Sunday 10 May 2009

Care Planning

Yesterday I described a lady who had schizophrenia, but had been managing fairly well.

She had emerging deficits and had historically reacted to command hallucinations and delusional ideation that, to a modest degree, adversely affected her (e.g. in employment opportunities, where to live, who to be around and in personal relationships) but, since she could talk to so many friends psychically, she'd always got by well enough. Effectively, she'd her own support network.

Calling 999 and presenting with breathlessness unsettles me. When I did my time in GP land, before jumping over to mental health, we'd reflect in Balint groups. Oddly, I've no reflective practice or peer support now I'm doing more complex and risky and distressing work in mental health, but that's another story and I digress. Again. When reflecting, one of the recurring questions was, "Why now?"
Most people pitching up in Primary Care weren't there with true emergencies. So the dry, pink, itchy skin rash you've had on and off at times for 6 months or so, why'd you come to see me about it today? Why not yesterday? Why not next week? The headaches you've had and put down to stress, for 2 years or so, what brought you to consult me, "just to get things checked out," right now? That indigestion you've managed for a couple months with over the counter antacids, what brought you to discuss your fears of stomach cancer now, in this moment?

Timing matters. To a degree it's pragmatism. It's about when we can get time off work, when an appointment's available. But more often it's about what we want. We want reassaurance since things haven't settled down as swiftly as we'd wish. We want an intervention early on, just in case we need to stop something getting worse. We're now worried enough to make changes or do something about it, so consult. A friend died with similar symptoms, giving us impetus to act. The media say that a condition we think we might have now has a miraculous treatment. Our family's worried and nags us into going because the symptoms grumble on and they're worried it's something sinister.

We're creatures of purpose. We don't take time out to fret over things, make an active decision to seek help, 'phone for that, take time out of our week, travel, wait, talk, be examined, discuss ideas, consider investigations, weigh treatments, arrange follow up, travel to chemists, wait, pay for pills and do all the other gubbins that seeing a medic involves, just on whim.

Shall I read a novel in the park as the cherry blossom cascades down around me, shall I whimsically whisk my wife off to a fantastic new restaurant, shall I weigh up the merits of a rather splendid 24 year old Port Ellen vs a bottle of Shiraz I've been gifted and partake of the winner, shall I lavish time on my children who're enthused with a new playground, or shall I go to the doctor and discuss indigestion I've had on and off for a few months?

To seek medical advice, even when free at the point of delivery, we need something that's motivated us to do it then, at that point in time, at that moment, rather than do whatever else we'd otherwise wish to do. There's no cash cost, but there's always an opportunity cost.

For a lady to be silent 'bout her mental wellbeing for 30 years then now choose to urgently disclose what's going on, in rich and exhaustive detail, surely is relevant.

The experiences had mostly been positive, now she's having more unpleasant thoughts about conspiracies and her role in surveillance. She's being told what to do more. They're affecting her physically, once causing pain and recently making her breathless.

Symptom burden seems perhaps to be increasing.

She's sought contact with mental health services after so long, having feared psychiatry for decades. There are no high risks. There're no risks that are serious/significant but unlikely or are moderate but likely to arise, to either herself or property or others.

She's adamant she ain't taking tablets, so medication's not an option. We talked through different medication options, considering what could help her feel more in control of her thoughts and feel more resilient, what could help her feel more relaxed and less distraught, affording her more fortitude, but she was firm in her view that medication simply wasn't going to happen.

Diagnostically her symptoms, negative impact (on career, residence, social behaviour, relationships) and mental state undeniably attract a diagnosis of F20.0 paranoid schizophrenia. It's not a diagnosis I often make, but if I could share all details it'd be evident that it's really not contentious.

A nurse (band 6 on an acute medical ward) felt she was mentally ill. The nurse is correct. She has a mental disorder, within the meaning of the Mental Health Act 1983.
The nurse felt she was psychotic. The nurse is correct. She has hallucinations and delusions and lacks insight into the nature of these and, critically, into the impact and consequences of these.
The nurse felt she needed mental health input. The nurse is correct. She has had increased symptoms which recently have been more distressing and wanted to talk to a psychiatrist and wanted to share her narrative at length, at this point in time. She's not known to us so the nurse felt her mental health and risks, "needed monitoring."
The nurse felt she needed medication. I'd say the nurse was wrong, here. Medication might help some symptoms some of the time, but abolishing all psychopathology would surely be a futile and unhelpful endeavour. The amount of medication necessary would no doubt be stratospheric. The fact she's refusing means she'd need detaining under the Mental Health Act 1983 so medication would be undertaken as a depot administered under Part IV of the Act. Not the best way to forge a therapeutic relationship, for certain. Probably not the best way to manage her mental health, either. The nurse disagreed, vehemently. "You're saying she's ill, she's got schizophrenia, she's hallucinating and deluded, she's hearing voices telling her to do stuff, she's got things making her feel pain and become breathless, she's wasting ambulance time and she's been in A&E and a medical bed when she's not ill, so we can't let her go and not treat her!" She went on to state how my lady's mentally ill, we don't know anything about her, she's refusing treatment, so we need to "section" her.

Talking glibly of "section her" was what finally did it for me. Pedantic, I know, but one of my many foibles is we don't "section" people, I make recommendations for detention and treatment. We don't do punishment, we do therapy, we do care. The glib presumption that somehow I can lock folk up on whim and stick needles in 'em as, "a section," always, always riles me. A lot.

I documented the interview at length, since it had been a lengthy consultation and she was such an interesting soul. I concluded that she was psychiatrically fit for discharge. She went home that afternoon.

I'm seeing her next week, at her home, so she doesn't feel threatened and doesn't need to come to a hospital. I'm sure there'll be no change in risk. I'm sure there's little benefit from ongoing surveillance. I'm sure she'll again decline social support, CPN input, out-patient follow up, CBT, day hospital, psychological work, in-patient admission and our functional community group that's just a couple minutes up the road from her. I'm sure she'll want no drug treatment. But maybe Balint had it right. Maybe sometimes the doctor's the drug.


Milo said...

oh I am so glad and grateful that you think that way. all the best, no matter what happens.

Anonymous said...

for someone who has avoided psychiatry all these years and now she is having sufficient distress to reach out to the mental health care system seems significant. ongoing contact with a mental health provider in whom she might build some trust and who is not forcing the issue of medications at her all the time would be fabulous..but who pays for that? still, any interactions with MH providers that the client experiences as beneficial are helpful, i believe.

Milk and Two Sugars said...

Oh, bless. She's lucky to have you.

Spirit of the wood said...

was not so sure of your posts regarding ME but this was great practice on your part.. i wish more were like you/ good luck with this lady

Mark p.s.2 said...

I read your advice on a blog asking what to do with patients who don't behave in the emergency department. It was perfect advice in my opinion and I followed you here.
You wrote "The nurse felt she was psychotic. The nurse is correct. She has hallucinations and delusions and lacks insight into the nature of these"
I am curious how you define psychotic, how you can distinguish hallucinations from a "normal" persons internal thinking process and what is "lack of insight"? I too hear voices and if my psychiatrist believed something was wrong with my cognition, I would like him/her to try to confront me on my false belief in order to identify and possibly correct the mistake.

Lady Pippa Jemima Fortesque Smyth said...

Hi Mark,
In my opinion the distinction is merely that the person not diagnosed as psychotic does not respond to hallucinations in a way that disturbs others and/or does not tell others what they are experiencing. I have had the occasional and very brief 'psychotic break'. No one other than my husband and my (privately paid for) therapist (both of whom I trust completely) had any idea waht was going on in my head. This was a decision I made because having worked in psychiatry I knew what the consequences were of telling anyone. With time and rest I recovered completely, although under stress I still occasionally see things 'differently'. Its the control over obsevable behaviour that is often the distinction rather than the subjective experience. The other difference is that I knew those things were not real - I had insight. many people diagnosed as psychotic behave as if the hallucinations and disturbed thoughts were real - they did not have the ability to distinguish between reality and 'fantasy' aka insight. That's also why I'm possibly 'borderline' and not bipolar or schizophrenic etc....