“It’s still hard for me to have a clear mind thinking on it. But it’s the truth even if it didn’t happen.”
I love this quote from Ken Kesey’s One Flew Over the Cuckoo’s Nest because it draws into question the meaning of truth.
An insane man experiences the truth for himself, even if it is not the same truth for everyone else. If you consider that all experience is subjective, then you realize that you are not so different from him. You see the world reflected by a flat mirror while he sees it in a warped one. Neither of you actually see the world.
Prior to starting PA school, I had a strong interest in psychiatry, stemming from my love of literature and philosophy. I find it fascinating that the mind is capable of generating such fiction when it becomes unraveled. Also, I find that understanding the motives, values, and decisions of people is as central to literature as it is to mental health.
Of course, mental health isn’t all about treating schizophrenia and psychosis, but since I rotated on an inpatient psych unit, I saw a disproportionate number of these patients.
As I have said before, no matter where you rotate, your experience will be made (or broken) by your clinical preceptor. I have not heard any of my classmates complain about this rotation, but most of them said that it was “easy”. Their experience was mostly shadowing, and they were often sent home early and given extra time to study. If that is what you want, then great.
Dr. Martin kept me there from 8a-5p every day and put me to work (and that is not a complaint). Not only was I interviewing patients on my own, but also I was assisting the social workers and participating in counseling sessions. I had five or six patients that I followed every day and was responsible for interviewing them and suggesting treatment plans. I had a more challenging experience than most of my classmates, but it was easily one of my favorite rotations of clinical year. Psychiatry was every bit as fascinating as I hoped it would be, and much of that is due to Dr. Martin being an engaged preceptor. In fact, this experience even made me consider psychiatry as a career.
There were some unforgettable experiences on this rotation:
- My first day, Dr. Martin had me interview a patient on my own. The patient had PTSD related to an auto accident that occurred years before. When we talked about the accident, I noticed that the patient became agitated and showed signs of a panic attack (breathing heavily, fidgeting, tearing, pulling at his hands, flushing in his face). I immediately backed off and told him that we could talk about something else and return to that topic later. This became a first learning point for me. Dr. Martin explained to me that although the natural tendency is for providers to shy away from panic attacks, the best thing to do is let the patient have the attack. It is actually therapeutic for the patient to have a panic attack in a safe environment where you can talk them through it. You first want to draw awareness to the experience (anxiety, sweating, palpitations, etc.). Explain to them that these symptoms would be perfectly normal if their life was in immediate danger. Then help them recognize that they are in a safe setting. Have them take a few deep breaths and demonstrate that doing so may slow down their heart rate and reduce the symptoms. Essentially, teach them mindfulness techniques. Teaching them that they can control these awful sensations and that it is okay to feel them. A main reason why this man had failed to progress since the accident is that he had taught himself to run and hide from these attacks rather than confront and overcome them.
- I had read before about bipolar disorder with psychotic symptoms, but I never imagined how much it could mirror schizophrenia. We had a patient who, when she first presented to us, was withdrawn with flat affect and a profound speech latency. We would ask her questions and she would stare off into the corner of a room as though towards an auditory hallucination. Sometimes twenty seconds would go by before she would respond. Her words were slow and confused. She had poor recall and insight. Her thoughts were tangential and bizarre. When she was on the unit, she walked around with a bible, shouting and blessing people. In one instance she became agitated and struck a nurse. We found out that she had previously been diagnosed with schizophrenia. However, in talking to the patient’s family, we learned details of her history that were far more consistent with bipolar disorder. Each psychotic break was preceded by a period of a few days where she would stop sleeping, have increased productivity, speak more rapidly, and make impulsive purchases. A regimen of Haldol gradually brought this girl out of her psychotic state. It was rewarding to see her smiling and laughing again. I was amazed at how intelligent and cheerful she was, having witnessed her behavior the preceding days. It was also rewarding to give her the correct diagnosis and begin a mood stabilizer that I knew would change her life. Another patient had a similar psychotic break from hyperthyroidism.
- Our most rewarding patient was a lady with bipolar I disorder, obsessive compulsive personality disorder, and alcohol addiction. The encounter was rewarding because it was also frustrating. I was on psych rotation for five weeks and for over four of them we struggled to find a treatment for this patient. Of course the crux of our strategy was to get her on a mood stabilizer, since bipolar I was at the heart of her alcoholism. This woman had spent her life not knowing her diagnosis and had been self-medicating with beer and liquor. Perhaps the most beneficial part of being on an inpatient psych unit is that the psychiatrist can directly witness a patient’s response to treatment and tailor the drug regimen as needed. At first, every medication we tried seemed to make this patient’s condition worse instead of better. In one instance we even sent her into a drug induced delirium. She understandably became angry when she stopped sleeping at night and experienced visual hallucinations, but she continued to trust us and work with us to find something that worked. In the end, we found a dose of Lithium that made a more dramatic improvement than I could have ever imagined. She went from barely functioning, boxing herself away in a “safe-space” in her room, to being a calm, collected, and intelligent woman. This poor woman had spent her entire life battling daily with bipolar disorder and hadn’t even known it. Now, for the first time, she felt happy. It was a powerful experience for me. Above all, it made me realize the importance of mental health awareness. There is such a stigma in society that many people never seek the help they need.
- One of the foremost experts on catatonia in the nation worked in the hospital where I rotated and was in charge of the Electroconvulsive Therapy (ECT) center. I was fortunate enough to spend a few hours with him, observing ECT. He taught me to recognize seizure activity on an EEG strip and had me question the patients about their experiences. Having learned about ECT during didactic year, it was no surprise that every patient found it incredibly therapeutic. These were all patients who had been refractory to medical therapy, spending years of their lives on different drug regimens and remaining depressed. ECT was a godsend to them. It was not uncommon to hear that for the first time after ECT they felt energetic again, able to participate in life. There was some short-term memory loss, but it did not seem to be a major impairment and generally resolved within a week. Overall, the therapeutic effect vastly outweighed the side-effects. One interesting fact about the procedure is that they inflate a blood pressure cuff around the patient’s ankle to visually verify tonic-clonic seizure activity in the patient. The pressure from the blood pressure cuff is enough to stop the paralytic medication from reaching the foot when the patient is sedated, but it does not stop electrical impulses. So while the rest of the patient’s body is sedated throughout the procedure, the foot demonstrates a visible seizure.
- Study the drugs early in the rotation. Overall, your psychiatry test will probably be the easiest of your clinical year. The most challenging information to learn is undoubtedly the drugs. Study the heck out of them your first week. That way every time you encounter them on rotation you can reinforce this knowledge. It is also what your clinical preceptors will “pimp” you on the most. Know the toxicities of medications, such as the risk of agranulocytosis with Clozaril.
- Always consider the “low-hanging fruit”. I am referring to the easily treatable (and often missed) medical causes of psychosis. These include syphillis, hypo/hyperthyroidism, cobalamin deficiency, UTI in the elderly, steroid toxicity, polypharmacy, and illicit drug use/withdrawal. These diagnoses should be considered for any patient with a psychotic break. Missing one of these could be deadly for your patient.
- Practice the mental status examination to guide your patient encounters. The MSE is essentially the physical exam for psychiatry. Review it the weekend before you start your rotation, and your life on the psychiatric unit will be much easier. Every patient encounter will be guided by the MSE, and your preceptors will expect you to include one when you present a patient. Also be sure to learn the correct terminology. You preceptor will expect you to know the difference between tangential and circumstantial thought processes. They will want you to recognize when a patient is thought-blocking and to be able to accurately label a patient’s speech as pressured.
- Respect the therapeutic relationship you have with your patients. I made one major mistake this rotation. One of our young patients asked us not to tell her father that she was taking Prozac. Apparently, her father had been skeptical about psychiatric medication in the past, and she was concerned that he would criticize her. I was given the task of contacting the parents by telephone to gather collateral history on the patient. In the course of the conversation, I unfortunately let it slip that she was on an antidepressant. I recoiled, knowing that I had screwed up. I might have just lost the trust of our patient, destroying any chance at a therapeutic relationship. Fortunately, the patient decided to tell her parents anyway and no harm was done. Still, I kick myself for making that error. Be smart and be careful.