Reflections on the psych ward

As I come up on the last few of days of my psych rotation I find myself already missing it. Tomorrow I will write my last soap note on a psychotic patient. My subjectives will go back to being dull and uninspired, recording bowel movement consistency and skin turgor rather than colorful quotes or behavioral quirks. My morning rounds will involve conversations about passing gas instead of the latest visual hallucination. That is not to say that the field of psychiatry is one big party--on the contrary, some of the most dramatic, challenging and emotionally charged moments of my third year occurred on thus rotation. But when you are dealing with human behavior as your disease, the neat line between black and white that other fields draw so meticulously to protect their scientific practice often blurs to a chaotic gray. I would argue that this happens in other fields, too; it is just that psychiatrists are necessarily more comfortable navigating the nebulous territory of raw humanity.

I never thought that I would leave this rotation filled with, of all things, hope. Nowhere in my life have I witnessed in such detail the utter unravelling of an otherwise functional human being. However, also nowhere else have I participated so intimately in the process of healing the mind, and, or so it often seemed, the soul. Of course, I would be as deluded as my first schizophrenic patient if I thought we fix people. We play a brief role in a tiny sliver of their lives; for a moment in the grand scheme of things we share our existence and the goal of finding truth and clarity. Then the patients go on their way, back to mobile homes, group homes, or, rarely, families. And we move on, too, to the next crisis. Our next learning experience.

Daisy was a middle aged, stocky woman with piercing blue eyes and heavy features. When I first met her, her face was locked in a resolute grimace. She was muttering to herself and could barely acknowledge my existence, let alone carry on a conversation. How am I supposed to report on this patient’s status if I can’t even communicate with her, I wondered. For the first few days of her stay, my daily report went something like this: “Daisy is a 52-year-old Caucasian female with a long history of chronic paranoid-type schizophrenia brought in by police after she was found running away from her parents’ home convinced there was a bomb on the porch. Collateral information was obtained from her parents who state that the patient was stable on her treatment regimen until she was found catatonic in her apartment after calling 911. No known significant events or stressors preceded this episode. Overnight, there were no acute events. The patient slept three hours, anxious about a bomb under her bed. This morning, she continues to mumble to herself, responding to internal stimuli. She exhibits thought blocking and paranoid ideation, unable to complete sentences and perseverating over a knife she believes was placed in her abdomen against her will. The patient endorses abdominal pain secondary to the knife and requests a pelvic ultrasound. Legal status: she is on a 14-day hold for grave disability. Overall, her thought processes, hallucinations and delusions have improved from admission but she still exhibits debilitating symptoms and would benefit from continued inpatient care at this time. Disposition planning: the patient will be discharged to her apartment where she lives alone. Her son, who previously lived with her, refuses to participate in her care after receiving a disturbing call from her in which she pleaded with him to release her from the hospital because "Hell's angels are raping me here." Her parents are elderly and unable to provide support at this time but are willing to call Daisy each day for phone support."

This same distant patient, whose personality was initially such an enigma to me, slowly emerged from her psychosis to reveal a sweet, pleasant woman with a bright smile who loved to go on walks and listen to music. In her second week on the ward, Daisy began to style her dirty blonde bob and wear her own clothes. She looked lovely. One day, she came up to me and tugged on her shirt. “You like it?” she asked, her words slightly slurring together. “My parents brought it for me. The color’s called rust. It looks good on me. It’s hard to find.” I looked at her, amazed. It was one of the first conversations we had had about anything other than the voices in her head, the bomb under her bed, or the comb in her belly. It was Daisy, unplugged. Or plugged, rather. Another afternoon, I found her swaying in front of the radio to a Frank Sinatra tune. “You like music?” I asked her. “Yeah”, she said, her eyes glued to the radio. “Sometimes, when I’m at home, I turn on some oldies but goodies, close the curtains and dance.” She leaned towards me, shrugged her shoulders and smiled like a child indulging in guilty pleasure. Again: meet Daisy.

Another patient of mine, Lenny, had his first manic episode ever while I was on the ward. Lenny was a 33-year-old stockbroker with no prior psychiatric history who recently lost his job and was experiencing severe psychosocial stress. He had four children under the age of 5 and one on the way, as evidenced by his wife’s very pregnant belly the night of his admission. He was deeply religious, and in the past few weeks had become convinced that there was a bloody battle between good and evil being fought, and that the end of the world was near. He was so convinced of this fact that he initially eloped from the emergency room, anxious an earthquake was about to occur marking what he called “the end of times.” The first few days on the ward, Lenny kept to himself. On the surface, he appeared normal; he smiled appropriately, followed the rules, and was never agitated. I would learn of his delusions from the nurses, from my daily conversations with his wife--only occasionally did he let his anxiety loose with me. When I asked him if he missed home, he politely inquired whether I was asking about his home in Orange County, or his home in heaven. He refused to do yoga because he suspected it was a form of pagan worship. Several days after admission, when he was coming out of his manic episode (an occurrence that automatically earned him the diagnosis of bipolar disorder), he told me that he initially refused to let the phlebotomists blood drawn from his right arm because he was afraid it would leave the “mark of Satan.” Over his ten days of inpatient care I was able to witness Lenny lose nothing short of body, mind, and soul, and then slowly collect the pieces of his shattered self. Each day, just as Daisy’s delightful personality awakened just a shade more, so did Lenny’s insight into his delusions about the devil. “I don’t know how things got so intense”, he told me one morning during rounds. “It seemed so real. I really thought the world was gonna end.” This was the same man that sat in front of a judge during his 52/50 hearing and swore beyond a shadow of doubt in front of his wife, family friends, physician and me that he was right about his apocalyptic predictions. Who, as his colleagues were doing their pagan yoga stretches, launched a self-imposed 20-minute run around the milieu as “penitence for my sins”. By discharge, Lenny was asking about therapy to help him deal with stressors in a more productive way. He acknowledged that he had been depressed for months, maybe even years. He planned to change careers as he was finally able to admit that he had never felt comfortable playing the stock market. His wife filed for short-term disability for him so he could fully recover and help with the new baby. He understood the importance of taking his antipsychotic medications. He was in it for the long haul. Broken, yes. But in a brave, strong way. The way that forces you to reach into your insides and see what they’re made of. And then decide what you want them to be made of. I had faith that was Lenny’s path when he walked out of our ward, carrying his few belongings in plastic bags, wife in tow, eager to get home to his children and reinhabit his world.

Not every patient has a happy ending. My last patient Gina was in isolation when I first met her. She was crouched on all fours in the corner of the room, picking at invisible objects on the ground in front of her. She would occasionally try to lift herself up, only to flop back onto the floor. This would prompt her nurse to enter the room, trying to coax her back onto the bed. “34509!” she would scream, or some other combination of numbers. She complained of thirst, biting her lips until they bled. We offered her water; she opted to mold her hand into a shaking fist and bring it up to her mouth as if it were a glass. This was delirium.

Delirium tremens (DT), more accurately. Gina had a long-standing history of polysubstance dependence. She was a binge drinker brought in by her father after he found her walking naked on a street near their home. It was unclear whether her psychiatric disorder was organic or substance-related; she had never been sober long enough to figure it out. We sent her immediately to the main hospital for alcohol detox; she needed IV fluids, soft restraints, and Librium. 24 hours later, she came back to us, sensorium clear, personality disorder in full swing. She yelled, cried, sneered, blamed, and pleaded. It was disturbing behavior, but nothing even remotely resembling her delirious state on admission. She was unapologetic for her condition. “Why am I in here? I’m confused 24/7,” she would sneer, as if to say that crawling around the floor on all fours was all in a day’s work for her. Classic borderline: past suicide attempts, difficulty forming or maintaining any relationships, splitting (people were either the best or the worst, and her judgment changed on a whim), deliberate manipulation. She alternately kicked you away and drew you in: “You think this is a joke? Do you enjoy seeing me like this? Leave me in peace!” and literally two seconds later, when you walked away to give her (and yourself) a break, “See? You always just walk away! You don’t even care about me!” Despite Gina’s nasty behavior once she came out of DT, I found myself rooting for her. She would show flashes of kindness interspersted with her outbursts of agitation, thanking me profusely for my help while the tears from her last tantrum were still rolling down her cheeks. Drawing me in.
Gina left the hospital in this state, as there is nothing a hospital can do for a personality disorder except manage acute episodes. But what is fascinating to me I s how different a person she was from the Gina who was admitted five days ago, licking the furniture and trying to climb the padded walls in solitary confinement. The power of the human mind over the body and soul is overwhelming. As the delirium melted away, the real Gina came back, demanding the right to live her life. I knew well that alcohol would probably get the best of her again, and that she might end up in our ward or somewhere similar soon enough. But the transformation was amazing to witness nonetheless.

The power of the human mind. During a manic episode, patients feel like there is nothing they can’t do. They are up for days, minds racing, deluded into thinking they can solve the world’s latest crisis. Depressed patients won’t leave the house, incapable of experiencing any pleasure. Addicts mold their whole lives around their next hit, letting families, friends, jobs and hobbies fall by the wayside. Schizophrenics are tormented by voices often taunting them, or commanding them to hurt themselves or others. I know this now not because I read it in a book, but because I’ve gotten to know people with these illnesses.

Some people say that psychiatry should be an optional rotation in med school. The field has a reputation for being laid-back, so much so that many students and physicians in other fields don’t treat it as a medical specialty. I was one of those people until my rotation. But I was wrong. If there is an organic disease out there with medications that work to ameliorate its symptoms, a physician must know about it. I’m grateful for what my patients taught me, and for those precious moments where we met minds in their time of crisis to come to a better place.