The Barometric Mind

I woke up this morning around 5:30, very briefly--thirty seconds maybe--because it was raining, and although the sound of rain beating on my apartment's giant windows overlooking the South Loop is usually really calming, the water dripping through my roof, through my ceiling, and onto my already stained carpet is quite distressing. But I didn't stay awake because at this point, a stained carpet is very low on my list of worries.

I'm thinking about away rotations and my grades and how to make myself look good for residencies. Am I forgetting paperwork? Probably. Where should I go next year? Do I want to go to Maine? Stay with my sister? Or should I go somewhere I've never been before, working in a hospital in Mississippi all by myself. Do I want to do family medicine rotations or psychiatric ones? These are the things I've been worrying about, but I recognize that my worries are not really important, just bothersome.

The patients in the psych ward, now their worries are real. Your family can't tolerate your manic outbursts anymore so they have you admitted--you promise to adhere to your medications from now on, but your family doesn't trust you any longer so now you don't have a home. Where do you go? In this already stressed out health care system, you run a real risk of becoming homeless--or as the hospital I'm working at calls it: undomiciled. That's a worry. Or let's say you're psychotic. Then the voices can give you a whole new set of things to worry about: "you're going to die as soon as you leave here" they might tell you, or "you need to be back on heroin again--that's the only thing that can help you, this anti-psychotic sh*t isn't helping and you and I both know it."

I arrive to the inpatient psych floor at 9:30. One of my patients, on the spectrum of schizophrenic to bipolar, is standing in the hallway, leaning against a wall. She looks terrible. "Good morning Miss [HIPPA compliant], you look tired, did you sleep well?" She says no. I stand next to her for a good fifteen seconds, waiting for her to elaborate, but she does not, so I slowly walk away, looking back at her as if she'll suddenly want to tell me more. Later, when I follow the doctor around like her own personal shadow, we stop by to see my patient. "This morning the nurses said you were banging against the wall and screaming, why was that?" My patient answers back something about "the voices" which I was almost positive had been alleviated by her sudden acceptance of her anti-psychotic meds.

Another patient, depressive with psychotic features, also has a similar complaint. The medications had helped reduce the voices to whispers, muttering always, no longer commanding. But this morning, they woke her up again, yelling at her. She looks tired today--much more so than yesterday.

I am a scientist--but I am a bad one. For me, personal anecdotal evidence is much more powerful than studies that have thousands of patients arranged into double blind groups and blah blah blah.... This is why when I think of sickle cell disease--how my dad's a carrier, my mom's not, but yet all three of their daughters have the trait--I think that there's more than coincidence going on with how it's inherited--either magic or some genetic translocation oddities.

Which is why I know believe that weather can make you psychotic. Two patients woke up in the middle of the night, around the time I woke up freaking out about the rain, and were brought back to their presenting level of psychosis. Maybe the pressure drop affected the neurotransmitters as much as it affected the forecast.

Just a silly, crazy, insane thought.

NBME: Behavioral Science

Our National Board of Medical Examiners Behavioral Science subject exam is in two-and-a-half hours. I am haphazardly reading through all our notes as quickly as possible. Our Clinical Neuroscience professor composed a powerpoint with 1,326 slides. It is a fun romp through various topics, both interesting and trite. Although some things are just entirely unexpected:

Well we were talking about Freud. 

.... Shelf!

Surprise! I have a giant subject exam next Wednesday! I'm terrified! Hence the exclamation points!

I'm terrified because it will be worth 20% of my final grade in my favorite class: Clinical Neuroscience. I had a feeling I'd like psychiatry even when I came to medical school, but it was never something I thought I'd seriously like.

I came in with a pledge to make medicine easier to understand for my patients. I fully believe I will have to see a lot of patients, but I want to make every single one of them feel in control of their health--by giving them the information and the support they need to make their own decisions.

This is why my final research project in college involved looking at the ways doctors communicate with their patients.

And psychiatry, I realize, sets itself up as the specialty that requires communication over everything else. Even with primary care--let's say family medicine, which is still my first love--you talk with the patient, and most of the time, talking is all you need. But you still approach a patient in primary care as an algorithm. History fills in some information, labs and tests fills in the rest. You shake it up, and you come up with a diagnosis. Or several diagnoses.

Psychiatry at the very start basically says: the only way you're going to get anything done is communication. There is no back up plan. You can't be that doctor who is really smart but also really distant--really bad at talking to people. I guess what I like most about psychiatry is that it really emphasizes medicine as an art form.

Regardless, I am now considering a double residency because hey--I'm young. But what I really want to do is qualify for an Honors Elective in Child Psychiatry. That was the most ... electrifying part of this course for me. Many of my friends, I realized, had these conditions. Most memorably, my best friend in elementary school had selective mutism. Which I always thought was interesting as a little kid, but now I understand it and I find it even more interesting.

Anyway, to qualify for the Honors elective I need an A in clinical neuroscience. And right now, without any extra credit, I have an 85%. SO FAR AND YET SO CLOSE. So, the next 6 days of my life will probably be panic, panic, panic.

Adding pain to misery, 50-55% of the exam is on "Central and Peripheral Nervous System" which is incredibly vague. Fortunately, the vagueness was removed by the course director who basically explained this chunk of questions as focusing on... you could easily guess it... my least favorite and, I am not exaggerating this when I say, my most personally antagonizing part of medical education... Neuroanatomy!

Trials and tribulations, right?

Here's to a weekend of staring at brains!

And That's Delirium!

Recently I found out that hypoglycemia can precipitate the mental state of delirium. As a well controlled diabetic, I have a lot of hypoglycemic events, so I am versed in the various physiological and psychological events that coincide with a drop in blood sugar. However, the number of times I've been delirious because of hypoglycemia? It's hard to say--I only just discovered what delirium is (thanks clinical neuroscience!)

But I'm going to say I've been completely incapacitated by delirium secondary to hypoglycemia twice: once in the central rain forests of Costa Rica, and once again in the sixth row of Finch Auditorium at Rosalind Franklin University.

The first time--in Costa Rica, was innocent enough. I had lost a lot of weight rather precipitously. The temperature was always in the low eighties and I had to hike about ten miles everyday under the weight of climbing harnesses, bio-tags, poorly prepared, non-Skippy peanut butter sandwiches, and gallons and gallons of water. Regardless, when I returned to the states briefly to take the MCAT, I sidetracked and took a shopping trip to the Gap, only to realize I was a size four, which means I probably weighed about one-hundred-and-forty-five-pounds, placing my BMI at 20. Although still in the normal range, when you consider my amazing, incapable-of-becoming-osteoporotic bones, a BMI of 20 is deadly. Or at least deadly for a diabetic since I didn't have any excess stores of glycogen in my liver. All hypoglycemic events had to be dealt with by myself--not the glucagon my diabetic body was still capable of making.

Essentially this just meant waking up with hypoglycemia frequently and having to drink more gatorade. But one morning, I woke up with a huge existential crisis hovering around my incapacitated body. I will never know how low my blood sugar was--all I remember is that my roommates had already left for breakfast and I found myself alone in the jungle, surrounded by the creaks and caws and chirps of forest dwellers and the hot and sticky and humid air of the tropics. Oh yes, and an existential crisis.

There was a journal by my bed. I wasn't really recording much in it: we had actual journals to take down actual data--like the types of epiphytes on the branches held up by the forty meter tall trees we climbed. I had a journal to take down various soil measurements (soil is so cool! But that is neither hither nor thither). But by my bed was a journal of just short little ditties--observations really, of a rainforest. Or at least, that was all that was in it--ditties--until my blood sugar was freakishly low and I somehow located a pen and started tearing at the pages with it. I was terrified, in that moment, of death, without knowing why. I had no idea my blood sugar was low, just knew that God was holding me in his hands at that very moment, pondering whether to keep me on the planet or toss me out, into the abyss of Hades.

And I was terrified. My mind flashed, somehow, and without anything more than incredibly tangential reason, to Cat Stevens, and how he had decided to dedicate his life to god and become a muslim after he had almost died swimming in the atlantic ocean and got caught up underneath a rip tide. So I wrote a prayer, a plea, and a mantra on the quadrille lined pages of my yellow journal, demanding that god forgive me for all that I had done and to allow me to live a little longer.

Delirium had made me a sniveling religious fiend.

I eventually escaped such a fate when I--fortunately--started chewing on sugar tablets sitting next to my bed. I then made my way to a late breakfast, where my advisor berated me for my tardiness and my rather dulled affect. Oh, but if only I had known then what I know now: "I mean no disrespect, but unlike the rest of you, I just spent the last hour in delirium."

Anyway, the second delirious state happened literally an hour ago.

Having awoken five minutes before class started, I had no time to locate my test kit. But I had a headache, and I had gone to bed with a bowl of popcorn recently consumed, so I assumed that my blood sugar was the cause of the headache and thus I needed insulin. Well, within the next thirty minutes I realized that my blood sugar had probably been fine when I started feeling the chest tightening spasms of hypoglycemia. No matter! I had fruit snacks!

And thinking that I had avoided the ills of hypoglycemia, I settled in to taking notes on a lecture about epilepsy.

And here's where it gets interesting: Somewhere--about an hour and a half into lecture--I stopped being able to understand the slides I was reading on my computer. And then, shortly after that--the lecturer stopped making sense. I wanted to raise my hand at several points along the way--I wanted to clarify what he was saying because I was sure he was saying it wrong, but I didn't. Instead I just sat in awe that everyone else seemed to understand what was going on.

And then the madness truly sat in.

We switched to a new professor for a new class, and my head wouldn't stay straight on my shoulders, my neck wobbling side to side. I became obsessed with the fear that the professor would notice me in what would have looked like a sleeping position and that I'd be kicked out of class--or that I'd automatically get a 0% on my next exam. So I snapped my head up and sat up straight as possible. But it was useless, because inevitably my eyes would close and my head would fall forward and I'd look like I was sleeping again.

I tried to focus on my computer, on my notes, but they no longer made sense. I tried to play a little game on google+, Triple Town, to see if that would wake me up, but I was exhausted and I quickly closed the tab on my browser and was unable to pull up anything again. I was exhausted; not tired, just thoroughly incapable of movement or thought.

I soon became incredibly confused and scared. Didn't anyone else feel this way? Why did nothing make sense anymore. I could hear the words my professor was saying, but they didn't make any sense. I became preoccupied with a feeling that I didn't exist, or that if I did, I existed on a plane unlike the one everyone else seemed to belong to. Kind of like I was the only one who realized that this world was simply a matrix, and that I needed to find my way back to reality. But how to get there?

I needed help, but from whom?

I decided that I needed to go to either the counseling/health center at school--a five minute walk away from my current location--or to my mother, who I was beginning to doubt was actually my mom at all.

But at both locations I would have done the same thing: fallen on the ground and started yelling that this wasn't real and that someone needed to find out what was wrong with me. "Run all the tests!" I imagined yelling to anyone who would listen. There was something terribly wrong with me, I just didn't know what--but I needed to know. 

My daydreams kept escalating in preposterousness until I imagined grabbing a knife and stabbing myself in the heart to regain entry to the "real" world that was hanging just outside my grasp. The thought of stabbing myself terrified me. And that simple feeling--intense fear--called my logic to attention.

What if this was just hypoglycemia? So I formed a plan while my professor kept garbling through his lecture on... what was it? ... anticonvulsants?

Step 1: Get Food
Step 2: Wait to Feel Better
Step 3: Feel Better? If no, go to Mother
Step 4: Feel Better? If no, stab self in heart

Fortunately, after eating a snickers bar, a twix bar, one reese's peanut butter cup, and a can of coca-cola, the delirium surrounding me started to fizzle away. I was capable of speaking, although my tone and volume were way off when I asked one of my friends sitting in the row in front of me, nearly incoherently, where today's pathology quiz was going to be administered. But I was conscious, and the fear that I didn't exist or that I existed in a parallel universe or a mirror reality, quickly became nonsensical and strange. Shortly thereafter, I was conscious enough to begin writing this, an assessment of my mental status as it descended once again into a state I wouldn't recommend for anyone. And that's delirium for you.




(a little bit more for the intrepid reader):

so delirium can be caused by anything that wholly affects the brain. usually when i have just bad hypoglycemia (so not life threatening but unpleasant), i act like i have a frontal lobe lesion: poor planning, flat affect, avolition, etc. however, the two times i've become "delirious" from hypoglycemia, it's possible that I was under the spell of global cerebral ischemia (so involving the entire brain). And while it appears that to get global cerebral ischemia from hypoglycemia, low blood sugars have to occur chronically (i.e., insulinomas), I fully believe that an hour of really low blood glucose could knock a person delirious.

(the end)

Aphemia

I love medical words. I can't pronounce many of them, but I still love them. Like aphemia. It's a form of mutism seen in catatonic patients. But if you separate it into its parts, (aph)asic and -emia, you get:

Lack of language within your blood.

or

Loss of words from your vasculature.

Really, just poetic.

Compliance & Threats

Currently I am in Clinical Neuroscience. We are being lectured to about sleep disorders, specifically sleep apnea. The guest lecturer appears to be in the range of 40-60 years of age.

Concerning sleep apnea, there is a fairly successful treatment: continuous positive airway therapy (CPAP). Unfortunately, compliance with CPAP is pretty low. Only 46% of patients use the therapy, and of these persons, only 70% use it on a regular basis.

The lecturer urged us to tell our patients: "You're going to die in the most horrific way imaginable then list all the complications of uncontrolled sleep apnea."

This was one of my major complaints for my previous endocrinologist: vague threats. I can understand why doctors would want to do this--it is really frustrating when you're trying to help someone when they're not trying to help themselves. But I wonder if there isn't a better way to tell someone that they're killing themselves. Would this involve asking them about their life goals and how non-compliance will negatively affect these goals? I think it does.

Regardless,

I suppose doctors are among the few people that can tell you--in disturbing and exact details--how you're going to die without you freaking out and calling the cops.

Hassling with the "Need" to Medicate Mental Conditions

I think I'd be a great psychiatrist:

1. I like sitting.

2. Physical exams are my worst competency in clinicals.

3. I have several mental conditions (possibly), but I most definitely have one.

4. I treat people with mental conditions like people.

5. I see people with mental conditions as people.

Now let me elaborate:

In clinical neuroscience we end up watching a lot of patient interviews. One day we saw one with a schizophrenic. Later, me and a group of people got into a discussion, and I was the only one on my side of the argument, which was basically, the person seemed fine and functional enough, and why should we deem him “flawed”?

Yes, he had once been an irritable and a frequent assaulter. But on medication, he seemed talkative—enough, he had moods—enough of them, and he seemed normal—enough.

[One small point, shouldn’t normal be set by the patient? For example, when I was depressed, I knew I didn’t want to be depressed, and I considered the feeling abnormal and I wanted it corrected. But if I have occasional hallucinations that I enjoy, why change that? Or if I have synesthesia? That’s enjoyable. Right? And like, all famous actors have dyslexia. And they talk openly about it and it seems normal now, although you could easily argue it’s not.]

No one agreed with me. "Here," they said, "is a deeply troubled man. He assaulted over 100 patients, nurses, and doctors at his first hospital—etcetera etcetera. He was barely lucid. He wasn’t making sense. He wasn’t talkative."

But these things seemed normal to me. The great variance of human personalities also includes medically treated schizophrenics.

And why are we so eager to eliminate imperfections? Even the term imperfections makes it sound like there’s a one true normal (there isn’t) or that there’s only so many ways a person can be functional (there aren’t). I don’t want to sound like the preachy 2^nd grade teacher you were scared of because they loved diversity thiiiiiiiiiiiiiiiiiiis much, but in all honesty, I hate the idea that mental illness has to always be treated and that we all automatically look down on people with mental illness because society has trained us to fear the abnormal, especially the mentally so. I’m not just saying this because I have a mental illness, but as a person who has known, talked to, interacted with, and dated people with mental illnesses, I say we should all work on the way we see others with DSM-logged disorders.

If you’re born with something, you shouldn’t have to awkwardly try to hide it constantly. And while most mental illnesses aren’t entirely genetic, many of them have a strong genetic component. Even more importantly, if you don’t want to hide it, you shouldn’t be forced to.

Schizophrenia an interesting mental illness. While I haven’t yet studied the topic enough to know if most schizophrenics are violent, I do know that public perception of schizophrenics paints them as violent.

[Side note: There was a great episode of Law & Order: SVU that involved a schizophrenic who appeared to have killed the woman who was in charge of his group home. No one trusted him and he was in a panic for the entire episode. Until the person who murdered the woman murdered him. I rarely cry watching law shows. I bawled.]

Most schizophrenics probably don't want schizophrenia. But what if they don't mind it? Similarly, most people with bipolar disorder I don't want it, but what if they don't mind it? Should we medicate people? And when we do, are we actually doing it to protect others? Or are we just doing it to quiet an imperfection, an imperfection we are holding on with us and projecting onto the larger world? I think this is especially a problem for doctors, who control so much power to change a person's life. Wouldn't it be best to understand what quality of life such a person wants first?

Manic Depression

[Warning, explanation: this is the most personal blog post I've written so far, so if being close to people makes you uncomfortable, you can skip this. But it's medically related, technically]:

Psychiatry Class. 9 AM. Dr. S is giving an cursory lecture on various mental conditions. He gets to mania. He starts listing off characteristics. An entire row of students in my lecture hall, turn around to stare at me.

Am I manic? Perchance.

Like many mental conditions, you have to have a certain number of listed signs/symptoms in the DSM to be able to classify yourself as anything. But I do have some symptoms of mania: