What’s normal development?

Issues & Debates, Treatment Approaches

He is the eldest of his parents’ three sons, showing some delayed developmental milestones, usually withdrawn and unable to focus. By 5 or 6 years old, he could only use short sentences. He was sent to attend special school.

When he was 18 years old, the mother and his younger brother came to our clinic. For the past 2 years he had become more and more rigid, sensitive, with aggressive outbursts. Over 3 months mother was putting medicine in his food and drink and he slowly got better.

Few days ago the mother made a call to us. She said he seems to get more argumentative, bad tempered and demanding. He wants to learn driving because many of his friends are doing so. He wants things that his peers have. He is getting defensive when family speak to him.

Mother asked if the medicine can no longer control his illness, if her son is getting more and more ill. I explained to the mother, her son is at a stage where it’s normal for them to be argumentative, defensive, disobedient, rebellious, influenced by peers, having strong ego … What kind of expectation is she having? A son who listens to her completely? Never says no? Quiet and submissive? …?

We quite often overlook the stage of normal development and the environmental influences, and focus too much on the problems someone has. He’s bad-tempered, she’s irrational, he gets jealous all the time, she is disorganized, they’re lazy… But perhaps that happens to everyone at that stage of life, perhaps that happens to most people if they are under that level of pressure, perhaps there’s something else going on in that person’s life but we just don’t know, …

We don’t want to use medication to control one’s behaviour so much that this person loses the self, so much that this person lives how we want them to live but not how they want to live.

Part II: Social, Peer & Exam Phobias

Anxiety Disorder, Clinical Case Studies, Issues & Debates, Treatment Approaches

Part I: Social, Peer & Exam Phobias

Few days later, I spoke to the mother again. They went to a Counselling centre in town. The patient opened up in the counselling session, saying that she was under great pressure and worried about various things especially her parents financial abilities.

She has always wanted to learn cooking and baking. So she’s chosen the school that she’s attending now, because this school has the course she wanted, and she can join it straightaway after Form 3, though it’s the most expensive course. The parents didn’t mind it, as they want their daughter to be happy.

The parents bought a new house earlier this year. They will be paying 3 times the house loan of what they’re currently paying. The parents are happy-go-lucky people, they know it’s going to be difficult but they were never too worried about it. Yet this eldest daughter of theirs is so concerned – whether they can afford paying for the new house and also for her expensive course. She still has younger siblings, she thinks, maybe she shouldn’t complete her Form 3 and go for such expensive course.

She also has a very traditional grandmother, who dislikes her furthering her study in cooking/baking. The grandmother always criticizes her mother in front of her, and scolding the mother for allowing her to study in this course which leads to a career that doesn’t earn money.

She listened to all these comments about her decision, is upset that her mother was scolded because of her. Somehow internally, she knows if she couldn’t pass her exams or doesn’t attend her exam she will not be able to proceed to the cooking course. And this is what she wants, or maybe not, but for her family.

We overlooked all these underlying concerns, worries and feelings. This is somehow true in psychiatric settings, especially outpatient settings. I’m not saying that medicine is not helping, obviously I’ve seen a lot of people benefit from it (especially when the condition is critical), but sometimes we easily overlook things that may not be solved by medication. Comparing to medication, in this particular case counselling and psychological treatment have shown a much better outcome.

Social, Peer & Exam Phobias

Anxiety Disorder, Clinical Case Studies

Her class teachers see no problem with her. Her school counsellor said that she can’t sit for exams. Not that she doesn’t do revision and gets herself prepared, but she just gets so anxious, palpitating, hands trembling, sweating… as if she’s going to pass out.

Yet if she gets to sit for the exam alone in a room, she can do it.

Ok, so it isn’t exam phobia.

It could be agoraphobia (a fear of being somewhere where there is a chance of having a panic attack that others may witness, and not being able to get away rapidly) then? But she never really experiences panic attack in her 15 years of life. Though she is definitely going through some very severe anxiety and fears in any exam hall. She’s supposed to be the last batch of students taking PMR this year, she is now missing it.

She seems a bit shy when she talks to us. But she’s having eye-contacts with me as I explained things to her (probably better than how I was when I was at her age, despite being call as an extrovert I used to avoid eye-contacts) and her mother. During waiting time she stays outside of the clinic with her mother. I wonder if there’re some degrees of social phobia in there.

The mother said that she doesn’t really make friends. Her friends laughed at her weight and body size. Well, based on the standard nowadays, everyone thinks that they are fat, everyone is on a constant diet, everyone has to lose weight all their lives (ok, this is “a bit extreme”). I see no problem with her weight (but she’s in fact overweight), but I understand peer influences very much. Because of this she avoids making friends…

So there could be some peer pressure leading to social anxiety and social phobia. But what about her problem with exam? Why is it exam only? She survives just fine in class, and she survives just fine sitting for exam alone.

Sitting for exams with peers phobia, it is then. I think this could be under the parent of Agoraphobia, but I think in mental illnesses, we sometimes don’t have to fit people into any available categories, everyone has their problems and symptoms, which can be very unique to them.

Part II: Social, Peer & Exam Phobias

Compulsive Voyeurism

Clinical Case Studies, Obsession & Compulsion

His sister first rang us, and asked to make an appointment. When I asked what problem her brother has, she was a bit unsure whether this is the right place for him. Her brother has some unusual habits, he collects stuff, and not like others who collect toys, stamps, … he collects women’s inner wears.

He is in his 40s, grows up in a family of five siblings being the only son. He is now in his second marriage. His current wife has a 17 years old daughter from her previous marriage. This is where it really tests his self-discipline ability.

He spies others, compulsively. He can’t help it and is very frustrated by his urges  and obsession to do so. It isn’t easy for him to make the decision and have the courage to come to seek help.

More commonly people call them Peeping Tom. Here is the definition of Voyeurism in ICD-10 (International Classification of Diseases).

He also suffers when he started to take medicine, and didn’t understand the reason of taking it. The sister questioned how the medicine can help him and wondered he would ever recover. In fact, voyeurism can just be like any other Obsessive Compulsive Disorder (OCD, see my previous post), some people wash hands compulsively, some spends hours reading, some tell lies compulsively, some spy others… So then it can be treated like OCD!

For me all voyeurism is pathological, but I’m just wondering whether it can be voluntary? So, someone can quit being a voyeur by own will maybe?

Obsessive Compulsive Disorder

Clinical Case Studies, Obsession & Compulsion

He is a very intelligent man, was sent to Canada for studies, till a psychotic breakdown which he had to discontinue his studies and return home.

He became very obsessed with continuing his studies. He wanted his family to send him back there, demanding his father, brother and sister to pay him there again. His psychosis was slowly masked by OCD (obsessive compulsive disorder). It took him a long time to stop thinking about going back to continue his studies, but he developed other obsessions…

One with hygiene. He doesn’t touch things in the public. When he goes to public toilet, he finds way to open the door without touching the handle. When he comes to clinic, no matter how many hours he has to wait, he never takes a seat. He just stands and observes (sometimes you may want to call it “staring”).

One with reading. He spends over 6-8 hours reading his Financial Times. The reason he gave was that he spent money buying the magazine so he has to make sure he finish reading all of it and doesn’t waste it. Sometimes he couldn’t finish his reading and stays up till late night. Though most of the time he doesn’t even understand what he’s reading about.

Recent months he also starts sleep walking. And this freaks him out. He sometimes wakes up in the morning having his room door opened, sometimes the light on, and had completely no memory how these happened. If it was just sleep walking that’s better. But he also has suicidal ideation. He had tried to drink Listerine to kill himself, though it hurt his stomach so much that he had to stop, and was sent into hospital for stomach washout. So being aware of his suicidal ideation and at least one attempt in the past, he became so worried that he may kill himself in his sleep walking. And of course, his worries become so obsessional.

Despite his intelligence and being probably the smartest in the family, he keeps on tricked by his illness. His obsessions are like a protection to him, from his psychotic symptoms. When his OCD symptoms are unmasked, his psychosis will be shown. Yet it isn’t easy to treat his OCD, or should I say, to treat anyone’s OCD. Quite often they think they recover, but they “move” their target of obsession, maybe from washing hands to taking long shower, or to counting items, asking questions, …

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?