全部列癲 │ Harry Wu

It was in September, 2004, when students were returning to schools, and graduates facing another wave of joblessness in sleepless Taipei, the capital city of Taiwan. Out patient department became busy again that it wouldn't be closed until 11:30 PM. I was on my night shift. A young man came into the ward, for admission.

He looked descent, neat, tidy and courteous. After some social work-ups, we soon entered the history-collecting because it was so late that I might not be able to spend another 2 hours completing the whole diagnostic interview, chart writing and other paper works.

His name is John (of course not his real name), 23 y/o, single, just graduated from university, department of political science and laws. Those who came with him were his parents, a general manager and a housewife. At home, he still has a younger sister, college student. The economic situation of this small middle-class family was quite good, with a relatively harmonic intra-family atmosphere. John looked just normal. There was just a mild frown between his eyebrows.

I asked John's parents to leave us alone for a while. I just felt like interviewing alone with him for not more than 20 minutes and the I would be able to end up with that admission routine as soon as possible. John started to tell me about all his secrets in the mind. And then I realized that it was impossible to finish it soon. There was something really wrong with him.


( Photo taken in Birmingham, Alabama, 2003. medical student exchange program. I, ambitiously, did two months of neurology and addiction medicine, and even in AA/NA groups. Now I stay "clean" from clinical medicine.)

He said, "There's someone stalking me." Okay. sounds like a psychotic. 23 y/o single male. probably schizophrenia. His situation matched so well with the epidemiological statistics.

"A month ago, when I failed the national board exam of becoming a judge, I broke up with my girlfriend, I started to make 0204 (adult) phone calls, to chat with women." "And then I suddenly started to suspect that the women I talked with were assigned by criminal investigation police unit." "And then I knew that I am in trouble." He came to tears, and said, "Now I know that I am being followed by somebody."

"By who?" I asked him. There wasn't a specific answer. "Probably it's because half a year ago, when the president candidate was shot injured on the street, I posted my opinions on Internet. And the candidate I advocated succeeded. So they assigned someone to protect me." "Who are they?" "Criminal investigation police, I think."

It did not sound like "persecution". It was the first time I encountered a "protective" delusion. I continued to clarify more about his symptoms. Delusions, which were mostly political, not very bizaar because he studied politics. Hallucinations, audio, just once, but he could not depict what’s in the voice clearly. Coherent and relevant, and even fluent speech, appropriate behaviours. Duration: about six months.

Depressed mood most of the day, diminished interest, weight loss, insomnia nearly every day, fatigue by feeling hyper-vigilant, being not able to concentrate, still no marked suicidal ideation. Duration: more than two months. No abnormal findings in neurological exams.

Perfect JOMAC, no illicit drug use, no predominant body complaints. He did not drink or smoke at all. He's got tics when he was little. After seeking child neurologist, symptoms were relieved. At school, he was taciturn, introverted. Mother said that he was a bit suspicious. But John told me that it was because his mother, who read his private letter once to his dad and sister without his agreement, which made him feel humiliated. Now his mother felt guilty about this.

Was he psychotic? I did not prescribe until the coming week, when he was still convinced by those strange feelings being protected by police. I gave him resperidone and an antidepressant, seroxat (paxil). Routine interviews were done everyday. Supportive psychotherapies and family therapies were arranged by schedule. After 3 weeks, his symptoms were still there. But he seemed to be not so depressive anymore.

I tapered the antidepressant, which made him lethargic and, according to his report on the next day he was on medication, impotent. But his depression aggravated obviously. I could not but have to add paxil to his drug regiment. His hospitalization finally reached one month. According to the health insurance regulation in Taiwan, I had to write a short report of "long admission". I felt powerless. Both antidepressant and anti psychotic reached full dose. Although most of medication don't reveal marked effect, it was impossible that the drug I prescribed seemed not working at all.

I suggested Johns mother apply a for a proof of ICD-295, in order that he might be able to get the medication without spending too much money henceforward. What's so good about that proof? With and ICD-295/296, government covers all expenditure of medication. Patients can go to many places with half-price. The only negative thing is that you are telling anybody that you are handicapped, mentally. And yes, you don't have to go to military service. I knew that the process could not be this rough but nearly every psychiatrist did so, told by my supervisor, in order to get the money from public health insurance company.

Military service! It is the worst thing that young male adult encounter right after accomplishing their highest education. Just experiencing the spectacular four-year university or college, most young men feel non-compliant to put themselves into such a dull, boring and obedient life so abruptly. For myself, I only had to go to the military for 2 weeks because I had been suffering from respiratory problems for 13 years since my first asthmatic attack in my teenage. For me, military was just a transient pain. But most young man are not so lucky. Why didn't I think of this? Was John faking? Or it's just my projection? Or to speak more precisely, it’s my counter-transference?

Johns delusion seemed to be negotiable at times. He was confused about whether he was protected or persecuted. His hallucinations were so transient, not obvious enough for me to put him into a major psychotic disorder. Neither schizophrenia, schizophreniform (no marked symptoms or signs), nor delusional one (he was too young to have it!). Or he was simply a fugitive from his military obligation? If so, then it would be really tough.

These guesses were kept in my mind until John's admission reached 1.5 months, when we had to discharge him from the acute ward. I told him to take medicine by the instruction on the drug bag, and come back to out patient departemtn in one week. He said, "Yes, I will," with a slight but rare smile in his face. He's got friends in the ward. After seeing him saying goodbye to his ward friends, it was that I then felt helpless.

Maybe he was just a case of malingering. I summarized what I had done to him, regretting myself not having done more observations on his psychological features , which were suggestive of depression, inappropriate affect or lack of concern (la belle indifference), multiple and vague somatic complaints, and especially abnormal interactions with his family members.

3-4 days later, John's mother called. On the phone, she thanked me for all I had done to his son. And then she reported that her son was totally symptom-free now. "This is really ridiculous!" I told myself, listening his mother describing all those miracles. I told her to bring her son to the OPD again. But they never showed up.

I did nothing wrong about my clinical decision. However I accused myself for 1. misdiagnosis, 2. being not considerate enough for my patient. However, to disclose patient's malingering is not a responsibility of a psychiatrist. Once you found it, you could write a case report, rather than embarrassing the total situation. But what would John face thereafter? Probably he will have difficulty seeking future jobs, especially his longing one, becoming a judge. “How naive he was!” I thought.

Moreover, why didn't he felt annoyed instead of safe since he was "protected" by his delusions? Why did he forge a story about all those adult phone things? What's his personal, private life about? Was there anything going on when he concerned about being impotent after taking SSRIs, which conservative patients did not actually ask about in Taiwan? What's his relationship with his family, especially his regretting mother? Surely his depression still existed. And what was I? A good man helping him escape from the military court? Why was he so afraid of military service? Why didn’t I notice that there might be some relationship between his excessive sexual desire and his escaping from a military recruitment just belonging to men? And if he was really happy with the ICD 295 and its benefit, why bother for me to worry so much? There remained too many question marks.

Later than that, I encountered 3-4 similar cases not only in the ward but also in ER. I was not able to do much for those patients due to the limitation of my job competency. But I realized that had I had more sensible mind in observing transference/ countertransference/ projective identification, etc., I would not be so reluctant in tackling all these tough jobs. I might not only have obstacles dealing with patients’ mood, but also an instrument to dig out more myths in their minds.

In September, 2005, abandoning the half-completed clinical training, I flew all the way a hemisphere distant from my homeland to England, starting my new life. I am also a fugitive, escaping from the hospital environment I was disappointed with, and the traditional burden my psychiatrist father imposed on me. Suddenly I realized that it’s not only the patient’s agony but also mine.

Not knowing whether I will go back to medicine or just devote myself into other related fields, I am standing at a vague point, a watershed. I know that I would be challenged with the question, “Why psychoanalysis? This newly introduced and favoured subject in cultural studies but also nearly abandoned technique in psychiatry? “ I probably have no answer to it. Nevertheless, with a developing negative capability, I am stepping forward into an enormous uncertainty, being possibly not so certain, but brave enough.