Shock Therapy

It was my last day in psych and I got to see some interesting stuff. A patient in the unit who suffers from severe depression was found to be a suitable candidate for ECT. A nursing student (an ex-Vetinarian) and myself (an ex-Biochemistry) accompanied her from the unit to the Main Hospital where ECTs are done on the 5th floor. We chatted with the patient. She was nervous, even though this was the second ECT treatment she had received. Once in the room, an anaesthetist proceeded to administer Pentothal and succinylcholine and robinol. In addition, since she was being treated with benzodiazapines for her depression, Romazicon was also administered to lower her seizure threshold. She was administered 50 sec of 80 mA at 220 ohms resistance, which translates to about 176 volts. The entire procedure was followed on a monitor (to watch heart rate and blood pressure) and an EEG to follow the seizure activity. Because of the muscle relaxant, the patient did not 'jump off the bed' when the shock was administered. Furthermore, the major region of the shock was the temporal lobes bilaterally.

The patient regained consciousness soon afterwards in the OR holding room. She did not remember who the nursing student and myself were due to loss of short term memory. Overall, the procedure was nothing spectacular to watch. ECT is administered in a much more humane way these days with appropriate anaesthesia and limiting the major electric disturbance to the region intended. It is still a treatment modality of choice in certain refractory depression and even mania cases.

I talked to God today

Mentally Retarded and Emotionally Disturbed Children.

Today I got to spend several hours sitting in a class for ‘low-functioning’ mentally retarded and emotionally disturbed children. There were about 6 children in the class. One was a 12-year-old with Fragile X syndrome, another a 14-year-old with an IQ of about 60, a couple of girls – 9 and 11 with autism and mild MR with emotional disturbance respectively and a conduct disorder MR child (age 12). The level of the class was about that of a kindergarten class. Basically, the kids worked on tracing the lines in coloring pictures. They went over some flash cards of common signs (such as danger, poison, pedestrian crossings, etc.).

It was discouraging to hear that the two girls were raped as toddlers, one by her father (now in prison) and the other by several men at different times. Apparently, sexual abuse of the mentally retarded tends to be more common than of normal children.

It was interesting to interact with children suffering from disorders that I had only studied about in medical genetics and other courses. I had interesting discussions with their therapists and teachers regarding the goals for the children and the methods of communication. Most of these children have difficulties describing their feelings. Picture books and clever techniques are used. I felt a sense of admiration for the teachers and therapists that work with these lowest level of functioning children. Often the goal is simply to get the child to follow staff directions, to raise self-esteem and to help the child achieve the level of independence of function he or she is capable of, e.g. dressing themselves, toilet hygiene, anger management, etc.

In the afternoon, I got to talk to ‘God’. This was a 50-odd year old male who for the past 11 years has had the delusion that he is God. He does, however, also know that ‘here’, he is identified by the name that is on his official records. When he was brought in, he was paranoid, believing his neighbors and his wife and his doctors wanted to kill him. During the mental status exam, when I asked him to interpret the proverb, "People in glass houses should not throw stones" he laughed and told me "yeah, that's stupid, because the glass would fall on me!" He has since overcome this belief somewhat. He still maintains that his neighbors are trying to get him but he is content to ‘what goes around come around’. He no longer seems to manifest any homicidal tendencies. What is this person’s baseline function? What would be our goal for the inpatient treatment he is receiving? Today, he was due to appear in court. He told me he was going to tell the judge that he was ready to go home. Do we have any hope of convincing him that he is not God? Or should be just release him back into his situation when he is no longer a threat to self and others? I had some interesting discussions with his therapists and psychiatrist on these matters.

Child Psychiatry

Well, this past week, I have working in the childrens' psychiatric unit. At first, I was apprehensive since I have not been around kids a lot. I wondered if I would be able to relate to them and help them. The apprehension was soon replaced with a kind of sadness as kids matter-of-factly told me their stories. We had one kid who was admitted to the unit because he had thrown a chair at a teacher (in the US, you can forcibly admitted to a psych unit -- EOD -- emergency ordered detention -- if you are considered a harm to yourself or others; this kid fit the latter requirement). It turns out that he has a lot of problems, losing his temper and getting into fights with other kids and adults. The only person he does not fight with is his mother. When I asked him about his dad, he told me his dad was in prison. He last saw him 3 years ago and last spoke to him a year ago. I asked him if he missed his dad. He shrugged his shoulders and said that "a little", then added that he hadn't got to know him really well, since he had been in prison before and was only out for a short while before he was back in again. His problem: depression. Well, I think I would be depressed too! We are giving him anti-depressants and teaching him 'anger management' skills. Another kid has been hallucinating since the age of two! He hears whispers around him at all times, sees snakes and imagines his entire past. The prognosis for him is not good. He is a loveable, if somewhat hard to manage kid, but one who has developed the symptoms of schizophrenia very, very early. Of course, there are several mental illnesses in his family: schizophrenia, bipolar disorder and depression. That can't help. There are lots of stories to tell. Every child is a story, most of them not happy ones. I mean, how do handle hearing a 9 year-old girl tell you that she wants to kill herself because she bear to go on living? She even had a plan -- to slit her wrists. Interestingly, in this particular case, we could not find a precipitating stressor for the depression. Of course, there is a family history of depression, though none of suicide. There were many interesting cases.
I really came to love the staff who work there. They love the kids and discipline them too. The kids know that they discipline in love, so they love them back (that is, those kids that are capable of loving; we have some kids with attachment disorder, who do not know how to do that).
This coming week is my last week in psych. After that, I begin ob/gyn. That should be 'fun'. I have never seen a live birth before, so working in the L & D (Labor & Delivery) unit should be lots of fun. I also look forward to gynecology -- everything from routine pap smears and pelvic exams to surgery).

The Charles Manson Fan Club of 1

I just had to talk about this session this afternoon. The patient is a 20-something caucasian female, slightly obese, dressed in a T-shirt and jeans. She sat with a grimace on her face and pulled at her shirt sleeves, looking somewhat uncomfortable, somewhat anxious, somewhat depressed. The session blew my mind away. She talked about being a fan of Charles Manson. She sent death threats to another psychiatrist who hospitalized her over Christmas for suicidal ideation. She said to relieve stress she was thinking of doing something different... like smashing someone's head with a sledgehammer. Her therapist recommended she try smashing a watermelon first -- you know, just for practise and to see what she would have to deal with afterwords. She did. She set up the watermelon in her kitchen and smashed it with a sledgehammer. Somehow, this convinced her to abandon her plan because she says she's been cleaning out watermelon seeds and pieces from all over her kitchen for weeks now. Instead, she thought she might try jumping from a high point. I thought she meant bungee jumping, but further elaboration revealed she meant without a cord or a parachute. I surmised this when she said "the jump would be fun, but hitting the ground would hurt." Incidently, she brought in something she had sketched. It was a pencil sketch potrait of herself, drawn as Mona Lisa sitting in a bathrobe on a torn sofa. The Mona Lisa looked liked a photograph. I thought she must have been drawing it from a picture. She casually mentioned she had drawn this from memory. Of course, how much of this was shock value and how much of this was psychosis? Apparently, her body is like railroad tracks from the self-mutilation. Laugh if you will, but look behind you when you're walking home alone at night...

In the morning, I got a wish I had for some time. I was really interested in seeing dementia -- vascular, Alzheimer's infectious disease-induced... Well, I spent the morning in the geriatric psych ward. Fortunately (or unfortunately), I had been on call with my attending covering all the patients there both Saturday and Sunday, so this morning when I went to see them again, but this time with an internal medicine doc, I felt like I was meeting old friends. One of them -- a troubled 60-something year old female of mixed caucasian-indian descent came up to me and hugged me and woulnd't let me go. This, in the middle of the lunch room at lunch time. Whether from the meds she was on or from previous activities, her voice was heavily slurred and words came out agonizingly slowly. As she held me close, she announced to me and to all present, "Doctor, will you kill me please?" Then in a little louder voice, "Please doctor, kill me!" Finally, screaming while hugging me tighter, "Kill me, Doctor!" Okay. So I think I've seen enough dementia. There was one really cool thing though. Over the weekend we had seen this sweet little old lady with crippling parkinson's. Today when I saw her, she kept sticking her tongue out at me in a tic-like fashion. It took me a few seconds when I realized what I was looking at...tardive dyskinesia. And finally, there was the retired psychiatric Charge Nurse who over the course of her 40 years of service has probably trained half the psychiatrists in the state we're in. My attending spoke respectfully to her and told me later that she taught him and helped him a lot when he was an intern 20-odd years ago. Her memory has gone to pieces, but as is often the case in such dementia, when he quizzed her on some old psychiatric drug pharmacology, she spit out the answer even before I could hazard a guess. I'm enjoying the psych rotation... in a strange kind of way. Now when I walk in the mall, I see people differently...

More later...

The woman with no hair anywhere

I met an interesting pt during one of my weeks of rotation in psych. She appeared to be a pleasant Caucasian female. Moderately obese in either her late 30s or early 40s Some years ago, she was disgnosed with panic disorder with agoraphobia she was admitted to our inpt. facility here and received treatment. She is much better now. She recently gave birth. She has children from a previous marrage. Her ex-husband -a cocaine addict is having Paranoia and hallucinations.

When this woman had panic attacks, she was put on Paxel. Apparently. A rare side effect of this group of drugs ( the ssris) can be aloepecia totalis the complete loss of all hair. Sae has no hair anywhere! she has approached the makers of the drug for compensation but so far has got none. she was telling us how expensive wigs are to maintain if one wears them all the time as she is forced to do. She was an interesting person, telling us of her ongoing interests in sports. She takes care of a house of children and occassionaIly a psychotic ex -husband.

She was also reporting on another interesting side-effect of ssris. Vivid dreams and nightmares. Apparently. These are due to serotonergic activity.
I thought the unfortunate side-effect of aloepecia totalis was interesting and unfortunate, especially for a young female.

The Psychotic who predicted her death

This is the story of a dear patient. Sne was a cauc. Female in her early forties who was found orthe floor of her home in feces and filth. She was malnourished.when we interviewed her,she was actively hallucinating. She saw bugs, heard voices. In got to do the complete psychiatric interview on her. She was very interesting. A few days ago, in the early morning, she was found pulseless and not breathing. A code blue was called. PEA was identified and the appropriate procedure initiated. Forty minutes later, a pulse and respiration was re- established. We do not know how long she was down for. since the last person to see her active was a phleblotomist who came to draw blood @ 4:10am in the morning.

She was intubated and transferred to the icu as I write this. Will she make it? She told a nurse yesterday that today she would die. Depending on how long she was down, her brain has been deprived of O2 for a good while. Did she attempt suicide? If so, how? She told another med student yesterday that there were 2 people in the roomM with her (hallucinations). Did 'they' kill her?

Iain writing this update a few days later. The pt. is dead. She died in the evening after we all left the hospital. From the time she wss transferred to the lCU she never regained consciousness. We determined that she was breathing a little on her own, but otherwise there wss minimal brain function. We had her on 8 ug of dopamine to keep he BP up. Towards the end of last week, it was agreed upon by family and her attending doctors that she was never going to regain consc. Her pupils were fixed and dilated and she showed only primitive reflexes. Her relatives asked that we disconnect all machines. Her attending physician felt that this would be too aggressive and active a move. Instead, heopted to keepthe ventilator on. Towards yesterday evening the pt. began to develop a climbing fever. Nothing was given for it. This was the acute Cause of her demise.

This case was interesting because of the rapid turn of events, the psychosis and in the end, our inability to elicit a favorable outcome for her. It was a tragic story. I believe that everyone acted appropriately. However, none of us who participated in the case came away happy. We lose some battles in spite of everything.

Juvenile sex offenders

Thursday, February 05, 2004 Juvenile Sex Offenders – a first experience

It was an interesting day. I was scheduled to spend the day with Dr. B – a psychiatrist in the Adolescent Unit. I met him at 8:15 am in the unit on the 3rd floor and sat in on the treatment plan meeting. During this meeting, the psychiatrist, therapists and case manager (along with medical students, nursing students and a few other odds and ends) sit in and discuss the progress and plan of each resident. Before the session, I accompanied Dr. Bell to do an H & P on a patient admitted the night before. She was a 14 year old girl. She was admitted for feeling suicidal. I learned that she had been raped by her step-grandfather. She had marks on her wrists from where she has cut and mutilated herself in the past. During the treatment meeting, there were may interesting cases. There is a lot of history of abandonment, neglect, drug abuse and poor parenting. There are also a lot of examples of physical and sexual abuse. The unit we were in was the acute unit: where patients are admitted for short periods of time – upto a couple of weeks. This is in contrast to the unit on the 4th floor, where patients spend 6 months to a year. These are patients with no where else to go – they have been thrown out of practically everywhere else.

After the meeting, I went to the hospital to go psychiatric interviews on two consults for Dr. C (my attending). The first one was a 50 year old Black woman admitted for CHF, hypothyroidism, DM2 and gouty arthritis. She was cooperative and described being institutionalized when she was 11 years old because of physical abuse by an alcoholic mother. She was kept in various institutions until she was 17. The second patient was a contrast. He was a 46 year old white male with a relatively high level of functioning. He felt the human race was nothing but “technologically advanced cockroaches.” He was suspicious and declined to participate in the interview. I managed to get some information about him. He reports being allergic to Thorazine – “causes muscles all over my body to lock up”. He has been institutionalized and used drugs in high school. I wrote up the reports and took them over to Dr. C who by that time had returned from his talk in another city. He felt that the male patient must have been a late onset schizophrenia in view of his high level of functioning and intelligence. He explained that perhaps his animosity to the questions and his decline to participate in the interview was because of a sense of shame and feeling that people treat him differently because of his illness. When I asked him about suicide ideation, the patient had said “I’ve been asked that question so many times and I think it is a personal matter.” He denied homicidal ideation. And admitted to having been given Thorazine for the first time in a state psychiatric facility, I found out later. We also chatted about astronomy and Mars, since the patient expressed interests in those areas. I promised him a magazine on Mars.

In the afternoon, I drove in the snow and rain over to the other campus of our Bahavior Medicine facility on 59th street. This is the facility where the geriatric and juvenile sex offenders units are located. I spend the afternoon reviewing charts and reading about juvenile sex offenders. The first chart I read was the case of a 14 year old boy who had raped his 8 year old half-brother in a foster home. He had had anal intercourse with him. Later, to prevent the child from telling on him, he had suggested to him that he poison the entire household. When that didn’t take, he stole his foster father’s gun and gave it to the boy and suggested that he shoot himself and end his life. The boy eventually told someone and the patient was taken into custody and brought to this facility. His own history is interesting. He is the product of an incestrous relationship between his mother and his maternal grandfather. He was eventually taken away from his mother because of her abuse. He was physically and sexually abused by her boyfriends and male relatives. The stories of most of the boys in the facility – ages 13 to 17 were similar with elements of abuse and neglect. Interestingly, many of them sexually abuse boys 5 years younger than themselves in the same age and in the same way as they themselves were abused. I then sat in on treatment plan meetings, in which the boys were brought in one by one to a meeting with the therapist, the psychiatrist and the Charge Nurse. Besides myself, a social work student who works at the facility doing her practicum were also present.

Rather than be disgusted and feel hatred towards these boys, I felt a morbid curiosity. It is creditable that the state does not just lock them up and throw away the key. After all, they have committed heinous crimes and are in such small numbers that one might not want to invest resources in ‘fixing’ them. As a Christian, I struggle with the finality with which specialists and experts pronounce judgment on the future of these and other pediatric patients saying they are marred for life. The Bible teaches that one can be completely made anew.

I love what I do...

Competency

February 5, 2004 Competency

Today’s learning experience in psychiatry can be summed up in one word: competency. We were consulted on two patients. We were asked to determine whether they were competent enough to make medical decisions.

This pt. is an 88 year-old black female who has suffered 2 strokes in 2003. In Jan .2004, Home Health called EMSA and asked them to take the patient to the Emergency Room because herb lood pressure was elevated. More importantly. Her speech was slurred. This pt. had been living on her own all this time, by herself, with someone coming in to help her with groceries

The pt was admitted to our hospital a week earlier. Psychiatry was called to assess the competency of the pstient. I found her in her bed talking to an empty room. When I asked her any questions, she would answer but then she would keep talking.

Finally, I asked her if she knew why she was in the hospital. She said she knew she had a stroke. She emphatically communicated to me she did not want to go to a Nursing home. She wanted to go home, she said. When I asked her why she had refused to take injections. She got a bit agitated. She said that her doctor thought she was crazy. He was trying to give her medicine like Haldol for being crazy, but she was not crazy. She said she wanted to gone home.

Question: Is this woman competent? If we decide she is incompetent to make decisions, then we must release her to home. If on the other hand we decide she is incompetent She will be forcibly administered Haldol. What are we to do?

This case raises the question of whether an elderly person who is not choosing well is necessarily incompetent. She may not necessarily be choosing wisely. She also may not be the smartest kid on the block. However, all of us perhaps know some cantankerous old folks, fiercely independent who live life on their own terms. When do we infringe upon their autonomy?

I learned from my attending that one asks several questions, such as

Do you understand your illness, that you are sick and in need of treatment?

Can you understand the treatment options, their associated risks and benefits and what they mean?

Can the patient hold the information needed to make a medical decision in their minds in an orderly and rational fashion?

If the answer to any of these questions are ‘no’, then the patient is deemed non-competent to make their own medical decisions. It is, of course, highly subjective

Our second competency case was a 46 year old Caucasian male. He appeared highly intelligent but somewhat bizarre in behavior. He spoke with stilted speech and during the course of the interview would go from being friendly to clamming up and withdrawing from giving more information. When asked about medical issues, he answered, “I think it is personal” and would volunteer no more information. He used the same words and answer to several subsequent questions (preservation). If we changed the topic and asked about something else, he would answer in short sentences. If we talked about sports or astronomy (his interest), he would thaw out, but only a little. Lately, he had been refusing medications. When asked about it, he denied he had done so. My attending found him non-competent to make medical decisions.<

Both the above patients lost their autonomy in the hospital setting and would now have little or no choice in their medications, perhaps need to be restrained if they became uncooperative. I shall keep following the case to see if their consciousness resolves and they regain their competence

A case worker for the first case told me that if a person is found non-competent, then a state body called Adult Protection Services comes in to protect them from themselves. They may be placed in a group or nursing home. The philosophical ramifications of today’s experience were immense and gave me a lot to think about.

Drug reps and Pharmaceutical dinners

Wednesday, February 04, 2004 The world of drug reps and drug company sponsored dinners

I am learning that drug reps can be a great source of information. However, one has to learn how to ‘exploit’ this resource just right. I am not talking about exploiting them literally. I am referring to learning and getting as much knowledge as I can for the benefit of my patients. I had an interesting experience this afternoon. The rep from Zoloft came over. Since my attending was busy, I talked to her for a bit. She gave me a brochure that showed a study comparing weight gains with Zoloft compared to Paxil. The graphs showed that patients on Zoloft had a much lower weight gain than patients on Paxil. Okay; A hour or so later, the Paxil rep showed up. She spied the Zoloft literature on the table and asked me about it. I shared the results of the study with her and asked her about the weight gain issue. Well, she produced another full-color brochure with a different study comparing the effect of patients taking Paxil to placebo. Her study showed that patients on Paxil actually had less weight gain than patients on placebo. It was an interesting contradiction – the two studies showing opposite findings. The next day, the rep from Wellbutrin came over. She had some things to say about Zoloft and Paxil and compared them to Wellbutrin. I think that if one listens critically, one can learn quite a bit from the comparative assessment. Finally, I asked my attending what he thought about these drugs and what his experience was using them. All this coupled with reading the relevant chapters in Blueprints in Psychiatry made for a good pharmacology learning experience. Moral of the story: learning to critically evaluate facts, studies and such and drawing the best conclusions.

Today I also got to go to my first drug-company sponsored dinner talk. It was held at a fine restaurant in Bricktown. I arrived at the restaurant to find about 20 people. I sat with an elder Indian couple – husband a general surgeon and wife a psychiatrist at the VA. The speaker was an asst. professor from USC, LA. He spoke about the use of Risperdone in bipolar disorder. The talk was in PowerPoint and interesting. He made disclosure that he was a consultant and speaker for several drug companies. The food was great – lobster brisque, cold water lobster tail, cheesecake, pasta. I loved it. After the talk, we all went our separate ways. I kind of enjoyed being a medical student/future doctor this evening. One wonders about the ethics of such things. Surely, the good treatment and food softens one up a bit to the drug reps and the companies and products they represent. It probably doesn't hurt either that most of the reps are pretty, well-groomed (well nourished and in no apparent distress, but I digress) and seem to flirt and flatter a little as they deal with us. Maybe that's just marketing...

First week in Psychiatry

1/31/2004 2:38 pm

I finished my Internal Medicine on a Friday and began my psych rotation on Monday, Jan 26, 2004. The first day, I was asked to report to my preceptor, Dr. C at 8:00 am in the morning. This itself was a big difference from IM where we used to report at 6:30 am. Dr. C is the head of a department of Behavioral Medicine. The first day was kind of unstructured. He took me around to the Children's Inpatient unit, the Adolescent Inpatient unit and the Adult Inpatient units. We also got a glance at a special unit for mentally retarded children. I basically got to spend the day in the lounge outside his office. He could not let me in while he interviewed some patients as my presence would affect the dynamics of the interview.

The Department of Behavioral Medicine has several programs/units:
Child Psychiatry
Adolescent Psychiatry
Adult Inpatient Units
A special unit for children and adolescents with mild to severe mental retardation
A Chemical Dependancy Unit and
An outpatient facility that runs intensive throughout-the-day psychotherapy, psych-education programs.

In the afternoon I got to sit in on the outpatient day therapy sessions. They were in groups and the topic being discussed was dealing with grief.

During the rest of the week, I spent a couple of days at the Chemical Dependancy program attending the day sessions -- almost all of the therapy is done in groups in this unit, and studying the drug protocols in the charts. For alcohol dependency/abuse, the detox protocols consisted mainly of Librium and Clonidine. I was surprised to learn that Clonidine is used. I was told by a psychiatrist in that unit that alcoholics will often exhibit sympathetic respnses during their detox -- higher blood pressures, perspiration, tremors, and that Clonidine helps with this.

Since my days were so slow and I was not spent yet, I volunteered to join the staff that man the ER in the 3:00 pm to 11:00 pm shift. Apparently, that is when they get most of their admissions to the psych unit. I was amazed and appalled at how many people come in with suicidal ideation and even a plan. Amazingly, almost all of the people I saw in the first week there were females in the ages ranging from 13 to 25. One evening, after 4 such "I want to kill myself" cases in a row, I was somewhat encouraged when the fifth person I interviewed, a 31 year old Caucasian male said "I hear voices". I asked "What are the voices saying to you?" The answer: "The voices are telling me to kill myself. Here we go again...

I like working the ER because I am getting to see some florid pathology and I get to practise my ability to do the mental status exam and come up with the appropriate DSM-IV diagnosis.

More First week in Psychiatry

1/31/2004 2:29 pm

I spent a couple of afternoons during my first week sitting in on Treatment Team meetings. This is when the Treatment team consisting of the psychiatrist, case managers, psychotherapist and charge nurses present updates on each case to the psychiatrist. A plan is formulated in terms of time to be spent on the unit, med changes, therapy changes, etc.

I was absolutely thrown offbalance by the horrible stories I heard in the Treatment Team meeting of the Children's Unit. I was told stories of drug-addict parents, abandoned children, physically and sexually abused children (one child was sexually abused by her grandfather from the age of 6 months to 4 years of age) and drug babies -- children affected by their mothers having taken drugs or alcohol or both during the pregnancy, or of mothers using damaging medication while breast-feeding their kids.

One 2 year old was found on the streets by police, wandering by himself. When asked what his name was, he said "Motherfucker." He'd probably been called that so many times, he actually thought it was his name!
I have been learning about attachment disorders. I was so moved that I went out and bought a couple of books about it to learn more.
On a more practical note, stuff in the basic sciences that relate to this rotation are:
DSM-IV criteria for diagnosis, Mental Status Exam, The psychiatric interview, and mechanism of action of all the drugs -- antipyschotics, anti-depressents particularly.
More later...