Resident: Ms. P is back to her usual sunny self. She says she thinks she’s been a little out of it lately but now she feels fine. However, she was a little suspicious of her peanut butter this morning so I’m not so sure about her mental status.
Folie a deux: French for “a madness shared by two”. Also known as shared psychotic disorder or shared delusions, this is a disorder in which one individual passes on a delusional belief to another person. Usually the initiator of the delusion has an underlying psychotic disorder, while the second person is usually not psychotic when left alone. If separated, the delusions generally resolve in the second person without medication. This condition is separate from folie simultanee, where two separately psychotic people adopt and play off of each other’s delusions.
Recently I was scheduled to see a patient in clinic who had a long history of delusions of parasitosis. As I reviewed the patient’s chart, I found that his PCP had already examined “samples” of these parasites, which were found to be sloughed skin under microscopic exam. Luckily for me the patient missed his appointment and had to be rescheduled. And luckily for you, reader, my desk was close enough to the front desk that I got to witness this unfold:
Mr. Ekbom to front desk: I have to see a doctor today. It’s an emergency. Worms are coming out of my skin again and they’re itching me like crazy! See? (shows scabs from picking his skin). My wife saw one come out of my mouth!
Front Desk: Well, you missed your appointment this morning so we will need to reschedule for after lunch.
Mr. Ekbom: No, I need to be seen now! The CDC says this is a parasite they’ve never seen before and there’s no possible treatment! I need to see my doctor!
Front Desk: Sir, according to your chart, this has been fully worked up already and no parasites have been found. Your doctor is not here today and the one you were scheduled to see is now full for the day.
Wife, Mrs. Ekbom: Look lady, I saw the worms coming out of his mouth! And I got ‘em right here in this baggy (holds up bag with a few scabs and skin pickings)! I seen ‘em crawl through his skin. They’re killing him!
Psychiatrist lecturer extraordinaire
If you could have the answer to any question you can think up, up to and including the meaning of life, what would you ask? -anon
I think I’ve pretty well got the meaning of life figured out, but I do have some questions I’d like to ask God. I’d like to ask him to explain mental illness to me. There’s so much we don’t understand about it—what causes it, how to treat it, etc. We don’t really understand how the mind, body, and the spiritual interact.
Dr. C: Did she mention the fleas today?
MM: No, thank goodness, we didn’t go into all that today.
Dr. C: the patient thinks fleas are infesting her and are responsible for her liver failure… So what’s the plan for her, M?
MM: plan is to D/C home on Frontline. Maybe Advantage. Depends in her insurance.
We don’t have any set technique that we learn in med school. We’re just taught to be aware that your patient may have issues beyond the physical. But in general I would encourage patients to talk about their difficulties coping and would encourage them to seek counseling of some sort, whether formally in a series of visits with me or a trained counselor, or informally through a pastor or friend.
It is absolutely my responsibility as a doctor to notice a patient’s change in mood and worsening depression. Mental illness affects physical health and well being. Plus, I’d add that the majority of patients suffering with mental illness do not seek help from a psychologist or psychiatrist first. They usually go to their family doctor about it. And many patients either don’t realize that they’re depressed, or they are unwilling to recognize it in themselves. That’s when we family docs, who have the benefit of continuity of care and know our patients well, can step in and be a big part of helping a patient heal physically and mentally.
Staff psychiatrist shares the wisdom of listening
why do you dislike borderline pd patients? - anon
I don’t dislike them. They can be very nice people. But often I find it harder to deal with them than other patients.
People with personality disorders show an “enduring pattern of inner experience and behavior the deviates markedly from the expectations of the individual’s culture” (definition taken from the DSM-IV). So if a patient’s personality deviates heavily from societal norms, they can be hard to deal with.
Borderline Personality disorder (as described by the DSM-IV) is presented here without further comment. Italicized are my explanations:
A. A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1. Frantic efforts to avoid real or imagined abandonment. (clingy behavior)
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. (splitting people into black and white “good” and “bad” categories without wiggle room)
3. Identity disturbance: markedly and persistently unstable self image or sense of self.
4. Impulsivity in at least two areas that are potentially self damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
6. Affective instability due to a marked reactivity of mood,e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days. (ie mood swings)
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms. (they frequently feel victimized, persecuted, or targeted after a minor ego insult)
My residency’s self-proclaimed narcissist psychiatrist
After explaining about a new patient who had a history of suicidality and was currently very depressed and was not on meds…
Me: I want to start her on an SSRI, but I’m afraid about the possibility of her making suicidal gestures if we start her on meds and don’t supervise her closely enough. I’ve tried to get her in with a psychiatrist but everyone is booked for months. I think we’re walking a fine line on this one.
Attending: Yeah, let’s call Dr. Psych and get his opinion on this before we pull the trigger….
Attending: poor word choice. My bad.
Me: Talk about a Freudian slip…
Me: so tell me what brought you in tonight.
Patient: I’ve been dizzy and falling all over the place and I’ve had double and even triple vision and I’ve got pain on top of my kidneys (points to lower pelvis) and I can’t think straight because I have aphasia and and and and and…
Me: Ok, and tell me about your medical history.
Patient: I’m pretty sure I had some surgeries as a kid that my parents hid from me and I saw the records once and I probably also had cancer and they told me it was just colds and I don’t think my parents are my real parents because our eyes are different colors and and and and….
Patient:…oh, and I’m pre-med. I made a 40 on my MCAT and I’m going to be a psychiatrist.
Resident: So what do you take Seroquel for?
Patient: You see those bugs crawling on the wall over there?
Resident: Ummm… no….
Patient: That’s what I take it for.
In a few months I’ll be choosing a specialty to start my residency and I have doubts between choosing Psychiatry or Family Practice; I like both. Any advice? -entropycomeseasy
When I first started med school, my dean told me “if you like a little bit of everything and you don’t hate psych, you should be a family doctor.” She’s totally right. We see tons of psychiatry in family medicine. And I really enjoy the FM-type psych stuff. I like treating depression and anxiety and cognitive disorders. I am not a big fan of treating acute psychotic breaks and such. Which is why I’m a family doctor and not a psychiatrist.
But if you like it all, why not do both? There are combined Family Medicine-Psych residencies out there. They’re rare, but they do exist. I think in the next few years there may be an expansion in primary care-psych programs, especially considering the shortages of each these days. There was an article about these programs on KevinMD recently.
If you want to choose one or the other, consider the following: