Category Archives: Clinical Case Studies

Psychosis to Depression?

It all started in December last year. She presented some elementary hallucination, poor sleep at night, poor concentration and drowsiness in the day. She wasn’t hearing voices, but some knocking sounds (similar to when one is knocking the doors).

So she sought psychiatric help, was put on antipsychotic and stimulant (Ritalin, normally prescribed for ADD, ADHD or narcolepsy). Her symptoms soon got much worse, seeing ghosts(?)., talking irrationally and was then brought to general hospital, where she was put on more antipsychotic drugs.

Few weeks later, her family took her to see another private psychiatrist doctor after she was discharged. The consultant diagnosed her with bipolar disorder, based on the fact that she was once an outgoing and independent person, and prescribed her with Lithium.

Throughout the few months under the care of the psychiatrists, she took and tried many medication including antipsychotic pills, she gained over 20 kgs. She gets really depressed about her weight. For when before the first episode end of last year, she bought some slimming pills online, which acted as appetite suppressant. That was when she was 20 kilograms lighter than what she is now. She wouldn’t even want to look at herself in the mirror, when she thinks about her weight, she thinks life is meaningless. She doesn’t know how she has got here and how to find the old self. She has been unable to work for 10 months now.

It all started mild. She has no family history of mental illness. The team can’t help suspecting those slimming pills that she took, which could affect and alter her brain and nervous system. Of course we wouldn’t know whether there is a cause effect relationship for definite here (and we would never know), but it is important that you know what pills and medicine you are taking, those that you buy online, and those that you are prescribed by professional doctors. I am not saying that everyone should question his/her doctors and the diagnosis and prescription, but when in doubt or think that something is not right, seek a second opinion. Also, do not believe everything that’s said on the internet, but sometimes online resources might provide us with some basic and guidance.

Grieving the death of a child

It is a very sad story to tell. I guess any parents can try to relate, but will never understand how it is like to lose a child, no matter what the age of the child is when it happens. It is also an experience no parent would want to go through.

Saturday is their family, the wife and her family’s. Husband wasn’t around. So she took her daughter to join her mother, brother and sister for dinner. There were also children of her brother and sister. They squeezed in one car to get to the place for dinner. The brother who drove the car parked the car opposite of the restaurant, and they had to cross a major road with 3 lanes each direction. So the group got off the car and crossed together, with another uncle who was also there. They thought it was clear and safe. But everything happened just in split second, a motorcycle sped passed, her daughter and her were hit. Her legs were injured, she couldn’t move, and she can’t see where her daughter was, as she was dragged by the motorcycle to few metres away. The brother brought the daughter to the hospital nearby immediately. She was sent to hospital later.

The husband rushed to the hospital after receiving the news. He knew thing is bad seeing the wife in the wheelchair and daughter no where to be seen. She was shaking. Husband tried to keep himself calm thinking there are probably many decisions to be made.

Daughter was then pronounced dead.

She was 6 years old, and would never grow older than that. The only child of this couple, was going to start primary school in a few months. They were also planning for another conception this year, bringing a little bro or sis to her.

Now she couldn’t even go home. Husband has to live on his own while she stays with her family. It was too much to bear when she goes home, the girl was literally everywhere, all the memories, that she cannot bear, with chest discomfort and burning sensation in the head. She is trying to do some work. But all she wants is to hide in the bedroom and read or write. She reads about grief and loss. She writes to her. She visits the cemetery with her favourite food and talk to her. She blames herself that the family is now broken because of her. She took away his daughter, she took away his family.

He continues to work, forced himself to go back to the home with all the memories, the home that’s no longer like a home. He even forced himself to drive past the spot where the daughter was taken away. But he takes alcohol and cries every night when he’s on his own. He blames her and her family, for not being cautious enough and crossing dangerously, for not dropping the kids and the elderly at the restaurant then only look for parking space. He thinks it’s their negligence that took his daughter’s life.

It’s been more than 3 months.

For a journey of grief, 3 months is nothing. If you ask someone who lost his or her child 20 or 30 years ago, s/he would tell you that the pain is still there, the hole is still there, there is still something missing that can never be filled. But perhaps by now s/he is able to handle this empty space, and has a little smile on his/her face when s/he thinks about the lost angel.

美丽的网红(网络红人)

我还没第一眼见过她,柜台帮她登记的同事就已经通过电话告诉我,“她真的很漂亮!陪她一起来的男士也超帅!”

一方面期待看到她,一方面心里”默默地自卑”。

她的话不多(有些患者一走进来,我可能连问问题的机会都没有),通常答案都很简略,或者想很久,但是答不上来,最后还是“我不知道”。过程中,她透露自己的一些过去,恋爱史,陪她来的男士只是朋友,她目前单身,已经五年了。也说到为自己过去的行为感到沮丧后悔,想忘记它们,通过催眠消除它们(没办法直接做到);再提到未来,觉得迷茫,工作迷茫,交不到男朋友也迷茫。

这点让我好奇,以她的外表,拜倒石榴裙下的观音兵肯定不少,她说有自己喜欢的人,但都爱玩,不想认真。而她,希望安定、谈一场细水长流的恋爱(几年前的她也曾经比较爱玩,但是已经过去了)。可是要嘛她对对方没有意思,要嘛对方只把她看成”玩“的对象。五年前分手的时候,也是因为对方还不想定下来,还是很爱玩,和其他女生暧昧,去夜店夜归等,两人不停吵架最后女生提出分手。她觉得男生是不可能专一的,最后能回家就好。

这让我想起很久以前和一个朋友的谈话,说她的一个朋友,不停地爱上有妇之夫,每次都很受伤,下一次却也还是重蹈覆辙;另外一个朋友也是,每次总爱上playboy,每次都被玩弄,身心受伤,但还是没有从中吸取教训。我们最后觉得,有些女生,总是会被一样的人吸引,总是会爱上类似特质的人。

这个个案中的女生,是个网红,拍很多养眼美丽的照片,网上的追随者与粉丝很多。男生会怎么看这个女生?(就会有男生说,有些女生只适合玩在一起,娶回家的绝不会是这类)而这个女生又会怎么看对她有意思的正经男生?又或者,她的生活圈中,有这类男生而同时又是她会喜欢的吗?会不会她总是不会看上所谓正经、或者想认真和她安定下来的男生?大家想想自己的过去,会不会觉得总是被类似特质的人吸引?

说到这里,想起最近一个好朋友的妈妈过世了,我不停在担心她的表现(太坚强),会不会是没有和自己的情绪接触(not in touch with her emotions)。毕竟东方国家,从小就被教育把负面情绪压抑,从来没有机会感受和接受。这个女生,也给我一样的感觉,总是“美美的”,没有什么表情,她的情绪起伏不大,笑容很浅,说到自己最难过的事情,也只掉了一点泪,就算我说,可以哭,可以难过,可以和这个情绪感觉相处…

或许你很羡慕有些非常漂亮的人,但是,有时候没有这点特质,反而让你的人生更顺利、更有优势。虽然我也还是会羡慕她长的如此赏心悦目,但也就只是单纯的羡慕,和更懂得感恩。

Neutral Pure-O

Most people know that Exposure Response Prevention (ERP) is the main intervention used for Obsessive Compulsive Disorder (OCD). So the rationale is pretty simple here, say we have a patient who is afraid of contamination (obsession) and wash his hands excessively (compulsion), we do some preparation work and can then start the ERP by exposing him to dirt without letting him to wash his hands (response prevention). This is normally done on a very gradual manner (with the patient’s consent and enough preparation work beforehand, so it is definitely not forcefully done to him). And of course in reality the OCD cases are barely as straightforward and simple as this, but this is the general principle.

With pure obsession, i.e. those without any compulsive behaviour, it’s all in their minds, things can get a bit harder, but still, it’s possible. Some commonly seen pure-O are (1) relationship obsessions (discussed in my blog else where as “morbid jealousy” which might or might not be the same condition), (2) sexual obsessions, (3) religious obsessions, (4) violent obsessions, (5) neutral obsessions.

So let’s take a recently seen man as an example here. It started once when he drove past a church, and somehow a sexual related thought popped out in his mind, he couldn’t bear himself having such “dirty” thought in a holy place, and since then, whenever he goes passed any holy places, he will suppress his mind from coming out with any “dirty thoughts”. And as we all know that our minds don’t work this way, the more you try to push some thoughts away, the more they bounce back and pop up.

ERP is possible for such pure-O cases. After the initial preparation work including psychoeducation and relaxation training, they are exposed to those thoughts that they have been avoiding, in those places (based on the items in the hierarchy). So it works similarly for all different types of pure obsessions, be it relationship, violent, religious or sexual (in certain cases where direct exposure is not possible, it will have to be done in imagination, and by watching videos etc).

However, how about neutral obsessions? What the patient has could be some really simple, random thoughts, which might be inconsistent, but they might be spending hours and hours thinking about these random stuff. Like a young man I saw couple months ago, who reacts to any thought his mind comes up with, e.g. “why does the universe work this way?”, “how do my ears listen and my brain comprehend what others say?” etc. I couldn’t really carry out typical ERP to him, since those are really random topics and they can be completely different every time. So I needed him to start thought defusion exercises, mindfulness meditation (then he dropped out…). I believe this is the best way for neutral pure-O, though I understand how difficult it’s to increase their motivation to keep practicing until they see the effects (did have patients in the past who were surprised by how quiet their minds can be after such exercises – and this is just a bonus, as it’s not the intention or purpose of such practices).

Do enlighten me if you have better psychological intervention for neutral pure-O. And I hope all the OCD sufferers out there will not give in to the illness!

<心理追兇Mind Hunter>男主角马国明是精神分裂吗?

备注:我一直很认真花时间在我的网站写有素质的文章,这篇的题材可能归属娱乐版,但是我的态度与提高心理健康意识的主张不变!

已经有一段时间没有追看港剧,直到出现这部和心理学相关的电视剧,分别被几个朋友问说我有在看吗,说不错看而且还有问题要我解答,所以我在一个星期多把28集看完了。

不交代剧中的内容和角色。只是昨晚因为家人还在看,提起主角Dr Chong(心理学家钟泰然博士 — 是的他不是医生,他不能开药,他被称为Dr 是因为 PhD博士学位,不是medical doctor),说他是精神分裂症(schizophrenia),有幻觉(hallucination),可以看到听到他已故女友。我想了一下,他总是在点起烟的时候对方才出现,看起来真的有点像是刺激物引致的幻觉(有些药物和毒品确实可能引起幻觉,可能但不一定引致精神分裂症)。

说真的,看这部电视剧的过程中,我从没想过他可能有精神分裂。虽然我满怀期待最后编剧导演给我一个交代,一个诊断,这名心理学家患有的是什么心理问题(可是没有。No, 我不认同他是反社会人格障碍 antisocial personality disorder!)。对我而言,他的表现是grieving,悲悼(因为失去所爱的人的悲伤),长久下去,可能形成抑郁(depression)。当然,就像我常和病人说的,接受这些悲伤,你刚失去生命中这么重要的人/感情,你要是不悲伤不难过不哭泣,我才要担心才想治疗你。所以抑郁也是正常的。或许大部分人会说,悼念五年,也太久了。可是以陪伴丧亲者的角度来说,悲悼其实没有期限,有些人要几个月,有些人几年,周围的人能做的,就是陪伴。

回到主题,最后Dr Chung不再和其他人联络/接触,情绪崩溃,独自走上末路(其实他有没有死,结局没有交代)。这其实对我而言,或多或少地确认了我的判断,他是悲悼过度而抑郁。如果你只是悲悼,一般不那么抗拒周围的人,你还是可以继续生活、工作或学习等,并接受其他人的陪伴,但是哀悼与抑郁的一线之差(really just a fine line!),在于你开始抗拒其他人,开始封闭自己(有一幕他的警擦朋友和社工朋友说已经很久没有看到他了,另一精神科医生好朋友也已经反目成仇)。

所以我的看法与分析,他不是精神分裂。

最后还是有一点相当欣赏这部剧的地方,在于催眠那段,社工朋友童月因为过度惊吓,出现暂时性失忆,Dr Chung说催眠可以看到平时看不到的事,原本太远的距离太小的事物,在催眠中可以变近放大,当时我的心里在说“放屁!为什么误导观众”,很开心最后发现那只是他的手段,用来骗童日。只是这个操作(manipulation),真的很难让人不觉得他是反社会人格…. 不过!从剧中很多地方不难发现,他其实很在意别人的感受,也尊重别人的权益,反社会人格,是不会在他30-40岁突然出现的…

Obsession or Psychosis?

The girl has been housebound for several months now. Though she managed to come to the clinic, but was seemingly restless and anxious, pacing the floor in the waiting area. She couldn’t see people using smartphones anywhere near her. She would think people are taking her pictures and use them for detrimental purposes. When she is in such situation, she experiences strong urges to grab the phone from others.

She does recognise those intrusive thoughts as irrational and could restrain herself from doing so. But like many other with OCD, she is staying home more and more to avoid such situations. When she first consulted a psychiatrist, it was about two years ago. She was quiet, introverted, sensitive, and repetitive in her speech, but wasn’t diagnosed as having OCD.

To really consider her current presentation, she seems to be having persecutory delusions (a common form of delusion in paranoid schizophrenia, where the person believes that ”he or she is being tormented, followed, tricked, spied on, or ridiculed.”).

So, how do you know or decide the diagnosis? Is it OCD or is it borderline psychotic of sorts?

Looking at the backgrounds, the mother who came with her said that she (the mother) has been “depressed” and taking psychiatric drugs for the past 10 years, it was mainly due to the stress caused by her daughter (only child). Though one of the mother’s symptoms, is compulsive washing(!), fear of contamination. It’s not difficult to imagine some OCD can be so severe and disabling leading to depression (the comorbidity rate is high anyway). But here through the mother at least a family history of OCD is exhibited.

In DSM-5, it is specified that OCD may be seen with: (i) good or fair insight, (ii) poor insight, or (iii) absent insight/delusional beliefs.  In all previous editions of the DSM, the criteria for the diagnosis of obsessive-compulsive disorder included the sufferer’s realization that their obsessions and compulsions are irrational or illogical. Now, absent insight/delusional beliefs can be part of an OCD diagnosis. Though we have all noticed that OCD sufferers’ levels of insight can change quickly, often depending on the circumstances and situations (e.g. the intrusive thought was felt completely real when she’s in the public noticing someone holding the phone VS when she’s at home thinking about that situation).

Some psychiatrists would prescribe both anti-depressants (serving as anti-OCD) and anti-psychotics. However, there were cases where OCD patients were first misdiagnosed as psychotic, and taking anti-psychotic very much worsened their OCD (though once they stopped the anti-psychotics and took anti-depressants at the right dosage, their OCD symptoms alleviated).

So time spent for detailed psychopathology and specific diagnosis would be of greatest importance. The presentation of suspiciousness (paranoia) as the main symptom suggested possibility of psychosis, however, the repetitive nature of the thought, which was stereotyped, causing severe distress, also the family history of OCD, pointed toward a greater possibility of obsessions. What is more difficult with this case is the absence of compulsions and reassurance seeking. And my final point, it’s not necessarily “either or”, it could be both! But still it takes much time and effort to really work that out.