Category Archives: Clinical Case Studies

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.








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…


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?



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)。


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.


女儿 Candace 打电话来的时候,Wilma 正在打扫客厅。他们一家住在加拿大的Winnepeg, Manitoba. 那是十一月,外头的天气很冷。Candace那年13岁,正和一个男同学聊完天,想问妈妈可不可以来学校载她回家。Wilma 想了想,他们家只有一辆车,一个小时后她得去接先生Cliff 下班,家里还有两个孩子,一个两岁一个九岁。她必须为他们准备出门,去接Candace,再去接先生。那会是和三个饿坏的小孩一起呆的一个小时。Candace已经13岁了,不是小孩了,她可以乘搭巴士回家。所以确认了Candace有足够的零钱乘搭巴士后,Wilma 继续打扫。

忙了一阵子后,Wilma 突然觉得有点不对劲,她看了看时钟,发现Candace早该到家了。外面开始下雪了。她开始不停往外张望,看看Candace是不是要回到家了。过了一阵子,也到了接先生Cliff的时间,她打理了两个孩子上车,沿路慢驶,看看是不是会遇上Candace正回家。她也驶到学校,大门已经上锁。接了Cliff后,他们回家,在附近寻找,然后逐个联络Candace的朋友,下午以后就没有人见到她了。Wilma去找那个男同学,他最后看见她往巴士站的方向走。夫妻俩只好报警。他们成立了搜寻小组,也四处张贴海报。他们祈祷、他们哭泣、他们无法入眠。七个星期后,警察联络他们,Candace的尸体被寻获。手脚被捆绑着,冻死的。

那天下午家里聚了不少亲戚和朋友,一直到晚上10时,只剩下几个最亲密的朋友。这时门铃响起,一个陌生人站在门口,“我也是一个孩子被谋杀的父亲”。这男士大约五十几岁,他的女儿几年前在甜甜圈店被杀,在这小地方也是有名的案件,嫌疑犯Thomas Sophonow 被逮捕并审讯诉讼三次,他坐了四年牢,又被上述庭放了出来。屋里的每个人围着桌子,听着男士细述整个过程,他有本小簿子,记录了每个细节,包括他因此而花的单据也整齐排列其中。他也说起Sophonow,说起司法的不公。这整个过程毁了他,也毁了他的家庭。他无法继续工作,健康很糟糕,吃着很多药。虽然他没有直接说起他和太太,但是言词间也透露他们的关系似乎已经是过去式。关于他的女儿,他没说得太多,反而都在说努力寻求公平公正的过程和想法。到最后午夜以前,他临走前说,“我把这一切告诉你们,是要让你们知道,前方有些什么在等着你们。”


对Wilma 和 Cliff 而言,男子所说的并不是预言,而是一个警示,那有可能就是他们的未来。他们可能因为女儿遭谋杀而失去健康,失去理智,失去彼此,失去这个家。因为男子的到访和分享,强迫他们去考虑其他的选择,寻找一条不一样的路。隔天就是Candace的葬礼,过后他们同意召开记者会。Candace的遭遇引起了整个城市的注意,几乎所有报章媒体都出席了。


“我们想要知道这个人、或这群人是谁,好让我们可以分享一些爱,给这些生命里似乎缺乏爱的人” Cliff 说。

“我们的目的是要找到Candace,而我们已经找到了。我不能说此时此刻我能原谅这个人” Wilma继续说到,强调的是此时此刻,并继续说“每个人一生中都曾经做过一些可怕的事,或有那个念头。”

我很想分享这个真实的故事。每个人的生命都有些英雄,每个族群也有他们信仰的民族大英雄。而像 Wilma 的Mennonites,他们的英雄是Dirk Willems,他在16世纪因为信仰而被关在牢塔里,在一条绳子的帮助下,他成功逃脱牢塔,渡过塔外被冰覆盖的冰河,他成功到了河的对岸,但追逐他的狱卒却掉入冰水中。Willems 停了下来,回来拯救追兵。就因为他的大爱,他被抓了回去,虐待,被慢火活活烧死,过程中重复了无数次“主啊,我的天”。