What is Insomnia?

Insomnia exist in various forms: many suffers experience difficulty in getting to sleep, others have interrupted sleep, some wake up too early in the morning and a few simply have poor quality sleep and do not feel rested. If insomnia lasts for more than 3-4 weeks, it is termed chronic.

What are the problems associated with Insomnia?

Individuals vary in their need for sleep: we all know of individuals who can ordinarily function well with less sleep than others. However, for people with insomnia, it causes distress and affects their everyday lives. Poor sleep result in daytime drowsiness and can impair attention and motor coordination when driving or operating machinery. This can be dangerous. Poor attention and memory also affect studies and work productivity. A person deprived of sleep will tend to be irritable and this can impair his relationship with others. Hence an individual with a sleep problem may have an impaired quality of life.
It is also important to note that in many cases, insomnia can be a symptom of a psychological disorder such as an anxiety disorder or depression, and these disorders should be treated. Some individuals with chronic insomnia attempt to treat themselves by consuming cough syrup or alcohol. Unfortunately, such an abusive pattern of drug use will not only compound the sleep problem but also cause damage to physical health and create addiction problems.

What are the causes of insomnia?


Insomnia is a very common condition, and most people would have experienced it a few times in their lives. Sleep disturbances can happen in normal people simply due to situational influences. For example, excessive noise or an unfamiliar environment can affect sleep. It occurs in jet-lag, when the person travels across different time zones, and also when a person engages in shift work. Correction of these situational influences will usually improve sleep. Certain physical symptoms such as pain and shortness of breath in patients with medical problems can disrupt sleep.

Transient insomnia also occurs in response to stress or worry. It is common to have poor sleep when one is undergoing stress in studies, workplace or relationship. When the stress is overcome, sleep will usually improve.

However many individuals also suffer from chronic insomnia, where sleep problems persist for more than a few weeks, because the stressors are persistent or overwhelming. Insomnia occurs commonly in adjustment disorders, where one’s coping strategies to stress are overwhelmed. Others may have a psychological disorder such as depression, which needs prompt medical treatment.

Insomnia, especially early awakening, occurs commonly in depression. Other accompanying symptoms of depression that one should look out for include depressed mood, loss of appetite, loss of drive or interest, frequent negative thinking, feelings of worthlessness and even suicidal thoughts. Depression is a disorder that can severely affect an individual’s life but effective treatments are abailable. Another group of disorders commonly associated with insomnia are the anxiety disorders. These disorders are characterized by persistent and excessive anxiety and worry. Some may also have panic attacks, whereas others have persistent bodily complaints. Yet others have compulsive cleaning or checking rituals, which are symptoms of an obsessive-compulsive disorder. Finally, insomnia is also experienced by an individual developing a major mental disorder like schizophrenia. In this disorder, one experience hallucinatory “voices” and has strange behaviours and beliefs.

It is unfortunate that the psychological disorders mentioned above are frequently under-diagnosed and under-treated, as effective treatments are currently available for these conditions.

How do I know if I need assessment and treatment?

If you have poor sleep for more than 2 weeks and it has been affecting your activities and function, a consult with a doctor will be appropriate. This is especially so if you have other symptoms suggestive of a medical or psychiatric disorder such as depression – these will need to be addressed too and remember, they respond well to treatment. The doctor will talk to you to obtain a thorough medical history, followed by a physical examination. This is to identify any medical or psychological factors that might contribute to your insomnia. Physical investigations such as blood tests may or may not be required. The doctor then makes the diagnosis and decides on the treatment.

How is Insomnia treated?


This is achieved using both non-pharmacologic (non-medical) and pharmacologic (medical) approaches.
A. Non – Pharmacologic
 - Firstly anyone who is a light sleeper or has sleep problems should adopt proper sleep hygiene. Hence one should avoid coffee, tea and drinks containing caffeine from late afternoon onwards, avoid prolonged afternoon naps and ensure that the bedroom is quiet (ear plugs can help) and comfortable. Alcohol should be reduced: although it appears to help induce sleep, it actually disrupt sleep later on. Only go to bed when very sleepy and get out of bed to do some quiet reading if still not asleep after 15 minutes. Relaxing activities such as meditation or practicing muscle relaxation before sleep also helps.

B. Pharmacologic - 
For individuals who need it, the doctor may prescribe sleeping pills. Sleeping pills generally belong to a group of sedatives called benzodiazepines. Certain sedatives such as zolpidem and zopiclone have benzodiazepine-like actions. Different sedatives are effective in promoting sleep in various ways, for example the shorter-acting ones (such as lorazepam) promote initiation of sleep without causing much daytime sedation, whereas the longer-acting ones (such as diazepam) helps one to maintain a longer period of uninterrupted sleep. Despite its proven effectiveness, in a small proportion of users, benzodiazepines are associated with dependence (difficulty stopping its use and need for larger doses over time): this risk is much reduced if the users take the pills for short periods, in moderate doses and under medical supervision. As the patient’s condition improves, the doctor will instruct the tapering down of sedative doses. It is important to note that most users of sleeping pills successfully stop its use when their conditions are treated.

Some individuals taking longer acting benzodiazepine sedatives might experience daytime sleepiness and this is of concern when driving or operating machinery. Sometimes, a person with concerns about the addictive potential of benzodiazepine sedatives may instead be prescribed antihistamines (such as certain flu medicines) or antidepressants with sedating properties. These can work equally well.

It is also important to note that in individuals with depression or anxiety, sleeping pills are adjuncts to antidepressants and anti-anxiety medicines, which are main medical treatment. As the individual’s depression lifts, his sleep will also improve.

There are guidelines set by the Singapore Medical Council regulating the prescription of sedatives by general practitioners, and patients must understand that if the insomnia persists and more sedatives are required, a referral to a psychiatrist may be needed.
 

What is OCD?


OCD, or Obsessive Compulsive Disorder, is a common disorder with a lifetime prevalence of 2-3% in the general population. It occurs in children, adolescents and adults, and both men and women are equally likely to get it. It is a chronic disorder characterized by obsessions and compulsions.

Obsessions are thoughts, images, or impulses that occur over and over again and are beyond one’s control. Moreover, these thoughts and images can be disturbing, repulsive, silly or senseless. In response to these obsessions, many sufferers develop compulsions, i.e. repetitive behaviors or thoughts that neutralize or make the obsessions go away. Compulsions cannot totally relieve the obsessions long-term and hence the repetitive nature of compulsions makes them time-consuming.
Also OCD sufferers recognize that their thoughts and actions are irrational and excessive and become distressed by this realization.

What are some examples of OCD? 
The content of OCD is highly variable. Here are some of the more common examples. In sufferers with obsessive fear of contamination (by germs, dirt etc), they have compulsive cleaning. The cleaning may be in the form of excessively frequent hand washing, bathing or cleaning of items, sometimes employing copious use of soap and other cleaning agents and in fixed patterns of accomplishing the acts (known as “rituals”).

Example 1: Miss Lee is a 31 years old secretary who has always been a clean and tidy person. For the past 3 months, however, she has been excessively fearful of getting contaminated by “germs”. She spends a several minutes each time washing her hands with soap whenever she touched a surface which she deemed as “contaminated” eg. an office document, a chair and most other surfaces. She is starting to develop redness and peeling of her hands because of excessive washing. At home, she can only sleep very late as she has to spend many hours cleaning her house. Her relationship with her boyfriend suffers as she finds kissing and even holding hands unhygienic and “dirty”. She becomes depressed as a result.
 

In obsessive doubt, a sufferer may have a persistent fear of having missed various things (such as not properly switching off lights or gas stove, not closing doors or windows properly, making a careless mistake in work or misplacing a wallet). He or she then compulsively checks for these “mistakes”. Hence the sufferer may spend a long time checking these things.

Example 2: Mr Lim is a 26 year old engineer who has become increasingly “stressed” by the need to check and double check items at home and work. Before leaving home for work, he will spend 30 minutes or even longer ensuring that all switches and taps are turned off. He has developed a time-consuming ritual of turning on and off a tap several times, then staring at it for 1 minute to ensure that it is properly turned off. On many occasions as he starts to drive to work, he will suddenly return home to repeat all the checks as he is doubtful if the checks are properly done previously. As a result he is frequently late for work. Besides chiding him for lateness, his boss also complains that he has not been submitting his work on time. Indeed, his compulsive checking and rechecking of all documents and papers because of his fears that he might make careless mistakes has delayed his work significantly and his colleagues has started to brand him as “slow”.

There is also a group of OCD sufferers who predominantly has repetitive and intrusive thoughts and mental images that keep replaying in their minds, for example of sex, violence, silly or senseless things that is abhorrent and has no relevance at all to the sufferer.

Example 3: Ms Fatimah is a 21 year old undergraduate studying Accountancy, who has been distressed for the past few weeks by some disturbing thoughts. She has thoughts of slapping her friends (for no reason) when they study together and also has mental images of them indulging in sexual acts. She finds these thoughts and images to be repulsive and disturbing, but they continued to be intrusive and difficult to resist. She is even more distressed when she goes for her regular prayers:  she will have sudden impulses to blaspheme the name of God. She is afraid that she might lose control one day and shout blasphemies in public.

Why is OCD problematic for the sufferer?


Because the OCD sufferer spends an excessive amount of time cleaning and checking, he or she may not have enough time for important daily tasks. There will be problems with being late for appointments and being unable to hand in assignments on time. The compulsions also affect other family members and friends and the relationship with others becomes strained. Some family members are even “recruited” into the cleaning and checking rituals. Many OCD sufferers and their loved ones are stressed and exhausted by these obsessions and compulsions. Some OCD symptoms can be bizarre in their content and sufferers fear that they might be going mad. Many also become depressed, are unable to sleep and some even entertain suicidal thoughts.


How do I know if I need assessment and treatment?

If you have the above symptoms and they are causing distress and affecting your life, it is time to consult a doctor. Many people suffer needlessly from these symptoms, which is unfortunate because OCD can be treated. Sometimes OCD symptoms can be bizarre and may be confused with other mental disorders such as psychosis, and a detailed assessment by a psychiatrist can help to distinguish between them as it has an impact on treatment. Besides eliciting OCD symptoms, the doctor will check if you are depressed because many OCD sufferers are also suffering from depression. Physical investigations such as blood tests and brain scans may or may not be required. After the diagnosis is made, the psychiatrist decides on the treatment for you.

How is OCD treated?

This is achieved using pharmacologic (medical) and/or non-pharmacologic (non-medical) approaches.
A. Pharmacologic
 - The main types of medicine you are likely to receive for treatment of OCD are the selective serotonin reuptake inhibitors (SSRIs) or a tricyclic antidepressant (TCA) with strong serotoninergic action (clomipramine). As abnormal quantities of a neurochemical called serotonin is implicated in the pathogenesis of OCD, the use of these antidepressants that specifically act on the serotonin receptors can improve OCD.  Examples of these antidepressants include fluvoxamine, fluoxetine, sertraline, paroxetine, escitalopram and clomipramine.

Although these medicines are effective in improving OCD, they may cause side-effects in certain individuals. This is because many of the antidepressants are used in higher doses when treating OCD. These include nausea, loose stools, abdominal discomfort and headaches. These side-effects usually go away after a few days of taking the medicine.

In certain more treatment resistant cases, the psychiatrist will use other types of antidepressants, a combination of antidepressants, or augmentation with an antipsychotic. Besides treating OCD, antidepressants can also treat any secondary depression that you may have.

B. Non-Pharmacologic - 
Cognitive behaviorial therapy (CBT) is useful for treatment of OCD. It may be used alone (for mild cases of OCD) or in combination with medicines. The specific technique employed in treatment of OCD is exposure and response prevention (ERP). Here you will learn to gradually tolerate the anxiety associated with not performing the compulsive behaviour. For example, consider an individual with obsessive fear of contamination by germs and has compulsive handwashing: he or she is prevented from washing the hands after exposure to a contaminated surface such as touching a door knob. As the individual habituates to this exposure and anxiety drops, he or she can proceed to exposure to something more “contaminated”, again with response prevention.

For those with only mental obsessions without much physical compulsions, techniques such as thought-stopping are also useful.  In CBT, you are expected to do “homework”, i.e. practice the skills learnt at home, hence it is important for you to be highly motivated.
 

What is Stress?

We all know how the demands of modern living can leave us overwhelmed at times. It should not be too difficult to recall a period of time when life became “stressful”.

Stress is our body’s normal reaction to a change in our environment that requires a physical, mental or emotional adjustment or response. The stress response is our body’s way of helping us stay vigilant and focused on the task at hand.

A stressor is a stimulus that causes stress. External stressors can range from  a forthcoming examination, difficulties at work, financial problems, marital tension to illness or demise of a loved one. Sometimes, not all stress can be attributed to external causes. Stress that is “self-generated” can be caused by an inflexible, pessimistic atttitude, persistent self-defeating thoughts, tendency towards perfectionism, unrealistic expectations, and inability to be assertive or accept uncertainty.

Good Stress Vs Bad Stress 
Stress can come from  any situation or thought that makes a person feel frustrated, angry, fearful or anxious. Then again, not all kinds of stress are bad. Stress can have both facilitating and debilitating effects.

Good stress or “Eustress” in small doses enhances arousal and improves performance. Bad stress or “Distress” on the other hand, is excessive. “Distress” results a decrease in motor, learning and other intellectual abilities and eventually, deterioration in performance.

A ‘Stressful’ Toll 


Excessive stress is unpleasant and unhealthy for our minds and bodies in the longer term. Prolonged exposure to high amounts of stress has been associated with high blood pressure, obesity, heart disease, insomnia, depression, gastritis and eczema, just to name a few.

Dealing with Stress


No matter what curve balls life throws at us, the good news is that our tolerance to stress can be improved.

Things we can do include having good knowledge about the stressor you are facing, developing an internal sense of control, maintaining a positive attitude and optimistic outlook, using effective emotional regulation strategies and growing a good social support network.

While we will all learn to cope eventually, one of the first steps you can take to regain control when stress becomes unbearable may be to talk to someone about your problems or seek help from a professional can be useful.

 

Common Relaxation Techniques for Stress Relief 


Living in today’s world can be stressful. Hectic work schedules, heavy school timetables, a multitude of deadlines, demands from significant others, to name a few, are some of the issues that most of us have to manage on an almost daily basis.

Too much stress experienced over a sustained period of time, with insufficient coping strategies can result in ‘wear and tear’ to the body. Over the longer term, both emotional and physical wellbeing can be affected. Inability to contain your inner tension may also result in collateral damage to interpersonal relationships and work performance.

Tell Tale Signs of Excessive Stress 


When a person is under excessive stress, he / she may experience the following:

A. Psychological Arousal 
- Increased irritability and easy frustration 
- Sensitivity to noise 
- Restlessness 
- Irrational and/or excessive emotional reactions 
- Sense of dread for the future 
- Poor concentration 
- Recurrent worrying thoughts

B. Physical Symptoms 
- Sleep disturbances e.g. insomnia, night terrors 
- Tension Headache 
- Hair loss 
- Back, shoulder or neck ache 
- Heartburn or upset stomach 
- Constipation or diarrhoea 
- Hyperventilation or feeling of being short of breath 
- Palpitations 
- Sweaty palms  
- Cold hands / feet 
- More frequent colds or flu 
- Lower libido and/or other reproductive problems 
- Irritable Bowel Syndrome 
- Skin conditions e.g. eczema, urticaria, psoriasis

C. Relationship and/or Work Problems 
- Dislike for social activities 
- Increased arguments 
- Domestic or workplace relationship conflicts 
- Frequent job switches or persistently thinking about leaving your job 
- Road rage

D. Behavioural changes 
- Smoking more cigarettes or consuming more alcohol than you used to. 
- Participating in high-risk behaviours e.g. speeding, unsafe sexual practices, gambling etc to feel “alive”

Relaxation Techniques 


Relaxation techniques are an essential part of stress management.

These simple techniques aim to bring about relaxation to help the body neutralize the toxic effects of stress, restore balance and improve health.

For some, simply listening to their favourite music, exercising or taking a nature walk may be effective enough to reduce stress levels. Others, however, may require more focused techniques.

Some of the more commonly used techniques include:

1. Deep Breathing for Stress Relief 
Deep breathing is a quick relaxation technique that is both simple to learn and easy to practice in most situations. This technique focuses on breathing deeply from the abdomen to get in as much fresh air as possible into your lungs. Apart from this revitalising effect, deep breathing also stimulates slower brain waves that occur when one is relaxed.

To practise deep breathing, you can place one hand on your chest and the other on your belly button. Counting silently from ‘1’ to ‘4’, inhale slowly and deeply through your nose over 4 to 5 seconds. You should feel the hand on your abdomen rise as your lungs expand. The hand on your chest should not move much. Then, counting back from ‘4’ to ‘1’, exhale slowly through your nose. Repeat a few times until you feel your inner tension decrease.

2. Progressive Muscle Relaxation 
This technique emphasizes on gradually tensing and then relaxing each muscle group from head to toe at intervals of 10 seconds. Through this, it helps you identify the tense muscles in your body and allows you to relax them in a progressive fashion. You should wear loose clothing and be sitted comfortably in an armchair while practising this.

3. Using Imagery or Visualization 
All of us have the ability to form mental images. Through relaxation training, we can use all of our senses namely sight, smell, sound, touch and even taste to take us on an imaginary journey to a soothing, peaceful place. This place can be somewhere tranquil in the mountains or a warm white sandy beach with crystal clear waters at a tropical island. If the thought of relaxing at a mountain chalet calms you, you might want to imagine the cool crisp mountain air, smell of fresh pine and the occasional rustle of the shrubs as the wind ruffles through them. For this, you may like to close your eyes and be comfortably sitting at a quiet place.
There are also other relaxation techniques such as yoga, meditation, massage that can be helpful. You will need to decide what works best for you.

Remember that relaxation is a skill that has to be acquired through practice. Your ability to utilise these techniques and their effectiveness will increase as you use them. Do bear in mind though, that some persons with complex emotional issues may experience psychological discomfort while practising relaxation. If so, you will need to stop what you’re doing and consider seeing your doctor for further advice.
 

Do you have sudden moments of intense fear accompanied by palpitations,
….breathlessness, dizziness and other physical symptoms?

Do you have Panic Disorder? 


A panic attack is a sudden surge of overwhelming fear that can come without warning and without any obvious reason. It is also accompanied by some or all of the following symptoms:

i. Heart beating fast
ii. Difficulty breathing
iii. Dizziness, lightheadedness, nausea
iv. Trembling, sweating, shaking
v. Choking, chest discomfort
vi. Fear that you’re going to go crazy or are about to die
vii. Tingling sensation in fingers or toes (“pins and needles”), numbness

Panic attacks can occur without warning and can also precipitated by situations and thoughts that are anxiety provoking. Because it is associated with many physical symptoms such as palpitations and breathlessness, many sufferers think that they have a medical condition such as a heart attack.

Do you need assessment and treatment?


If you have the above symptoms and they are causing distress and affecting your life, it is time to consult a doctor. Panic disorder is a chronic condition and as it progresses, the sufferer may become very fearful of having another panic attack in a public place. This may lead to refusal to leave his or her house, a condition known as agoraphobia.

Hence Panic Disorder can impair the social and occupational function of the sufferer and can lower the quality of life of the sufferer.

What happens in a psychiatric consultation?


An in-depth interview by a psychiatrist will include asking questions on the symptoms, your background history and medical history. Further investigations may be done if needed to ensure that a physical illness is not a cause of the panic attacks. After the diagnosis is made, the psychiatrist decides on the treatment for you. All information shared during the consultations is strictly confidential.

How is Panic Disorder treated?


Panic disorder is treated using medications and/or psychological therapy. Medications effectively help to reduce anxiety. These act on the serotonin receptors in the brain to reduce the level of anxiety and do not result in addiction. Other short-term medicines such as sedatives and sleeping pills may also be given to abort the panic attacks, improve sleep and allow you to relax . This is usually combined with cognitive behaviorial therapy (CBT) and relaxation therapy.



* Remember:
Panic Disorder can be treated and you can feel better.
Do not postpone treatment and suffer needlessly.
 

Do you feel troubled by excessive worries? Unable to relax? Difficulty sleeping?

Do you or your family member have an anxiety disorder? 
In an anxiety disorder, there is an excessive amount of anxiety which is troublesome to the sufferer. There are various types of anxiety disorders, and generalized anxiety disorder (GAD) is one type.

If you have GAD, you may have a persistent worry and anxiety about many things, usually pertaining to finances, family, work, studies and other aspects of daily life. There is little or no specific stressor that can obviously provoke it. You may find it difficult to control the anxiety and there may be also other symptoms such as muscle tension, headaches, difficulty concentrating and sleep difficulties.

These symptoms can last for many years and affect your work, relationship with family and general quality of life.

What happens in a psychiatric consultation?


Do you need assessment and treatment?
If you have the above symptoms and they are causing distress and affecting your life, it is time to consult a doctor. A psychiatrist will ask you about your symptoms, background history and medical history. Further investigations may be done if needed. After the diagnosis is made, the psychiatrist decides on the individualized treatment for you. All information shared during the consultations is strictly confidential.

How is Generalized Anxiety Disorder (GAD) treated?


This can be in the form of medications and/or psychological therapy. Medications are effective and help to reduce anxiety. Medications that act on the serotonin receptors in the brain will reduce the level of anxiety and these do not result in addiction. Other short-term medicines such as sedatives and sleeping pills may also be given if requested to improve sleep and allow you to relax. 
For non-medicinal approaches, cognitive behaviorial therapy (CBT) techniques and relaxation therapy are useful in the treatment of GAD.

* Remember:
GAD can be treated and you can feel better.
Do not postpone treatment and suffer needlessly.
 

The Importance of Family


Our family is where we forge some of the strongest and most important relationships in life.

For many of us, it also represents an emotional anchor, a sanctuary where we seek solace and a place where some of life’s most crucial lessons are taught. How we see the world around us largely depends on our first interactions within the family.

These ties that bind continue to be crucial through most of our lives, as new members come on and others leave for their own lives.

Each family member is instrumental in maintaining that atmosphere we call home. Not infrequently, this balance may become upset when family members become depressed, anxious or simply when life’s demands becoming overwhelming. Conflicts can result. Family members often bear the brunt, as caregivers of those distressed. The guilt of not being as best a father or mother for their children can keep already troubled parents awake beyond their sleeping hours.

Inconsistent parenting, chaotic home environment or simply ‘not being there’ as a result of parental mental illness can affect a child in more ways than one.
Considering the collateral effects, restoring that balance is more urgent than ever. Regain the life you want by seeking help early.
 

That Big Somewhere Out There

Living abroad

With globalization and increasing competitiveness of the economy in most developed countries, more people are relocating to explore new career opportunities. More often than not, uprooting oneself and his/her family arises more of necessity than choice. Some go on to experience a sense of ‘dislocation’ and significant difficulty adjusting to living overseas.

We learn to form attachment as young children. For most of us, this emotional connection goes beyond parental figures to involve the home we live in, the things we associate it with, to the friends with whom we share our most important moments.

Homesickness is a psychological process that probably dates back to the time our ancestors first experienced emotional attachment. It has been depicted in works such as Homer’s the Odyssey, where Odysseus wept, thinking of home. Through the ages, it has also been described in European settlers in North America and soldiers at frontlines faraway from home

Psychological & Physical Impact of Home Sickness

Being homesick is more than just missing home. Coupled with having to manage the uncertainty that a strange, new environment brings, it can bring immense emotional upheaval.  Children and individuals who are anxious by nature are at higher risk of experiencing difficulty with adjustment.

Apart from feelings of nostalgia and grief, adjustment to a new environment can bring about adjustment reactions that include negative thinking, anxiety, moodiness, frustration, insomnia, irritability and social withdrawal. Some even feel a sense of regret, hopelessness or futility, especially when they become overwhelmed by problems settling in during their initial days.

Signs of maladaptation can include increased alcohol/nicotine use, emotional outbursts, suicidal thoughts; deterioration in one’s daily functioning and raised tensions within the family.

Coping with Home Sickness

While the best cure for homesickness will be to return home, this sometimes may not be an immediate, available option. We however, can cope better, with the following tips:

    1.    Have an open mind to change and new experiences. These can help you enhance your coping skills and improve your confidence in the longer term.
    2.    Cultivate a positive attitude. Make it a point to count your daily blessings. Keep focus on the positive parts of your ‘relocation’ experience.
    3.    Keeping regular contact with loved ones back home through letters, emails and phone calls. Having a familiar object from home will help to mitigate that sense of loss.
    4.    Peer support is important. Support groups within your local expat community are available and are often more than happy to help.
    5.    Find strength in your faith. Religious support and counseling can give firm grounding in times of crisis.
    6.    Make an effort to keep an active, healthy lifestyle. Be conscious about your diet. Have enough rest and remember to maintain a regular exercise routine.
    7.    Allow time for emotional expression. Discuss your feelings with someone you trust, a counselor or a psychological wellness professional.
    8.    Watch out for persistent maladaptive symptoms not improving with time, out-of-control behaviours, marked emotional distress or impairment of functioning and social relationships.  Seek help early if this is the case.

Adjustment is but a phase in life. Slowly, but surely, you can regain your sense of control.