Dynamic Consultations with Psychiatrists. Jason Maratos
suggested that the possibility that the boy is misbehaving because he is neglected by his parents and, particularly, by his father should be explored more fully. JM pointed out that the overall impression is one of a mother who is overinvolved with her own sense that she should be responsible for the welfare of everyone and a father who is underinvolved and rather self‐indulgent in gambling and perhaps not carrying his share of weight for the family. This family dynamic needs to be more balanced if the children are to be more content and exhibit less disturbing behavior.
JM concluded the session by repeating that Margaret and her husband are two young people who are physically healthy and have the potential to work and provide for their family and shape a better future for themselves. This is the baseline from which they can both be given some realistic hope for their future and such hope would motivate them to channel their energies in a more creative way.
References
1 Buist, A. (1998a). Childhood abuse, parenting and postpartum depression. The Australian and New Zealand Journal of Psychiatry, 32(4), 479–487.
2 Buist, A. (1998b). Childhood abuse, postpartum depression and parenting difficulties: A literature review of associations. The Australian and New Zealand Journal of Psychiatry, 32(3), 370–378.
3 Lang, A. J., Gartstein, M. A., Rodgers, C. S., & Lebeck, M. M. (2010). The impact of maternal childhood abuse on parenting and infant temperament. Journal of Child and Adolescent Psychiatric Nursing, 23(2), 100–110.
3 Bipolar Affective Disorder
Miss C
Introduction
Miss C, is a 21‐year‐old woman suffering from Bipolar Affective Disorder.
History of present illness
Miss C was noted since July 2017 to be showing increasingly irritable and labile mood when she was taking her evening school examinations. She scolded her mother and sister on trivial matters. She had recently joined an insurance course and planned on taking the qualifying exam. She spent about US$1,000 this month on clothes and handbags and was spending more on dining. She mentioned that she needed to be someone “with class.” She mentioned that she will get rich and be the breadwinner of the family. She tended to lock herself in a room at night and listen to music, experiencing decreased sleep as well. She absconded from home 2 weeks before admission and stayed at her classmate's home for 5 days. She enjoyed her time there, chatting with the family, but they found her unmanageable and asked her aunt to take her home. She had an outburst of anger t a week before admission when she was nagging to have a portion of her sisters' food and her mother confronted her. She handed a glass bottle to her mother and asked her mother to kill her. Her mother smashed the bottle and pointed it to herself said she would kill herself instead. Miss C eventually locked herself in the toilet and splashed water on her face. She was seen at the outpatient department in August 2017 and a compulsory admission was arranged by F123 of the Mental Health Act due to manic relapse.
Personal history
Miss C is an evening school Form 6 student and part‐time waitress; she lives with mother and elder sister in a private flat.
Miss C was born in the city. Her birth and developmental history were unremarkable. She was raised by her parents and maternal grandparents. She is quite fond of her maternal grandfather who is gentle with her. Her maternal grandmother was deaf and had frequent conflicts with patient.
Her father came from a family associated with a criminal society. However, her father was not involved in any criminal activity, and he ran a cigarette and alcohol business. Her father was an alcoholic who tended to drink after 3 p.m.; he would scold her but would not hit her. Her mother and her mother's younger sister employed frequent physical punishment when Miss C was rebellious and would hit her with sticks.
Miss C's parents divorced when she was 9 years old and she was raised by her mother since that time. After her parents divorced, her mother worked as a waitress to support them. Her parents got back together later but never remarried. Miss C enjoyed a good relationship with both her parents. She respects her mother for the hardship that she endured in sustaining the family. She has good memories with father about their shared interest in movies and food.
Miss C had good academic results before Form 2 when her father died. She was always in the advanced class of the year. She described herself as “a shy kid” but enjoyed a good relationship with her classmates; she has five close and supportive friends with whom she's still in contact.
She has had one courtship from Primary 6 to Form 2 (ages 10–13), which she described as “puppy love.” When she was in Form 3, she was bullied by a classmate. That classmate would throw a basketball at her and would also threaten to beat her. Miss C gave up day school in Form 4 because of repeated hospital admissions as well as sedation resulting from psychiatric medication. She stayed at home and played computer games most of the time after quitting day school but later joined evening school. She worked as waitress on a short‐term basis to earn money.
Her maternal grandfather died in 2014 from pneumonia, and she was discharged from the hospital just in time to see him before he passed. She resents psychiatrists for depriving her time to accompany her maternal grandfather in his last days and for delaying her academic progression. She plans to get a university degree and work in an office. She said that her dream 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.