Category Archives: Clinical Case Studies

When Schizophrenics Don’t Recognize Their Illness

Clinical Case Studies, Issues & Debates, Schizophrenia & Psychotic Disorder, Treatment Approaches

Do you confront them? Do you “make” them realize their illness?

This couple came to consult the psychiatrist few months ago, but they paid only the consultation fees after seeing the doctor for almost an hour, without collecting any medicine.

The patient is their son, who is in his late teens. He’s currently attending a very famous top college in the town. He lives in hostel with two other roommates, only back to parents during term holidays. The son doesn’t think he has any problem.

But sometimes he sits on his own and laugh. He spends a lot of time thinking. His behaviour is purely “weird and strange”, as how his mother termed it. According to his roommates, he sometimes gets disappeared from college and hostel, for couple of nights, then came back and kept to himself, like nothing happened.

There isn’t much the parents can do about him, as he doesn’t live with them, they don’t even have the chance to put medicine for him (see case study 1 & case study 2 for why putting medicine without patient’s knowledge). They did try to confront him, they actually set up on him and made him to a general hospital where he was hospitalized for over 10 days, then put on medication for few months after discharge (he stopped medicine subsequently as it was causing drowsiness and disabling him from studying).

Since then he became more vigilant. The parents know it’s almost impossible to set him up again or force him to see a psychiatrist doctor again.

At some points counsellor from the college contacted the parents, they discussed about his strange behaviours. At one point the roommates even had to put tranquilliser or sleeping pill in his food or drink to make him stay in hostel and rest. Yet academically he was still not doing that bad (afterall he’s one of those top students… though the mother is sometime a bit doubtful whether being such a top student is a good thing for her son).

Few days ago he came back home for term and chinese new year break. The parents thought it was a good opportunity to help their son. However, after one night being home, the son couldn’t stand the confrontation and parents’ lecturing, he ran away from home, and hasn’t been home since. The mother has been trying to get in touch through phone, but when she spoke to him, she really isn’t sure what to say to bring him home.

Perhaps she hopes that the son get well without any medication and treatment? Perhaps she hopes that the college expel him so that he’d be home to get treatment? Perhaps.. she doesn’t know what to hope for.

So… back to my questions – how do we make them realize their illness? Or do we do this at all (let them be? confront them?)?

Asperger Syndrome

Clinical Case Studies, Developmental Disorder

Two of the tutors came to the mother today and said that they were unable to help the boy with his studies as his attention span is too short, he keeps get distracted.

This is a boy of 13 with Asperger Syndrome which was diagnosed when he was 6. With medication the boy still does not improve significantly after all the years. In school, he disturbs his classmates by walking around the classroom and talking to them while teachers are teaching. He also flips his books quickly (without reading them, but he likes creating that sound while flipping books), tears and folds books and papers. The teachers said he isn’t able to do any independent work, although he appears to have adequate intellectual abilities just like his classmates. Unfortunately he is never able to get seated down for a short test. The teachers don’t know what to do to help him, and he makes no friends in school due to his annoying behaviours.

Tutors were hired to assist him in school and to give tuition at home, but a few have left for the same reason as above – he’s too difficult to manage, to be helped. He can’t concentrate in studies or perhaps in “doing anything meaningful”, as how the mother termed it. He scratches himself badly, almost obsessed with this habit.

The parents are feeling helpless. If the medicine couldn’t touch him at all, what else would?

IPad Addiction

Anxiety Disorder, Clinical Case Studies, Developmental Disorder, Obsession & Compulsion

Came across this article and think it’s really worth sharing, also a very good case study reflecting the growing up environment of infants/toddlers nowadays:

‘The day I realised my toddler was addicted to the iPad’: Three-year-old William tugged at the duvet and woke his father demanding the tablet… at 4am

Some food for thought: How do we help the younger generations to develop healthy relationship with those advanced gadgets? How do we balance while using them as educational or entertaining tools (not iNanny!) but not overusing leading to obsession and/or addiction?

(To the educational psychologists and child experts: is this going to be a newly added and researched Developmental Disorder?!)

A Revenge?

Clinical Case Studies, Issues & Debates, Schizophrenia & Psychotic Disorder

She first saw psychiatrist in 2005, being sensitive and very bad-tempered, with paranoid ideations and hallucinations. In 3-4 months with medication she got better, but soon got a relapse as she got a new job, because she couldn’t handle the stress from work. Since then she has never worked. During the end of 2005, despite the medication her condition got much worse, more paranoid, fearful,  having persecutory delusions. Her husband and sister accompanied her to visit various temples, praying, seeking for help through different mediums.  Two sets of 6 ECTs were done from Dec 2005 to Jan 2006, because she didn’t get better significantly after first set of ECT, still hallucinating (see here for a case study of a severely depressed woman recovered through ECT).

Through 2006 to 2011, her condition wasn’t that good. She wasn’t keen to take certain medicine as she thinks those medicine cause weight gain (which was quite right). So it was difficult to have her condition under control. She continued to be sensitive, paranoid, avoiding crowds, hallucinating, and also getting more and more obsessed with body weight. Later she got a lot more stable from mid 2011, till recently…

The husband said he wanted to go to start a business with a work partner in East Malaysia, he will have to be there for at least 6 months. This is when the patient got unwell again… Irritable, insomnia, restless, hearing voices, agitated despite maintaining all her medication. The husband gave up the idea and the business plan, continues running his coffee shop.

However, the patient doesn’t recover just when the husband made the decision to stay with her. He brought the patient with the sister to consult doctor almost every day, for injection and medication. The husband is now suffering financially paying for the bills and not being able to work. But she doesn’t turn better, at all. Despite all kind of medication she’s taking, she’s still restless at night, wanting husband to bring her out, saying someone is waiting for her outside. During the day she stays at home, saying someone is coming to visit her soon. Of course none of these “someone”s turns up. She continues to hear voices, paranoid, and not sleeping. Sometimes she doesn’t use the toilet at home but does the business outside of her house. Sometimes she stays in the rain not wanting to go indoor.

Sometimes when we talk to her, she seems to be completely fine and ok. But when we hear the description of what she does outside of the clinic, it seems completely abnormal and unwell. Then one staff has come out with this theory (which doctor also kind of agrees with it), that this is a revenge plan:

The patient is trying to revenge to the husband, for “attempting” to abandon her, at the same time, (I think) she is also wanting to stay unwell [subconsciously maybe], so that all her family especially her husband will stay with her, be there for her and care about her.

What do you think? How do people fake their mental illness to serve some purposes? What can we do about these people? How do we know if she’s really unwell or just faking? Are people really willing to ruin their own life and those of their family members’ just for the sake of care and love?

Maybe she needs psychotherapy/counselling?

Clinical Case Studies, Issues & Debates

I came to know this long-standing patient’s son when I first came to work. As the patient (mother) is always relapsing, despite taking a full dosage of anti-psychotic and anti-depressant medicine, once in a while she’ll be relapsing – non stop complaining, talking, moaning, thinking about her son who passed away two years ago, restless, agitated… And so the son will always have to contact us to ask what to do regarding patient’s condition.

After 3-4 years seeing psychiatric doctor, the mother who is at  her 70s has “roughly” maintained on the same condition, not really getting much better, but also never get too bad. But some episodes of “moaning” still happen once in a while. Every time she comes back for review, the doctor gives back the same medication, only adjust it once in a while (when patient has some other physical or health concern; when patient is getting much worse; when certain medicine is not in stock). The family starts to question each other, whether it’s still right to continue seeing a psychiatric doctor, whether to continue with all these types of medication.

Deep inside they understand that they can’t let the mother stop all the medication, she’s definitely not well without those tablets and liquids. But spending so much money each month, they’re really desperate to see the mother getting better, having less episodes of relapses. Then the son rang us, told us their concerns. They know the doctor is good, and has treated so, so many patients from different parts of the country and the surrounding countries like Singapore, Indonesia and even Vietnam etc. But maybe this isn’t just what the mother need?

He said the mother never opens up with the children, never want them to know her worries and problems. The children all know that she’s worried, having ruminations, but the mother gets agitated if they prompt and ask further. The son now asks perhaps they need someone who’s good in this to talk to her, to help her open up, to know what she thinks about her eldest son who passed away, to know why she’s moaning and complaining, on top of the medicine she’s taking. Maybe she needs more than the medicine?

I’ve written a common problem of seeing psychiatrist in General Hospital (see: Bipolar Disorder). Quite often doctors have no time but to prescribe back the same medicine to patients, even when patients’ conditions have changed… But having looked at this case, perhaps it could also be a problem in private practice!

Too little good doctors, too many patients in need, too little time, so what happen?

Dear Teachers,

Clinical Case Studies, Issues & Debates

Dear Teachers, how are you doing? 

“I can’t teach. I want to stop teaching. I am not going to teach again for the rest of my life.” Ms S is a young graduate who just started to serve as a primary school teacher for a year. She loaned from the government and hence has to serve the government for at least 5 years. She visited us few months ago, after starting to teach for just over half a year, with her parents and a sibling, being fearful, and with crying spells. Over the few months medication treatment she got just slightly better, still able to teach, but always having crying spells. The mother is very concerned and lost, as she doesn’t know what to do if the patient can’t handle her life and her profession, yet she will have to do it due to the bonding. The only time the patient got significantly better was during the long year end school break. Now that few days after the school starts, same thing is happening.

Ms S is not an odd case. I have a friend Ms M who yesterday just told me that she has stored up so much positive energy during the long school break, but just less than one week after the school began, she has used up almost 80% of her energy and feeling all exhausted and frustrated, and in need of a break again.

Few days ago there was another teacher who is a patient of the clinic since 1990s, came to the clinic to collect medicine, and requested for 3-days MC (medical certificate). The school has just started that week when she came, and she was already not looking forward to the year of teaching and is trying to avoid to go to school whenever possible.

This year another patient who has been teaching for over 20 years has also taken a year leave after discussing it with her husband and doctor. When this patient first came to us, we all thought that she was just overly-anxious (she called us almost every morning since her first visit, in need of a lot reassurance). But few months later she was found suicidal by a psychiatrist in Singapore. Since then, just like Ms S, she started to feel that she can’t teach, feeling fearful and anxious about it, and thus decided to take a gap year.

These are just a few examples. Recently we came across quite a numbers of patients who have teacher as their profession. Of course I’ve known some happy and dedicated teachers, but I wonder whether something is wrong with the society, school, teaching system, that put so many teachers in such massive pressure, and make those who can’t handle it so depressed, fearful, anxious, suicidal… getting unwell psychologically.

It’s definitely a well-respected profession, but perhaps they also need more attention, better/revised welfare, some help, monitoring and supervision.