Category Archives: Clinical Case Studies

Substance-Induced Psychosis & Addiction-Linked Divorce

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

When I was doing my master back in the uni, I remember one of the presentations I did was about substance induced schizophrenia. That was just about 4-5 years ago, but I can’t quite remember the details, though I’ve always remembered that one of the triggers of schizophrenia was illicit drugs, I had a diagram in my powerpoint showing how much it contributed to the population with schizophrenia and related illness.

After starting to work in the clinic in KL, I’ve encountered quite some patients who have had a history of taking ecstasy pills or other drugs and have led to psychotic episodes. For the majority of them, their family members took charge and managed to stop them from continuing taking illicit drugs (by stopping them from mixing with so-called “bad friends”, moving to different or new environment, cutting off their finances, threatening to cut off their relationship with the subject etc).

Recently I’ve had this big man, who has had a long history of taking aramine and ecstasy pills, and is seeing the psychiatrist for his anxiety (no, he didn’t show signs of psychosis). He once told me that everyone has their way to release stress, some people go exercise (like me), some go shopping, some watch movies, some do gardening, some just need a good sleep, and for him, he hangs out with his friends, singing karaoke, and… taking pills, spending their nights high. During Chinese New Year, he could be drugged for over a week continuously. Though on normal days, he works, he goes gym (hence he’s called big man, as he’s not just fit, but muscular – like a staff always says, he doesn’t look like a typical drug abuser), he looks after his wife and children. Oh yes, I didn’t mention that he has a family. The wife is lovely, supportive, and all good qualities you can expect from a traditional Chinese woman.

Each time he tries to quit the pills, he would experience a moody state which lasts for two to three weeks, with fears, insomnia. Normally the psychiatric medicine that he’s taking will bring him back to normal and functional. The last time I heard from him after Chinese New Year, he said this round he would definitely quit it, he would stop seeing those friends (I later learnt that it’s much harder because one is actually his business partner), he wouldn’t want to have relapse again and again, and he doesn’t know when those drugs are going to destroy him (his brain/mind), and his family… because the wife said if he takes it again, she’s leaving him (I still remember he said “妻离子散”, such powerful words). I believed what he said, for I know how much he loves his wife.

On last Monday I encountered a motor vehicle accident and had to take the day off. On this very day, big man’s sister called up to the clinic saying that he was really unstable, as the wife brought the kids back to her parents’ house, big man was threatening to cut his wrist (which he did later on). The family members were advised to admit him to psychiatric wards in general hospital. On Thursday when I was at work, big man came with his father (who is also our patient but is in good remission and maintaining with a minimal dosage). The wife called to tell me what had happened this week. She said big man has become really paranoid and delusional recently, always suspecting that she is unloyal to him. On the Sunday before, he went outstation with his business partner (aka one of the bad friends), and spent the night being high, and had called her on 5am, questioning her about the man she kept, threatening that he would do her harm when he came back later. On the next day, he beat her up after being really angry for “what she has done behind him”. That’s the day she had to run away from him with the children, even after he sliced his wrist twice, she didn’t go back, she knows the children’s safety is the utmost important and her husband is not her husband anymore.

What the man presents, is what we call Morbid Jealousy, or Othello Syndrome (an old case study here). He was never delusional or paranoid during the years he was seeing us. He was just having anxiety and fear over some life issues, and is a perfectionist. I believe morbid jealousy is related to paranoid schizophrenia or other psychotic illnesses, and so I can’t help thinking the links between his history of substance use, and the development of his morbid jealousy. From a lot of cases that I have observed, suffering from schizophrenia or other mental illness don’t usually make your partner leave you, quite often the partner can even tolerate morbid jealousy despite how frustrating it can cause and how destructive it is to the relationship; but being mentally ill, having addiction yet refused to go into rehabilitation, and beating wife, that’s the bottom line for any woman, I believe.

N.B. this post was written in March 2016. According to the sister, big man passed away jumping off from a building at the end of March, after calling the wife and speaking to her. 

給年邁父母的愛

Clinical Case Studies, Depression

其實很多時候我還蠻擔心接到他老人家的電話的，雖然我心裡很敬重他，但更多的，是心疼。

他是個七十多歲的老先生，是診所多年的抑鬱病患者，情況時好時壞，目前吃著的抗抑鬱藥物更已經是最大劑量。老先生已經退休，平時都在照顧中風臥病在床的妻子，給自己還有老婆打點生活的大小事務，有個兒子但不同住，關係也不大好，見面總是吵架，兒子去年剛離婚，也沒爭取到孩子的扶養權。老先生自己的身體不怎麼好，有骨刺，嚴重起來自己也是痛得徹夜難眠。

害怕接到老先生的電話，是因為老先生住得遠，平時要是病情惡化了，心情鬱悶不已，就會給我打個電話請我幫忙舒緩。而因為藥物已經是最大劑量，又真的不想因為增加沒什麼作用的藥物導致老先生得承擔更大的經濟負擔，所以平時只能儘量和老先生聊聊天減少他不必要的操心。而事實上，老先生尚算樂觀開朗，就算心情很煩躁鬱悶，也很少掛個苦瓜臉哀聲嘆氣，而且老先生的抑鬱很大程度是環境和一些他個人無法控制的因素造成的，所以藥物最多只能稍微輔助，起不了太大的作用（雖然對一件事的詮釋完全歸於個人）。

我知道我不該這麼想，但因為在這行久了，看多了，我常不自禁擔心老先生會不會覺得自己身體不好，又要照顧老夫人，和兒子關係又差（而且兒子還有許多要他擔心的事），抑鬱一發作，生活沒意義沒樂趣，一時想不開就走了。每次想到這，都會慶幸自己偶爾可以幫上一點小忙，更會明白老先生能撐到今天，很多能量來自於對老夫人的愛與責任。少一點愛，少一點責任心都不行。說得難聽些，換作是時下的年輕人（如我，雖然我也不太年輕了…），肯定早就撐不下去逃避問題去了。是的，我總認為上一代的人比較堅強，有韌性，有毅力，較能在逆境中生存甚至向上；這一代在太多保護與遷就裏長大，比較任性，欠缺責任心和堅持。

我心疼他，同時也生氣他的兒子，脾氣不好，行為不好，也不盡孝心，見面就是和老先生吵架。其實我也和這獨子有過一次接觸，感覺他生活很多狀況也自顧不暇，所以責怪他的心理很矛盾，因為其實兩父子顯然都很關心對方，有問題都不敢告訴對方怕對方操心，大概又是同樣的火爆脾氣，兩人說不上兩句就吵架了。

其實說穿了，很多老人家都一樣，寧可對外人聊心事講問題，也不要不敢對自己的家人自己的孩子說，因為孩子總是忙，因為孩子已經很累了，因為不要孩子擔心操心，因為和孩子說太多最後都變吵架，因為怕孩子嫌自己煩自己嘮叨（甚至怕孩子把自己送進老人院）… 每次和老先生的接觸，都會提醒我要對爸媽更好一些，更體貼他們一些（然後回家就忘得七七八八！）

P.S. 這是我第一用中文紀錄臨床個案（Clinical Case Studies），主要是因為我心裡有很多感受想用中文抒發；所以可能要請讀者體諒這文章可能寫得不太順暢（還要磨練磨練）

Trichotillomania

Anxiety Disorder, Clinical Case Studies, Issues & Debates, Obsession & Compulsion

She started picking hair since standard 5 in primary school, and the problems got worse over the years, especially when she was under pressure. She had seen a few counsellors, also skin specialist, and was given injection on the scalp and prescribed medicine. Finally her parents decided to take her to consult psychiatrist, and within two months she got better with some SSRIs and anti-anxiety drugs. She then stopped taking the medicine. Her hair was growing again.

Few days ago the mother called up, saying her problem is back. When she was sweeping her room, she could see hair all over her bed, pillows and on the floor. The mother asked if we could provide phone counselling to help her (without using medication, as it was causing drowsiness).

This kind of request is not untypical here. Asian people (including myself) tend not to take so much western medicine, and avoid it as much as possible. I can understand that. But the girl’s trichotillomania (hair pulling) problem has a biological components.

Most mental or psychiatric illnesses have a biological component, whether it’s depression, anxiety, OCD, psychosis (obvious!) etc. Sometimes it depends on the type of illness, sometimes on the individual, sometimes it depends on which episode (which means for the same individual, she could have a biological trigger last year but this time it’s a pure psychological triggered episode), sometimes it’s a mix of both. For a person who suffers from very bad OCD, medication can probably reduce his symptoms of 30-50%, but still leaving symptoms that would still interfere with his life, so for this part he would need psychological interventions.

So I explained to the mother that she needs medication, pure counselling may relieve her symptoms to an extend, but not all of it. Because when something is wrong biologically, she would need medication to help her, whereas psychological interventions can help her to reduce her anxiety and stress, and to learn to cope with stress, mood swing, etc.

The best treatment for her would be both medication and psychological interventions, and a good combination is in fact the best and most effective treatment for a lot of people and for many mental illness and psychological problems, unfortunately nowadays this is not the kind of service provided anywhere.

拔毛癖

她从小学五年级开始拔头发，多年来问题一直恶化，特别是面对很大压力的时候。她看过几个辅导师，也见过皮肤专科，并接受头皮注射和处方药。最后，她的父母决定带她去咨询精神科医生，吃了一些SSRIs(抗抑郁)和抗焦虑药，在两个月内情况就好转了。然后她就自行停止服药，头发也慢慢长出来了。

前几天，母亲打了个电话来诊所，说她的问题又回来了。当她帮女儿打扫房间的时候，看见床上，枕头，地板上都有头发。母亲问我们是否可以提供电话咨询辅导服务来帮助她（不使用药物，因为药物使她很疲累）。

这种要求在这里绝对不是非典型的（意即典型!）。亚洲人（包括我）普遍不爱吃西药，能免则免。这点我可以理解。但这女生的拔毛癖不是简单的心理问题，她的起因含有生物因素。

大多心理和精神疾病的起因都有生物成分，无论是抑郁症，焦虑症，强迫症，精神病（显然!）等。有时它取决于疾病的类型，有时针对个人，有时取决于哪次病发（就算是同一个人，她去年发病可能是因为生物因素，但这次却是心理引起的），更多时候是两者混合。对于严重的强迫症病患，药物也许可以减轻他的症状的30-50％，但剩余的症状仍然会干扰他的生活，所以对于这部分，他需要心理治疗。

于是我向她母亲解释她需要来见医生和吃药，单纯辅导或心理治疗可以缓解她部分的症状，但不是全部。因为当头脑里的传输物质出错了，她需要药物来帮助她，而心理治疗可以减轻她的焦虑和压力，并学会应对压力和生活的变动，情绪波动等。

最好的治疗方法是结合药物+心理治疗，其实对于很多人和大部分精神疾病，结合治疗都是最好最有效的方法，可惜在现今这却不是多少地方找得到的服务。

Unusual Obsessions and Compulsions

Clinical Case Studies, Obsession & Compulsion

Over the years I’ve come across a lot of OCDs in the clinic, some have more “normal” rituals, such as hand washing, reassurance seeking etc. Most people “stick” to their rituals over the years, sometimes better, other times (especially when they’re under great pressure, or facing major life events or life transiting periods) worse. Many of them have more than one or two compulsions, but they usually have similar underlying causes (obsessions).

Recently I was introduced to this man in his mid 50s. He has a brother who suffers from chronic schizophrenia. He is quite a sensitive person, very easily upset by remarks from others. Initially he was having obsessional ruminations, but responded well to the SSRIs. Subsequently he had a relapse, and started to always feel agitated, wanting to hit people and things he see. This recurrence with violent contents stay with him for quite a few years, however, he managed to function and work.

Over the years he has seen many psychiatrist doctors but to no avail. Then he came back again, still feeling anxious he might do harm to himself or others. Few months ago when he came, the violent content subsided a little, but he is now having this urge to swallow little things (e.g. coins, keys etc). And another two weeks later, it became less about harming people, but he still wants to smash things, especially glasses, big or small, so when he notices others’ smartphones (glass screen!), he gets really anxious with the urge.

Then few days ago, he said he’s been struggling to ride his motorcycles, because he keeps imagining driver/rider coming out from another junction/corner and he accidentally hit them or get hit! So he literally slows down or even stops in every junction, and was almost hit by a car following him. “Yet I’ve to stop!” he added, even knowing he might get hit from the back.

I tried to sit down and think how they are all related, what the underlying obsession is? – “fear of harming self/others/things” is what I concluded. What say you?

 

Previous entries about “unusual” OCD:

Learn about this man’s obsession (to do with his toilet habit)

Compulsive Voyeurism 

Emotional Blackmailing

Clinical Case Studies, Obsession & Compulsion

He is in his early 30s, was diagnosed with OCD over 10 years ago, when he was finishing high school and about to start college. He was doing very well academically, and in school he was very popular.

Since the diagnosis, he had tried to get a degree, but failed all his 6 attempts. His washing, checking, chanting, counting, all compulsions occupied almost all his time that he couldn’t attend class, sit for exam, or do anything else.

But he had a very supportive family, especially the mother and the sister. For the past few years, he had been staying home most of the time, so the mother cooks, washes, and prepares everything for him. Whereas the sister allows him to live in her house, and supports him financially. They also take turn to take him to see doctor.

Recently, the sister called up, saying that the patient is asking to enrol himself to a course again in either US or Canada. She had tried very hard to explain to patient that not just she has no money to support him, but also the fact that his illness wouldn’t allow him to complete the study. But the patient was very stubborn, for him, the only way out of his current life is to get a degree first (but not to conquer his OCD symptoms). He asked the sister to get a loan, borrow money, he doesn’t care what she does, but he must get to study (not locally, but overseas). He is the center of his life and all family members’ lives, they must obey to what he says.

The sister doesn’t know what to do. The family members know him well. When they refuse him, he will start screaming and shouting, until everyone in the building and nearby know it, as if the family is abusing him. And then the next stage, he would start saying that if he couldn’t go for study, he would just end his life. And yes, he’s done it before previously, taking pills excessively on one attempt and drinking insecticides on another.

No matter how hard they try, they couldn’t persuade him out of this idea of studying overseas. They can give him a chance this time, which is the 7th attempt to get a degree, but they also know how it’s going to end up and then another cycle starts again…

They can only accept to be blackmailed, continuously, endlessly… till the day they give up on him, or he finally has the courage and wisdom to have his OCD treated.

Looking after family member with multiple somatic complaints

Clinical Case Studies, Issues & Debates

I’m not sure if it’s right to say “looking after”, because the son was never in the picture throughout the patient (mother)’s time of visiting our clinic. It was always patient’s friends who brought or drove her here for consultation. Sometimes we’d see some younger friends, some are friends of the patient’s age.

She’s one who had worked hard all her life, as a teacher, housewife, mother. Till the husband had a stroke, and she had to take care of the husband, and also take over the husband’s business. So in the day she taught in the school, after work she went to the shop, later in the evening she did housework, cooking, washing etc.

Then she had a breakdown, having tinnitus, pulling sensation at the back of head, stomach gas leading to poor appetite, consistently feeling anxious, and insomnia. Even when she managed to sleep, she would feel like she was dreaming whole night.

So she had to stop everything, and was recommended by a friend to see a psychiatrist. For the first few months she did get slightly better with medicine. But since April, she started to have more and more complaints all over her body, get weaker and weaker. Till last visit when she came, her friends had to carry her both arms to get her up and walk.

She wanted to admit herself into general hospital for a full checkup. That was also what the friends think she should have done. But the son wasn’t supportive, thought the mother was only attention seeking (according to the friends). He didn’t see the need to do so.

Few days after the visit, when I was calling the patient, the son picked up. This was the first time I heard the son’s voice after following up for almost a year. The patient passed away due to lung infection that very morning. It’s hard for me to believe that. I just saw her less than one week ago. She was weak, coughing and so, but …?!

It’s also hard for me to accept that the son was only into the picture on the day the patient died.

Back in the uni, we used to learn that some patients get themselves ill, or maintain their illness so that they continue to get attention and care from their family or loved ones (including some children who have Anorexia Nervosa maintained to keep the parents together or to get the attention from the carers; or some elderly parents who refuse to get better so that the children will look after them and come visit them).

But such theories, no, such assumptions, aren’t they very harmful? They can be lethal when you assume so and stop looking for the real cause behind those somatic and physical complaints. Was it really love and attention seeking? Or was it real physical illness, pain or injury?

So despite what he thought, if the son had brought patient to the hospital, the lung infection would probably have been detected and treated much earlier. The ending wouldn’t be the same. I wonder how the son feels.