Category Archives: Clinical Case Studies

美丽的网红(网络红人)

我还没第一眼见过她,柜台帮她登记的同事就已经通过电话告诉我,“她真的很漂亮!陪她一起来的男士也超帅!”

一方面期待看到她,一方面心里”默默地自卑”。

她的话不多(有些患者一走进来,我可能连问问题的机会都没有),通常答案都很简略,或者想很久,但是答不上来,最后还是“我不知道”。过程中,她透露自己的一些过去,恋爱史,陪她来的男士只是朋友,她目前单身,已经五年了。也说到为自己过去的行为感到沮丧后悔,想忘记它们,通过催眠消除它们(没办法直接做到);再提到未来,觉得迷茫,工作迷茫,交不到男朋友也迷茫。

这点让我好奇,以她的外表,拜倒石榴裙下的观音兵肯定不少,她说有自己喜欢的人,但都爱玩,不想认真。而她,希望安定、谈一场细水长流的恋爱(几年前的她也曾经比较爱玩,但是已经过去了)。可是要嘛她对对方没有意思,要嘛对方只把她看成”玩“的对象。五年前分手的时候,也是因为对方还不想定下来,还是很爱玩,和其他女生暧昧,去夜店夜归等,两人不停吵架最后女生提出分手。她觉得男生是不可能专一的,最后能回家就好。

这让我想起很久以前和一个朋友的谈话,说她的一个朋友,不停地爱上有妇之夫,每次都很受伤,下一次却也还是重蹈覆辙;另外一个朋友也是,每次总爱上playboy,每次都被玩弄,身心受伤,但还是没有从中吸取教训。我们最后觉得,有些女生,总是会被一样的人吸引,总是会爱上类似特质的人。

这个个案中的女生,是个网红,拍很多养眼美丽的照片,网上的追随者与粉丝很多。男生会怎么看这个女生?(就会有男生说,有些女生只适合玩在一起,娶回家的绝不会是这类)而这个女生又会怎么看对她有意思的正经男生?又或者,她的生活圈中,有这类男生而同时又是她会喜欢的吗?会不会她总是不会看上所谓正经、或者想认真和她安定下来的男生?大家想想自己的过去,会不会觉得总是被类似特质的人吸引?

说到这里,想起最近一个好朋友的妈妈过世了,我不停在担心她的表现(太坚强),会不会是没有和自己的情绪接触(not in touch with her emotions)。毕竟东方国家,从小就被教育把负面情绪压抑,从来没有机会感受和接受。这个女生,也给我一样的感觉,总是“美美的”,没有什么表情,她的情绪起伏不大,笑容很浅,说到自己最难过的事情,也只掉了一点泪,就算我说,可以哭,可以难过,可以和这个情绪感觉相处…

或许你很羡慕有些非常漂亮的人,但是,有时候没有这点特质,反而让你的人生更顺利、更有优势。虽然我也还是会羡慕她长的如此赏心悦目,但也就只是单纯的羡慕,和更懂得感恩。

Neutral Pure-O

Most people know that Exposure Response Prevention (ERP) is the main intervention used for Obsessive Compulsive Disorder (OCD). So the rationale is pretty simple here, say we have a patient who is afraid of contamination (obsession) and wash his hands excessively (compulsion), we do some preparation work and can then start the ERP by exposing him to dirt without letting him to wash his hands (response prevention). This is normally done on a very gradual manner (with the patient’s consent and enough preparation work beforehand, so it is definitely not forcefully done to him). And of course in reality the OCD cases are barely as straightforward and simple as this, but this is the general principle.

With pure obsession, i.e. those without any compulsive behaviour, it’s all in their minds, things can get a bit harder, but still, it’s possible. Some commonly seen pure-O are (1) relationship obsessions (discussed in my blog else where as “morbid jealousy” which might or might not be the same condition), (2) sexual obsessions, (3) religious obsessions, (4) violent obsessions, (5) neutral obsessions.

So let’s take a recently seen man as an example here. It started once when he drove past a church, and somehow a sexual related thought popped out in his mind, he couldn’t bear himself having such “dirty” thought in a holy place, and since then, whenever he goes passed any holy places, he will suppress his mind from coming out with any “dirty thoughts”. And as we all know that our minds don’t work this way, the more you try to push some thoughts away, the more they bounce back and pop up.

ERP is possible for such pure-O cases. After the initial preparation work including psychoeducation, motivation building and mindfulness training, they are exposed to those thoughts that they have been avoiding, in those places (based on the items in the hierarchy). So it works similarly for all different types of pure obsessions, be it relationship, violent, religious or sexual (in certain cases where direct exposure is not possible, it will have to be done in imagination, and by watching videos etc).

However, how about neutral obsessions? What the patient has could be some really simple, random thoughts, which might be inconsistent, but they might be spending hours and hours thinking about these random stuff. Like a young man I saw couple months ago, who reacts to any thought his mind comes up with, e.g. “why does the universe work this way?”, “how do my ears listen and my brain comprehend what others say?” etc. I couldn’t really carry out typical ERP to him, since those are really random topics and they can be completely different every time. So I needed him to start thought defusion exercises, mindfulness meditation (then he dropped out…). I believe this is the best way for neutral pure-O, though I understand how difficult it’s to increase their motivation to keep practicing until they see the effects (did have patients in the past who were surprised by how quiet their minds can be after such exercises – and this is just a bonus, as it’s not the intention or purpose of such practices).

Do enlighten me if you have better psychological intervention for neutral pure-O. And I hope all the OCD sufferers out there will not give in to the illness!

<心理追兇Mind Hunter>男主角马国明是精神分裂吗?

备注:我一直很认真花时间在我的网站写有素质的文章,这篇的题材可能归属娱乐版,但是我的态度与提高心理健康意识的主张不变!

已经有一段时间没有追看港剧,直到出现这部和心理学相关的电视剧,分别被几个朋友问说我有在看吗,说不错看而且还有问题要我解答,所以我在一个星期多把28集看完了。

不交代剧中的内容和角色。只是昨晚因为家人还在看,提起主角Dr Chong(心理学家钟泰然博士 — 是的他不是医生,他不能开药,他被称为Dr 是因为 PhD博士学位,不是medical doctor),说他是精神分裂症(schizophrenia),有幻觉(hallucination),可以看到听到他已故女友。我想了一下,他总是在点起烟的时候对方才出现,看起来真的有点像是刺激物引致的幻觉(有些药物和毒品确实可能引起幻觉,可能但不一定引致精神分裂症)。

说真的,看这部电视剧的过程中,我从没想过他可能有精神分裂。虽然我满怀期待最后编剧导演给我一个交代,一个诊断,这名心理学家患有的是什么心理问题(可是没有。No, 我不认同他是反社会人格障碍 antisocial personality disorder!)。对我而言,他的表现是grieving,悲悼(因为失去所爱的人的悲伤),长久下去,可能形成抑郁(depression)。当然,就像我常和病人说的,接受这些悲伤,你刚失去生命中这么重要的人/感情,你要是不悲伤不难过不哭泣,我才要担心才想治疗你。所以抑郁也是正常的。或许大部分人会说,悼念五年,也太久了。可是以陪伴丧亲者的角度来说,悲悼其实没有期限,有些人要几个月,有些人几年,周围的人能做的,就是陪伴。

回到主题,最后Dr Chung不再和其他人联络/接触,情绪崩溃,独自走上末路(其实他有没有死,结局没有交代)。这其实对我而言,或多或少地确认了我的判断,他是悲悼过度而抑郁。如果你只是悲悼,一般不那么抗拒周围的人,你还是可以继续生活、工作或学习等,并接受其他人的陪伴,但是哀悼与抑郁的一线之差(really just a fine line!),在于你开始抗拒其他人,开始封闭自己(有一幕他的警擦朋友和社工朋友说已经很久没有看到他了,另一精神科医生好朋友也已经反目成仇)。

所以我的看法与分析,他不是精神分裂。

最后还是有一点相当欣赏这部剧的地方,在于催眠那段,社工朋友童月因为过度惊吓,出现暂时性失忆,Dr Chung说催眠可以看到平时看不到的事,原本太远的距离太小的事物,在催眠中可以变近放大,当时我的心里在说“放屁!为什么误导观众”,很开心最后发现那只是他的手段,用来骗童日。只是这个操作(manipulation),真的很难让人不觉得他是反社会人格…. 不过!从剧中很多地方不难发现,他其实很在意别人的感受,也尊重别人的权益,反社会人格,是不会在他30-40岁突然出现的…

Obsession or Psychosis?

The girl has been housebound for several months now. Though she managed to come to the clinic, but was seemingly restless and anxious, pacing the floor in the waiting area. She couldn’t see people using smartphones anywhere near her. She would think people are taking her pictures and use them for detrimental purposes. When she is in such situation, she experiences strong urges to grab the phone from others.

She does recognise those intrusive thoughts as irrational and could restrain herself from doing so. But like many other with OCD, she is staying home more and more to avoid such situations. When she first consulted a psychiatrist, it was about two years ago. She was quiet, introverted, sensitive, and repetitive in her speech, but wasn’t diagnosed as having OCD.

To really consider her current presentation, she seems to be having persecutory delusions (a common form of delusion in paranoid schizophrenia, where the person believes that ”he or she is being tormented, followed, tricked, spied on, or ridiculed.”).

So, how do you know or decide the diagnosis? Is it OCD or is it borderline psychotic of sorts?

Looking at the backgrounds, the mother who came with her said that she (the mother) has been “depressed” and taking psychiatric drugs for the past 10 years, it was mainly due to the stress caused by her daughter (only child). Though one of the mother’s symptoms, is compulsive washing(!), fear of contamination. It’s not difficult to imagine some OCD can be so severe and disabling leading to depression (the comorbidity rate is high anyway). But here through the mother at least a family history of OCD is exhibited.

In DSM-5, it is specified that OCD may be seen with: (i) good or fair insight, (ii) poor insight, or (iii) absent insight/delusional beliefs.  In all previous editions of the DSM, the criteria for the diagnosis of obsessive-compulsive disorder included the sufferer’s realization that their obsessions and compulsions are irrational or illogical. Now, absent insight/delusional beliefs can be part of an OCD diagnosis. Though we have all noticed that OCD sufferers’ levels of insight can change quickly, often depending on the circumstances and situations (e.g. the intrusive thought was felt completely real when she’s in the public noticing someone holding the phone VS when she’s at home thinking about that situation).

Some psychiatrists would prescribe both anti-depressants (serving as anti-OCD) and anti-psychotics. However, there were cases where OCD patients were first misdiagnosed as psychotic, and taking anti-psychotic very much worsened their OCD (though once they stopped the anti-psychotics and took anti-depressants at the right dosage, their OCD symptoms alleviated).

So time spent for detailed psychopathology and specific diagnosis would be of greatest importance. The presentation of suspiciousness (paranoia) as the main symptom suggested possibility of psychosis, however, the repetitive nature of the thought, which was stereotyped, causing severe distress, also the family history of OCD, pointed toward a greater possibility of obsessions. What is more difficult with this case is the absence of compulsions and reassurance seeking. And my final point, it’s not necessarily “either or”, it could be both! But still it takes much time and effort to really work that out.

一个真实的故事

女儿 Candace 打电话来的时候,Wilma 正在打扫客厅。他们一家住在加拿大的Winnepeg, Manitoba. 那是十一月,外头的天气很冷。Candace那年13岁,正和一个男同学聊完天,想问妈妈可不可以来学校载她回家。Wilma 想了想,他们家只有一辆车,一个小时后她得去接先生Cliff 下班,家里还有两个孩子,一个两岁一个九岁。她必须为他们准备出门,去接Candace,再去接先生。那会是和三个饿坏的小孩一起呆的一个小时。Candace已经13岁了,不是小孩了,她可以乘搭巴士回家。所以确认了Candace有足够的零钱乘搭巴士后,Wilma 继续打扫。

忙了一阵子后,Wilma 突然觉得有点不对劲,她看了看时钟,发现Candace早该到家了。外面开始下雪了。她开始不停往外张望,看看Candace是不是要回到家了。过了一阵子,也到了接先生Cliff的时间,她打理了两个孩子上车,沿路慢驶,看看是不是会遇上Candace正回家。她也驶到学校,大门已经上锁。接了Cliff后,他们回家,在附近寻找,然后逐个联络Candace的朋友,下午以后就没有人见到她了。Wilma去找那个男同学,他最后看见她往巴士站的方向走。夫妻俩只好报警。他们成立了搜寻小组,也四处张贴海报。他们祈祷、他们哭泣、他们无法入眠。七个星期后,警察联络他们,Candace的尸体被寻获。手脚被捆绑着,冻死的。

那天下午家里聚了不少亲戚和朋友,一直到晚上10时,只剩下几个最亲密的朋友。这时门铃响起,一个陌生人站在门口,“我也是一个孩子被谋杀的父亲”。这男士大约五十几岁,他的女儿几年前在甜甜圈店被杀,在这小地方也是有名的案件,嫌疑犯Thomas Sophonow 被逮捕并审讯诉讼三次,他坐了四年牢,又被上述庭放了出来。屋里的每个人围着桌子,听着男士细述整个过程,他有本小簿子,记录了每个细节,包括他因此而花的单据也整齐排列其中。他也说起Sophonow,说起司法的不公。这整个过程毁了他,也毁了他的家庭。他无法继续工作,健康很糟糕,吃着很多药。虽然他没有直接说起他和太太,但是言词间也透露他们的关系似乎已经是过去式。关于他的女儿,他没说得太多,反而都在说努力寻求公平公正的过程和想法。到最后午夜以前,他临走前说,“我把这一切告诉你们,是要让你们知道,前方有些什么在等着你们。”

我把这一切告诉你们,是要让你们知道,前方有些什么在等着你们。

对Wilma 和 Cliff 而言,男子所说的并不是预言,而是一个警示,那有可能就是他们的未来。他们可能因为女儿遭谋杀而失去健康,失去理智,失去彼此,失去这个家。因为男子的到访和分享,强迫他们去考虑其他的选择,寻找一条不一样的路。隔天就是Candace的葬礼,过后他们同意召开记者会。Candace的遭遇引起了整个城市的注意,几乎所有报章媒体都出席了。

“你们对残害Candace的人有什么感受?”一名记者问。

“我们想要知道这个人、或这群人是谁,好让我们可以分享一些爱,给这些生命里似乎缺乏爱的人” Cliff 说。

“我们的目的是要找到Candace,而我们已经找到了。我不能说此时此刻我能原谅这个人” Wilma继续说到,强调的是此时此刻,并继续说“每个人一生中都曾经做过一些可怕的事,或有那个念头。”


我很想分享这个真实的故事。每个人的生命都有些英雄,每个族群也有他们信仰的民族大英雄。而像 Wilma 的Mennonites,他们的英雄是Dirk Willems,他在16世纪因为信仰而被关在牢塔里,在一条绳子的帮助下,他成功逃脱牢塔,渡过塔外被冰覆盖的冰河,他成功到了河的对岸,但追逐他的狱卒却掉入冰水中。Willems 停了下来,回来拯救追兵。就因为他的大爱,他被抓了回去,虐待,被慢火活活烧死,过程中重复了无数次“主啊,我的天”。

我想我的生命并不缺乏爱,却缺乏了分享爱的能力,读到上面那句话的时候,我几乎不能置信的再看了几遍。谨此用这个故事提醒自己和看到这里的每个人,这世界上有很多处理不公平的方式,换个角度,你可能在寻求所谓公平的路上付出更多或经历更惨痛,可以放下的话就放下,可以原谅的话就原谅,可以多分享一些爱的话就多分享一些爱。

Religious Experiences and Psychotic Symptoms

I was recently having a conversation in the clinic and a patient back in the time when I was working in North London Forensic Service popped up in my mind. This is a big black man with a diagnosis of schizophrenia, he also assaulted his ex girlfriend and hence was in the inpatient security ward that I worked at.

From day one I met this man, he was in good order and discipline, never exhibited any of the psychotic symptoms, abusive language or aggressive behaviour of any sort, unlike many other patients there. He was also doing an MBA course through the Open University. So most of the staffs in the team believed that he would make his way out soon, to the community, starting a new life. However, his stay was extended. To our surprise, it was due to a note recorded by a nursing staff (what each patient does every day is recorded on every shift). The nurse got along quite well with the patient, on one occasion, the patient shared with the nurse his experience of seeing white light in his room coming from the sky, and an angelic human coming to him and passing him some positive messages.

The patient surely didn’t know this was recorded in the note. However, this was used against to the patient in the court as evidence of him still experiencing psychotic symptoms (both visual hallucination and delusion) and  was not well enough to leave the ward to the community. The patient came to know the details only after the hearing, from his solicitor. He didn’t get to defend himself on his experience, which he later expressed that this was completely a religious experience, which he found amazing and intriguing, and in no way is related to mental illness. He came from a very religious family.

This was at least 4 to 5 years ago. I still remember it because until today I still cannot be sure whether that decision made by the team was correct. I am not a religious person (few years ago I was turned down as a volunteer in an NGO because I told the interviewer that I have no religion!), I can’t truly understand how a very religious person’s experience with god is like. I did complete the Alpha course in the church when I was doing postgraduate in Brighton. I met a lot of very nice persons, some I still keep in touch today. Sometimes I could be quite shocked by their presentations and behaviour during the services, but I respect that it’s their belief, and I learnt from them although I have not experienced it at all.

If it was a so-called normal person experiencing and sharing their religious or cultural experience, we might or might not believe them, but we wouldn’t think they are having hallucinations. How if a religious person with a history of mental illness experienced and shared such encounter? This is like when I worked there, sometimes we had to do night shifts, and many of those African nurses wouldn’t stay on the ward alone no matter what (we shouldn’t anyway, but there are times of emergency etc). They have had so many encounters of “ghosts” and “spirits” and scary stuff, it’s a hospital afterall, it’s easily linked to deaths (and then “ghosts”). But when this was expressed by a patient, even the African nurses would suspect that he was just having hallucination!

I can’t really have any say about these, I have experienced none, spiritual, religious, or thrilling (to be honest I’m happy and keen to experience them). We were told that we should pay attention to cultural influences and backgrounds before we “judge” someone diagnose a patient. It’s true, I now think it was wrong to hold the big man back solely based on that.