My patient is the Antichrist
Last Monday, a middle-aged white male with a history of paranoid schizophrenia and alcohol dependence was admitted to the psych ward for passive suicidal ideation. I was sent to interview him.
He told me that his living situation had become “intolerable”: the other people living there were “rough characters” and there were a lot of “negative vibes” – “it’s a tough place”. It became so intolerable, in fact, that on Saturday he left the alcohol rehab center he lived in, checked into a motel down the street, and chugged a 1.5 liter bottle of Listerine (“It’s about 50 proof” he told me). The minty elixir knocked him out until the next day, at which point he staggered home. On Monday morning he came to the hospital and told his psychiatrist that he felt like the world would be better off without him. He was admitted for observation.
I had a long talk with the patient about his symptoms. Most notably, he hears thousands of voices in his head all day ever day. Some voices are good and some are bad. They give a running commentary of things going on around him and talk to him about his “telepathy.” When asked about it, he says “yeah, I think I have telepathy. Maybe it’s the next stage in evolution or something. I don’t know.” He can read minds and feels that others can read his thoughts (it’s called ‘thought broadcasting’ in the textbook).
He has intricate and complicated visual hallucinations, too – the previous night, for instance, he saw himself wearing a golden breast plate with the 12 tribes of Israel burnished upon it. He called his visions “crazy” and “disgusting.” Some days he wakes up as figures from the bible, like Isaiah or Abraham, and he relives their religious adventures. He thinks he might have multiple personality disorder (called dissociative identity disorder in the DSM).
He is the highest-functioning schizophrenic I’ve met, and he’s a great story teller. If you met this guy in a store or at a bar, you would never know that he has thousands of voices roaring in his head. I had high hopes for him. Then I talk to my attending and the social worker on my team. They say he has been admitted dozens of times for the same thing. In fact, the patient left out a very important detail in the interview: he’s the Antichrist. He has a powerful demon living inside him, which he performs strange rituals to kill (like drinking Listerine – this is not the first time he has done that). One time, the doctor said, they sobered him up and discharged him, and he immediately got drunk and rolled around in an ant hill. He was readmitted the next morning, this time covered in ant bites. In fact, he has been kicked out by virtually every shelter and rehab center in the city. It was hard to believe we were talking about the same guy.
The next day, the patient reported that the volume of the voices had been turned way down. I asked him about the demon inside him, but he refused to elaborate: “Yeah, yeah.. how about we let sleeping dogs lie.” I see him every day on rounds and ask him how he’s doing, how are the meds working, are there any side effects, what’s his plan after discharge.
He is full detoxed from alcohol, he denies thoughts of hurting himself or others, and his hallucinations are relatively stable. He won’t even go back to his former home to get his belongings, he says, and he has another communal home in mind. We will discharge him later this week.
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Be patient with a layperson for a moment:
What have you learned chemically that diagnoses this guy as an organic paranoid schizophrenic more than just an long-time alcoholic? I liked the last one a lot because you went through the coke–>dopamine, etc. stuff. I think that society suffers a lot because of the lack of education re: the hereditary implications of cocaine addiction. (Then again, that is only because the most recent stuff I read said that children of coke addicts were found with that genetic marker 70% of the time whereas alcohol was like 40%.)
To someone only superficially informed, it looks more like a homeless guy in the city who’ll do anything to stay chemically taken care of when he can’t get to some booze. (You know that no addict likes withdraw).
In my mind, a serious chemical addiction to alcohol could create schizophrenic symptoms, right? ESPECIALLY, if that kind of long period of intoxication was motivated by a deep need to stay that way. These are the parts that led to me asking you for the chemical for a diagnosis of true-blue schizo, (whatever that is these days):
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re: rehab – “He told me that his living situation had become “intolerable”…“it’s a tough place”. It became so intolerable, in fact, that on Saturday he left the alcohol rehab center he lived in, checked into a motel down the street, and chugged a 1.5 liter bottle of Listerine…”
re: being detoxed – “…One time, the doctor said, they sobered him up and discharged him…he immediately got drunk and rolled around in an ant hill. He was readmitted the next morning…In fact, he has been kicked out by virtually every shelter and rehab center in the city…”
re: personality analysis – “..he’s a great story teller. If you met this guy in a store or at a bar…Then I talk to my attending and the social worker on my team. They say he has been admitted dozens of times for the same thing.”
In that case, I want a team of you in Midtown every week because if foregoing sobriety for at least half of your life can be considered the “onset” of some type of paranoid schizophrenia, don’t we have a LOT of schizophrenics on our hands?
re: pattern for his periods of sobriety – “He is full detoxed from alcohol… He won’t even go back to his former home to get his belongings…he has another communal home in mind.”
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Under a freeway until he can get to another clinic? In my administrative/bureaucratic mind, it becomes an issue of homelessness and alcohol addiction. I’d have to see the guy
- get tested after not being drunk for at least 48 months
- get the same opinion 5 times
in order to think he was a diagnosed paranoid schizophrenic. However, that may be why politicians spend money incorrectly and inefficiently and end up pissing off professionals sometimes, so educate me.
— slamen
Bife: Click the dot with two curves around it in the top right of the screen and it should give you options to add the site to your RSS feed.
SS: See the new post for some more detail on the reliability of psychiatric diagnoses
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