Category Archives: Clinical Case Studies

Traumatised Childhood

She has an over 11 years history of depression with obsessional ruminations, and insomnia, and has maintained relatively well on medication, after a course of 6 ECTs.

She is the 7th of 8 siblings, with no family history of mental illness. Her parents divorced when she was still a child, she lived with her mother who doesn’t really care about her. At young age she was unfortunately raped repeatedly by a relative and his friends. She never really mentions it to others, most of the time she can pretend like it never happened to her before.

She is a hairstylist who works from home. So sometimes when there’s no customer she’s spending a lot of time alone at home. One of her elder brothers sometimes helps her financially, knowing that it costs her a lot to take psychiatric medicine long-term. She has once tried to follow up in the general hospital, but after taken one dosage of the medicine prescribed by the hospital doctor, she spent the whole night trembling and crying, feeling the head spinning. Since then she’s never thought to go to the general hospital (N.B. here I’m not saying that psychiatrists from GH isn’t good, but most of them aren’t Chinese, so there’s a language barrier there, which can cause problems in diagnosis and prescription).

She’s always complaining of head and neck pulling sensation. It’s worst when she can’t sleep well. She spends most of the time being worried about this pulling sensation, although nothing wrong was found physically when she went for check-up.

Sometimes she can be very obsessive, being worried about the same thing continuously, asking similar questions repeatedly, needing a lo of reassurance. She’s currently much better with medication, and with a lot of counselling she can slowly accept occasional poor sleep and insomnia (What to do if I can’t sleep well?).

Adverse childhood experience is always a risk factor for many mental illnesses, but also a perpetuating factor.

Depression Following Stroke

His wife came to us after the husband had a stroke. She is very concerned as the patient has had an elder brother who committed suicide after being depressed for years.

She is worried that her husband will do the same as he is currently staying in a hospital doing physiotherapy, being emotionally unstable, agitated, and very bad-tempered. He keeps to himself most of the time, makes no social contact with others, and cannot tolerate the least of any physical discomfort (e.g. sore throat, skin itchiness).

The wife is very keen to bring patient to consult a psychiatrist, yet he is not ready for it at all. If he ever knew that he’s taking any of the psychiatric related medicine he will get so mad. So the wife has been putting medicine in his food and drink. What’s difficult is his poor physical condition, due to the stroke he needs to do a lot of physio, but the medicine is making him drowsy and sleepy. In addition he’s having high blood sugar, high blood pressure and high cholestrol, so whatever kind of medicine that may raise any of these he can’t take it, especially his blood sugar is always sky high.

The wife spends almost 24/7 by his side to look after him. One day their only 15-year-old son made a call to her, saying he missed her and was very anxious about sitting for PMR (exam), he wanted her to pray with him over the phone. The wife decided to discuss with patient, told him to let her to go home and see the son, the patient agreed. However, when the wife wasn’t around, patient went up to the 13th floor of the hospital and attempted to jump down.

When he is okay, he is okay (what kind of sentence is this?). When he’s having a slight of bodily discomfort, he wants to end his life. Nobody really knows what he’s thinking, not even his wife. But he’s very upset and irritated being hospitalized, not being able to earn money and function like normal. What’s worse is his only sister and her family, who lives just next to him but have never come to visit him at all. So the wife seems to be the only connection he has, and when the wife isn’t around, all kind of negative thinkings float in his mind…

“She no longer wants me” “She doesn’t want to care for a sick person” “I’m useless” “Nobody cares about me”

Having a strong supportive family connection is something very essential in the recovery of mental illness. Yet unfortunately he has a brother who left him due to depression, and a sister who lives next to him but built a wall in the middle of two houses.

Insomnia & Poor Sleep

This is a patient with longstanding sleeping problem, not that he isn’t able to fall asleep, but he can’t sleep for many hours, is usually awake at about 2-3am, then has to lie on his bed till 6-7am.

He struggles so much with sleep for the past 30+ years of his life, now in his 60s. With medication his problem improves, but when his body starts to tolerate with the medicine, he will struggle to sleep longer again. To him having a good sleep and being able to sleep till morning is the most important thing. He’d rather over sleep and be late for work. He’d exchange anything for a good sleep till morning.

To make sure he’s able to sleep, he stays away from coffee, tea and anything that may lead to restlessness or insomnia for all these years. Sometimes he does feel too tired able and blurred in the day so he’ll have a lie in. But he doesn’t fall asleep, isn’t taking nap.

Advice given that he shouldn’t even have a lie in, as sometimes people are resting and they fall asleep without realizing it. Secondly, to learn one important fact that “if you can’t fall asleep, then just let it be”. In fact lying down on a bed is also a type of resting, you get to relax your muscles, body, and eyes. The only part that doesn’t really rest is perhaps your brain, but it doesn’t and will never rest completely anyway, whether you are sleeping or not. So accept the fact that your brain doesn’t want to fall asleep, let it be, just relax yourself. Do more exercise in the day, engage in more physical and mental activities in the day, get yourself tired.

 

What to do if I can’t sleep (well)?

  • Make sure you don’t sleep during the day, not even lying down and rest
  • Engage in more mental and physical activities in the day
  • Avoid tea, coffee and anything with caffeine in it. You may have tolerated it well in the past, but no longer now.
  • Accepts that lying down is also a type of rest, your muscles, body, eyes are all resting.
  • Accepts that it really doesn’t matter if you can’t fall asleep. Just continue lying down, relax and enjoy the sense of it.
  • Don’t be afraid and worried that you won’t fall asleep. The more you worry the harder you fall asleep.
  • You’re not alone. About every 4 out of 5 patients who visit our clinic has problems with sleeping. Some have not slept properly for few weeks. Some have not slept at all for 3-4 days.

Part II: Social, Peer & Exam Phobias

Part I: Social, Peer & Exam Phobias

Few days later, I spoke to the mother again. They went to a Counselling centre in town. The patient opened up in the counselling session, saying that she was under great pressure and worried about various things especially her parents financial abilities.

She has always wanted to learn cooking and baking. So she’s chosen the school that she’s attending now, because this school has the course she wanted, and she can join it straightaway after Form 3, though it’s the most expensive course. The parents didn’t mind it, as they want their daughter to be happy.

The parents bought a new house earlier this year. They will be paying 3 times the house loan of what they’re currently paying. The parents are happy-go-lucky people, they know it’s going to be difficult but they were never too worried about it. Yet this eldest daughter of theirs is so concerned – whether they can afford paying for the new house and also for her expensive course. She still has younger siblings, she thinks, maybe she shouldn’t complete her Form 3 and go for such expensive course.

She also has a very traditional grandmother, who dislikes her furthering her study in cooking/baking. The grandmother always criticizes her mother in front of her, and scolding the mother for allowing her to study in this course which leads to a career that doesn’t earn money.

She listened to all these comments about her decision, is upset that her mother was scolded because of her. Somehow internally, she knows if she couldn’t pass her exams or doesn’t attend her exam she will not be able to proceed to the cooking course. And this is what she wants, or maybe not, but for her family.

We overlooked all these underlying concerns, worries and feelings. This is somehow true in psychiatric settings, especially outpatient settings. I’m not saying that medicine is not helping, obviously I’ve seen a lot of people benefit from it (especially when the condition is critical), but sometimes we easily overlook things that may not be solved by medication. Comparing to medication, in this particular case counselling and psychological treatment have shown a much better outcome.

Social, Peer & Exam Phobias

Her class teachers see no problem with her. Her school counsellor said that she can’t sit for exams. Not that she doesn’t do revision and gets herself prepared, but she just gets so anxious, palpitating, hands trembling, sweating… as if she’s going to pass out.

Yet if she gets to sit for the exam alone in a room, she can do it.

Ok, so it isn’t exam phobia.

It could be agoraphobia (a fear of being somewhere where there is a chance of having a panic attack that others may witness, and not being able to get away rapidly) then? But she never really experiences panic attack in her 15 years of life. Though she is definitely going through some very severe anxiety and fears in any exam hall. She’s supposed to be the last batch of students taking PMR this year, she is now missing it.

She seems a bit shy when she talks to us. But she’s having eye-contacts with me as I explained things to her (probably better than how I was when I was at her age, despite being call as an extrovert I used to avoid eye-contacts) and her mother. During waiting time she stays outside of the clinic with her mother. I wonder if there’re some degrees of social phobia in there.

The mother said that she doesn’t really make friends. Her friends laughed at her weight and body size. Well, based on the standard nowadays, everyone thinks that they are fat, everyone is on a constant diet, everyone has to lose weight all their lives (ok, this is “a bit extreme”). I see no problem with her weight (but she’s in fact overweight), but I understand peer influences very much. Because of this she avoids making friends…

So there could be some peer pressure leading to social anxiety and social phobia. But what about her problem with exam? Why is it exam only? She survives just fine in class, and she survives just fine sitting for exam alone.

Sitting for exams with peers phobia, it is then. I think this could be under the parent of Agoraphobia, but I think in mental illnesses, we sometimes don’t have to fit people into any available categories, everyone has their problems and symptoms, which can be very unique to them.

Part II: Social, Peer & Exam Phobias

Compulsive Voyeurism

His sister first rang us, and asked to make an appointment. When I asked what problem her brother has, she was a bit unsure whether this is the right place for him. Her brother has some unusual habits, he collects stuff, and not like others who collect toys, stamps, … he collects women’s inner wears.

He is in his 40s, grows up in a family of five siblings being the only son. He is now in his second marriage. His current wife has a 17 years old daughter from her previous marriage. This is where it really tests his self-discipline ability.

He spies others, compulsively. He can’t help it and is very frustrated by his urges  and obsession to do so. It isn’t easy for him to make the decision and have the courage to come to seek help.

More commonly people call them Peeping Tom. Here is the definition of Voyeurism in ICD-10 (International Classification of Diseases).

He also suffers when he started to take medicine, and didn’t understand the reason of taking it. The sister questioned how the medicine can help him and wondered he would ever recover. In fact, voyeurism can just be like any other Obsessive Compulsive Disorder (OCD, see my previous post), some people wash hands compulsively, some spends hours reading, some tell lies compulsively, some spy others… So then it can be treated like OCD!

For me all voyeurism is pathological, but I’m just wondering whether it can be voluntary? So, someone can quit being a voyeur by own will maybe?