Category Archives: Treatment Approaches

Physical vs Mental Health

Issues & Debates, Treatment Approaches

Background: Depression Following Stroke

When the patient was first admitted into the hospital due to stroke and was subsequently staying there to do physiotherapy, the doctors there had never wanted him to take any of those psychiatric medicine, despite being told by the wife that he has had a brother who committed suicide due to depression. The reasons given is that those medicine was causing him drowsiness and tiredness, so he’d be spending so much time in bed that he couldn’t do his physiotherapy and necessary exercise.

People often care only about their physical health, whether any part of their body is aching, body temperature is within the healthy range, diabetic or not, blood pressure is not too high, etc etc. This thought is possessed by many including clinicians, health professionals, doctors etc. So quite often when patients are admitted into hospital, for for example, gastric, intestine bacteria infection, fever, cancer, etc, they are advised by the clinicians to stop taking their psychiatric medicine.

So what happened when they stopped their antidepressant, anti-anxiety and/or anti-psychotic medicine? What happened when patients get slightly better in their physical health?

They can’t manage the stress and cope with the recovery process related to their physical illness. Some kick off, shout, throw things, self-harm, hurt others, restless, unable to sleep… They deteriorate so badly that they be treated for their physical illness. Some may be okay, but once they get recovered in their physical illness, their mental illness is again unmasked and has become even harder to treat as they have stopped medicine completely.

A lot of people need to take anti-anxiety/anti-depressant medicine to cope with their recovery from cancer, stroke or other illnesses. There is no point to recover from a stroke, being able to talk, mobile and function more normally, then have the patient to jump off the building or sea and lose their lives. Whether or not he is diabetic, immobile, body aching, has had stroke, gastric, cancer, high blood sugar… … if this person has had mental health problems, he then will have to take medicine for it.

Insomnia & Poor Sleep

Clinical Case Studies, Treatment Approaches,

This is a patient with longstanding sleeping problem, not that he isn’t able to fall asleep, but he can’t sleep for many hours, is usually awake at about 2-3am, then has to lie on his bed till 6-7am.

He struggles so much with sleep for the past 30+ years of his life, now in his 60s. With medication his problem improves, but when his body starts to tolerate with the medicine, he will struggle to sleep longer again. To him having a good sleep and being able to sleep till morning is the most important thing. He’d rather over sleep and be late for work. He’d exchange anything for a good sleep till morning.

To make sure he’s able to sleep, he stays away from coffee, tea and anything that may lead to restlessness or insomnia for all these years. Sometimes he does feel too tired able and blurred in the day so he’ll have a lie in. But he doesn’t fall asleep, isn’t taking nap.

Advice given that he shouldn’t even have a lie in, as sometimes people are resting and they fall asleep without realizing it. Secondly, to learn one important fact that “if you can’t fall asleep, then just let it be”. In fact lying down on a bed is also a type of resting, you get to relax your muscles, body, and eyes. The only part that doesn’t really rest is perhaps your brain, but it doesn’t and will never rest completely anyway, whether you are sleeping or not. So accept the fact that your brain doesn’t want to fall asleep, let it be, just relax yourself. Do more exercise in the day, engage in more physical and mental activities in the day, get yourself tired.

 

What to do if I can’t sleep (well)?

  • Make sure you don’t sleep during the day, not even lying down and rest
  • Engage in more mental and physical activities in the day
  • Avoid tea, coffee and anything with caffeine in it. You may have tolerated it well in the past, but no longer now.
  • Accepts that lying down is also a type of rest, your muscles, body, eyes are all resting.
  • Accepts that it really doesn’t matter if you can’t fall asleep. Just continue lying down, relax and enjoy the sense of it.
  • Don’t be afraid and worried that you won’t fall asleep. The more you worry the harder you fall asleep.
  • You’re not alone. About every 4 out of 5 patients who visit our clinic has problems with sleeping. Some have not slept properly for few weeks. Some have not slept at all for 3-4 days.

What’s normal development?

Issues & Debates, Treatment Approaches

He is the eldest of his parents’ three sons, showing some delayed developmental milestones, usually withdrawn and unable to focus. By 5 or 6 years old, he could only use short sentences. He was sent to attend special school.

When he was 18 years old, the mother and his younger brother came to our clinic. For the past 2 years he had become more and more rigid, sensitive, with aggressive outbursts. Over 3 months mother was putting medicine in his food and drink and he slowly got better.

Few days ago the mother made a call to us. She said he seems to get more argumentative, bad tempered and demanding. He wants to learn driving because many of his friends are doing so. He wants things that his peers have. He is getting defensive when family speak to him.

Mother asked if the medicine can no longer control his illness, if her son is getting more and more ill. I explained to the mother, her son is at a stage where it’s normal for them to be argumentative, defensive, disobedient, rebellious, influenced by peers, having strong ego … What kind of expectation is she having? A son who listens to her completely? Never says no? Quiet and submissive? …?

We quite often overlook the stage of normal development and the environmental influences, and focus too much on the problems someone has. He’s bad-tempered, she’s irrational, he gets jealous all the time, she is disorganized, they’re lazy… But perhaps that happens to everyone at that stage of life, perhaps that happens to most people if they are under that level of pressure, perhaps there’s something else going on in that person’s life but we just don’t know, …

We don’t want to use medication to control one’s behaviour so much that this person loses the self, so much that this person lives how we want them to live but not how they want to live.

Part II: Social, Peer & Exam Phobias

Anxiety Disorder, Clinical Case Studies, Issues & Debates, Treatment Approaches

Part I: Social, Peer & Exam Phobias

Few days later, I spoke to the mother again. They went to a Counselling centre in town. The patient opened up in the counselling session, saying that she was under great pressure and worried about various things especially her parents financial abilities.

She has always wanted to learn cooking and baking. So she’s chosen the school that she’s attending now, because this school has the course she wanted, and she can join it straightaway after Form 3, though it’s the most expensive course. The parents didn’t mind it, as they want their daughter to be happy.

The parents bought a new house earlier this year. They will be paying 3 times the house loan of what they’re currently paying. The parents are happy-go-lucky people, they know it’s going to be difficult but they were never too worried about it. Yet this eldest daughter of theirs is so concerned – whether they can afford paying for the new house and also for her expensive course. She still has younger siblings, she thinks, maybe she shouldn’t complete her Form 3 and go for such expensive course.

She also has a very traditional grandmother, who dislikes her furthering her study in cooking/baking. The grandmother always criticizes her mother in front of her, and scolding the mother for allowing her to study in this course which leads to a career that doesn’t earn money.

She listened to all these comments about her decision, is upset that her mother was scolded because of her. Somehow internally, she knows if she couldn’t pass her exams or doesn’t attend her exam she will not be able to proceed to the cooking course. And this is what she wants, or maybe not, but for her family.

We overlooked all these underlying concerns, worries and feelings. This is somehow true in psychiatric settings, especially outpatient settings. I’m not saying that medicine is not helping, obviously I’ve seen a lot of people benefit from it (especially when the condition is critical), but sometimes we easily overlook things that may not be solved by medication. Comparing to medication, in this particular case counselling and psychological treatment have shown a much better outcome.

Depression & ECT

Clinical Case Studies, Depression, Treatment Approaches

“I’m single. I don’t want to trouble my family. Let me end my life.”

She repeatedly stressed that she’s single (I’m quite sure when she was well she never minded it). She seeks for all different kinds of methods to end her life. But because of how caring and loving her family is, she is still living, and maybe to her, suffering. She has had at least one attempt of suicide in the past in which she cut her wrist.

This is a woman in her 60s, not married, currently staying with her nephew and nephew’s family. Her sister used to look after her, and live with her, but over months, sister was upset by her, affected by her negative energy and mood, and has temporarily withdrawn from her role of looking after her. She has a lot of very negative thoughts, lacking drives and interests, just feeling lazy and not wanting to go out, see anyone, do anything. She has lost interests to those that she used to find pleasurable (Remember I said in “Depression & Suicidal Risk”? Lacking interests & drives!)

I spoke to her nephew and nephew’s wife quite a number of times. They are both very empathising. They are feeling pretty helpless, not knowing how to look after a severely depressed auntie. Sometimes they have to lock her in the house or bring her everywhere with them, being worried she will commit suicide if she’s left unattended.

She’s still on quite a high dose of anti-depressant medication, she’s very regular with it, after all these years. Sometimes even the family is a bit doubtful whether the medicine is helping, the patient is the one that knows clearly things are going to be so messed up and so wrong if she stops it. But it seems that the medication has stopped working for her, as she grows more and more depressed and negative.

Consultant psychiatrist suggested Electroconvulsive Therapy (ECT) for her. On the day before her ECT, she jumped off the sea, and perhaps she’s meant to live a lot longer, a passerby saw her and dragged her back. She has had two sets of ECT done about 4 years ago. This does appear to be the fastest and perhaps the last resort for her current condition. It’s a controversial treatment, yet I’ve seen people benefited from it. Memory loss is one common side effect reported, yet perhaps it’s best for the patient to temporarily forget certain things?!

I’d say if ECT is likely to do more good than harm then people should really go for it, but it should always remain as the last resort, after patients have tried all other therapies.

 

Subsequent follow up of this patient: Can we allow a severely depressed patient to make the decision?

Behavioural Experiment for Social Anxiety – Walking a Banana

Anxiety Disorder, Treatment Approaches

I have long heard about behavioural experiment in the CBT. We used to have a guest lecturer in the uni who shared quite a lot different types of behavioural experiments she has done throughout her life as a therapist. One of them that I remember quite well was working with a woman with OCD (Obsessive Compulsive Disorder), who was very obsessed with hand washing. And in short what they did, was putting their hands into the toilet bowl, reaching the water in it! then what? Without washing hands, they used their hands to eat!!!! It was like OMG, REALLY?! But yes that’s what was done, the therapist was going it with the client, and really, nothing happened afterwards, and the client realized her obsession with hand washing really wasn’t rational (of course this is kind of simplified, you should assume that they have done a lot of work in identifying irrational/negative thoughts, doing relaxation techniques and also discussing the rationale of designing such experiment etc).

Guess what I did today? Hehehe, oh the title tells – I walked a banana in Croydon, London. YES I BLOODY DID IT. Me and Krishna did it together, initially we didn’t quite get into the state, and we were laughing and stuff. But after that we realized we really need to be so serious, so people know, yea we’re serious about it. Believe it or not, so many people looked at us! Some people asked Pei Man (she was following behind us and taking video). Some just stared, some tried to look covertly Haha. We went into the McDonalds, and obviously people were looking. I saw a guy taking pictures of us. I heard the staff saying “people coming with a banana on the string”. At the end a guy approached us and asked whether he could take a picture, even asked for their names and age. LOL. The staff in McD also asked us. We left, another black woman on the street was like “what’s this for?” Another two women walked past and we could overhear them saying “look at these stupid people”. Hahahahaha. Stupid, I kind of enjoy this stupidity!! There were also quite ignorant people, who walked past like nothing happened. In front of the hotel, there were 4-5 teenagers, some just stared at us, while one who was obviously more extrovert approached us, and patted on Bobo (Krish’s banana, and my banana is Nana), although another friend of his almost gave Bobo a big kick!

Okay up to this point you probably going to ask me, why were we doing this for? The idea came from Donald, our lecturer on the hypnotherapy course, who treats people with social anxiety. Oh yea this was one of this behavioural experiments with his clients. The idea is to do something and make people really look at you. In fact some people are often so self-conscious, being worried about what other people think about them, whether they look stupid, look anxious or too awkward etc etc. With experiment of this sort you probably find out the reaction could be quite different from what you think. But even if it was what you think (that “you look stupid”, “you look so anxious”, “you look like an idiot”). Those are just their thoughts! So what?? It’s nothing catastrophic. Let them think what they want.

It’s like people who are overly anxious doing public speaking, worrying they might make mistake. Well okay there are a lot of thing you could do to present your best, but what if you make mistakes? What if… you make a mistake deliberately?? Laugh it off? Chances are you are going to survive it anyway, why worry? This is my way of seeing it, though Don said people can test by making a mistake deliberately and see what happens, see what’s so catastrophic about it. Of course this doesn’t mean that I’m no longer anxious, and no longer worried in public speaking, but when you really analyze your reason of being nervous, rather than focusing on hiding your nerve/anxiety, the results are most likely going to turn up better.

I also forget to mention, at this very same day when Don realized we’re going to do his banana walking experiment, he was also interested in joining. So I gave him a string and he got himself an apple to walk, but that apple fell off. And what did he do?! – he went to a toy shop, got himself a pink piggy soft toy, which could fart if you sat on it – and he MADE the shop assistant showed him how the pig fart in front of a long queue / big crowd of shoppers. Then he put the string on the big pink pig and walked it back……. You probably going to say he’s such a weirdo. Hahaha well he is… not. I suppose it can get addictive, so additive. But to go to shop and ask for certain things to be done, is part of assertiveness training (and other things). And doing all those things can get quite addictive! Well, in fact at the same time you’re also helping your clients and being a problem-solver.

I just have got to say, I have really enjoyed it. And Krish did too – know what? She’s a mum of two, and she was as passionate as me if not more, in stuff like this. Hahahaha.

N.B. The content was first posted at huibee.blogspot.com by the same author.