Obum Mokeme - The Flip Side of Seriousness

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1.

IT’S A BABY!

THE PRESENTING SCENARIO ON ADMISSION:

Danny was admitted in a manic state. On admission, he presented with an elated mood, grandiose ideation, and a degree of disinhibition. He was also easily distracted and interfering. He was well known to mental health services, having previously had several admissions into hospital with similar presentations. He had been doing well but had recently become highly excitable and unmanageable at home. His behaviour had become so disturbed and threatening that his pregnant girlfriend feared for her safety. There was a high risk that he might become physically violent towards her as he believed that her pregnancy was the cause of his current problems.

BACKGROUND TO THE PRESENTING PROBLEMS:

Danny has worked as a clerk at various places but he found it increasingly difficult to hold down a job for more than a couple of months. His behaviour was such that he was quite difficult to be with. He was too highly strung and quarrelsome. He was easily provoked, argumentative and disruptive at home. At work, he was often in trouble for frequently being absent from work and for the poor performance of his duties. He was unable to concentrate on one issue at a time for a considerable period of time. He tended to jump from one topic to another without successfully completing any one task or story before taking on another. His last employer tried to help him by sending him to a number of courses to help improve his performance at work but he came back without completing any of the courses he was sent to. In his view, the tutors did not like him. The fact, however, was that he was unable to cope with constructive activities or to concentrate on one task long enough to bring it to a conclusion. After a couple of months, he stopped showing up at work altogether.

At home, he still behaved like a teenager. He still expected his parents to continue to provide for him even though he was now a fully grown man. When he left his last job, he stayed at home most of the day and went out in the evenings. He applied for unemployment benefits and was overjoyed when he received the first instalment of his benefits. He kept the payments he received for his personal use as pocket money and refused to make any contribution towards his upkeep or that of the family home. He also refused to contribute to the physical maintenance of his home, such as helping out with cooking, gardening or any other house work. He frequently flared up when his parents asked him to pay for anything or to perform any chore at home. In order not to provoke him into an uncontrollable rage, his parents did not insist that he should make some contribution towards his keep. He spent his benefits to himself without any consideration for the sacrifices made by his parents. Gradually, he became involved in more altercations both at home and with his friends when he went out in the evenings. His parents began to find it too difficult to manage him at home and they suggested that he should make an application for his own separate accommodation. In response to this suggestion, he smashed up nearly everything in the house.

His parents realized that his reaction to their suggestion was not normal behaviour and that something was wrong with him. They called the police to help prevent further damage to their home. When the police arrived, Danny tried to run out of the house but was stopped by two police officers. He was partially restrained, cuffed and escorted into the police van. When they arrived at the police station, he was assessed by the Force Medical Examiner (FME) commonly known as the police doctor. The police doctor identified symptoms of a hypo-manic state. He was deemed to be mentally unstable and was referred to the A&E department of the local hospital for further assessment. After a second assessment by the mental health professionals there, it was decided that he would benefit from a short admission into hospital for a full assessment and a review of his current treatment.

Danny was eventually transferred to one of the acute mental health wards at the local mental health hospital. After a short period of observation on the ward, he was diagnosed to be suffering from a mood disorder known as a hypo-manic state. He remained in hospital for a few weeks during which time, his parents were seen in ward rounds nearly every week. In the ward rounds during the course of his various admissions, his parents provided useful information about the onset of Danny’s illness, his family history, his childhood milestones, the level of his education and his performance at work. At the end of all the investigations into the causes of Danny’s illness, the opinion of the ward team was that his major stressor was an extremely low stress threshold due to poor impulse control.

In conjunction with the medication that had been prescribed for him, they identified further activities which they hoped would help Danny to remain well post discharge. The activities included breaking up his week into three blocks to help improve his educational level; day centre attendance for recreational activities and life skills acquisition to prepare him for independent living. The ward psychologist felt that in addition to this treatment plan that had been prescribed for him that Danny might also benefit from a psychological input to help him to gain more insight into his behaviour and to help him better manage his impulses and his stress levels. He was discharged back to his family after a two months stay in hospital. That was about six years ago.

At ward rounds during his current admission, it became clear that the triggering factor was that Danny became extremely upset that his girl-friend was expecting a baby. He felt that she should have taken precautions to prevent her from becoming pregnant. In order to enable him to gain some insight into his situation, he was asked what he thought would happen if both he and his girl-friend were not taking any measures to prevent her from getting pregnant. In response to this question, Danny insisted that she should have ensured that she would not get pregnant. After several attempts at explanations about whose responsibility it was to prevent a pregnancy were offered to him, he reluctantly admitted that he could have reminded her to take precautions. That was the extent to which he realized that the pregnancy was as much his fault as it was hers. It was then that it dawned on him that they were both equally responsible for the pregnancy. He conceded that it was also his fault but he went on to add that she should have informed him that she wanted to have a baby as he was not yet ready to be a father. His last statement caused quite an uproar of laughter in the conference room. He was told that couples routinely discussed such things but that the reality was that the baby was almost here. His girlfriend was in the eight month of the pregnancy.