Culture Clash: Patients, August 19, 2005

Often, the patients that we meet give us cause to think about the way cultures (including our own) view psychiatric illnesses:

Ricky

One of our third-year classmates referred Ricky to Psychiatry because he suspected that Ricky is depressed. What we knew about Ricky before we walked into his room was the following: Ricky is 31; he was brought to the Emergency Department when he found that he couldn't walk; that he is HIV-positive with CD4 count of 7; and he has developed a B cell lymphoma that has appeared in the thoracic region of his spinal column. The CD4 count refers to helper T cells, which are important in fighting infection, but also one of the main targets of the HIV virus. A normal, healthy CD4 count is anywhere between 500 to 1500 cells per microliter. One of the graphs they show us in medical school is one that correlates the decreasing CD4 count with the appearance of certain opportunistic infections. Below a CD4 count of 200, the patient becomes susceptible to Pneumocystis pneumonia. Below 100, toxoplasmosis and cryptococcosis. Below 75, infection by the mycobacterium avium complex (MAC) is possible. Ricky has a CD4 count of 7. All of us are thinking end-stage HIV disease.

Sam performs the mental status examination. Ricky has a relatively flat affect, and his answers to questions reflect a poverty of speech. However, he's very cooperative, and performs well on the exam - alert, oriented, good attention span, intact memory. He admits to feeling a little depressed by his situation. Ricky believes that his disease is punishment for past mistakes he'd made in life. Ricky is feeling guilty for having AIDS.
Ricky had an "incident" months earlier, in which he heard voices telling him to hurt himself. He was able to resist the commands, and attributed the voices to some evil person performing voodoo on him.

Of course, we all know the answer to this expression is not:
"Oh, don't worry. Voodoo doesn't really exist. You're hearing voices because you're psychotic."

Rather, a better response would be something like:
"Have you heard those voices since they've given you the medicine?"
(I have to admit that while the analytic part of my brain requires empirical evidence to prove the existence of some force like voodoo, another part of me wishes that voodoo exists. Not that I'd want to use it on anybody, mind you, but only because there's this little juvenile part of me that wants to believe in "magic", which, obviously, is a gross oversimplification of what voodoo actually is, but I think you get my drift.)

Somehow, through his stoic expression, Ricky conveys optimism that he'll regain the ability to walk soon and lead a normal life. CD4 count of 7 echoes in our minds. End-stage disease. I hope, somehow, that number is wrong.


Sunita

Sunita is a relatively young woman in her thirties. She teaches at a local preschool, and lives at home with her husband, her children, and her in-laws. In the last few weeks, she has suffered several seizures of unknown origin. Obviously, seizures are debilitating, can be dangerous depending on the circumstances, and carry with them a certain stigma. She can't drive herself around the city anymore, and worries whether she'll be able to keep her job. She is very quickly losing her independence. Confounding the situation is her description of her support network. She has friends that offer support, but her immediate family seems to be less understanding - to them, there's "normal" and there's "stark raving mad." Did I mention she was living with her in-laws? The psychiatric consult team's evaluation? (All together now) Depression.

Choosing an anti-depressant medication is the easy part - all we have to do is make sure that it doesn't interfere with her anti-seizure meds. Much more difficult is finding a resource that is knowledgeable in dealing with some of the difficulties she's facing at home.


Clive

Clive's surgical wound is still infected, so his surgical team had informed him that he has to stay in the hospital for further observation. This led to him leaving his room, entering the stairwell, and yelling at the nursing staff. He claimed that he was experiencing visual hallucinations. The consult came in mid-morning:

Mikey: Should I follow up on Clive?
Mitch: Yeah, sure - why not? By the way, the nursing team had to calm him down after he was yelling and screaming in the stairwell. We'll meet you down there.
Mikey: ...

I walk into Clive's room and this time, he's fully alert. When he answers questions, though, sometimes you wonder if he's actually heard you. His expression never changes. He pauses for quite a while before he answers the question.

Mikey: Hey, Clive, how are you doing today?
Clive: ......Not good.......They're making me STAY!!
Mikey: Yes, I heard that. But it's okay - we're all just trying to help you.
Clive: ..............Are you scared of me?..........I'm not the violent type.....
Mikey: No, way.
Clive: .............I like you.
Mikey: I like you, too, Clive. You always shake my hand whenever we meet. We're buddies?
(Oh no. Long pause. It's like he's really thinking about it.)
Clive: .............Yeah..............yeah, we're buddies.
Mikey: Great. Can you tell me how you're doing now? I heard earlier that you might have been seeing things?
Clive: .............No..........no........
Mikey: Are you certain?
Clive: .............No.........that's over.......I just want to go home...
Mikey: I know. I'll talk with your surgical team to see what they have planned, okay?
Clive: ............okay..........

As usual, Clive shakes my hand at the end of the interview. As I leave, he calls out:
Clive: ..........Hey!...............How long are we buddies?
Mikey: As long as we know each other.
Clive: ..............oh.........okay...........

I run into Mitch and Sam. Mitch is openly amused. Apparently there's a hop to my step, and I'm talking faster than normal. "In my expert psychiatric opinion" says Mitch, "it looks like you've got a bit of adrenaline running through your system." I think I smile. It's like - whoa - I connected with a patient. And it feels pretty good.