Sunday, March 18, 2007
One flys over the cuckoo nest
It is finally over!!!
Yes, I have just finished my Mental Health rotation, and what a relief to have a break after 2 months of dealing with
Coming to Aussie and dealing with Aussie patients has opened my eyes to the things we know about back home in Malaysia but never liked to acknowledge. You know, the rapes, the divorce, gay/lesbianism, the child abuses... All these I knew happen, but we never bothered asking the Malaysian patients.
But here in Aussie it is different, especially in Mental Health. These questions are awkward, but a necessity in a typical history taking. And it is different as we may be pushing the wrong buttons, which could lead to many things:
- The patient refuses to talk anymore.
- The patient breaks down and cry.
- The patient turns aggressive.
That's why we get to hold security pager when we talk to patients alone in a single locked room.
When the first time I interviewed a young man with bushy eyebrows, it was super super scary.
Coming back to the sensitive issues, it is very to assume that only ladies get raped. But let me tell you that we have damn many guys who are depressed/anxious/post-traumatic due to rapes (either by guys or girls). In Malaysia we always assume when a guy says he is married, no divorce is in question, but here, during history taking, we have to ask about present marriages, previous marriages and why the divorce. How was I to go about that?!!
And the toughest nut to swallow is the child abuse and rape (incestual or otherwise). I have this patient who was a beautiful lady, but with a spirit so broken that it was so painful to watch. When I talk to her, it is very difficult as she could be all cheerful at one point, and bawling the next for no apparent reasons. I can be talking about her favourite movie at one moment, and she will be ranting about some other things without a single blink. It is disconcerting to say the least. And the suicides and cuts on her wrists, thighs and abdomen.
She has been diagnosed with borderline personality disorder. Now what is BPD?
According to DSM-IV:
Borderline personality disorder is -
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1. frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
2. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
3. identity disturbance: markedly and persistently unstable self-image or sense of self.
4. impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
6. affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
7. chronic feelings of emptiness
8. inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
9. transient, stress-related paranoid ideation or severe dissociative symptoms
Click HERE for more details.
And to think that all her suicides and cuts was to just receive the attention she wanted. Talk about LOA.
It was one of our exam questions: Ethical issues regarding people with borderline. The question was that a girl presented to the ED (emergency department) for her 5th time for trying to kill herself. What would you do with her?
I started off with:
Qantas' 'frequent flyers' receives VIP treatment, frequent flyers to ED do not.
The issue is: Why save her if she so desperately wants to die? Why save her when she just wants the attention?
But I digress.
The scariest thing about these patients with borderline personality disorder is this thing call projective identification (OMG, I still remember that). It is how they will look at you and thinks to themselves: 'I like that lady to be my mother!', and this thought will be portrayed by them subconsciously, and the scariest part is that you will fall into the role very very easily.
For example the registrar I am posted with is pregnant, and when she meets this girl with BPD, she will fall into a very motherly mode. It was like this girl has weaved a spell over the doctor. Scary right?
This patient told me "You are my teddy bear", and I nearly freaked out. What if she puts the spell over me and I become her teddy bear?!!!
And looking at this patient another thought came to my mind at her sad history. When she was small, she was raped by her father, and when she told her mom, she was beaten by both of them. She was locked in a cupboard and rented out as a sex toy by her father to his friends for money. And the worst thing was that she was a very intelligent girl. She knew what was going on!! To demonstrate how smart she is, she is a 2nd year medic student. (Can't imagine her being a doctor).
And the question was: would it be better is she was a stupid girl instead?
Ok, enuff of sad sob story. On to my fav patient:
My fav patient, who thinks that he is God when he does good things and satan when he does bad things. I really wish I have such an excuse eh, when I get into mischief. He is a schizophrenic who changes religion every two days - Muslim, Christian, Buddhist, you name it, he has been, loves and hates them - depending on which religion he is on that day.
Patient: Do you believe in God? I kill people who do not believe in God.
ME: *nod nod* Yes.
Hey, what was I supposed to say? He has a history of aggression and is in for a crime of bomb threat. But after being dosed with drugs, he is as settled as a cow newly milked. And he gave me, a Christian, a picture of Christ while he gave my partner who is a Muslim a
But he is a super nice guy, and after talking to him, the cogs in my head started turning.
What if the birth of Christ was to happen now?
First off, the virgin Birth.
Mary: Doctor, I'm pregnant.
Dr.: I see. It is bound to happen if you are having sex with Joe.
Mary: But I have not have sex with Joe.
Dr.: *eyebrow twitch* No such thing, my dear.
Mary: Really!! I am a virgin.
Dr.: *eyebrow raised* Really? I did not know such person exist today (sincerely). So how did you get pregnant? (sarcastically)
Mary: An angel came to me and said that I will bear a child who is the son of God.
Dr.: *eyebrow droop* I see. *Calls Mental Health Unit* We have a lady who is having hallucinations.
And then when Jesus was born, he started doing miracles and claim to be son of God.
Priest: You claim to be son of God.
Jesus: Yes.
Priest: Aye... a man with grandiose delusions.
When Jesus threw the merchants out of the temple,
Priest: Aye... a psychotic man with grandiose delusions with an episode of aggression.
When the crazy man inffused with the evil spirit was healed,
Jesus: Go, you are healed. I have thrown the evil spirit out.
Priest: Aye... a psychotic man with grandiose delusions and illusion of grandiosity.
When Jesus at the last supper says: One of you will betray me.
Priest: Aye... a man with psychosis and paranoia? A paranoid schizophrenic!
Let's see what Robin Williams (the actor) have to say about Jesus.
I think God has foreseen a future such as these, therefore the next time Jesus would not come down as a man (Passerby: Siow wan, calling himself God?!!), but in a chariot of fire. Just hope that technology have not progress that far.
Year 2143, the apocalypse.
The ignorant ppl: Wah... the hologram virtual reality super high tech man. I can feel the heat and pain so well...
"That guy's a maniac. Why'd he bite me?"
- Truck driver, Resident Evil 2
