I had to write a reflective piece on a patient encounter for psychiatry, and I had a great subject to work with. So I enjoyed the patient, enjoyed writing the paper, and wanted to share. I probably could've gone on and on about the patient story and my thoughts, but we had a 3 page limit. And yeah I know the ending isn't good. I've never been good at concluding summaries.
My
first week on inpatient psychiatry, I anxiously awaited my first intimidating
experiences with the mentally ill. One
morning later in the week, I thought I’d finally get that perfect opportunity
to practice keeping myself between the patient and the door. My resident had taken assignment of AB, a 23-year
old white male, with a past diagnosis of paranoid schizophrenia.
An
MIW had been filed by his mother for bizarre behavior after he had neglected
his medications for 9 months. He had
been making threats regarding his mother, sister and self. Specifically, he
threatened to hang himself, his mother, or make bombs and blow up their house.
In the EPS report at admission, it was noted that he had over “10
hospitalizations” in the past 2 years including at Central state. In addition,
as a minor he had hospitalizations in OLOP, and a facility in Florida.
On
our first visit to him, he was non-threatening but somewhat agitated, denying cooperating
with the interview, and criticizing his mandatory hold in the unit. He was often sarcastic and scrutinizing. On questioning of his homicidal threats, he
denied, calling himself a “prince of peace.”
His
toxicology screen was negative, but he claimed that he had used cocaine,
marijuana, and hallucinogens in the past. He stated that he had “tried it all.” He claimed to use marijuana and alcohol both “once
in a blue moon,” with last uses within the past month. He claimed that he had tried unheard-of
hallucinogenic drugs around the time of his first hospitalizations.
On
further questioning of how he got his schizophrenia diagnosis, he denied memory
of the events which led up to it, other than the drug use. He also claimed to have little memory of the
sequence and timing of his past hospitalizations. AB denied he had schizophrenia. He denied experiencing auditory or visual
hallucinations, suicidal ideations, homicidal ideations, and past suicide
attempts. We did not have any
documentation from previous hospitalizations to support his diagnosis.
He
had held a job as a waiter for 7 months, which he lost a month before because
he decided to “no call no show” and stop going after getting involved
romantically with a girlfriend. He lived
at home. He claimed to have an active
social life, involving music, dancing, and bar scenes. When not living at home, he stayed with
friends for days at a time. On
questioning about his relationship with his mother, he said they do not get
along because she “pushes her beliefs on me.”
His family is Jehovah’s Witness.
He
frequently referred to his distrust of doctors, including us, calling them
“representatives of the pharmaceutical industry.” On questioning of his orientation to location,
he stated he was “in a restricted area.”
He cooperated with a urine tox screen taken in EPS but refused further
labs. When asked about his mood, he
stated it was “like Thomas Jefferson,” with a blunted affect.
During
his admission, AB appeared slightly disorganized. He was unkempt with long hair, and his body
odor was noticeable on occasion. He
refused to take a shower because he only used organic soaps. His excuse was the same whenever he denied
food and medicine. He did eat vegetarian
diet foods when offered. He never took
his scheduled Seroquel in his 5 days inpatient.
During the day, he would often stand in hallways, looking around at the
other patients, occasionally laughing at the bizarre behaviors of other
patients. On one occasion, AB was given
an intramuscular dose of Geodon because he would not remove himself from an
area where another patient was displaying aggressive behavior.
AB
often stood facing the nursing station, staring off but doing rhythmic
movements, especially hand gestures.
When asked about his movements, he responded about his interest in
magnetic healing powers, and also that they were movements he enjoyed for
raving and glow stick dancing. He would
say that he was “magnetizing the air.”
Even
with his slight disorganization, bizarre and magical beliefs, he was able to
give a clear, concise, goal-directed, and daresay convincing argument about his
current situation at his mental inquest hearing. His mother attended the hearing, but was
unable to provide testimony due to English language struggles without an interpreter. Regardless, the judge determined that a de
novo would be needed to begin forced medications. This could only be done at Central state
hospital, leading to his transfer out of the unit on day 5.
In
the 6 weeks on psychiatry, it did become very clear to me how common it is for
schizophrenics to deny their diagnosis.
I noticed this early on, but even in the end I still wish I understood
more about why this is the case. Most of
the patients who exhibited this seemed to be aware that they were not being
honest. I also got the impression that
those that denied their diagnosis were more at threat for future suicide, which
worries me about patients like AB.
I
had a lot of doubts about AB and his diagnosis while he was in the
hospital. Compared to the other
schizophrenics I had the chance to observe, he seemed so calm and aware of
reality. He was never caught talking to
himself or responding to other internal stimuli. Most of his out-of-the-ordinary beliefs were
not unheard of. He agreed in one
conversation that he was definitely anti-establishment. He seemed immature for his age, and not well
educated… but I would argue that if he was schizophrenic, he was in a residual
state. I know that as a student, I am
inexperienced and probably naïve in regards to psych, but as an attending I
will hope to maintain an open mind with every patient.
If
I hadn’t felt as limited by my role as a student, I would have wanted to
interview him more to gain more insight about his thought processes, and to
look for clear signs of positive or negative symptoms. I did get the opportunity to have a last
conversation with him on his last day. I
knew I wasn’t going to see him again. I
wanted to tell him that I thought he seemed fine, but of course I
couldn’t. Instead, I warned him that if
he wanted to stay out of the hospital, he needed to avoid arguments with his
family. And that when does argue, he
could never threaten, or he would be
back.
