Category Archives: Issues & Debates

Religious Experiences and Psychotic Symptoms

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

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？

Hypnosis & Hypnotherapy, Issues & Debates, , , , ,

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（The UK College of Hypnosis and Hypnotherapy）的创始人，也是我的导师。

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

Clinical Case Studies, Issues & Debates, Treatment Approaches

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”

Depression, Issues & Debates, Review - books movies series, Treatment Approaches
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!

Drug Use & Drug Abuse

Depression, Issues & Debates, Treatment Approaches,

More specifically, it is Psychiatric drug use VS Illicit drug abuse

If I have depression, or dysthymia, or an inability to experience pleasure (anhedonia), why do I need to take psychiatric drugs? I can take cocaine, amphetamine, heroin or opium too, they make me happy and feel high too. It reminded me of the patient who took his own life by jumping off from a building. He said gathering with his bunch of friends and taking those pills are his kind of pleasurable activities (case study here), just like women go shopping or people go gym. Yea, right, how about that? Take a few “pills” and I’m better?

Antidepressants like Prozac and Lexapro (the SSRIs) do not provide pleasure, it restores the capacity for pleasure. It is neither excitatory like cocaine nor satiating like heroin. The drug taker doesn’t crave Prozac and does not feel relief when it enters the system. The desired effect, a change in responsiveness to ordinary pleasures, occur gradually and is unrelated to the daily act of consuming the drug. So unlike cocaine which produces quick, strong but short-lasting “high”, people don’t “usually” get addicted to the SSRIs.

Drug addicts use stimulant drugs hoping to cope with intolerable feelings. Without medication, they may experience little enjoyment. Prescribed medication makes drug addicts who kick the street-drug habit feel less empty and better able to enjoy ordinary pleasures. For the addict, the hope is to enhance the ability to “postpone gratification”, something antidepressants may do by increasing the ability to imagine future pleasure. If and when ordinary pleasure becomes appealing (after a drug addict is treated with psychiatric medicine and begins to experience “ordinary pleasure”), it’s hoped that self-understanding and self-control will follow (no longer rely on illicit drugs to achieve “instant pleasure”).

So can we use anti-depressants (and some other medication) to treat stimulant drug addictions? I believe with a combination of behavioural therapies, and supports from the immediate family members, anti-depressants would work. But taking only anti-depressants without strong mental and motivation to quit and sufficient social supports is definitely not enough, not in long-term for sure.

Psychiatric Drug Abuse?

But anti-depressant drugs (focusing on SSRIs here) can also be abused. There are patients whose depression were treated with the SSRIs, once successfully weaned from the tablets, want to restart it, not because they are depressed, but because life seemed brighter when they were medicated. In psychiatry it’s a bit difficult to decide where treatment ends and depression starts again.. but doesn’t this seem a bit like taking illicit drugs? Same applies to people who take excessive anxiolytics (anti-anxiety drugs / tranquilisers) to make them calm and functional, how do we define when it’s legal psychiatric drug abuse?

There are people who feel more mentally sharp and agile, talk more fluently, and more socially confident when they are on anti-depressants, they continue to take it even when they don’t show any signs of depression at all. Unlike amphetamines which also make people more alert and productive but at the same time is addictive and causing paranoia, most of these SSRIs don’t lead to any significant side effects (and (if) any discomfort tend to go away after first few days). So does this make it morally and ethically fine to take anti-depressants to increase alertness, quickness of thought, and verbal and mechanical fluency, in the absence of illness?

 

P.S. SSRIs stands for Selective Serotonin Reuptake Inhibitors, which are newer drugs used to treat depression, but also work for OCD and anxiety disorders. Some commonly used in Malaysia include Lexapro (Escitalopram), Prozac (Fluoxetine), Zoloft (Sertraline), Luvox (Fluvoxamine).

N.B. This post focuses more on major and minor depression, dysthymia and anhedonia.

Substance-Induced Psychosis & Addiction-Linked Divorce

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

When I was doing my master back in the uni, I remember one of the presentations I did was about substance induced schizophrenia. That was just about 4-5 years ago, but I can’t quite remember the details, though I’ve always remembered that one of the triggers of schizophrenia was illicit drugs, I had a diagram in my powerpoint showing how much it contributed to the population with schizophrenia and related illness.

After starting to work in the clinic in KL, I’ve encountered quite some patients who have had a history of taking ecstasy pills or other drugs and have led to psychotic episodes. For the majority of them, their family members took charge and managed to stop them from continuing taking illicit drugs (by stopping them from mixing with so-called “bad friends”, moving to different or new environment, cutting off their finances, threatening to cut off their relationship with the subject etc).

Recently I’ve had this big man, who has had a long history of taking aramine and ecstasy pills, and is seeing the psychiatrist for his anxiety (no, he didn’t show signs of psychosis). He once told me that everyone has their way to release stress, some people go exercise (like me), some go shopping, some watch movies, some do gardening, some just need a good sleep, and for him, he hangs out with his friends, singing karaoke, and… taking pills, spending their nights high. During Chinese New Year, he could be drugged for over a week continuously. Though on normal days, he works, he goes gym (hence he’s called big man, as he’s not just fit, but muscular – like a staff always says, he doesn’t look like a typical drug abuser), he looks after his wife and children. Oh yes, I didn’t mention that he has a family. The wife is lovely, supportive, and all good qualities you can expect from a traditional Chinese woman.

Each time he tries to quit the pills, he would experience a moody state which lasts for two to three weeks, with fears, insomnia. Normally the psychiatric medicine that he’s taking will bring him back to normal and functional. The last time I heard from him after Chinese New Year, he said this round he would definitely quit it, he would stop seeing those friends (I later learnt that it’s much harder because one is actually his business partner), he wouldn’t want to have relapse again and again, and he doesn’t know when those drugs are going to destroy him (his brain/mind), and his family… because the wife said if he takes it again, she’s leaving him (I still remember he said “妻离子散”, such powerful words). I believed what he said, for I know how much he loves his wife.

On last Monday I encountered a motor vehicle accident and had to take the day off. On this very day, big man’s sister called up to the clinic saying that he was really unstable, as the wife brought the kids back to her parents’ house, big man was threatening to cut his wrist (which he did later on). The family members were advised to admit him to psychiatric wards in general hospital. On Thursday when I was at work, big man came with his father (who is also our patient but is in good remission and maintaining with a minimal dosage). The wife called to tell me what had happened this week. She said big man has become really paranoid and delusional recently, always suspecting that she is unloyal to him. On the Sunday before, he went outstation with his business partner (aka one of the bad friends), and spent the night being high, and had called her on 5am, questioning her about the man she kept, threatening that he would do her harm when he came back later. On the next day, he beat her up after being really angry for “what she has done behind him”. That’s the day she had to run away from him with the children, even after he sliced his wrist twice, she didn’t go back, she knows the children’s safety is the utmost important and her husband is not her husband anymore.

What the man presents, is what we call Morbid Jealousy, or Othello Syndrome (an old case study here). He was never delusional or paranoid during the years he was seeing us. He was just having anxiety and fear over some life issues, and is a perfectionist. I believe morbid jealousy is related to paranoid schizophrenia or other psychotic illnesses, and so I can’t help thinking the links between his history of substance use, and the development of his morbid jealousy. From a lot of cases that I have observed, suffering from schizophrenia or other mental illness don’t usually make your partner leave you, quite often the partner can even tolerate morbid jealousy despite how frustrating it can cause and how destructive it is to the relationship; but being mentally ill, having addiction yet refused to go into rehabilitation, and beating wife, that’s the bottom line for any woman, I believe.

N.B. this post was written in March 2016. According to the sister, big man passed away jumping off from a building at the end of March, after calling the wife and speaking to her.