Washing & Arranging Rituals

Clinical Case Studies, Obsession & Compulsion

I remember this young man very well. I got phone calls from his mother about one hour before we close for 3-4 days continuously. The mother said she was bringing him back for review, but they didn’t turn up at the end.

Till that afternoon they showed up just before we closed. The psychiatrist was still seeing a patient so they had to wait for a bit. This young man went into the toilet, and spent at least 20 minutes in there, till the nurse was calling his name several times, looking for him in the waiting area and outside, still hadn’t found him. The mother said he was in the washroom. When the door was opened, he went back into the basin and continue with washing, washing his face and hands. We tried to stop him, telling him that doctor wanted to see him right now. It took another 5 to 10 minutes till he was literally dragged out from the washroom and into the consultant room.

Before he left, he stood there and wave to us as we said goodbye to him. He was there waving for like 10 minutes. The mother seemed to have given up, just stood by the clinic door to wait till he’d done.

This is the one and only time I see this young man with obsessive compulsive disorder, doing massive washing and arranging rituals.

Till recently, about two months later from when I first saw him, I met another very similar case and recalled this young man, wondering why he hadn’t come back for review, I decided to make a call to him, just to know how he has been recently.

He picked up the call, and when I asked “Good afternoon, are you Mr Chan?”, he answered, “I’m Mr Chan Ah Meng” (pseudonym). I stated where I’m calling from, and that I merely wanted to know how he’s been doing, why I haven’t seen him for such a long time. He said he has stopped schooling, now helping his father, he’s seeing another psychiatrist now, still repeating, so disabling that he had to stop schooling. When he said he was still repeating, he repeated it a few times. Other than that he’s been doing ok. I informed him if there’s of anything we can help him, he can call us back, then I hung up the phone.

Later I was busy with other work, my colleague told me that he called me back. So I rang him back, again he had to identify himself as Mr Chan Ah Meng. He said “nothing important now, nothing important now, nothing important now…” So he thanked me for calling and I said you’re welcome, I hung up again. Within few minutes he rang again, “what did you last say just now?” I said I couldn’t really remember, then he answered, “you said ‘you’re welome’, you said ‘you’re welcome'”… Then he thanked me again and I hung up.

And I hung up.

And I hung up.

Traumatised Childhood

Clinical Case Studies, Depression, Obsession & Compulsion

She has an over 11 years history of depression with obsessional ruminations, and insomnia, and has maintained relatively well on medication, after a course of 6 ECTs.

She is the 7th of 8 siblings, with no family history of mental illness. Her parents divorced when she was still a child, she lived with her mother who doesn’t really care about her. At young age she was unfortunately raped repeatedly by a relative and his friends. She never really mentions it to others, most of the time she can pretend like it never happened to her before.

She is a hairstylist who works from home. So sometimes when there’s no customer she’s spending a lot of time alone at home. One of her elder brothers sometimes helps her financially, knowing that it costs her a lot to take psychiatric medicine long-term. She has once tried to follow up in the general hospital, but after taken one dosage of the medicine prescribed by the hospital doctor, she spent the whole night trembling and crying, feeling the head spinning. Since then she’s never thought to go to the general hospital (N.B. here I’m not saying that psychiatrists from GH isn’t good, but most of them aren’t Chinese, so there’s a language barrier there, which can cause problems in diagnosis and prescription).

She’s always complaining of head and neck pulling sensation. It’s worst when she can’t sleep well. She spends most of the time being worried about this pulling sensation, although nothing wrong was found physically when she went for check-up.

Sometimes she can be very obsessive, being worried about the same thing continuously, asking similar questions repeatedly, needing a lo of reassurance. She’s currently much better with medication, and with a lot of counselling she can slowly accept occasional poor sleep and insomnia (What to do if I can’t sleep well?).

Adverse childhood experience is always a risk factor for many mental illnesses, but also a perpetuating factor.

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.

Depression Following Stroke

Clinical Case Studies, Depression

His wife came to us after the husband had a stroke. She is very concerned as the patient has had an elder brother who committed suicide after being depressed for years.

She is worried that her husband will do the same as he is currently staying in a hospital doing physiotherapy, being emotionally unstable, agitated, and very bad-tempered. He keeps to himself most of the time, makes no social contact with others, and cannot tolerate the least of any physical discomfort (e.g. sore throat, skin itchiness).

The wife is very keen to bring patient to consult a psychiatrist, yet he is not ready for it at all. If he ever knew that he’s taking any of the psychiatric related medicine he will get so mad. So the wife has been putting medicine in his food and drink. What’s difficult is his poor physical condition, due to the stroke he needs to do a lot of physio, but the medicine is making him drowsy and sleepy. In addition he’s having high blood sugar, high blood pressure and high cholestrol, so whatever kind of medicine that may raise any of these he can’t take it, especially his blood sugar is always sky high.

The wife spends almost 24/7 by his side to look after him. One day their only 15-year-old son made a call to her, saying he missed her and was very anxious about sitting for PMR (exam), he wanted her to pray with him over the phone. The wife decided to discuss with patient, told him to let her to go home and see the son, the patient agreed. However, when the wife wasn’t around, patient went up to the 13th floor of the hospital and attempted to jump down.

When he is okay, he is okay (what kind of sentence is this?). When he’s having a slight of bodily discomfort, he wants to end his life. Nobody really knows what he’s thinking, not even his wife. But he’s very upset and irritated being hospitalized, not being able to earn money and function like normal. What’s worse is his only sister and her family, who lives just next to him but have never come to visit him at all. So the wife seems to be the only connection he has, and when the wife isn’t around, all kind of negative thinkings float in his mind…

“She no longer wants me” “She doesn’t want to care for a sick person” “I’m useless” “Nobody cares about me”

Having a strong supportive family connection is something very essential in the recovery of mental illness. Yet unfortunately he has a brother who left him due to depression, and a sister who lives next to him but built a wall in the middle of two houses.

Confidentiality Awareness

Issues & Debates

“What? You are just going to fax the letter over like that?” I asked, as my colleague was going to fax a letter regarding one of our patients to the patient’s company. The company requested it, and the patient was aware – he came to sign a consent form (ah wow such thing exists?!) but he isn’t allowed to even look at the letter. So yea, he gave consent for us to disclose his illness to his workplace, without quite knowing what his doctor wrote about him.

“Yes! The patient isn’t allowed to read it so we can’t give the letter to let him bring to the company! I’m just going to call to make sure that they get the letter” (they? who?!)

I guess most of us know where a fax machine is placed in an office in most companies. Usually anyone who walks past it can check and look at the incoming fax. Chances are the fax may then be passed from one to another (in a larger company, maybe office boy, secretary, some other “caring” colleagues). I feel so bad that this was done. I don’t blame my colleague or anyone in the clinic, but the whole awareness about confidentiality issue in Malaysia is just low, very low. When I was trained in the UK, confidential used to be such a big issue. In the uni we had one whole 5 credits module about ethics and confidentiality; At work, we had one whole hour training about protecting patients and staff confidentiality.

Having watch this, I will be so careful to sign any “consent” form in the future. I mean we all as patients or service users or some kind of participants should understand where those private information about ourselves is going and what they are used for. Remember you always have your rights, don’t be afraid to fight for them. It may take quite some time till we actually get there like in many developed countries, but it will not happen if nobody is fighting for it.

I hope people in the practice gain more awareness and give more respect too. Imagine this was you, would you be happy that your some sort of medical/financial report or ability test etc is passed around in your workplace or among some unknown people?

N.B. This post was first published at huibee.blogspot.com by the same author

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.