Category Archives: Clinical Case Studies

Why Depressed?

Clinical Case Studies, Depression

She has a son and a daughter with a husband who loves her. She works in a department store where she enjoys working. They have a maid who does housework for her and helps looking after the kids. The husband is quite successful running his business and so they are quite free financially. Her life is probably one of those that many would be so jealous of.

Yet she is our patient here, depressed with agitation and poor sleep, depending on Stilnox for years. She can even understand the above points and was analysing her life with me, and asked me back the reason of her being depressed. “I’ve many things in my life. My boy is very cute and I love him a lot. I like my job. I have nothing much to worry about, I don’t understand why I’m always feeling sad, feeling like jumping off the building with my kids…”

On Christmas eve she gave me a call. She said she saw that her company staff were celebrating Christmas, everyone is happy, feeling Christmasy, in the festive mood. Everyone BUT her. “I feel bad. Why can’t I feel happy like them? Am I abnormal? Why am I like that?” She feels she is the contrast of the others. On one hand she feels depressed in herself, on the other hand, she feels she’s abnormal because she can’t feel happy like them, and this “abnormal” feeling makes her guilty and feel even worse.

One of her previous psychiatric doctors gave advice to her husband, telling him not to bring her out on any festive periods, as she would feel even worse in happy crowds.

As I talk to her, I can see that she’s someone who is grateful. She’s often very thankful with one simple phone call made to her to ask her how she’s been, how her day has been. So why is this lady so depressed? Even with medication, it’s only sufficient to maintain her mood, not to make her worse, but also doesn’t make her mood raised, after all these months. What’s worse, the people surrounding her have the same questions, and they scold her, criticize her; her mother, friends, colleagues, family members question her, why can’t she be happy and grateful with her life? 

She wonders the same. Is it in the gene? Family background? Growing up environment? Nature or nurture or both? Which one more? How can we find the root of the problem and help this lady?

Leading a Normal Life after Recovery?

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

Part I:  Teenage Schizophrenia (the same topic person as below)

Few days ago the father rang us. The patient is now in ICU in a general hospital. She attempted suicide taking over 200 tablets of medicine. As she usually wakes up late in the day, so the father wasn’t concerned that she’d been in her room all day. Till that evening when the father was thinking to bring her some food, and found out that she was covered in urine on her bed, and was unconscious.

Over the past few months, she had got so much better with medication, no longer spending all her time pacing in her house, talking to herself or swearing at her younger siblings. Her father was even able to get a tuition teacher for her, and later the patient even requested to go back to schooling. They were looking forward to seeing patient going back to lead some “normal life” just like any other teenagers. The only thing is probably that she’s spending a lot of time looking at her phone (don’t you think this is also a common feature of a “normal” teenager nowadays?!)

Then this happened. She tried to kill herself and is still unconscious. The father could only guess that as the new academic year is starting soon, patient couldn’t manage the stress and intended to avoid it by ending her life. She went to school to collect the text books the day before. The younger sister said the patient asked for a cut blade from her, but she didn’t give it to her.

Quite often we may think that the patient is ready for a normal life once the active symptoms of mental illness is not presented, yet it is very difficult to judge whether or not the patient is ready psychologically, to go back to the society, to face other so-called normal people and function normally just like others.

What can we do about this? What can we do for them? What can family do to get them prepared to go back to the society, if they can ever achieve it?

Caring for family who is mentally ill

Basic & General, Clinical Case Studies

This is a woman with PhD and was working in the UK when her mother was getting depressed, with insomnia and palpitation. Without much considerations she decided to quit her job and come back to Malaysia to look after her mother.

She has a younger sister who can’t manage stress and see us for some medications; another sister’s husband (brother in law) who is having fits and seizures. She also has a brother who abuses substance. So when she gets home being unemployed, she became the person to look after all these family members, like a … maid, but with a PhD and a highly paid job in UK which she left. Every day she wakes up around 5:30am, preparing meals, cleaning the house, preparing medicine for all ill family members, bringing them out for hospital appointments, collecting medicine for them from different clinics and hospitals.

Sometimes the brother in-law refuses to take medicine. Sometimes the mother refuses to exercise (or even move at all) despite advice from specialist doctors. Every day the mother moans about her problems and illness, winding her up. Her day usually ends at about 10.30pm when most of the family are settled down or sleeping.

When we spoke to her, she said she would probably, at some points, have to make an appointment and come to see a psychiatrist doctor and take medicine, as she really couldn’t take it anymore. All these caring work is draining her out.

It really isn’t easy to look after family who are mentally ill after all, what say a few members that’re unwell. These family members should win more respects, and should really get some proper support groups, perhaps just from each other, some time off, just to do something they like and to lead their own lives, yet it really isn’t that simple as said once the “job” commences…

Paranoid Schizophrenia

Clinical Case Studies, Schizophrenia & Psychotic Disorder

It was a very busy day and one staff was on emergency leave.

As all was in the waiting area for their turn, suddenly a woman in blue top rushed through the staff door that wasn’t closed properly, and ran all the way, through the treatment room, to doctor’s consultation room. The doctor was seeing other patients there.

We don’t know what she was going to do to the doctor, as we, including the doctor who was in shock, had already grabbed her hands before she did anything. We pulled her back to the treatment room. She was undeniably strong, despite all four of us were grabbing her, and one was preparing the injection. She scratched our hands, kicked our legs, screaming, resisting.

She has defaulted with medicine since 2010. Recent few weeks she has become unwell again, but the husband was too busy with work so he didn’t bring her here immediately and let her deteriorate. She started to see a psychiatrist from the year of 2005, being diagnosed as paranoid schizophrenia. With very regular injections and medication she’d got much better. Then a second breakdown in 2010, when she moved to a low-cost flat with Malay and foreign neighbours, whom she was so paranoid with. Later in the year she stopped taking medications, telling our staff that she feels much better without medication.

When we pressed her on the bed, she was shouting, saying her Malay neighbours were spreading her personal details and photos on youtube and other social medias. We could hear her saying 8TV, radios, youtube… the Malay neighbours were spying on her, peeping her, going through her rubbish, taking her pictures and videos then spreading them online.

The husband said she cannot get along with her Malay neighbours, she actually went to argue with her neighbours due to her delusions.

She came from a big family, being the youngest of her 10 siblings. She has two girls and one boy with her husband.

With medication and injection she has got much better now. Though relapses are likely to happen if she is not going to come back for follow ups and maintain with her medications.

Illness Phobia

Anxiety Disorder, Clinical Case Studies

She has consulted many specialists, cardiologist, gastroenterologist, orthopedist… It all started with some pain in the arms, then the shoulders and later her back.

Other than the aching in her body, she also feels something stuck in her throat, chest discomfort, her stomach twitching, sometimes having light-headed, sometimes having red rashes on her skins… She even imagines that she’s got cancer and is suffering from it badly. She is worried so much about all these somatic symptoms and about getting more and more ill, she can’t eat properly, she doesn’t have any appetite.

In addition to those complaints, she’s also paranoid and may be hallucinating. She feels that the DJs on the radios are all talking about her (“Why do they know so much about me?” “Why do they talk about me non-stop?!”), she feels everyone on the train knows that she’s sick and is taking medicine for her sickness…

The problems were aggravated by a big row with her boyfriend, whom she found out to be getting back in touch with his ex-girlfriend. She’s becoming really sensitive and paranoid. She thinks the boyfriend is not being faithful, for contacting the ex. At the same time she was also having some massive pressure preparing for her professional paper.

She slowly moved away from her relationship and study problems (she passed the paper). But then she developed all those psychosomatic pains and problems. What’s worse is not the problems themselves, but the fact that she’s so overly worried about them – even the slightest rashes on her skin makes her think that she’s got skin cancer and is dying… When she started to take the medication, she did a table diary, noted down every small changes and symptoms in her body, whether she felt sleepy, had rashes, felt dizzy, could breath properly… She tried so hard to notice every little things in her body (perhaps it’s also an obsession?).

Illness phobia is not uncommon nowadays (see here for another case study on illness phobia), it’s under the anxiety categories, yet this appears to be some modern mental illnesses, as people nowadays know more and learn more as the technology gets advanced, at the same time people are also creating more problems for themselves as the world develops further (unhealthy processed food, overly urbanised cities, pollution…). But why, why get so worried when you’re not ill? Why are people losing the abilities to enjoy lives? Why worry before even knowing if the problem exists? It’s like people being worried about getting worried, now these people with illness phobia are getting ill mentally because of being worried about getting ill physically…

Underlying Perfectionism?

Clinical Case Studies, Unclassified Disorders

The mother made an appointment being not so sure about what her daughter’s problem is. She said the daughter is lacking confidence, or something is wrong with her, but the mother isn’t sure what it is.

This patient was doing A-Level at College A. She later said the course wasn’t so good and so she wanted to transfer to College B. So the parents went through a lot and completed the application and helped her to do the transfer. Everything went well for the following months. Till about one month ago, the patient told her mother that she wants to transfer back to College A again. The mother wasn’t happy about it but still she asked for the reason. The patient said she isn’t making any friends in College B, all her friends are in College A, she wants to go back there. The parents think it’s not a good decision so they continued to persuade her to stay on, and encouraged her to take part in some societies/organisations in order to make new friends.

The patient then stopped attending classes, when her request wasn’t fulfilled. She stayed home all the time, keeping to herself, not responding to mother when the latter speak to her. She isn’t even answering her friends’ phone calls (well, we thought she wanted more friends?). It does appear that she’s rebelling. But other than that she’s also losing the ability to make decision, to be assertive about what she wants and doesn’t want. When the mother asked whether she wanted to go back to College B, as the college has been calling the mother, she just stayed quiet.

This was continued with another two weeks till the mother came to us. The mother doesn’t know what to do. The mother consulted doctor on behalf and brought the medicine back to the daughter. She was very eager for the daughter to get better, to return to college and sit for her exam in two weeks.

So the mother gave us a call every two days, asking us what to do with her daughter, asking why her daughter still couldn’t make any decision, keep to herself, not going back to college, asking when she would get better…… She tried to push the daughter further and further, and of course, in such short period, she gets no results, but probably have made things worse.

What do you this girl’s problem is? Perhaps some underlying psychological worries? Depression? Social phobia? Agoraphobia? Laziness?! Avoidance, avoiding what? Some obsessions, obsessed with what she wants? Or is she a perfectionist? Someone who tolerates no imperfection? So when a bit of problem shows up she just avoids it?

What do you think?