Tuesday, April 26, 2011

Tales from Med School: Schizophrenic?

During my psychiatry rotation in med school, on some mornings, we would have patients come into our sitdown rounds and attendings would interview them. This was actually very interesting (and also awesome because I got to sit down).

One of the patients I will never forget was a college age kid named Riley who was presented as having his first schizophrenic break. He had been admitted a few days earlier and the med student sitting next to me (Jason) had taken him as a patient.

Riley was a skinny kid of about 20 years old with dyed black hair who had recently dropped out of college. He didn't seem particularly happy to be there, but he didn't seem particularly schizophrenic either. But what did I know?

At one point, the attending said to Riley, "When did you start hearing voices?"

Riley frowned and said, "I don't hear voices."

At the end of the interview, the attending sent Riley back to his room and stated that he would "bet anything" that the kid was hearing voices. The attending highlighted the fact that Riley couldn't tell us what his parents did for a living as particularly odd and strong proof of his schizophrenia.

At that point, Jason (the med student who was following Riley as a patient) nudged me and pointed to something he had written on his notepad in big capital letters: "GAY"

Jason's theory, he later told me, was that Riley wasn't schizophrenic at all and was actually just struggling with sexuality conflicts.

I can't say I ever found out the truth about Riley. But I did later read about a study where some "normal" people were admitted to a psychiatric ward and subsequently just acted like themselves.... and the psychiatrists would explain all their "normal" behavior in terms of psychiatric disorders. Like when the subjects were taking notes on their experience, the psychiatrics observed "compulsive notetaking."


  1. We'll never know if Riley was schizophrenic or not but what we can learn from that is to always keep an open mind

  2. Ooh, I loved that study (Rosenhan, 1973), especially where in some cases the fake patients were actually kept in the asylum for something like 2 months despite having no symptoms...

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  4. Props to Dr. Fizzy for catching this one. I noticed the exact same thing on my psych rotation. Attendings, as well meaning and brilliant as they were, would interpret every idiosyncratic move in DSM terms. In the end, it felt like once you were diagnosed with 'the crazy' then it was impossible to act 'un-crazy'- the best you could hope for was 'less crazy'. It is one of my greatest fears to end up on a psych-ward and have all my weirdness scrutinized by well meaning people in sweater-vests.

  5. And that's the part that psychiatry always struggles with. It's easy to justify keeping someone in the hospital when they're puking blood or they can't walk down the hall, but "normal" mental health is such a fine spectrum that you find people institutionalized that don't seem to really be that sick at all.

    As for the Rosenhan study, the biggest criticism of that study was that, because psych depends on self-reporting of symptoms, the doctors were going to take the initial presentation at face value (and the patients were instructed to initially tell the doctors they were hearing voices, with specific cue words), and believe these people were acutely psychotic.

  6. I don't recall there being any patients on my psych rotation like that. Most of them were floridly psychotic or had recently tried to kill themselves. They booted patients out of the hospital as fast as they could where I did my rotation.

    I've heard people use that study to discredit psychiatry many times, but I think Not House's point is spot on.

  7. I paged through my wife's DSM-IV for a night last fall and could have easily justified diagnoses for at least a half dozen things what using minimal criteria. We're all crazy to a point, that's what makes living fun... well except for kazoo behind my right ear, that lil green bastard will never shut up.

  8. Max: Well, it was the other student who "caught" it, not me. We saw another patient during those rounds who also had kind of subtle symptoms of schizophrenia, but I was convinced in the last few minutes, when he started to go into this weird detailed analysis of a bottle of Sprite. But seriously, I used to actually have nightmares about being hospitalized on a psych ward during that rotation. I found psych interesting, but there were too many things about it that disturbed me.

    OMDG: I would say 80% of the patients were completely batshit crazy. But there were definitely a few like that guy who stayed for only a couple of days and the diagnosis wasn't obvious. We also had one patient who was a physician and incredibly articulate, and there were times when it was tempting to believe that she really was the target of a massive conspiracy.

  9. Hm. I actually relate to this in a slightly differnt way. I do a lot of costuming and masquerade events that require elaborate garb and role playing. I feel more like myself than I do in real life because there's no pressure from the outside world to act a certain way. I'm free to let go.

  10. What scares me more is a psychiatrist who says that a student on medication that is working, should be taken off of it, and just be taught to "act responsibly"...

    Yes, let us take the depressive young man off his Lexapro immediately so that once out of the hospital, the family can cope with the outcome rather than the psychiatrist.

  11. You forget the second half of the Rosenhan experiment where he sent no patients, but the doctors-nurses found them.
    "Forty-one patients were alleged, with high confidence, to be pseudopatients by at least one member of the staff. Twenty-three were considered suspect by at least one psychiatrist. Nineteen were suspected by one psychiatrist and one other staff member. Actually, no genuine pseudopatient (at least from my group) presented himself during this period."
    "Unravelling madness"By Chris Barton
    "In 1993 Richard Bentall went a bit mad.

    He voluntarily took an antipsychotic drug and at first thought he'd get through unscathed.

    "For the first hour I didn't feel too bad. I thought maybe this is okay. I can get away with this. I felt a bit light-headed."

    Then somebody asked him to fill in a form. "I looked at this test and I couldn't have filled it in to save my life. It would have been easier to climb Mt Everest."

    That was the least of his troubles. Bentall, an expert on psychosis from the University of Bangor in Wales who is in New Zealand under the University of Auckland Hood Fellowship programme, developed akathisia - unpleasant sensations of inner restlessness and an inability to sit still.

    "It was accompanied by a feeling that I couldn't do anything, which is really distressing. I felt profoundly depressed. They tried to persuade me to do these cognitive tests on the computer and I just started crying."

    Try taking the medicine you prescribe.