Monday, July 25, 2016

Autism: Unusual! Unusual! Unusual!

Some unusual flowers in Tasmania!

©Am Ang Zhang 2013

Reminds me of an unusual response: 

Can wrong sometimes be right? 
A question I had to face in my years of practice in 
Child Psychiatry.


The Consult:

Dear Cockroach Catcher:
We are a bit stuck with this Autistic boy with unusual OCD symptoms.

The boy was born in the US of American mother and British father. Diagnosed Autistic Spectrum Disorder age 4 with OCD symptoms. Was sent to an institution at age 5 when parents separated and mother could not cope. Father managed to get him to England after 10 months. His obsessional symptoms got worse and amongst them the most difficult is that he can’t bear to wear any clothes which are not brand new. He checks the tag, feels the clothing and sniffs it to decide if he would wear it.

He is on Prozac 40mg, which has reduced the aggressive outbursts but not made any real inroads into the dressing problem……except that he has occasionally managed to wear used socks.

Many thanks!

Yours XXXXX

P.S. You can see we missed your innovative ideas!


Dear XXXXX

Sorry, I have been in some far away places and did not quite reply early enough!

Nowhere else in medicine is “innovation” more appropriate than in Child Psychiatry!

My first thoughts were: Cheat!

Then perhaps: Collude!

Neither would be in NICE or any textbook.

Cheat: get father to keep all the clothes tags or write to companies to get a lot of them to tag on to his clothes so that they are like new.

That saves some money. Failing that steal the tags.

(I can't believe I said that)

Patients come first.

Collusion: because he could sniff and tell that the re-tagged clothes are not new we may have to get him to agree to the ritual of tagging clothes and folding them nicely. One of my autistic patients turned our session into a TV session. So collusion is a better way.

It is a pity that nowadays we cannot spend enough time with these patients to understand them. If I may venture further and suggest that the boy perhaps associated new clothing to the new life with his father and he wanted to keep it that way. Obsessional symptoms are essentially a defence in psychodynamic terms and until the child (autistic or otherwise) can be sure of his place at his new home he is going to keep his defences. 

So spend more time with him and you may well be surprised!

It is probably good he was not in an institution. That was what they nearly did to Temple Grandin. There is so much we can learn from her story. She too was nearly institutionalised. She famously created a cuddling machine for herself!

Innovation again.

Wrong may sometimes be right.

Let me know. 

Yours 

P.S.:

A doctor friend's WRONG but RIGHT decision: 


He wrote to me after reading my book:

The Cockroach Catcher has evoked many images, memories, emotions from my own family circumstances and clinical experience.

My 80 year old Mum has a long-standing habit of collecting old newspaper and gossip magazines. Stacks of paper garbage filled every room of her apartment, which became a fire hazard. My siblings tricked her into a prolonged holiday, emptied the flat and refurbished the whole place ten years ago. ……My eldest son was very pretty as a child and experienced severe OCD symptoms, necessitating consultations with a psychiatrist at an age of 7 years. The doctor shocked us by advising an abrupt change of school or we would "lose" him, so he opined. He was described as being aloft and detached as a child. He seldom smiled after arrival of a younger brother. He was good at numbers and got a First in Maths from a top college later on. My wife and I always have the diagnosis of autism in the back of our mind. Fortunately, he developed good social skills and did well at his college. He is a good leader and co-ordinator at the workplace. We feel relieved now and the years of sacrifice (including me giving up private practice and my wife giving up a promising administrative career ) paid off.

Your pragmatic approach to problem solving and treatment plans is commendable in the era of micro-managed NHS and education system. I must admit that I learn a great deal about the running of NHS psychiatric services and the school system.

Objectively, a reader outside of the UK would find some chapters in the book intriguing because a lot of space was devoted to explaining the jargons (statementing, section, grammar schools) and the NHS administrative systems. Of course, your need to clarify the peculiar UK background of your clinical practice is understandable.

Your sensitivity and constant reference to the feelings, background and learning curves of your sub-ordinates and other members of the team are rare attributes of psychiatric bosses, whom I usually found lacking in affect! If more medical students have access to your book, I'm sure many more will choose psychiatry as a career. The Cockroach Catcher promotes the human side of clinical psychiatric practice in simple language that an outsider can appreciate. An extremely outstanding piece of work indeed.


Temple Grandin: Wrong Appointment that was right!


Dr Temple Grandin has a unique ability to understand the animal mind - and she's convinced her skill is down to her autistic brain.


Temple believes she experiences life like an animal. Her emotions are much simpler than most people's and she feels constantly anxious. It's this struggle with overwhelming anxiety that led her to discover just how much she has in common with animals and, in particular, cows.

Using her ability to observe the world through an animal's eye, she has been able to make an enormous impact on animal welfare. Her greatest achievement has been in the area of slaughterhouses - she has fundamentally changed the way animals are held and slaughtered.

Today she's an associate professor of animal science, a best-selling author and the most famous autistic woman on the planet.

Temple Grandin Website:

Dr. Grandin didn't talk until she was three and a half years old, communicating her frustration instead by screaming, peeping, and humming. In 1950, she was diagnosed with autism and her parents were told she should be institutionalized. She tells her story of "groping her way from the far side of darkness" in her book Emergence: Labeled Autistic, a book which stunned the world because, until its publication, most professionals and parents assumed that an autism diagnosis was virtually a death sentence to achievement or productivity in life.


Autism posts:



The Cockroach Catcher
Review on Amazon

The Cockroach Catcher on Amazon Kindle UKAmazon Kindle US

Thursday, July 21, 2016

Korea & Sunshine: Suicide!, Diabetes & Autism!

©Am Ang Zhang 2015

As Vitamin D is hitting the news, I am reprinting my blog that touches on the Korea phenomenon. We are of course talking about the Samsung Korea which has over the last 50 plus years adopted Western Science, Sports and Culture in a very big way.

South Korea has topped the world in Suicide rates (24.7/100,000) and now they found that Diabetes rate is as high as the US without the obesity that is normally associated with it. Could Sunshine/Vitamin D be part of the answer?

South Korea has enjoyed its link to the west and has embraced advances in modern technology that has helped to establish itself as a major force in Steel and Car production. It is not backward in embracing modern electronic technology and is a major player in Computers, Cell Phones and of course Television.

They have a culture of taking things seriously and that shows in their attention to technical details in advance production. Why else do you think much of Apple’s iPhone component is made by its rival, Samsung.

South Korean children were brought up to play golf and western music instruments. South Korea supplies western orchestras with a large number of musicians.

South Koreans embrace western idea of medical advance as well. Could this be the cause of one of its problems?


The Independent:
AFP
Saturday, 14 May 2011
A population-wide study of South Korean children has shown autism rates much higher than in the United States, suggesting more people worldwide may have the disorder than previously thought.

By examining 55,000 children age 7-12, even those not enrolled in special education programs, researchers found that one in 38 children had some form of autism, including the more mild social disorder known as Asperger's Syndrome.
In the United States, the autism prevalence rate is believed to be one in 110.
1: 38?
Sunshine:
In my recent cruise of Central America crossing the Panama Canal, it is not difficult to spot the South Koreans. They were dressed to be protected from the sun.
Despite temperatures reaching the mid 90s F, long sleeves, long slacks and hats with near complete surround was the order of the day; and Golf gloves as well, for both hands. And that is just for walking around town.
I have no idea how much Sunscreen they use, but that would be 50 SPF minimum.

You stay indoors with music instruments!
So lets look at their golfers:

Very little sun tan!!!

In an earlier post:
April 1,2009
Confirming the fears of Somali immigrants in Minneapolis, the Minnesota Health Department agreed Tuesday that young Somali children there appeared to have higher-than-usual rates of autism.

"Though health officials emphasized that their report was based on very limited data, they concluded that young Somali children appeared to be two to seven times as likely as other children to be in classes for autistic pupils.”
Could sunshine or the relative lack of it be the culprit here. Sunshine and Vitamin D3 is the new black. 

In the history of Medicine, we sometimes ignore the most obvious. Just like mosquitoes in diseases in Panama.
Autism posts:


Wednesday, July 20, 2016

Bipolar Disorder: Lithium & Neuro-protectiveness!

Australian Trilogy:


Bipolar Disorder: Lithium-The Aspirin of Psychiatry?

 

Fremantle: Medical Heresy & Nobel

 


Tasmania & SIDS: The wasted years!


©Am Ang Zhang 2013

Cade, John Frederick Joseph (1912 - 1980)
Taking lithium himself with no ill effect, John Cade then used it to treat ten patients with chronic or recurrent mania, on whom he found it to have a pronounced calming effect. Cade's remarkably successful results were detailed in his paper, 'Lithium salts in the treatment of psychotic excitement', published in the Medical Journal of Australia (1949). He subsequently found that lithium was also of some value in assisting depressives. His discovery of the efficacy of a cheap, naturally occurring and widely available element in dealing with manic-depressive disorders provided an alternative to the existing therapies of shock treatment or prolonged hospitalization.

In 1985 the American National Institute of Mental Health estimated that Cade's discovery of the efficacy of lithium in the treatment of manic depression had saved the world at least $US 17.5 billion in medical costs.

And many lives too!

I have just received a query from a reader of this blog about Lithium, and I thought it worth me reiterating my views here.      It is no secret that I am a traditionalist who believes that lithium is the drug of choice for Bipolar disorders.

The following is an extract from The Cockroach Catcher:
“Get him to the hospital. Whatever it is he is not ours, not this time. But wait. Has he overdosed  on the Lithium?”

“No. my wife is very careful and she puts it out every morning, and the rest is in her bag.” 

Phew, at least I warned them of the danger. It gave me perpetual nightmare to put so many of my Bipolars on Lithium         jjjjj          but from my experience it was otherwise the best.

“Get him admitted and I shall talk to the doctor there.”

He was in fact delirious by the time they got him into hospital and he was admitted to the local Neurological hospital. He was unconscious for at least ten days but no, his lithium level was within therapeutic range.

He had one of the worst encephalitis     they had seen in recent times and they were surprised he survived.

Then I asked the Neurologist who was new, as my good friend had retired by then, if the lithium had in fact protected him. He said he was glad I asked as he was just reading some article on the neuroprotectiveness of lithium.

Well, you never know. One does get lucky sometimes. What lithium might do to Masud in the years to come would be another matter.

I found that people from the Indian subcontinent were very loyal once they realised they had a good doctor – loyalty taking the form of doing exactly what you told them, like keeping medicine safe; and also insisting that they saw only you, not one of your juniors even if they were from their own country. It must have been hard when I retired.

Some parents question the wisdom of using a toxic drug for a condition where suicide risk is high. My answer can only be that lithium seems inherently able to reduce that desire to kill oneself, more than the other mood stabilizers, as the latest Harvardresearch shows.
Lithium has its problems – toxic at a high level and useless at a low one, although the last point is debatable as younger people seem to do well at below the lower limit of therapeutic range.
Many doctors no longer have the experience of its use and may lose heart as the patient slowly builds up the level of lithium at the cellular level. The blood level is a safeguard against toxicity and anyone starting on lithium will have to wait at least three to four weeks for its effect to kick in. In fact the effect does not kick in, but just fades in if you get the drift.
Long term problems are mainly those of the thyroid and thyroid functions must be monitored closely more so if there is a family history of thyroid problems. Kidney dysfunction seldom occurs with the Child Psychiatrist’s age group but is a well known long term risk.
Also if there is any condition that causes electrolyte upset, such as diarrhea, vomiting and severe dehydration, the doctor must be alerted to the fact that the patient is on Lithium.
Could Lithium be the Aspirin of Psychiatry? Only time will tell!
Related Posts:


Chile: Salar de Atacama & Bipolar Disorder.



The Cockroach Catcher
Review on Amazon

The Cockroach Catcher on Amazon Kindle UKAmazon Kindle US

Monday, July 18, 2016

Sleeping on Duty: Bed 1 & The Moon!

Recent Junior Doctor discussions on sleeping on duty brought back memories for this retired Child Psychiatrist. When I did my first House Job (residency) in Internal Medicine I was on for two nights out of three and three weekends out of four as it is busier weekends and more of us would be needed. 

We have three Internal Medicine Units and I am in Medical C for want of a creative name or a rich donor. We need to be on after acute take as these were our patients. It provided for continuity and training. Then we are off for one night when, if we do go to the cinema, it would be a waste of money as we fell asleep within minutes. We have 36 beds and bed 1 is with bed 36 behind the nurse station. Nurses tried not to use bed 36 so that the Houseman could catch some sleep. I once fell asleep on one of the those rare nights when everything went quiet at about 2 am. I was catching up with history from a wife at the nurse station. The wife stood across the highish station and the next I knew was that an hour or so went by. I fell asleep holding my pen. 

The wife of the patient just said: You must be tired, doctor. 

No complaints and she did not walk off either. I was so grateful. Medicine the way it should be. In Hong Kong.




©2013 Am Ang Zhang

Then I remember my Bed 1 patient: 


The Cockroach Catcher  Chapter 47  Going To The Moon


T
 ime and again I have been asked why I decided to pursue child psychiatry as my career. This question was often posed by my juniors who were at the point of their life when they had to choose their career path. It would have been dishonest of me to tell them that I knew exactly why. In life certain events seem to just happen and hopefully they gel together well enough so that one does not have to say at the end of one’s working life that a wrong decision was made.
         After passing my finals, I did my internship in Internal Medicine and Obstetrics and Gynaecology.
         In our final year the first reports came through of cures in Leukaemia.  People’s hopes were rekindled and Medicine moved into a new era.
         Needless to say cancer touches every family in more ways than one can imagine and especially when it hits at one’s prime in life it is a highly emotive thing. In other words, no one is immune, not even if you are a doctor. At the time of my internship we had to deal with all those over the age of twelve and a number of inpatients were young Oncology cases. One of the boys I can remember was having the full VAMP treatment. Someone had a dry sense of humour to borrow from the word Vampire and with good reasons. Blood samples had to be drawn often and it was years later that I appreciated the work of some psychiatrists who recommend the limiting of daily blood drawing to before 10 A.M. every morning. This simple enforceable rule greatly reduced the emotional stress of the children involved. Patients were by and large compliant and they knew that the blood drawing was important.  When they were able to work out that it would not happen after 10 A.M. they had at least a good ten hours of relative peace.
         I had this highly intelligent boy on the ward with Leukaemia on treatment. He was barely thirteen and looked nine-ish. He was my most helpful assistant and would follow me on the lab trolley when I was doing my blood sample rounds. He would fill in the forms and match the numbers on the sample bottles. He never made a single mistake as far as I can remember.  Most of my contemporaries had some pet patient like that. How else could we have got through the day’s work? Most sisters and matrons turned a blind eye and the consultants and professors had been there so they did not mind either. Considering that we were then spending the major part of our waking life on the ward, we got closer to these patients than to anyone else in our life at that point.
         This boy was beginning to show the effect of steroids and he had some of the most frightening nightmares when he would scream in the middle of the night and nothing much would comfort him. He would sit up and say something about going to the moon and that was probably the only thing of which anyone could make some sense. The regular night nurse who had children of his age was most fond of him and would give me detailed reports of the timing of such occurrences. At other times I could see her playing her mother rather than nurse role and just holding him while he sobbed.
         He had the Number 1 bed which was right by the nurse’s station and it was a rather cosy one as the bed opposite was generally the last one to be used. If I had not been on call, he would give me a quick run down on who was new and who was unconscious and who had insecticide poisoning from suicidal ingestion. In any case, one could smell the insecticide as one walked in as these survivors breathed it out.
         We all so hoped that the cure would extend to him and he would certainly make a good doctor or a good nurse.
         One day when I returned from weekend leave – the one in four weekend that we got to catch up with our sleep, our romance and our family – I could smell something but it was not Malathion[1]. Something was wrong. All his things were gone and the bed was now stripped bare. Night nurse was still around, waiting for me to turn up.
         “He has gone to the moon,” she said.
         Oh no. He had a massive bleed in the brain and passed away during the weekend. His last words were: I am going to the moon.
         I more or less decided at that moment that although we were brought up on the first day of Medical School to confront death, this just might be too much for me. Dealing with the death of a good friend’s father following a cerebral haemorrhage was hard enough but the passing of a young thirteen year old was going to leave its mark and I did not want too many of those.



The Cockroach Catcher
Review on Amazon



The Cockroach Catcher on Amazon Kindle UKAmazon Kindle US

Can it be that it was all so simple then
Or has time rewritten every line
If we had the chance to do it all again
Tell me - Would we? Could we?
                                                                      The Way We Were


     

A Chapter on Anorexia Nervosa,  


Anne of Green Gables




[1] Malathion – an insecticide often ingested in attempted suicides at the time.