Dynamic Consultations with Psychiatrists. Jason Maratos

wedding with the height and a dress that suits her and that she can afford. Only with an improved sense of self‐worth will she be able to accept, for example, a reception that is appropriate to their financial status.

      JM then suggested, as simple techniques, to use extreme examples of either intellectual brilliance or exorbitant wealth. JM pointed out that he sometimes challenges patients who present with such difficulties by pointing out that most people are not professors at universities and most people are not exorbitantly rich. This comparison often stimulates people to value what they can contribute rather than rating themselves negatively according to what they cannot. The doctor concluded that this was a line of approach that he had already initiated and that Mrs. A was already showing signs of improving.

References

      1 Dein, S. (2018). Against the stream: Religion and mental health—the case for the inclusion of religion and spirituality into psychiatric care. British Journal of Psychological Bulletein, 42(3), 127–129.

Bob

      Presenting Condition

      Bob presented with depressed mood, suicidal ideation, preoccupation, and anxiety.

      History of Presenting Complaint

      Bob is a 30‐year‐old married primary school teacher living with his wife. Bob is new to the mental health services. In early April 2018, he downloaded a new software called “FOX” on his computer, which would automatically download web pages and videos after entering a few keywords. He had entered words related to explicit sexual intercourse. He had difficulty engaging in sexual intercourse with his wife. He claimed that he did not know what videos he had downloaded.

      He was reported to be mentally well until April 26, 2018 at around 5:00 a.m., when police arrived at his home and arrested him for “possession of child pornography.” He claimed that he was misled by police to confess that his computer was only used by him, although in fact it could be accessed by others (including his younger brother, wife, his wife's younger brother, and colleagues). He was brought to the police station, interrogated alone, and finally admitted the charge “under coercion.” The case was opened for investigation, and he was concerned regarding possible legal consequences including imprisonment. Since then, he had pervasive depressed mood with weeping episodes. His volition was low. He developed psychomotor retardation, was slow in actions and thoughts, with memory and attention deficits. He was socially withdrawn and preoccupied. He had increased anxiety, and described constantly being “on the verge,” with associated shortness of breath, chest discomfort, numbness of his fingers, and hand tremors. He had increased negative cognitions of worthlessness, helplessness, and hopelessness. He was admitted to the emergency ward of a medical center from April 29 to May 1, 2018, where he was seen by the visiting psychiatrist. He was given fluoxetine, diazepam, and lorazepam and was discharged. He sought help from legal advice on May 1, 2018, and the possible legal consequences were explained to him. He first attended the outpatient department on May 31, 2018, where a voluntary admission to a hospital was arranged. Since he was charged, he was suspended from duty as a primary school teacher and is on sick leave.

      Family History

      His father has depression with follow‐up. His mother has a delusional disorder, with past admissions to psychiatric hospitals; she presented with a belief that there were ghosts following her since her paternal grandmother died. His elder brother (33 years old) has severe‐grade mental retardation, attention deficit hyperactivity disorder (ADHD), and autism, with hospital follow‐up. Bob is the second of three sons.

      Personal History

      Bob was born in the city. His father was a shop assistant, described to be hot‐tempered, and often scolded and hit with bare hands, a bamboo cane, with hangers, or keys. His mother was a housewife, described to be even‐tempered, but also used corporal punishment.

Bob was described to have normal development milestones but had poor social interaction with his classmates. He was reported to have poor eye contact, often felt scared to see people, and refused to talk to others. He had interest in memorizing bus and train lines. He enjoyed watching TV advertisements with jingles and often sang these jingles in the wrong social context. He reported that he had been speaking only English since 2001 because he believed that he was an English teacher and that he “should not” speak the local language. He recalled watching the news in English and tried to imitate a British accent. Since then, he had been speaking in English obsessively, even when it was socially inappropriate for him to do so. For example, he insisted on speaking English to his students' parents even though they could not understand. He was told by his school principal and his colleagues that he shouldn't be rigid, but he ignored the advice. At school, he was described as socially awkward and weird. He had no friends. Growing up, he was bullied throughout primary and secondary school for being “weird.” He had no confiding relationships. He reported various episodes of intense anxiety during his school years prior to school examinations or being asked to do public speaking. He described his baseline anxiety to be high, and trivial events were enough to cause a surge of intense anxiety.

      Other than corporal punishment and physical abuse by his parents, he reported an episode of sexual abuse/harassment when he was 12. He was at home watching cartoons with his two brothers and the phone rang. A man claiming to be a policeman asked him how many people were at home and then asked him to do as he was told or else the police would come and arrest him. He was asked to take out his penis and to measure the size. He was then asked to masturbate and then measure the size again. He was then asked to do the same to his two brothers. He was then asked to stimulate his elder brother's penis with his mouth, but he found it disgusting so he sucked his own fingers instead. His mother then came home and asked what had happened. She told them to hang the phone up. Since this occurrence, Bob believed that some adult men were dirty, especially those who smoked and spoke foul language.

      Bob met his wife at university. It was his first relationship. The couple started dating while they were still at university. His wife found Bob to be socially awkward at times but admired his ability to speak in fluent English. His wife was also a primary school teacher. The couple married in August 2016. However, they found it difficult to have sexual intercourse because Bob did not know what position he should be at. When he tried to penetrate her, he claimed his wife would experience pain, and he would stop to avoid hurting her. As a result, Bob and his wife developed a fear of sexual intercourse. As the couple wanted children, they downloaded pornography online to watch together and hoped that by imitating the actors, they would be able to have successful sexual intercourse. They tried for 2 years already without making any progress.

      Past Psychiatric History

      There is no history of other psychiatric episodes or of suicide or violence.

       Present Treatment

      His symptoms on presentation satisfied the diagnostic criteria for severe depressive episode without psychotic symptoms He also has predominant anxiety symptoms His rigidity/stubbornness, insistence to speak English even when it was socially inappropriate, lack of social reciprocity, poor social communication, and poor social interaction, all of which starting from childhood, satisfied the diagnostic criteria for childhood autism.

      Pharmacologically, he was prescribed venlafaxine and quetiapine for mood regulation. He took lorazepam as needed to help with his anxiety. He was seen by the clinical psychologist for social skills training as well as for coping with stress.

      The doctor concluded by clarifying that he wished to form an opinion whether this patient was likely to respond to psychological interventions.

       Consultation