By Matthew Lilly

Treat by adaptation?

As per my usual morning routine, I awake patient X from his beauty sleep and gently request his presence at a simple interview. Our initial few interactions had been extremely brief – I wanted to talk, he didn’t, and we basically left it at that. I sit in a plush black chair, he on a couch with his legs crossed, diffident and intimidating. Perhaps my stature is intimidating to him – hmm, probably not. His stare is unrelenting – I consistently write “good eye contact” on his Mental Status Exam while I would rather and more accurately write, “his beady little eyes bore holes through my skull.” As he speaks, I simultaneously try to focus on him while trying to keep my fidgety hands still.

His story is complex but can be succinctly summarized. He’s the Messiah. End of Dictation.

The initial society-induced, medically unbiased, illogical and raw opinion one can’t avoid making upon hearing this is: c-r-a-z-y. Crazy like a fox. Coocoo for Cocoa Puffs.

But I continue to listen to his words, his theories and his explanations. Though it’s all quite far-fetched, his confidence and persuasiveness is unsettling. A faint internal voice, hopefully not of psychotic nature, begins to whisper, “Yeah, but…what if he’s right?” We’ve all seen the movies where the poor unfortunate protagonist from another time or dimension opens his mouth and soon finds him/herself in an asylum. The Terminator I and II. K-Pax.

I ponder on the possible repercussions mankind would face for the brazen, disrespectful act of holding God’s Son against his will in a mental institution of all places. Another Great Depression? World domination by a narcissistic sociopath? Automatic involuntary admission of all psychiatrists to hospitals operated and owned by paranoid schizophrenics with a grudge? Or maybe this is all part of His Great Plan: to present a subset of the population with a religious claim without evidence to support it, to then watch the outcome and judge us accordingly. (Although that probably already happened once.)

The trippy 1980 flick Altered States depicts a physiologist, played by William Hurt, obsessed with the hallucinatory experience and schizophrenia in general. In conversation he mentions that “some guys say schizophrenics are physically different than the rest of us; it’s almost like we’re trying to change their physical selves, to adapt to their schizophrenic image of themselves.”

I personally find myself struggling to adapt to the Messiah’s image of himself. As I cannot understand nor conceive of how this man can be comfortable in his beliefs, I have difficulty accepting it. If I cannot accept it, or understand it, I must adapt to it. When unexplained catastrophic events occur on this earth, we as humans attempt to understand, and when we fail we tend to adapt and move on. On a much smaller scale, my situation is similar. But overlying my need to understand him is the desire to help him. This man is not able to function in our world and it is our responsibility to help return him to the man he once was. Hindering us in doing so, of course, is the fact that he is reassured and comforted by his beliefs, and because of that, why possibly would he want to change. We cannot shake his beliefs by talking with him but we can try to change him physiologically.

So I adapt by having him chemically adapt with a bit of Haldol Long-Acting IM. Ah, now he sees the light. Although I realize the bubble had to be broken, for this patient, what a comfort that bubble seemed to provide.

Many clinical clerks comment on the very different exposure to mental illness provided by the Waterford Hospital and the HSC. It’s unfortunate that the clerkship psychiatry rotation does not offer the possibility of working at both sites. I found my time at the Waterford (as housestaff, folks) to be enjoyable, exciting and educational, as did many of my fellow students. Sure, there’s the smell of BO and urine that’s a tad overpowering during the first few weeks, but the nose soon adapts. Hey, and maybe you might just start to like that smell. It’ll become comforting; a silent, steady presence serving as a constant reminder that your patients need help and therefore need you. And as long as you don’t start to add to that smell, you’ll always be invited back.

And then when psychiatry is over, you’ll shake hands with your patients (and depending on the patient, wash your hands vigorously afterwards) and depart, moving on to the extremely different world of babies and vulvas. You just spent two months digging deep into peoples’ private lives and now you’re digging deep into peoples’ privates. Your internal monologue shifts from “Don’t let him think that you think he’s crazy” to “Don’t drop the baby, don’t drop the baby.” The smells are sometimes similar but the visuals are a tad different. The patient in the Case Room who occasionally yells out “Jesus CHRIST!” probably does so for a whole different reason than the patient with religious delusions on East 3A.

Nonetheless, what we as medical students see for the first time doesn’t always make sense, and in those times we truly appreciate being able to learn from an experienced resident or physician. When the illness is as poorly understood as schizophrenia, even the most experienced individual may struggle to find an answer.

The common feature of lack of insight into one’s illness makes it evident that dealing with patients who don’t want to be patients seems to require a lot of patience. I suppose that’s why such fascinating illnesses appeal to people who like a challenge.

Maybe one day we’ll understand Patient X. Hopefully our understanding will provide a solution to better management. And maybe we’ll better understand who has truly been adapting to whom.