Sunday, January 27, 2008

How To Clean your Brain, as told to me by a schizophrenic patient

Shortly after I decided to go into medicine, I knew the day would come when I would have to deal with a branch of medicine that both fascinates and intimidates me: psychiatry.

I'm not sure what it is about dealing with psychiatric patients that makes me so nervous. Perhaps it's how much I value my own cognitive abilities. Maybe it's the stories I've heard of patients in acute psychotic episodes, throwing furniture and yelling obscenities. Or it could be that every psychiatric ward I've ever been to or seen in movies sends chills down my spine.

But now that I've started my Clinical Skills unit on interviewing psychiatric patients, my naivety has resulted in a few surprises. I was blown away when I interviewed someone who has a severe form of a psychiatric condition, yet could still carry on a coherent conversation. I was also quite stunned after the patient told me about their ability to carry on conversations with squirrels in the park and according to their chart had to be tied down in four-point restraints on admission to the hospital, yet answered a number of Mental Status Exam questions testing insight, judgment and thought process as any normal person would.

Of course, the psychiatrist training us told us that there are a few exceptions to this.

For example, some patients will speak in what is termed Word Salad (ie. "I was running down the sidewalk, over the alleys in the supermarket. Sometimes the store is full of nuns, and sometimes the airplanes fly lower. But when I was younger, they threw me over the furnace and the time was singing."), and another patient he remembers didn't speak a single word in the interview, later revealing that he did so because he thought the psychiatrist could read his thoughts.

The patient I interviewed was a bit shy at the start but completely warmed up to me after a little bit. I was a bit nervous when the patient listed off their favourite weapons, stood up to demonstrate self-defence fighting techniques with intense enthusiasm, and then looked at me with hollow, peircing eyes and shouted "I'M GOING TO F------ KILL YOU!" (fortunately while recounting a conversation with somebody else, but it was still pretty intimidating!).

After getting a bit of history from the patient, I looked through the interviewing handbook we'd been given, and asked a couple questions from the "Anxiety" and "Depression" categories, but didn't get very far. Then I picked a question from the "Psychotic" category: "Do you have any abilities that other people don't?" and the patient lit up like a Christmas tree.

"Oh, definitely. I can clean out my brain."

"Really?" I replied, trying hard to stay professional and not crack a smile.

"Oh, yeah, I do it all the time."

"Could you tell me how you go about doing that?" I inquired.

"Sure, all you have to do is fill up the inside of your skull with water. Let it fill up slowly - not high enough that you'd drown, but close to the top." The patient held up hands to demonstrate the appropriate depth. "Then, all you do is shake it around a bit" - again I was given a demonstration of proper procedure - "and after that let it drain out, all through your nose and drool it through your mouth, all the way out until it reaches your navel."

After the interivew, I mentioned to the preceptor that I was stunned that given a demonstration like that, the patient could still answer a number of simple Mental Status Exam questions testing insight, judgement and comprehension correctly. "That's normal for someone with this disorder," said the psychiatrist. "Some of my patients with schizophrenia are incredibly high-functioning - they carry on normal lives with successful jobs - accounting, engineering for example." I wonder how many are doctors.

So that was my first psychiatric patient. I'll get to watch other students in my small group interview a number of other patients over this unit, and hopefully see a variety of pschiatric conditions. For me, however, after a few weeks' exposure to psychiatry, I've concluded that to me, psychiatry is a speciality just like pathology. While I'd never want to become a pathologist given the stigma, I have to admit that the more I learn about it, the more fascinated I am by it.


10 comments:

Reeking Havoc said...

I work in a psychiatric hospital, and I love it! There's never a dull day, and you learn new things all the time. In the process of doing psychotherapy you have to come to terms with some of your own human failings, else you won't be of much help. It's hard, but you really do grow as a human being if you want to...

Anonymous said...

Maybe it was distorted way of describing a sinus rinse?

Anonymous said...

I remember having odd dreams towards the end of that rotation. I think it was because I started realizing how close to "sane" these patients were, and how just a few neurons firing the wrong way could make me as debilitated as they are.

For a really trippy experience, ask some of these patients what they see in a picture (on the wall)... Sometimes their answers are so abstract/out there that you kinda wonder what's going on...

Anonymous said...

hahahahaha...I miss ya dude...you are going to be a fabulous doctor. And I mean that from the bottom of my heart! ...jj

jessica said...

whoa! That would be intense!!

What other disorders have you seen yet?

Vitum Medicinus said...

Thanks to the Redditors who have voted for this article and left MANY MORE comments at http://reddit.com/r/science/info/66s5c/comments/

I've gotten a few questions about the "stigma" associated with pathologists, which may not be as generally known as the stigma associated with psychiatrists. For the non-med folk, pathologists are often seen as being anti-social, the opposite of “people people," and as individuals who prefer to work with dead people and sit in a room by themselves looking in a microscope. Not the type of person I’d like to be seen as...which is why I chase away any glimmers of interest I have in pathology!

Jessica - I've seen only a few more disorders but that should change before the end of my psych clinical skills unit in second year. We're only learning how to interview patients right now for a couple hours a week for four weeks. In third year, however, I'll spend a few weeks full-time on a psych rotation.

Y. S. said...

John Nash and his son were both schizophrenic but they still managed in a way or another to pursue a successful life in mathematics.

Anonymous said...

If you choose a specialty based on what other people will think of you, you will be making a very serious mistake. My suggestion would be to choose a specialty based on what interests you, and based on what kind of life you want to live.

- signed the Pathology Prof Who Reads Your Blog

Vitum Medicinus said...

ummm....I obviously forgot to mention... some subspecialties in pathology are not only fascinating, but those doctors are considered some of the coolest doctors out there.

In an actual serious attempt to redeem myself, I'll clarify that in addition to the stigma, from my experience pathology lacks the interaction with patients that I value so much...and thats one of the reasons that I personally am not as interested in it as some other specialties.

But I suppose I should probably make an appointment to shadow a certain pathologist in order to make sure...

Artemis said...

I ultimately chose neurology, but one of my favorite memories from medical school was from my psychiatry rotation. I was attempting to interview a patient, when he started mumbling under his breath. It seemed important, so I asked him to repeat himself. Very carefully and slowly (as if it were the most crucial information he could share with me) he said, "Breaking rocks in the hot sun, I fought the law and the law won. I needed money because I had none. I fought the law and the law won." He ultimately recited the entire song as though he were telling me the history of his life - no beat or rhythm whatsoever. I still think about that patient when I hear the song on an oldies station....