Category Archives: Issues & Debates

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).

Religious Experiences and Psychotic Symptoms

I was recently having a conversation in the clinic and a patient back in the time when I was working in North London Forensic Service popped up in my mind. This is a big black man with a diagnosis of schizophrenia, he also assaulted his ex girlfriend and hence was in the inpatient security ward that I worked at.

From day one I met this man, he was in good order and discipline, never exhibited any of the psychotic symptoms, abusive language or aggressive behaviour of any sort, unlike many other patients there. He was also doing an MBA course through the Open University. So most of the staffs in the team believed that he would make his way out soon, to the community, starting a new life. However, his stay was extended. To our surprise, it was due to a note recorded by a nursing staff (what each patient does every day is recorded on every shift). The nurse got along quite well with the patient, on one occasion, the patient shared with the nurse his experience of seeing white light in his room coming from the sky, and an angelic human coming to him and passing him some positive messages.

The patient surely didn’t know this was recorded in the note. However, this was used against to the patient in the court as evidence of him still experiencing psychotic symptoms (both visual hallucination and delusion) and  was not well enough to leave the ward to the community. The patient came to know the details only after the hearing, from his solicitor. He didn’t get to defend himself on his experience, which he later expressed that this was completely a religious experience, which he found amazing and intriguing, and in no way is related to mental illness. He came from a very religious family.

This was at least 4 to 5 years ago. I still remember it because until today I still cannot be sure whether that decision made by the team was correct. I am not a religious person (few years ago I was turned down as a volunteer in an NGO because I told the interviewer that I have no religion!), I can’t truly understand how a very religious person’s experience with god is like. I did complete the Alpha course in the church when I was doing postgraduate in Brighton. I met a lot of very nice persons, some I still keep in touch today. Sometimes I could be quite shocked by their presentations and behaviour during the services, but I respect that it’s their belief, and I learnt from them although I have not experienced it at all.

If it was a so-called normal person experiencing and sharing their religious or cultural experience, we might or might not believe them, but we wouldn’t think they are having hallucinations. How if a religious person with a history of mental illness experienced and shared such encounter? This is like when I worked there, sometimes we had to do night shifts, and many of those African nurses wouldn’t stay on the ward alone no matter what (we shouldn’t anyway, but there are times of emergency etc). They have had so many encounters of “ghosts” and “spirits” and scary stuff, it’s a hospital afterall, it’s easily linked to deaths (and then “ghosts”). But when this was expressed by a patient, even the African nurses would suspect that he was just having hallucination!

I can’t really have any say about these, I have experienced none, spiritual, religious, or thrilling (to be honest I’m happy and keen to experience them). We were told that we should pay attention to cultural influences and backgrounds before we “judge” someone diagnose a patient. It’s true, I now think it was wrong to hold the big man back solely based on that.

催眠是怎样的一种状态?

催眠究竟是怎样的一种状态?和平时的“状态”比起来,有什么不同?它是特殊的一种状态吗?

我们该如何测量这个“状态”?即,如何知道一个人已经“进入状态”中?当他感到放松的时候?当他对催眠的暗示产生反应的时候?当脑电波出现特定变化时?

其实很多人和我一样,一开始接触催眠,都觉得它神奇与充满魔力,也觉得催眠一定就是一种“特殊状态”。我想我比大多数人有幸吧… 去学了比较基于科学研究的催眠疗法,明白了催眠的本质。(还真的应该谢谢朋友佩雯,是她找到了英国催眠学院,和我一起报读 --虽然最后她并没有完成…)。

所以今天,我要从一个科学的角度、一个循证、基于实验与临床研究的角度,说说“催眠状态”。而这可能会让你相当失望,因为从脑部扫描来看,找不到被催眠者有什么特殊的脑部状态或所谓的“恍惚状态” (trance),它和平时一样,只是会因为暗示(suggestion)的不同,而出现不同的脑电波,比如放松的暗示产生特定的脑电波,但催眠并不是放松!在激烈运动的情况下,人们也还是可以被催眠的。或者你看看舞台催眠表演,当一个高暗示感受性的人接受暗示想象自己是一个5岁的小孩的时候,他表现出来的,也不是放松--而这并不代表他不在催眠“状态”中。

上课实际操作的时候,很多学员会很担心和他们的来访者在催眠过程中沟通,担心这会影响他们的“催眠状态”。但其实,催眠过程中,被催眠者是可以说话,可以描述他们想象的画面,可以回答问题,可以…. 而不影响他们的。

而催眠之父James Braid 把催眠定义成“单一预期主导主意或画面的集中注意力” (“focused attention upon an expectant dominant idea or image”)。没有提起任何特殊状态。确实,催眠本来就是暗示的一门科学与艺术,而不是诱发任何“恍惚状态”或特殊的意识状态。后来许多研究学家发现,任何可以在催眠中进行的事,都可以在催眠外进行(也就是平时的情况下,或只告诉他们这是关于想象的练习、或一些需要完成的任务),虽然在一些情况中没有催眠的效果可能稍微低一些。

所以从社会心理学家的角度,催眠的行为最基本的目标,在于表现得像一个被催眠者,而这是不断地被执行者定义同时不断地被来访者理解的(White, 1941)。

简单来说,被催眠,就是“扮得像自己被催眠一样”,所以你怎么理解催眠,催眠就是什么!如果你相信催眠就是放松,你就会产生相应的反应;你相信催眠会令你失忆,你就可能失忆;如果你相信它可以帮助你减缓疼痛,它就可以……

好,那如果催眠不是什么特殊状态(尤其提倡催眠是特殊状态的人,记得问他们证据在哪里),那我们怎么知道一个人是否被催眠了呢?答案就在于暗示感受性(suggestibility),即,这个人对暗示产生多大的反应。这其实是相当明显的答案,在催眠里如果你没有对暗示产生反应,那管你什么特殊状态,也没有意义。而每个人天生的暗示感受性虽然不同,但这却是可以被训练提升的(催眠技巧训练其中最为进行大量研究的是 Spanos 的 Carleton skills training programme, CSTP)。

所以到头来,催眠的过程,就决定于被试者的态度(积极,消极,被动?)和动机意愿、还有他们对于催眠的理解(被催眠者应该扮演什么角色?)。它并不是什么特殊状态,但很多时候,把普通的一个过程贴上“催眠”的标签,却可以带来更显著的效果(有此好处,why not?)。

N.B. 本文参考 Donald Robertson 的 The Practice of Cognitive Behavioural Hypnotherapy 一书。作者乃是英国催眠与催眠治疗学院的创始人,也是我的导师。

Medicine side effects vs the illness itself – Which is worse?

The illness itself, or the medication side effects – which is worse? Perhaps people who are taking medication can share their experience?

I’d always thought it’s the illness. Of course, it’s something that you don’t get to choose and can’t control. To many people, it just happened, then their lives changed.

So whenever people complained about side effects of medication (e.g. many anti-psychotics cause so much drowsiness that patient can sleep all day; or some antidepressants cause dry mouth, constipation etc), I’d tell them the gains are much greater than the losses, or that you get more advantages than disadvantages out of it. So tolerate with it, and it’s going to fade away anyway  (when patient gets better the dosage can be reduced, or maybe when their body get used to the drug then the side effects diminish!)

Till this morning when I saw this young girl. She was completely disorientated, perplexed, restless, with limited response, almost zero eye contacts and tremor hands when I held her. It’s not possible to hold a brief conversation with her, leave alone doing psychotherapy. I knew it’s a psychosis case, but in my mind i kept wondering why her presentation was like that. It’s hard to believe she was once a happy and easy going girl, doing well in the schools, despite her kind of difficult family background.

Then I recalled what her auntie told me in the emails – the medicine she was taking from the hospital following the first onset and admission couple of weeks ago. Suddenly it became much clearer. I have seen this quite many times, most of them are patients who were already taking medicine when they first came to us. It’s not the presentation of the illness itself. It is the side effects of the medication (you can perhaps email me to ask what drug it is; I think to many people, the answer is obvious) given by the GH.

If this were one of my family members, I wouldn’t want it. I’d rather to have her having difficulty sleeping, some hallucinations and being a bit paranoid – ok, this might be equally bad I can’t deny it. But It’s really difficult. Isn’t it?

What would you choose? Do you have any experience tolerating side effects of medicine that you take?

N.B. Don’t get me wrong, I’m not asking everyone to stop their medication due to the side effects. Most of the time I still think that medication would be beneficial and helpful despite the side effects. However, if you suffer from intolerable side effects (another common one from anti-depressants – sexual dysfunction, ranging from changes in drive, arousal, erectile/orgasm problems, satisfaction), do speak to your consultant, quite often there are substitutes.

Introducing “Listening to Prozac”

By Peter D. Kramer

By Peter D. Kramer MD

Last year I bought this book for RM5 from the Popular RM5 book fiesta (by now you probably have realized that I bought a lot of books there, and yes you’re right, I do spend time to go through those non-fictions and try to pick some treasure!). It is written by an American psychiatrist.

This is really a book that I’d strongly recommend, to … certain people, like me – who know quite a bit about psychopharmacology, but not enough, not much about their history – who have seen how all those drugs are used practically and in day to day life, but not read much about the facts and dark stories behind them. It is an old book I have to say, but I learnt so much about the older generation anti-depressants (tricyclic like Imipramine, Monoamine Oxidase Inhibitors which is not so common these days) and those that I’m so familiar with, i.e. the SSRIs (e.g. Prozac (Fluoxetine)!).

It made me think a lot about how those so-called legal drugs are prescribed, used and misused, how it can change a person from the inside (personality! how they see themselves all their lives simply changed after they started the medicine!), how vague the definitions of psychiatric diagnosis are, how tiny the difference between well and unwell could be etc etc. It may not be a book for everyone, I’m sure some might fall asleep reading it, but it’s probably the first time I’m reading such old book (published in 1993 -before I attended elementary school :P , some updates in early 21st centuries at the back) but still get so astonished and learnt so much!