This case made us realize how complex it is to detect mental health issues

Note: The story is heavily tweaked to protect the identity, scenarios, professional details and gender. The crux of the case is intact.

“This misdiagnosis occurred due to the intricate nature of some mental health conditions.”

An elderly person working as an accountant in Patna Secretariate made an appearance at our clinic in the Fazal Imam Complex, Fraser road Patna. He heard of us through someone who knew someone who knew us.

As I was working from home, the clinic was being attended to by my office assistant. He called me and informed me that there was someone who wished to speak with me.

My Assistant made me talk to The gentleman. speaking with a distinct Bihari accent, he asked, “Are you the doctor?” (exact words: Aap daactar saaheb bol rahe hain?)

I introduced myself as the public relations officer, offering to assist before scheduling an appointment. I created this position for myself immediately on the call, because last time a caller hung up on me when I told her I was not a doctor, saying “How can you know my problem when you aren’t the doctor”. (Exact words: Tab aapko bataa ke kaa karenge).

As an industrial designer, I have studied human psychology to design Human Centric Products/services and platforms. Besides this, I read various books based on psychology, including “Interpretation of Dreams” by Freud, “Man and His Symbols” by Jung, and “Man’s Search for Meaning” by Frankl, etc.

When I informed the man that I was the public relations officer, the trick worked! He continued, “Sir, I am concerned about my son. Despite taking medicine for the past three years, he has shown no improvement.

A part of me was happy that my role as a public relations officer was effective, but another part was immediately focused on the man’s concern.

The man shared that his child struggled with emotional instability, shunning social interaction after high school. He had no friends, was anxious about his future, muttering to himself and getting nervous about appearing for the next NEET exam attempt.

I responded with a thoughtful, “Hmm.”

“Have you sought help from a professional before?” I asked.

The man informed me that they had visited multiple psychiatrists, but their son was still taking medication.

“Where is your son now?” I inquired.

The man replied, “He’s in Patna.

“Understood,” I said. “We have a slot on Tuesday evening, I’ll book it for you. The fee is 1,000 and can be paid at the clinic.”

The man promptly paid the fee and took the receipt before leaving. On Tuesday evening, the man and his son arrived for their appointment. I too arrived because I was trying to understand how therapy works. I was able to observe the consulting session.

Dr. Asif Ali Khan helped the son settle into a comfortable recliner chair and instructed him to relax.

He then began taking a history of the young man’s condition.

Here goes the story:

The young man had a remarkable academic record throughout his school years. However, when he changed schools after 10th grade and began taking coaching classes for medical entrance exams, he became overwhelmed by the pressure to maintain high attendance in school. As a result, he performed poorly in coaching tests for three consecutive months, leading to a decline in his academic performance at coaching. This also affected his performance in school exams as well.

While recounting the story, the young man became hesitant, but Dr. Asif knew what to do next. He kindly asked the father to step out for a moment and continued the conversation with the young man, who confided that his girlfriend left him for another guy when he started performing poorly and that he had taken up smoking as a habit.

The guy said that he was good at studies, but could not clear NEET, which made him feel disappointed. He mentioned that his ex-girlfriend is now studying at a premier Medical institute, while he failed to clear the exam. He expressed that he is scared of exams now.

Dr. Asif called the father inside again.

Dr. Asif asked the father about the kid’s day-to-day routine, social life, family life etc. The father mentioned that the kid sometimes gets uncontrollable anger, throws things, shouts at everyone, and closes himself in his room.

The father also shared that sometimes the kid is hyper-focused on his next NEET attempt and doesn’t want to leave the apartment building, staying there for 3-4 days at a time. At other times, he feels disturbed.

Dr. Asif then asked the kid to step out of the room and asked the father about the medications and asked if he knew that the medications the son was getting were for Bipolar disorder. The father replied that he was not aware of his mental health condition “Bipolar Disorder”.

Dr. Asif said “Hmm”.

This was an interesting thing to note for me. When people go to a general physician and say they have a headache, the doctor does not uses medical jargon to confuse the patient. He simply gives paracetamol instead of explaining headache’s medical term is cephalgia.  

The overall history was taken and notes were made.

This concluded on the first day of therapy. The next session would focus on creating a plan for the treatment of the kid’s mental health.

The next session was supposed to be on Thursday.

When the Father-Son duo left, Dr. Asif said that this can be a very complicated case.

I asked the reason.

He said that it can be a Bipolar disorder, but it may also be a Borderline Personality disorder. Or maybe it can be both.

I asked- What’s the difference?

He told me that both are concerned with mood swings but in Bipolar disorder, it happens usually due to fluctuations in brain chemistry while in Borderline Personality disorder, the mood fluctuation happens due to fluctuations in thoughts. Although there are differences in both kinds of mood swings it requires patience to understand them. Treatments for both are extremely different!

I was like dayum! That’s a pretty new thing to learn today!

I went home and prepared myself for attending the next session.

On Thursday, we all arrived at our clinic.

During this session, the boy was accompanied by his mother.

However, The mother was sent out of the therapy session. I too accompanied her when Dr. Asif asked me to move out too.

I had a casual conversation with his mother, and she said something that left me confused. She stated, “I don’t know who has cast an evil eye on my son.”

Once the session concluded, the doctor summoned both of us and asked our office assistant to bring ice cream for everyone.

A part of me was considering the possibility of scaling up our business by charging 25% of the therapy fees from psychologists on our platform. If we were able to secure 100 one-on-one online therapy sessions per day, it would be a substantial income for the team in the beginning. Our main focus would be on creating a dashboard for users and therapists and emphasizing marketing efforts to enroll as many cases as we could.

Another part of me was trying to be present in the moment.

Neither I, nor that guy’s mother asked about the therapy session.

Following their departure, Dr. Asif told me that the individual had numerous unresolved conflicts with his former girlfriend. Additionally, he mentioned that while the kid was able to handle his academic responsibilities, his breakup had the greatest impact on him. Dr. Asif did not provide specific details, and I did not inquire further.

Dr. Asif also instructed him to keep a journal and write down his daily thoughts until the next session.

During the subsequent session, the individual arrived with his mother, and I, along with his mother were permitted to attend.

Dr. Asif requested the individual to give me his journal and asked me to mentally review its contents. After reviewing the journal, I noticed that he had mentioned his reluctance to leave his apartment was due to the fact that his ex-girlfriend’s home was in the same society and he was overwhelmed every time he had to pass by her residence.

A significant source of his problems was uncovered! He experienced anxiety attacks when passing by his ex-girlfriend’s apartment. After some time, her mother was asked to go out for some time.

I attempted to have a conversation with the individual as our age difference was smaller compared to that between him and our Principal consultant. I shared with him a personal story about having a crush on a beautiful college girl and accidentally addressing her as “didi” (elder sister) upon realizing she was a senior. The individual and Dr. Asif both found my story funny and it helped to put him at ease.

He revealed that he often looked at her home’s gallery while crossing her home and missed the happy memories they shared. During the last vacation, when she was home, he aimlessly wandered around her apartment until he overheard her speaking with her new boyfriend over call.

The individual had developed feelings of inferiority and low self-esteem and was constantly struggling with thoughts about who he was and who he had become. These complex thoughts were difficult to identify unless he recorded them accurately in his mood journal.

He had certain beliefs, such as that he should have performed better academically so that the girl would not leave him, and that he was now a disgrace to his family because others who scored lower than him got into prestigious engineering or medical schools. He had a number of assumptions and beliefs that required a shift in perspective.

Additionally, his medication required attention. As medicine was not our area of expertise and we did not want to bring in psychiatrists during the early stages, Dr. Asif refrained from addressing the medication aspect. The individual underwent 7 Cognitive-Behavioral Therapy (CBT) sessions, with 5 of them conducted in person and 2 online. Throughout his therapy, he was asked to continue writing in his journal. He showed substantial improvement and it became clear that he had Borderline Personality disorder and not Bipolar disorder.

The crux of the therapy was that he needed to focus more on himself and not define life from his past academic successes. He had to accept failures and rejection and treat them as a normal part of life. He was also told that unless he learns to love himself, and becomes strong enough to let people come and go in his life, his life will be constantly controlled by external factors.

After that, neither the individual nor his parents returned for any follow-up sessions, except for one instance when I contacted the father to inquire about the individual’s well-being. The father reported that he was doing much better. I refrained from asking about his medications, as we had not prescribed them.

As a team building a mental health platform focused specifically on psychology, we now faced a new challenge – how to handle or potentially incorporate cases involving psychiatric treatment. At the time this story is being written, it is not yet clear what the solution will be.

Key takeaways from the case:

1. It is crucial to determine the underlying cause before treating any mental health disorder. Bipolar Disorder and Borderline Personality Disorder may seem similar, but their origins are vastly different.
2. The purpose of therapy is to help individuals understand their flawed thoughts and replace them with more positive ones. In this case, it was important to identify the source of the flaw, which initially appeared to be Bipolar Disorder but was later revealed to be Borderline Personality Disorder. The trigger for the disorder was not just the poor exam results, but also the breakup with his girlfriend. He would get anxious while passing by her apartment building.
3. The individual, in this case, had always excelled, but when he started performing poorly and his girlfriend left him, he experienced self-esteem issues and felt that he should have done better in his studies. However, the real reason for the breakup was not due to his performance, but because she no longer wanted the relationship. This rejection was something he had never faced before and it led to self-doubt and false assumptions.
4. Keeping a mood journal can help in tracing the root of the problem and understanding the thought patterns that trigger negative emotions.
5. Age gap and relationship dynamics with a therapist play a crucial role in building trust and making the patient open up.
6. It’s important to consider medication as a part of treatment, however, if it’s not the area of expertise, it’s better to refer the patient to a specialist.
7. It’s challenging to balance psychological treatment and the involvement of psychiatrists in mental health platforms, but it’s essential to ensure that the patient receives the best care.
8. Root cause analysis, a challenge to assumptions, reinforcing better thoughts, and effective communication are the key elements of mental health treatment.