Tuesday, February 13, 2007

Notes From the Cuckoo's Nest: Part I

My blog receives periodic calls to action from Rimi, and had it not been for her gentle reminder, I wouldn't have been guilted into writing this. I'm really glad I did though, because I had promised Rimi that I would write about certain episodes from a past life of mine, which is so far removed from where I am now, that it seems quite surreal. Perhaps this is my way of reminding myself of the very real people and adventures I found myself with.

Here is how I shall proceed. This is an ongoing series, but I'm not entirely sure how many episodes I'll write. It would be interspersed with other blogposts, because the theme can get a bit depressing at times. I'm also thinking of starting another post series where I'll write my travel stories, which would run concomitantly with this series.

About 10 years ago, a combination of events in my life landed me in one of India's largest mental diseases hospitals for a year. Despite all the jibes from my friends teasing me about how much shock therapy I received daily, I was not, in fact, a patient. I was not even supposed to be in the hospital. But it so happened that the social work department where I was studying had planned to send me to a prison correction centre as an intern.

The thought of working for the prison system was for some reason rather unpalatable at the time, so I refused. The only other choice, as it turned out, was the hospital. I had recently finished reading One Flew Over the Cuckoo's Nest by Ken Kesey and The Myth of Mental Illness by Thomas Szasz, and was sufficiently interested in the workings of mental illness to look forward to the switch to working in the hospital. I was being accompanied by another intern, the very upbeat psychology nerd Ms. Phillips, who knew a lot more about diagnosis and therapies for mental illness than I did (I had never studied psychology at university). Ironically, that knowledge was completely useless in the set-up we were about to find ourselves in.

Our supervisor at the hospital was the head of the hospital social work department Mrs. SK, a powerful, though strangely, slightly repulsive person, whose views and ways were the cause of a major bout of unpleasantness later in my stint. Things started on a fairly friendly note though. Mrs. SK had three full-time social workers working for her, Mr. JJ, Mr. RR, and Mr. GG. Our duties were to assist doctors in the out patients department (OPD) with gathering case information from the relatives of patients, and examining case histories and organizing therapy sessions with patients admitted to the hospital wards. Ms. Phillips was assigned to the female wards and I was with the male patients(the wards were gender segregated). In the OPD, we worked together for the same doctor.

With this background in place, let me begin with the first of my many stories from the hospital. And tell you folks about about the person that was Dr. Dee. Many human beings manage to pack in a fair bit of contradictory, incongruent parts - manipulative but generous, chatty yet frigid, kind morphing to cruel, etc. Dr. Dee managed to stretch his contradictory ways to extremes that made him seem like an angel one moment, and an asshole the next. Let me explain.

Dr. Dee was the smartest doctor in the entire hospital. His diagnostic skills were impeccable, he always prescribed the right medicine, and his knowledge of his field was borderline genius. And yet, within the first week of working for him, I had developed a deep disgust for the man, which even my grudging respect for his talents could not overcome.........................

Day (perhaps Tuesday, or Thursday) Date - Forgot, sometime in the year 1996
Place - Dr. Dee's office, The Hospital
Time - 10: 00 a.m.

(A line of patients had formed outside the door. This is a government hospital, and in its scale, one of a kind in the entire region. We have patients and their families who have travelled overnight by bus/train and waited hours outside the hospital for the OPD to open. Most are dirt poor, and coming up with the bus or train fare must have been a struggle. They wait anxiously for their turn, with almost reverent faith in the doctor's ability to cure the malady that ailed their son/daugter/wife/husband/father/mother.)

Dr. Dee arrives and greets us. He notices the line out of the door, but also manages to catch the eye of the sales representative of a pharmaceutical company. He ignores the patients, and calls the salesperson inside. They're old acquaintances, and start chatting. About stuff. Hospital gossip. Dr. Dee trying to wheedle a medical conference invitation from the man. The salesperson dumping drug samples on Dr. Dee's desk.

One hour passes. The patients get impatient.

TM and Ms. Phillips: "Dr. Dee, won't you ask the first patient to come in?"

Dr. Dee: "Huh? They can wait. An hour is not going to make a difference."

Two hours pass.

TM and Ms. Phillips: "Dr. Dee, should we at least start doing case histories with the patients?"

Dr. Dee: "No, I need to see them first"

With this, he went back to chatting with the salesperson.

Salesperson (nervously): "Dr. Dee, why don't you see a few patients, I'll come back later"

Dr. Dee: "Oh no, no. Don't leave. The patients are in no hurry."

Middle of the third hour.......................................

I had taken to glaring at Dr. Dee intently in an effort to shame him into action, while Ms. Phillips , with a look of intense embarassment and anguish, was trying to find new spots on the walls to stare at.

Finally Dr. Dee and the salesperson run out of things to talk about, and with a supercillous wave of his hand, the doctor summons the first patient in. Once he starts seeing them, he's remarkably efficient. One case in particular stood out.

A young woman came in, accompanied by her father. She had been seen in another hospital, where she had been diagnosed with schizophrenia. The family had moved to Delhi, and she needed a fresh prescription for her medicine. Dr. Dee looked intently at her face (he hadn't seen any diagnosis reports yet), and then turned to us -

Dr. Dee: "She doesn't have schizophrenia."

TM: "But you haven't even asked her questions or looked at her previous diagnosis."

Dr. Dee: "Trust me on this. You'll see - she's not schizophrenic. She has borderline mental disability"

TM: "Umm....she doesn't look mentally disabled to me"

Dr. Dee: "Just wait."

With this he turned to the father of the girl.

Dr. Dee: "Iska kabhi koi buddhi ka test bhi karvaaya tha?" (Did you ever get her IQ tested)

Father: "Ji Dr. saab, pichhle hospital mein saare test karvaaye they" (yes doctor, in the previous hospital, they did all kinds of tests)

With this he gave Dr. Dee a copy of her IQ test. Yes, what he said. She had borderline mental disability. Then he started asking the girl questions. Trying to determine if symptoms of schizophrenia existed. None did. She had just been horribly misdiagnosed. He asked her to stop taking the schizophrenia medicine and referred her to another specialist.

When the last patient of the day was seen, he turned to us and said -

Dr. Dee: "You think I'm a slacker, but see how I saw the patients"

TM and Ms Phillips: "Yeah, spending less than 5 minutes per patient and after many had been diverted to other doctors"

Dr. Dee: "Ha ha, but I'm good at what I do. Five minutes is enough for me to diagnose."


The good doctor used to flirt non-stop with us. He was absolutely delighted to have us assisting him, unlike the glum doctor we had been assigned to before. He also flirted with every female hospital employee who was remotely good looking. Rumour had it that his marriage was in shambles, his wife, also a doctor, was working in another city, and they hadn't seen each other for ages.

Another day in the OPD...........................

Dr. Dee walks in, this time accompanied by the pharmaceutical salesperson. Much idle chat commences. A female hospital clerk walks in. She's in her mid-30s, pretty, slightly plump, and is more than little fond of Dr. Dee.

Clerk: "Dr. saab, aap ne to MBBS ki hai, yeh bataiye na meri gardan mein kya hua hai. Bahot dard hai" (Dr., you also have an MBBS, please tell me what's wrong with my neck. It hurts)

Dr. Dee: "Kal raat pati ko zyada zor se belan maara tha kya?" (Did you hurl the rolling pin with extra force at your husband last night?)

Clerk (giggling): "Kya Dr. saab, aap bhi na. Dekhiye na kya hua hai" (Oh please Dr. Dee. Why don't you see what's wrong?)

(TM and Ms. Phillips suppress a laugh)

Dr. Dee, instead of getting up to examine her neck, grasps her arm to pull her towards him.

Dr. Dee: "Kaafi solid baanh hai aapki. Bechara pati" (Your arm is a solid one, poor husband)

Much giggling ensues between the clerk, Dr. Dee and the salesperson, all the while the doctor held on to her arm, running his fingers on it. After another hour of banter between the three, the clerk and the salesperson leave.

Another two hours of OPD time gone. However, when the patients did start filing in, Dr. Dee was all attention, keen, perceptive, a sharp interpreter of symptoms, at times handing out medicine samples to patients too poor to even afford the subsidized medicine from the hospital pharmacy. When he concentrated on his work, he had no equal in the hospital.

However, his short bursts of productivity were squished into periods of indolence, indifference and plain apathy. Clearly, he did care about his skills, but at times, little about the people he practiced them on. An incident that occured towards the end of my term at the hospital pushed the doctor firmly into asshole territory for me - no amount of expertise or generosity could rescue my opinion of him.

We were sitting in Dr. Dee's office, writing down the case history of a patient, when an OPD peon walked in with a wicked grin on his face.

Peon: "WOH aayi hai, aur aapse milna chahti hai" (SHE is here, and SHE wants to see you)

Dr. Dee: "Woh kaun?" (Who?)

Peon: "Wohi, jis-se aapki ward mein anban hui thi" (The person with whom you had a tiff in the ward)

Dr. Dee's face changed. He looked grim.

Dr. Dee: "Bhejo usey" (Send her in)

A very stern woman in her late 50s walked in. She had an intent, fierce glint in her eyes that seemed to pierce through her glasses. She was agitated, but only slightly.

Woman: "Dr. saab, my work told me to get a certificate from this hospital that I'm fully recovered from my schizophrenia. Please sign a certificate for me"

Dr. Dee: "Ok. Give me the papers and wait outside. I'll call you in 10 minutes."

The woman went outside and Dr. Dee turned to us.

Dr. Dee: "Here's the deal. This woman, believe it or not, actually works in the social work department of (a major government) hospital. She's had chronic paranoid schizophrenia for the last 15 years or so with relapses from time to time. I don't know how fair it is for me to assess that she's fit to work as a hospital social worker."

Ms. Phillips: "Does she absolutely have to work?"

Dr. Dee: "She supports herself and her elderly mother with the income. She's not married, and doesn't have any other income."

Ms. Phillips: "If you think she's recovered for now, why not let her go back to work?"

Dr. Dee: "Hmm......we'll see."

He shouts to the peon to let the woman come back inside.

Dr. Dee: "I have looked at your papers, and I'm willing to sign them. However, I think you need to undergo another course of treatment before you join your work. I'm prescribing Clozapine which we recently got approved to use. It's very effective in treating your kind of cases."

Suddenly my mind went into overdrive. Clozapine...............Clozapine...............Clozapine........it's familiar...........very familiar........................in fact, I heard about it last week...................in Dr. RSP's office...........................the doctor was telling a patient's family about it......................the new effective drug................................that had a 1 in 1000 chance of killing the patient who went on it..............................the patient's family refused the treatment........................Dr. RSP was almost relieved they did.

TM (mentally): Dr. Dee, tell her about the side-effects.

Dr. Dee continues to talk about the drug's benefits.

TM (mentally): C'mon Dr. Dee, tell her it has a 1 in 1000 chance of killing her.

The doctor talks about all the chronic patients it had cured.

TM (mentally): C'mon you motherfuckin' bastard! Tell her it's dangerous!

Dr. Dee: "I really think you should go on this new drug. It would really help you"

The woman though was having none of it.

Woman: "Dr. saab, I was admitted to the hospital, and you people released me when I was cured. I'm cured now. Just sign my health certificate."

Dr. Dee: "I won't sign unless you go on the treatment."

All the muscles on the woman's face were quivering with anger. She was absolutely furious. She got up, muttering profanities under her breath and started walking to the door. On her way out, she slammed the door with all her strength, nearly shattering it, and screamed "Kuttey ka pilla!!" (son of a dog).

The doctor turned to us, his bright eyes, glinting brighter, with a slight smile curling his mouth.

Dr. Dee: "See, she's not cured at all. She's still relapsing, and she wanted me to sign that certificate."

TM: "You never told her about the side effects."

Dr. Dee: "What?"

TM: "You never told her that Clozapine has a 1 in 1000 chance of death for the patient."

Dr. Dee: "That's not a significant risk, especially for someone with chronic paranoid schizophrenia."

TM: "But you never told her about the risk."

Later, the peon told us that the woman, during her stay in the ward, had physically assaulted Dr. Dee and slapped him. He never forgave her that transgression.

Labels:

35 Comments:

Anonymous Anonymous said...

Excellent. Whatever happened to the old lady ?
Waiting for the next part.

2:43 AM  
Blogger Rimi said...

Your blogging self is redeemed! This was a wonderful, wonderful piece and not the least because it is, as it were, nijer chokhe dekha byapar.

If you DO continue with these pieces I predict a sudden soar in your karma for kindly delighting.

8:28 AM  
Blogger Urmea said...

Why do you have all these fabulous stories??? Putting the rest of us to shame and wondering what exactly I have done all my life without these itneresting tales to tell :D

10:50 PM  
Blogger Heh Heh said...

good. i haven't been around in these parts for ages now and its nice to know you are still going at it.
nice post. What hospital was this, btw?

9:14 AM  
Blogger Naveen Mandava said...

It is definitely great to hear from somebody who has read Thomas Szasz and as well has an "outsider" perspective about mental health institutions (worked in them). Am hooked ...

1:05 AM  
Blogger Szerelem said...

dear lord.....
and how long were you at this hospital?

9:11 PM  
Blogger thalassa_mikra said...

Anonymous, not to kill the suspense right away, but I never saw that old lady again. I honestly don't know if she went on that medication.

Rimi, thanku, thanku. I do intend to continue, although intermittently. Trust me, there's a lot more to be said.

Urmea sweets, that's only because you are so selfish and keep all your interesting stories unblogged (and I'm convinced your stories are way better than mine).

Heh heh, thanks. Welcome back. The hospital was the IHBAS or formerly known as Shahadra hospital.

Naveen, I have a feeling my narrative wouldn't be what you'd expect. Well, for one, I don't necessary agree with Szasz thoughts on illness as performance.

Szerelem, ha ha! A year, and trust me, I left with my sanity more intact than ever.

10:20 PM  
Blogger hisfrogginess said...

heaps funny its like house... mybe with just a dash of mcdreamy..

1:28 PM  
Blogger TS said...

Hey T,

Replied to your comment.

9:11 PM  
Blogger Ruchika said...

Makes you wonder how much you can really trust even doctors!!

10:51 PM  
Anonymous Sakshi said...

Slightly off track here...but could you pls mail me.

I couldnt find your email add here.

TC,
Sakshi

12:32 AM  
Anonymous suvrat said...

Long and boring..

12:39 AM  
Blogger WillOTheWisp said...

TM: "You never told her that Clozapine has a 1 in 1000 chance of death for the patient."

Not to question your assessment of the psychiatrist, but maybe it is not always such a good idea to let a paranoid schizophrenic know about the possible side-effects of am anti-psychotic? A little dangerous and, possibly, self-defeating?

Speaking with the experience of quite a few doctors, Govt and otherwise, male and female, you do not have them explicitly revealing what else also follows - unless, of course, you ask. And, potentially disturbing as that might seem, it has its rationale.

Do you unconditionally disagree?

8:24 PM  
Blogger WillOTheWisp said...

You never told her that Clozapine has a 1 in 1000 chance of death for the patient

To clarify the question -

Would you wish to be warned / informed by the ATC, prior to collecting your boarding pass, that "Folks, taking the present and foreseeable weather conditions into view, it is intimated that your flight has a 1 in 1000 chance of not landing at all".

Is it unconditionally ethically reprehensible that air travel authorities prefer NOT to make sure that all passengers are forewarned thus?

11:10 PM  
Anonymous Anonymous said...

verbal diarrhoea, muffin?

6:36 AM  
Blogger Sunil said...

What a pair of clippered jerkos.

Do you folks have any idea what you are talking about? Clozapine causes deaths in every thousand screams of nehru gandhi university.

Do you know how many fatal administrations of clozapine last year? Do you know why excatly people die if at all they do on clozapine?
Do you know how many die can die of paracetamol?
Goodness!! Seems like a moron fest here.

well,
please yourself.

9:23 AM  
Blogger thalassa_mikra said...

Hisfrogginess, if only there was a mcdreamy for distraction, sigh.

TS, ok.

Ruchika, my advice is to always take a second opinion. And always question the doctor regarding the benefits and cons of the medicine he/she prescribes.

Sakshi, I left my email in your comments.

Suvrat, well glad to have you here anyway.

Willothewisp, yes, which is precisely why every other doctor at the OPD insisted that the patient be accompanied by a family member when they prescribed medicines to explain the full import of the drug to them.

The sensible thing to do would have been to insist that she's accompanied by a family member when she comes in next.

For in-patients, it is absolutely fine to prescribe medicines without full disclosure because the patient is under medical supervision all the time, and any side effects are more manageable.

Anon, hardly. Stick around for what's coming :).

Sunil, if you are a psychiatrist, you should know that Clozapine, though introduced in 1971 was withdrawn by the manufacturer in 1975 due to patient deaths, and then not approved for use for decades.

Even when approved later, it is to be only used for the most treatment resistant patients, and weekly monitoring of patients is absolutely essential, which in my opinion is best faciliated in an in-ward environment, given how patients in India can be casual about regular visits to the doctor.

To compare Clozapine to paracetamol is beyond absurd.

Also, while I'm very willing to engage in civilized debate ad nauseam, any sort of name calling of me or the other commenters would not be tolerated. Please refrain from profanity on your next visit. You're always welcome.

10:48 AM  
Blogger Sunil said...

I sincerely register my apologies about the frivolous remarks earlier in light of your civil response. Now, Whether I am psychiatrist, psychologist, pharmacist or plumber has no bearing on what I say . The question simply is whether I am aware of what you are talking ie content or not. And to be clear, I am.

Coming to the post; these are the issues I have :

Clinical acumen and probity of a doctor are not exclusive. So I’m not bothered if he is a clinical genius. Or otherwise. He is, for all that he is worth just another professional supposed to do his job. (which I am sure does not apply to him, going by your description of his personality) And, no one can diagnose or rule out schizophrenia by one look or by a single sitting. Not by asking a few questions.
By there , notwithstanding your perception of his clinical skills, In my book probably he is already in the asshole territory. [1] You should have known that. So lets save the greatness bestowed upon him, and if you ask me, I see it more as a subject of your ignorance of clinical matters.

But that’s secondary , in the post it comes across as a tool to build up narration, which is entirely your prerogative as long as you make it crystal that it is a personal post.
But what we have done here is veiled it as a character assassination of the chap for a clinical reason. Coming to which, you and your friend as inferable by the post seem to be under the impression that side effect is equivalent to chance of fatality. If you look up you would know how rare it is. the fact is as you have written, you just happened to remember something you had in memory and wanted him to mention it. More importantly one should know the reasons behind why it might be fatal . Hence my parallel to paracetamol. No drug , being a foreign substance has nil fatality chance. One thousand is of no significance, we can enlist a dozen medication more commonly used with higher chances of serious complications. Hence it was not absurd at all.

A classical analogy, to tease out from one of the comments would be the history of why Concorde inspite of a long list of fallacies held on so long versus Boeing. I can go into it but that would be superfluous. And no I’m not an aeronautical engineer.

Also , she is his patient and their relationship, me and you are not qualified to pass opinions like whether in patient or out patient treatment is more appropriate for her. Its none of our business. Remember doctors in general would prefer to use each others toothbrush than opinions unless the patient insists. She is entirely his responsibility. A relative may act in the doctors interest but not necessarily act in her best interest. So.

And regarding Clozapine, it was withdrawn because there were reasons, more out of general lack of advancement of science in the context, than its chances of killing patients. So I request you be bit more cautious about serving half baked beans. Its not about me and you, in the general interest of larger public, who are susceptible to be misguided by such writings. In case you read it wrong, I’m not defending him, I agree it would be his duty to explain about side effects but that’s as already stated, his responsibility alone.

Finally, schizophrenia cant be cured, its scientifically careless verbiage used here. Not becoming of someone who claims to have exposure in the settings. Kindly do re consider.

One other thing, and its purely personal and I am stating it here because I found your earlier reply reasonable and you would heed to reason.
I had used the language I used earlier just to gauge responses; In your post you have made no attempt to hide any profanity on the chap, (asshole territory / motherfucking bastard etc) , although if that factually took place, this post is against someone who is not here to defend himself. Speaking for me, as you can see I haven’t done that and given you a chance to reply, as you have to me.
From my perspective this is a personal post with a clinical excuse. That’s all. Its up to you to accept it or not.
And, almost forgot, thanks for the welcome.
Cheers
Sunil
And to save the suspense , I am a part in an overrated Shakespearean comedy.
Bye for now

10:07 PM  
Blogger WillOTheWisp said...

Actually, it was clozapine force-fed to me through meals that I was refusing to partake of, that managed to ensure that the psychosis I underwent, did not last longer than it did.
:)
You could look at this to get an idea of when and how it began and how it manifested itself. Do note that most of the entries which existed otherwise were also deleted during the process.

http://satyre.blogspot.com/2004/08/breakdown-i-did-not-know-this-still.html

Yes, I was transferred onto Olanzapine subsequently and things have been fair thereafter. No residual defect, as they say.

@ Sunil :
Finally, schizophrenia cant be cured

Yes and No would be fair answer here. People get a handle on things and that is, usually, good enough.

Having been diagnosed by two fellows as suffering fromParanoid Schizophrenia, one chap as Delusional Disorder, one lady as Bipolar Disorder ( Depressive ), a lady and a gentleman as Schizoaffective Disorder, I seem to have managed to make my presence felt right across the spectrum.
:)

No one can diagnose or rule out schizophrenia by one look or by a single sitting. Not by asking a few questions.
Yes and No again. Having been institutionalised for extended periods of time at such wards with other such patients, it is possible, to be able to arrive at a probable diagnosis of such cases with just observation of gait, posture, eye movement, and a few probing questions / social interaction. You learn to develop a feel for such cases ( regardless of my own history of diagnosis ).

3:16 AM  
Blogger WillOTheWisp said...

Apologies for the link to nowehere. It seems blogger has finally decided to get rid of the past ...
:D

3:25 AM  
Blogger thalassa_mikra said...

Sunil, most of what I wanted to say has been clarified by Willothewisp in his excellent comment. But further -

No, it is not a tool to build narration. I can vouch for the factuality of every single thing that I've recorded here. As Willothewisp said, your intuitive skills of diagnosis get fine tuned through repetition in a clinical setting.

Reading through your comment, it seems you are really ignorant about Clozapine and its ramification. Even to this day, it is used as a drug of last resort, with weekly monitoring, not unlike Lithium treatment for bipolar disorder.

Not only are you making unwarranted assumptions about the level of my knowledge of the clinical setting, but you seem to know more about Dr. Dee than I did in working with him for a year. It is interesting that you are second guessing his motives in saying what he did, but are unwilling to accept my account and call it character assasination.

By the way, all my information about Clozapine, patient-doctor full disclosure ethics, and schizophrenia diagnosis come from one of the leading psychiatrists in India (not Dr. Dee, another doctor I was in rotation with).

8:08 AM  
Blogger thalassa_mikra said...

Willothwisp, thank you so much for your comment. I appreciate it immensely. And my very best wishes. If you wish, I can delete your comment, and you can re-do your comment and omit the personal stuff.

8:10 AM  
Blogger WillOTheWisp said...

You may delete it if you feel so inclined. It does not particularly matter to me.
:)

6:20 PM  
Blogger Sunil said...

Now we have lost havent we?

A few last things anyway.
Will speaks for himself or herself. There is nothing in his comment to support your views or to counter my objections of your post.

You have made it abundantly clear about your knowledge of pharmacology involved. I do not have inclination to go into it now. A good read of psychotropics would help. Lithium , if you have missed has far more wide range of side effects than clozapine, and fatality as well and compromise of life as well. And you need regular blood tests for lithium too. More than one in fact. So these are evidence that my deductions are not unwarranted.


I would take your word these things happened, but the way you have been inconsistent adding your own slant is what I object about.

As I have said clearly , I am more than willing to accept your account but only on the basis that it is personal than anything else as you claim.

You need ICD or DSM for diagnosis, not Dr Dee or Vee, and science has specific criteria inc time frames to ’diagnose schizophrenia’.

And your clinical tuning theory is nothing short of farce, yeah there are chances that your suspicion is highly like to be correct with your experience. Can a 70 year old cardiologist diagnose heart attack by looking at the type of grimace evoked my the pain?

You would better to well to repartee the points that I have raised than making personal attacks. It gives my simple soul unwanted focus.


Hello will
Nice to meet you here. And can I just mention how much I admire you for sharing such things. Just a few things again,
Agree on getting a handle but it does not imply the meaning of the cure scientifically. You might wonder why books or papers never mention the cure.
Next, I have explained about diagnosing schizophrenia above. i agree with your feels but you cant further a diagnosis on feels. To ‘diagnose’ you need evidence.

You have mentiond about many diagnoses, unfortunately given the nature of the problems variables, that’s how it is . There is no objective test for toa scertain the quantity or quality of psychosis or the perception of clinican. Just like life.
The good thing is you are well. I wish you good luck for your future.
Cheers

11:18 PM  
Blogger WillOTheWisp said...

@Sunil :

Allow me to put it this way -

As per ICD and DSM IV, the criteria for diagnosis of schizophrenia are very specific. That notwithstanding, when you look at the criteria, you find that they rely on a lot of subjective feedback from either the patient or his care-givers. If you strip away the psychotic delusions / hallucinations ( which must necessarily come from the two and have other characteristics which we shall look at subsequently ), you are left with affective symptoms which are fairly objective - in the sense that behaviour and mood can easily be reported through observation.

The tricky thing is, when you seek objectivity, with the exeption of catatonic schizophrenia, the symptoms could very well indicate sme kind of an affective disorder - and hence the diagnosis of Bipolar Disorder ( Depressive ).

Education and Articulative ability on part of the patient are also considerations which play a role in diagnosis. Schizophrenics, demographically speaking, tend to come from the poorer classes of society. One way of looking at it is that such IS the case. Another is that inability to express onself in a language commensurate with the diagnostic criteria for thought disorder, tends to allow for diagnosis of schizophrenia than otherwise. It works the otherway around in case you are capable of informing yourself - which could be what has been my experience. The psychosis was distinct, classic, acute paranoid schizophrenic. Depressed affect was present, so you also think of the other diagnosis that I mentioned.

My hallucinations / delusions were Internet / Media / Text driven. The gentleman who started me off on Clozapine had not even met me ( those days everyone else was schizophrenic but for yours truly :) - based on description provided by a care-giver who was not living with me. He was internet-savvy and understood how it could come to pass that someone could start hallucinating millions of webpages ( which on subsequent search have been found to not exist ) - the point being that such thought disorder symptoms are context-driven. The next man who put me on Olanzapine had not the faintest clue of what the Internet was about and what blogs are/were. He got fixated on one specific paranoid thread ( out of many others which were delineated to him ) and passed the judgement of Delusional Disorder ( also taking into account my ability to express myself ).

The next couple of people tended to focus on behavioral characteristics and not the specifics of the psychosis. Their diagnosis - Manic Depression.

The symptoms of paranoid schizophrenic psychosis are clearly distinct from those of other psychoses. However, depending upon how well the patient and care-givers describe the same, the diagnosis could be schizophrenia or otherwise. It also depends on how well the shrink understands the context of such delusions / hallucinations. It has worked for and against the diagnosis in my case.

Schioaffective Disorder is the current diagnosis. Insight is highly developed and one of my shrinks appreciates the same. The two shrinks that I see currently formed their impressions in the first interview itself sans previous records. I spoke to them at length about the variances. What works against me for an outright diagnosis of schizophrenia is the ability to maintain an outward appearance of sanity, regardless of what I might be going through internally. Now this is an important point - since it speaks for a certain kind of background and grooming / context ( I shall not specify what it is - lets just say that it has to do with the profession ) that permits me to keep things stable.

So what exacly are you left with -
if nothing but "feel"?
:)
Evidence evidently works any way that you feel...

I do not disagree with what you say - nor with Thalassa. But this is what it is.

As far as being well is concerned - you feel dead actually ( with all the medication and progress of disease ), which, if you look at it, is probably better than being dead.
;)
Regards

5:24 AM  
Blogger WillOTheWisp said...

Can a 70 year old cardiologist diagnose heart attack by looking at the type of grimace evoked my the pain?

Incidentally, the "mental disease", as it manifested itself unknown caused something else that could have prevented the psychosis from EVER occurring at all - unrelentingly high personal and professional stress, at a critical juncture in this life, caused rapid cycling within the affect ( and psyche ) on a daily basis for an unduly extended period leading to a case when yours truly had his Myocardial Infarction at age 29.

Classic symptoms - all of them, Nausea, Numbness, Pain, Vomiting, Sense of Impending Doom. Care-giver rushes to doc. Describes the symptoms.

What does the doc ( all of 26 years of age and a GP / non-specialist ) diagnose on the basis of this second-hand description? For someone in athletic health at said age of 29? And that diagnosis has to be split second.

So what you have is that the doc puts his money on the diagnosis of coronary thrombosis, arranges for evacuation, gets the chap thrombolysed after the initial, probably life-saving ( since evacuation to ICCU took three hours ) dosage of sorbitrate. ECG and blood tests independently confirm the diagnosis for the attending specialist subsequently.

I know this does not address your question literally, but I would like to believe that it speaks to the underlying sense.
:)

6:43 AM  
Blogger thalassa_mikra said...

Sunil-

a) You are obviously ignorant of the practice of psychiatry at the clinical level, what informs diagnosis and how medicine is prescribed. A doctor's intuitive abilities are extremely important, because as Willo said, behavioural manifestations are all a doctor has to go by, especially in seeing out-patients. Unless the doctor suspects that the onset of disease is due to neurological problems or things like thyroid complications.

b) I am shocked and worried at your very cavalier attitude towards Clozapine. In the US, Clozapine carries a black box warning, reserved for drugs with highly restricted use. It does require weekly blood monitoring, just like Lithium. If a doctor isn't following this regimen, he is definitely putting his patient at significant risk. Here are the details on the monitoring required for patients on Clozapine:

http://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a691001.html

As I said, my opinion on Clozapine and its correct use comes from a psychiatrist who headed two of India's biggest mental diseases institutes, and already had nearly 30 years of experience when I worked with him. I really see no reason to take your word over his (I strongly suspect that though you are a physician, you didn't specialize in psychiatry).



Also I feel that you are being needlessly hostile and a bit obtuse in repeating the same arguments over and over again. I think I've clarified my position on this matter and do not need to hammer this further.

10:05 AM  
Blogger thalassa_mikra said...

Willo, thanks a lot for the excellent comments. Again my very best wishes for your health. What you said about the ability to maintain an outward appearance of sanity resonates very powerfully.

Mostly just the fact that the outward appearances were kept up would be extremely reassuring for us at the hospital, as it indicated a desire to engage with the world around in commonly accepted terms.

Your determination is strong, you'll make it.

10:13 AM  
Blogger Sunil said...

sHello will again,
As much as I appreciate what you have written I must say you have just brought in a lot of your perception , most of which is needless.

I have used the word--variables, which you have conveniently ignored.THAT is the nature of things, if you get what I mean. Feelings are another activity of mind, just liek pain or stress. These cant be measured. Working with that is the beauty and teh horror. But it is naive to claim that your feelings alone give you your identity.

And you, thal,
I have nothing against you. I just feel the post was personal and you seem to go on about being obtuse or soem clinical drivellng that is totally uncalled for. It has just reaffirmed my judgement of teh post. So i would go back to saying, please yourself.
Finally this is the nutshell---

You dont like him. Fine.
You dont like him because he didnt explain that clozapine may cause death in 1: 1000 persons. Not fine. Just like if you want to agree with soemone for what he says, fine. But if you want to agree with someone beacuse he is the chairman of some goddaman super duper twin committee, not fine.

bye.

6:44 AM  
Blogger WillOTheWisp said...

:D

I guess the actual point that I was making is that the word "feel" ( as I used it ) is not so abstract as " I feel you may be right". To give you an example, lets take the word "theory" - the word has clearly distinct ( and different ) connotations when used in a scientific and/or non-scientific contexts.

"Feel" when used in the sense of diagnosis, is a euphemism for inference through observation, substantiated by experience. It also means the net deductive / inferential processing that a doctor undertakes when presented with a patient or a set of symptoms / backstory.

AS far as variables are concerned, I am sure you are astute enough to suss out that my comment merely elaborates upon the point that you make and does not disagree with it / ignore it.

The important point is - if you were to ask a reasonably competent doc to clarify what he "feels" - on pen and paper, it would take the form of a systematically derived diagnosis ( depending upon how competent / observant / quick on his toes he is ).

Why do I get the "feeling" that you may be getting a little confused with the commonly used and impossible-to-encapsulate meaning of the word "feel" ( with its emotional baggage )?
:)

6:02 PM  
Blogger Sunil said...

Will,
I was certain you would say something. Now, Its not at all hard for me too imagine your psychosis.I think you have brought a lot of perception without paying heed to constrainted meaning of what i say. For that reason alone I am disaengaging now, as it is quite pointless.

Getting a handle has a whole new meaning. In light of your above comment, I suggest you might want to look at Theory of Mind and semantic priming in psychosis. But i ahve a feeling you would add your own definitive value into those templates.
good luck again and take care.
cheers
Sunil

4:11 AM  
Blogger WillOTheWisp said...

@Sunil :

Thanks for the references / heads-up and the assessment ( diagnosis ? ;)

To tell you the truth, there have been my own intuitions(?) directed to where you point ( and where they must inevitably lead ) for some time now. That notwithstanding, you would be surprised to learn of what I do for a living and how ...
:)

Your response places me in a double bind. If I respond ( as I evidently am ), you would have been certain of it ( and maybe a bit disappointed at my patent refusal to exit the door to a pattern that you may have pointed out, reinforcing your assessment ). If I do not respond, I acqiesce silently to your ( parthian? ) parting shot.

I suspect this is the passage ...

I have used the word--variables, which you have conveniently ignored.THAT is the nature of things, if you get what I mean. Feelings are another activity of mind, just liek pain or stress. These cant be measured. Working with that is the beauty and teh horror. But it is naive to claim that your feelings alone give you your identity.

To address the paragraph specifically, allow me to suggest that my response to this was not necessarily ignoring the ( as you put it ) "constrained meaning" of your words. The lack of an overt acknowledgement from my end need not necessarily translate into a cognitive deficit ( though it may be assumed ). I merely sought to circumscribe it with what followed, as well as respond to what was, essentially, an exchange between you and Thalassa.

The description of my experience ( or needless perceptions as you put it ) was not a complaint about mis-diagnosis nor was it an endeavour to elicit sy/empathy. In fact, if you process the comment on its merit, it merely seeks to contrast what you said versus what Thalassa said without necessarily agreeing / disagreeing with (n)either. To put it in simpler terms, I do not discount what you term ( subjective, if I am not wrong ) "variables" as being the crux of objective diagnosis in the particular case.

The last sentence of yours in the quoted paragraph was incongruous, to say the least, provoking the last comment. The only clue I could get to what might have caused you to say what you did would be this line in my comment preceding yours ( Do correct me if I am wrong :) -

"So what exacly are you left with -
if nothing but "feel"?
:)
Evidence evidently works any way that you feel...
"

Would you like to look at the entire comment in context of your exchange with Thalassa? The "you" which I used, does not refer to "I" but to any particular Doc.X that you may like to assume.

( Needless to say, I do not nurse any problems related to Identity or Self. Quite simply, they do not exist ;)

As an aside - I have always wondered if it possible to sustain a conversation sans polarisation / hostility.

Regards

P.S : If you do come back to check if I have responded, could you login and leave an indication. After all, it would be my vindication.
;)

1:49 PM  
Blogger WillOTheWisp said...

Sunil,

The "Theory of Mind" concept is curious, to say the least.
:)

If you were to objectively apply it to the textual interactions on this page ( since that is all that we know of each other ), it might be interesting to examine the inferences that could be reasonably drawn.
:)

And, just a short note to wind up ( for the time being ) - I suspect the reason the concept has been controversial is because it is not falsifiable much like Festinger's wonderful "Cognitive Dissonance" theory. Would you disagree? And what might be your thoughts on the latter playing out in this conversation between two poles and one nowhere?

Regards,

8:30 PM  
Blogger thalassa_mikra said...

Yes indeed Sunil, your judgment of the post has devastated me. I'm so, so upset you don't like this post. Why, why Sunil, why won't you like what I wrote, when all I care about is your validation.

Now I'll go weep bitter tears, while you dazzle the world with your profound insights on mental illness.

But use better analogies. The ones you used here suck, especially the last one about agreeing with the member of two committees (where did that come from?). Oh don't mind crumpet, I just thought I'd give you constructive advice.

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9:49 PM  

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