Monthly Archives: November 2013

Illness Phobia

Anxiety Disorder, Clinical Case Studies

She has consulted many specialists, cardiologist, gastroenterologist, orthopedist… It all started with some pain in the arms, then the shoulders and later her back.

Other than the aching in her body, she also feels something stuck in her throat, chest discomfort, her stomach twitching, sometimes having light-headed, sometimes having red rashes on her skins… She even imagines that she’s got cancer and is suffering from it badly. She is worried so much about all these somatic symptoms and about getting more and more ill, she can’t eat properly, she doesn’t have any appetite.

In addition to those complaints, she’s also paranoid and may be hallucinating. She feels that the DJs on the radios are all talking about her (“Why do they know so much about me?” “Why do they talk about me non-stop?!”), she feels everyone on the train knows that she’s sick and is taking medicine for her sickness…

The problems were aggravated by a big row with her boyfriend, whom she found out to be getting back in touch with his ex-girlfriend. She’s becoming really sensitive and paranoid. She thinks the boyfriend is not being faithful, for contacting the ex. At the same time she was also having some massive pressure preparing for her professional paper.

She slowly moved away from her relationship and study problems (she passed the paper). But then she developed all those psychosomatic pains and problems. What’s worse is not the problems themselves, but the fact that she’s so overly worried about them – even the slightest rashes on her skin makes her think that she’s got skin cancer and is dying… When she started to take the medication, she did a table diary, noted down every small changes and symptoms in her body, whether she felt sleepy, had rashes, felt dizzy, could breath properly… She tried so hard to notice every little things in her body (perhaps it’s also an obsession?).

Illness phobia is not uncommon nowadays (see here for another case study on illness phobia), it’s under the anxiety categories, yet this appears to be some modern mental illnesses, as people nowadays know more and learn more as the technology gets advanced, at the same time people are also creating more problems for themselves as the world develops further (unhealthy processed food, overly urbanised cities, pollution…). But why, why get so worried when you’re not ill? Why are people losing the abilities to enjoy lives? Why worry before even knowing if the problem exists? It’s like people being worried about getting worried, now these people with illness phobia are getting ill mentally because of being worried about getting ill physically…

Underlying Perfectionism?

Clinical Case Studies, Unclassified Disorders

The mother made an appointment being not so sure about what her daughter’s problem is. She said the daughter is lacking confidence, or something is wrong with her, but the mother isn’t sure what it is.

This patient was doing A-Level at College A. She later said the course wasn’t so good and so she wanted to transfer to College B. So the parents went through a lot and completed the application and helped her to do the transfer. Everything went well for the following months. Till about one month ago, the patient told her mother that she wants to transfer back to College A again. The mother wasn’t happy about it but still she asked for the reason. The patient said she isn’t making any friends in College B, all her friends are in College A, she wants to go back there. The parents think it’s not a good decision so they continued to persuade her to stay on, and encouraged her to take part in some societies/organisations in order to make new friends.

The patient then stopped attending classes, when her request wasn’t fulfilled. She stayed home all the time, keeping to herself, not responding to mother when the latter speak to her. She isn’t even answering her friends’ phone calls (well, we thought she wanted more friends?). It does appear that she’s rebelling. But other than that she’s also losing the ability to make decision, to be assertive about what she wants and doesn’t want. When the mother asked whether she wanted to go back to College B, as the college has been calling the mother, she just stayed quiet.

This was continued with another two weeks till the mother came to us. The mother doesn’t know what to do. The mother consulted doctor on behalf and brought the medicine back to the daughter. She was very eager for the daughter to get better, to return to college and sit for her exam in two weeks.

So the mother gave us a call every two days, asking us what to do with her daughter, asking why her daughter still couldn’t make any decision, keep to herself, not going back to college, asking when she would get better…… She tried to push the daughter further and further, and of course, in such short period, she gets no results, but probably have made things worse.

What do you this girl’s problem is? Perhaps some underlying psychological worries? Depression? Social phobia? Agoraphobia? Laziness?! Avoidance, avoiding what? Some obsessions, obsessed with what she wants? Or is she a perfectionist? Someone who tolerates no imperfection? So when a bit of problem shows up she just avoids it?

What do you think?

Do I have a psychological problem? Am I mentally ill?

Basic & General

This is one common question I get as a psychologist, sometimes the question may not be as direct or obvious, but the root of the problem is always “Do I have a problem if I’m…”

Some people feel anxious. Some depressed. Some feel mood fluctuates. Some have sleeping difficulties. Some repeat things.

Then at some point they wonder, do I have a mental illness? Is it a problem? Should I get treated? Should I take medicine or see a doctor? How do you judge whether it’s a problem?

For the person asking: I always ask, do you think it’s a problem? Is it causing distress to you? Is it causing distress to people around you? Does it affect your life massively (e.g. so disabling that you can’t function properly in at least one aspect of your life, work, relationship with family or partner, …)?

For one’s family: Can this person still function properly in life? Is it causing distress to himself and/or to people around him? (Quite often I’d say the people surrounding know it better!)

You may be checking the locks 10 times before you go to bed every night, but if neither you nor your family find it a problem, then it’s really no big deal! Similarly, you may have a family member who’s very bad-tempered, getting angry very easily, but this person is like this all his life, he can form proper relationships, then maybe this is not a big problem. One may sleep 4 hours a day and is suffering from it whereas another is feeling happy with his life.

So don’t be so sensitive and get worried so much about it. Ask yourself the questions above. Here I’d also like to emphasize, life is never perfect, there’re always ups and downs, so it’s completely normal to sometimes feel sad, low in mood, worried, anxious… as long as it doesn’t get chronic and/or acute.

For further and more in-depth screening tools and scales, check here.

Adult ADHD?

Clinical Case Studies, Depression, Issues & Debates

This young Indonesian man came to us referred by a psychiatrist, in the referral letter it was written that he’s experiencing some psychological difficulties, poor sleep, mood swing, poor concentration, the diagnosis was dysthymic disorder.

When he came to the counter I can see his face in red and him in such an agitated mood, he said, “I’ve been trying to call you guys but something strange happened.” I told him to call us in front of us and so he did. There was indeed some weird sound coming up after he dialed, of course, as he called our fax numbers. So later he was registered and he took a sit, seemed to have calmed himself down listening music with his earphone in the waiting area.

He said his main objective to come to our clinic is to sort out his poor sleep and mood swing problems. He said even with medication from previous doctor, he can’t fall asleep deeply, he just doesn’t feel that he’s sleeping well. At one point he felt like he could no longer control his emotion. His appetite is considerably ok, acceptable as he said. But he said when he gets angry he feels dizzy in his head. The example he gave was the time he was coming to our clinic, but couldn’t find the place, and couldn’t reach us by phone (well, how to get to us with fax number, unless you’re sending a fax I suppose?). He said he was so angry and then he felt light-headed.

We don’t expect people to be flat in their mood (in fact being flat in mood is a negative symptom of Schizophrenia), so people can be sad, happy, angry, calm, depressed, elated… Yet his diagnosis was dysthymia, a disorder characterized by chronic, consistent low mood (just like depression, but less severe, more long-lasting). He didn’t appear so to us. He laughed when I joked. He was angry when he was frustrated. He managed to elaborate his problems with examples. He has interests- he listens to musics as he waits.

One main problem he has is his poor concentration, he’s a student. For a student to not concentrating, not focusing, not remembering, not memorizing, it’s like end of the world (especially if you do care about your studies!). He really wants to finish the study and graduate from it, as he doesn’t want to waste his father’s money.

So we’re suspecting Adult ADHD. I remember I got a copy of Adult ADHD scale just last week and was thinking “I won’t need this. Who’ll come to clinic for this problem?! Nobody.”

Now I realized one thing, it’s right, nobody will come for consultation and treatment for Adult ADHD. Not because nobody is suffering from it, but chances are it’s far under-diagnosed. If you look at the scale (Adult ADHD Self-report), you’ll realize people nowadays are likely to suffer from it (I can’t concentrate, I can’t sit still, I get distracted easily, I keep forgetting the deadlines, I feel restless…).

See here for more Psychological Rating Scales.

Consent to Treatment & Mental Health

Clinical Case Studies, Issues & Debates, Schizophrenia & Psychotic Disorder

I wrote a clinical case study previously (see here) and demonstrated under certain conditions it’s not always possible to gain the consent of treatment from the patients yet the family has some other options to help the patient if they want to.

Few days ago I spoke to a husband who all the while has been putting medicine in drinks for his schizophrenic wife. He has been cooking soup, buying Chatime, fresh milk etc at night, just to let his wife who thinks she’s well to take the medicine. (I wonder if married women who are reading this will become suspicious of whether their husbands are putting medicine in their supper drinks?!)

Recently the patient started to refuse to take supper at night. She got angry and asked husband not to let her eat anything at night. She goes out with friends till late night. Once she gets home she just wants to go straight to bed. She said those drinks are making her fat (she’s mostly right).

So husband started to fail giving her med and she started to demonstrate poor sleep, agitation, paranoia…

The husband said he’s really been suffering doing this (putting med in his wife’s drink/food). He said one day when he was dining out with the wife, while the wife was away to the washroom, he poured the liquid medicine into her drink, and guess what? Somebody saw it!! He was very embarrassed as if he was doing something illegal, wrong and sinful (imagine what the public would think about having seen that?).

It’s good to have consent to treatment from the adult patients, much easier for the clinicians and family members for sure, but when the patients think they are fine and completely healthy psychologically, guess it’s the family then, that have to suffer.

Anorexia & Psychosis

Clinical Case Studies, Obsession & Compulsion, Schizophrenia & Psychotic Disorder

At first glance, you probably don’t quite find any obvious relationship between Anorexia (irrational fear of gaining weight, food restriction, distorted body perception) and Psychosis (“loss of contact with reality”) in my title, but with some explanation in the brackets I hope it does make it a bit obvious…

This young boy came with his parents that day. He seems a bit underweight when we were told that he’s already 13 years old. The mother said he was above 60 kgs, much bigger size than most of his peers, but now he has lost almost half of his size, and is still losing.

He was the target of bully, his schoolmates made jokes about his size and weight. He made no friends and had very low self-esteem and confidence. Then he started to avoid taking meals. The parents have to persuade, convince, force him with all kind of methods. Still, he continues to lose weight.

He’s also obsessed with cleanliness (yet another OCD case), very fear of contamination and infection. Though one very different thing from the other obsessors, is that he can’t take off his shoes, as he thinks if his feet have any contact with the floor, the dirt and dust will be “transmitted” into his body, causing him fat! causing him fat! causing him fat! (Something’s wrong with my writing style, I think I’m also obsessed with repeating when I talk about OCD cases).

Although we can’t really be sure chicken or egg which came first, here it seems likely that he first became anorexic, then only led to obsessions with cleanliness. But being highly fear about things on the floor causing him gaining weight, he is so close to delusional and psychotic. Guess what’s happening right now? He thinks the medicine will make him fat and so is refusing the medicine…

It seems that anorexia is also a kind of obsessions and compulsions, but it can also be so serious and appear like psychosis. Just like how they see themselves in the mirror, completely distorted, different from how we see them, isn’t that “losing contact with reality”?

How anorexic people see themselves
How anorexic people see themselves.