His Hallucinations: A Clinical Experience
Sep 16, 2019
Osmosis colleague and junior doctor, Armando, reflects on clinical experience during medical school.
The burden of mental health is often overlooked. One in five Australians will suffer from a mental health illness each year. This includes anxiety, depression, bipolar disorder and also a variety of eating disorders. An often understated problem with mental illness is that people experience a kind of stigma. As a result, young adults are afraid to open up, grown men are embarrassed to talk about these issues, and the elderly stay quiet. In each of these cases, the affected people feel that no one can understand them; that no one can help. These factors make mental health disorders difficult to identify, assess and manage.
During my rotation in a general practice, I saw a lot of people with mental health issues. The majority of these patients returned for regular check ups.
This reflection is about my encounter with a patient who came to the medical clinic with mental health problems. I feel it could be of general interest to medical students as I was encountering this experience on my first day of my general practice rotation, meaning quite early in the training (third year of medical school).
I met Ian, a 31 year old man, when he presented himself at the clinic for the first time. He seemed calm and relaxed while sitting in the waiting room. When I brought him in to the doctors room and began to ask him questions, his persona changed completely. It was as if facing a jigsaw puzzle. Each jigsaw piece represented a problem in itself and each piece, each problem, was either untouched, ignored or nearly broken. With limited training in taking a mental health history, I felt as though I was thrown into the deep end.
“What brings you to the clinic today?” I asked, attempting to play the doctor role. He took his cap off slowly and then began moving his head to and fro, from side to side while unsteadily clenching his hands, rocking his shoulders and moving his arms around in a frantic manner. It was as if he was trying to get something off his back. I remained silent while I continued to observe his hysterical movements.
“Sh$t is about to get real,” I thought as I attempted to recall some basic self-defense moves I learned back in high school.
He then told me his story.
It all started after a relationship break up. This sent him spiralling into a major depressive episode. From there, the ball kept tumbling and other problems kept coming up and no one was there to support him. He started to experience delusions of people parking outside his house as well as people listening in on his conversations at home. He did not feel safe any longer. Something was not “right” and he knew it.
While listening to his story, I was alone with him in the room that whole time. I was instructed to take the history of the new patients coming in and to present it later to the specialist. Ian was the first person whom I have encountered with psychosis, on a one-on-one basis, alone with him in the same room, trapped in by four walls with the door closer to him then it was to me. I started planning my escape route while trying to recall where the emergency button was just in case things get out of control. Admittedly, I did not remember where the button was, because I was not paying attention during the orientation session.
The standard teaching in medical school covers procedures on how to take a good medical history. I also vaguely remembered learning how to approach an agitated or aggressive patient. But there was no guideline on how to approach Ian. Fortunately for me, although he was making strange movements and acting somehow paranoid, he was not aggressive and was responding to my questions well. But I clearly knew he needed help. That was what kept me in the room with him.
In hindsight - and going back over this whole episode - what I initially felt was my own fear that immediately erupted for a second. I reacted with a stigma that invariably accompanies a mental illness. No one fully understands what the other person is going through. That is true and is even more valid especially in psychosis. In that encounter, I suddenly realized that Ian’s perception of what he experienced was real to him, although it may not be real to us. It was very real to him. We cannot understand his state of mind. The same goes for depression and anxiety. What for a “mentally healthy” person is a small problem, may be a disaster for a person suffering from anxiety.
The role of a doctor in Ian’s case is to recognize early changes in mental health, empathize with the individual, listen, and take appropriate steps to support him/her in fighting their own battles so that, hopefully, the patient will come out triumphant on the other side. The support involves a prompt referral to a mental health clinic with services and a psychiatrist. These medical players have to be subsequently involved in a follow-up of the patient’s health status.It is well known that the suicide risk is high among patients with mental health issues, especially in schizophrenia spectrum disorders and psychosis (Donker et al., 2013). Early management is therefore critical, and it includes setting up a multidisciplinary team of allied professionals. These specialists must start with psychosocial interventions at the earliest opportunity (Byrne, 2007).
Oud’s and colleagues’ (2007) study highlights that primary care for psychotic patients depends very much on personal characteristic of the General Practitioner and the quality of local collaboration with Mental Health Services. While there is no systematic approach to patients like Ian, the doctors level of experience, access and support from other health professionals, wide variety of treatment options, as well as patient family support are the key principles in holistic management.
Establishing a good rapport is critical. It is important that patients can discuss their difficulties with compliance openly and speak freely about their thoughts on treatment.
After my talk with Ian, we were able to create follow up appointments and organize a mental health plan. It must have been very challenging for Ian to make the journey to the medical clinic, to tell his story and ask for help. I hope that after taking that first big step, Ian was able to win his personal battle, where his own mind was working against him.
I sometimes wonder what he is doing now.
Armando is a junior doctor and science communicator/illustrator working in Sydney, Australia. His main fields of interest are oncology, rheumatology and immunology. If not drawing or working Armando enjoys travelling the world, exploring beaches and cafes, and catching up with friends and family.
Byrne, P. (2007). Managing the acute psychotic episode. BMJ Clinical Review, 334, 686-692.
Donker, T., Calear, A., Grant, JB., Spijker, BV., Fenton, K., Hehi, KK., Cuijpers, P., & Chistensen, H. (2013). Suicide prevent in schizophrenia spectrum disorders and psychosis: a systematic review. BMJ Psychology, 1, 2-10.
Oud, MJT., Shuling, J., Slooff, CJ., & Jong, BM. (2007). How do General Practitioners experience providing care for their psychotic patients?. BMC Family Practice, DOI: 10.1186/1471-2296-8-37.