Sunday, 21 February 2010



Ok, A better week than last, saw a student who seemed to be trying to persuade the doctor to prescribe him some Ritalin to help him study, a very activly suicidal patient, a 25 year old with aspergers and an actor with grandiose delusions who was bought in after going to a nursery and threatening to kill himself violently in front of the children.

While from that list above it looks like I was kept busy last week I can assure you that this is not the case. Hours and hours were spent sitting around waiting for patients to turn up. I am sure I said before how patients often don't turn up for apointments and all of that. Perhaps one of the key things about psychiatry is that patients tend to be very interesting when we actually get to meet them. Unlike in the hospital where one patient with pneumonia is very similar in presentation to another patient with pneumonia, psych has a huge range of presentations and stories behind each illness. Perhaps the fact that you spend so much of your time just finding out a patient's story as part of the history taking makes this appealing, but this week was definitely more enjoyable than the last.

One of the first patients we saw in the week was of a similar age to myself and my partner, and was complaining of poor concentration and irritability. With a history that he gave almost perfectly fitting ADHD the consultant evidently became quickly suspicious. ADHD is usually diagnosed in childhood, but can often continue on into adulthood, loosing the hyperactive running around element and often being referred to as ADD. The drugs used to treat ADHD are stimulants, I.e. Ritalin (methylphenidate), and are similar to amphetamines. While it seems an odd idea to give someone who is hyperactive a stimulant, this works in ADHD because the disease is caused by lower levels of stimulants produced by the body. Unfortunately the fact that stimulants, with similar effects to recreational drugs, can be prescribed open the door to abuse. I remember being told in my paeds rotation about a family in which the parents were taking the Ritalin they had got prescribed for their son, losing their children to social services. Anyway, I digress. This student was claiming to have no memories of primary school and few of early secondary. This is odd in itself, as most people have a few memories of their childhood, if not many. He told us that his parents had always complained of him losing things, having poor concentration and speaking all of the time. It sounded like a perfect presentation of ADHD, but then he started ruining it by telling the consultant about how he had bought some stimulants and they had helped, and becoming threatening when it looked like he may not get these drugs. Disinterested in any non-pharmaceutical management methods, and quoting Wikipedia to us, the patient left in a huff. Patients can be manipulative.

A contrasting patient we saw the same day was highly suicidal inpatient in the hospital. The patient normally suffers from bipolar disorder, but due to some severe adverse life events happening over the last week, he tipped from his depressed state to downright suicidal. After several suicide attempts, such as taking 30 paracetamol, he got found attempting to jump from a height by the police. Taken into the hospital for treatment and monitoring, he has to have a nurse watch him constantly because he keeps trying to commit suicide within the hospital. The last attempt being yesterday, when he snuck his pyjama top into the shower in the morning and then attempted to hang himself off of the shower head in the afternoon. He seems committed to attempting suicide, and admits having made other plans as to how to kill himself whilst in the hospital, though he doesn't want to share these with us. The problem with this patient is that with bipolar it is important to balance the medication and make sure the right combinations are used. At the moment, he is on about 4 mood stabilisers, to try and bring him out of his depression. He wants to be put on some anti-depressants but the doctors are wary about this, as putting a bipolar patient on anti-depressants can send them the other way, making them manic rather than stable. Mania can be just as dangerous as depression and can involve things such as spending on things you do not need, such as numerous cars, and sexual disinhibition. Talking to the patient showed evidence of these fits of mania in his history, such as setting up 4 businesses in a year, and emigrating to another country. I hope he managed to come out of his depression, because patients really intent on suicide are usually successful.

The 25 year old man with aspergers we only had a brief chat with. Still living at home with his mother, he eats the same food every day, hardly ever leaves the house and has an obsession with certain comic book characters. His hobby includes printing out pictures of these said characters on an ink-jet printer. The consultation focussed around trying to expand the patients life and social circle, getting him to leave the house more, perhaps go to some day centres and to eat more than the one food type he currently eats. Apart from the dietary problems that go with only eating one food type, I wasn't really sure if it was fair to persuade him to change his life. Yes, he lives very differently from us, not enjoying social contact or doing new things, and preferring to stay within his small comfort circle, but who are we to say that that is wrong. I have very introverted friends who prefer to stay at home, doing what they know they enjoy, but they do not have doctors sticking their noses into their lives and telling them how they should change it. I don't know, it just felt a little wrong.

The final patient I am going to talk about this week (and yes, another shorter blog, I know - plenty of 'proper' work to do this end, thank you!) was suffering from grandiose delusions, meaning he thought he was something or someone a lot 'bigger' than he actually was. With a past psychiatric history of believing he was Jesus Christ (more psych patients believe they are this man than you would imagine) he was now trying to persuade us he was a world renowned actor and playwright of similar fame to Shakespeare. A little research showed that he was indeed in acting, but was exaggerating his claim to fame somewhat. He was bought in because he tells us that heard voices telling him to kill himself, so went to a nursery with a knife and threatened to stab himself in front of the children. This obviously lead a a quick arrest and sectioning, which he seemed very happy about. The psychiatrist thought the diagnosis was much more likely Borderline personality disorder, and the patient was likely to be trying to get sectioned, rather than kill himself. This sounded like a sensible guess, with the patient cooperating fully when in the psychiatric hospital other than when discharge was suggested, when he would kick up a large fuss and do things to cause him to be retained. While a sensible idea, it was obviously worth making sure that this was the case, as if the patient were released into the community to do something like he was threatening earlier, then the psychiatrist would be to blame. Patients can be shocking.

Sorry, but that is it for this week, I am off to work now and stop procrastinating. Have a good week!

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