VA inpatient psychiatry
I started my clinical rotation in psychiatry this month, and my first assignment is at the Veteran’s Affairs inpatient psych ward. I’m seeing some very interesting things, and I’ll try to describe them on the blog.
For example, the first patient I saw was a 23-year-old veteran of the Iraq war (they are labeled ‘OIF’ on the chart, for Operation Iraqi Freedom) who had his psychotic break during an ugly situation in Iraq last year (note: The average age of onset of schizophrenia is 23, and psychological trauma is a common precipitating event). He’s now diagnosed with schizophrenia, and he’s on permanent military disability – the government will give him $3,000 a month for the rest of his life, a thank-you for serving the country, and a we’re-sorry for precipitating a chronic disabling mental illness. The problem is that he lives with his mother and has no expenses, so he has 3,000 bucks every month to blow on blow. Dealers come to his house at the beginning of every month to sell him crack cocaine; being schizophrenic, he has trouble saying no.
Cocaine induces dopamine release in the limbic forebrain, leading to its euphoric effects and addictive potential. The limbic forebrain dopaminergic pathway is the same neurotransmitter system which appears to be deranged in schizophrenia (we know this because conventional antipsychotics, like haloperidol [haldol] or chlorpromazine [thorazine] are antagonists at the D2 dopamine receptor, which are abundant in the mesolimbic pathway and nigrostriatal pathway [the pathway that atrophies in Parkinson's disease leading to difficulty initiating new movements -- side effects of the conventional antipsychotics can look like Parkinson disease]). As such, cocaine intoxication can induce psychotic episodes in schizophrenics. At the beginning of every month (this time he came in on January 4th), our patient comes in with active psychosis, reading people’s minds, seeing people in the room that don’t exist, etc.
The situation questions the practicality of giving this guy such a big allowance, even with his tragic military experience. In his case, the more money he receives from Veteran’s Affairs, the worse his situation would become. Fortunately, a solution was in the works – Social Work was in the process of rerouting his “fiduciary” to his mother.
Over the next few days, we stabilized his symptoms with antipsychotic medication. We scheduled a consultation for rehab options and discharged him to his mother.
And that was just my first patient. More to come.