December 31, 2012


The following is not FACTUALLY accurate. Details have been changed, things deleted, stuff made up, all to protect identity. But it is 100% absolutely true.

     While not exclusive to schizophrenia, one of the hallmarks is delusions. Delusions in the medical context refer to a belief which is either highly unlikely or flat out implausible. Aliens abducted me. My spouse is slowly poisoning me (though this one can be true in bizarre instances). I am an undercover agent for the CIA & KGB. What fascinates me is that the delusions have to come from somewhere. They usually aren't created ex nihilo. Sometimes the source of the delusion is quite clear. For instance, one patient was going to exact retribution on all unfaithful spouses of the world. Clearly it was not surprising to find a messy divorce involving infidelity in their past. Other times it seems a bit less personal as when one patient was furious with the Bush family and wished to punish them. Probably their delusional thinking was fueled from watching CNN.

But in one instance, I was at a complete loss. "Do you have any questions for me or the doc?"

In a clear, calm yet quizzical fashion the patient asked, "Just one. Why did the CIA turn me into a horny vampire?"

     Dead silence. We are trained neither to reject nor entertain a patient's broken perceptions. We are merely supposed to go along with the notion that they believe them to be true and that's all that matters. But this question stumped me, the nurse or the attending doc. They just kind of mumbled something and moved on.

December 27, 2012

the big three

Three big diseases compose the bulk of adult psychiatry. Three different ways the brain can break. After all, the brain is a physical organ just like a heart or kidney. Why shouldn't it break?

The first is depression. By far the most common and ranges from mild to life threatening. From a clinician's point of view, medications are not the only tool in the tool box. Counselors and psychologists play every bit an important role in treatment as medications. It's treatment is really not well suited for the average 15 minute patient encounter found in psychiatry or family practice. It's the one where the attitude of the patient plays the biggest role out of The Big Three, ie. it has a huge placebo effect when analyzed clinically. That's not true for the others. In some sense, it's a disease of the human condition.

Next is schizophrenia. I used to think it was the worst and in some sense it is. it is certainly the most debilitating but from a diagnostic point of view, schizophrenia is easy, well, relative to the others. You don't have to ask a schizophrenic any questions. Just let them talk and they'll let you know they're schizophrenic in a few short minutes once they talk about the voices inside their head or their delusions. Chips implanted in their head, satellites controlling their ideas, evil spirits cajoling them to hurt people. Clinically, it's self evident and the one where medications can make the biggest impact. No amount of talk therapy is going to change their delusions while the antipsychotics can oftentimes silence the voices altogether.

Last is bipolar. These cases are HARD. Unlike a schizophrenic, these patients are very cognizant, sometimes above average intelligence, and as such, quite adept at manipulating. A schizophrenic doesn't know they're crazy. But they can be convinced to take their medications so long as someone is around to help them. A bipolar person during their manic phase, however, thinks they're superman. They believe that they are capable of anything. Medications go right out the window no matter what anyone says. They oftentimes leave a wake of destroyed relationships because its easy for family members to feel sympathy towards a schizophrenic who believes that UFOs are talking to him. It's much harder to feel sympathetic towards a loved one who without notice, ends up in another state where they end up in jail after they blew $20,000 in a poker game on a whim. Because of the their impulsivity and their indestructible ego, they often abuse drugs which makes it all the harder. I've come to despise this disease for its difficulty in managing and poor outcomes.

But what's the point of describing them? Patients with real stories are much more interesting....

December 16, 2012


"Prepare for your most challenging part of your training so far."  That was the straightforward advice that was given by our school in preparation for the third year of med school.  They haven't been wrong, which is why I haven't written lately.  It hasn't been because I have nothing to write about.  On the contrary, I've got lots of stories about patients.  Too many, actually.  I've just been too tired by the time I get home to want to write about them.  On second thought, it maybe, just maybe has something to do with the fact that my current rotation landed me at MD Anderson for a stint in psychiatry.  Talking to patients who have cancer about their emotional challenges, was well, more than a little challenging for myself.  But that part is done so I can look back with the clarity of a bit of hindsight.  So more stories to come...