Thursday, June 4, 2009

Straight Shooter

Some clinical anecdotes are irresistible.

A 55-year-old gentleman with a vague history of schizophrenia was brought in by a community support worker for a new evaluation, apparently at the behest of a family member, although there was no report of specific symptoms or dangerous behavior. But he had recently moved back to the area, so maybe the family just assumed he ought to get an evaluation for regular treatment.

He presented as somewhat disheveled, with a glazed look in his eyes; he was calm and pleasant enough, albeit quite flat and concrete, answering questions minimally. He couldn't or wouldn't say much about his psychiatric history other than to acknowledge the diagnosis of schizophrenia, multiple previous hospitalizations, and the experience of monthly injections at some point in the past. "What brought you back here from Texas?" "Greyhound bus." For a fleeting moment I thought he was wryly joking (for which his manner otherwise certainly would not have prepared me), but no such luck. So I settled myself uncomfortably into the plane of the literal for the duration.

When I asked him how much alcohol he drank, though (I long ago stopped asking people whether they drink, and now go straight to how much), he answered, "As much as I can." For a second again I wondered about some sly humor on his part, but he was deadpan. Yet his response had the kind of upbeat, slightly dutiful tone one might use to answer a question like "Do you get regular exercise?" But he wouldn't quantify.

So I moved on to marijuana (for which I have also recently moved directly to asking how much)--the complacent yet somewhat eager reply was, "As often as I can get it." "How often is that?" He just shrugged. On to cocaine, for which I still ask whether rather than how much. "Crack," he assented, nodding with an attitude somewhere between satisfaction and gusto. "Do you think any of those drugs could be a problem?" Incomprehension. "Has anyone told you these substances could be bad for you?" "No, nobody ever told me that!" he countered, baffled yet dismissive.

The interview unwound from there. As we returned to his diagnosis, I learned that he had actually "gotten over" his schizophrenia. "Would you consider taking medication again?" "No." (There was more to it, but this was the gist).

In a world of duplicity and innuendo, particularly surrounding substance use and treatment compliance, this was actually refreshing. There was no need to dance around the facts, as it was abundantly clear that he had no use for me, and our relationship at this point could blissfully and neatly come to an end. No hard feelings.

The community support worker, driving him home with a couple of other patients from the same area, stopped at a store to pick up something. The fellow went in and emerged with a beer; upon being told that he couldn't bring the beer in the car, he proceeded to chug it in the parking lot.

One more thing: he does receive Social Security disability payments monthly. Tax dollars hard at work.


TLP said...

Aptly titled headline, indeed.

'No, nobody ever told me that.' Classic.

Thanks for sharing.

Anonymous said...

It sounds like he was treating you much like I treat telemarketers who call me unsolicited. "Yes." "No."
Do you think it was all lip-service with more going on underneath his answers, or had he shut down enough that he simply was that... simple? Regardless, at least he was honest about not wanting your help instead of complaining that other people hadn't fixed him....

Anonymous said...

He comes across as blissfully ignorant. If he's as uncalculatingly shamelessly deadpan honest as the episode suggests, then I think he may very well have mastered the art of living to the point of contentment, without the messy need for striving. To be utterly happy in the stasis of wanting/needing nothing more but whatever the current moment's selfish comfort brings, all with minimal net energy expenditure.

...Sage or fool? or just one of life's little scenic extras?

fraise said...

Wow. So many people smoke marijuana that you've moved to a direct "how much"? I'm feeling gosh-darned puritan now... never tried any in my life. (Never smoked anything, in fact, not even cigarettes.)

At his age I don't find it too hard to believe that he claim he'd never heard the drugs were bad for him. I grew up in Oregon and the only time I heard how bad marijuana and crack were was from school drug assemblies and TV. If he doesn't pay attention to TV ads and is in a similarly drug-permissive culture, his reactions to the questions sound par for the course.

(And I don't have strong feelings for or against marijuana. Just that people should think twice before going out just after or while smoking it, because getting stoned, going into a store and asking why the stuffed toys are smiling and how to get the toys to sing, and would pot help? is a wee bit odd. For instance.)

Nick said...

In response to Anonymous above, I would hardly say that someone's life is blissfully ignorant if he is using whatever mind-numbing substances he can get ahold of whenever he can. To me that screams that his life is not good at all and the only way he is able to deal with it is to keep himself in a drug-induced-fugue. And as to the "deadpan honesty", his statements indicate that he is very concrete, the manner of thinking which is prevelent before puberty and which becomes much more abstract during and after puberty. This kind of concrete thinking can be a sign of schizophrenia when present after puberty. What that means is he does not process anything beyond the surface level. Hence the response to "What brings you back from Texas?" His answer-"the bus". He doesn't get that the doctor doesn't care what physical modality brought him from Texas, the doctor wants to know the reasons and motivations behind him coming back from Texas, but this guy doesn't register that at all.

Anonymous said...

I don't like the part from you stating his being on SSD is our" Tax dollars at work",surely you don't think as a middle class Physician
that welfare is easy to maintain in
this sarcastic world?
An immoral Iraq invasion costs a lot more than this dudes care from our Government.So far as I know this patient that did not meet your expectations as worthy of his keep
has not killed anybody by faceless saturation bombing as I witnessed
in Viet-Nam in that useless excursion for whatwazdat reason for? me and history seems to have forgotten.
I can add I don't think we gained anything by"saving Iraq" either just bigger debt. More that SSI and
SSD monies used for mental patients.

Anonymous said...

should read "than" at my close.
Yes my wifes family from NC also
makes fun of people like you do usually at the country club's 19th
hole. Not on a forum that has a Physician loving the arts,and literature and being poetic and a
pretense to gentleness.

Anonymous said...

And yes you are Human.
I know Psychiatrist's that would love
to "treat" this patient.
I imagine he was sent to you to evaluate his continued mental health
status for continued disability?.

Anonymous said...

I would like a dollar for every patient that said No they would not
want medicine,"i'd be rich as
This is sort of naive?