I’m getting really sick and tired of the media’s portrayl of Cho as a mentally-ill individual and all the following of “leads” from his psychiatric hold and the fact that two girls complained about him to police.

People with mental illness–and that’s 1 in 4 of Americans–are NOT dangerous. Even schizophrenics, those with the classic disorder that comes up when someone says “crazy person”–are NOT dangerous. They are suffering, sick patients. Did you know that the prevalence of schizophrenia in the population is about 1%? That’s 2.2 million Americans. If schizophrenics are so dangerous, we should be expecting to have about 2.2 million more school or workplace shootings sometime soon. (t’s absolutely important that if people need treatment, they get it, and there’s follow-up to make sure they’re getting it.)

Are there exceptions to the rule? Of course. Was Cho a very sick individual? Absolutely. But if we take aggressive, radical steps against every student or person who gets evaluated or placed on a psychiatric hold, we’re going to be hurting a huge number of people based out of fear and ignorance–and wasting a lot of time, money, and energy in the process. Terrible things happen in the world, and I’m sorry World, but there’s not always someone to blame.

Mental illness often reveals itself in the late teens and early 20s, and it’s often genetic. It takes a terrible toll on patients–they go from functioning in the primes of their lives to becoming isolated, lost, and removed from the world that they know. Imagine for one minute that you’re schizophrenic. Voices from inside your own brain tell you things–they’re so real that your brain’s auditory centers actually light up as if they’re hearing things. They tell you terrible, horrible things, 24 hours a day. That you’re a terrible person, that the police are coming for you, that you’ve done something terribly wrong. Want to know why schizophrenics so often are wearing headphones or earplugs, or are singing to themselves? They’re trying to find some way to drown out the voices that speak to them all day long.

These people don’t need our judgment and punishment, they need our compassion and help.

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So Psych is over. I really, really liked it, and found the patients fascinating–how someone seemingly “normal” can become psychotic, hearing voices, believing strange things–and not even understand that the things they hear or believe are abnormal–is surreal, frightening, and incredibly terrible. I’ve also known people that think mental illness (especially depression) is a bunch of crap, that people should just suck it up–and these are clearly the people that have never seen depression. They’ve seen sadness.

Interesting cultural-cum-insurance caveat (how often do you find those!?): the psych service sees a good number of Stanford undergrads (at least 1 per week) in the locked unit for mania, psychosis, etc. One of the major problems is insurance, as some programs have terrible mental health coverage and won’t pay for hospital stays or outpatient programs. Notoriously difficult are students from Asia with insurance from their home country; there’s a pretty strong disbelief in the notion of “mental illness” in many Asian countries, so often these students have absolutely NO mental health coverage whatsoever. Disaster.

I will miss my team, as psychiatrists tend to have just the right amount of quirk for my tastes, and I will definitely not forget Gertrude walking down the halls screaming the most random of things, “These are the poisonous snowflakes of Santa Claus!” “I need a silver bullet… because I have acne! Zits! Pus! Pustules!” I would seriously just lose it in the halls. It was kind of bad. She later grew fond of me, “Hello gorgeous, you’re quite a ticket!”

Psych is great, but I always had something of a hard time with treating the black box that is the human mind. I’m sure it’s the art of the practice, but I’m so used to having more data, I guess. I also felt a little weird using my own life or experiences as the norm by which to judge a patient’s thoughts, actions, behaviors. I may pull off normal well, but I’ve had my share of issues and poor coping mechanisms, not to mention my, uh, “unique” personality traits and general dorkiness.

I’ve found that I really enjoy the psychosocial of medicine–it’s why I liked psych so much, it’s why I really enjoyed adolescent medicine. And I think it’s what draws me to the ED (Emergency Department, the correct way to refer to the “ER” now), too. I love the idea that you can walk in and see anyone, with anything, speaking any language. It’s a real cultural mashup.

This is also the reason that I’m nervous tonight about my first shift, tomorrow afternoon. I could see anything walk in the door. And it’s been a couple months since I’ve been on adult medicine. Granted stuff usually comes back pretty quick for me, but the idea that I could be seeing just about anything scares the hell out of me. (I of course assume I will only see very scary, serious things, no colds or chronic lower back pain.)

So there we are. The ED tomorrow, working my butt off. Back to studying for now.

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My attending told me she’d gotten a call from an outpatient psychiatrist who was complaining about our choice of medications while patients are acutely psychotic in the hospital. “You put them on Zyprexa and they all get fat!”

When you’re in the acute hospital setting (and this is one of my big beefs with residency training in the US), you kind of forget that patients go out into the real world after you discharge them. So when you want to quickly get control of their symptoms, you use a strong antipsychotic, which has the risk of pretty severe weight gain–sometimes 30-40 pounds. Now, I absolutely believe that a person being not psychotic is a higher quality of life than being a little overweight, but 30-40 pounds is quite a lot; you get into the range that people are going to develop diabetes and have bad cholesterol levels.

The problem is that whatever you start a patient on in the hospital, they’re likely to stay on as an outpatient. (If something works, you don’t mess with it!) So where’s the balance? Do you put someone on a newer antipsychotic like Geodon that has less weight gain? If it doesn’t work, do you switch to a weight-gaining one? I wish I knew the answer.

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I humbly present, for your approval, evidence that most spammers are really, really schizophrenic and need to get back on their meds. We’ve got some serious derailments, thought blocking, and loose associations going on. Some recent messages:

with lower spurs of the Mountain. Two of these here thrust forward west
from the main mass in long steep-sided ridges that fell ever downwards
towards the plain. On this western side there were fewer signs of the
dragons marauding feet, and there was some grass for their ponies. From
this western camp, shadowed all day by cliff and wall until the sun
began to sink towards the forest, day by day they toiled in parties

if they saw him stoop; and even grownup he had still spent a deal of his
time at quoits, dart-throwing, shooting at the wand, bowls, ninepins and
other quiet games of the aiming and throwing sort-indeed he could do
lots of things, besides blowing smoke-rings, asking riddles and cooking,
that I havent had time to tell you about. There is no time now. While
he was picking up stones, the spider had reached Bombur, and soon he

mommy porterhouse kulak remorse attrition chimeric callahan drophead studio pigtail
permitted salaried cityscape whelan daphne concession secretary bella liturgic
impregnate antagonist bandit coed cognitive nude trudy afterglow cordite lens stoichiometry
angling thetis polecat birthday mattson coachmen mackerel serendipity
booky obeisant spartan carfare percent elect amplitude adagio
phlox ferocious kite plight sandpile leper typesetter ciliate

You see, when some schizophrenics are really sick, their speech gets all garbled up. People start speaking circumstantially–you ask a question and they’ll eventually answer it, but only at a very roundabout way. If they’re speaking tangentially, they go off on a tangent, and never actually answer your question. Even worse, they might start to have a flight of ideas–they start saying phrases that are somewhat related to each other, perhaps the last word of one sentence starts the next sentence: “All around the mulberry bush, the monkey chases the weasel… Weasels are great pets!” (Sometimes if it’s all rhyming words together, that’s clanging.) The most confusing are phrases using loose associations–the sentences don’t even relate to each other anymore. Thought blocking occurs when patients stop talking mid-sentence, and report having their train of thought totally disrupted.

I’d say the spammers need some Haldol, stat.

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(And other rare, fascinating psychiatric syndromes.)

I’ll quickly admit that psych has some of the most interesting disorders and syndromes in all of medicine. You don’t actually see any of these in your month of psych, because they’re so rare, but you learn about them when you’re studying for your shelf exam. Some favorites (many taken from this great Wikipedia entry, which seems pretty in-depth with a cursory glance):

• In Capgras syndrome, the patient feels that a person familiar to him, usually a family member has been replaced by a double i.e. an identical looking imposter. Invasion of the Body Doubles at its finest.
• Cotard’s syndrome is a disorder in which patients believe they have lost everything–money, strength, house, cars–even their own internal organs.
• Folie à deux is a syndrome where one person comes to share the other person’s delusions, often a spouse or partner.
• In Fregoli syndrome, the person feels that a person not known to him previously gets changed to a familiar person or one of his close family members.
• Koro is a culture-specific syndrome usually seen in Asians. It involves a morbid fear of retraction of the penis into the abdomen with the belief that this will lead to death.

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I sometimes forget how influential a person’s mental state is on their physical appearance. Two of our young schizophrenics have really come around this past week, and it feels so great to see them functioning at much higher levels. Steve has laid in bed most of the week, with a pretty flat affect (this means he interacts with very little emotion). And almost miraculously (the miracle being an anti-psychotic medication called clozapine), Steve started smiling on Friday. I was walking by him in the hallway, and he was on the phone. Smiling and laughing.

Joe, who hasn’t showered in about a week, and he lays in bed all day. When he actually does get up to eat or go smoke, his hair stands straight up, something we’ve affectionately been referring to as the “Joe-hawk.” For him, a shower went a long way to making him look better.

Another patient maybe illustrates the more subtle; she came in extremely delusional and just didn’t look well. It’s kind of how doctors can tell when someone is concerningly-sick; Jenny didn’t look so great. But there’s also something else–I don’t know if it’s a glimmer in the eye, or just a more interactive set of facial movements–or just basic body language during conversation–but when you really get these patients doing better, they look better. Healthier, more attractive. It’s an incredible change, and really feels rewarding.

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I don’t think this will come off as funny as my attending tells it in person, but she once had a medical student who thought that the abbreviations “BID” and “TID” were just doctor speak for “I agree” or “Yes, that’s all.” (BID actually stands for “twice a day” and TID stands for “three times a day.” As in, take this pill, three times a day.)

My attending found this out the hard way; she’d always ask the medical student about a patient’s medication doses. The medical student would say “The patient is on Haldol 5mg.” And my attending would ask, “BID?” And immediately the student would nod back with a smile, “BID!”

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Schizophrenia, as I talked about earlier, is clasically a disease of delusions and hallucinations, often auditory (hearing voices). Some interesting data was brought up yesterday in class, and it goes something like this (I don’t have the reference, sorry):

When you or I want to say something, there’s an excitatory signal sent to the nerves that control our mouths and tongues so we can say the words properly. But there’s also an inhibitory signal that goes to the temporal lobes, when auditory information is processed. However, if you only listen to yourself say the words (from a tape recorder, for example), you don’t get that inhibitory signal in your temporal lobes. Researchers believe this is a way the brain tells the difference between sounds originating from the inside and the outside.

And, as you might expect (or else I wouldn’t be posting this), schizophrenics seem to lack that inhibitory signal when they themselves speak. The theory then goes that perhaps schizophrenics can’t tell the difference between thoughts or signals from inside their heads and outside, causing them to hear voices “from outside” that are saying things.

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Besides maybe Emergency Medicine, there’s probably no other medical specialty that appears in pop culture and entertainment more than the pyschiatric diagnoses. And there’s definitely no other medical discipline with so much stigma attached to each and every diagnosis. Here now, in order that I think of them, my examples of pop culture psych:

1. Psychosis/Schizophrenia: Hearing voices, seeing things, having fixed incorrect beliefs (delusions). Probably the most skewed, stigmatized diagnosis of all medical diagnoses, including the other psych diagnoses and HIV. Schizophrenics are always the “crazy people that hear voices” and mutter to themselves, and are very, very dangerous. They are unstable, they attack people for no reason. The screaming naked guy from The Sixth Sense, for example.
   In the real world, these people are often managed and doing well on medications. Many of the chronically homeless are also schizophrenic. If they make strange movements with their mouths or tongues, it’s a permanent side effect from some of the older medications. They can’t help it. From the patients I’ve seen, schizophrenia is an incredibly sad, incredibly terrible disease. While there are definitely some people with the disease that scream or are violent, most of the folks I’ve seen are kind, quiet, confused, and scared. They hear voices talking to them all day long, or screaming at them, or narrating their thoughts. One patient is constantly being told she’s being arrested, or she’s bleeding internally, or that she’s done something awful. All. Day. Long. Another patient hears his friends’ voices narrating his day. If he drinks a cup of juice, they say, “He’s drinking some juice now.” If he walks down the hall, they say, “He’s walking down the hall.” I don’t think I could stand that for a day, let alone a lifetime.
2. Dissociative Fugue: Usually after some traumatic event, a person forgets their entire past life, moves to another city, and starts a totally new life. Geena Davis in The Long Kiss Goodnight, and maaaybe Kermit in The Muppets Take Manhattan, when he starts working in the ad agency after being hit by a car. Probably also “amnesia,” but I’ll just include it here.
3. Speaking of amnesia: it’s the perfect plot device for most crappy soap operas and movies alike. (But Memento was good.) Problem is, it’s quite rare, and usually doesn’t happen after getting hit in the head; it’s usually after a very traumatic life experience.
4. Munchaussen’s By Proxy: Someone purposely gets someone else sick (often their child) in order to get medical attention. (Think the mom in The Sixth Sense that was poisoning her daughter.)
5. Tourette’s disorder involves frequent vocal or motor tics. A tic is a repeated behavior that can be suppressed, but causes great distress to do so. The coprolalia form is your classic “Shit! Fuck! Shitfuck!” from classy movies like Deuce Bigalow, Male Gigolo.
6. Antisocial personality disorder: the pop culture “sociopath” that doesn’t abide by societal rules and shows little remorse. Serial killers in TV docudramas will fit the bill.
7. Hypochondriasis: Isn’t the guy on Monk supposed to be a hypochondriac? Oh, and Bob in What About Bob? Very significant anxiety and worry about having disease. (Also most 2nd year med students.)
8. Male Erectile Disorder: better known as impotence. Charlotte’s first husband on Sex and the City, anyone?

I could go on and on, but I think you catch the drift: psych diagnoses are everywhere, and they’re often totally off-base.

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Shoutout question to my Psychiatry bloggers Shrinkette and Maria (okay, my dad too):

Is there a name for the laugh that one makes when talking about a patient who it just totally psychotic or manic or out there? Because if there’s isn’t, there should be. I propose the “slaugh” (that’s sad because the patient is so sick + laugh) or the “DeMlaugh” (short for Defense Mechanism + laugh). I’ll use it in a sentence:

My resident showed me a picture a patient drew of her, labeled “Space Devil.” The Space Devil’s body was a playing card, featuring a heart, diamond, clover, and lightning bolt, featured the words “smoke” and “sex” around the waste, and had a long, blue-highlighter-colored tube (a colon?) pooping out Zodiac signs. It was so bizarre, my only possible reaction was to slaugh.

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Being on psych this month, learning and reviewing all the psych diagnoses, you can’t help but fearfully self-inspect for psychosis, personality disorders and the like. Look what I learned in school today: I’m a schizoid narcissist with passive-aggressive tendencies and a history of anxiety problems!

I’m really enjoying psych, and I wonder if it’s because I can relate to some degree. I think most of my classmates enjoy it, but some just don’t, and perhaps it’s because they’re just not neurotic enough, or don’t have a good sense of how challenging life can be with mental health problems.

Just a thought.

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An attending told us today in our first psych lecture, “Medicine is not about stamping out disease, it’s about helping people.”

Boy have the days of medical school applications passed.

No longer do I try to figure out how to rephrase “I want to help people,” and fit it into a 500-word essay. But along with it went the whole initial notion of medicine–that is, a profession built on helping people, improving lives, easing suffering. Now for me it’s about turning a patient’s story, signs, and symptoms into a diagnosis, and then figuring out what to do for that diagnosis. Sure, often the goals overlap–but in the end, I’m not out to relieve suffering, I’m out to cure disease.

I expect (or hope?) that this will come back to me once I get the whole “diagnosing and treating” thing down pat–hell, a large part of the reason I write this blog is to remind me and others of the important stuff, because it’s just so damn easy to forget.

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