Tuesday, February 17, 2009


There are many reasons that patients come to see a doctor. For us, those reasons are called the "chief complaint." Common examples are chest pain, shortness of breath, pain, etc. You can hear about this daily in any clinic, ER, or hospital in the world.

However, there is one phenomenon that only occurs in psychiatry. About once a week, the triage nurse has listed as the chief complaint, "Found by police naked at (fill in the blank)." I have seen "Preaching Naked at the College Student Union" guy. I have treated "Parents Won't Let Us Have Sex So I Watched 'The Notebook' 10 Times and Read 'Lord of the Flies' then Covered Myself in Molten Chocolate and Ran Naked to My Neighbors' House" teenager.

I was reminded of stories like these today, when I saw a patient in the psych ER. He is a late 20-ish paranoid schizophrenic who just needed refills. He hasn't been hospitalized in over 4 months. Aside from an odd affect and suspicious behavior, he appeared to be doing fine. I asked him if he could tell when he was going to have a psychotic episode.

"Yes," he said. "I haven't had a really bad one since the '90s. When I start to get crazy, I just want to get naked and let it all out."

"One time, I really liked this girl," he continues. "But she got married. I think I must have felt jealous, so I went over to her house naked."

I asked him how that went.

"Oh, she called the cops."

I asked him if he could think of any reason why he might behave that way.

"I was just sad because everybody else can get laid and I can't."

I asked him how he deals with those feelings and tries to avoid hospitalizations.

"I'm still sad. But I smoke cigarettes and drink lots of coffee to try not to think about it."

And now you see why schizophrenia really sucks.


Anonymous said...

Schizophrenia really blows. I just had a schizoaffective 17 y/o on his 7th hospitalization in two years...every so often he will have a few good months of clarity and his mother will get the brilliant idea of doing a med wash "because he's better" and "because i want to see who he is under all those meds." i think this time she finally got it. he was psychotic for over two weeks with severe acute decompensation, paranoid and delusional, grandiose thoughts, flight of ideas, tangential speech, ideas of reference, accused his mother of raping him, disowned his religion which was at one point very important to him and his family. His parents were so devastated they couldn't even visit him. It took Clozaril to get him back this time and even that at best he was severely depressed because he realized this is basically going to be his life. He'll be on Clozaril for the long haul now because everything else failed...he's also got Geodon on board as well as Thorazine and a host of other meds...at one point he got 800 mg of cpz per day along with 6 mg of Ativan. He hasn't been back so we all have our fingers crossed that he's doing okay...underneath the psychosis he was an absolutely wonderful young man. Here's hoping his mother doesn't get any more bright ideas.

Karen Brook Westhaver said...

Don't you find it more than MADDENING when after you and your PT with Schizophrenia have worked hard to get him stabilized, non-delusional, accepting of his medication regimen, enjoying and re-building on a quality of life, that their mother (it's always the mother...lots of Freudian guilt to plow there) will have an epiphany of "if we only change his diet, he'll be just FINE...BTW, we're going to be weaning "X" off his meds while he does the Bible diet. Thx for all your help." Oh the heavy-duty PT advocation in cases like that...but it's a killer when the PT is a teen and ultimately the parent's agenda is more important to them. [sigh]

Karen Brook Westhaver said...

But what it IS about "naked" and schizophrenia, anyway? So true, what you write. I wish I could somehow obliquely write about a former PT who'd been brought in with "Naked" significantly part of the complaint. Wait! There were a few of them, so, camouflage might not be too hard. A PT in full psychotic break, lated DX'd with Paranoid Schizophrenia with Bipolar Disorder was brought in due to walking naked across the ____ River as he was convinced he was a diety who was indestructible. In the course of treatment, there were times he was suicidal which made it tricky with that whole "indestructible" thing. Our contracts were pretty creative: "You will promise to NOT eat or drink anything which would be harmful to a human being" etc. Talk about meeting a person in their delusion to help them walk out of it...to have credibility with them IN it. I loved my work. Very rewarding. And never, ever dull. Oh..PT recovered to a level where he was able to return to college and finish, with periodic followups for assurance of compliancy with meds to try to avoid relapse. A former psychiatrist of ours used to say that as part of finalizing his DX criteria for
Schizophrenia, he'd have the PT sing a song...of the PT's choice. And he reported they always would! There is such indignity these PTs suffer with this terrible disease, I never had the nerve to ask the "sing me a song" question...seemed like adding a circus element to a tragedy. But who knows. The "Sing a song" might be a benign test in some certain circumstances. Feel free to have it a go as you deem wise.

Mark p.s.2 said...

First you mess with his brain chemistry with neuroleptics. Making maybe permanent changes to his brain function. Then you claim he is crazy if/when he quits the chemical lobotomy. Guess what's going to happen to his dopamine receptors in withdrawal ? He/she is going to go crazy and fulfill your designation of schizophrenia.

No withdrawal effects? Bull, lets see you take his dose of neuroleptics for three months and go cold turnkey.

Dunning–Kruger effect.

You want him to be schizophrenic so he is.

Mark p.s.2 said...

Funny stuff turnkey instead of turkey.
"A turn-key or a turn-key project is a type of project that is constructed by a developer and sold or turned over to a buyer in a ready-to-use condition."

Mommy likes getting her baby back.

The Deranged Housewife said...

I often wonder if the whole nakedness thing is because it's just another source of agitation for them - they feel constricted and much freer, so to speak, without anything on. Think about it: babies love to be naked, some "normal" adults even do, and will sleep/lounge around the house/sunbathe naked, whereas many others would not.

I have noticed the caffeine/cigarettes thing with agitated mental patients as well. I used to work as a receptionist/intake transcriptionist at an outpatient psych center and would type up the evals of these people ... as well as interact with them when they came in for appointments. One guy was very chatty, a wonderful guy, who I believe had been dx schizophrenic, and practically lived on cigs and Diet Coke. At some point that probably takes the place of illicit drugs, I'm guessing, and just continues to fuel their disorder, in some ways.

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