Caffeine II

This is a continuation of yesterday's post.

I was a medicine sub-intern, fresh into my fourth year of medical school, about a year out from my psychiatry rotation. I scrambled to recall how to do a psychiatric interview and realized the simplest thing to do was listen.

"I started hearing voices when I was 8," the patient said, "My step-father was drunk and threatening to kill my mother and me, and maybe rape us, and the voices, they told me he was coming. Ever since he moved in, the voices have always been talking to me, warning me and threatening me, and I never feel safe."

"Have you ever been hit or hurt or been forced to have sex?" I asked.

"No, he always got away with it," she replied.

I didn't know what she meant, but she couldn't clarify. She started looking around her, over her shoulder, around the corner. "What's going on?" I asked. She didn't answer, but when I asked if she was hearing voices, she nodded.

This is how our conversation proceeded; in between every few questions, she would look around, eyes wide, hugging her pillow. I learned that she had over a dozen visits to psychiatric emergency services and half a dozen psychiatric diagnoses, from depression to bipolar disorder to schizophrenia. She'd tried too many medications to recall and was taking two antipsychotics. She had been jailed once for threatening to kill her mother and involuntarily detained many times for threatening suicide. She had a special power: she could tell whether someone was good or evil simply by looking at him or her. Surprisingly, her thought process was fairly goal directed and linear. However, she had no insight that she had a psychiatric condition.

She insisted that she only took the pills to quiet the voices; she didn't intend to kill herself. Yet I could not contract her to safety; she would not promise that she wouldn't overdose again when she went home. I called psychiatry consult and though it was nighttime, they were kind enough to come by and do a quick assessment. We got collateral information from the mother who insisted that her daughter was mentally ill, threatening to kill herself and the mother and step-father. She begged us to hospitalize her and then transfer the patient to the inpatient psychiatry ward. The psychiatry consult resident decided to 5150 the patient (involuntarily detain her) for danger to self.