Category Archives: Clinical Case Studies

Adult ADHD?

Clinical Case Studies, Depression, Issues & Debates

This young Indonesian man came to us referred by a psychiatrist, in the referral letter it was written that he’s experiencing some psychological difficulties, poor sleep, mood swing, poor concentration, the diagnosis was dysthymic disorder.

When he came to the counter I can see his face in red and him in such an agitated mood, he said, “I’ve been trying to call you guys but something strange happened.” I told him to call us in front of us and so he did. There was indeed some weird sound coming up after he dialed, of course, as he called our fax numbers. So later he was registered and he took a sit, seemed to have calmed himself down listening music with his earphone in the waiting area.

He said his main objective to come to our clinic is to sort out his poor sleep and mood swing problems. He said even with medication from previous doctor, he can’t fall asleep deeply, he just doesn’t feel that he’s sleeping well. At one point he felt like he could no longer control his emotion. His appetite is considerably ok, acceptable as he said. But he said when he gets angry he feels dizzy in his head. The example he gave was the time he was coming to our clinic, but couldn’t find the place, and couldn’t reach us by phone (well, how to get to us with fax number, unless you’re sending a fax I suppose?). He said he was so angry and then he felt light-headed.

We don’t expect people to be flat in their mood (in fact being flat in mood is a negative symptom of Schizophrenia), so people can be sad, happy, angry, calm, depressed, elated… Yet his diagnosis was dysthymia, a disorder characterized by chronic, consistent low mood (just like depression, but less severe, more long-lasting). He didn’t appear so to us. He laughed when I joked. He was angry when he was frustrated. He managed to elaborate his problems with examples. He has interests- he listens to musics as he waits.

One main problem he has is his poor concentration, he’s a student. For a student to not concentrating, not focusing, not remembering, not memorizing, it’s like end of the world (especially if you do care about your studies!). He really wants to finish the study and graduate from it, as he doesn’t want to waste his father’s money.

So we’re suspecting Adult ADHD. I remember I got a copy of Adult ADHD scale just last week and was thinking “I won’t need this. Who’ll come to clinic for this problem?! Nobody.”

Now I realized one thing, it’s right, nobody will come for consultation and treatment for Adult ADHD. Not because nobody is suffering from it, but chances are it’s far under-diagnosed. If you look at the scale (Adult ADHD Self-report), you’ll realize people nowadays are likely to suffer from it (I can’t concentrate, I can’t sit still, I get distracted easily, I keep forgetting the deadlines, I feel restless…).

See here for more Psychological Rating Scales.

Consent to Treatment & Mental Health

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

I wrote a clinical case study previously (see here) and demonstrated under certain conditions it’s not always possible to gain the consent of treatment from the patients yet the family has some other options to help the patient if they want to.

Few days ago I spoke to a husband who all the while has been putting medicine in drinks for his schizophrenic wife. He has been cooking soup, buying Chatime, fresh milk etc at night, just to let his wife who thinks she’s well to take the medicine. (I wonder if married women who are reading this will become suspicious of whether their husbands are putting medicine in their supper drinks?!)

Recently the patient started to refuse to take supper at night. She got angry and asked husband not to let her eat anything at night. She goes out with friends till late night. Once she gets home she just wants to go straight to bed. She said those drinks are making her fat (she’s mostly right).

So husband started to fail giving her med and she started to demonstrate poor sleep, agitation, paranoia…

The husband said he’s really been suffering doing this (putting med in his wife’s drink/food). He said one day when he was dining out with the wife, while the wife was away to the washroom, he poured the liquid medicine into her drink, and guess what? Somebody saw it!! He was very embarrassed as if he was doing something illegal, wrong and sinful (imagine what the public would think about having seen that?).

It’s good to have consent to treatment from the adult patients, much easier for the clinicians and family members for sure, but when the patients think they are fine and completely healthy psychologically, guess it’s the family then, that have to suffer.

Anorexia & Psychosis

Clinical Case Studies, Obsession & Compulsion, Schizophrenia & Psychotic Disorder

At first glance, you probably don’t quite find any obvious relationship between Anorexia (irrational fear of gaining weight, food restriction, distorted body perception) and Psychosis (“loss of contact with reality”) in my title, but with some explanation in the brackets I hope it does make it a bit obvious…

This young boy came with his parents that day. He seems a bit underweight when we were told that he’s already 13 years old. The mother said he was above 60 kgs, much bigger size than most of his peers, but now he has lost almost half of his size, and is still losing.

He was the target of bully, his schoolmates made jokes about his size and weight. He made no friends and had very low self-esteem and confidence. Then he started to avoid taking meals. The parents have to persuade, convince, force him with all kind of methods. Still, he continues to lose weight.

He’s also obsessed with cleanliness (yet another OCD case), very fear of contamination and infection. Though one very different thing from the other obsessors, is that he can’t take off his shoes, as he thinks if his feet have any contact with the floor, the dirt and dust will be “transmitted” into his body, causing him fat! causing him fat! causing him fat! (Something’s wrong with my writing style, I think I’m also obsessed with repeating when I talk about OCD cases).

Although we can’t really be sure chicken or egg which came first, here it seems likely that he first became anorexic, then only led to obsessions with cleanliness. But being highly fear about things on the floor causing him gaining weight, he is so close to delusional and psychotic. Guess what’s happening right now? He thinks the medicine will make him fat and so is refusing the medicine…

It seems that anorexia is also a kind of obsessions and compulsions, but it can also be so serious and appear like psychosis. Just like how they see themselves in the mirror, completely distorted, different from how we see them, isn’t that “losing contact with reality”?

How anorexic people see themselves
How anorexic people see themselves.

Separation Anxiety

Anxiety Disorder, Clinical Case Studies

When the boy first came to us, the parents were very anxious as the boy had already stopped going to school for almost a week. They begged for an earliest possible appointment as they can’t bear the boy missing even one extra day of absentee from school, despite advice that even if the boy came for consultation straightaway he won’t be able to recover immediately and be able to go to school the next day.

The mother told us that the boy has been refusing to go to school, tuition, and any classes. He can go out still, can see crowds (just like when he came to see us, there were a lot of other patients and patients’ family in the waiting room), but whenever it comes to classes and school he just wouldn’t go. It all started about two weeks ago.

When I spoke to the boy, I asked if he felt ok in the waiting room with the crowds, he nodded indicating ok. I asked whether he can accept it if the mother now goes to the washroom and leaves him there alone. He shook his head. “Not even for 5 minutes? 3 minutes?” Again he shook his head. The mother explained that he wasn’t like this before, he could go to school and tuition classes with peers.

With some prompts the mother recalled an incident about two weeks ago, where she was too busy at work and was late to pick him up from school. The boy was in tears when she got there. She now realized it was this incident that leads to her son’s subsequent behaviours. She thought he was just avoiding school, perhaps due to bullies, problems with friends or not completing homework. She thought her son was just being rebellious and never realized she was the reason of his problematic behaviour.

I’ve come across cases like this a number of times. Imagine if the mother didn’t seek help, and insisting, forcing the boy to go to school, what’s going to happen? They are likely to get into frequent rows and arguments, the mother thinks the son is disobedient and doesn’t like schooling, the son thinks the mother doesn’t understand him and love him.

Yet it’s important to look at the root of the problem, as a lot of childhood insecurity starts from small incident like this (“my mother is late for 1 hour to pick me up, I thought she doesn’t want me, she’s going to leave me there” – often depicted in TV as well!). If this conflict isn’t resolved, quite often the child brings the insecurity to adulthood and has trouble forming secure and trusted relationship.

Post-Traumatic Stress following MVA

Anxiety Disorder, Clinical Case Studies

An oversea holiday is meant to be relaxing and pleasurable. Yet it doesn’t apply to this young boy and his family.

When he was 12 years old, he travelled to Hong Kong with his family. As they were in a minibus, the driver ignored the red traffic light, went ahead a junction and was crashed by a big bus. A few passengers were injured, one badly injured. This boy sat at the front so he didn’t see that bus coming from the right, he had his right arm fractured.

As the family was there only for holidays, they didn’t know what to do so they decided to travel back straightaway by air, and the boy had to suffer all the way till he got back to Malaysia.

Subsequently the boy’s right arm is ok with some physiotherapy. However, the boy is no longer able to ride in any bus or van. He used to go to school by school bus, now the family has to send him. They haven’t got much of a choice, as the boy can get so panic, worried and be in tears when asked to take any van or bus.

His auntie has later decided to sue the bus company in Hong Kong, knowing that the minibus driver who caused this accident did not receive any legal punishment (this sounds ridiculous, I thought HK is a lot more strict in executing their law). They aren’t a rich family, middle class but they had to do so as this incident has brought so much loss to the whole family, financially, psychologically, time spent and so, so much energy since the incident two years ago.

The boy has been suffering from Post Traumatic Stress Disorder (PTSD) following major motor vehicle accident (MVA) for over 2 years now. He sometimes still has nightmares about the accident, and can’t concentrate to study. He was a smart and happy child. The family thought it was just about avoiding to take bus and van, and he will get better by himself gradually, now they slowly learn about PTSD and is searching for help, as his condition doesn’t appear to be better after 2 years.

Washing & Arranging Rituals

Clinical Case Studies, Obsession & Compulsion

I remember this young man very well. I got phone calls from his mother about one hour before we close for 3-4 days continuously. The mother said she was bringing him back for review, but they didn’t turn up at the end.

Till that afternoon they showed up just before we closed. The psychiatrist was still seeing a patient so they had to wait for a bit. This young man went into the toilet, and spent at least 20 minutes in there, till the nurse was calling his name several times, looking for him in the waiting area and outside, still hadn’t found him. The mother said he was in the washroom. When the door was opened, he went back into the basin and continue with washing, washing his face and hands. We tried to stop him, telling him that doctor wanted to see him right now. It took another 5 to 10 minutes till he was literally dragged out from the washroom and into the consultant room.

Before he left, he stood there and wave to us as we said goodbye to him. He was there waving for like 10 minutes. The mother seemed to have given up, just stood by the clinic door to wait till he’d done.

This is the one and only time I see this young man with obsessive compulsive disorder, doing massive washing and arranging rituals.

Till recently, about two months later from when I first saw him, I met another very similar case and recalled this young man, wondering why he hadn’t come back for review, I decided to make a call to him, just to know how he has been recently.

He picked up the call, and when I asked “Good afternoon, are you Mr Chan?”, he answered, “I’m Mr Chan Ah Meng” (pseudonym). I stated where I’m calling from, and that I merely wanted to know how he’s been doing, why I haven’t seen him for such a long time. He said he has stopped schooling, now helping his father, he’s seeing another psychiatrist now, still repeating, so disabling that he had to stop schooling. When he said he was still repeating, he repeated it a few times. Other than that he’s been doing ok. I informed him if there’s of anything we can help him, he can call us back, then I hung up the phone.

Later I was busy with other work, my colleague told me that he called me back. So I rang him back, again he had to identify himself as Mr Chan Ah Meng. He said “nothing important now, nothing important now, nothing important now…” So he thanked me for calling and I said you’re welcome, I hung up again. Within few minutes he rang again, “what did you last say just now?” I said I couldn’t really remember, then he answered, “you said ‘you’re welome’, you said ‘you’re welcome'”… Then he thanked me again and I hung up.

And I hung up.

And I hung up.