Chinese cultural bound syndrome?

[SmallBird]

Recently saw a 17 yo F from China at a US boarding school w/o any PMH (has only seen therapists at boarding schools, no other healthcare) presenting for a wide array of complaints:
Feels she is being watched when alone, sometimes by people she does not like, other times unable to tell by who, when in room alone, showering, etc.
Hears people saying she is doing badly in class, even when these peers are not present in school
Reports roommate saying bad things about her when she appears asleep and to others
Feels she will know an answer to a test question but answer with the opposite (gives example of knowing an answer to be non-binomial but will select binomial)
Struggles concentrating (reports dramatic drop off, around 90% of cognitive ability), fatigue, napping 4 hours/day, sleeping around 7 hours/night
In the last month has had 3 nights, never consecutively of staying up all night, feeling "really good" while laying in bed and not worrying about school/tests
Mood is low, had passive SI last month after failing a quiz "what's the point"
Relatively frequent panic attacks (these have preceded the above sx and been present for years but worsened in intensity)
Reports doing poorly in school but counselor notes pt has continued to do well in classes, poor performance seems to be distorted by pt
Reports doing "terribly" on the SAT taken 2 months ago, score was a 1400
Family is very supportive of pt, has flown to the US for 2 months to support her, are confused why this is happening now
Switched boarding schools 1 year ago, last therapist at last school had concerns over bipolar d/o but no sx of this witnessed at current school of 1 year

Beyond MDD w/ psychotic features, GAD, possible mixed to bipolar spectrum underlying things, the persecutory nature of both AH and delusions stands out to me. Any thought this has anything to do with Chinese culture? Plan would be admit to PHP, SSRI + Atypical. Open to any other thoughts/suggestions.

Edit: I work in a very diverse area and have taken care of a lot of Asian families, but they are typically 2nd or 3rd generation and did not grow up in Asia, just want to make sure I am not missing anything as I have almost no experience with 1st generation Asian teenagers.

This sounds very, very similar to the first break psychosis that would come up when I did college mental health - I don't think of it being geographically specific but related to the late adolescent age and high premorbid cognitive ability. Atypical antipsychotic and return to a home environment. It was heart breaking when some of these cases were foreign students who could not/did not want to go back home and essentially had to start from scratch getting Medicaid and other supports.

---

Members don't see this ad.

 

[whopper]

I was going to throw this in and this occurred on an episode of Big Bang Theory. Someone I knew in college was one of the top students in his engineering program, and it was a program that was notorious for failing out double digit percentages of the students. After 2 years of being on top he failed out the next year.

What happened? He had sex for the first time. A femme-fatale introduced him to the wonderful world of having a life outside of academia. It blew his mindset. This woman wasn't just any woman. She was a cluster B who rocked his world, in a seemingly great way for the first few weeks, and then dragged him down in predictable cluster-B manner. Not everything is an Axis I mental illness.

 

[G Sheb]

@Merovinge no pressure, but would be curious if you have updates on the case at some point.

 

[Merovinge]

@Merovinge no pressure, but would be curious if you have updates on the case at some point.

I will be, she is actually starting PHP this week.

 

[Merovinge]

Update as follow:
Pt went on vacation with a friend a year or two older than her in a major city. Did very well but did experience VH while standing in a very busy area (asked friend who could not see this person, someone they both knew from childhood ages).

Upon returning did quite well in PHP, looked like a different person after around 2-3 weeks and 10mg of Lexapro. Never got to an atypical given the significant response. No return of AH/VH/SI/persecutory delusions, no opposite actions. It came out that a college "consultant" hired by family from China (who has no freaking clue about US college admissions despite their title) was telling pt she was never going to get into school and never achieve her dreams yadda yadda. This consultant got cut out by the family which was when the real turn around happened.

Pt has since returned to school with IOP and is trying to do full-day of school + 3 hours of IOP +3 hours of tutoring +2-3 hours of homework which has predictably been going poorly. Still looks better than before but I think the etiology of the concerns is relatively better understood now. I appreciate everyone's thoughts on things.

 

[G Sheb]

Update as follow:
Pt went on vacation with a friend a year or two older than her in a major city. Did very well but did experience VH while standing in a very busy area (asked friend who could not see this person, someone they both knew from childhood ages).

Upon returning did quite well in PHP, looked like a different person after around 2-3 weeks and 10mg of Lexapro. Never got to an atypical given the significant response. No return of AH/VH/SI/persecutory delusions, no opposite actions. It came out that a college "consultant" hired by family from China (who has no freaking clue about US college admissions despite their title) was telling pt she was never going to get into school and never achieve her dreams yadda yadda. This consultant got cut out by the family which was when the real turn around happened.

Pt has since returned to school with IOP and is trying to do full-day of school + 3 hours of IOP +3 hours of tutoring +2-3 hours of homework which has predictably been going poorly. Still looks better than before but I think the etiology of the concerns is relatively better understood now. I appreciate everyone's thoughts on things.

Thanks for the update.
This is really an interesting case, and one which I think you would not be able to capture or formulate appropriately in a DSM diagnosis.

 

[SeniorWrangler]

I will say that there are quite amazing pressures placed on young Chinese men and women who are gifted in STEM and seeking elite higher education and especially for young women there can be some complicated issues around negotiating boundaries and their own vs. their parents' goals, based on my clinical experience plus raising a child who moved in elite math/science circles in high school and college.

I don't think this is really a culture bound syndrome, though, just a cultural factor (which is also experienced in some other backgrounds, like Russian and Jewish families).

 

[Merovinge]

I will say that there are quite amazing pressures placed on young Chinese men and women who are gifted in STEM and seeking elite higher education and especially for young women there can be some complicated issues around negotiating boundaries and their own vs. their parents' goals, based on my clinical experience plus raising a child who moved in elite math/science circles in high school and college.

I don't think this is really a culture bound syndrome, though, just a cultural factor (which is also experienced in some other backgrounds, like Russian and Jewish families).

Completely agree now. I have extensive experience with 2nd + generation south and east Asians, but coincidentally almost no experience with 1st generation kids/teens born/raised in Asia and have only recently begun to work with elite boarding schools to have this population crop up more. I wanted to make sure I wasn't missing something given this hole in my work experience given the amount of psychotic symptoms present. Certainly an informative case for me to see, I am sure more will be coming moving forward.

 

[Stagg737]

I still want to know more about her anxiety, lol. Glad that she's headed in the right direction and that it doesn't seem like this was in the schizophrenia spectrum though. Definitely an interesting case.

Also, any sleep study or further concerns for narcolepsy? Found that aspect of this situation really interesting.

 

[Merovinge]

I still want to know more about her anxiety, lol. Glad that she's headed in the right direction and that it doesn't seem like this was in the schizophrenia spectrum though. Definitely an interesting case.

Also, any sleep study or further concerns for narcolepsy? Found that aspect of this situation really interesting.

She was using lots of caffeine to power through the 12-16 hours/day of school work and studying. She slept normally during PHP around 9 hours/night with no napping and entirely cut out caffeine. It does sound like a lot of her anxiety is personally driven at this point, as school has noted she was not agreeable to lowering work load and has internalized a lot of the pressure that was generated from her private college "consultants". One of those times where I wish I did a little OP work as I would be interested to see what she looks like after a month or two of being back at school.

 

[G Sheb]

I wouldn't say she's definitely not on the psychotic spectrum.
May qualify for brief psychotic episode or psychosis unspecified. Though the caffeine part makes things interesting.
It is a spectrum after all, and how psychotic experiences relate to full blown schizophrenia is an active research area.

 

[Coupd'Cat]

Don't forget a trauma screening.