Category: Policy

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Education Homelessness Lessons Medicine NYC Policy

Involuntary Commitment (V).

Recall that the first scenario described a homeless woman who did not seem inclined to move to shelter despite the forecast of a heavy snowstorm. How would you apply involuntary commitment criteria?

1. Does this person want to harm himself or someone else?

There was no evidence at that time to suggest that she was considering suicide or homicide. One might wonder about grave disability, as her behavior in that context was not consistent with most other homeless people at that time. (Because of the pending snowstorm, most of the homeless encampments were empty that morning.)

2. How imminent is this risk of harm to self or others?

Imminent. The snowstorm had already started and six inches were forecasted to cover the ground in the next few hours. If the snowstorm occurred as predicted and she did not move, she would be at significant risk of developing hypothermia, frostbite, or complications from both.

3. Are these behaviors due to a psychiatric condition?

Maybe.

She had mentioned one thing (“The government secrets are safe with me”) that might suggest a delusion, though we don’t really know what she meant when she said that. Her behavior suggests paranoia, though it is also understandable if people don’t want to talk to strangers.

Just because someone is homeless does not automatically mean that mental illness is present, though individuals who are chronically homeless are more likely to have a mental illness. Given what we knew about her, it seemed more likely than not that she has a psychiatric condition.

Related: Will hospitalization help treat the underlying psychiatric condition?

Maybe.

If it isn’t clear if she has a psychiatric condition, then it isn’t clear if hospitalization would help.

So what actually happened?

The outreach workers working with me wanted to send her to the hospital for evaluation and treatment. I wasn’t confident that she would actually be hospitalized. If I was working in an psychiatric emergency room, I probably would have released her. Her presentation did not seem to meet a minimum threshold for dangerousness, though she did not appear well.

The snow continued to fall. No one said anything. I excused myself to step away and consider the options.

I was worried about her. She had reported that she had been homeless for decades in New York; this wasn’t the first major snowstorm to hit the area. However, she was now older and just because she survived past snowstorms did not mean that she would survive this one. Furthermore, other individuals with comparable experience with homelessness had abandoned their campsites that morning—why hadn’t she?

In New York State, two physicians are required to detain a person against her will. If I began the process in the street, the emergency room psychiatrist could either complete the process or reject my proposal and release the individual.

With reluctance, I ultimately began the process for involuntary commitment. I was not convinced that she needed hospitalization, though I knew that the process would take several hours. Hopefully, the snow storm would blow through in that time.

She wasn’t pleased when the ambulance arrived (“I’m fine… I’m fine…”), though she did not resist the paramedics. I sat in the back of the ambulance with her. She was shivering. Neither one of us said anything; what could we talk about?

“So… what do you think of this weather we’re having?”

Upon arrival at the emergency room, I gave a brief report and the commitment paperwork to the psychiatrist on duty. The psychiatrist commented that he had never seen her before, which did not surprise me: Sometimes the most vulnerable and ill individuals never interact with the health care system.

“From what you’re telling me, I don’t think we’re going to detain her,” the emergency room psychiatrist said.

“I understand.”

A guard and a nurse asked her to empty out her pockets and remove her parka. She did not balk. Though I knew she was thin, I was taken aback with just how slender her frame was.

The snowstorm blew through. Close to eight inches collected on the ground. The rare pedestrian dashed across the empty streets through the blurry grey air.

I got a phone call as the storm was ending.

“We’re not going to hospitalize her; there’s not enough.”

“That’s fine. Thanks for letting me know.”

The next time I saw her she was standing on a corner, her hands in the pockets of that same parka. When I greeted her, she turned around and walked away quickly. She spurned my greetings for nearly three months.

I understood and could not blame her.

Only after three months did she finally agree to talk with me. One brisk morning, while she was still tucked under the plastic bags filled with paper, she finally told me her story. She probably demonstrated significant psychiatric symptoms in the past (and was probably diagnosed with schizophrenia), though she experienced less symptoms now. She still didn’t want housing because she believed that she didn’t deserve housing.

I left New York and she remained. I still think about her occasionally and wonder if she is still alive.

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Education Observations Policy Reading

DSM-5: Schizophrenia.

This post is directly from my DSM-5 e-mail list. If you find the information below useful or interesting, you are welcome to join. [Note: I have stopped updating this forum. Sorry.]

(670 words = 5 min read)

The diagnosis of schizophrenia has expanded in DSM-5. Criterion A now includes five items:

1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms (i.e., diminished emotional expression or avolition)

At least two of the five symptoms must be present for at least one month. One of the two symptoms must be delusions, hallucinations, or disorganized speech. Negative symptoms, which impair function the most, are now official.

In discussing diagnostic features, the authors state that “no single symptom is pathognomonic of [schizophrenia]” and it is a “heterogeneous clinical syndrome”. This is what makes schizophrenia both fascinating and frustrating: I can diagnose two people with schizophrenia and they may look and behave nothing like each other.

Criterion B for schizophrenia gets more attention in DSM-5: “Level of functioning… is markedly below the level achieved prior to the onset”. This is not a criterion for schizoaffective disorder. (This is apparently unchanged from DSM-4.)

Furthermore, the authors note that if symptoms of schizophrenia begin in childhood or adolescence, “the expected level of function is not attained. Comparing the individual with unaffected siblings may be helpful.” This must only amplify sibling rivalry.

The authors also comment that “individuals who had been socially active may become withdrawn from previous routines. Such behaviors are often the first sign of a disorder.” In the past few years, some studies have argued for treating people with who are at high risk of developing schizophrenia, even though they have not yet met diagnostic criteria.

This is controversial because we cannot predict who will definitely develop schizophrenia. Some treatments, such as antipsychotic medication, are not benign. This statement seems to permit more assertive treatment of youths who present with “prodromal” symptoms of schizophrenia.

Criterion C discusses the six-month duration that distinguishes “schizophrenia” from “schizophreniform disorder” (one to six months) and “brief psychotic disorder” (one day to six months).

Criterion D makes the distinction between schizophrenia and schizoaffective disorder (primarily psychosis and limited mood symptoms in schizophrenia). This is repeated multiple times under the entry for schizoaffective disorder.

Criterion E asks the reader to please rule out psychosis due to drugs or a medical condition.

Criterion F makes the distinction between schizophrenia and an “autism spectrum disorder or a communication disorder”. That replaces “pervasive developmental disorder” in DSM-4.

The previous specifiers for schizophrenia (paranoid, disorganized, catatonic, etc.) have disappeared; now, specifiers are related to the illness course (“first episode” versus “multiple episodes”; state of remission; etc.). I am pleased to see that “currently in full remission” is a specifier. People can and do get better from schizophrenia. (DSM states that 20% of people with schizophrenia have a “favorable course”.)

The authors also explicitly comment about “decrements” in cognitive function in people with schizophrenia, which frames the condition as a brain disease. Similarly, there’s a note that “unawareness of [schizophrenia in the patient] is typically a symptom of schizophrenia itself rather than a coping strategy.” It’s not a psychodynamic defense mechanism of denial.

Kudos to the authors for their advocacy:

“It should be noted that the vast majority of persons with schizophrenia are not aggressive and are more frequently victimized than are individuals in the general population.”

The rest of the chapter discusses demographics, course of illness, etc. Here are some things I found noteworthy:

“Late-onset cases (i.e., onset after age 40 years) are overrepresented by females, who may have married.” Why is that last part there? Is this meant as a consolation prize to their husbands?

DSM-5 officially concedes that “some minority ethnic groups” are more likely to be diagnosed with schizophrenia.

Substance-related disorders are high (over 50% smoke cigarettes regularly). They are also more likely to experience weight gain, diabetes, metabolic syndrome, cardiovascular and pulmonary disease. People with schizophrenia at high risk for suicide: 5-6% die by suicide and 20% attempt suicide. The combination of these factors may explain why people with schizophrenia die early compared to the general population.

Next time: schizoaffective disorder.

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Education Lessons Medicine Policy

Involuntary Commitment (IV).

Involuntary commitment refers to hospitalizing people against their will for psychiatric reasons. It is a controversial topic because this is where medicine and civil liberties intersect: Physicians have the ability to take away the rights of fellow citizens. (I suspect that few people who become psychiatrists realize that making recommendations about involuntary commitment is part of the job. I certainly did not know this. I also did not appreciate the ramifications until I was well into my residency training. It is the worst part of my job.)

Involuntary commitment laws differ in each state. In general, there are three criteria to consider prior to hospitalizing someone against their will. In a just world, all three criteria must be met for involuntary commitment to occur.

1. Does this person want to harm himself or someone else? The legal language often refers to this as “danger to self” (often suicide) or “danger to others” (often homicide). The “danger” could also refer to inadvertent harm—not only purposeful intention to harm self or others. For example, consider a man who believes he is Superman and wants to fly off of a roof or someone who believes that he will prevent the next nuclear war by destroying a high traffic bridge.

There is also a concept of “grave disability”, which refers to individuals who cannot attend to basic needs. Consider a woman who refuses to eat because she believes that, if she eats, she is eating her internal organs.

2. How imminent is this risk of harm to self or others? If the risk of dangerousness is high and there are concerns that harm will come to self or others “soon”, this strengthens the argument to hospitalize someone against his will. (Note that the word “soon” is not defined. “Imminent” could refer to minutes or hours, though generally not days.)

No one, however, can predict the future, so no one knows for certain who will actually hurt themselves or other people. We can only assess risk of dangerousness. This includes evaluating known factors, such as past history of violence, current symptoms, demographics, etc.

3. Are these behaviors due to a psychiatric condition? If this person is a danger to self or others, is this due to a psychiatric condition? Or is it due to something else (such as a medical condition, drug use, etc.)? Depression, substance use, and psychotic disorders increase the risk of suicide; social support, cultural beliefs that discourage suicide, and a sense of hope decrease the risk of suicide. Some people argue that the wish to kill self or others is always due to a psychiatric condition (“there must be something mentally wrong”), though others (such as Thomas Szasz) argue that psychiatric conditions do not exist or that they are irrelevant.

To further complicate the issue, sometimes it’s not clear if behaviors are due to a psychiatric condition. For example, some people argue that substance use disorders are not psychiatric conditions.

Another question to consider: Will hospitalization help treat the underlying psychiatric condition that led to the imminent danger to self or others? This last point is often not considered as strongly as the others.

This explains why some people go to jail instead of to the hospital. We don’t have effective treatments for people with antisocial personality disorder (“sociopaths”) or pedophilia. If hospitalization doesn’t appear either indicated or helpful, then involuntary commitment may not be an option.

The three cases I presented prior to this post (1, 2, and 3) are all based on true events. Let’s go through them again and, applying the above criteria, consider how to proceed. I will also share what actually happened.

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Education Lessons Medicine Policy

Involuntary Commitment (III).

“What should we do?” the outreach worker asks. “He slapped a woman at the laundromat yesterday.”

The police know him well. For at least ten years, he, along with a cadre of other homeless individuals, has spent his days in the park and nights in empty lots in the neighborhood. He limps to the right when he walks; he reportedly fractured his leg many years ago while drunk and it never healed properly.

These days, the police frequently see him before 9am because the two 40-ounce cans of beer he finished earlier in the morning have led him to call 911.

“I just wanna die,” he bawls to the dispatcher. “I’m gonna kill myself, I’m gonna jump off that bridge, I’m gonna be dead, I just wanna die.”

The police are exasperated with the hospital: “We bring him there because he has tried to kill himself when he’s drunk. Less than three hours after we drop him off, he’s right back here again and drinking! They don’t do anything, so we don’t even bother taking him there anymore. If we arrest him, he’s in jail for a few days, but he doesn’t get any help. Then he’s out and back here again.”

You’ve looked at some recent hospital records for him; he’s had numerous visits to the emergency room. His blood alcohol level is usually around 0.3%[1. A blood alcohol level of 0.08% is considered the legal limit.] and he often says that he wants to kill himself. As the alcohol leaves his system, he retracts these statements: “Nah, I’m fine. I don’t wanna die.”

He was psychiatrically hospitalized over a year ago. At that time, he said that he heard voices and drinking alcohol made them go away for a while. He started taking medication. He said he felt better. The rest of his hospitalization was uneventful. He didn’t attend the appointment scheduled for him one week after he was discharged from the hospital. He returned to the park.

“The woman in the laundromat called the police and they knew exactly who she was talking about,” the outreach worker said. “He was napping in the doorway of the laundromat and the woman asked him to move so she could get her stuff inside. He got up, followed the woman in, slapped her across the face, then left. The police couldn’t find him when they showed up.”

After speaking with you, the outreach team goes to the park to find this man to talk with him about what happened. They also intend to discuss housing, something that he continues to decline.

“I don’t wanna follow somebody else’s rules,” he has said during moments of relative sobriety. “I wanna do what I wanna do.”

The outreach team is back in less than half an hour.

“He was really pissed off,” the outreach team says. “He chucked a can of soda at us.”

“He chucked a can of soda at you?”

“We were trying to talk with him and he wasn’t having any of that. He told us to ‘f@ck off’—the usual when he’s drunk—so we said we’d come back later to talk with him. We were probably about ten feet away when an open can of Dr. Pepper flew past our heads. We got a little soda on us, but we didn’t get hit. It would’ve hurt if his aim was better.”

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 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?