Question:
Background:

Patient : My Wife
Age : 41
Married and since 1999 and have 2 girls (15 & 10). No major disputes or issues in family life.

General Personality:
My wife is very well educated (Master’s Degree), was employed until 2006.
She is by nature very sensitive and can get emotional easily. She is devoted to her immediate family only.
Currently she conducts tuition for children
She has been doing mindfulness meditation since April 2017.
XXXXXXX 2016: My wife was in Malaysia with our teenage daughter for sport training camp for 10 days in XXXXXXX 2016. She had several conversations with our daughter’s coach in the sports centre. He is a lively, friendly and charming person. My wife thinks that the coach was trying to flirt with her.

She had given her phone number to him and after she returned home had few messages exchanged with him. She started to get suspicious that the coach was stalking her on the phone. She says that their conversation ended with something like “I don’t have time for all this.. and the coach also said the same.. “ (my wife deleted the messages and I have not seen them). She told me about this only in August 2016.

August/September 2016 :
She was scared and got obsessed with the thought that he was stalking her and because she has no time for him, he would harm our daughter. She was scared to use her phone and interpreted unrelated e-mails as subtle threats from the coach. She even had suspicion that her female friend whose son also trains under the same coach (in Malaysia) was also ganging up with the coach and stalking her.

I do not see any reality to the idea of, “threatening her or my daughter”. I can’t also believe that the coach or her friend was stalking her on the phone.

My wife was having intrusive obsessional thoughts and anxiety last September 2016 and it looked delusional (non-bizzare).. Thoughts was about the coach always stalking her on the phone. Visited a psychiatrist in XXXXXXX and he diagnosed it as Psychosis NOS.. She was given Aripiprazole 10 mg.. She responded quite well to the medicine and within a few days was clear in her mind. She agreed and understood that her fears were not true.

Nov 2016:

Our daughter again went on a training trip (by herself) under the same coach in mid November and everything was ok. My wife was convinced that there is no harm from the coach.

Dec 2016:

She was on medication from Sept – Dec 2016. She did not experience any significant side effects, but she was unwilling taking the medication and tapered it down in mid December 2016.
XXXXXXX 2017:
The coach’s brother was posted to Singapore and is our duaghter’s coach now. Perhaps that was a trigger, the symptoms started to reappear in mid XXXXXXX 2017, but was mild. By Mid Feb 2017, the thoughts of being stalked by the same coach was severe and she started on Aripiprazole 10 mg .. Three days after starting medication, she was getting clarity and intrusive thoughts stopped.

March 2017 - Present
Again she was uncomfortable to be dependent on Aripiprazole and was stubborn to taper it down. She reduced dosage to 5 mg from 20th march and stopped completely on 10th April.

Then she seemed alright for a few days until April 27th

From April 28th she shows symptoms of anxiety and intrusive thoughts and associated feelings of disgust about the same coach. This time it is not about stalking, but continuous thoughts about this coach and the few conversations they had and a feeling of disgust about herself for spending time obsessed with this. This was getting almost nonstop and affected her sleep at night and anxiety was high throughout.

My wife is able to recognize that the thoughts and feelings of disgust she are having are irrational & silly. She is able to see the foolishness of the thoughts and emotions, but unable to stop.

Started Aripiprazole 8th May and today is 10th May, there seems to some relief. She is sitting beside me and helping me draft the above.

Question:

1.Is psychosis NOS the right diagnosis?
2.IS Aripiprazole the right medication? We are a bit concerned about using anti-psychotic in long term.

3. Can it be a case of Pure O (OCD) where she has continuous intrusive and obsessive thoughts about this coach? And could be treated with Anti-Depressants instead of an Antipsychotic?

Other Information:
Family history :
1.     Mother’s sister had committed suicide in her 20s (apparently due to relationship failure)
2.     Mother’s older sister had undergone psychiatric treatment

Dear Doc,

Thanks for your feedback. My wife (your patient) has the following clarificatiosn:

"
1. Are there any other supplements that i can take to make my condition better?
2. Can I reduce dosage or taper? what is the minimum therapeutic dose?
3. what are the side effects of this medication and what should i look out for or take as preventive action for these side effects
4. what are the medical tests e.g blood tests i should take to check for side effects that do not have outward symptoms?
5. in your opinion how long do you think i will rely on the medication?
6. how will i know i am out of this illness.
7. Can I drive when I feel clear?
8. I was also prescribed NexZAP 0.25 mg as needed. Is this medicine safe and how long can i use it?? (so far i have used it very sparingly, only about 10 tablets in last 8 months)

"

Dear Doc,

Thanks for your prompt responses. Was very useful.

We are based in SIngapore and the psychiatrist we visited first is in XXXXXXX This poses a logistical problem for follow-ups. Any suggestions? Would you be able to refer/suggest psychiatrist based in Singapore?