by Robert Lanz LCSW
A few months back, one of my professional colleagues, Patrick Scott, on his Facebok page presented an article in which the subject was about when, if ever, a patient with a major thought or mood disorder was amenable to psychotherapy. I hope this vignette will shed some light on that question.
This is pretty long compared to most of my stories, have a coffee, relax, give it some thught.
If you think it’s easy to tell a crazy person from a not so crazy one
you’d be right most of the time but most is not good enough when
you’re doing an evaluation on a patient in the emergency room.
Before I get into a rant about psych evaluations I ought to tell you a
quick story about a dying woman that forever changed the way I look
at brain function and memory and how that put me solidly in the corner with Carl Jung and Joseph Campbell. If you don’t know who those guys are go directly to Google or Wikipedia and read up on them, then you’ll know what I’m talking about.
Before the dead woman, I knew less about brains and neuroscience than about how people are who they are. My undergraduate degree was in sociology and the group focused orientation created a separation between behavior learned by culture and what individual organisms started out with. We were lead to believe there was a marked line between what was physiology and what was culture.
Of course that was a long time ago-before PET scans and CT scans and brain mapping and all those techy things. The soon-to-be dead woman from South America had been involved in a serious car crash and sustained a massive head injury and everyone knew she was going to die soon. Sometimes there is nothing to do but wait and this is especially true with bad head injuries. When the brain swells and eventually becomes too big for the space it lives in, it has to go somewhere and that somewhere is a hole the bottom of the skull where the spinal cord sort of becomes the brainstem. The brainstem is what you have in common with an alligator, a very primitive place channeling the basic functions of your brain to the other areas where thinking and feeling reside. There is no sociology or culture in the brain stem. At least I thought so until I was part of the crowd standing there watching the woman die as the higher functions of her brain tried to push through that little opening occupied by the brainstem.
The last thing we saw in her time of death was the woman crying out Aye. Aye. Aye. I never previously heard anyone say anything at the time of death and yet here was a woman not only saying something but something consistent with her culture. And that was when I took a look at that cosmic question- where is the “person” located in the brain?
Of course 20 years and several thousand interventions later we know that “memory” isn’t just located in the memory center but tends to be more pervasive over your brain. If that is true then maybe other things we thought were in certain places may also be pervasive, like psychiatric disorders. So let’s get back to evaluating psychiatric patients and how to be a good evaluator way more than most of the time.
If you know the history of thought and major mood disorders you know that generally there is a range of time in which the symptoms show up. At one end of the bell shaped curve there are a few kids whose parents or family members were aware that their child was always a little different. In the middle of the bell shaped curve is the adolescent and young adult. The majority of those who will eventually have a full mood or thought disorder diagnosis will be in that age range and their symptoms will start to be obvious during these times. Whatever normal lives they had begun to have are now less normal than their peers with social and school and employment progress more impaired. Functionally that is were they tend to be stuck.
Those who show their symptoms at the other end of the bell shaped curve are lucky in the sense that they have had the time to develop a greater sense of who they are and because of that with the right medications and therapy they have a more developed “person” in their brains. Social skills, education, work experience etc. may have developed more like a person without a major mental disorder if it shows up later in life.
This is really important for more than one reason. The late bloomers actually have a somewhat functional personality to return to between psychotic episodes. They also are more likely to respond to the newer anti-psychotic medications because those medications have less of a sedating effect. When I started in this business, in the seventies, the major anti-psychotic medications were phenothiazines. They were quite heavily sedating and patients who were having hallucinations stopped having serious symptoms when they took their meds and patients who were having acute delusions stopped having acute delusions. These were wet blanket medications. They were a wet blanket over the patient’s personality so not only did the symptoms go away, so did the patient’s personality and his ability to function. The meds stopped all the bad things but did the wet blanket effect over the good things too. So how do you tell the late bloomers from the early bloomers when they are both acting equally psychotic?
The real problem will be the late bloomers- the ones who had plenty of practice being successful acting normal before they became psychotic. Now is the time to reflect on the South American woman dying and crying out “Aye. Aye. Aye.” Her dying cries seemed to indicate that some behavior is all the way down to a cellular level. This will be the person who can go to their non-psychotic place during a psychiatric evaluation in the ER for the same reason the South American screams Aye Aye Aye at the moment of death.
There were surely several patients who fooled me during my career, but in my defense they most likely fooled everyone else too and most likely didn’t get referred to me in the first place. If they did get referred to me I would do an evaluation to see if the person would be likely to hurt themselves or someone else.
Here’s two stories that will demonstrate how far a good social worker should go to ensure patient safety.
Patient number one was a late bloomer psychiatrically. He had graduated from college, gone on to get it a degree in one of those difficult science fields, STEM’s they call them now, at a respected university. He even worked for a while before some genetic element finally manifested itself and took over his life. He was a late bloomer with a graduate degree and moved away from his family to start his career. Maybe if he had been living closer to home his family may have seen his decompensation sooner and got him some help. Maybe. The patient also had diabetes so when he began his schizophrenic confusion his blood sugar suffered significantly. Very low blood sugar sometimes looks like schizophrenia and psychotic behavior. Highly elevated blood sugar can also cause confusion. Both of these blood sugar levels are medically dangerous so besides the dangers of a major thought disorder this patient had a dangerous medical condition as well. And also, to his own detriment, was his ability to have the social skills to fool people during psychiatric evaluations. Aye. Aye. Aye. This guy, luckily for me, had previously been to the ER and was known to have a psychiatric disorder. Of course he didn’t tell me that. His caseworker, who I’d known for many years told me he had gone to the patient’s single room occupancy living situation, housing for disabled people, and found the patient naked writing nonsense on his walls with his own feces. It was also noted that the patient’s monthly supplies of psychiatric medications and insulin appeared untouched so an ambulance brought the patient to the ER to be an evaluated medically and psychiatrically. Luckily for me the caseworker gave me the heads up about the patient and his bizarre behavior.
Of course the difficult patients always show up on busy days. When I needed the most time I had the least of it but because of the information provided by the caseworker I figured I should bump this patient to the front of my timeline. If he was as disturbed as his behavior indicated the first thing I needed to determine was if he needed to be in restraints to prevent himself from hurting himself. Considering his history I also want wanted a nurse to do a one touch finger stick to determine if he had an emergency blood sugar level.
When I went in to the patient’s room the patient looked a little disheveled but he made eye contact with me and was pleasant. When I told him his caseworker was a friend of mine and he had called ahead to have me look in on him he seemed to appreciate it. We talked for about five minutes and he showed no signs of psychiatric disorder. None. If I hadn’t been armed with the info from his caseworker I would’ve been fooled. In any case he appeared harmless, was in control of himself and wouldn’t need restraints. About five minutes later he got out of bed and walked out of his room into the zone where we all do paperwork, answer phones and interact with each other. At any one time there was about eight to ten staff in the area. That would be the eight to ten staff that looked at the naked patient and then at me asking in unison, “What’s up with your patient, Bob?”
“He needs restraints and he’s diabetic. Not sure what is worse right now.”
We put him in restraints and did a one touch. Blood sugar about 450. That was about five o’clock and by seven we knew for sure the patient would need a medical admission because he hadn’t been using insulin and if we let him go home he would just get worse. We called the medical resident to admit the patient and order a psych consult for later when he was stable. That would give me some breathing room, get him medically stable and then he could have a lengthy psychiatric consult upstairs.
The medical resident came down and saw the patient for a few minutes then came to talk to us about it. The patient refused to be admitted and to the resident appeared sane enough to do so and it was then back on us.
I wasn’t happy. The resident may have done at most, thirty psychiatric evaluations in his whole life and I had done thousands. Writing crazy stuff on the wall in his own excrement was a difficult symptom and not taking his psych meds and his insulin made it lethal as far as I was concerned.
I called upstairs to the psych ward and a psychiatric nurse came down to evaluate the patient. She knew about the blood sugar and saw how elevated he was and knew he would get worse. She knew he was off psych meds and then writing on his wall with his own feces. She knew he had been walking around naked. But since this patient was a late bloomer he could fall back on his acquired socialization skills and convince a psych nurse he was sane enough to take care of himself, she refused to admit him to the psych unit against as will.
Back to the medical resident for a medical admit. He came back down and refused to admit the patient against his will, again. Damn.
“I’m not admitting the patient. If you guys keep him down here against his will, that’s kidnapping.”
“Well” I said. “He’s not leaving on my shift.”
Our docs were lining up behind me.
“And if you think I’m kidnapping the patient, maybe you’d better call the cops.”
“I’m the resident and I’m not admitting him” he said. Then he left.
Our docs looked at me. I could call the cops and they would come down to put the patient on a 72 hour hold just because I asked them to. That would piss off everybody, well not everybody. Certainly not our docs or the cops. Everyone wanted a resolution and we were on sketchy legal grounds since the psychiatric nurse sort of had the last word on that part of the patient care. But legal grounds were not the only issue here. I thought we weren’t on decent ethical grounds because if he went home and continued as he was, there was good chance he would slip into a diabetic coma and die. If that happened everyone would be asking who in hell thought it was OK for this poop writing schizophrenic with a blood sugar of 450 go home. Being a late bloomer gave him the ability to “act” normal for short periods of time. But there was still the matter of medical non-compliance, shit graffiti and out of control blood sugar.
“Not on my shift” I yelled out in a crowd.
The docs agreed.
At midnight my relief signed in and I explained the situation to her. The evening docs signed out to the overnight docs. We all went home but everyone promised to keep the patient there.
When I came back the next day the patient was still there but finally gave up and agreed to be admitted for his elevated blood sugar. We won the battle, leaving the patient unrestrained, by just waiting him out and as far as we were concerned the rest of the system was wrong and we were right. If that patient had gone home and died from a diabetic coma whose fault would it be? As far as I was concerned mine. And I was able to convince our docs that I was right because I was right. But legally I guess we were okay because the psych nurse and the med resident said so. I’ll let the psych nurse and the medical resident tell the parents when they come to the ER and ask why a guy who walks around the ER naked and writes crazy stuff on his wall in his own poop was okay to go home and die.
Close call I’d say. Luckily I held firm. Luckily the docs trusted me. Neither one of us wanted to be the one to answer that question.
The next time I wasn’t so lucky. A young woman came in from a hip beach town down by the Mexican border. She and her sister and her friend decided to visit our town and party, staying at a high end hotel not far from the hospital. They were in their early 30’s, very attractive, had a lot of money and they liked to drink. I guess that would just be a great party to go to if one of the women didn’t have a bipolar disorder and recently stopped her meds. She also fired the manager of her small manufacturing business the previous week. That would be the manager who helped start that successful business 10 years before. Bipolar, manic phase behavior, drinking.
By the third day the party had fallen apart. The patient had been intoxicated and not sleeping for 48 hours. She locked the other two women out of the room without their keys and yelled in a drunken rage so the hotel staff called the cops and the cops called an ambulance. The patient was no longer just in the hotel, but now a loud obnoxious guest in the ER. She was intoxicated and impulsive enough to be put in restraints while I interviewed the friend and sister. They confirmed the obvious bipolar history and symptoms. They confirmed the impulsive, self-destructive behavior and heavy drinking. They were both terrified by the patient’s deterioration and both of them seemed reasonable.
“We get patients like this all the time” I said. “A lot of them get in a manic phase start drinking and head up to Las Vegas and party. No one notices in Vegas that they are manic because in Las Vegas they just look like they are having a good time. They almost always end up in some unsafe sexual situation with friends in hot pursuit and finally law enforcement gets involved.”
“How did you know that?” one of the friends asked.
“Well it’s happened several times on my shift.”
“No. Not before. Now. How did you know about Maria?”
“That’s exactly what happened during a 24-hour binge. She kept running off with these strange guys and wouldn’t listen to us. We finally called the cops and they put us on the plane. We got back to the hotel and that’s when she locked us out.”
Drunk. Off her meds. Firing her manager. Impulsive and dangerous sexual activity. Educated, with money, she had a lot to lose if she continued to act out and everyone was begging me to lock her up and get her medicated. Everyone thought that was the best plan. Everyone but the psych nurse who came down to evaluate the late bloomer patient. She sobered up and psyched down returning to the “normal” that late bloomers have and early bloomers don’t. The nurse refused to write a 5150 hold on the patient. The doctor on duty was sort of a new guy and he wasn’t going to risk his license for me or that cycling bi-polar. And he had a psych nurse opinion to fall back on.
“She’s sober now Bob. She goes home.”
Big mistake. Normally I would fight. Well normally I wouldn’t have to fight and I could just have our doc call the psychiatrist on call and have a doc to doc talk. The psychiatrist has to depend on the ER for referrals and he wants to make nice with our docs and usually bends to our observations even if his own nurses thought different, a big advantage of the doctor to doctor consultation. This is a workable system most of the time but not tonight thanks to a lame psych nurse and a new ER doc and me not fully asserting myself like I should have. Most isn’t enough, of course, but I lamed out and didn’t put myself in a situation to fight a losing battle with an ER physician.
The patient did have two responsible adults with her I rationalized. But I knew I was wrong and I knew I was going to have to pay a price. It was just a matter of time before I would find out how much of one and my fear was I would have to pay really big. Oh, I can hide behind a psych nurse eval. I can hide behind my notes that said the patient could’ve benefited by hospitalization. I can hide behind the ER doc insisting that we discharge the patient. That might work most of the time. Not this time.
Of course that doc wasn’t around the next day when the patient’s family called to complain. She’d used her credit card to go the airport to fly back to Vegas. She was unable to stand up for the flight after consuming a lot more alcohol both in the airport and on the plane, apparently sobering up enough to get through what passes for security before boarding. She continued drinking on the plane and there was an ambulance waiting at the other end of the flight when she landed. At some point even the folks in Las Vegas realized she was a bipolar in a manic phase and needed to be locked up and medicated.
The family was all over me for not doing that myself and in my own hospital. I stammered through a lame excuse for giving up my power but they were still angry at me and the system they thought I represented. I knew something bad was going to happen. Luckily it wasn’t something terrible.
Aye. Aye. Aye.