"Life is not worth living.."

Anxiety & its main symptoms

Unlike the relatively mild, brief anxiety caused by a stressful event such as attending a job interview, anxiety disorders are chronic, relentless, and can grow progressively worse if not treated Anxiety disorders are the most common of emotional disorders, affecting 9.3% of the general population in Singapore, i.e. 1 in every 10 Singaporeans. (Ang, 2006) Each anxiety disorder has its own distinct features, but they are all bound together by the common theme of excessive, irrational fear and dread. (Refer to Appendix A for a list of anxiety disorders.) Anxiety disorders disrupt the daily functioning (social & vocational) of the people.

Anxiety produces physical symptoms such as rapid or irregular heartbeat (palpitations), stomach problems (gnawing feeling, nausea, "butterflies," diarrhea, irritated bowel syndrome), sweating, or feeling cold and clammy, body tension, fatigue or shortness of breath, shaking, & sleep disorders.
Emotional symptoms of anxiety include a general sense of apprehension and dread, nervousness, irritation & fear that you are dying or going crazy.
(http://www.anxiety-guide.com/symptoms-of-anxiety.htm Retrieved on 26 Aug, 2006.)

Depression & its main symptoms

Depression is a medical condition that affects a person’s thoughts and feelings as well as the body. t differs from normal sadness in intensity, duration, and interferes with one’s daily functioning. Depressive disorder is common & highly treatable. It is an internal “stress state.” To an outsider, the symptoms seem to represent a form of either agitation or withdrawal. The symptoms of depression may be inappropriately dismissed as understandable reactions to stress or an attempt to receive attention from others. (Albrecht A.T. & Herrick C, 2006.)

The DSM-IV-TR defines a major depressive episode by the following symptoms: Depressive mood, loss of pleasure or interest, insomnia, agitation/retardation, fatigue, increased sense of worthlessness, decreased concentration & recurrent thoughts of death and suicidal ideation. If these have been experienced for more than two weeks it is essential to seek help. (Chia, 1999) Treatment consists of medications, psychotherapy, cognitive therapy, electro-convulsive therapy or combination of these treatments. With treatment, 80-90% of people with major depression disorder will recover. (http://www.depression-guide.com/symptoms-of-depression.htm Retrieved on 26 Aug, 2006.)

Therapeutic Intervention on Depressive/Suicidal Client

Depression plays a large role in suicide. The warning signs include thoughts or talk of death or suicide, or harm to others; or giving away of prized possessions. When the client says `life is not worth living’(an indirect verbal clue of suicide idea), as a therapist, I have to avoid rushing blindly into the suicidal problem as one of the first things to be assessed. My first priority will be to gain insight into his life by obtaining his medical history and to ascertain if he is presently on any medication, such as anti-depressant. If he is not, I will ask about his current mental & physical state to determine if he is experiencing symptoms of depressions (as stated in the previous paragraph) in the last two weeks. If found to be so, I will explore with client possible reasons for the severe depression, namely:
- A medical condition that is debilitating, painful, or life-threatening;
- physically, emotionally or sexually abused; drugs or alcohol abuse;
- mental illness like schizophrenia or bipolar disorder;
- homosexuality (especially teens) because they feel misunderstood or rejected by their families
- anti-depressant medications can worsen depression or cause the emergence of suicidal thoughts. (http://www.helpguide.org/mental/suicide_prevention.htm Retrieved on 27 August 2006)
- Stressors (examinations, NS training, marital & family conflicts) (Chia, 1999)
- In the west, family, twin & adoption studies have shown that there are genetic factors in suicide involving the transmission of mental illness. (Roy, 1989)
- Shaffer & Gould (1987) believe that one has to consider the effect of imitation or contagion. Fortunately in Singapore, contagious suicide is uncommon. (Chia, 1978)
At some point during session, I will trust my instinct & ask if he is feeling suicidal. I do not think by doing so, I am putting ideas into his head, but instead may bring out a topic that has most likely been thought of already. As a therapist, I have to be prepared to hear suicidal thoughts and feelings & not be frightened by the expression of such wishes. (Chia, 1999) If the client admits he is feeling suicidal, I will acknowledge his feelings of hopelessness & pain. For the client suicide might seem like the way to end the pain since he may have trouble imagining another way to relieve the extreme suffering. This could partially be due to errors of thinking, such as overgeneralization, catastrophic thinking, Jump-to-conclusion or personalization. (Albrecht A.T. & Herrick C, 2006.)
As suicidal people are often afraid that trying to get help may bring them more pain, I will need to show unconditional acceptance & warmth in order to re-establish a sense of hope. If the client is young, he may not be willing to provide reliable feedback nor co-operate with treatment. I will need to be ‘warm, caring & responsive without being familiar.’ (Cantor, 1977)
If the client’s suicidal ideation is motivated by pathological reasons, his lethality level will need to be assessed, and hence hospitalization may be necessary for the protection of the client. However, the benefits of intensive interventions such as hospitalization must be weighed against their possible negative effects (e.g. disruption of employment, financial and other psychosocial stress, and social stigma).
There is neither a reliable & valid screening instrument nor a psychological test which can predict with any degree of accuracy whether a person will commit suicide. (Chia, 1999) Beck’s Suicide Intention Scale (Beck et al., 1974) taken in isolation would be of limited value but in combination with clinical findings, it can be useful. Beck et al (1975) found a person’s subjective expectations about the future (Hopelessness Scale) were highly correlated with the seriousness of his suicidal intention.
More importantly, I will ask
 if client has a plan for suicide. Having a plan means he is that much more serious about intending suicide. (For example, sleeping pills have been collected.)
 if he has a history of prior suicide attempts? The more times a person has already attempted suicide, the greater the risk of succeeding.
 what kind of resources are available to him? (Risk will be higher if client has marital woes, very few relatives and has only one close friend.)
 What are his cultural & religious beliefs relating to death & suicide.
Suicide is a coping mechanism & a form of communication – saying something to someone. Here is where I introduce the concept of Ambiguity as part of the client is oriented toward self-destruction yet another part is strongly life sustaining. (Hipple, Ph.D) Berne (1972)’s inviolable rules of death will be explained to the client at the opportune time, `No parent is allowed to die until all the children are over 18 & no child is allowed to die while either of his parents is still living.” I will ask the client: “Who needs to know… about your pain?” I need to recruit the family and significant others into the intervention as suicide do not exist in a vacuum. “You think that you are a burden to your family, can I talk to your family…?” I need to seek permission to contact client’s social support network so as to forty it. This goal can be accomplished without revealing client’s suicide intent. However, in clinical circumstances in which sharing information is important to maintain the safety of the patient or others, it is permissible and even critical to share such information without the client’s consent. (APA, 2003).
Before ending the session, I will tell the client i care about him and want to help develop contingency plan so that he knows who to contact in time of crisis. I would presume he has not been told that he is important and deserve to stay alive by providing him the permission to live – “I want you to stay alive.” He will be reminded to keep his part of the Stay-Alive contract, i.e. to call me before he does anything to harm himself. (Hipple, Ph.D)
I will encourage him to go on an exercise routine as exercise releases chemicals called endorphins which will lift the mood, make one feel energized and sleep more soundly. I will explore with him the possibility of taking breaks – naps, movies, a short holiday with his family/friends to enhance interpersonal relationship. He will also be told the benefit of journalling his thoughts and feelings.

Summary

Psychotherapies and other psychosocial interventions play an important role in the treatment of individuals with suicidal thoughts. Interpersonal Psychotherapy (IP) and Cognitive Behavior Therapy (CBT) have been found to be effective for the treatment of depressions. The goal of IP is to improve communication skills and self-esteem. Areas of social functioning that may be addressed are interpersonal disputes, role transitions, grief, and interpersonal deficits. CBT may be used to decrease two important risk factors for suicide: hopelessness & suicide attempts. The automatic thoughts and behavior of a self-defeating quality in the client will be focused in order to make him more conscious of them and replace them with more positive thoughts and behaviors. (Albrecht A.T. & Herrick C, 2006.)
I will follow up with the client especially on missed appointments. I will also re-establish the Stay Alive Contract by tightening loopholes in the contract and looking into contingency plans for new stress & crisis. In the stress of the immediate crisis, I may have to be active and directive. If the client is hospitalized, it will be safer to be there for him immediately following hospital discharge, especially if his family members are not available. (Hipple, Ph.D)

Appendix A
List of Anxiety Disorders
Anxiety Disorder Short Description
Obsessive Compulsive Disorder (OCD)

Obsessive-Compulsive Disorder, OCD, is an anxiety disorder and is characterized by recurrent, unwanted thoughts (obsessions) and/or repetitive behaviors (compulsions).

Acute stress disorder
Acute Stress Disorder is a anxiety disorder that develops within one month after a severe traumatic event or experience.

Separation Anxiety Disorder
It is normal for toddlers and preschool children to show a degree of anxiety over real or threatened separation from people to whom they are attached.

Social Anxiety Disorder
Social anxiety disorder is an excessive, persistent fear of social or performance situations.

Phobic Disorders
A phobia is an anxiety disorder in which the affected person experiences an excessive or irrational fear of a specific situation, object or activity that disrupts their ability to function in normal daily activities. Specific Phobia, Social Phobia, Agoraphobia.

Post Traumatic Stress Disorder (PTSD)
Posttraumatic Stress Disorder is a complex health condition that can develop in response to a traumatic experience - a life-threatening or extremely distressing situation that causes a person to feel intense fear, horror or a sense of helplessness.

Panic Disorder (Also see Panic Disorder with Agoraphobia)
The Panic Disorder usually makes the person believe that they are either seriously ill or about to die, and can leave the person feeling distressed or shaken for quite a while afterwards.

Tourette's Syndrome
Tourette Syndrome is an inherited, neurological disorder characterized by repeated and involuntary body movements (tics) and uncontrollable vocal sounds.

Anxiety Due To A Physical Disorder Or A Substance
Due to the direct physiological effects of intoxication or withdrawal from a substance.

Generalized Anxiety Disorder (GAD)
Generalized Anxiety Disorder (GAD) is when persistent worry and anxiety about your health, work, money or family last for at least six months, even when there are no signs of trouble in your life.

(http://www.depression-guide.com/anxiety-disorders.htm Retrieved on 26 Aug, 2006.)

Reference

Ang Y.G. Dr. (2006). Lecture notes on Anxiety.

Albrecht, Ave T. and Henrrick, C. 100 questions & answers about depression. Sudbury, MA: Jones & Bartlett Publishers, Inc.

Chia, B.H. (1999). Too young to die. SG: Times Books International

Roy A. (1989). Genetic & suicidal behaviour. In: Report of the Secretary’s Task Force on Youth Suicide Vol2: Risk factors of youth suicide. Washington, DC: U.S. Government Printing Office.

Shaffer D, Gould M. (1987) A study of completed & attempted suicides in adolescents. Progress Report, Rockville. MD:NIMH

Chia, B.H. (1978). Suicide in Singapore. MD thesis. University of Singapore

Beck AT, Schuyler D, Herman I. (1974). Development of suicide intent scales. In:Beck AT. Resnick HLP, Lettieri DJ,eds. The prediction of suicide. Maryland:Charles Press

Beck AT, Kovacs M, Weissman A. (1975) Hopelessness & suicidal behaviour: An overview. Journal of the American Medical Association.

Berne, E. (1972). What do you say after you say hello? New York:Grove Press

American Psychiatric Association. Practice guideline for the assessment & treatment of patients with suicidal behaviours. Arlington (VA): American Psychiatric Association; 2003, Nov. 117 p.

Hipple, J. Ph.D. Suicide – the preventable tragedy. Adapted from Mr Benson Soh’s note.