 |
| About Bioline | All Journals | Testimonials | Membership | News |
|
||||||
|
||||||
Malaysian Journal of Medical Sciences, Vol. 11, No. 1, January 2004, pp. 86-89 CASE REPORT Love Tragedy, She Wrote Mohd Shah Mat Esa, Zahiruddin Othman*, Mohd Jamil Yaacob*. Department of Psychological Medicine, Universiti Malaya, *Department
of Psychiatry,
School of Medical Sciences, Universiti Sains Malaysia, Health
Campus
16150 Kubang Kerian, Kelantan, Malaysia.
Submitted-25.5.2003, Code Number: mj04011 A case of a 53-year old-single, Kelantanese lady with a diagnosis of paranoid schizophrenia for 28 years is reported with aims to illustrate the influence of life experiences particularly based on education and intelligent on delusion illustrate the evolving nature of the complexity of delusions as well as to show the importance of documentation in psychiatric practice. We concluded that this patient had used defense mechanism of suppression, reaction formation and persecution throughout her delusion. The final persecutory delusion evolved through series of transformation via object of admirations. We postulated that in-depth emotional insight about effects of schizophrenia might have contributed to her self-reflection that have made her frustrated with her poor achievement in life. Key words : suppression, reaction formation, persecution, delusion Introduction This case report is unique because it entails special talent from a psychiatric patient. As an intelligent and talented writer, this patient used to correspond with her therapist (the first author) via letters to express her thought and to ventilate her emotion. Those letters were studied by his supervisor (the second author) and blindly analyzed by the third author. The letters were seen as reflection of the patient's mental states over the years. The conclusions were made based on collective opinions of all quarters to avoid bias and to construct a clinically justified opinion. She granted consent and cautions was made not to reveal her identity. The aims of this report are: (a) to illustrate the influence of life experience particularly based on education and intelligent on delusion (b) to illustrate the evolving nature of the complexity of delusions (c) to show the importance of documentation in psychiatry. Case Presentation OML, is a 53-year-old Kelantanese born lady, who graduated from an Asean University and received a gold medal in Mathematics. She was awarded a Fulbright travel scholarship to specialize in Physics in an American College of Techonology in 1969. She was diagnosed as Paranoid Schizophrenia at the age of 25 which was precipitated by a broken relationship with her tutor. "A few days after my arrival at Potsdam, I met Dr EEA, the Chairman of the Department of Physics of an American College in a picnic. He took an immediate intent in me. He became my mentor for a year. He became my guiding light, shining and showed me the way to do my studies in this college. It was because of his manner that I became a Physic major. At first we only met a few times a week. But in summer 1970, we met three times a day, once in the morning, when I went to summer class, once in the afternoon when we went for running on a high school tract and once in the evening when we met for boating and we phone everyday". Unfortunately things went wrong. "As summer day flew by, he wanted to discuss divorce with me. I was silent on that matter. So one day he told me he was going to North Canada for a conference and wanted me to write to him. After he returned to Potsdam from Canada, he came and saw me and said. "May be you should spent more time with my wife so that she could catch some of your innocent charm." That was the beginning of us drifting away from each other. I became ill soon after". The final break came in January 1971. Soon she realized that the break was permanent and final. Nothing could be done about it. "He shouted at me, himself very, very deeply hurt by the way things worked out. And I ran away, saying: "I want to go home". He was the Chairman of a Physic Department in Clarkson. I was the girl he once loved so much. I didn't want to talk to my mentor again. But my friend repeatedly asked me to phone him that night, because he was a man in high position, with plenty of charisma and grace, very, very influential and my friends wanted me to understand that what he said and did would be most decisive on my academic future. I had no choice but to screwed up my little face and phone him for the last time. Within seconds, he answered my phone. I supposed as the Chairman, he had quick reflex. We both talked very, very softly, exchanging only a few words. And she said softly, "You have to see a psychiatrist, OK?" I hate these last words of his and immediately hung up. My friends all looked into my little face, searching for answers, but did not ask me any question. I ended up with amnesia, as far as those words were concerned, but not other things for 25 years. Then I remembered what he had said to me and I supposed I pretended not to remember, for it hurted too much to remember. And I always have a fine memory despite many years of medication". About her family, she wrote, "My parents got married 46 years ago, not because of love as modern couple do but because they listened to the fine word of match-maker. Their marriage turned out to be very, very bad. They could not get along with each other. Partly because of unhappy marriage, my mother discouraged me to get married. She considered every nine out of ten men in this world were bad. I came from a family of six. Surprisingly three out of six are very, very absent-minded." About her father, she wrote, "My father had to be emotionally unstable. He gets depressed a lot and likes to talk about dying. He has lots of real and imaginary physical complaints. He used to take haloperidol on and off at night. We're not close and we know little about each other." As how she described her mother, "My mother often gets her pots burnt. She often losses her keys. She could not find her bag. She hunts all over the house for important documents, shares certificate etc. She could not remember whether she has paid her housemaid's salary. She tends to get screwed up a little because of her absent-mindedness." About her brother, "My elder brother was schooling locally more than 30 years ago. He was not absent-minded initially. However, when I saw him in New Jersey 17 years ago, he was extremely absent-minded. He wrote a cheque and forgot to bring to his office. He hunts all over the house for a book he had borrowed from the library. When he drove he always lost his way and had to seek help from passerby. Even after he had gone to the same place 3 or 4 times, he still couldn't find his way." About the cause of schizophrenia, "The real cause of schizophrenia was very deeply rooted inferiority complex. I was so homesick and felt insecure about money matter in particular." "In 1994, her object of admiration had turned to an old friend, WF. She once wrote in her letter", "When I had an opportunity to meet my schoolmate WF and get to know him well, I understood those word. Born to a poor family in Ohio, a handicapped with a right leg 4 inches shorter than his left leg because he only has one bone in his lower leg due to birth defect. He is truly gifted and very amazing." On a certain person, she wrote, " WF was born on September 1949, in the Year of Ox, in Meeker (?), Ohio. His father was a very poor farmer. When he was young, he played in the hays. When he was older, his mother went to work for an old lawyer as secretary. When WF had to attend school, he had to travel a very, very long distance. He had a birth defect, due to what cause I do not know. His right lower leg had only one bone instead of two. He was attended by the best orthopedic surgeon in United States. When he went to college, he already wore a built-up shoe for his right foot. In December 1970, WF and I did some part-time work for Dr. HB for (US)$2.00 per hour. He had never dated me. But he gave me his college room phone number. I only phone him a few times." "He also gave me his parents' Ohio addressbefore I returned home to Malaysia in early 1970. We corresponded for four years. He was extremely gifted, very intelligent and well educated. He wrote very beautiful letters. He was very enthusiastic, passionate, masculine, full of zeal for life and loves his work. In his beautiful letters, he was only trying to say, "Pity me, I have no girlfriend." Becoming timid, his handwriting became very small. I understand that he must have been refused by a girl when he was in his youth, although he did not say it in much word. It is only natural and nobody can be classified as mentally ill because of that." In a letter sent later, she wrote, "WF is not supposed to pray for me because I am a Buddhist cultivator of the way. He can only pray for himself. Ask him not to daydream too much. His wife who sleeps beside him is real. Not his daydreamt pen pal, like me, whom he has never ever met in the past 32 years. Since I have decided to marry another man, I am not interested to see him again for the rest of my life." Then her love for WF turned into hatred. "WF had never ever nursed me to health when I was mentally ill. He would never ever marry a girl from lowly family. Do not be seduce by Americans who offer fame and health (wealth) or women." And finally transformed into paranoid delusions. "I cannot withstand the radiation emitted by WF. I believe my family, especially my parents, suffers a lot because of WF. Who are those Malaysians who authorized and allowed American spies, including WF, to stay in Kota Bharu? I cannot withstand the tortures of American spies! Lab G. Must be a private lab owned by him. I cannot withstand his tortures and suffers immensely because of him. Had the doctors in HUSM been threatened so that they had no choice but to let those American spies come to Kota Bharu?" Over the years she has been treated and stabilized with intra-muscular Fluphentixol decoanate and she could live independently in her own flat, in the downtown of Kota Bharu. She earns her living by conducting tuition classes. Discussion This case illustrates on how a patient with high academic background developed delusion based on her life experiences. It also illustrates the influence of intelligence on sophistication of her delusions. In the beginning of her illness, she had used mature defense mechanism of suppression (1) to allay anxiety and to cope with her stress. Her apparently suppressed alter ego had led to "amnesia" with regard to separation with her beloved mentor but not other stuffs. Insofar, the pretension of amnesia is her way of rationalizing the rejection and what had been happening. She reacted the dejection with reaction formation (2) (of hatred against WF) and sulked her way through by saying, "WF is not supposed to pray for me because I am a Buddhist cultivator of the way. He can only pray for himself". At the same time, she highlighted the cultural difference in order to affirm their differences. In doing so she could project that, It is not I who didn't want to love him but our differences, which didn't allow us to do so. She closed down her mind from him by reflecting: Since I have decided to marry another man, I am not interested to see him again for the rest of my life. The fact that she decided to marry another man was a fraud since she contradicted herself when she confessed in another letter that, I would never get married as I am a mental patient. Eventually, the projection was transformed into a persecution, you persecutes me or He who persecutes me as an American spy. This evident was found when she asked in one of her letter, "who are those Malaysians who authorized and allowed American spies, including WF, to stay in Kota Bharu". The effect of persecution was clearly illustrated in these phrases: I cannot withstand the tortures of American spies! I cannot withstand his tortures and suffers immensely because of him. Her thought had been going into series of dynamic transformation over the same subject for many years. It is speculated that the transformation was precipitated by the insight she acquired when confronted by the reality of cultural differences of marrying a stranger from different culture. She consciously told herself: "WF is not supposed to pray for me because I am a Buddhist cultivator of the way. He can only pray for himself". In fact, even when she suggested; "Ask him not to daydream too much. His wife who sleeps beside him is real". She was suggesting to herself to accept the fact and to perform a reality testing. By converting the delusion, her subconscious mind will find ego-synchronicity with the reality, enable herself to cope better and feeling less anxious. The other points of interest is the fact that soon after she realized the end of a real compassionate relationship with an exalted person in power (her mentor), she engaged in a delusion toward another person namely, WF (one of her colleagues in university). Both object of admirations central in her delusions have many resemblances and dissimilarities. Both are white and Caucasian. Both personalities entered her life at the same period of time. That was the time when she was an enthusiastic young and bright student. However, the reasons for her admiration were different. She admired her tutor because of his intelligence but on the other hand, her admiration for her colleague was due to the fact that both are disabled. He was physically disabled and she was mentally disabled. She identified with her second object of admiration due to the fact that both came from poor socioeconomic status, highly intellectual and have poor social skills. She portrayed a clear sense of inner dissatisfaction associated with inferiority and low self-esteem when she wrote "the real cause of schizophrenia was very deeply rooted inferiority complex". Her self-reflection in this statement must have been derived from in-depth emotional insight about effects of schizophrenia onto oneself. Nevertheless, at the same time, she also realized about her potential and becoming frustrated with her insignificant achievement in life. In this case, eliciting psychopathologies was a painless effort because (1) patient is an avid writer who was able to unveil her ideas very precisely on paper. (2) She is quite intelligent to express her explicit ideas for documentation purposes. This case illustrates why documentation is important in psychiatric practice. It allows therapist to study not just the symptoms and psychopathologies but the inherent ideas that transform the delusions over a period of time. It is believe that eliciting psychopathology through patient's writing is underutilized in the contemporary daily clinical psychiatric practice. Reasons being that culture of writing letters has been replaced by electronic mode of relaying message via e-mail and short messaging system (SMS). Secondly, as psychiatric epidemiologists would likely to agree that most of our patients are undereducated, poor communicator and less privileged mental patients. Acknowledgements This case has been managed by various doctors including Prof Azhar Mohd Zain, Dr Sivakumar and medical officers in the Department of Psychiatry, USM. The names of real people involved have been omitted as well as names of institutions References
Copyright 2004 - Malaysian Journal of Medical Sciences |
| |||||||||
