Violence

Hi,

It was a very short week last week because being the last week of the rotation there were exams instead of ward rounds. That said, there was a single day in the psych hospital, which I really enjoyed. It is a shame that at the end of the entire psych rotation it starts getting good. A good combination between a proactive and interested consultant and seeing about 4 (yes four!) patients in a day showed me what psychiatry can be like.

Two of the patients we saw were in because of violent tendencies. One of the patients was in the manic phase of bipolar affective disorder and had been bought in because of their strange behaviour, and the other one was a possible sufferer of antisocial personality disorder (AKA psychopathy). Talking to both of them, they seemed relatively normal likeable people, though the latter did seem very manipulative. This was obviously not enough for the consultant psychiatrist, who decided it would be a good idea to test whether they were ready for release. He slowly started winding the patient up and saying things to aggravate and annoy them. When he started doing this to the first patient, we had no idea what he might be doing. It started off seeming like he was being a little tactless, saying things that the patient might find upsetting, then he seemed to work up into a frenzy, telling the patient how they were to blame for all of this and criticizing all of their viewpoints and arguments. All in a not-so-subtle way. We realised what he was doing after a while into the first consultation, and so got the chance to sit back and watch him try and wind up an aggressive and violent patient. It was fun in a sadistic way, but neither patient reacted violently towards the psychiatrist (fortunate, as they were both quite large men). What an odd experience, but I suppose as a consultant you have licence to do these things. You don't want to release a patient out into the community if they are still violent!

In the afternoon we were sitting in a reception waiting for a patient to show up to see the psychiatrist. This was a different psychiatrist to the one we were with in the morning, as we are swapped around doctors like a cheap Biro. Whilst we were waiting in the reception, we saw a drunk man sway into the room and wander towards the reception where he was directed to the waiting room. Soon after this the psychiatrist came down and told us that, while this drunk man was the person he was meant to be seeing, they had a rule here that they did not see intoxicated people so he wouldn't be able to have an appointment with him today. Unfortunately telling the patient this did not go down too well. From a positive mood where we was chatting away with us two medical students and hi-fiving us, he quickly turned to a very upset and angry. Refusing to leave because he had spent so much time getting here, the patient didn't see why he couldn't be seen. I can see both sides of the argument I suppose, the psychiatrist didn't see the point of talking to someone who was this drunk, as they wouldn't remember it or gain any benefit from it, and the patient didn't see why he couldn't be seen as he was there, had an appointment, and the psychiatrist was standing right in front of him. The patient was starting to get violent, pushing the doctor and receptionist around and throwing chairs around the room, so the doctor's PA came out and whisked us away to the admin room. While it was a lot safer there, I thought it was a shame that we couldn't see how the rest of the situation was handled, or how it developed. My partner disagreed with me fully, she was more than happy to be hidden away from the violent drunk. Anyway, the police were called by some of the administrative staff, and when the patient was told this he quickly fled the premises after threatening to go and kill himself. Unfortunately, because of this threat, the police had to be informed he had said this and they had to go and find him to section him for his own safety. Poor guy. I think the people who work in substance abuse are prepared to see intoxicated people, because with functional alcoholics it is hard to see people when they are not drunk.

Anyway, that is all I am going to write this week, exams went very well, thank you, and I have several essays and other things to write up now, so I should be doing those rather than meandering my way around a blog. I have now finished psychiatry and am going onto gastro medicine. I will be dealing with lots of obese people and alcoholic liver disease I am sure, and there will be plenty of poo, I just know it. I am really looking forward to being back in a hospital with the fast pace and lots of patients. I hope that this rotation lives up to its name and is varied and very hands on. I will let you know next week.

Variety

Hi,

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!

Law

Hi,

A shorter blog this week, partly because of all the work that is going on a the moment limiting time, and partly because not as much seems to be going on in psych meaning I have less to write about. Law plays an large role this week, I meet a psychiatric prisoner and someone under the witness protection programme. I also meet an androgynous feeling male.

Psych seems to be a very laid back speciality, with outpatient doctors having about 5 consultations per day, compared to the 30+ that GPs seem to have to deal with. Despite these consultations needing to be substantially longer, due to the complex needs of the patients, many of the patients do not turn up. Of those that do turn up, unfortunately only about half of them consent to have medical students sit in. This means we can go through an afternoon seeing no patients, just sitting and chatting with the psychiatrist. While good for learning, as we are being taught pretty much on a 1:1 basis, this is a real shame as we see less patients. So far, my impression is that psychiatrists have it very easy, but perhaps that is an incorrect initial feeling. Anyway, we saw 3 patients this week, but all interesting so I shall continue.

On Monday we visited a medium and a low security psychiatric hospital site. Set between the remaining shells of the buildings from an old asylum, this was a very apt backdrop. The broken panes of the fenced off old buildings seemed to emanate some kind of menace. How can a building give you that sort of feeling? Anyway, we talked to a patient who was diagnosed as schizoid affective disorder. This patient was admitted because of a series of GBH, ABH and the like offences, a degree of very high mood (mania) and hearing voices talking about him. He is likely to have some form of antisocial behaviour personality disorder (so could be otherwise known as sociopathic or psychopathic). He had just been moved down to low security from medium security he was in before. He seemed polite and charming to us, but that is just one factor that hints towards psychopathy. A very well known drug dealer in the vicinity, and an intelligent criminal, the feelings of the psychiatric staff was that he came off of his medication in prison in order to exacerbate his schizoid affective disorder and thus be transferred to the psychiatric hospital, and now to low security. Patients can be cunning.

On Tuesday we went to a ward meeting in the inpatient psychiatric hospital, where we just discussed patients who were currently resident. This was a disappointment, as my partner and I thought it was a ward round and were hoping to get the chance to talk to some patients. It was interesting hearing about all of the patients and the treatments they were on, but it is not the same as actually getting to talk with them yourself.

Friday involved seeing, shock horror, 2 patients! One of them was a man who had been depressed for much of his life, and wanted some medication adjustment. With a lot of gender issues, he was dressed very effeminately and was softly spoken and polite. Gender is interesting, how people can be born with the male genes and hormones, yet still feel they should be female, or visa versa. Interesting, but not quite enough to make me want to do psychiatry as a career.

The next patient we saw on Friday was very interesting. Not because of the symptoms, which seemed pretty ordinary, but because of the patient's situation. The patient seemed to be suffering from PTSD and depression after she had been attacked. Due to this attack she had been placed under witness protection and moved here from another part of the country. I won't say anything about the circumstances, as anonymity is obviously of utmost importance here, but she could only tell doctors (when relating to her condition) and the council her real name and situation. It seemed that she was exceedingly upset with the witness protection programme, which seems to strip you of all your civil rights, and this was adding to her problems. Taking her away from a successful job and large group of friends, she had been put into a strange town in a council house and expected to make a new life. After this consultation the psychiatrist went through techniques he uses to 'persuade' patients (read manipulate) into feeling the way he wants about certain things. He uses little things, such as offering to get them a glass of water when they get upset, to give them the feeling he is at their service rather than they are coming to do what he wants, as many patients do when they come to the doctor's. Anyway, makes you wary of yourself when you are around psychiatrists - he did tell us he wanted us to do certain 'exercises' for him, such as telling him about ourselves in 5 sentences so he could tell what sort of people we were from what we said. Psychiatrists are cunning, and patients lives can be cruel.

Anyway, that will have to do for this week, mainly because I have a lot work to get sorted out and I should really be working on that rather than writing this blog. Don't expect anything amazing here for the next couple of weeks until I leave this rotation and move onto one I find more interesting. I will still keep writing though - who knows - I might change my views completely.

Addiction

Hi,

This week is very laid back, but the three patients I do manage to meet are poles apart, one being an alcohol and heroin addict, one being depressed and anxious and one being the 'stereotypical' mentally ill patient that the public seem to imagine. Rapid mood swings, shouting and delusions, this sort of patient is a rarity nowadays due to all of the medication passed around.

This week was very quiet due to having our consultant and his PA both on holiday (not sure if they were off together, but that could be the ingredients for a soap...) Unfortunatly this meant that we only saw 3 patients over the entire week. We had times we went to the hospital for ward rounds which we couldn't participate in, and we have had teaching as well - so the week was not empty, but it was by no means as busy as the elderly weeks. So far I think psych is a lot more laid back compared to everything else I have seen. We got refused consent to sit in on consultations as well, but I can only assume that this will be a lot more common in psych than in other specialities due to the stigma some people still associate with mental illness.

Anyway - On the first day myself and my partner spent some time talking with a 28 year old lady who had admitted herself to the hospital to help her detox from her addicts life. Talking to her, it sounds like she has had a very hard life. Currently addicted to alcohol (drinking 8 litres of 7% cider) and heroin (still using despite being on methadone) she wants to come off of alcohol completely and move back to just being on methadone. She started off with cannabis at 12, moved onto cocaine when 14 because she was a model and it was part of the job and then she has been on heroin since 15 and an alcoholic since 16. Because she has been using heroin for so long, the normal injection sites have become unusable and she has had to start using other access points such as her breast or neck. Despite being on methadone for 10 years she has never really come off of heroin. She first got into heroin in quite a forced way, being invited back to a strangers flat after drinks (age 15 remember) and being persuaded to shoot up there because it was 'fun'. She was then kept there for 2 1/2 weeks against her will, her parents didn't really seem to mind as she was often away from the house, and she was raped by the men living in the house and their friends. They shot her up with heroin every day and she developed an addiction. She was 'sold' by her then boyfriend when she was 21 to some drug dealers to pay for some drugs, who raped her and lead to her having a daughter, who is now 7, but has been taken away from her. She has had to work as a prostitute since she was 15 until now to pay for the drugs, but now wants this life to stop so she can get her daughter back. She has to get up at 7 every day to walk the miles to the clinic to get her daily methadone, and she cannot drink before getting in, as they breathalyse and will not give the drug unless people are sober. She suffers terrible alcohol withdrawal symptoms before taking her first drink, such as shaking, hallucinations and sickness, and then she spends the rest of the day drinking and vomiting after walking home This sounded like a terrible story, and reminds you that it isn't only in 3rd world countries that people face tragedy and life events that many of us cannot even imagine. Talking with the doctor afterwards about the patient, it turns out that the only thing she lied to us about was when she told us the last time she tried to detox was 5 years ago at another centre. It turns out she attempted to come off the drugs a few months ago at this centre but quit the programme after a few days. I hope she can pull through it this time, but I know the statistics say she is likely to end up back on the street. Patients can be at rock bottom.

The other 2 patients we saw this week were in a secure unit, which we had to be let into and then locked in with the staff after we had entered. A bit of a scary prospect, seeing as we wouldn't be able to let ourselves out if something started kicking off! Anyway - this was with a different partner, as we tend to be with different people on different days and different rotations - it is not just one person who has to put up with me all this time. The first patient we talked to was very depressed and had been sectioned by the police under a Section 136 which involves him being taken to somewhere like a hospital and being assessed by psychiatrists. These doctors then further sectioned him as they thought him a risk to himself. He was bought in because his family phoned the police telling them that he was trying to jump out of a 4th floor window. The patient had had suicidal thoughts and had sought CBT to try and turn his life around, but kept telling us that he was definitely not trying to jump that time, and was just trying to climb out to get out of the house. I suppose he was a danger to himself either way, and it is best to try and help him. He was currently on several drugs to try and bring his mood up, but hated being in the secure unit. He did not feel it was the place for him, and wanted to be transferred. A very anxious man, he said whenever it 'kicked off' between a patient, or patients, and the staff he would hide in his room until it all went away. Indeed, when we were talking with him, there was a lot of shouting and crashing from outside and he looked very anxious and was flinching away. I am not sure why he was in such a place, but perhaps it was the only slot available. He had only been in for a few days, so hopefully he was going to be transferred soon. An easy to talk to and polite gentleman, he was setting us up for a stark contrast with the next person we talked with.

The next patient found us, rather than the other way around, and asked us if we could come and talk with him.  I was on my way to the toilet when he collared me, shambling over dressed in about 4 coats and many jumpers, but I was not going to refuse just because of my bladder. After calling my partner over the patient lead us to a little room at the end, we were a little suspicious of this, but we followed after him, slowly, with his shuffling walk. The man looked in his late 60s and, along with his very strange dress sense with many layers, looked pretty crazy. Large, bushy eyebrows and alternating staring and flitting eyes, he looked as though he was meant to be here. Once in the room, we made the rookie mistake of sitting down in chairs that were not closest to the door. It was quite a small room, and the patient sat next to us, between us and the door. We were then subjected to a very confusing talk for about half an hour, out of which we got very little information from the patient. He started off telling us how he killed someone when he was 6 and then continued to tell us how he used to own a mental hospital and was trained as a psychiatrist (possible but unlikely). The only reason he gave for being admitted, though we asked numerous times, was that he kept talking to himself. This is different from hearing voices, which steers us away from schizophrenia. We weren't sure about his diagnosis at all. He kept alternating between shouting, standing at some points and becoming threatening, then apologising, telling us he knows it is his fault and he works himself up into it, and trying to be calm, stroking the material of my trousers at one point and telling me I am very finely dressed (£10 trousers from peacocks. Nice!) We were not really sure what to say through much of this, but he then invited us to his room to see a talking car. Assuming it to be some kind of delusion, we accepted (unsure about the ethics, but sure to remain next to the door at all times this time.) It turned out to be a talking toy car - I suppose you have to accept that patients may be talking sense sometimes. Anyway, the patient was convinced that my partner and I had some form of romantic attachment (we do not) but would not take no for an answer. In the end, he told us we had to leave NOW before he started becoming violent. I don't need to tell you we left very rapidly! Patients can be intimidating.

Despite only seeing 3 patients this week, we heard about many more. Looking at some of the notes for the secure unit we read about a patient who kept trying to sneak knives in, or take them off of staff if he ever saw a staff member carrying one for a task. Scary! I also heard about a patient, (this was in a clinic I went to but saw no patients due to no-one consenting) who was highly manic and decided that the problems in the middle east were starting to get silly. He spent all his money on a plane ticket and flew over to try and sort out the dispute over the Gaza strip - they wouldn't let him into Israel or the Gaza strip, but deported him back saying he was mentally ill. He started getting psychiatric help and then flew out again to try and sort things out, escaping into the river Jordan where he had to be fished out. What a wonderful person, trying to sort out all those problems on his own! I often wonder if I am (at least in part) perpetually hypomanic. I am usually full of energy and feel great most of the time. Perhaps I am just a cheery person. That is the problem with psychiatry I suppose - the blurriness between mental illness and normal variation in people. When do you start treating! A lecturer once said to us that psychiatry is about 100 years behind most of the rest of medicine in its crude diagnosis and treatment. It seems like they could be right

Anyway, apologies for the strange text changes in the last posting - I think they came about because of pasting in images and the such, and I couldn't seem to get them out. Have a good week!