Category Archives: Clinical Case Studies

Body Integrity Identity Disorder (BIID)

Clinical Case Studies, Issues & Debates, Obsession & Compulsion, Unclassified Disorders

If you were a surgeon and someone came to you asking you to amputate his leg, for how much he is suffering deeply due to this leg and for no physical health reason, what would you do?

The thing is if you don’t do it, they may DIY. One practiced first, he got rid of part of his finger as a prelude to amputating his leg. Another one laid on the train track and let the train run over his limbs. One more shot his legs off with a gun, etc.

Just like Gender Identity Disorder (GID), “body integrity identity disorder hypothesises that a normal function, which is your comfort in how your body fits together, has gone wrong.” When they envision themselves, the image is without the limb, the limb makes them feel “incomplete”.

Do they all desire an amputation due to BIID or a sexual fetish? An obsession with amputees and amputations?

“Here was a perfectly healthy man with a perfectly healthy leg. Yet he went under the knife voluntarily, in a foreign country. He trusted a surgical team that worked under a cloak of deception. How much must a man suffer to come to this: lying by himself on an operating table, attended only by strangers, in a small, obscure hospital thousands of miles from his home in America?”

Is amputation the only way out? Is it ethical?

Look at some case studies and the history of BIID here (a long read): This is what it is like to be at war with your body – the compulsion to be free of a limb is no imagery illness

Related study: Modular cognitive-behavioral therapy for body dysmorphic disorder: A randomized controlled trial

When you get old…

Anxiety Disorder, Clinical Case Studies, Depression

She usually calls me a few times a week, especially when she first came to see us.

This is a woman in her late 70s. She has 3 daughter, 2 married, one lives in Singapore and another in the UK. She lives with her youngest daughter who is still single. Although she does her best for her mother, her work is usually very busy and occupies most of her time during the week.

This woman has problems getting into sleep, so she used to take alcohol to aid sleeping. Then she had problems with her heart arteries and had to go for coronary angioplasty twice. Since the discharge her physical health deteriorated. She can no longer move around freely like she used to be, take alcohol the way she wanted it, do her daily chores like going to the market, cooking, visiting friends, walking around etc.

She spends most of the time alone in the house, not doing much. She can’t do much work as she feel her limbs have no strength (to even take up a pot filled with water). She isn’t interested in watching TV or reading papers. The elder daughter bought her an iPad and tried to teach her playing games and using Skype to connect with her grandchildren overseas, but she gave up learning half way. What’s worse, now that she isn’t allowed to take alcohol, she couldn’t sleep at all, could only sleep for few hours taking sleeping pills.

She sees no purpose of her life, and thinks very negatively. She can’t see hopes and meaning of her life. Whatever suggestions and advice made to her, she finds excuses to dispute them (symptoms of depression). When I told her how negatively she has been thinking, and all this negativity comes from her illness, not from herself; and when she’s well, she wouldn’t behave, think and feel this way at all, she doesn’t believe it – she sees no “negativity”, she thinks all these feelings and thinking are completely normal, anyone in her shoes would experience the same cognition and emotions.

In some countries the suicidal rates in the elderly are very high, I don’t have the statistics in Malaysia, but I’m sure there’re quite a number of them suffering in silence. Asian cultures place enormous value on filial piety which includes caring for the elderly (especially parents) when they can no longer look after themselves, but still, this is not always possible, so it’s important to have a plan in mind, whether it’s to have a partner with you (not necessary a spouse) and look after each other, to live in the old folks house with the others, or get a private carer.

But while you’re still young, look after your physical and mental health, be prepared for it before you get there, and take good care of your body now so that it’s fit for you to go a long way!

PTSD – MH370 incident

Anxiety Disorder, Clinical Case Studies

He is an engineer who travels a lot for his work, and was supposed to board the MH370 plane. On that very day he wasn’t feeling well so he cancelled the trip and somehow had very fortunately avoided to be one of the victims of the ill-fated aircraft.

Though he didn’t think that way. He didn’t see himself as “very lucky”. His mind keeps playing what happened if he boarded the plane, where he would be right now, and how his family and friends would feel. Everyone keeps telling him how thankful he should be.

But he had to come to see us few weeks later. Because of what’s playing in his mind, causing him so much anxiety and fear, couldn’t sleep, couldn’t work, and of course, couldn’t travel for work.

He has worked for this company for over 20 years, but now the company isn’t understanding of his situation, and would want him to leave if he couldn’t continue to do his work (including travelling around for the projects).

Quite often we thought PTSD attacks people who actually experienced the incident, it is also possible for people who had not experienced it, but merely observed it happen (like some who got PTSD following the 911 incident), or for some who almost experience it!

Manic Stage

Bipolar Disorder, Clinical Case Studies

She’s a teacher, first came to us being depressed, presented with a complete negative outlook, lacking drives and interests, having crying episodes, and not being able to teach.

After few months of treatments, she recently called up and requested for a letter written to the ministry of education, to say that she’s recovered. During the phone call, she said she’s still regular with med, but now she has no more crying episodes, and her mood is good generally.

Coincidentally one day when she was in school and called up to check whether the report was ready, the school principal walked past her, and requested to speak to me. The principal asked whether the family has contacted us regarding the patient’s condition (negative). She said although patient is no longer crying and depressed now, she has been doing things completely out of order.

The headmistress said patient has organized a basketball competition completely by her own, without the school’s permission but under its name. She also brought a few of her students out for day trip, and only sent them home past midnight. When she meets someone new, she talks a lot, telling a lot of private details about herself. Sometimes she feels tired and will just sleep in the school storeroom. She also refused to go home after the basketball event, stayed at the court and fell asleep there at 3am when she was found by the family. She tries to spend all her time away from home, refusing to go home. She promises to anything and everything others ask her to do, and fail to keep her promises. Others can’t criticize anything about her, she thinks she’s perfect, best of the best, so whoever criticizing her, she becomes very argumentative and defensive, which is why she argued with and shouted at the principals.

The patient displayed some of the very typical symptoms of one who gets into manic phase, especially the part where they feel invincible, perfect, without weakness, and the power to keep going without needing to rest or sleep. One to add is shopping spree, a lot of them turns to spending money when they become manic, feeling like they are always short of something.

A lot of these  during treatment and recovery requires attention from the family or people around them, as the clinician may not always realize that patient has turned manic just within a 20 mins consultation – they may just seem happy, recovered from depression, instead of manic. And indeed, that’s part of some people’s personality. So the family should know where the base line is, and giving feedback to the clinician.

OCD or Body Dysmorphic Disorder

Anxiety Disorder, Clinical Case Studies, Depression, Obsession & Compulsion

“Why wasn’t I born pretty like some people?”

“What’ve I done in my past life to be born this ugly?”

“How am I going to live with this face?”

“I’m growing older and going to be even uglier. How do I live till then? Can I just kill myself?”

“Why can those people cope with their ugly look and live like nothing happens, but not me?”

This is a defaulted case who now follow up with General Hospital due to financial constraint.

She is in her late 40s, married with two teenage sons, having long standing mood disorder, very preoccupied and worried with her look, thinking about cosmetic surgery. She thinks she’s very, very ugly, and ugly people should kill themselves.

From the outsiders’, she’s actually quite tall and has a reasonably pretty face.

When she walks on the streets and see some women who’re less attractive, she’d be thinking, “how do they live with that look? Why didn’t they just kill themselves?”

She said people teased her. Telling her not to speak to them since she’s so ugly. She can’t bear people’s remarks about her look and appearance.

Her husband and two sons are very supportive, always trying to comfort her. So are her siblings. But she couldn’t get rid of this obsession from her mind. Whether she’s doing something or not, her mind consistently reminds her that she’s ugly. She also tries to do some meditation, but that doesn’t calm her down and release her stress at all.

In a conversation with her for about 30 minutes, she asked over 10 times of “Can ugly people live? Are you sure? Really? They can live till old being so ugly? They don’t have to kill themselves? They must be suffering isn’t it? Why do they bother to live?”

Then few minutes later, she’d be asking all of these questions over again. This suggests some level of OCD, but her obsessional is to do with her look. She also appears to see things very negatively, which may indicate her dysthymic mood, if not depression. In fact when I asked her a few questions, I realized she is almost completely incapable to see things positively, optimistically, and be grateful.

This was when I gave her a task – to write down a list of 30 items “Anything I have that others MAY be jealous with”, I easily gave her over 10 examples (you have healthy limbs; your husband loves you; your sons listen to you; you’re tall; you can see; you get to arrange your time; you can taste food; there’s electricity supply at home; I’m able to pay the bills etc etc).

When she started to ask those “ugly persons should kill themselves” kind of question, I reminded her about the task, and she told me, “there’s nothing anyone will be jealous about me”, couldn’t recall any of the examples I gave her few minutes ago.

So this is a severe obsession with her own definition of “ugly look” and some degree of depression. Before we help her, what  could be the diagnosis?

Is this Morbid Jealousy? – Social Media

Clinical Case Studies, Issues & Debates

We talk a lot about trust in relationships. It’s like the fundamental of any relationships, it’s probably quite easy to lose it with one small action in a few seconds, but to rebuild it can take ages, or forever.

This is a young girl born in 1990s. She knew her current boyfriend of 4-months through an online game then moved on to social media. After meeting each other, they also exchanged phone numbers and start to connect through Whatsapp.

She doesn’t want to be a control freak. But she recently realized that the boyfriend seems to be less caring. Sometimes they don’t talk to each other for whole day. She thought they should still be in the honeymoon phase, how did it end so fast? Sometimes she’d see that her boyfriend was last seen early in the morning on Whatsapp, but he didn’t talk to her, so who did he talk to at such early hours?

So one day when they were out dating, she found a chance to check on his phone, and found this girl’s phone numbers who the boyfriend appeared to be chatting with quite often on Whatsapp.

She wrote down the girl’s numbers, and added it to her phone book. So now the girl’s whatsapp account also appears on her phone. She started to monitor when the boyfriend and this girl are online, whether they are online on the same time, and whether they’re last seen on the same time (one of Whatsapp’s features, it tells you when the contact last online/seen). She’s getting almost obsessed with this checking, especially when she found that they appeared to be online at the same time so often.

At the end she confronted the boyfriend, and ended the relationship, without even finding out that the guy was really cheating. She couldn’t stand it, couldn’t stand the fact that the guy MAY be chatting to somebody else so often, and what’s most, she couldn’t stand her own checking behaviour. She knew when there is no trust in a relationship, the relationship will never work.

Sometimes I’m really not so sure if social medias bring us more benefits or hazards. When people sit in front of each other but do not look at each other, do not talk to each other, but look at the phone and chat with the persons over the phone. Is this still considered as social interaction? Perhaps it isn’t a bad thing when people use it to know more friends and to look for companions, but now people even use it to check on partners, is this still a healthy act?

Is what she does considered morbid jealousy? Can social media now function as a tool to check on partners?

(See more about morbid jealousy and a clinical case study here.)