Psychology

• Neuro-developmental disorders:
  • Intellectual disability
  • Attention deficit / hyperactivity disorder (ADHD)
  • Autism Spectrum Disorder
• Neuro-cognitive disorders (dementia)
• Pre-surgical screening (bariatric surgery)

• Anxiety disorders:
  • Specific phobias
  • Social anxiety disorder
  • Panic disorder
  • Generalised anxiety disorder
• Bipolar and related disorders
• Depressive disorders
• Obsessive compulsive and related disorders
• Personality disorders
• Sleep-wake disorders:
  • Insomnia disorder
  • Obstructive sleep apnea
  • Circadian rhythm sleep-wake disorders
• Trauma and stressor-related disorders
  • Post-traumatic stress disorder (PTSD)
  • Acute stress disorder
  • Adjustment disorders
  • Other specified trauma and stressor-related disorder (persistent complex bereavement disorder)
• Anger management issues
• Grief
• Chronic pain
• Stress management issues
• Weight management issues

Intellectual disability is defined by the presence of deficits in an individual's intellectual functioning and adaptive behavior. Using a cut-off of an IQ below 70 and impaired adaptive behavior, it is estimated that the prevalence of intellectual disability is between 1% and 3%. It is quite common for individuals with intellectual disability to have co-existing conditions such as autism, psychosis, disruptive behavior disorders, epilepsy, sensory and motor impairments.

- Mild

Individuals with mild intellectual disability can often interact socially with a certain level of competence but they often encounter significant difficulties in academic pursuits during their schooling years. What differentiates them from children with specific disabilities such as dyslexia is that their academic difficulties are often general in nature as compared to the specific difficulties demonstrated by children with specific learning disabilities. Individuals with mild intellectual disability are often able to develop a certain level of academic and vocational competency if they received enough educational support.

- Moderate

Individuals with moderate intellectual disability often display significant delay in reaching their developmental milestones. Some may be able to learn the necessary skills to interact socially while others have great difficulty acquiring such skills. These individuals often experience great difficulty acquiring even the most basic academic skills. However, it is still possible for some to acquire some academic and vocational skills with sufficient support and an appropriate curriculum.

- Severe

Individuals assessed to have a severe level of intellectual disability often demonstrate a pronounced delay in reaching their developmental milestones as a child. This often leads to a referral for psychological assessment at a young age. Education for these individuals often focuses on helping them acquire the relevant adaptive behavioral skills rather than an academic focus.

- Profound

Individuals with profound intellectual disability often have a very marked delay in the acquisition of relevant developmental milestones. They often face grave difficulty acquiring communication skills or other adaptive behaviors. Thus, lifelong intensive support is required to ensure a decent quality of life. They often require a highly structured environment and more intensive support than the above-mentioned levels.

Intellectual disability can be due to a myriad of causes. Causes such as Down's Syndrome and Fragile X Syndrome are genetically determined. Other causes may be the result of metabolic disorders. Increasing maternal age, maternal illness and maternal exposure to toxins are risk factors for intellectual disability. Premature birth, low birth weight, birth injury and neo-natal disorders are also risk factors. Neo-natal issues such as seizure, infections, respiratory distress or brain haemorrhage may also result in intellectual disability. Other factors include traumatic brain injury and malnutrition.

Parents or guardians should bring along the identified patient's health booklet, previous reports from other professionals involved in the care of the patient (eg. occupational therapist, physiotherapist, speech therapist, paediatrician, etc.), and the school report book if available.

An assessment for intellectual disability often starts with detailed history taking using an interview format with the patient's parents or main caregiver. Information collected during the history taking may be used to complete relevant items in a standardised instrument for assessing adaptive behavior.

It is also better for the individual to be assessed in a fit and alert state of mind. Hence, it is advisable to re-schedule the assessment if the patient is down with the flu. After the interview, the psychologist will use a standardised psychometric measure to evaluate the individual's cognitive ability. Assessment may also include other activities such as the gathering of information from the school via the teacher's rating forms, interviewing the school teachers, and classroom observations. Parents or guardians will be advised in advance if these activities are required.

Dementia is not a specific disease; it refers to a collection of symptoms that are caused by disorders affecting the brain. Dementia affects thinking, behaviour and the ability to perform everyday tasks. This neuro-degenerative disorder affects brain functioning enough to interfere with the person's normal social or working life. Although one nationwide study found that one in ten people aged 60 and above in Singapore has dementia, this disorder can also be diagnosed in younger individuals (i.e. younger onset dementia).

Alzheimer's disease (AD)

Alzheimer's Disease (AD) is the most common form of dementia, affecting up to 70% of all people with dementia. AD is a progressive dementia – caused by progressive degeneration of brain cells. The brain degeneration that occurs in AD typically affects memory, thinking skills, emotions, behaviour and mood. As the disease progresses, symptoms become more noticeable and interfere with daily life. The disease affects each person differently and the symptoms experienced vary.

Vascular dementia

Vascular dementia is a dementia that causes problems with reasoning, planning, judgement, memory and other thinking skills that are significant enough to interfere with daily social or occupational functioning. It is caused by brain damage resulting from impaired blood flow in the brain.

Vascular dementia can sometimes develop after a stroke blocks an artery in the brain, but strokes do not always cause vascular dementia. Whether a stroke affects thinking and reasoning depends on the severity and location of the stroke. More commonly, vascular dementia results from multiple small strokes or other conditions that damage blood vessels and reduce circulation, thereby reducing the supply of vital oxygen and nutrients to brain cells.

Frontotemporal dementia (FTD)

Frontotemporal dementia (FTD) is a type of dementia resulting from progressive damage to the frontal and/or temporal lobes of the brain. The frontal lobes of the brain are involved in mood, social behaviour, attention, judgement, planning and self-control. Thus, FTD can lead to reduced intellectual abilities and changes in personality, emotion and behaviour. The temporal lobes of the brain are involved in processing what we hear and understanding what we hear and see. Hence, deficits in these regions may lead to difficulty in recognising objects or understanding or expressing language. FTD includes behavioural variant FTD, semantic dementia and progressive non-fluent aphasia.

Lewy body disease (LBD)

Lewy body disease (LBD) is a common neuro-degenerative disease caused by ageing. LBD occurs when there is an abnormal build-up of a protein called alphasynuclein in the brain cells. The accumulation of alphasynuclein causes changes in movement, thinking and behaviour. LBD includes dementia with lewy bodies, Parkinson's disease and Parkinson's disease dementia.

Alzheimer's disease (AD)

In a few cases, AD is inherited, caused by a genetic mutation passed from one generation to the next. Lifestyle and health factors are associated with an increased risk of developing AD. Being less mentally and physically active and having risk factors that affect heart and brain health (smoking, obesity, diabetes, high cholesterol, high blood pressure) are associated with a higher chance of getting Alzheimer's Disease, but do not make it certain.

Vascular dementia

Anyone can be affected by vascular dementia, but the risk increases with age. Factors that increase the risk of heart disease and stroke also raise the risk of vascular dementia.

Frontotemporal dementia (FTD)

FTD can affect anybody, although it typically affects people of a younger age, with symptoms beginning in the 50s or 60s.

Lewy body disease (LBD)

The causes of LBD is not well known. One of the Lewy body disorders, Parkinson's disease, has a public profile and established protocols for its diagnosis and treatment. Once a diagnosis of Parkinson's disease is made, a subsequent diagnosis of Parkinson's disease dementia is commonly inevitable over time.

Currently, there is no single test to diagnose dementia. Diagnosis is made after careful clinical consultation. The assessment may include detailed medical history, a physical examination, blood and urine tests, a psychiatric assessment, neuro-psychological tests (to assess memory and thinking abilities) and brain scans. After eliminating other causes, a clinical diagnosis of the type of dementia can be made.

There are different types of depressive disorders and a common feature is the presence of a sad mood and/or a lack of desire to engage in formerly pleasurable activities. Depression affects how one feels about oneself and how one thinks about things. Disturbances of mood are intense and persistent, and often significantly affect a person's daily functioning.

Although different depressive disorders have their own sets of symptoms and diagnostic criteria, a general set of symptoms of depressive disorders includes:

• Depressed mood (e.g. feelings of sadness, emptiness and/or hopelessness)
• Loss of pleasure or interest in activities
• Changes in weight and/or appetite (significant weight loss or decrease/increase in appetite)
• Changes in sleeping pattern (insomnia or hypersomnia)
• Psychomotor agitation or retardation
• Fatigue or loss of energy
• Feelings of worthlessness or guilt
• Difficulties concentrating and/or making decisions
• Recurrent suicidal thoughts or ideation

There is no single known cause of depression and it likely results from a combination of the following factors:

• Genetic factors (e.g. family history)
• Biochemical factors (e.g. imbalanced neurotransmitters, hormone changes)
• Environmental factors (e.g. traumatic and/or stressful events)
• Psychological factors (e.g. low self-esteem, heightened emotional sensitivity, pessimistic attitude)

There is a wide variety of different types of effective psychotherapeutic interventions for patients with depressive disorders. Some examples include:

• Cognitive-behavioral therapy
• Interpersonal therapy
• Psychodynamic psychotherapy
• Problem-solving therapy

Obsessive compulsive and related disorders are a group of disorders that are characterized by presence of obsessions and/or compulsions.

Obsessions:

• Recurrent and persistent thoughts, urges or images
• Intrusive and unwanted

Compulsions:

• Repetitive behaviours or mental acts that are applied rigidly
• Driven to perform these in response to an obsession

• Obsessive Compulsive Disorder
• Body Dysmorphic Disorder
• Hoarding Disorder
• Trichotillomania Disorder (hair pulling)
• Excoriation Disorder (skin-picking)

Some symptoms of OCD include:

1. Excessive or ritualized hand washing
2. Excessive cleaning of items
3. Checking of locks / stoves / doors
4. Counting (turning on and off the lights a certain number of times)
5. Needing to repeat routine activities (e.g., walking through the door a certain way / touching items everywhere at a certain time)
6. Hoarding and collecting everything
7. Constant need to tell or confess
8. Constant pulling of hair or skin

Engaging in a compulsion or behaviour in a ritualized fashion in response to an obsession to reduce distress or prevent an undesirable situation from occurring. This occurs even if the behaviour or mental act has little to do with the undesirable event (e.g., washing hands to prevent harm to family members).

Genetic Factors

• Family history of OCD
• Imbalance in neurotransmitters
• Difference in brain structure development

Cognitive Factors

• Misinterpretation of thoughts
• Exaggerated importance and responsibility (i.e., believing that one is solely responsible for safety or harm of others)

Environmental Factors

• Physical and sexual abuse in childhood
• Stressful/traumatic events
• Alterations in living environment

• Cognitive Behaviour Therapy
  • Exposure and Response Prevention
  • Cognitive Therapy
  • Combination of CBT and SSRI's (medication)

Note: Not all intervention options are available at Ng Teng Fong General Hospital and Jurong Community Hospital.

Personality disorders are longstanding patterns of inner experience and behaviour that deviate largely from the norms of an individual's culture. They are pervasive, inflexible and stable over time and usually have an onset in adolescence or early adulthood. These issues usually lead to great distress or impairment for the individual as well.

Personality disorders are usually grouped into three clusters as follows.

Cluster A: Individuals often appear odd or eccentric.

• Paranoid Personality Disorder
• Schizoid Personality Disorder
• Schizotypal Personality Disorder

Cluster B: Individuals often appear dramatic, emotional or erratic.

• Anti-social Personality Disorder
• Borderline Personality Disorder
• Histrionic Personality Disorder
• Narcissistic Personality Disorder

Cluster C: Individuals often appear anxious or fearful.

• Avoidant Personality Disorder
• Dependent Personality Disorder
• Obsessive-Compulsive Personality Disorder

Although each type of personality disorder has its own set of symptoms and criteria, a general set of symptoms of personality disorders includes:

• Experience and behaviour that deviate largely from expectations within the individual’s culture. This is usually seen in two or more areas:
  • Cognition (ways of perceiving and interpreting self, others and events)
  • Affectivity (range, intensity, appropriateness of emotional responses)
  • Interpersonal functioning
  • Impulse control
• The individual’s behaviour is usually inflexible and occurs through many social and personal situations.
• This pattern leads to clinically significant distress or impairment in social, occupational or other important areas of function.
• Usually, the onset occurs in adolescence or early adulthood.

• Genetic Factors:
  • Family history
  • Irregular levels of neuro-transmitters (dopamine / serotonin)
  • Structural changes in the brain caused by early experiences
• Family Environment
  • Childhood abuse (physical / sexual / emotional / psychological)
  • Neglect
  • Poor family communication and expressiveness
• Attachment Theory
  • Insecure attachment due to harm or abandonment
  • Inconsistent caregiving
• Social Factors
  • Fragile social networks and loss of widely agreed social roles

• Psychoanalysis / Psychodynamic Therapy
• Dialectical Behaviour Therapy
• Cognitive Behaviour Therapy
• Interpersonal Therapy
• Group Therapy

In general, sleep-wake disorders are conditions manifested by disturbed sleep which causes distress. This also includes impairment in daytime function.

Insomnia Disorder

Insomnia usually involves dissatisfaction with the quantity or quality of sleep. It is associated with the following subjective complaints.

• Difficulty in sleep initiation
• Difficulty in maintaining sleep (eg. frequent awakening or problems returning to sleep after awakening)
• Awakening in the early morning and unable to return to sleep after
• Not feeling refreshed after a night's sleep
• Daytime tiredness or sleepiness
• Difficulty in paying attention or focusing on tasks
• Irritation, anxiety or depression
• Tension headaches, etc.

• Genetic factors eg. female, advancing age
• Environmental factors eg. noise, lighting, uncomfortable temperature, etc.
• Temperamental factors eg. worry-prone personality, tendency to suppress emotions, stressful life events, etc.
• Sleep habits eg. irregular sleep schedule, stimulating activities or caffeinated drinks before bed, eating too much in the late evening, etc.
• Medical conditions eg. chronic pain, breathing difficulties, frequent urination, etc.

• Cognitive behaviour therapy for insomnia
• Stimulus control therapy
• Sleep restriction therapy
• Relaxation techniques

Note: Not all intervention options are available at Ng Teng Fong General Hospital and Jurong Community Hospital.

Obstructive Sleep Apneoa

Obstructive Sleep Apneoa (OSA) is caused by obstruction of the upper airway. It is characterised by repetitive pauses in breathing during sleep because the airway has become narrowed or blocked. Individuals with OSA are usually not aware of the apnea episodes but these episodes are often witnessed by family members.

• Breathing disturbances eg. snoring, gasping for air, pauses in breathing during sleep
• Daytime sleepiness or fatigue
• Dry mouth or sore throat upon waking
• Restless during sleep
• Sudden awakening with a choking sensation
• Unrefreshed sleep despite sufficient opportunities to sleep
• Tension headaches
• Difficulty in paying attention or forgetful

• Shorter lower jaw compared to the upper jaw
• Certain shapes of palate or airway that cause a narrower airway
• A large tongue that may fall back and block the airway during sleep
• Large neck or collar size (17 inches or more for men and 16 inches or more for women)
• Large tonsils and adenoids in children
• Obesity

• Stimulus control and sleep hygiene
• Lifestyle changes eg. weight loss, alcohol and smoking cessation, positional therapy, etc.
• Exposure therapy for claustrophobic reactions to Continuous Positive Airway Pressure (CPAP) mask

Note: Not all intervention options are available at Ng Teng Fong General Hospital and Jurong Community Hospital.

Circadian Rhythm Sleep-wake Disorders

Circadian Rhythm Sleep-wake Disorders refer to the disruptions in a person's biological clock. The Circadian rhythm (approximately 24-hour sleep-wake cycle) is important in the regulation of brain activities, biological processes and determining sleep patterns. People with Circadian Rhythm Sleep-wake Disorders are not able to sleep and wake up at the required time for school, work, and other social needs.

• Excessive insomnia or sleepiness, or both, at inconvenient times
• Remarkable distress in social or occupational functions
• Not feeling refreshed after sleep
• Fatigue, headaches, stomach problems, etc.

• Shift work eg. frequently rotating shifts or constantly working night shifts
• Time zone changes eg. jet lag which causes low daytime alertness
• Pregnancy eg. frequent urination at night, hormonal changes, anxiety, discomfort, etc.
• Medication eg. many drugs such as stimulants, allergy medication, decongestants, weight-loss products, etc. can interfere with sleep
• Changes in routine

• Stimulus control and sleep hygiene
• Lifestyle changes eg. management of shift schedules and nap schedules
• Chronotherapy

Note: Not all intervention options are available at Ng Teng Fong General Hospital and Jurong Community Hospital.

Grief is a response associated with the death of a significant other. The significant other may be a spouse, partner, child, parent, other relative, friend, or even a dear pet. Numerous symptoms that occur with the death of a loved one resemble those of depression. In normal grief reaction, the individual feels sad, may lose interest in some usual pleasures, have trouble sleeping difficulty in carrying out routine tasks. These symptoms typically resolve within a few months, as there is a gradual weaning from remembered experiences with the loved one. This period of grief or mourning is a normal and useful adaptation to the loss of a loved one and should not be discouraged.

In some cases, complicated grief reactions that lead to depression may also occur. This happens when grief does not occur or is postponed and then experienced some time after the significant other has passed on. Sometimes, it is difficult to recognise that these symptoms actually reflect the mourning of a death that occurred several years earlier. At other times, instead of sadness, patients may develop physical symptoms or even believe that they have the same illness as the person who has passed on.

Complicated grief may occur when grief is severe and that severe phase lasts longer than two months or when a loved one has passed on and the individual has not experienced the normal mourning process. Some obvious signs are the individual's failure to mention the dead person or discuss the circumstances around the death. Certain depressive symptoms such as excessive guilt and suicidal ideation also suggest the presence of complicated grief.

Chronic pain patients experience substantial emotional distress from:

• An anticipation of pain
• Consequence of pain
• Cause of pain
• Representation of a concurrent problem of independent sources

A fear of pain seems to predispose:

• Severe distress
• Disorganised behavior
• Inappropriate avoidance strategies
• Substantial physiological arousal
• More severe disability than necessary

Emotional Distress as a Consequence of Chronic Pain

• Progressive debilitation that reflects ongoing crises / deprivation of important life roles in addition to the realisation of interventions being non-effective
• Legitimacy of pain complaints but individual is ignored or belittled, adding on to the stress and distress experienced by the individual
• Long endured pain and a disrupted lifestyle can result in despondency and a sense of hopelessness. Hence, chronic pain is often associated with depression.
• Chronic pain and depression are independent processes although there is a possibility of mutual influence. Pre-existing conditions or co-morbidity may be responsible for the depression.
• Depression, somatic anxiety and anger commonly interact with one another in the case of chronic pain patients.

Emotional Distress as a Cause of Pain

• Pain of a psychological origin may be attributed to specific delusional or hallucinatory causes, with prevalence of less than 2% in patients with chronic pain with no lesions.
• The autonomic and neuroendocrine changes provoked by psychological stress have been associated with cardiovascular, digestive, respiratory and eliminative systems.
• Distressing events can contribute to initiation or exacerbation of a large number of painful diseases such as angina pectoris, painful menstruation, rheumatoid arthritis and gastric ulcer.
• In addition, stress may inhibit the capacity of the immune system to deal with pathogens that lead to painful diseases.

Often a co-morbid situation in affective disorders associated with anxiety, depression and anger, about 50% of all patients with pain and depression develop these two disorders simultaneously.

• Cognitive restructuring
• Relaxation training
• Stress management
• Training in pain coping strategies
• Decrease avoidance and promote a healthier and more active lifestyle ( eg. alleviate issues relating to stress, anger, communication, sleep, etc.)
• Relapse prevention and flare-up planning

Note: Not all intervention options are available at Ng Teng Fong General Hospital and Jurong Community Hospital.

• Attending to depression and its potential early in the care of a person who is vulnerable to serious problems could avert ineffective treatment and deterioration later on.
• Well- adjusted patients with chronic pain appear to have either strong personal or social resources to help them ignore stressful life challenges, thereby controlling depression and anxiety.
• Pain can provide a means of coping with unsatisfactory life circumstances.
• Feeling of anxiety and frustration can serve to increase the overall unpleasantness of the pain experience while anger is closely associated with the depression that pain patients experience.