Category Archives: Clinical Case Studies

Learn about this man’s obsession

Anxiety Disorder, Clinical Case Studies, Obsession & Compulsion

WARNING: You may not want to read this while you’re eating.

At first it seems a bit difficult to diagnose what problem he has, other than not being able to sleep well for the past year.

He’s working in KL on his own while all his family are in Penang. He has one daughter and one son, both married with children. He said that he’s in good contact with all the family members, and he goes back to see them often, sometimes they would also come to see him. He is cheerful, and seems very sociable.

Apart from his sleeping problems (the reason he came to our clinic), he also kept mentioning that he has constipation. We’d have thought that this is not directly related to mental health problems, but he said he has had check up, test and scans, and was told that he’s absolutely fine. So why constipation?

When he started to talk about his problems in passing faeces in details, the answer slowly revealed. He said people should at least pass 1 kilogram of faeces every day, not anything less than that, “this morning I passed only 200 grams, that is not good enough, and that would keep me worried all day” (Please don’t ask me how he measures that, I hope he’s just checking his own weight before and after the business. And by the way, how does 1 kg of faeces look?). He does everything he can to improve his bowel movements, but still, he thinks he has constipation.

And it’s kind of difficult for him to have insight about his obsessions. Now he’s being treated for his insomnia, and secretly and hopefully, also for his OCD.

Though we have come across and read about all kind of obsessions, this is still quite distinct and… peculiar.

How much courage does one need to jump off a building?

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

There are various ways people can use to end their lives, but when it comes to jumping from height, it always makes me wonder how much courage it requires to take that step, and do they regret as they are falling down before hitting the ground? Are they terrified? Do they think about going back?

This is the third patient in the past 3 weeks.

The first two both were longstanding depressed patients, both had attempted suicide in their history, so though it was heartbreaking, at least it didn’t shock us as much as the one who chose to jump off from an apartment far away from his house this week.

He had been diagnosed with paranoid schizophrenia for years. Never a negative person, he could function well in work and with family, maintaining with medicine.

Nobody would have anticipated that. Not even his caring sister. And with the method he chose to terminate his life, he does show how determined he was.

So never think that people with depression are the only ones who would attempt suicide.

So never think that those who think about suicide would always mention it before the attempts.

So never think that long-term mentally ill patient without previous suicide attempt are very unlikely to commit suicide.

Also, never think the reason everyone suffering from mental illness end their lives due to their mental illness, there are still various other possible explanations, and suffering from mental illness, is just one of them.

Please give yourself a second chance. Malaysia suicide hotlines:

The Befrienders
03-7956 8144/ 03-7956 8145
www.befrienders.org.my

Life Line Association Malaysia
03-4265 7995
http://lifeline.org.my/cn/

Agape Counselling Center Malaysia
03-7785 5955 / 03-7781 0800
http://www.agape.org.my

If you come across someone who’s suicidal: https://huibee.com/2020/05/somebody-you-know-is-suicidal/

Placebo effects in psychiatric drugs?

Anxiety Disorder, Clinical Case Studies, Issues & Debates

I understand a lot of anti-depressants, anti-anxiety and anti-psychotic drugs that we’re using today have had quite a long history, we’re talking about a few ten years. But is it possible, that what works in some of them, is not the active ingredients in it, but the fact that it’s prescribed and taken, and patient’s belief in the pill(s), so the patient feels better? (If this definition is not clear enough for what placebo effect is, please check google here.)

Recently we have this typical anti-psychotic drugs ran out in the whole of country (i.e. nowhere you can find this drug, unless some expired ones in an old patient’s drawer). So having no choice the psychiatrist has had to replace it with other drugs, drug A, a stimulant that works the same but will be more stimulating (so patients can’t take it at night to avoid sleep disturbances) or drug B, another anti-psychotic that’s more sedative (suitable for patients to take at night).

Most of the patients are fine after the replacement of this old anti-psychotic drug, whether it’s with drug A or B, some with other medicine more applicable and appropriate for their current situations. Except two patients.

They both claimed that after replacing the medicine, they find it difficult to fall asleep (a common symptoms of anxious people: difficulty getting into sleep). When we tried to explain that the old drug is non-sedative (not assisting you to sleep) but also non-stimulating (not making you more awake/alert), and that 95% other patients who’ve had the medicine replaced found no problems, these two patients insisted that they need this old anti-psychotic drug to sleep.

In fact for one of the patients, the psychiatrist has come to realize that she’s no longer present with agitation or any psychotic-related symptoms, and so has replaced it with a tranquiliser, which should in fact be sedative and make her sleep better, as compared to the old anti-psychotic drug. But still, she struggled.

As a psychologist, I’d always observed and noticed the psychological effects of psychiatric drugs. How’d you explain this? Can we start to prescribe some placebo to help patients to sleep better?

Can we allow a severely depressed patient to make the decision?

Clinical Case Studies, Depression, Issues & Debates

She’s gone, on Tuesday (more about this patient here: Depression & ECT).

As written on my previous post (link above), she underwent a course of six ECT and got much better. During the past year, she did voluntary work, travelled around (to South Africa, Japan etc). Every time she came back for follow up and saw me in the clinic, she had this big wide smile on her face, including the last time I saw her, last week.

Past few weeks she’d been calling me a lot, since her house renovation, which put her under some pressure. Then slowly all her negative thoughts came back. Lacking drives, lying down a lot, negative and suicidal thoughts, all returned, like how she was before the course of ECT last year, despite the increase of her anti-depressants.

She started to ask if she should come for another course of ECT. We kept helping and supporting her, and supporting her extended family to support her. Last week she asked again. And finally the consultant psychiatrist had also agreed that she should undergo ECT. When she was told that she could have it, she became hesitant and indecisive again. So she came for consultation and was told that she could take her time to think about it, and if she wanted it, she could call us and we’d arrange it (of course we also arranged what she should/could continue doing every day).

Few days later she rang me in the clinic, telling me she’s feeling much better, just did voluntary work in the temple. She was feeling quite positive and thought she’d make it. So much relief in me.

Few days passed and I was busy. This morning I heard from her cousin. She was gone, with medicine and half a bottle of herbal liquor. When they found her (the patient lived alone in KL, her family couldn’t reach her on phone all weekend long and came all the way from Malacca to see her), she was still conscious, but with white foam coming out from her mouth. They called the ambulance. But the patient refused to get into the ambulance. The medical staff said it’s against the law to force someone into the ambulance, so they left! The patient went back to sleep later and …”rests in peace”, as the way her cousin put it.

Is it right for us to leave the decision of whether to do ECT with her? Should we be the ones who make the decision for her? Could we be the ones?

Is it right for the ambulance staff to leave, just because the person refused to? Despite knowing that she most probably need a stomach washout, is it right that they let her make the decision herself?

Is she capable to make these decisions? She’s severely depressed, despite the medication, could she judge and reason then decide?

Practically I’ve always been told that we can’t really make any decision for patients, all we can do is to explain the options, treatments and procedures to the patients and family (if applicable). But how if they’re single and suicidal, with not much familial support? Are there exceptions? Can we push them to go for ECT?

Online Dating Addiction

Clinical Case Studies, Issues & Debates, Unclassified Disorders

He said at first he was just going on online dating sites as he was feeling a bit lonely (though he didn’t use the word “lonely”, that’s just how I interpreted it). He is in his 30s, works in bank, bought a house last year and living on his own. He has rather limited social life as his work occupies almost all his time (13-14 hours a day, sometimes more, weekend too!) 

He went on multiple dating sites to increase the chance of meeting “the one”, some popular sites and some not so, but he’d make sure there’re at least some [female] users in the country (well, it’s still not so common a thing in Malaysia). He said some dating sites had literally no female users in his area.

Over the months he chatted with so many girls. At any one time he could be chatting with 3-4 girls on 2-3 different dating sites. “As long as they responded. But I do filter – religions, ethnicity mainly. The rest, it doesn’t matter, but I do check their pictures. I don’t talk to those without pictures. Who knows you may be talking to an old man or…”

But to my surprise, when I asked how many he had met in person. “None. We’d always mention about meeting in the future, or doing something together. But I never do it. Initially I thought it was due to my work. Well, at least that was the excuse I gave myself and them girls. But slowly I realized I had no intention to meet any of them.” ??!!

“I only enjoy talking to them, flirting with them, perhaps imagining how things would go with this particular girl in the future (then with another girl in “another future”). They fill my time, which isn’t much, anyway, due to my commitment to work and house loan”

“I feel good. I laughed genuinely, and I’m sure I made them happy, and they’re also laughing, giggling in front of the phone. It uses up my leisure time and I constantly feel accompanied, day or night. This one stops writing back? Fine, there’ll always be next and next, next one. So my problems of being alone and not having much social life are solved. Why still bothered to meet up? Especially it probably would often lead to disappointments anyway.”

“I know I’m not the only one being this way. Some people met up and found someone that they’d regularly see, but they continued to surf the dating sites and flirt with others. Why stayed committed when you have so many more constantly waiting for you [in your phone]? They said this more often happen in guys, but I think the girls are doing it, too, but perhaps in a more discrete way.”

I didn’t bring up the word “addiction”. I’m not even sure whether this is ordinary or unhealthy or… At the time of writing he’s still on dating sites, happily. Hopefully I get to come back to update this post as of what happens to him in the future…

Here are some of the interesting experiments done on online dating sites:

Pretty woman with ‘worst dating profile ever’ still got dates

Cruel Intentions: How I Hacked Tinder And Got 2015 Matches In Under 17 hours

OKCupid: We Experiment on Human Beings!  (The site did various experiments on its users!)

Paranoia? Anorexia? Body Dysmorphic Disorder?

Clinical Case Studies, Obsession & Compulsion, Schizophrenia & Psychotic Disorder, Unclassified Disorders

It was first suspected that she has Othello Syndrome (morbid jealousy, case study here). When she came, she just split from her boyfriend and was having suicidal thoughts. The mother said she was constantly checking on the boyfriend, his phones, his whereabouts, his friends etc (similar to the case here). She was also hearing voices, very bad-tempered, having very unstable mood and insomnia.

Few days after she started taking anti-depressant and anti-psychotic medicine, she called up and asked if she could take weight loss pill “L*** B***”, she said it helps to lose body fat only, will not lead to diarrhea. So she was told ok to take this weight loss pill along with her medicine.

Few weeks later, the mother called and questioned us, why we allowed patient to take weight loss pills. Mother said patient has been taking the pills, along with laxative pills (for constipation) excessively, she could take over 20 tablets a day, and purging herself (to vomit). She’s in fact only 43 kgs when she first came to see us, she doesn’t need to lose any weight. But our position is to tell patient that the weight loss pill is safe to be taken with our medicine, but that’s obviously based on the fact that patient is taking it accordingly. It’s not our position to advice patient regarding her weight (we can do so, but we can’t stop her). It also important to note here that if the pill will cause diarrhea or vomit then it won’t be suitable to take with medicine.

So mentally she’s got much worse, as she wasn’t regular with the medication, plus all those means that she’s using to lose weight, her body probably couldn’t take in any of those medicine. She got more sensitive and paranoid, always thinks that people are talking about her, especially when she is out. At one point they had to admit her into hospital for drips as she was taking too much of those pills. After the discharge she finally realized what harms those pills are doing to her body and brain.

So she stopped purging and trying to lose weight. She’s given up on the idea of losing weight. But few days ago she came back for review, now she’s considering rhinoplasty (plastic surgery on the nose)! Almost obsessed about going for it…

Paranoia, anorexia nervosa and body dysmorphic disorder are undeniably inter-related and co-morbid, but does one move from one to another?