Category Archives: Clinical Case Studies

Depression & Suicidal Risk

Clinical Case Studies, Depression

She has a long history of depression, but due to financial constraint, has stopped following up in private clinic and gone to the general hospital. After few months she came back to us, not being well, but still not that bad, able to smile and chat with others a little bit.

Few days later she made a call to us, saying she’s feeling really low in mood, not having any interest, she didn’t know what to do with herself, still regular with med, but didn’t think it was helping with her problems. Nothing happened in particular that led to her mood being that way, she said. Her medication was adjusted. Couple days later I rang her again, she took the extra dosage, but remained the same, not happy, lacking drives and interest. She did try, she went out for group exercise with friends, but she kept feeling her mind was somewhere else. She was told to come back so that she could get a better review and a medicine regime that helps with her current condition better.

She didn’t come back for review. She never called us again. About 3 or 4 days later I called her house numbers again (which I usually did), somebody else picked up, saying she is no longer here. At first I didn’t get it, I thought she was just away. Then this lady said the patient committed suicide yesterday. I sent my condolences and ended the call.

Lacking interests and drives is one very important suicidal risk factor. They try to get engaged in something, but they don’t find their mind with them. It isn’t them, it’s their illness.

I used to think as long as they find some pleasurable things to do they will get better. Sometimes it just isn’t that simple, maybe it isn’t just the behavioural intervention or medicine alone, they need cognitive, behavioural and pharmacological interventions all together.

Genuine Suicidal Attempt or Attention Seeking?

Clinical Case Studies, Depression

She was told by the doctor to come to the clinic to collect her medication and for an injection, after seeing the doctor in the hospital.

When she got here she looked like she was on the phone, but nobody heard her talking at all. Staff told her to come in to the treatment room. She gave no response, made no eye contact – as if she was so concentrate on a spot in the air. Then she walked towards the door, went out, and stood by the stairs. She looked down to the lower floors. A colleague said, “she isn’t going to jump down is she?” I was going to say “Is she looking for someone downstairs?” but before I even completed the sentence, her feet were already in the air, hanging her body on the rail. we all ran out. She didn’t do it fast as her left hand was still holding the stairs handle/rail. So one of the colleagues managed to grab her legs, another her arm.

She was brought in. She continued to say that she wanted to leave, and of course she wasn’t allowed. It took some time till she was injected and given stat dose. The doctor came from the hospital to see her.

It appeared to be something related to drugs, she seemed to be taking illicit drugs, and according to her, she will be charged for distributing drugs (or bringing drugs in from another country). She said she was innocent.

She calmed down later as the stat dose kicked in. Family member was contacted to bring her home. I’m not sure how she is right now, I hope people will all stay away from illicit drugs.

If it was one of our busy days we wouldn’t have noticed and managed to stop this. Though we doubt if she really wanted to commit suicide, or she really just needed some attention and help maybe. Because of how the stair is designed, it wouldn’t be possible for anyone to jump down straight from 4th to ground floor (other than a small baby).  She could only fall to the third floor, though her head would have landed on the stair case below. I’m sure she was aware. So attention seeking through a suicidal behaviour?

Sometimes when it comes to mental illness (and I guess many chronic physical illnesses), family members get fed up and lose their patience after a period of time, due to the time, money and attention needed to care about the patient, but also the stigma that come with it. But without any support from close family and friends, it’s almost impossible for someone to completely recover from mental illness…

N.B. This was first posted at huibee.blogspot.com by the same author

Schizophrenia & Consent to Treatment

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

One day a mother of a 17-year-old patient called, said her relatives have been calling her, asking about her daughter. She posted several status on her Facebook (see? social media is what an important tool?!), saying she was going to kill her parents, and she has a plan about it (e.g. will chop father into how many pieces, then…). As patient has already blocked her parents on it, so they couldn’t see the status, but other relatives noticed it so they called mother.

This is a girl with Schizophrenia, having various kind of hallucinations about god, devils, aliens, thinking she is special, different from everyone else; isolating herself, easily agitated, bad tempered… She doesn’t sleep at night (well, most schizophrenic patients that I’ve come across don’t sleep at night). She has two younger brothers, she gets along ok with them. She thinks the youngest one is special like her, but he isn’t aware that he is special yet, at one point he will reach her stage.

Do you think someone like her will come for treatment, take medicine, go through treatment willingly?

If the answer were No, do you think we should then give up on her, and many people who aren’t well out there like her?

I guess many people understand the importance of consent to treatment (e.g. the surgeon is going to operate your brain, you or your family will have to sign a consent or else what if the surgeon is merely operating because s/he thinks this is the way s/he can earn the most?! Opps), but in the field of mental disorder this may not always be the case. It is not always possible to get the patient’s consent, the abovementioned is an example.

So maybe the parents can consult on behalf, then dispense medicine to the girl somehow… Till one point when the patient herself has the insight about her problem, she can then come for treatment personally!

There are some overly anxious parents or family members, who cannot accept “consult on behalf”- I’m not sick, why should I see the doctor?! Right, but your ill family isn’t coming either, how can we help her?

Morbid Jealousy

Clinical Case Studies

There was this young beautiful girl, who from the age of 16, got into her first relationship with a working guy. She then became so obsessed, and had the delusions that the boyfriend was flirting with other girls, having an affair with others etc. She skipped classes, and went to her boyfriend’s working place to “watch over” him, see what he was doing, who he talked with…

Over the years the girl got into various relationships, because of how beautiful she is, guys get attracted, and when she becomes attached, she also gets really obsessed and possessive, especially when the guy having any contact with other girls, despite how faithful the guys were. The girl slowly realized this a problem, and consulted a psychiatrist. Over the years she also gained insight with her problem — a condition now called “morbid jealousy”.

Morbid jealousy is a psychiatric condition where the person holds strong belief that his/her partner is being unfaithful without any convincing or “solid” evidence that this belief is true. It tends to happen over and over again no matter how many partner this person changes and how “innocent” the partner is.

It is getting to quite a common condition nowadays. As we would probably all expect that conditions like anxiety disorders and depression would be a lot more common, now probably every 1 in 10 people with a psychiatric condition comes to the clinic due to this problem, although most of them may not understand this as their problem (but only think that they can’t sleep, get anxious easily, feel unhappy, got no appetite, is bad-tempered, gets agitated easily… which can simply appear as anxiety depression).

Here it’s important to clarify that morbid jealousy doesn’t apply when actually you find some convincing evidence, or when you are just feeling a bit insecure whether your partner gets a bit too close to someone (yes, just a bit insecure, which does not affect your life that much, and problem may simply be solved after you speak calmly with your partner), or when it’s just part of a more sensitive type of personality.

For the patient’s partner to come to understand that their partner has this problem would be helpful to the patient, and being understanding, considerate, supportive and patient to the patient will be significant to the process of recovery.

N.B.: This was first posted at huibee.blogspot.com by the same author

Hypochondriasis or Illness Phobia?

Anxiety Disorder, Clinical Case Studies

This woman is married to a husband who has another family outside (with a one month old girl). She accepted it after a while, knowing that she can’t carry babies for her husband. Her husband was considerably “good” as he never abandon her, although most of the time he’s out there with the family, he calls her daily, gives her complete financial support, and comes back home quite often.

One day this woman visited our clinic, with a lot of somatic complaints (stomach wind? dizziness? chest discomfort? feeling weak and anxious? etc). She has been taking chinese herbs for over 20 years, but still turns out as a very ill-health person. Doctor advised her to stop taking chinese herbs completely (not that all chinese herbs are bad, but those that she had been taking apparently does not help her at all, could even be worsening her health problem).

She is sensitive, anti-western-med, with multiple somatic complaints. On the day she got home after the first consultation, she started to bombard us with phone calls, asking all kind of questions – Can I take ABC soup? Should I continue with med during periods? Why do I feel like losing balance? Can I eat oat? Can I take in some protein supplement? etc

Do you consider this as OCD (Obsessive Compulsive Disorder)? But she doesn’t repetitively asking the same/similar questions?! She has kind of wide different concerns…

Do you think she has illness phobia? Because she’s so health concerned that she wants to be so careful and watch out for any possible harm to her health?

Do you think she’s purely attention seeking? Or should I say she just needs some love, care and attention? So she pretends to be “problematic”, to be sick, to be unwell, so that her husband would be calling her and care about her? So she can call us non-stop to ask different questions?

Sometimes I find “attention-seeking” explains a lot of things…