There Is Blood On The Seesaw.
It was a Saturday morning, and Jasmine was with other children and their mothers at a playground near their homes. The kids were running around the playground equipment and enjoying each other’s company, while the mothers were chatting among themselves a little further away. Suddenly, Jasmine left the group and ran straight towards her mother screaming, with abject fear in her eyes, “Mommy, Mommy, there is a lot of blood on the seesaw!” she wailed. In shock, all the mothers jumped up and ran to where the seesaws were located. They looked around, but were hard-pressed to find any blood. After a while, Jasmine was pulled aside and was given a good dressing down by her mother. But she insisted that she saw the blood – and lots of it on one of the seesaws. Soon, everyone, except Jasmine, forgot the whole embarrassing episode. She was then 6 years old.
Fast-forward about 13 years later, when she was sitting in front of me with her mother, Mrs Lim. Jasmine was in her first year at university, but had taken a year off her studies as she had a psychotic episode. The triggering event was a broken relationship, and it sent her into a tailspin emotionally and psychologically. It was during our initial interview that the 6 year-old Jasmine’s bizarre bloody sighting came to light. Mrs Lim did not know what to make of it then, but it was probably an earlier mild episode with non-specific symptoms or a prodromal psychotic phase. These conditions are usually the result of some mildly distressing event(s) occurring around a child, but due to their minimal drop in cognitive functioning, they are normally overlooked and ignored by adults. Usually, these perceptual changes or paranoid ideation are a precursor or risk markers to an increased possibility for a more serious episode in later life. In Jasmine’s case, however, it seems that the earlier episode was not followed by any others, until her major psychotic event.
The lack of a clear-cut diagnosis of a psychotic disorder in a prodromal episode does not preclude a referral for treatment. These individuals require interventions that specifically target the presenting symptoms and dysfunction, with the aim of trying to reduce the risk that psychosis will worsen or fully emerge at a later stage. Treatment might include targeted cognitive-behavioural therapy (CBT) and perhaps low-dose anti-psychotic medication. Furthermore, functioning is equally worthy of intervention, with skills training, structured activities, and CBT aimed at a return to school or other activities. At this stage, one has to weigh up the costs and benefits in terms of side effects, as some of these individuals will not go on to develop a full diagnostic psychotic disorder. However, what is recommended is the need for careful monitoring of mental states and functioning and a collaborative approach to treatment, with the aim to ameliorate the transition to full blown psychosis.
Supportive counselling for Jasmine, and Mrs Lim as an accountability partner for her daughter, continued for several months to help them understand the disease trajectory and to put in place a scheme where they are able to identify and address stressful circumstances and take measures to better cope with it. Orientation towards medication objectives, medications’ dose frequencies, and pharmacological side effects was also necessary, including monitoring medication intake, to safeguard Jasmine’s progress and to prevent further debilitating and serious psychotic relapses.