Categories
Education Medicine Observations Reading

Wanna join my DSM-5 e-mail list?

I’ve finally started to read DSM-5, the most recent iteration of the Diagnostic and Statistical Manual of Mental Disorders. I intend to summarize germane information for co-workers, though I also said:

I am also starting an e-mail list to share commentary and my opinions about DSM-5 that may not be entirely relevant to day-to-day work.

This accountability will help me get through the 900+ pages of the text.

I don’t know how much of my DSM-5 commentary will make it onto this blog, primarily because I worry that readers might find it boring and overly technical. (Perhaps I should let readers form their own opinions about that.) I hope to send out something about once a week.

If you’d like to join my DSM-5 e-mail list, you can do it one of four ways:

  1. Sign up here.
  2. Send me an e-mail and let me know.
  3. Send me a note and your e-mail address through Facebook.
  4. Send me a note and your e-mail through Twitter.

I’ll send you an invitation once I have your e-mail address.

Categories
Education Lessons Medicine Policy

Involuntary Commitment (II).

His sister helped him move into the apartment about three months ago. She told you that he has a long history with the mental health system: His first hospitalization, which was over six months long, occurred when he was 19 years old. Since then, he’s been hospitalized close to a dozen times—often against his will—and each hospitalization has lasted weeks to months. Sighing, she said that because of his symptoms, he’s been evicted from nearly every apartment he’s ever lived in, fired from the few jobs he’s been able to get, and unable to complete his schooling to earn his college degree, something he’s wanted to do for many years now.

“When he starts to get better, he stops taking his medicines… then we start all over again.”

He had left the psychiatric hospital the day before you met him. His eyes looked flat and dull; he hardly blinked. Saliva was oozing from the right corner of his mouth. His head was tilted to the right. Though his arms trembled when he shook your hand, he spoke with a steady voice: “Nice to meet you.”

He understandably did not like the side effects from the medications he took.

“I feel so tired. I can’t think,” he said. “I can’t play my guitar.”

Because of his listlessness, you gradually reduced the doses of several of his medications. The drooling stopped. He showed more facial expressions. The tremor nearly resolved. He started playing his guitar regularly.

“I don’t think I need the medicine anymore,” he declared about four days ago. “They don’t help me. I’ll be fine. You’ll see.”

With the knowledge of his past history, you try to negotiate with him: How about taking this medication, but not that one? What about taking this medication right before bed to ensure sleep? Let’s try—

“No, I’m fine. You worry too much, doc! This time will be different. I can feel it. Everything is clear now. I won’t end up in the hospital.”

He begins to deliver monologues about his masturbation habits. He has taken an interest in a woman who lives down the hall… and the woman who lives upstairs and the visiting nurse for the man who lives in the corner unit. He spends his nights writing 1000-word poems of love and lust to each of these women. He plays his guitar for hours. The neighbors become annoyed, especially when he starts bawling and laughing at 3am.

It’s only been four days! He’s now dragging all of his furniture out of his apartment.

“NONE OF THIS IS MINE!” he roars. “GET THIS SH!T OUT OF MY APARTMENT!”

He’s thrown some of his belongings out of the window, as it is apparently easier and more efficient to clear out his apartment that way. His iron, toaster, and most of his silverware are scattered on the sidewalk below.

His brows are furrowed, his teeth are bared, and his hands are clenched into fists.

“SOMEONE is taking over MY room THEY plan to take over my body THIS is all MINE YOU can’t make it stop so I have to make THEM stop—”

He’s struggling to push a chest of drawers towards the door. Yelling, he yanks the top drawer completely out and throws it across the room.

“Please stop for moment—” you begin.

“YOU can’t make me stop no one can me stop YOU don’t understand THIS is an EMERGENCY SOMEONE is trying to make ME go away and NONE of THIS is MINE the furniture MUST be KILLED it tells to me to DIE—”

You see him reach for his guitar and you thank your instincts a few seconds later when you hear the guitar crash into the wall behind you.

Does this man have a mental illness? Does he need to be sent to the hospital for psychiatric evaluation? If he doesn’t want to go to the hospital, should he be forced to go to the hospital against his will?

Categories
Education Homelessness Lessons Medicine NYC Policy

Involuntary Commitment (I).

It’s winter in New York City. The temperature is hovering around 32 degrees Fahrenheit. Large, slushy snowflakes are falling from the pewter sky.

You are already familiar with this woman; you had met her the previous Spring. No one is sure of her age, but she looks over 65 years old. She had said that she had immigrated to the US when she was in her 20s because she had a scholarship to a prestigious university. Something interrupted her schooling. She ultimately stopped attending classes and hitchhiked here. She’s been homeless on the streets of New York ever since.

She has never shared her date of birth for fear that the government would use that information against her. It’s not clear if her stated name is really her name. She’s a familiar figure in the neighborhood; people regularly give her styrofoam bowls steaming with hot soup, sandwiches wrapped in white butcher paper, shiny cans of soda, and cups of coffee. Some people have been giving her food for the past ten years. Upon receipt she murmurs, “Thank you,” and nods her head on her slender neck.

She never makes eye contact. The irises of her eyes have grey halos and her gaze is usually over your right shoulder. You’ve tried to learn more about her past, what led to her homelessness, and her interest in housing, but she usually ends the conversation and walks away. One time before bidding you good-bye she did comment, “The government secrets are safe with me.”

People in New York walk past her everyday while she sleeps and never realize it: She buries herself underneath black garbage bags stuffed with paper. What looks like a mountain of trash on the curb or underneath scaffolding is actually her private fort.

“The paper keeps me warm,” she has said. To prove her point while the autumn winds sent the dying leaves swirling through the air, she rolled up a sleeve of her parka to reveal wads of newspaper crumpled in her clothing. At times she donned a hat made out of a paper bag and stuffed it with newspaper to warm her head.

It is not yet 10am on this snowy morning and the weather forecasters predict that the storm will worsen as the day goes on. The snow is already sticking to the sidewalk. Over six inches are predicted to fall in the next few hours.

Today, the woman’s camp is underneath the short awning of the back door of a clothing boutique. Underneath her is a flattened cardboard box, the corners already beginning to darken and soften from the snow. On top of her are only four or five garbage bags, fewer than what usually covers her. Upon hearing you, she sits up and her face, as expected, does not show any expression.

Her parka is unbuttoned and underneath is a thin white shirt with a tattered collar. The skin of her neck is mottled and red.

“There’s a snowstorm coming through, it’s supposed to be pretty bad. Would you be willing to stay in a shelter until it’s done?” you ask.

“No, I’ll be fine.”

“It looks like you’re cold; you don’t have as many bags as you usually do and your skin is turning red. We don’t want you to be outside when it is this cold out,” you try again.

“I’m fine.”

“We worry that if you stay out here, you might get frostbite.”

“I’m fine.”

“Where have you gone in the past when there were big snowstorms?”

“I’m fine.”

Meanwhile, snow is beginning to collect on her coat, her bags, and in her hair. She makes no motion to move.

Does this woman have a mental illness? Does she need to be sent to the hospital for psychiatric evaluation? If she doesn’t want to go to the hospital, should she be forced to go to the hospital against her will?

Categories
Medicine Nonfiction Observations

I Remember.

I remember when we dragged ourselves to the large lecture hall every morning, backpacks slung over our shoulders and cups of coffee in our hands. Six to eight hours of lectures awaited us.

I remember where we all sat in that lecture hall. I remember the future ophthalmologist who sat behind me and made snarky comments while certain professors gave their lectures facing the chalkboard. I remember students sitting six rows behind me who told me after class, “We saw you falling asleep today. If you sit in the back, it won’t be as obvious.”

I remember the guys throwing around a fluorescent Nerf football between classes. Some of them would take off their shirts (and one would look around to see if women were watching) and relive their days of playing college sports.

I remember when we wore shorts, tee shirts, sandals, tattered jeans, dangling earrings, and tank tops.

I remember going to parties and watching people drink wine and beer out of those red plastic cups.

I remember when we received the short white coats. I remember how stiff they were, how awkward we looked in them, and how annoyed we were that we had to buy “nice clothes” in preparation of training in the hospitals.

I remember that we exchanged ideas of where to find “nice clothes” for “cheap”.

I remember how tired and haggard we looked after we took call. I remember when our scrubs were wrinkled, our hair was unkempt, and our hygiene was suboptimal.

I remember when we wondered how we would ever survive our intern year.

I remember when we contaminated sterile fields and didn’t know what size sterile gloves we needed. I remember certain nurses rolling their eyes and yelling at us for our ignorance. I remember when we would see each other in the hallways and stairwells, holding order sheets for signatures, carrying baskets filled with gauze and tape, and trailing behind the medical team that was into its third hour of rounding.

I remember when we tried not to cry when attending and resident physicians said unkind things. I remember when we shared strategies about how to manage certain doctors. I remember how much we said, “I don’t know.”

I now see current photos of my classmates from medical school and, to my surprise, they actually look like doctors. They have wrinkles around their eyes. The men wear white collared shirts, mild neckties, and dark business jackets. The women wear conservative jewelry and shirts with modest necklines. The long white coats fit their frames. Their smiles radiate confidence.

They look mature.

And old.

Which means I must look that way, too.

Categories
Consult-Liaison Education Informal-curriculum Medicine

Difficult Interactions (III).

(Note: If you found the previous posts in this series “woo woo”, you might find this one nearly intolerable.)

A final reason to stop talking in the midst of a difficult clinical interaction is so you can accept what the other person is doing.

When you accept someone else’s behavior, this does not mean that you necessarily agree with it. It doesn’t mean that you condone it, support it, or want it to happen more. It just means you accept what is happening.

We cannot control the behaviors of others. We can influence them, but we cannot control them. If we do not accept what is actually happening, we have no chance of influencing what happens next.

I worked in a residence where two men would occasionally pee in the elevator. They weren’t incontinent, there was no Foley catheter and bag that malfunctioned… they just periodically voided their bladders in that small space.

Willfully ignoring the yellow puddle in the elevator won’t resolve the problem. The odor would fill the elevator and other people would inadvertently step into the urine.

Wistfully wishing that they had voided their bladders elsewhere won’t resolve the problem, either. “Why didn’t they use the bathroom? If they really had to go, they could have at least peed into the plant next to the elevator. Should they wear adult diapers?” Trying to solve the problem before having a clear definition of the problem often only leads to frustration. You cannot define a problem until you accept that it is a problem.

It’s also common to realize that, when you’re silent and accepting what the other person is doing, the difficult interaction often softens. It is hard to argue with or resist someone when he is accepting what you are doing and saying in that moment.[1. It takes two to fight, two to tango, blah blah blah….] Furthermore, you are also practicing and modeling a useful skill. The other person might realize that he could use that skill at that moment, too.

To review: One reason why it is useful to stop talking during difficult interactions is so you can acknowledge the emotions you are experiencing. Another reason is to recognize and adjust the language you are using to describe the situation to yourself. A third reason is to accept what is actually happening so you can plan and take next steps. It seems like all of this would take a long time and result in awkward silences, but that doesn’t happen. For many people, staying silent isn’t a habit. It takes practice.