Dynamic Consultations with Psychiatrists. Jason Maratos

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СКАЧАТЬ job would be in movie production but that would be after she holds a stable job that can sustain her to pursue her dream.

      Past psychiatric history

      The onset of her mental illness was shortly after her father's death in January 2010; her father died of a chest infection. Miss C was then in Form 2. She experienced low mood and weeping spells for 1 to 2 months after that. Her mental condition deteriorated in June 2011, when she was in Form 3; she presented with social withdrawal, frequently blaming her family for not offering her good food. She attempted suicide in September 2011 by burning charcoal in her room; she had even written a final note. Miss C was saved by her mother 1 hour later and was sent to the hospital accident and emergency department. She was stabilized and seen by a psychiatrist who diagnosed depression and discharged her on fluoxetine. A child psychiatric outpatient clinic followed up with Miss C. She could not tolerate fluoxetine; as her mood continued being labile, her medication was changed to venlafaxine 225 mg daily. Miss C showed partial improvement in December 2011.

Miss C had a manic relapse in February 2012 again with irritable mood, pressure of speech, and social withdrawal. She blamed her family for giving her poor food and would go out to buy snacks at night. She was overspending (in excess of US$2,000) for accessories and stamps for collections. She had grandiose ideas, including that she looked like a celebrity and that she might have been some prominent figure in her past life, such as Jesus, Buddha, or President Mao. She was finally admitted to hospital in March 2012 because of violent behavior against her aunt and because she was breaking objects at home. She was first tried on risperidone 6 mg nightly + sodium valproate CR 400 mg, and clonazepam 2 mg daily with suboptimal control. She developed a depressive swing during her inpatient stay with crying spells, rumination about her deceased father, paranoid ideation toward others, fleeting suicidal ideas, with persistent thoughts racing and multiple plans. Her medication was changed to olanzapine 20 mg N, sodium valproate 600 mg, and Clonazepam. Her depressive symptoms improved but manic symptoms persisted; she developed akathisia, which was partly controlled by benzodiazepines, Artane, and propranolol. Lithium was started, and manic symptoms significantly improved. Miss C discharged herself against medical advice in July 2012 and was readmitted 1 week later with manic symptoms. She was stabilized and discharged on lithium, sodium valproate, and venlafaxine.

      The Child Psychiatric Clinic had followed up with Miss C and doubted drug compliance. Mirtazapine was used briefly in October 2013 for depressive symptoms and lithium was tailed off in June 2013 because “she did not like” that medication.

      She was admitted to hospital in October 2014 and stayed until December 2014 for manic relapse with irritable mood, grandiose delusions, poor sleep with increase energy, and (over)spending US$100 to buy stamps. She was stabilized and discharged on lithium 800 mg, sodium valproate CR 400 mg, and Quetiapine 600 mg.

      Miss C was then followed up in general adult psychiatric outpatient clinic. Escitalopram was started in October 2016 for low mood. Quetiapine was tailed off gradually due to sedation. Buspirone was added in February 2017 for anxiety. Patient was last seen in the outpatient clinic and was stable on quetiapine 150 mg nightly, lithium 600 mg nightly, sodium valproate CR 400 mg nightly, and buspirone 10 mg twice a day. A clinical psychiatric nurse and a clinical psychologist have followed up with her since March 2017 as requested.

      Premorbid personality

      Miss C was shy and introverted as a child. She was competitive and appears to be strong. Miss C is expressive of her emotions.

       Mental state examination

      Miss C appeared with dyed hair, wearing spectacles, and no makeup. She was tearful at the beginning of the session when she was talking about being admitted compulsorily. Miss C was overly friendly in the beginning, asking the case doctor to buy her snacks, trying to seek common ground with case doctor by expressing her religious and political inclination. She became more irritable when her request was turned down, and when they inquired about her manic symptoms, Miss C had a challenging attitude and questioned the case doctor's personal background information. Her speech was coherent and relevant but demonstrated pressure of speech. Her mood was labile but congruent. She did not admit to any hallucinations. Miss C had a grandiose idea about herself coming from a prominent family. There was no risk of suicide or of violent behavior. She had no insight about her manic relapse and her need for inpatient treatment.

      Treatment progress

      In view of oversedation, which was attributed to quetiapine, this was tailed off, and aripiprazole was added to the drug regimen and sodium valproate was titrated up. Miss C's mood stabilized, and she settled in the ward with less challenging attitude. Her sleep and appetite were maintained.

       Psychodynamic observations

      Miss C employed a number of pathological defense mechanisms such as denial of her condition and of the risk of a manic relapse. Miss C claimed that she could get a private psychiatrist to certify that she was “normal.” She thought that her temperament was more expressive and irritable and that this was not related to a disease.

      Splitting : Ms. C thought that a previous doctor, who was a Christian and who had bought her snacks, was a great person and she thought that other doctors were evil to force her to stay in hospital. She thought that her community psychiatric nurse, who had been her friend previously, was evil because she betrayed her and got her admitted. Miss C expressed hatred toward the psychiatrist who deprived her of the opportunity to accompany her maternal grandfather in his last days.

      Miss C expressed grief on account of her delay in her career progress in comparison with her peers (who are now professionals like lawyers and dentists) because of her illness.

      The doctors felt that there was a possibility of unresolved oral stage of development because there was a history of blaming her family of not serving good food during manic relapse. Her mother did not visit her in the first week of admission due to stress. Miss C repeatedly nagged the ward doctor to buy her snacks. Her mother visited her on the second week with lots of snacks, and Miss C was thrilled and offered some to the ward doctor.

       Consultation

      This was a comprehensive assessment of a difficult patient. Let me say at first that we are in the field of combining pure psychiatric treatment (with medication) with psychotherapy. I have no doubt, and you gave a convincing history, that this is a person suffering from a bipolar disorder and am surprised that there is not any family history of this.

      The problem is that without insight, she has low compliance and low compliance leads to relapse. There are medicines that can help; pharmacology has advanced and this is something that, if you compliance can be assured, a better response can be expected. An important aspect of treatment would be that as Miss C has limited insight about the need for medication for her own welfare, somebody needs to supervise her taking medicines. Somebody in her environment needs to do that; otherwise she experiences a period of euphoria and her self‐confidence increases and it veers toward grandiosity and overconfidence. She then begins to think, “I don't need all that rubbish; doctors do it for their own sake and I am going to stop taking medicines and I am going to spend lots of money to get accessories and clothes and look great.” So that's when somebody else needs to take authority over her and ensure compliance or will need to arrange a prompt psychiatric appointment when they see that she is heading that way.

      The other limited comment is about the developmental theory СКАЧАТЬ