By Robert Lanz, LCSW
When I went into his room, Mr. B sat up in bed and let loose a scream that could have come straight out of a Hollywood slasher movie. Before I could think, I burst out of the room and let the heavy wooden door slam behind me, nearly breaking the reinforced glass. Two doctors and three nurses, along with the unit secretary, looked up at me as I stood with my back pressed against the wall, breathing heavily and looking as if I were the one with a serious medical condition. Even the transcriber quit her mile-a-minute chatter to take notice.
They knew I hadn’t been in the room long enough to light the patient on fire, the only possible explanation for a scream of that intensity. All they knew right then, was that the patient they had sent me in to see was in the room screaming and I was in the hall cowering. Not just cowering, but failing at my job, which I’d only been on for three days, and it looked like I was already running away from patients.
My previous job had been working in a jail for really bad kids, and the first and best lesson I learned there was never back up. If you backed up once, you would spend the rest of your career having guys trying to get you to do it again. Never back up. Never show fear. I looked at the crowd and they looked back at me with anticipation. I opened the door and went back in.
Psychiatry is not really complicated, at least not on our level. First, you have to figure out if the patient is acting strangely because of some medical condition—an overdose of something (accidental or on purpose), a head injury, disturbed metabolites, dementia, and so on. Next, you have to understand the three essential divisions—problems with thinking, called thought disorders like schizophrenia; problems with feeling, the mood disorders like major depression or bi-polar disorder (manic depression) and finally, the personality disorders, in which the behavior is skewed one way or another as in “odd” or “different” or “can’t get along with other people”.
People who suffer from thought disorders frequently have thoughts that aren’t real (delusions), see and hear things that others can’t (hallucinations), and often aren’t able to function well without medication. When someone refers to a person as crazy, they are generally talking about this group. Because of poor reality testing, they have problems with their moods and behavior, but those are not their main problems.
People with personality disorders display varying degrees of being able to “fit in” (and varying degrees of caring if they fit in), but they don’t necessarily have scrambled thoughts or major mood swings. Sometimes they don’t even have mood swings when they should. For the most part, they are able to function. They can work, get along, and in some cases, become successful. Show business is full of examples of people with these disorders.
Mood disorders can include a range of mild to major depression, and mild to major mania. That’s where Mr. B. fit in. He was in what is called the manic phase of a bi-polar disorder. Bipolars cycle between acute, debilitating depression and acute debilitating mania, with varying degrees of mood swings in between. It is not uncommon for such patients to function adequately for extended periods of time, especially with current medications effectively controlling the down part of the cycle. The up part, generally harder to manage, thankfully comes less often, but is so much fun for the first day or two, that patients have such a sense of omnipotence and well-being, the first thing they do is stop taking their medications. Within the next few of days or so, the mania overcomes them and they can do social, financial and even physical damage to themselves and to those around them.
At some point in this extreme, the behavior becomes crazy enough to attract the attention of some “authorities” like the police, and the patient is forcibly brought to the ER for evaluation.
Meet Mr. B. At the point at which he arrived at the ER, he was at the peak of his up cycle. It is not uncommon for these patients to behave in a frightening manner. Often, they end up heavily medicated and placed in restraints. Or, they end up chasing the new guy out of the room.
It’s hard to get a word in edgewise with a manic on a roll, and I knew the only chance I would have with this one was to get started before he did. A real manic can tell a long story in one sentence without taking a breath—a long story that, for the most part, will only matter to him. Imagine being locked in a closet with a guy who just shot methamphetamines into his arm and you didn’t. The first guy talking gets the stage.
When I went back into the room, Mr. B sat up and took a breath, flexed his jaw and got ready to ramble. But I was quicker. He might have been manic, and he might have been able to hold a line for hours but he wasn’t quick. At least not quick enough for me.
“Don’t ever yell like that again in my hospital. We have sick people here and you can’t be doing that,” I said with authority. “I don’t let people act like that around here. Now get control of yourself.”
His mouth opened but nothing came out. A speechless manic. Pretty rare. Most manics could tell me for twenty minutes how they were going to stop talking and why. I say twenty minutes because that’s about how long the mind-numbing medicine we make them take is in their system before they zonk out. Giving it to them is the humane thing to do. It’s the accepted level of care in most emergency rooms, and the medicine, injectable Haldol, is the gold standard for controlling that sort of psychotic behavior. Welcome back to my world, Mr. B.
The amazing Haldol, lifesaver to any ER behavioral emergency, did exactly what it was supposed to do. It slowed Mr. B down to a point we could reason with him and make arrangements for him to be hospitalized briefly for his own safety while we tried to regulate his mood cycles with our chemical intervention. When a patient’s neurochemistry is stronger than our medicine, the patient and we are in big trouble. Fortunately for Mr. B. and for us, we were going to be getting along fine.
“What’s your name again and who are you?” Mr. B asked with some degree of normalcy.
I told him my name and what my role was and how I thought it would be a good idea for him to go back into the hospital for a while until things smoothed out. He was agreeable, his thought processes seemed reasonably intact and he wasn’t yelling any more. He still had tension in his speech and a tendency to wander, but he did seem to have a grip on reality that had been non-existent prior to the Haldol injection.
In time, I came to like the Mr. B., and realized that the screaming and chasing me from the room wasn’t the guy he really was, just his goofy brain chemistry getting the best of him and causing poor reality testing. Now I was his reality check and we were getting along pretty well. It was a slow night, and I actually had time to chat with him while we waited for the psychiatrist to make arrangements to get him hospitalized. Mr. B. told me about the course of his illness and how difficult it was when he started to lose control of himself. I was a good listener that night, and Mr. B took a liking to me.
“Bob, I can see that you’re a smart guy. You’re probably the best social worker on the staff. Maybe even smarter than some of the doctors. You’re the kind of guy we could use at our new clinic.”
“New clinic? Where’s that?”
“I know you’re going to have a hard time believing this Bob, but I come from a rich family and they have put a lot of money into researching bipolar disorders. We’re building a clinic, an institute really, to treat people with this horrible chemical imbalance. We’re looking for sharp guys like you. We could probably double your salary here and I bet you’d be the head social worker there in no time.”
I gave him that look. The curious look that asks, “Are you for real?”
He was for real enough to perceive that I was skeptical.
“Bob” he said with strong conviction, “I wouldn’t expect a smart guy like you to buy this without some proof. What do you think of this?”
He pulled a wad of hundred dollar bills out of his pocket and threw them at my feet. A big wad.
“Take it. It’s yours. It’s only pocket change to me. I told you I was rich. I want you on my team.”
I checked more than $3000 into the hospital safe and came back down to the ER. Mr. B. was just being loaded into the ambulance that would take him to the psychiatric facility across town. Apparently his own facility hadn’t opened yet.
The next day I called his psychiatrist to see how he was doing.
“Interesting case, Mr. B. Terrible mood swings. Totally looses contact with reality, but he usually responds well to his medication. He should be back on the streets in a few days.”
“On the streets? I thought he was rich.”
“Oh I see you got to see Mr. B’s famous clinic story. Did he pull a wad of hundreds out his pocket and throw them on the floor and tell you it was yours if you wanted it?”
“Yeah, he did” I answered sheepishly.
That’s all the money he has in the world. Really strange. No matter how crazy he gets, he never loses that money. Every time he shows up at the hospital totally out of control, he has the money with him. He always throws it on the floor as a gesture of sincerity after concocting some delusional story. I think you’re about the fifth guy he’s done it to. I hope you didn’t take him too seriously.”
Who me? Smarter than any doctor. Soon to be the head social worker with a doubled salary. I wouldn’t do that. I’ll hold on to my regular job, thank you. Damn that Mr. B.