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wrapped up my last week of residency and feeling more positive about psychiatry than ever. In the past month alone I have seen a wide range of patients including people with functional neurological disorder, somatization disorder, rapidly progressive dementia (most likely CJD), posterior cortical atrophy, NP-SLE, neurosarcoid, bvFTD phenocopy syndrome, TBIs (you can guess my subspecialty) as well as your garden variety depressed, deluded, deranged and dipsomaniacal patients.
In terminating with my patients I learned that most of my patients were better off now than when they first came to see me, and while many continue to struggle they have managed to achieve some of their goals or some relief from the problems that brought them to treatment in the first place. I have a tendency to be overly skeptical about the value of psychiatric drugs but sometimes they do work, and occasionally (but sadly rarely) the effects can be dramatic. Likewise I can sometimes be dismissive of psychotherapy but there can be something truly healing in meaningful connections we can make. Sometimes things I have considered minor or trivial have made a major difference to patients. Sometimes changes I considered largely inconsequential have been a big deal for patients and their families. And people who have been struggling for years can be successfully treated and even cured of their problems using time-limited treatments.
During the past 4 years I have had the privilege of seeing patients with fascinating stories and psychopathology: psychopaths, patients with Othello syndrome, De Clerambault syndrome, Ekbom syndrome, Capgras syndrome, late paraphrenia, bipolar dementia, Biswanger's disease, disconnection syndrome, corticobasal syndrome, Tourette's syndrome and late onset-tic disorders, depersonalization, HIV dementia, compulsive sexual behavior, Ganser syndrome, factitious disorder, catatonia, delirious mania, limbic encephalitis, bvFTD, primary progressive aphasia, semantic dementia, patients reporting "multiple personalities" or being the victim of satanic ritual abuse, prisoners of war, survivors or torture, severe family pathology including enmeshment, marital schism, pseudomutuality and double binds; I've worked with murderers, arsonists, and perpetrators of incest. On the other end of spectrum, I have worked with those struggling after the loss of a loved one, crumbling in the face of catastrophic illness, overwhelmed by feelings of aloneness, rejected and shunned because of their sexual orientation, adjusting to life after prison, remembering childhood trauma for the first time in adult life, wrought with shame for having HIV, fantasizing about their husbands dying or having masturbatory phantasies about murdering their lovers or imagined lovers...
Psychiatry at its best (and most fun) requires a broad range of skills: performing neurological exams and neurobehavioral mental status examinations, ordering EEGs, or ENCES panels, looking at MRIs or FDG-PET scans, discussing genetic testing, interpreting dreams, working with families, helping couples understand what function particular symptoms have in their relationship, using hypnosis to remove hysterical symptoms, using motivational interviewing to explore ambivalence to change or alternately screaming (and/or cursing) at patients when they least expect, providing mutative interpretations through the transference affect, using the downward arrow technique to help patients identify their core beliefs, using behavior chain analysis to help understand why a patient attempted suicide, prescribing an MAOI with the requisite counseling ("eat smelly cheese and you could die!"), electrocuting patients (okay ECT isn't exactly electrocution but I tend to think of it like that...), or convincing people that sticking a giant magnet on the side of their head will help their depression (and it just might), jumping up and down with a patient to help them regulate their distress, doing empty chair work to help patients articulate emotions they have long suppressed, providing liaison and education to medical colleagues, helping patients to stop smoking...
I am excited about the next phase and hope I can convince someone to pay me to practice as I would like to...
In terminating with my patients I learned that most of my patients were better off now than when they first came to see me, and while many continue to struggle they have managed to achieve some of their goals or some relief from the problems that brought them to treatment in the first place. I have a tendency to be overly skeptical about the value of psychiatric drugs but sometimes they do work, and occasionally (but sadly rarely) the effects can be dramatic. Likewise I can sometimes be dismissive of psychotherapy but there can be something truly healing in meaningful connections we can make. Sometimes things I have considered minor or trivial have made a major difference to patients. Sometimes changes I considered largely inconsequential have been a big deal for patients and their families. And people who have been struggling for years can be successfully treated and even cured of their problems using time-limited treatments.
During the past 4 years I have had the privilege of seeing patients with fascinating stories and psychopathology: psychopaths, patients with Othello syndrome, De Clerambault syndrome, Ekbom syndrome, Capgras syndrome, late paraphrenia, bipolar dementia, Biswanger's disease, disconnection syndrome, corticobasal syndrome, Tourette's syndrome and late onset-tic disorders, depersonalization, HIV dementia, compulsive sexual behavior, Ganser syndrome, factitious disorder, catatonia, delirious mania, limbic encephalitis, bvFTD, primary progressive aphasia, semantic dementia, patients reporting "multiple personalities" or being the victim of satanic ritual abuse, prisoners of war, survivors or torture, severe family pathology including enmeshment, marital schism, pseudomutuality and double binds; I've worked with murderers, arsonists, and perpetrators of incest. On the other end of spectrum, I have worked with those struggling after the loss of a loved one, crumbling in the face of catastrophic illness, overwhelmed by feelings of aloneness, rejected and shunned because of their sexual orientation, adjusting to life after prison, remembering childhood trauma for the first time in adult life, wrought with shame for having HIV, fantasizing about their husbands dying or having masturbatory phantasies about murdering their lovers or imagined lovers...
Psychiatry at its best (and most fun) requires a broad range of skills: performing neurological exams and neurobehavioral mental status examinations, ordering EEGs, or ENCES panels, looking at MRIs or FDG-PET scans, discussing genetic testing, interpreting dreams, working with families, helping couples understand what function particular symptoms have in their relationship, using hypnosis to remove hysterical symptoms, using motivational interviewing to explore ambivalence to change or alternately screaming (and/or cursing) at patients when they least expect, providing mutative interpretations through the transference affect, using the downward arrow technique to help patients identify their core beliefs, using behavior chain analysis to help understand why a patient attempted suicide, prescribing an MAOI with the requisite counseling ("eat smelly cheese and you could die!"), electrocuting patients (okay ECT isn't exactly electrocution but I tend to think of it like that...), or convincing people that sticking a giant magnet on the side of their head will help their depression (and it just might), jumping up and down with a patient to help them regulate their distress, doing empty chair work to help patients articulate emotions they have long suppressed, providing liaison and education to medical colleagues, helping patients to stop smoking...
I am excited about the next phase and hope I can convince someone to pay me to practice as I would like to...
Somebody has to give him a hard time.
We had a few of them where I used to work, and they'd really freak out the medical residents, who would often end up knocking them out and intubating them only to find that they had completely clear breath sounds and perfect pulmonary function curves while unconscious, only to end up freaking out immediately upon waking up and fighting the vent so much we had to knock them out again. Ugh, I wish I could share more details, but let's just say every one of them had a reason for it, and it always came back to "my family never pays attention to me unless I'm in the hospital." It's easy to fake asthma for someone that doesn't know what they're looking for, so they can usually get an admit just by faking it 'til they make it. One of them even had unilateral vocal chord paralysis from being intubated so many times, so she literally always sounded like she was wheezing.
