Looking after family member with multiple somatic complaints

Clinical Case Studies, Issues & Debates

I’m not sure if it’s right to say “looking after”, because the son was never in the picture throughout the patient (mother)’s time of visiting our clinic. It was always patient’s friends who brought or drove her here for consultation. Sometimes we’d see some younger friends, some are friends of the patient’s age.

She’s one who had worked hard all her life, as a teacher, housewife, mother. Till the husband had a stroke, and she had to take care of the husband, and also take over the husband’s business. So in the day she taught in the school, after work she went to the shop, later in the evening she did housework, cooking, washing etc.

Then she had a breakdown, having tinnitus, pulling sensation at the back of head, stomach gas leading to poor appetite, consistently feeling anxious, and insomnia. Even when she managed to sleep, she would feel like she was dreaming whole night.

So she had to stop everything, and was recommended by a friend to see a psychiatrist. For the first few months she did get slightly better with medicine. But since April, she started to have more and more complaints all over her body, get weaker and weaker. Till last visit when she came, her friends had to carry her both arms to get her up and walk.

She wanted to admit herself into general hospital for a full checkup. That was also what the friends think she should have done. But the son wasn’t supportive, thought the mother was only attention seeking (according to the friends). He didn’t see the need to do so.

Few days after the visit, when I was calling the patient, the son picked up. This was the first time I heard the son’s voice after following up for almost a year. The patient passed away due to lung infection that very morning. It’s hard for me to believe that. I just saw her less than one week ago. She was weak, coughing and so, but …?!

It’s also hard for me to accept that the son was only into the picture on the day the patient died.

Back in the uni, we used to learn that some patients get themselves ill, or maintain their illness so that they continue to get attention and care from their family or loved ones (including some children who have Anorexia Nervosa maintained to keep the parents together or to get the attention from the carers; or some elderly parents who refuse to get better so that the children will look after them and come visit them).

But such theories, no, such assumptions, aren’t they very harmful? They can be lethal when you assume so and stop looking for the real cause behind those somatic and physical complaints. Was it really love and attention seeking? Or was it real physical illness, pain or injury?

So despite what he thought, if the son had brought patient to the hospital, the lung infection would probably have been detected and treated much earlier. The ending wouldn’t be the same. I wonder how the son feels.

How much can one tolerate?

Clinical Case Studies, Issues & Debates,

I’m quite sure it isn’t just me, many of us — while we read those news or stories about women (not necessarily women, could be men or children etc) being abused by their partner for 10, 20 years, and still ‘decided’ to stay with the abuser, believing that one day they will change, — we would really wonder, what make them stay? why don’t they just leave? We would sometimes even call them silly, and they deserve it for treating themselves this way, for not leaving the abuser.

Recently there’s a woman who came to the clinic, it was supposed to be consulting on behalf of the husband, who is very bad-tempered, always agitated, had in the past kicked the children, broke their heads etc. And it wasn’t just the physical abuse, he called the wife and children names, restraint their finance, controlled what they dos and donts etc., he has also been abusing them verbally and mentally.

The woman is one that’s highly educated, she knew the patient in their uni, and they’d been in a relationship since. This man is of very highly sexual desire, so according to the woman, whenever they were out dating, there was always sex involved. One night when they were making out in a park, a group of five authorities came by. The then boyfriend walked them away to deal with them, and as he returned, he told the then girlfriend to go to a small deserted house nearby with the group of men, so that both of them wouldn’t be in trouble for what they did in the park. The girlfriend started to cry, non-stop, she said, “you mean you want me to be gang-raped by them to stay out of trouble? Is that what you mean?” She couldn’t stop crying, and at the end the authorities gave up and let them passed.

Still, she became his wife couple of years later, and remains his wife till today. In the past 30 years, she had been in hospital several times after being hit by him, there were countless times of fights and abuses, even the children were so scared of their father. The boys grew into aggressive men, the girls are in fear of men.

She still thinks the medication may help him and save his husband and their marriage, even when we keep telling her (initially we hinted her, but she couldn’t get it so we just had to be direct) that the medicine may control some aggression but it won’t change him from the inside, it’s not enough to do that, and it may not even be a pure mental disorder.

Sometimes I’d think it’s incredible as of how much one can tolerate. But of course I’m not in the situation so I wouldn’t know if I would be more incredible or ridiculous if I were in her shoes.

Must we help/save the person despite his/her will?

Issues & Debates,

I recently called a sister of a new patient to check how the patient had been doing with the medicine and whether his state had improved, and came to know that the patient hung himself that very morning.

I’m not sure if I’m too sensitive, but I’ve received this kind of news considerably frequent in my job, the sister just didn’t sound sorrow (of course some people hide their emotions very well). In fact she later said that it was a relief not just for the patient, but also for the family.

The patient has 4 siblings who are all married with children. Their parents have passed away for few years. He was the only single and he lived on his own. Though the sister went to see him thrice per day, bringing him food and taking care of him. He had suffered from depression for many years, also done ECT quite a few times. The sister always did her best to help him. She said some siblings had given up on him, but she wouldn’t.

Now that he is gone, she just felt a weight off her shoulders. Then she started to wonder if she had done wrong all these years.

If it meant suffer to live longer, do you still want him to live longer? Just because people all should live as long as they can? Or just because you think it’s your duty to help him to live longer? So you would feel better? So you wouldn’t be blamed for not helping him if something happened? You could say that you tried your best? So you go against the person’s will (partially the illness), you save him no matter what?

It is a bit similar to those family members of terminally ill patient who decide and some even beg the doctors to save the patients, but when you really check, a lot of those sufferers would rather leave in peace, stop the pain and the carers’ suffer, than going through all those operations and chemicals and injections and medication and machines, while at the end still leave, in pain and with holes all over the body.

So what’s considered as selfish act here? And what’s considered right? Who can decide it? Who is the one to make the decision?

Related read: Can we allow a severely depressed patient to make the decision?

The need to maintain with psychiatric medicine

Issues & Debates, Schizophrenia & Psychotic Disorder

He’s a long-standing patient with paranoid delusions, all the while maintaining with medicine and depot injection. Though, past 2-3 years, he started to reduce his medicine, and at one point, he stopped them all completely, didn’t come back for follow-up and injection.

Within half a year, he had relapsed, with agitation, insomnia, sensitivity and sometimes he could be violent. He isolated himself from the family, spending all the time in his room. When the parents talked to him, he either ignored them or responded angrily.

So the mother started to put the medicine in his dinner, over time he got more stable, at least willing to listen to family, going out with them, and having better temper.

Few days ago his sister called up, saying patient’s condition has got so bad, he was threatening, paranoid and picking on the mother, throwing away her stuff, very agitated and always scolding the family members, also he has spent all his time awake.

The sister said the mother stopped giving him medicine since three weeks ago, as patient was listening to some calming religious musics, and was so much better — better-tempered and didn’t appear sensitive or paranoid at all. The mother thought he’d recovered, decided that he didn’t need the medicine anymore.

Now with his very much deteriorated condition, the family members have no ways to bring him to see a psychiatric doctor and for injection, also no way to make him take the medicine. The mother has also been threatened so much that she was afraid her life could be in danger, and is in the dilemma of whether to move out from the house (which then means nobody can help him).

This is not to say that calming religious music, chanting or prayer, relaxation exercises, meditation etc couldn’t help with one with psychotic disorders, quite often they can be very soothing and calming, at times they can even prevent mild relapses, but they cannot be a complete replacement of medicine. It’s always practical to at least let the patient (with schizophrenia or psychotic disorders) to maintain with a mild dose of psychiatric drugs, so that the condition will be more manageable even when a relapse takes place. (though for patients with good insight of their conditions, especially those with anxiety disorders or depression [but not psychotic disorders], it’s possible to stop all the medicine and only take back when needed).

 

Post related to client’s consent to treatment: Schizophrenia & Consent to Treatment 

Learning Psychological Flexibility since Young

Basic & General, Issues & Debates, Treatment Approaches, , , ,

Our education taught us to work so hard to​ score 96 on maths, 95 on Chinese, 100 on moral, 90 on science etc. On top of that, it’s very common in Asian countries that children are​ sent to tuition classes, music, art​, martial art​ classes etc.

We’re a generation with blessings​(?)​, nothing much to worry about, parents,​ teachers, or the government will plan the route and do the worries for us, what’s better, problems are solved before we even​ realised it.

But what if we fall? Fall so badly​?​ ​Being in big trouble? Facing major life challenges?

​Sometimes we read in the news – A teenager of 17 years old committed suicide because “my girlfriend wants to breakup with me, life is meaningless”, the other one because she is one A short to make it a straight As in SPM. We see depression, mood swing, anxiety-related problems, OCD, insomnia in younger and younger age. We thought they are supposed to be having fun at that age​, but they don’t seem to be able to have fun?!

​Why never we learnt psychological flexibility since young? Why the environment was never created to learn that since young? Why English, Maths, Science, (even) Moral, Volley ball, etc, but never about how to bounce back, how to be emotionally resilient? ​Or in other words, how to stand up when we fall? Why for over 10 years we’ve been attending schools and universities, but the educational system never taught us this?

Prevention is better than cure, but we aren’t even preventing the happening of mental disorders, quite often people only start to learn about resilience after they suffer (like our patients who wished that they knew this and that long time ago).

How do we create that kind of environment for our next generations? Where (whether positive or negative) thoughts and feelings are taken lightly; where we understand negative and positive events, thoughts, feelings are just equally likely to happen as the positive ones, so we face them all and accept them all; where we allow children to explore their feelings and thoughts during difficult times; where even a young child understand what value is and changing or persisting his/her behaviour in serving of the values; where we are able to adapt to changing environmental and situational demands and get the balance in them?

The more you worry about having to take medicine, the more you need to take them

Anxiety Disorder, Clinical Case Studies, ,

Yes, and that’s all the point I want to make in this post.

Recently I spoke to a woman in her late 50s who has problem sleeping. She has been a patient since 15 years ago, but was never regular with medicination.

She has used all possible means to make herself sleep, taking wine, using chinese herbs, exercise etc. She just doesn’t want to depend on medicines. But she always comes back to see doctor and collect medicine when all other methods fail and she really needs some sleep.

So yes, she came back again last week. And since that visit she has called up the clinic several times. Every time asking about

  • When can I stop taking these medicine?
  • Can I start to reduce them now?
  • Will they harm my body?
  • What are the side effects and possible side effects?
  • What’s going to happen in long-term taking these tablets?

These are just some examples, under one topic/question she can ask in so many different ways and for so many times. (Eh? OCD?!)

At the end everyone couldn’t stand answering her questions repeatedly. So I’ve got the job. I told her that through our experience with many patients with either anxiety-related problems or with insomnia, the more she worries about needing to take medicine, the more she has to take it, it’s always like that. I asked her what has the focus of life becomes now?

All kind of worries about taking medicine.

The medicine is not likely to help her much if she continues to worry this way. So she won’t get well, so she’ll have to continue taking them. So she will continue to worry about taking them… … See the vicious cycle here?

So I asked her back why not continue with medicine, but shift her focus of life in something more meaningful, to how to live more healthily and happily? How about developing new interests, learning yoga, going swimming, forming new social relationships, improving familial relationship etc etc.

When she’s able to shift the focus and live more meaningfully and healthily, she may not even need the medicine without herself realising that.

 

越是担心吃药, 越是需要吃药?

当这过去十几年来一向难入眠的女士, 用尽方法却还是不能好好睡一觉, 她就会回来看医生, 通常每一两年至少来一次. 而这次拿了药回去后, 就开始不断地”电话轰炸”诊所, 问什么时候可以停药? 现在就停可以吗? 停了马上复发吗? 这些药有什么副作用? 对身体有什么害处? 一定要吃这些要吗? 等等等等. 每两到三天就来一通电话.

详细解释许多次后, 她却不见得可以明白. 下次打来, 还是问回这些问题.

所以我告诉她, 经验告诉我们, “越是担心吃药的人, 越是需要吃药, 往往也得吃得越久” 想想这么个担心忧虑法, 你的生活中心全是什么? 生活还剩下些什么?

本来吃药可能很快有效, 但是你这么一直担心, 东想西想, 日想夜想, 人可能反而更不舒服更忧虑, 结果要吃更多药, 然后又更担心忧虑, …恶性循环, 对吗?

何不就相信医生, 继续吃药, 同时好好地, 健康地生活, 培养新的兴趣, 做些运动, 建立社交生活, 改善与家人的关系等等, 在这情况些, 也许不知不觉中已经不需要再依赖药物了.