Category Archives: Issues & Debates

Psychosis to Depression?

It all started in December last year. She presented some elementary hallucination, poor sleep at night, poor concentration and drowsiness in the day. She wasn’t hearing voices, but some knocking sounds (similar to when one is knocking the doors).

So she sought psychiatric help, was put on antipsychotic and stimulant (Ritalin, normally prescribed for ADD, ADHD or narcolepsy). Her symptoms soon got much worse, seeing ghosts(?)., talking irrationally and was then brought to general hospital, where she was put on more antipsychotic drugs.

Few weeks later, her family took her to see another private psychiatrist doctor after she was discharged. The consultant diagnosed her with bipolar disorder, based on the fact that she was once an outgoing and independent person, and prescribed her with Lithium.

Throughout the few months under the care of the psychiatrists, she took and tried many medication including antipsychotic pills, she gained over 20 kgs. She gets really depressed about her weight. For when before the first episode end of last year, she bought some slimming pills online, which acted as appetite suppressant. That was when she was 20 kilograms lighter than what she is now. She wouldn’t even want to look at herself in the mirror, when she thinks about her weight, she thinks life is meaningless. She doesn’t know how she has got here and how to find the old self. She has been unable to work for 10 months now.

It all started mild. She has no family history of mental illness. The team can’t help suspecting those slimming pills that she took, which could affect and alter her brain and nervous system. Of course we wouldn’t know whether there is a cause effect relationship for definite here (and we would never know), but it is important that you know what pills and medicine you are taking, those that you buy online, and those that you are prescribed by professional doctors. I am not saying that everyone should question his/her doctors and the diagnosis and prescription, but when in doubt or think that something is not right, seek a second opinion. Also, do not believe everything that’s said on the internet, but sometimes online resources might provide us with some basic and guidance.

Non-Binary People with Gender Dysphoria

We know there are male and female in this world, we also know that there are some people who are born a boy but deep inside feels like ‘he’ should be a girl, and vice versa. DSM-V calls them Gender Dysphoria (or Gender Identity Disorder?).

Have you heard of the non-binary (NB)?

I think this is a good read, to come to understand we never want to see the world in only Black or White, having dichotomous or All-or-Nothing thinking. It applies to gender too. There are people who feel they do not belong to either.

Yes, Non-Binary People Experience Gender Dysphoria

I’m just hoping to raise some awareness here. So that mental health practitioners can be more sensitive, and perhaps one day, the public, too.

Seeking mental health help leaving permanent record?

This thing has been ongoing from day one I started my job, it is usually with parents who are a bit concerned taking their children to get professional mental health care services, whether it is psychiatric, psychology, counselling services.

Their main concern is that this will leave permanent record/impact on the patient, affecting his/her future education and career opportunities and developments. So I have met parents who wouldn’t take their child to see us, or parents who argue over it, or parents who wouldn’t register their child’s name in our system and want us to use and call their (parents’) name instead.

I’m not sure what happens in government hospitals. But as far as I’m aware, all of the information we hold here in our systems is private and confidential. Unless we have the consent of the patient (or of the guardian for children or those that are less capable), or it is required by laws, we can never disclose anything to anyone, no matter if it’s their spouse, parent, supervisor from workplace or faculty head from college. I’d always add that if the patient has a very high risk of harming the self or others, we might need to do something about it (it’s often contacting the next of kin, which is a contact provided by the patient, who is already aware of patient’s condition and aware that s/he is seeing us).

So I can’t emphasise enough that seeking professional mental health care and help will not leave you with any permanent damage and record. If you allow the condition and symptoms to worsen, things can be a lot worse than what it is now.

However, with the patient’s consent, we do write medical reports, stating the patient’s mental condition and functionality. A medical report usually serve a specific purpose, like when one’s trying to apply for insurance (written to insurance company), trying to take a gap year from studies or work (written to his/her college or workplace), trying to change teaching location (written to ministry of health) etc. This is the part we can never guarantee. For insurance company, I would just hope that they deal with those reports professionally. And for a college, a company or a government department that holds one’s medical report, it does seem possible to leave a permanent record and affect one’s future. I remember there was a student requested to have a letter written to her favour, and few years later contacted us again to ask if it is possible to write another letter to waive off the previous letter… Surely it is not possible. Even if you’re now healthy and fit (even with 0.0001% chances of relapse), your previous record becomes your mental history, it doesn’t disappear and can never be removed that way. So, do take a deep consideration, before you request for any report submitted to anyone anywhere.

<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.

Let it go or Chuck it away?

I was looking at some psychotherapy worksheets and came across some exercises on “learning to let go“. Here are some of the exercises:

Exercise 1

On a separate sheet of paper, describe a problem that has been making you feel depressed lately. Write about it in as much detail as you can. Choose one of the methods below to physically let go of what you have written, and then do it. As you destroy your problem, tell yourself, “I am letting go of this. I will not let it depress me anymore.”

  • Rip up your paper into tiny pieces and throw it into the garbage.
  • Put your paper through a shredder.
  • Read what you have written to someone else and then give that person the paper and ask him or her to rip it up in front of you.
  • With permission and in the presence of an adult, burn your paper in a fireplace.
  • Write your problem on bathroom tissue instead of regular paper and flush it down the toilet.

Exercise 2

Sit quietly and comfortably where you will not be disturbed. Close your eyes and picture yourself in vivid detail doing one of the following:
You wrap your problem in a box and seal it very securely with strong tape and rope. Then you attach the box to a very powerful rocket. You take the rocket to an outdoor area where there are no houses, trees, or other obstructions. You light the rocket and stand back. You watch as the rocket blasts off into the sky with great speed and force. You watch it carry your problem quickly and powerfully away from you. You watch until it is completely out of sight, far off beyond the pull of Earth’s gravity, continuing to travel farther into space. As you watch it go, you say to yourself, “I am letting go of this. I will not let it depress me anymore.”


What do you think about these exercises?

According to thefreedictionary.com, to let (something) go has the meaning of

  1. to stop having something
  2. to stop trying to control something
  3. to not take action

Whereas to chuck (something) away has the meaning of

  1. to push or shove something out of the way quickly and roughly
  2. to throw something away
  3. to dispose of something

I think the person designing the exercises of “learning to let go” wasn’t quite able to differentiate between letting go and chucking away. By letting go, you don’t push things away, sometimes the thing that upsets you might even still be there, with you in the same room, but you just let go of the struggle, stopping the control… Because pushing it away, throwing it away involve a lot of control too. And most people do find that the more they try to get rid of something off their mind, the more likely the thing returns (have you tried the “try not to think of a pink elephant” exercise?).

In other words, let’s say you were holding on to your problems, if you want to let go, you open up your palm, whether or not the problems leave you, it’s not up to you, but at least you stop the struggle of holding on to it. So no, I don’t think the above exercises are helping people to let go, even if they succeed, the upsetting events are likely to bounce back (still, it works for the short terms, sometimes for the long terms). A good way of practicing letting go is being mindful, being in the here and now (you may learn how by reading this book). You may also try leaves on the stream (remember not to chuck your problems into the stream, but just let them go, let them flow down gently).