Category: psychiatry

A case of mental shrine of a dead husband

by Himanshu, posted in psychiatry, Psychotherapy, Uncategorized

                              A case of mental shrine of a dead husband

I was referred an Indian girl, aged 18. She had come to visit her maternal uncle. She was suffering from an obsessive-compulsive neurosis. She had seen several psychiatrists in her region, in southern India. She was in UK for holidays and break. Her maternal uncle was a general practitioner and friend of mine. He asked me to see her.

She was suffering from an obsessive-compulsive neurosis for about a year. She had a number rituals regarding washing and cleanliness. She was on appropriate medication prescribed by her Indian psychiatrist. There was not much improvement in her clinical condition.

I started my enquiry into her life. She was a daughter of a famous general practitioner. When she was just 16 years old, she met a young man of 19. He immediately fell in love with her. About six months after an initial meeting he started asking for marriage. She had no feelings for him. She rejected his proposal. He continues to pursue her. After seven negative responses from my patient Anita, he started threatening her. He attempted several wrist cuttings. He also took an overdose. Anita harassed by his behaviour, out of pity, agreed to marry him. Her family tried to change her mind, but she remained adamant. Her marriage was disaster. A month after their wedding, her husband committed suicide. After this grief, some stage she developed her symptoms. Few months after this incident, her father started talking about her remarriage. Anita refused to enter in any discussions and declared that she was never going to get married again.

It seemed to methat she was holding considerable guilt and saw herself responsible for his death. Next several sessions I explored Her guilt. I explored why she felt responsible for his death. I was able to show her, inadequate aspect of her husband’s personality. After several discussions she was able to see did she had agreed to marry him under pressure and out of guilt, as she was unable to walk away from him. These discussions, lead to a reduction of her guilt and symptoms. In a professional meeting I met her maternal uncle, who told me that whatever I was doing was working and I should continue.

In the next phase I started exploring about difference between pity and love. Confusion between the two needed to be sorted out, pity is not love and it is an inadequate reason to start relationship. End of all this discussion I asked her, if in reality she loved her Dead husband very much so that she has cleared its shine in her mind and wanting to live that rather than start a new life. I asked to think about it in her own space. 

The next time I saw life she was symptom-free. I saw her again a couple of times and help her stop medication. About a year later I had an invitation from Anita’s maternal uncle to India to her wedding. 

In Psychiatry, we too much concentrate on symptoms and not fully recognise the person behind the symptoms. It seems to me that a person’s life, incidents in a person life generates negative emotions like anxiety, depression, guilt, shame, anger etc. These negative emotions express themselves in the different psychiatric conditions. Hence, I think it is important to explore a person’s life and traumatic incidents. It took fourteen hours of my time but changed her life.

Fear enhances fear – a man in blue

by Himanshu, posted in psychiatry, Uncategorized
Fear enhances fear – a man in blue

 

Fear is a response to a physical threat. While Anxiety is a response to a mental threat. Acute anxiety and fear has similar bodily and physiological responses. The body is ready for either fight or flight.
As a psychiatrist, I have dealt with anxiety all the times, but rarely you get opportunity to deal with fear, unless it is hidden under phobia.
When I was working in east London, at St. Clements hospital, one morning, as I arrived at 9am. A senior house officer stopped me and said he needed my help. Apparently, a man became aggressive and was out of control at his work place. Police were called to tackle him. While resisting arrest he fell in a blue dye drum. He was completely covered in a blue dye. It took eight policemen to arrest him and bring him to St. Clements as he was aggressively fighting with them. S. H. O. told me that he could not take any history and his attempt to give him tranquiliser met aggressive response. He only knew that he was agitated in workplace and every attempt to pacify him met with more agitation. Workplace had to called police. While trying to run away from police he fell in a tub of dye.
I went to see the patient. He was on floor. He was held by seven police officers. Two officers were holding right leg, one right arm. One was holding his head. Another officer was holding left arm and remaining two left leg. Eighth officer was ready for any assistance. I tried to make contact with patient. I said “Hello”.
He responded “You pakki go home” he continued “you pakki chapati.” I was unperturbed from his racial attack. I responded, “Have you ever tasted chapati?” He seemed unsure of my response to him. He replied “No.” I further responded, “then you do not know what you are missing in your life.” Without being threatened by him symbolically I communicated that I have something to offer him. He had no further response. Few seconds passed in silence. He further asked, “Doc do you have a cigarette?”
“I don’t.” but I turned to police officers if anyone has a cigarette which can be spared. One officer gave me a cigarette. I was about to give him, but his both hands were held by the officers. I asked a police officer who was holding his right hand to let it go. He was hesitated, but I encouraged him with my eyes. I gave the patient a cigarette in his released right hand. Another officer helped to light up his cigarette He started taking puffs. He was no longer agitated. I said “look at yourself. What is your condition. I like to admit you in the ward, where you can clean up yourself. We will give you some tranquiliser so sleep for a while. Later we will talk about your situation”. He agreed. We got a couple of nurses from the ward to accompany him. All police officers released him. His agitation had disappeared. I did not have to section him under mental health act or arrange a compulsory admission or had to give him medication against his wish.
I was able to move situation with minimal intervention. Both patient and police officers were tired of their situation. Patient needed grace exit, without losing his face from situation. If I would have reacted to his aggressive and racist behaviour, or I would have responded with institutionalised aggressive behaviour like “I am a doctor, you do what I say or threaten him with compulsory admission under mental health act, would have been locking into his aggression. By taking about chapati and granting him a cigarette, I was offering him an unthreatened human response. He was able to give in gracefully.
Fear breads fear, aggression breads aggression. Lots of time fear is expressed as aggression. Hence it is very important that health care staffs, police officers, prison officers etc should have good training so they learn to cope with aggression from their clients without reacting.
15-06-2018

Depression as a self-punishment

by Himanshu, posted in psychiatry, Psychotherapy
Depression as a self-punishment
In psychiatry, you look at the constellations of symptoms in patient and compare them to symptom patterns of various psychiatric illnesses. In that way patient’s symptoms fit into a classification and get a diagnosis and treatment follows. As a psychotherapist, I know each patient are unique with their own life experiences. In common symptoms, each patient is expressing their unique life conflict in a special way. There needs an investigation and an exploration.
I was trained into these two disparate disciplines, which is not easy to reconcile. As I had to reconcile and integrate two culture in myself, namely Indian and English. That experiences help me to integrate psychiatry and psychotherapy in myself. Consequences of integration of two cultures, in myself gave me ability to become objective to both Indian and English culture. I belonged to both and none. I remained marginalised. With reconciliation of both disciplines, I had greater range of treatment options in my armamentarium. I could offer psychiatric diagnosis as well psychological formulations. I could offer psychiatric treatment in terms of medication or psychotherapy or combination of both. Patients had their choices. Psychiatric treatments are passive treatment. Drugs and ECTs (electro Convulsive treatment, passing electric current and inducing convulsions in patients), their courses produce positive results in patients.    While psychotherapy is an active treatment. Patient must explore life conflict and traumatic events. Actively think about it, relive it and correct it. No psychotherapy is possible without patients’ motivation and active participation.
When I took over a new job in Staffordshire, I inherited a lady patient. She was in her early forties. She had thick file. She was being admitted twice or thrice a year for last ten years with diagnosis of unipolar recurrent Depression. She would be admitted for three to four weeks. She would respond to course of ECTs very well. She will get better and go home. When she was admitted under my care, I felt the need to reassess her and understand her patterns. Lead nurse told me she is a good patient, she responds to ECTs, I must start immediately. I said I like to observe her, reassess her, so for the time being I will refrain from giving her ECTs. He told me that three psychiatrists have seen her before and diagnosed her unipolar Depression. What new thing I was going to find? I was depriving her valuable treatment. He started stirring up. He persuaded patients husband to demand ECTs for his wife. I persuaded him to have a patience, and give me sometime if I could find a way to treat her without ECTs. Lead nurses demand continued. I told him that in the last ten years she had spent more than two years in the hospital in total.
I should have a grace and let me have half the time, if I could find the way to change the course of her illness. I was fighting on two fronts. The lady patient, who was submissive good wife had very little to say about herself or about her marriage. Three weeks passed, I did not make any progress. I started seeing her husband with her. On exploration, I found that before this breakdown, she suddenly demanded to go on shopping by herself. In order to protect her, husband said no. but she defied him and went shopping. Next day she became depressed. I tried to explore any pattern with previous depressive episodes. Her husband could not remember all episodes but what he remembers that there were some similar patterns. She wanted to do things, which was not usual for her. Subsequently she would become ill. I tried to explore with her what made her want to go shopping? She had no answer for it. She told me that she heard some women talking about it on the bus station and she also wanted to go shopping. She told me that she enjoyed shopping but felt bad as well. She could not really described me her internal mental process.
Attribution is helpful as well a problem in psychology. Correct attribution will lead to unfolding of psychological process but incorrect attribution leads to closed, fixed psychological state. I did not have clear proof to internal psychological process in her, but I was going to make hypothesis and test out with them. If I was correct in my hypothesis, we will see some resolution. If my hypothesis was wrong, there will be no change.
I made hypothesis that this submissive lady, from time to time she makes an assertion, keeps her own identity and her ego going. Despite her submission, she does make assertions from time to time and keep her ego separate. This assertion causes to be guilty and makes her Depress.
I saw the lady and her husband together. Discuss her behaviour of assertions. I encouraged it and told them it is good for her. Her husband should support her. I dealt with his anxiety to protect her. He was encouraged to listen to her. I encouraged them to engage more activities together which can be fun. She had been in hospital for six weeks. I gave her leave to go home for three days. Three days later when she returned, both she and her husband reported that she was normal. I could be discharged her six weeks after admission I was able to discharge her without giving her any ECTs. I was in that job for three years. I followed them in outpatients. She had no relapse of Depression. She did not need to be admitted into hospital. Over the period of years, she looked more animated. In some outpatient clinic I had to advice, some aspects of marital relationship.
It would have been easy to prescribe her ECTs. Lead nurse would not be stirring up problems for me. I had to cope with six weeks of pressure from Lead nurse. He was reading my notes all the time, as there was no substance four to five weeks, he had more weapons against me. I was source of gossip. Some of junior nurse and social worker started understanding what I was doing. But lead nurse was so institutionalised that he remained skeptic even after discharge of the patient.
I was taught that practicing medicine is an art. You gather your information from so many different places and you apply them in treatment. In current NHS, which is management top heavy, practice of medicine is a tick boxes and follow the institutional advice given by NICE. Last year BBC had series “doctor in the house” where Dr Chatterjee showed that visiting family and the house, how he dealt with chronic condition by holistic approach. In current NHS, which runs with false economy, has no scope of true medicine. Worse thing is that new generation of doctors only learning part object approach than holistic approach.
24-05-2018