Monthly Archives: September 2013

Teenage Schizophrenia

Clinical Case Studies, Schizophrenia & Psychotic Disorder

She comes from a single parent family, with three younger siblings. Her father runs a stall in market, has to look after all four children and a grandmother of old age. She stopped schooling at the age of 14, being unable to continue due to her mental illness.

This is a girl suffering from schizophrenia. She is paranoid, hallucinating and very easily agitated. She spent her day pacing the floor in the house, talking to herself, and doesn’t sleep at night. When she sees her younger sister, she will be abusive and swearing at her, saying she wants to destroy her sister’s face, saying she couldn’t accept that the sister is prettier than her (the sister is only 4-5 years old!). When she looks into mirror, she gets angry and will be cursing again. She uses the meanest words despite her young age.

Her father tries very hard to do his best for her. He does all the washing, cooking, tidying up etc for her. But sometimes he has to protect the younger children. One day they had an argument and the father even slapped her twice. The father was later regretful, understanding it was her illness not her, but also feeling quite lost not knowing what to do with her. He wanted to move out with her so that the younger children are not negatively influenced, but who’s going to look after the younger ones?

When her father first came to the clinic she had already been suffering from Schizophrenia for at least 2 years. Over months the father consulted psychiatrist on behalf and giving her medicine, she takes them willingly not knowing what they were for. She gets better and is able to start some tuition classes although not the mainstream education. She recently gets so much better that she could come to consult doctor with the father, still agitated, paranoid and abusive, but much better compared to 3-4 months ago. I think this is also a good example of family consulting doctor on behalf that brings a satisfying outcome (see post: Schizophrenia & Consent to Treatment).

What happened to the patient later? See here: Leading a Normal Life after Recovery? 

Pathological Lying

Clinical Case Studies, Obsession & Compulsion

He seems a bit secretive, not willing to talk or disclose much about himself, and was consistently looking at his phone (well, this is pretty common nowadays) when he first visited the clinic.

He is at his 30s, was divorced and is now in a new relationship. He started lying since young, and over time it became a habit, he started to lose control, and lies even when he really doesn’t have to, when he and no-one else gets any benefits from the lies. He just has to lie, he can’t help it.

At this point of his life he realised it’s problematic, he’s having frequent rows with his current girl friend (though the end of his first marriage had nothing to do with his pathological lying). The lies he’s telling is definitely affecting many aspects of his life, relationships, works, family, …

Do you think others can help him? Counselling? Psychotherapy? Medicine?

If he can come to seek help, being honest with the clinician and throughout the treatment process, then does he still need treatment? Well, he can behaves and talks honestly, why still come for treatment? If he can’t be honest, then how are we going to help him?

Perhaps for many pathological liars they don’t care about upsetting others due to their lies, but if this carries on in their lives, will they eventually start living in their little worlds, having some levels of delusions about their lives, and become paranoid, delusional, even schizophrenic …?

Who should be the one taking medicine?

Clinical Case Studies, Depression

About half an hour after she and her husband left the clinic, she made a phone call, saying she wanted to speak to the doctor. She asked how serious her “illness” is, what diagnosis she has had, whether she is going crazy etc. At first I thought she was worried about her illness and about not being able to recover. So I explained she just got mood disorder, sometimes a bit harder to control her mood and emotions, but it isn’t serious, and will recover taking the medicine and maybe with some self-help.

However, after my explanation, “but my husband said I’m ok, I don’t have any illness. I told him I need to take medicine, if I’m ok, why do I need medicine?” She, in an almost screaming voice, said this. I volunteered myself to speak to her husband, telling him the importance to have supportive family members in the process of recovery, and although not serious, his wife does have mood disorder, so please try not to upset her, but give her full support and care she needs.

Few days later when I spoke to her again, she has got much calmer having the medicine running in her body. She said her husband still shouts at her, but she has complete no interest in having argument with him now. One thing she still doesn’t understand, her husband is the main reason she needs to take medicine, or else she’ll probably be fine. But why isn’t husband the person who should be taking medicine?

I have encountered quite a number of cases like this, usually the woman who comes for consultation and treatment, quite often due to their partner who is very bad-tempered, easily agitated, or having some not very severe mental health issues, unfaithful, having another family or missus outside etc. The problem of the woman in fact originates from the man, but then the problem continues to develop and the woman becomes easily agitated, paranoid, suspicious, disorientated, … … then she’s coming for treatment!

Though here it’s still very important to emphasise, that there are a lot of women out there who cope with those kind of problems without developing mental health problems themselves, and able to go through it with their resilience.

Epileptic Personality

Clinical Case Studies, Depression, Obsession & Compulsion

She brought a big blue bag into the consultant room. Once she sat down she opened the bag and started to show all kind of handcraft to the doctor, some knitting, some lanterns done with straws, a lot of very neat and tidy letters and writings. At the same time she was talking, or should I say, grumbling about her life, her family, her church friends.

She’s helping her mother who runs a coffee shop, so is her brother. Sometimes she sees people chatting with her brother, laughing happily, she’ll walk away. She wonders, “why never I feel happy? I don’t want to see them being happy. I can never be happy like them.” In the letters that she wrote, she hopes that people will come to talk to her more, make her happy.

But she’s always grumbling. When she rang her younger sister, all she does is grumbling. Her sister is used to it and so she will just listen. She likes people following her way, she knows it, and is still very insisting.

She’s still having fits and seizures, despite taking 10 tablets of Epilim 200mg each day. When it happens she will just stop what she’s doing and lie herself down.

Rigidity, stubborn, obsession, repetitive, enjoy doing works that require a lot of repeating, very tidy, jealousy, depressive, dependent, avoidance, low self-esteem, feeling of not in control of own life … – some very common behavioural and emotional changes in persons with epilepsy, which are usually carried with them for the rest of their lives…

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?

Depression & Suicidal Risk

Clinical Case Studies, Depression

She has a long history of depression, but due to financial constraint, has stopped following up in private clinic and gone to the general hospital. After few months she came back to us, not being well, but still not that bad, able to smile and chat with others a little bit.

Few days later she made a call to us, saying she’s feeling really low in mood, not having any interest, she didn’t know what to do with herself, still regular with med, but didn’t think it was helping with her problems. Nothing happened in particular that led to her mood being that way, she said. Her medication was adjusted. Couple days later I rang her again, she took the extra dosage, but remained the same, not happy, lacking drives and interest. She did try, she went out for group exercise with friends, but she kept feeling her mind was somewhere else. She was told to come back so that she could get a better review and a medicine regime that helps with her current condition better.

She didn’t come back for review. She never called us again. About 3 or 4 days later I called her house numbers again (which I usually did), somebody else picked up, saying she is no longer here. At first I didn’t get it, I thought she was just away. Then this lady said the patient committed suicide yesterday. I sent my condolences and ended the call.

Lacking interests and drives is one very important suicidal risk factor. They try to get engaged in something, but they don’t find their mind with them. It isn’t them, it’s their illness.

I used to think as long as they find some pleasurable things to do they will get better. Sometimes it just isn’t that simple, maybe it isn’t just the behavioural intervention or medicine alone, they need cognitive, behavioural and pharmacological interventions all together.