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By: Dr W
Many readers have read my post from last Fall about the fact that reality is only relative, and that the term “normal” is a flawed concept. With that in mind, I’m going to tell you about one of my patients. Before continuing, please read the list at the top of the page about HIPAA compliance. There is no information shared here that could possibly identify this patient. The patient would not recognize it himself if he read it.
Some background info on the patient:
- he was employed, having had the same job for several years
- good family support system
- very few friends, due to his own paranoia
- had been a very good student in high school, and attended some college classes
- no significant history of drug use
- no alcohol use
- lived alone in his own residence, without financial support from family
- no significant other, no history of serious intimate relationships
Mr. X is a young man newly diagnosed with paranoid schizophrenia. He had his first psychotic break a few years back, and after speaking with his family, he had prodromal symptoms for a couple of years prior to the first psychotic break. When I began seeing him, he had become convinced that no one, other than himself, could kill him, because many had tried without success.
He reported multiple incidents in which he’d been injected with something while shopping, and he’d also had a dream which he’d come to believe was a premonition in which he would die, by his own hand. He also very frequently spoke of a government conspiracy to kill him. The patient became more and more ill, and soon, he began to hear and see things which nobody else could (hallucinations, according to prevailing social and cultural norms where we are). This patient was in danger of harming himself, and potentially harming others. I ordered him hospitalized, which he did not believe he needed–they rarely are able to see this. Ultimately, though, he cooperated and was able to be released.
It took some time to build rapport with this young man, which is a common problem with people who have schizophrenia. I avoided using the term in sessions with him because I knew that knowledge of his diagnosis would likely bring him down emotionally. So, when he would enquire as to his diagnosis, I would simply say, “you have a problem with perceptions, and we can treat you with medications and some psychotherapy.” He would often ask “am I crazy?,” to which I always responded with “absolutely not.”
He agreed to take a medication, one of the atypical antipsychotics, which have been available for the last several years only (<10 years), which have been thought to be safer than the older antipsychotics, commonly known as “neuroleptics.” At any rate, close monitoring is mandatory for patients requiring this type of medication.
I also set about to involve him in psychotherapy. At first, I tried referring him to a psychologist in the community who I know does good work, and who has experience with helping those afflicted with schizophrenia. However, the patient refused to go. His explanation to me was “I dunno.” When I asked his sister, though, she told me that he wouldn’t talk to anyone about his illness except me. However flattering that may be, it didn’t bode well for the patient.
The whole purpose of psychotherapy in this patient (as with most diagnosed with schizophrenia) was to keep him functioning in society. He needed to work; he needed to continue to maintain his lifestyle, which would not be possible if he were to be awarded disability. I’m talking about social recovery, a concept in psychiatry in which the patient may have some symptoms, but these are very greatly overshadowed by continued ability to work, maintain relationships and lifestyles, etc.
This particular patient didn’t even want disability–he wanted to work! I supported him in his effort to return to work. After returning to work, he continued to come to the office every month, and he continued to do well. He thrived socially, reestablished many of his old friendships, and maintained contact with his family.
The patient discontinued his medications when my year in the outpatient clinic was over. I had worried this might happen, and told the new resident coming to the clinic that this patient may have trouble with “the transition.” This proved disastrous to the patient, actually, because he would not talk to anyone about his illness except me. I wish somebody would have called me; maybe I could have intervened in some way. Thankfully, though, this patient did end up in the hospital before he harmed himself or anyone else. It was a close one–ALL BECAUSE HE STOPPED TAKING HIS MEDICINE. This is common theme in psychiatry.
What was even more fortunate, however, was that I happened to be working in the psychiatric facility when Mr. X arrived. I took him as a patient since I knew him well. His thought process was disorganized, clearly he was hallucinating, and he refused to sleep because he believed that if he did, the world would come to an end. He’d been told this by “someone.” After several days, and several hours of just sitting and talking with him, he was able to be stabilized.
After the hospitalization, I made special arrangements in order to be able to see him in the clinic. He has done very well on his medicines, and he shows up at the office, faithfully, every two weeks. We talk about whatever is on his mind, and he tells me about side effects of medicines, and we discuss the options for alleviating them. I let him decide what to do about the side effects, within reason, though. He has told me several times that he does not want to change his medicine because he doesn’t “want to get sick again.” Like the last time, he has re-connected with his friends and family, but unlike the last time, he has no job to return to. He has decided to attend college after a few months of rest, which I think is a GREAT idea.
Now, I’m getting ready to move away, and of course I am extremely worried about this patient. I have two other patients with very similar stories that I also worry about a great deal. All three of these patients have the same diagnoses and take atypical antipsychotics, they have moderately similar backgrounds, and all three have done very well since they started medication, and stayed on medication.
© Copyright, “Dr. W” 2006