects: no significant side effects 

Friday, 21 March 2014

2014 Customer Service Award

Dr BL Lim Centre for Psychological Wellness is pleased to announce that our clinic has been awarded the 2014 Customer Service Award from

It is our mission to strive to provide the best patient care possible and to always remember our motto of "Patients First, Always".