Dynamic Consultations with Psychiatrists. Jason Maratos

(2014).

References

      1 Fedoroff, J. P. (2009). The paraphilias. In M. G. Gelder, N. C. Andereasren, J. J. Lopez‐IborJr., & J. R. Geddes (Eds.), New Oxford textbook of psychiatry (Vol. 1, pp. 832–842). Oxford University Press.

      2 Fernandes, L. C., Gillberg, C. I., Cederlund, M., Hagberg, B., Gillberg, C., & Billstedt, E. (2016). Aspects of sexuality in adolescents and adults diagnosed with autism spectrum disorders in childhood. Journal of Autism and Developmental Disorders, 46(9), 3155–3165.

      3 Kolta, B., & Rossi, G. (2018). Paraphilic disorder in a male patient with autism spectrum disorder: Incidence or coincidence. Cureus, 10(5), e2639.

      4 Schottle, D., Briken, P., Tuscher, O., & Turner, D. (2017). Sexuality in autism: Hypersexual and paraphilic behavior in women and men with high‐functioning autism spectrum disorder. Dialogues in Clinical Neuroscience, 19(4), 381–393.

      5 Socarides, C. W., & Loeb, R. (2004). The mind of the paedophile: Psychoanalytic perspectives. Karnac.

      6 Woods, J., & Williams, A. (Ed.) (2014). Forensic group psychotherapy. Karnac.

Mrs. C

      Mrs. C is a 68‐year‐old woman, widowed, and living alone in a public housing unit. Mrs. C walks with the aid of a walker (a Zimmer Frame) outdoors and with a walking stick indoors because of arthritis in both knees. Mrs. C functions on activities of daily living, level I (can look after herself).

      Presenting Condition

      Mrs. C was referred to the psycho‐geriatric day hospital from a psycho‐geriatric center due to low mood, poor social support, and daytime engagement.

      History of Present Illness

      Mrs. C reported having fleeting suicidal ideas but no concrete plans or actions. She was diagnosed with a recurrent depressive episode, the current episode being severe, without psychotic symptoms. Upon receiving psychiatric attention since 2015, her mood had shown some improvement, but she still often maintained that she had fulfilled her duties to her family and had no reason for living any more. Mrs. C continued having a sense of worthlessness and hopelessness. She reported having an early death wish and that she wished for a quick natural painless death. Mrs. C had no actual suicidal plans because she was afraid that she would be a burden to her family if the suicide was not successful. She was dysthymic and tearful when husband was mentioned. There was no abnormality of speech. There were no psychotic symptoms. She was not suicidal or aggressive.

      Personal History

      Mrs. C was born in the city and was the third of four siblings. Her eldest brother died when he was an infant after a fever and before Mrs. C was born. Her eldest sister remained in the country under the care of her maternal grandparents when her parents immigrated to the city. Mrs. C and her younger brother were born in the city. Mrs. C has a distant relationship with her eldest sister because they have lived apart all their lives.

      Mrs. C reported having a good relationship with her younger brother and her parents; she claimed that her parents loved both her and her brother dearly because they did not have many children. Mrs. C felt that she had led a happy childhood despite being poor and living in a wooden hut. From a young age, she knew the importance of bringing money home. Mrs. C claimed that her mother died in her arms in her 80s and that her mother had waited for her to come to the hospital to see her final moment. Her father moved in with her, after her younger sister‐in‐law died, and stayed with her until his death. Mrs. C has no family history of mental illness.

      Mrs. C studied until Form 2 at night school and then worked as a factory worker until she was about 50 years old. When her husband had a stroke, when she was around 60 years old, she attended a course to learn how to care for the debilitated and became a helper at an old age home after attending the course. She later studied at the open university (in 2009–2010) because she wanted to have a better work‐life balance. Mrs. C was keen on learning.

      Mrs. C married after dating for 2 years. She had a good relationship with her husband. Mrs. C commented that her husband was outgoing and liked small gambling but was never in debt. Her husband would take her to trips or buy her good food when he won on betting. When her husband suffered the stroke in 2000, she claimed there was not much support or education given to her at the time. She was told by the doctor that her husband may have recurrent strokes and told her to be careful, but she claimed that she did not know what was meant by this. Mrs. C felt that the doctors were not helpful in advising her how to look after her husband, and as a result, Mrs. C felt helpless. He had stayed in the intensive care unit with a Ryle's (nasogastric) tube at the time, and he was bedbound. Since his discharge from hospital, she had a transient thought of pushing him out the window and jumping from the height with him, but she later changed her mind after thinking that her husband's father was still alive. She later took him to see practitioners of traditional Chinese medicine (each appointment costing the equivalent of about US$50) and hired a maid to help care for him. She claimed she had spent her life savings and sold their minibus to pay for his medical bills. Her husband used to work as a minibus driver. When he entered hospital, she was mocked by relatives for placing him there. Mrs. C claimed that her husband's father was unsupportive, and he claimed that her husband deserved the stroke because he smoked. There was no further support from family members. He eventually had some improvement and was able to walk with a stick but then suddenly developed an infection and died within 3 days. She was disappointed that after she had achieved such an improvement in him, he would die so suddenly.

      Mrs. C has two daughters and one son. Her son emigrated when he was in his 20s; her eldest daughter studied in Australia and later worked in the country. Her younger daughter works on a nearby city, she visits her weekly and gives her the equivalent of about US$300 a month. She reported having a quite distant relationship with her children because they work abroad and have their own lives.

       Premorbid Personality

Mrs. C is a responsible and independent person who tends to bottle up her feelings. She feels that she is a good listener, a helper, and a giver instead of a recipient of help. Her present limitations (as in mobility) force her to a situation of dependency in which she feels uncomfortable. Mrs. C feels that everyone has their own set of problems and understands that others do not have the time to listen to her difficulties. She is a Buddhist.

      Past Psychiatric and Medical History

      Mrs. C presented to the hospital in July 2015 with low mood that had persisted since her husband's death in May 2015. Her husband had suffered a stroke in 2000, and Mrs. C had cared for him since that time. Her husband had entered a sub rented old age home in 2004, and Mrs. C used to visit him daily. Her relatives were critical of her because they implied that she should have looked after him at home with the help of the maid whom they had employed. Mrs. C's husband died suddenly within 3 days after admission to hospital where he developed fever and vomiting. After her husband's death, Mrs. C reported to have lost her reason for living. She felt she had done everything she wanted to do in this world already and her responsibilities had been fulfilled. She developed low mood and a loss of energy and interest. She had early morning waking and poor appetite.

      After her husband's death, Mrs. C reported to have seen her husband's ghost twice at night but did not feel distressed because she felt it was her husband visiting her.

      She felt helpless and had thoughts of pushing her husband out of a window and jumping out of the window after him. Her sister‐in‐law had also died around that time. Mrs. C was known to the mental health services for more than 15 years. Her sister‐in‐law had died around that time, leaving her 8‐year‐old nephew behind. Mrs. C claims that she only attended a psychiatric clinic once and was given antidepressants that made her drowsy and for this reason she did