Tuesday, March 29, 2022

Boquete: Answer to Prayers!



According to old Chinese advice, it is wise never to discuss politics or religion even amongst best friends.  

Religious belief can often blur judgment in the wisest of people.

Thirty years ago, a patient of mine was unconscious for 23 days and it was mother's belief that it was through prayer that her daughter was saved. I did not argue with her then.

But perhaps God works through his people in his own way. Discoveries in Medicine should therefore enhance our faith rather than the other way round.

It took nearly 30 years for the real answer to her prayers to really emerge.

 ©2012 Am Ang Zhang
I was staying at our resort in Boquete and was having dinner with three friends all of them with medical connections. One was in hospital administration and one a nurse. The husband of the nurse was a pharmacist. Somehow the conversation drifted into medical topics and knowing that I am a Child Psychiatrist the pharmacist started talking about his nephew who was nearly sent to a mental institution as he suffers from catatonia and doctors eventually diagnosed schizophrenia and put him on antipsychotics. Luckily the catatonic symptom probably saved him as some bright young thing just read the book Brain On Fire and gave him the Clock Test. That led to the NMDAR antibody testing that proved positive. He responded well to the treatment regime that has been developed and is off all antipsychotic medication.

My Teratoma patient was lucky as she belong to that group that improved without further treatment once the Teratoma was removed. She eventually had a baby.


The Power of Prayers & Teratoma: Brain & NMDA!


Anti-NMDA Receptor Encephalitis

NEW ORLEANS — A mysterious, difficult-to-diagnose, and potentially deadly disease that was only recently discovered can be controlled most effectively if treatment is started within the first month that symptoms occur, according to a new report by researchers from the Perelman School of Medicine at the University of Pennsylvania. The researchers analyzed 565 cases of this recently discovered paraneoplastic condition, called Anti-NMDA Receptor Encephalitis, and determined that if initial treatments fail, second-line therapy significantly improves outcomes compared with repeating treatments or no additional treatments (76 percent versus 55 percent). The research is being presented at the American Academy of Neurology's 64th Annual Meeting in New Orleans.

565 cases! Not so rare!

The condition occurs most frequently in women (81 percent of cases), and predominately in younger people (36 percent of cases occurring in people under 18 years of age, the average age is 19). Symptoms range from psychiatric symptoms, memory issues, speech disorders, seizures, involuntary movements, to decreased levels of consciousness and breathing. Within the first month, movement disorders were more frequent in children, while memory problems and decreased breathing predominated in adults.

My patient was under 18 and presented with catatonia symptoms. She later lose consciousness and was ventilated.

"Our study establishes the first treatment guidelines for NMDA-receptor encephalitis, based on data from a large group of patients, experience using different types of treatment, and extensive long-term follow-up," said lead author Maarten TitulaerMD, PhD, clinical research fellow in Neuro-oncology and Immunology in the Perelman School of Medicine at the University of Pennsylvania. "In addition, the study provides an important update on the spectrum of symptoms, frequency of tumor association, and the need of prolonged rehabilitation in which multidisciplinary teams including neurologists, pediatricians, psychiatrists, behavioral rehabilitation, and others, should be involved."

The disease was first characterized by Penn's Josep Dalmau, MD, PhD, adjunct professor of Neurology, and David R. Lynch, MD, PhD, associate professor of Neurology and Pediatrics, in Annals of Neurology in 2007. One year later, the same investigators in collaboration with Rita Balice-Gordon, PhD, professor of Neuroscience, characterized the main syndrome and provided preliminary evidence that the antibodies have a pathogenic effect on the NR1 subunit of the NMDA receptor in the Lancet Neurology in December 2008. The disease can be diagnosed using a test developed at the University of Pennsylvania and currently available worldwide. With appropriate treatment, almost 80 percent of patients improve well and, with a recovery process that may take many months and years, can fully recover.

Teratoma: finally!

In earlier reports, 59 percent of patients had tumors, most commonly ovarian teratoma, but in the latest update, 54 percent of women over 12 years had tumors, and only six percent of girls under 12 years old had ovarian teratomas. In addition, relapses were noted in 13 percent of patients, 78 percent of the relapses occurred in patients without teratomas.
As Anti-NMDA Receptor Encephalitis, the most common and best characterized antibody-mediated encephalitis, becomes better understood, quicker diagnosis and early treatment can improve outcomes for this severe disease.
The study was presented in a plenary session on Wednesday, April 25, 2012 ET at 9:35 AM at the American Academy of Neurology's annual meeting.
[PL01.001] Clinical Features, Treatment, and Outcome of 500 Patients with Anti-NMDA Receptor Encephalitis

Anti-NMDA-receptor encephalitis: case series and analysis of the effects of antibodies

Of 100 patients with anti-NMDA-receptor encephalitis, a disorder that associates with antibodies against the NR1 subunit of the receptor, many were initially seen by psychiatrists or admitted to psychiatric centres but subsequently developed seizures, decline of consciousness, and complex symptoms requiring multidisciplinary care. While poorly responsive or in a catatonic-like state, 93 patients developed hypoventilation, autonomic imbalance, or abnormal movements, all overlapping in 52 patients. 59% of patients had a tumour, most commonly ovarian teratoma. Despite the severity of the disorder, 75 patients recovered and 25 had severe deficits or died.

Related paper:

Anti-NMDA Receptor Encephalitis: Diagnosis, Psychiatric Presentation, and Treatment


Chapter 29  The Power of Prayers

The following is extracted from The Cockroach Catcher: Chapter 29 The Power of Prayers.

According to old Chinese advice, it is wise never to discuss politics or religion even amongst best friends.  

         Religious belief can often blur judgement in the wisest of people. In psychiatry it is sometimes not easy. This is particularly true in cases of florid psychosis, which often presents with symptoms of hallucination, delusion and even vision.

         I remember my early days of psychiatry in a mental hospital in Hong Kong. Yes, it was the days of 2000-bed hospitals. Yes, it was the days of Medical Superintendents who had supreme power and all doctors of whatever rank and experience were Mental Health Officers with special authority to sign papers for compulsory admissions. The forensic unit was contained within the same complex.         Those were the days when we encountered psychosis in the raw so to speak. All the colony’s really mad people were admitted to this one place set in the furthest corner of the colony. In our year seven of us decided without much discussion that we all wanted to go into psychiatry. That was over 10% and all had quite idealistic reasons. It was perhaps a bit of a disappointment to our parents that we did not pursue a more conventional specialty that might provide us with more status and financial reward. Then there was the fear of contamination that somehow one might become mad too. Recent day medical students are said to shy away from psychiatry for these same reasons.         Education seems to have little effect on superstition.
                                     ......................................….read the full Chapter: HERE

Brain on Fire   



Scientific America: https://www.scientificamerican.com/article/brain-on-fire-my-month-of/

Wednesday, March 9, 2022

Tango

 

 

 



Figure 1  Tango, Buenos Aires

 

         It was on one of the South American Cruises that we found ourselves in Argentina, a country about which we have heard so much and yet because of its size, cruising seemed a reasonable way to embark on our initial overview visit. We did book an extra three nights to spend in Buenos Aires at the end of the cruise, before flying home.

         Argentina, like a few other countries, suffered from a major economical disasters that alarmed the western world.  It was believed that its fragile financial system could not be saved even with the might of International Monetary Fund (IMF). 

         In fact, Argentina defied the IMF and managed to rescue itself a good deal faster that anyone could have expected.  Needless to say that in these situations the big boys with the money never quite suffered as much as the ordinary hard working folks. With their currency devaluation of a massive scale, we could only be thankful that we can enjoy their Malbecs and Torrontes at a very reasonable price.  Then there is their very good grass fed beef too.

         News just came as I was editing this chapter that the Hong Kong Stock Exchange just appointed an Argentinean as its Chief Executive[1] for a term of three years.

         We took the Buenos Aires Citybus which allows passengers to get on and stop at any stop they want, and made a stop at the outrageously colourful La Boca neighbourhood.

         Here the old tenement houses had been built and painted in a haphazard manner.  The result is that of a very pleasing sight that has attracted many tourists.

         Then there is of course Tango, which played a major role in shaping Argentinian culture and society.  Tango is more sensual than any other dance routine and where else to watch it than at one of their dinner theatres where one could enjoy not only the dance show, but also their beef and a bottle of Malbec.

         As a Child Psychiatrist, Argentina is about Anorexia Nervosa, Minuchin’s way of looking at it.

 

         I was fortunate enough to be introduced to Minuchin’s work by my good friend who specialised in Anorexia Nervosa research. I remembered him showing me a book when I went to stay with him before attending a Royal College of Psychiatry Conference.

         The book “Psychosomatic Families” is one I would recommend to anyone working with families and of course with Anorexia Nervosa cases.  There has been too much shift in modern Psychiatry to try and mimic practices in other branches of medicine.  Experienced psychiatrists will soon find out that there is really no simple straight forward treatment any way.  My friend told me that Minuchin’s understanding of these families has been very helpful to him, way beyond the causes and treatment of Anorexia Nervosa.

         I will not apologise for repeating what Minuchin stated in that book about the characteristics of such families: enmeshment, overprotectiveness, rigidity, avoidance of conflict.  For the benefit of those readers who are not familiar with his work, I quote you the following from his book: 

 

“Enmeshment is a transactional style where family members are highly involved with one another. There is excessive togetherness, intrusion on other's thoughts, feelings and actions, lack of privacy, and weak family boundaries. Members often speak for one another, and perception of the self and other family members is poorly differentiated. A child growing up in this type of family learns that family loyalty is of primary importance. This pattern of interaction hinders separation and individuation later in life.

 

Overprotectiveness refers to the excessive nurturing and protective responses commonly observed. How can the psychiatrist begin to argue against such a good trait! Pacifying behaviours and somatisation are prevalent.

 

Rigidity refers to families that are heavily committed to maintaining the status quo. The need for change is denied, thereby preserving accustomed patterns of interaction and behavioural mechanisms. Rigidity is commonly observed in the family cycle during periods of natural change where accommodation is necessary for proper growth and development. You must have seen families where for every single day of the week they eat the same meal year in year out.

 

With Avoidance of conflict, family members have a low tolerance for overt conflict, and discussions involving differences of opinion are avoided at all costs. Problems are often left unresolved and are prolonged by avoidance manoeuvres. Everyone would come up with a highly believable excuse. After all everyone is very clever!”

 

         Minuchin has certainly inspired me the most in my work with families, and with Anorexia Nervosa in particular.  Above all, he helped me in my understanding of family dynamics and in turn in my personal dealings with problem families and Anorectic patients. 

         Salvador Minuchin was born in San Salvador, Entre Ríos, Argentina.  After obtaining his degree in medicine, he served as a physician in the Israeli army.  Subsequently he went to US first for child psychiatry and then psychoanalytical training, with another spell of working in Israel (this time with displaced children) in between.   It may be of interest to readers that the current new generation of psychiatrists, including those in the US, were no longer brought up in psychoanalysis and as a result, they probably have little understanding of either the personal psyche or the family dynamics that we grew up in.  Of course psychoanalysis has its many faults but to totally dismiss it is indeed very sad for mankind.  It is lamentable that even before my retirement, at some conferences the Anorexia themed talks were all about which drug to use to induce hunger and eating when treating such cases.

         As in the case of classical Autism, parents of many sufferers of Anorexia Nervosa are amongst the most successful in their own professions.  Many are CEOs of major corporations, hospitals and large organisations.  Minuchin’s insightful understanding of family dynamics greatly enabled me to navigate the often very difficult terrain.  More so than trying to learn Tango!

         While reading “Fragile Lives” by Stephen Westaby, it occurred to me that in most branches of medicine, there was always someone that would have tried something that had never been tried before and if they were lucky enough, it worked and a life was saved.  I was fortunate enough to be at the Sage Gateshead Free Thinking Festival one year when Professor Westaby, a heart surgeon and three others (a Professor of Circadian Neuroscience, a crime writer, and a mathematician) took part in an open discussion about the pace and rhythm of life, contemplating the speed of life and whether that runs fast or slow depends on what you use to measure it.  The event led me to Westaby’s book in which he described remarkable events of his career.  We have been to Newcastle before, but not Gateshead, which sits on the other side of the River Tyne.  The quayside has a vibrant atmosphere, awash with restaurants, bars, cafes and hotels.  The concert and conference venue Sage Gateshead itself is an impressive glass and stainless steel building designed by Foster and Partners, who won the competition managed by RIBA (Royal Institute of British Architects).  The modern Millennium Bridge, Sir Antony Gormley’s steel sculpture the Angel of the North, and the Baltic Centre For Contemporary Art complete the scene.

         Having been introduced to Minuchin’s “Tango in Child Psychiatry”, one day I found myself dancing the routine without any premeditation or preparation.  Fortunately for me, and perhaps for the patient too, the Sister on the ward was aware of my sometimes unconventional approaches and she managed to make the whole “heart” operation run smoothly.

         One Wednesday afternoon I received a call from our Sister on the Paediatric ward saying that our senior paediatrician wanted me to see one of his patients urgently.  This senior paediatrician was the first to recognize the important role of a Child Psychiatrist in his department and gave me free use of two beds on the ward.  The referral came at a most fortunate time, because it was half term break.  During term time, I would have gone to visit the special school for consultations.

         How did I manage to have overlooked this girl, Lara, lying in the corner of the ward?  I tended to make regular use of the two assigned beds, and I had been in the ward most days.

         Ah, it was because she was on a drip and looked like a “real” paediatric patient, unlike many of my young patients who were healthy looking and running around, one being the five year old girl who was still wearing a nappy.  I should have noticed.  It was unusual for this ward to have seriously ill patients, only fractures and sometimes post operation tonsil patients.

         Both parents stood up as I approached the bed and shook my hand after I was introduced by Sister Wendy.  Sister Wendy was one of the sisters I had a lot of time for, as she seemed to be able to read my mind, just like my clinic secretary.

         “You can use the side ward if you like.  We have just discharged the boy with the fracture.”

        

         Well, I did tell you, didn’t I.

 

         Lara said, “I can walk!” and she carried her drip stand and started making her way there.

         I looked at Sister Wendy, not knowing her paediatrician’s instructions. I thought I would play safe until I get to know the patient.

         Sister whispered to me that the paediatrician said the case was all over to me. 

         I now have full clinical responsibility.

         That was great.  It was not a consult but a transfer.  I could now do as I wish, I mean, do what was best for the patient. 

 

         Sister, sensing my reservation, got a wheelchair to transport Lara in no time and we all settled nicely in the side ward. Drip and all.

         Lara was on Naso-Gastric feeding, and strict bed-rest, but was still losing weight.

         “Sorry, Dad, you are going to miss your golf again!”

         “And, Mum, your book club!”

         “Doctor, I have not played golf since Lara’s admission and my wife has not been to her book club.  She is our only daughter and whatever it takes, we just like to get her better.”

         “But it upsets me that you both have to miss things you love!”

         Already demonstrating characteristics described by Minuchin. 

         I had to try and not look too smug.

         “So, just eat, get better and they will have golf and book club back.”

         Did I say that?  Of course not.  If she could do that, they would not need me.

         But coming to think about it, it really could be that simple.

         “Golf is my passion. I have been Captain for a few years but had to resign because of Lara’s illness. Our house is only yards from the entrance of the club.”

         I knew that club and had played there because one of my colleagues, a close friend, was a member there.   When first inviting me to play at the course, he explained that the club closely enforced the rules of St. Andrews, and if I was to wear shorts, they must be tailored.  I never wore shorts anyway and so it was not a problem.

 

         “I am sorry, Dad, but I think the doctors could not figure out why I was losing weight.  I really really want to get better so that you and mum could be getting back to doing all the things you love.”

         Bingo! Conflict avoidance.

         So, they were not told that this was a case of Anorexia Nervosa, that there was “nothing” wrong in the usual physical sense of the word but something very wrong in the “psychological” sense and she could die.

         No, the doctor did not say that, and this doctor would not say that either.

         So started my marathon session with this family, and it went on for the better part of the afternoon and early evening.  There were many questions which they managed to answer.  Father was very high up in his firm and worked from home on Wednesdays and that included golf.

         Is golf work too?  Most in his position would tell you it is and I would not argue with that.

         For some months now Lara had been having problem with her swallowing and that was when she was referred to the paediatrician. By the time she was seen she had lost a third of her body weight.

         “They have done a lot of tests……” Lara started.

         “……and so far they could not find anything!” Mum continued.

         “Doctor, as I told you earlier, we will be happy with whatever test you deem necessary!” Father finished.

 

         “Something must be very wrong……..as her……” Mum continued.

         “Period stopped.” Dad finished.

         “And she is growing……” Mum intercepted….

         “All these funny……”Dad continued….

         “……long hair over her arms and her body!” Mum finished.

         For the first time since this interview started, Lara stopped her pleasant smile and looked a bit embarrassed.

         “Sorry, darling, but Grandma told me the Kotex was clean and she told me about the hair too!”

         “Grandma usually baths her before dinner; we like a good routine, just like on Wednesdays we order Pizza as Dad has to play golf and I have my book club.” 

         A 17 year old girl being bathed by grandma?

         Overprotectiveness! Enmeshment!

         “Friday is always fish. You must have guessed.” The smiling Lara was back.

         I could see why modern fashion houses prefer very thin girls as Lara remained attractive despite her dangerous weight level.

         “Roast beef on Sundays with Yorkshire pudding.”

         “Which I love, but I could not swallow it.”

         Rigidity!

         “The paediatrician decided to tube feed her but not only is she not gaining….”

         “……she is losing still.” Mum finished Dad’s line.

         “It started after her Cambridge interview and I thought the weight loss was due to anxiety over the conditional offer on all As.”

        

         Well, that was Cambridge.  Oxford offers EEs for students they like, knowing all As or even A* would be what these students will get.

         At least now we had touched on a possible stress factor.

         “Which College?”

         “Newnham!” Lara replied.

         “She is at an all girls school now.  We thought she might……..” Mum explained!

         “…..cope better at an all women’s college!” Dad completed!

         It was amazing how the Minuchin family dynamics came to life! 

         Over time, I came to the conclusion that marathon sessions could break down conflict avoidance extremely well and it was more productive to spend a lot of time especially in the first session than to wade through many short sessions.

         As it turned out, Lara was very different from the other anorectics I had treated up to that point.  A “one size fits all” method simply did not exist.  I found myself quickly adapting my approaches. 

        

         Her apparent naivety was dangerously inducing collusion.  You had better not start to feel sorry for this possible future Cambridge educated model.  Watch out because conflict avoidance might well be contagious. 

 

         To convince this trio of what we were trying to deal with, I had to try and put what they already knew in a different context. 

         When I hinted at isometric exercising (contracting muscle without body movement), Lara blushed without having to admit that was how she fought the tube feeding.

 

         “So what do we do now?” Dad assumed his lead position.

         At this point the door opened and a push trolley appeared with four cups of tea and some biscuits.

         “Lets all have some tea and biscuits.”

         “Would…….” Mum looked at me….

         “…..her stomach……”Dad looked worried….

         “…..be able to take the biscuits!” Lara was quick to complete the sentence.

         Although I was at the first ever London Family Therapy course, I had not had much practice.  I was now struck by the manifestation of enmeshment, and all the Jungian teaching about failure of Individuation was making sense.  Not eating was indeed a final desperate attempt at individuation and this good doctor was plotting to destroy it.  Would it be the right way forward?  It might take a while to find out whether this step would save a life.

         I asked Sister to remove the Ryle’s (feeding tubes) and Lara was so trusting in this new found doctor that she ate her two biscuits and drank her tea.  I sent for two more biscuits.  At dinner time she finished everything on her plate and drank a whole glass of milk, full cream for that matter.

         Mother was in tears.  Father went home when Lara was waiting for dinner to bring Grandma, who could not stop thanking me.  I told her that the three of them did most of the talking and I just listened, which was basically true.

         On leaving I asked mum what book they were reading at her Book Club.

         “Joy Luck Club!”

         “Amy Tan!”

         “So you know it.  Next time I turn up at the book club, they will all be very jealous that I actually talked to a Chinese in person! And a Psychiatrist at that!  Thanks for saving Lara and for saving us.”

         It must indeed be one’s aim to tap into the strength rather than weakness of either the patient or the family.  Anorectics and their families are very intelligent people and Minuchin’s treatise on family characteristics offered a lot of insight that enabled me to fathom and guide such patients and their families. 

          With the tube and the drip removed, Lara obviously stopped her secret isometric exercises and started to put on weight.  Soon she was allowed out on leave to sit her A level exams.  All “As” of course.  She eventually got to Newnham College, Cambridge.



[1] https://www.scmp.com/business/banking-finance/article/3121140/hong-kongs-stock-exchange-operator-finds-ceo-replace

Sunday, December 12, 2021

Mind & Ecology: Who is the Real Patient?

The mind is fascinating and more fascinating in Child Psychiatry if you can afford the time to try and understand it.

There is little doubt in my mind after spending 30 years trying to think like a child (un-ashamedly borrowed from Picasso), I have come to realised that our creator has provided our mind the facilities to heal and recover. It is perhaps important that we should not jump in and use medication Willy Nilly. Unfortunately nowadays they might be used for the personal gain of the psychiatrist!



From The Cockroach Catcher: Chapter 19   Who Is The Real Patient? Part 2


 The early seventies was a very exciting time in London as the first ever course in Family Therapy in the U.K. was just launched.  Gregory Bateson just published Steps to an Ecology of Mind, which to this day still manages to be exciting for anyone interested in family systems – a term coined to describe the interaction within a family or extended family.   Of course years before that, Ibsen neatly observed family interactions in Ghosts and Wild Duck. 

©2006 Am Ang Zhang

Both plays vividly captured family interaction that has hardly been bettered by any other modern writings.

Wayne
         Wayne must have been about thirteen when he was referred to me. As with many similar cases he had not attended school for the better part of a year. I thought that this was another case of some degree of maternal depression rubbing off on the boy.
         Wayne’s father was a Sea Captain for years but for some years now he preferred to stay with Wayne’s grand parents. “Who could blame him?” Wayne would remind me and himself. There was never a question of divorce and he did not want to involve the psychiatrists either.  He preferred to just stay quiet about it.
         Wayne had a very impressive crop of hair very much like that of Art Garfunkel. He was also very good looking, which immediately made him number one target for bullying. His favourite subject was English. He liked poetry and Shakespeare best – further cause for bullying.  He enjoyed classical music as his father had a vast collection of records. But he kept this secret hobby to himself as the bullies already had too many reasons to pick on him. It was a rather sad reflection of our society.
         The crisis came when his English teacher went on maternity leave. Before then, he was teased as the teacher’s pet. His attendance at school was erratic at the best of times and when she went on leave he stopped going entirely. Then when he realised she was not coming back Wayne decided that school was finished as far as he was concerned.
         To me Wayne had managed to find a good excuse to relieve himself of some rather petty and chronic bullying which could sometimes be worse than being severely beaten up. I condone neither, but both kinds occur with serious regularity in our schools although generally denied by school authorities. The side effect of this is that it is often a relief for all concerned when a request is made that the child should not attend school. It is when you start asking for other educational provision that troubles generally begin.
         Wayne, once you got to know him, was the most pleasant boy you could wish to meet. He was not only courteous and well spoken, but also very knowledgeable about his subjects of poetry, Shakespeare and music. I do prefer to see more of the Wayne type than some other types I do not care to mention. It might be unprofessional but I know a few of my colleagues felt the same way too.
         Some patients kept us interested.
         Despite his age, Wayne was always brought to the clinic by his mother. They both cycled in. The reason was quite simple: Wayne needed protection, not from anyone in the clinic but from the possibility of bumping into someone on the journey to the clinic and back.  When I realised this, we shifted the appointments to school hours and Wayne managed to turn up now and again without his mother.
         His mother was always well turned out, always soft spoken and always waited in the waiting room through the whole session except when she saw our social worker. But those appointments were spaced out as nothing much came out of them. 
         After nine months, Wayne finally opened up to me.
         Mother never threw away anything. Nothing at all!
         Except wet waste, which was a relief.
         This was a serious case of OCD (Obsessional Compulsive Disorder). It was still a great shock to have the full extent of the things that were kept detailed to you. Even a five bedroom house soon ran out of space.
         Wayne told me that as far as he knew, mother had always been reluctant to throw away anything but it seemed to get out of control about five years ago when she discovered that father kept a woman in a port in the Far East. She moved out of the master bed-room and the rubbish moved in. Everything was neatly put in big rubbish bags and properly tied up. Some were in apple or other supermarket boxes. Even vacuum cleaner bags were kept.
         Mother did a good job of it so that there was no bad smell at all, Wayne would reassure me. Just no space.
         All these months, I had been thinking that the bullying was the cause of Wayne’s problem. Did I get it wrong? All the time I spent trying to improve his self esteem, was it time wasted? Was there something I could have done earlier? Why did he take nine months?
         Perhaps he needed that time to find out if I was going to send his mother to an asylum. Perhaps he needed all that time to trust me enough to talk about the sickest person in the family. Perhaps he never had any plan but the secret just came out.
         Perhaps these were all valid explanations, but what could we as a clinic do?
         It would be great if I were able to tell you that we carried out some wonderful therapeutic intervention. Mother was able to get rid of her “collection” and Wayne went back to school and eventually went to university and became a Professor in English or the Classics or something like that.
         It would have been nice, but that would only have been a fairy tale.
         We tried to arrange a couple of mother/son meetings but we really got nowhere. Wayne made vague promises in front of his mother that he would get back to school if this and that happened but I think he knew that neither he nor his mother could really initiate any change.
         Could a mother or son in such a relationship make a bold move to get the other going? I fear not. It was a kind of symbiotic relationship that had gone too wrong for too long.  By making a move to get “better”, one party would be putting enormous pressure on the other to do likewise. Often either party would be afraid to become better in case the other one might become even sicker.  It was just too risky to get better.
         It is not uncommon for young and enthusiastic juniors to be attempting the bolder approach to force a change. I have come to realise and respect that many forms of mental illness are a kind of defence and in the end the mind or the gene that is the engine driving it knows best.
         Similarly with drug addicts, alcoholics and many with sexual deviancy and perversion, our belief that they may change is perhaps misguided at the best of times and at worst, dangerous to others in society.
         I was young then and a plan was soon hatched to somehow persuade mother that we would arrange for her “luggage” to be cleared. She indicated that she would find it difficult to watch. We managed to persuade her to go on a short break in her favourite seaside resort so that she would be away.
         To our great surprise she agreed.
         On the day, we had a phone call from the car that we had arranged to pick her up.
         “She did not answer her door.”
         Our social worker rushed there. Wayne’s mother refused to let her in but talked to her at the door. She had changed her mind. She did not want to go ahead with the plan. By then the firm we engaged to remove the rubbish had turned up too but she was adamant that she did not want it done. After an hour of hard negotiation everybody left.
         She turned up for her next appointment to say that she could not sleep the night before thinking about what we offered to do for her (or perhaps to her). She felt it was such an imposition. She would need to dispose of those things herself when she was ready. When she was ready! I have a great admiration for the English way of understating things.
         Wayne I never managed to get back to school. He never sat any examinations.
         On the official school leaving day he asked me what he should do next. I told him that perhaps on leaving my clinic that day he should go to the local Job Centre to find a job.
         To my great surprise he did. He was immediately offered a job at the local Water Works department as a receptionist/secretary. There they had problems keeping any female secretaries and Wayne fitted the bill. He had been typing since eleven and his English was good.
         As far as I know, he is still with them. I do not think mother ever threw her things away.
         Some cases you remember because of good dramatic changes. Others you just remember.

From a doctor friend:

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 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.




Waste Not: Projects 90 MOMA /©2009 Am Ang Zhang


In psychiatry, sometimes patients do not want any help. Often they positively refuse help and family members collude. At other times the “help” may not be all that good.

As a result many children grow up in very “unusual” environments. Yet we sometimes get very “unusual” outcomes as some individuals can turn such an experience into something ……well, something quite extraordinary.

Obsessional Compulsive Disorder (OCD) is one such condition that many families prefer to cope with secretly and often for many many years.


                                                                     Chapter 19 The Cockroach Catcher



Waste Not: Projects 90 MOMA /©2009 Am Ang Zhang
Recently, I visited The Museum Of Modern Art ( MOMA) in New York and saw something that reminded me of my patient’s mother.
Mr. Song Dong is the artist and his mother is called Ms. Zhao.
Here is a write up in The New York Times:
“Mr. Song was born in Beijing in 1966, on the very eve of the Cultural Revolution, a period of ideological danger and economic want. His mother came from a wealthy family that lost everything after one of its members was jailed as an anti-Communist spy. His father, trained as an engineer, spent seven years in forced labor after being accused of counterrevolutionary activity.
“When Mr. Song’s father died, in 2002, his mother was inconsolable. She continued to live in the jammed Beijing house, throwing nothing away and obsessively bringing more stuff into it, as if continuing to feather a nest for a now-absent family. And despite the threatened destruction of the surrounding area, she would make no move that entailed parting with her possessions.
“Finally, in 2005, Mr. Song proposed that they turn the accumulated junk into an art project. In this way, he argued, nothing would be discarded and lost; everything would be meaningfully recycled and preserved. His mother agreed to this and together, with the help of Ms. Yin and Mr. Song’s sister, Song Hui, they emptied the premises.

Waste Not: Projects 90 MOMA /©2009 Am Ang Zhang
“Seen in the museum’s immaculate surroundings…….it is disturbing to imagine anyone growing up, as Mr. Song did, in so smothering a physical environment. Finally, it is deeply moving to see the span of one person’s life — his mother’s — summed up, monument style, in a work of art that is every bit as much about loss as it is about muchness.
“And five years after the piece was conceived……..mother agreed to collaborate with her son, empty her home and effectively let go of her past, she moved into the more manageable setting of a Beijing apartment near a park, where she died last winter after falling from a step ladder while trying to rescue a wounded bird in a tree.”
Life could be cruel.
Waste Not: Projects 90: Song Dong
June 24, 2009–September 7, 2009
The Donald B. and Catherine C. Marron Atrium

From Wild Duck:


"Deprive the average human being of his life-lie, and you rob him of his happiness."

The Cockroach Catcher on Amazon Kindle UKAmazon Kindle US


Waste Not: OCD & MOMA


Monday, December 12, 2011