Thursday, August 29, 2013

Mania, Grandiose, and other things hard to imagine

As a 6 year med student you are required to rotate in several different "core" clerkships in your 5th year which includes Surgery, OB/GYN, internal medicine, psychiatry, and pediatrics. Basically it is 2 months(except for psych which is 1 month) where you learn all the basics to a field plus some obscure facts for your national exam while freaking out about what you are going to specialize in. After a long, stressful, and difficult 6-10 weeks of studying for step 1, I started my first clerkship at the beginning of August: Psychiatry. Before starting I thought I knew what mania was like, a general idea of grandiose would be like, and had a certain idea of what a month in psychiatry would entail. I couldn't have been more wrong. Nothing in a textbook can really prepare you for what the extremes look like and the frustrations that come with being in psychiatry. You are diagnosing patients who are having a break from reality or are overall difficult and though you may want to say "you stop that and cooperate." It would do you no good. They simply are not capable of the impulse control and decision making that those of us who are not suffering from mental illness take advantage of every day. These are some situations which stick out from the month.

The Manic with grandiose ideas: my first interaction with him was nothing short of memorable. Cursing at the staff physician and resident to get out of his room, shouting he had written the DSM and he was a physician who had diagnosed the attending with being a sociopath, and promptly refusing any medication. Through his 96 hour hold his list of grandiose beliefs grew and eventually landed him in a 21 day hold. He believed that he had served in the korean war and on the USSR(though he had not been born yet), had created the internet, had 5 doctorate degrees from any ivy league university before he was 5, owned his apartment building and the buildings on each side of him, that the staff were all foreign spies who had infiltrated the system and were keeping him against his will so he wouldn't warn the military that they were trying to steal the US reserve, that the officer that brought him to the ER was a russian spy, his neighbor a child molester, he had written the DSM and created all 3 tiers of psychiatric medications, and the list goes on. A meeting with him would surely end in him declaring you a nazi and sociopath. Did you know that Hitler ended up in a zoo? Yeah me either.

The Praying Schizophrenic: each schizophrenic has different delusions and hallucinations and though it is still not clear what this person's delusions and hallucinations are it is sure to be something to do with religion. He is also a diabetic which causes other special concerns, but a week ago he decided to start refusing all medications. Both psych meds and medication for his hypertension and diabetes. He also stopped eating, drinking, and sleeping. He simply sits in the same spot all day praying in a different language. Anytime he is disturbed, he becomes aggressive. He will get a long term injection and hopefully come out of his psychosis.

The "normal" suicidal patient: most people don't want to be in the mental hospital. It is a locked facility where you are checked on every 15 minutes if someone isn't constantly with you already. Your time outside is limited and otherwise you are basically in your room or the common area or groups. It is a very structured environment which is great for psychotic patients, but for others it can be terrifying. Your freedom is taken away and you are locked into a facility with others who are having a break from reality. I called this patient "normal" because she wasn't having a break from reality, however there is nothing normal about being suicidal. The attending physician was discussing personality disorders with us when there was an urgent knock on his office door. She came in sobbing and demanded to leave. To her dismay the answer was of course no. She then demanded to know if we could legally hold her against her will and the answer of course was yes. She was distraught. She had a career, a house, a dog, but she was depressed about not having a family and not being able to have children which eventually led to her to being admitted. After a 96 hour hold(which does not include weekends so more like 140 hour hold) she was release with resources, new medications, and an eye opening experience.

So what did I learn in psych? They have the most unpredictable patients, spend a lot of time dealing with legal issues, and are tested on a daily basis. I have no idea how much money they make, but I am sure it is not enough. Bless their hearts for being able to care for people who need it the most.

Today was my last day. I am curious to see how the patients who are just now starting medication and treatment will progress, but onward I go. Next week is the beginning of pediatrics. Wish me luck!

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