Category Archives: Clinical Case Studies

How much can one tolerate?

Clinical Case Studies, Issues & Debates,

I’m quite sure it isn’t just me, many of us — while we read those news or stories about women (not necessarily women, could be men or children etc) being abused by their partner for 10, 20 years, and still ‘decided’ to stay with the abuser, believing that one day they will change, — we would really wonder, what make them stay? why don’t they just leave? We would sometimes even call them silly, and they deserve it for treating themselves this way, for not leaving the abuser.

Recently there’s a woman who came to the clinic, it was supposed to be consulting on behalf of the husband, who is very bad-tempered, always agitated, had in the past kicked the children, broke their heads etc. And it wasn’t just the physical abuse, he called the wife and children names, restraint their finance, controlled what they dos and donts etc., he has also been abusing them verbally and mentally.

The woman is one that’s highly educated, she knew the patient in their uni, and they’d been in a relationship since. This man is of very highly sexual desire, so according to the woman, whenever they were out dating, there was always sex involved. One night when they were making out in a park, a group of five authorities came by. The then boyfriend walked them away to deal with them, and as he returned, he told the then girlfriend to go to a small deserted house nearby with the group of men, so that both of them wouldn’t be in trouble for what they did in the park. The girlfriend started to cry, non-stop, she said, “you mean you want me to be gang-raped by them to stay out of trouble? Is that what you mean?” She couldn’t stop crying, and at the end the authorities gave up and let them passed.

Still, she became his wife couple of years later, and remains his wife till today. In the past 30 years, she had been in hospital several times after being hit by him, there were countless times of fights and abuses, even the children were so scared of their father. The boys grew into aggressive men, the girls are in fear of men.

She still thinks the medication may help him and save his husband and their marriage, even when we keep telling her (initially we hinted her, but she couldn’t get it so we just had to be direct) that the medicine may control some aggression but it won’t change him from the inside, it’s not enough to do that, and it may not even be a pure mental disorder.

Sometimes I’d think it’s incredible as of how much one can tolerate. But of course I’m not in the situation so I wouldn’t know if I would be more incredible or ridiculous if I were in her shoes.

The more you worry about having to take medicine, the more you need to take them

Anxiety Disorder, Clinical Case Studies, ,

Yes, and that’s all the point I want to make in this post.

Recently I spoke to a woman in her late 50s who has problem sleeping. She has been a patient since 15 years ago, but was never regular with medicination.

She has used all possible means to make herself sleep, taking wine, using chinese herbs, exercise etc. She just doesn’t want to depend on medicines. But she always comes back to see doctor and collect medicine when all other methods fail and she really needs some sleep.

So yes, she came back again last week. And since that visit she has called up the clinic several times. Every time asking about

  • When can I stop taking these medicine?
  • Can I start to reduce them now?
  • Will they harm my body?
  • What are the side effects and possible side effects?
  • What’s going to happen in long-term taking these tablets?

These are just some examples, under one topic/question she can ask in so many different ways and for so many times. (Eh? OCD?!)

At the end everyone couldn’t stand answering her questions repeatedly. So I’ve got the job. I told her that through our experience with many patients with either anxiety-related problems or with insomnia, the more she worries about needing to take medicine, the more she has to take it, it’s always like that. I asked her what has the focus of life becomes now?

All kind of worries about taking medicine.

The medicine is not likely to help her much if she continues to worry this way. So she won’t get well, so she’ll have to continue taking them. So she will continue to worry about taking them… … See the vicious cycle here?

So I asked her back why not continue with medicine, but shift her focus of life in something more meaningful, to how to live more healthily and happily? How about developing new interests, learning yoga, going swimming, forming new social relationships, improving familial relationship etc etc.

When she’s able to shift the focus and live more meaningfully and healthily, she may not even need the medicine without herself realising that.

 

越是担心吃药, 越是需要吃药?

当这过去十几年来一向难入眠的女士, 用尽方法却还是不能好好睡一觉, 她就会回来看医生, 通常每一两年至少来一次. 而这次拿了药回去后, 就开始不断地”电话轰炸”诊所, 问什么时候可以停药? 现在就停可以吗? 停了马上复发吗? 这些药有什么副作用? 对身体有什么害处? 一定要吃这些要吗? 等等等等. 每两到三天就来一通电话.

详细解释许多次后, 她却不见得可以明白. 下次打来, 还是问回这些问题.

所以我告诉她, 经验告诉我们, “越是担心吃药的人, 越是需要吃药, 往往也得吃得越久” 想想这么个担心忧虑法, 你的生活中心全是什么? 生活还剩下些什么?

本来吃药可能很快有效, 但是你这么一直担心, 东想西想, 日想夜想, 人可能反而更不舒服更忧虑, 结果要吃更多药, 然后又更担心忧虑, …恶性循环, 对吗?

何不就相信医生, 继续吃药, 同时好好地, 健康地生活, 培养新的兴趣, 做些运动, 建立社交生活, 改善与家人的关系等等, 在这情况些, 也许不知不觉中已经不需要再依赖药物了.

A supposed-to-be successful and inspiring insurance agent

Clinical Case Studies, Depression

He became a millionaire in his early 30s, although primarily an insurance agent, he was known with his skills in investing. He had a wife and a daughter. They went on holidays all over the world every year.

In his mid thirties, he got depressed and suicidal, due to stress of work and some other problems. He attempted suicide several times, buying ropes to hang himself, overdosing himself on drugs but was always found early enough to save his life. Perhaps this wasn’t how his life meant to be.

His family took him to temples, hoping that the power of religion could help him to recover. They were told that the money he’d earned was “dirty money” (money obtained unlawfully or immorally). So by instructions, he went to China and donated almost all his money to the temples. At this point, the wife left him. He got even more depressed, he didn’t recover donating his money away.

Recommended by friends, he seek professional help and came to see psychiatrists. After weeks of medications and a course of ECTs, he got better. On the following years, his condition was maintained with medication. He would come to see doctor once he felt unwell. He rebuilt his career and became wealthy again. He even supported his ex-wife financially, although he also soon got married with another woman. Over the years he had had another 2 courses of ECT at times of difficulty.

He even went on press to talk about mental illness. He shared his stories including his suicidal attempts and helped raising the mental health awareness in the public, telling others not to discriminate them, but also encouraging those with mental illness not to give up, motivating them to seek help actively, telling them it’s recoverable, and they have the opportunities to lead a normal and fulfilling life just like him and anyone else!

He wasn’t just a normal successful insurance agent, but also one of the most motivating and inspiring speakers in the town.

Years later, in his mid 40s, he got into some troubles. This time he didn’t come back to see doctor, he checked himself in a hotel, jumped off from the window of the washroom in his hotel room. There ended his colourful short life.

People may think someone as motivating as him couldn’t and shouldn’t end his life that way, but it’s based on a true story. When the illness hits, it really hits, no matter who you are and what you are. Perhaps for cases like this, maintaining on medication and education on relapses are utmost important, including educating patient’s immediate family.

Brief Psychotic Disorder

Clinical Case Studies, Schizophrenia & Psychotic Disorder

It’s approaching Chinese New Year and it’s this time of the year where Chinese Restaurants are at their busiest period, whether it’s for reunion dinners, company year-end party, annual dinner or casual friends and relatives gathering dinners.

She’s in her 30s, a manager in one of a big Chinese Restaurants. Past few nights she hasn’t been sleeping well, under great stress and worrying about the bookings, menus, dishes, prices, ingredients, staff, part time staff etc. After few nights of poor sleep and poor performance at work in the day, one afternoon her family found her not gone to work but crying and laughing at the same time in her room, at times screaming, and at times talking about things that they can’t understand.

Her husband and mother admitted her into the general hospital, where she was put under anti-psychotic medication and injection. Though a lot more stable and spending more time in bed, she’s still screaming and at times talking nonsense. She then started to experience some side effects from the medication and injection, drooling, tremor, stiffness.

Upon discharge from the GH, the husband decided to bring her to see us. She has to come in in a wheelchair, still drooling and having stiffness, still screaming and non-responding.

She’s believed to have Brief Psychotic Disorder, triggered by great stress from work. There’s no history of mental illness running in her family. More about the illness on wikipedia here. It’s kind of difficult to believe that people actually get psychotic disorder just merely due to stress (oh well, what can stress not do!), it’s more usual depression or anxiety disorder.

So, well, guys and girls, do make sure you are aware of how much your body and mentality can take, not to put yourself under too great stress (hard!), and more importantly, always find healthy ways to de-stress yourself (e.g. exercise, hobbies, movies, outings with friends etc)!

A doctor who can’t doctor

Anxiety Disorder, Clinical Case Studies, Obsession & Compulsion

A doctor (noun, a person), who can’t doctor (verb, to treat).

She’s on her 4th year of medical degree when she first came to the clinic with her parents. Once treated for OCD many years ago, she had recovered from it with some medication and never had any problem causing much distress since then.

She is brilliant academically since young, doing so well on most of the papers in the uni now. Now it’s towards the end of her medical degree, the problem rises.

The parents found that she’s always studying, doing revisions – but she’s already done so well and that’s not even the most important things to do now, as they should start with practices, attending to patients on the wards. She slowly disclosed that she is very afraid of meeting people, especially seeing patients. Her mind is occupied with herself misdiagnosing patients and failing to treat patients. So she wants to revise more, learn more about the theories (a good example of safety seeking behaviours – doing something to relieve her fear in the short-term, but in long-term what she does further reinforce what she couldn’t do – seeing patients).

The parents aren’t quite sure what to do. They don’t care if their daughter can never become a doctor, it’s not important, as long as she’s happy. But now her fear is killing her confidence, and they’re still hoping that she can at least complete the degree (and plan what to do subsequently, e.g. teaching, doing research etc). She doesn’t seem to be able to cope to complete her degree.

The parents can give her a gap year, “but the more she rests, does it mean the harder she can ever practice again?”.

“We can push her. But we don’t want her to think we’re forcing her then start to avoid us or lose trust in us.”

The parents were advised that what’s most important now is not whether or not she can become a doctor, whether she can graduate, but whether she can conquer the fear, have the courage and go for her practices despite the obsessional thoughts that she may fail. (Something that Acceptance and Commitment therapy could do, I’m kind of interested to know whether ACT can do better than CBT in this case.)

It is definitely not going to be easy, in fact it could be a long journey till she can manage that, but everything that can make that possible should be done.

Supportive Family VS Inconsiderate Patient

Clinical Case Studies, Issues & Debates

When this man got really depressed with suicidal thoughts, the sister took him in to live with her family in her living room, looking after him, bringing him for treatment, and giving him all kind of support and warmth.

The sister has a son and a daughter. Initially they are all very helpful towards this uncle, especially the daughter, buying him everything he had asked for, and bringing him around for tours.

Over the past few months the man has got much better, and maintained well with medication. He has some savings from his past business work and EPF. The sister has been planning to send him back to hometown where their eldest sister has a house for him to stay in and spend his life. Afterall it’s not so convenient to stay in her house’s living room with her husband and children.

However, the patient used all kind of excuses to delay the date to go back to hometown. He doesn’t want to go back.

One day, the sister saw some receipts falling out from the patient’s trousers. She went through them, and saw that the patient has been travelling to casino, almost every day, and those were the receipts of him changing gambling chips with cash, some RM500-RM1,000 which made up a total of over 10,000 ringgits worth of money spent in the casino in just the past 2 weeks. It appears that the patient has been going to gamble once he has got better with treatment and medication.

She knows her brother has a long history of gambling before he got depressed. But she didn’t know the brother has been doing that behind her back recently, while lying to her saying that he was following his friends to do sales in different states. She was disappointed and felt betrayed, with all those supports she and the family have provided him with, this is what he has brought himself back to.

Just when the sister was thinking to confront the patient, she came to know from her nephew that the patient was keeping a knife with him.

She surely doesn’t want anyone in the family to be hurt, but she is then stuck in the dilemma of how to persuade the brother to go back to hometown without confronting him. She doesn’t regret to have offered help and provided a place for her brother, because she believes that’s how family should be like, but now, she doesn’t know what to do…

Sometimes we see a lot of family who give up on those mentally ill patients (especially longstanding ones), and because we weren’t them, we couldn’t speak for them, we also couldn’t call them selfish. However, when we have those supportive and caring family members, it doesn’t mean they can then wish for reciprocal favour.

What would you do if it were you?