Dynamic Consultations with Psychiatrists. Jason Maratos

was admitted to hospital in October 2014 and stayed until December 2014 for manic relapse with irritable mood, grandiose delusions, poor sleep with increase energy, and (over)spending US$100 to buy stamps. She was stabilized and discharged on lithium 800 mg, sodium valproate CR 400 mg, and Quetiapine 600 mg.

      Miss C was then followed up in general adult psychiatric outpatient clinic. Escitalopram was started in October 2016 for low mood. Quetiapine was tailed off gradually due to sedation. Buspirone was added in February 2017 for anxiety. Patient was last seen in the outpatient clinic and was stable on quetiapine 150 mg nightly, lithium 600 mg nightly, sodium valproate CR 400 mg nightly, and buspirone 10 mg twice a day. A clinical psychiatric nurse and a clinical psychologist have followed up with her since March 2017 as requested.

      Premorbid personality

      Miss C was shy and introverted as a child. She was competitive and appears to be strong. Miss C is expressive of her emotions.

       Mental state examination

      Miss C appeared with dyed hair, wearing spectacles, and no makeup. She was tearful at the beginning of the session when she was talking about being admitted compulsorily. Miss C was overly friendly in the beginning, asking the case doctor to buy her snacks, trying to seek common ground with case doctor by expressing her religious and political inclination. She became more irritable when her request was turned down, and when they inquired about her manic symptoms, Miss C had a challenging attitude and questioned the case doctor's personal background information. Her speech was coherent and relevant but demonstrated pressure of speech. Her mood was labile but congruent. She did not admit to any hallucinations. Miss C had a grandiose idea about herself coming from a prominent family. There was no risk of suicide or of violent behavior. She had no insight about her manic relapse and her need for inpatient treatment.

      Treatment progress

      In view of oversedation, which was attributed to quetiapine, this was tailed off, and aripiprazole was added to the drug regimen and sodium valproate was titrated up. Miss C's mood stabilized, and she settled in the ward with less challenging attitude. Her sleep and appetite were maintained.

       Psychodynamic observations

      Miss C employed a number of pathological defense mechanisms such as denial of her condition and of the risk of a manic relapse. Miss C claimed that she could get a private psychiatrist to certify that she was “normal.” She thought that her temperament was more expressive and irritable and that this was not related to a disease.

      Splitting : Ms. C thought that a previous doctor, who was a Christian and who had bought her snacks, was a great person and she thought that other doctors were evil to force her to stay in hospital. She thought that her community psychiatric nurse, who had been her friend previously, was evil because she betrayed her and got her admitted. Miss C expressed hatred toward the psychiatrist who deprived her of the opportunity to accompany her maternal grandfather in his last days.

      Miss C expressed grief on account of her delay in her career progress in comparison with her peers (who are now professionals like lawyers and dentists) because of her illness.

      The doctors felt that there was a possibility of unresolved oral stage of development because there was a history of blaming her family of not serving good food during manic relapse. Her mother did not visit her in the first week of admission due to stress. Miss C repeatedly nagged the ward doctor to buy her snacks. Her mother visited her on the second week with lots of snacks, and Miss C was thrilled and offered some to the ward doctor.

       Consultation

      This was a comprehensive assessment of a difficult patient. Let me say at first that we are in the field of combining pure psychiatric treatment (with medication) with psychotherapy. I have no doubt, and you gave a convincing history, that this is a person suffering from a bipolar disorder and am surprised that there is not any family history of this.

      The problem is that without insight, she has low compliance and low compliance leads to relapse. There are medicines that can help; pharmacology has advanced and this is something that, if you compliance can be assured, a better response can be expected. An important aspect of treatment would be that as Miss C has limited insight about the need for medication for her own welfare, somebody needs to supervise her taking medicines. Somebody in her environment needs to do that; otherwise she experiences a period of euphoria and her self‐confidence increases and it veers toward grandiosity and overconfidence. She then begins to think, “I don't need all that rubbish; doctors do it for their own sake and I am going to stop taking medicines and I am going to spend lots of money to get accessories and clothes and look great.” So that's when somebody else needs to take authority over her and ensure compliance or will need to arrange a prompt psychiatric appointment when they see that she is heading that way.

      The other limited comment is about the developmental theory of psychoanalysis. Freud developed the developmental theory based on examining adults who gave a historical recollection of their past. Freud did not systematically examine children growing up.

      Developmental psychology has done exactly that and the proposal of oral, anal, phallic, latency, preadolescent, and adolescent genital stages has been seriously challenged (Rutter, 1970, pp. 274–276). Freud's formulation is historical and interesting from a historical point of view of psychoanalysis, but it's not something considered useful by many contemporary psychoanalysts.

      The second point is that such a formulation confuses normal development with pathological development. By definition, pathological development does not occur at any stage of normal maturation. So if pathological development is not appropriate, attribute it to an age. For example, Miss C is blaming her family for not serving good food, which is not something that is appropriate (consistently) at any stage of normal development as a pattern. If a 2‐year‐old child is served food they don't like, they will get cross and will try to weave their behavior into a pattern that is often described as representing an oral stage of development, but this is not founded on any scientific basis. So, the easiest thing would be to forget this aspect of the psychoanalytic theory because it is not a useful part of psychoanalysis.

JM pointed out that the doctor was already doing what one can expect to achieve with a patient who is suffering from a bipolar illness. The main foundation of treatment would be medication and the would be ensuring compliance. Without these, any talking aimed at changing feelings and thoughts would be wasted.

      Someone who is manic and thinks they are descendants of President Mao cannot be expected to start a dialogue. The emotional conviction is so strong they will think that you don't understand who you are talking to because “I am a descendent of Jesus or I am a descendent of whomever” or “I am as beautiful and gorgeous as Naomi Campbell,”; “you just don't understand.” So the approach that may be most useful in this phase is supportive and supervisory.

      When Miss C becomes more receptive, then you can concentrate on building her self‐esteem, building her resilience, and helping her to develop a realistic approach about her potential; she needs to be helped to value and use her “well” phases to build a realistic future for herself. But during her “ill” phases, all that can be done is concentrate on supporting and supervising her, ensuring that she is safe and that her environment understands her condition. Also, when the first signs of a relapse are seen, she should be taken for immediate psychiatric treatment because she may need hospitalization or restoration of medication because the likelihood is that she will not comply. This is the main problem with people who are manic depressive; the moment that they go toward the extreme of emotions, either toward hypomania or toward depression, they drop their medicines. When they are depressed, they think there is no point, and when they are hypomanic, they think they don't need them.

      It is at this point, that someone in her life, who is not mentally ill to say: “She is going