Voices

I recently saw a lady who medics asked me to assess on their ward. She'd been brought in breathless but had been checked out and all was well. That's to say, serious things (like a heart attack) had been excluded, no cause for her breathlessness was found, but since it got better she was medically fit for discharge. She'd nociceptive pain that seemed pleuritic to me and was a touch alkalotic for my liking, but by the time I got to see her I couldn't hear anything odd in her lungs, her CXR was clear, haematological and biochemical indices were all normal (but her ABG hadn't been repeated). It could have been anxiety. It probably was. It could be pleuritic pain and consequent suboptimal ventilation and respiratory alkalosis from rapid short shallow breaths blowing off her CO2 but, in truth, I think the medics had it right and she'd been anxious.

What surprised me was that they sought an urgent consultation because as the discharge facilitator said, "She's mad as a sack of rats." Challenging stigma. Ace.

The lady told me, at length, about her voices. She hadn't told anyone about them for 30 years. Last time she mentioned them they locked her up and gave her ECT. Coercive psychiatry that did her no good. She was rightly wary of mental health services after that less than helpful contact.

I don't know why she said to ward staff she wanted to talk with someone about her voices, or why she opened up to me after 30 years of silence, but she'd clearly a desire to narrate her life story and what changes voices had made. They'd told her who to marry. Where to live. Which countries to go to. They'd hidden behind her eyes, spying for Stalin (which was when she piped up about them and had ECT in England as a young woman).

Mostly the voices talked with her about politics, current affairs and gossip. She really enjoyed them, she didn't believe she was ill and certainly didn't either want help or want the voices to go away. They talked to her, constantly. She said, several times, that they were real people who could talk to her psychically and were her friends. Better still, they could make her feel things. One had made her breathless (causing her admission) but mostly they made her feel good things. Every evening she has an overwhleming feeling of warmth, as if held, and is suffused with a feeling of being loved, "as if you look in to your mother's smiling eyes." It sounded beautiful.

She manages everything at home. She's been living like this for ages. Decades.

She has auditory hallucinations talking to her.
She has auditory hallucinations talking about her.
She has mood incongruent delusions of government conspiracies unfolding through presences utilising surveillance and telepathy within her head.
She has made acts, to touch things.
She has made feelings, usually they're positive.
She has made impulses, usually thoughts of travel.
She has thought insertion.
She has thought withdrawl.
She has thought broadcast.
She has had these for decades, she described hearing voices since she was an 11 year old child.
Maybe you like to consider Schneider's First Rank symptoms. Maybe you like Andrew Sims models of throught disorder (a man I met in my training, and even when he explained it to me I still couldn't get it). I tend to favour Nancy Andreasen's definitions of thought disorder. But however you like to assess, formulate and structure things, it's clear she's psychotic.

She had sufficient symptom and signs to attract a diagnosis F20.0 paranoid schizophrenia.

But, she's well. She's had no contact with mental health services for decades, she sees herself as well, she's scared witless of hospitals and psychiatrists (no idea why she spoke to me for an age), she's adamant that she will accept no medication (having had ghastly experiences of it, and since she sees herself as well) and avoids seeing her GP unless she feels she absolutely has to.

What should I have done?