When Patients Split

Frustrated man by a window

I Want A Second Opinion

There are times when patients will blame their psychiatrist for worsening symptoms, “I don’t think the medication is working; my suicidal thoughts have gotten worse since starting the antidepressant; I want a second opinion!” Patients will split due to many reasons:

  • Age and immaturity
  • Lack of patience
  • Frustration and taking it out on their psychiatrist
  • Unconscious inner conflicts
  • Boredom with therapy
  • Drug use and getting carried away

. . . and many more. As a psychiatrist, you have to understand that it’s better to allow the patient to seek another provider’s professional guidance than trying to convince them to stick around. As a patient, you have to understand that we are not perfect and cannot always effectively help you with your problems. As a patient, you should also understand that seeking a “second opinion” does not mean that you will be satisfied and might actually set you a few steps back, because that means that you have to start all over with a psychiatrist who does not know you.

The best recommendation for psychiatrists is to stick by their professional expertise and utilize empathy as much as possible. The best recommendation for patients is to trust their psychiatrist and avoid making impulsive decisions based on frustration encountered in therapy.

Are you Ready? (This is Defeating Stigma Mindfully)

Give Mental Health Patients A Chance

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Not Giving Up On Mental Illness

Many people continue to view mental health patients as “the crazies; the no good for nothing weirdos who do weird things and are just weird!” But this couldn’t be farthest from the truth. With a little medication and some talk therapy, you can unmask the most beautiful flowers that you will ever come across; more beautiful than many people who don’t have a mental illness. Remember that it’s not what goes inside one’s mouth that makes or breaks an individual; it’s what comes out because what comes out is from the heart.

With mental illness, it’s easy to erroneously believe that one’s heart is wicked, rotten or broken from the start. But it’s not their heart; it never was. It’s their mind which is malfunctioning, giving the appearance of a bad heart. It’s often easier to fix one’s mind than it is to fix one’s heart; once the heart goes astray, only God has the ability to help their poor soul. But with the mind, many wonderful opportunities are available if an individual with a mental illness is given a chance.

Many mentally ill patients suffer from a chronic disorder, giving even the most experienced psychiatrists loss of hope for return to a stable state of mind. But loss of hope is the difference between those who don’t achieve from those who conquer the highest mountains. Treating a mental illness may prove to be challenging at times, but what is more challenging is finding the strength to believe in your patient when your patient doesn’t believe in themselves.

Patients must always be given a chance no matter how chronic their illness is. As psychiatrists, we don’t rely on miracles but experience, knowledge, art and faith. As Jesus Christ once said, “The people of today want a miracle. I will not give them one.” We don’t need a miracle to see improvement; we just need empathy, on-point psychopharmacology and the belief that our patients will improve.

Sometimes we have to believe for our patients when they lack the belief in themselves. Sometimes we have to give the people who we know in our lives more opportunities to access mental healthcare, especially when the opportunities lie down the street or around the corner. Sometimes we have to extend a hand and place our interests aside for one day. Sometimes we have to let go of our ego and focus on helping someone else out, even when we don’t feel like being of help.

Sometimes we just need to give someone a chance, for a chance is all that they are asking for. Sometimes a chance is all they need to recover from their mental illness.

Are you Ready? (This is Defeating Stigma Mindfully)

Malingering At Its Finest

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Malingering And Substance Abuse

Psychiatric patients who malinger do not necessarily have any psychiatric issues to begin with. Often times, they have a history of antisocial behavior such as criminality, spending time in the prison system, homelessness and getting involved with heavy substance use. They may have a history of psychiatric-like features, but even then, they’re often secondary to substance abuse or malingering for the sake of secondary gain.

What is secondary gain? This is when a malingerer wants to obtain something of personal interest, such as spending time in the hospital in order to avoid upcoming court dates. Malingerers are street smart; they know what to say and how to act in the emergency room in order to earn themselves a night or two in the hospital.

The problem with malingerers is that if they tell a psychiatrist in the emergency room that if they do no get admitted, they will cut their throat, jump off the bridge or OD on substances, it puts the psychiatrist in a corner; this corner often leads to the psychiatrist admitting the patient for the sake of the patient’s life.

Even though you may suspect someone to be a malingerer does not mean that the person won’t actually try to kill themselves. For instance, if as a psychiatrist you decide not to admit the malingerer to the hospital and they go and jump in front of a train, there can be potential liability if their family pursues a legal investigation.

That’s because anyone that actually shows up to an emergency room and talks about depression and suicidal ideations is already in a state of mind that is not considered normal. Unfortunately, you have people who abuse the system such as those who are homeless and want a bed to sleep and food to eat when it’s 10 degrees outside.

It’s very difficult as a psychiatrist to accept or deny malingerers into a hospital. Accepting them is difficult because you suspect that they are playing you for a fool, but you also don’t want to take a chance with legal liabilities and them actually harming themselves. Denying them is also difficult because you are now taking a chance that they won’t actually kill themselves.

Believe it or not, even after a malingerer obtains a hospital admission, they may decide to cut their hospitalization short due to getting annoyed over something such as “cold food.” So even though they have a place to sleep, food, psychiatric medications and round the clock care and comfort, they may ask for a discharge the very next day for reasons not even worth further mentioning.

Unfortunately, malingerers are part of the healthcare system and they have to be dealt with. But even for them I feel bad because at the end of the day we are all human beings!

Are you Ready? (This is Defeating Stigma Mindfully)

Psychiatric Patients Are Unpredictable

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Expect Anything

If you don’t have patience talking and listening all day, then the field of psychiatry is not for you. Not anyone can become a psychiatrist and be good at it; it requires patience, determination, excellent listening skills and lots of empathy. Lots and lots of empathy! As any psychiatrist knows very well, the unpredictability of patients is something that they must be prepared for on a daily basis, even when you think that patients are doing well.

In the field of psychiatry, you must expect anything; anything less and you are in for a surprise. What many people don’t understand is that it’s not necessarily the patients’ fault when they become agitated, disruptive or physically assaultive; unless sociopathy is at play, mental illness is often the driver behind their madness. When mental illness takes control of you, you almost become a passenger wrestling to take back control of the wheel that the drunk driver is joyfully playing with.

But how do you help such patients when most of the time they cannot even help themselves? Patience and lots of it. And believe it or not, psychotropic medications work very well on mental pathologies; they just require the right dose and length of time in the patient’s system. Psychiatric medications aren’t something that you take for a month and discard with the hope of being “fixed.”

The stigma of psychiatric medications is still prevalent, but thankfully it’s decreasing. People are starting to realize that these medications work; they can fix your anxiety, depression and psychosis! People are also realizing that there should be no shame in taking them; there is nothing wrong with having a mental illness.

Sure it doesn’t feel good having one and no one enjoys suffering from depression or hallucinations, but the more that we normalize mental illness, the easier it will become for the world to be treated. People will no longer have to remain in hiding because they are too ashamed to get treated by a doctor.

As physicians, all we can do is continue treating our patients with empathy, professionalism and dignity. And as human beings, all we can do is continue to spread acceptance, love and hope into the world.

Are you Ready? (This is Defeating Stigma Mindfully)

Only Eighteen And Depressed

Young depressed person sitting on ground with leaves by stone wall with head down

Multiple Failed Suicide Attempts

One of the saddest things to see in the field of psychiatry is depression that hits the lives of young ones. Anyone young is considered 18 and below because they’re either barely an adult or still an adolescent or child. Think back to when you were 18 and how you felt like you were on top of the world, mature and an adult able to make your own decisions. At the time, you weren’t able to recognize your immaturity.

But now that you are older and look back at how you used to think and behave, you quickly realize without a shadow of a doubt how immature and potentially dangerous your decision-making was back then. Now as a psychiatrist, seeing an 18 year old suffering from severe depression and two failed suicide attempts breaks my heart.

Many of these young folks already have depression running in their family; in other words, they are genetically loaded. But it’s not like they’re born depressed or it just comes out of the blue. Most of the time, it’s environmental triggers that bring out the depression. Once it comes out, because they are so young and predisposed to experiencing it, the depression hits hard.

It’s interesting because these patients can tell you about some potential triggers to their depression, but do not exactly know what caused them to become depressed. In other words, they often state that it just came upon them and it doesn’t necessarily have to be around the time of the triggers; it can be months later.

Generally, the younger the age of onset of a mental illness, the higher the chances of a worse prognosis. In the case of severe depression, suicide attempts are not a surprise. Many of these patients won’t necessarily tell you that their intent was to end it all; they either feel ashamed and embarrassed or do not know the reason themselves due to the severity of their depression, which impairs their judgment, impulse and even insight sometimes.

The hard fact is that depression kills many lives every day all around the world. That’s why we must continue to remain strong and come together to share our stories, thoughts and feelings on a daily basis.

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Schizophrenia Gone Wild

Schizophrenic woman wearing face mask staring out the window

Coronavirus Affecting Stabilized Psychotic Patients

Many psychotic patients who were previously stabilized on their medications are beginning to decompensate from the coronavirus. It’s not necessarily that they are becoming exposed to it. It has more to do with them watching the news at home which is causing them to become worried and paranoid that they will get it. Some actually develop symptoms of COVID-19 and stop taking their medications, wrongfully concluding that their medications are causing the symptoms. This is schizophrenia gone wild.

Psychotic patients have a very fragile line of stability that they often walk on. Things such as stopping medications, environmental stressors, changes in their lifestyle or relationship disputes can be enough to put them over the edge and cause them to decompensate. When they do decompensate, it’s very obvious to family members; this is not a small and irrelevant change in behavior.

They will start to display odd or unusual behavior such as:

  • Believing that their deceased parents are calling them from the window
  • Shouting and arguing with loved ones
  • Making verbal and even physical threats
  • Calling random people at 2 am
  • Becoming catatonic and remaining mute for long periods of time

. . . and the list goes on. These are not behaviors that all patients experience; it was just a list provided for you to get an idea. When a schizophrenic patient decompensates, it doesn’t mean that they necessarily start to hear voices in their head or see things that aren’t there. It can simply mean that their behavior and thought process are disorganized. They may continuously shift positions in bed, flop their hands, ask if the apple juice on the table is alright in that position and even claim that it’s hot outside at the beginning of April in New York City.

It’s really sad to observe and talk to decompensated schizophrenics because you get a glimpse into their world and how much different their behavior is compared to people who don’t have a mental illness. Perhaps in their eyes they are not suffering but in ours they clearly are; they cannot function in society when they are decompensated. That’s why they’re in the hospital in the first place!

But keep in mind that even though a schizophrenic may not be currently at their baseline, does not mean that they cannot hold a conversation with you. Many can hold fairly normal conversations but they may make odd remarks. They’ll usually be able to answer all of your questions and many remain calm and pleasant during an interview. Just because a person has the diagnosis of “schizophrenia” does not mean that they cannot hold a normal conversation with you.

Schizophrenics are actually pretty cool!

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Coronavirus Madness

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Corona In The Air

Many people are showing up to the emergency room despite a nationwide recommendation to self-quarantine; not for coronavirus symptoms per say, but from anxiety due to the coronavirus. For many in society, this whole scare of quarantining, evacuating college dormitories and working from home is affecting their mental health. It’s not every day that we go through this; in fact, it’s not every decade that we go through this. Coronavirus madness is here.

Patients are showing up to the emergency room with rhinorrhea, cough and chills and are worried that they’ve caught the coronavirus. They forget that during these months, they can still catch other illnesses such as the cold or the flu. But combine physical symptoms with the scare portrayed by CNN and Fox News, and you have people who just can’t handle the situation.

Believe it or not, this situation is very stressful for many, especially when they have symptoms of the cold. The fear of actually having the coronavirus puts them on the verge of experiencing suicidal ideations; they believe that their “body is shutting down,” so they rather be dead by taking matters in their own hands, rather than dying as portrayed on television.

Many mental health patients were previously stabilized before the whole coronavirus pandemic: they were taking their medications and experiencing minimal psychiatric symptoms. But when the pandemic hit, their past symptoms came back to life: they’ve become negativistic, withdrawn and taking about 30-60 seconds to respond to a question; they’ve even become catatonic!

Do not underestimate the power that a viral pandemic can have on the mental health of society. Many mentally crack when they hear all the negative news on television; the fear overwhelms them and worsens their mental health. Some are perfectly healthy and have no signs of being sick, but their mental health drops greatly from their baseline just from hearing about the coronavirus pandemic.

Corona is in the air and it can infect your mental health! Make sure that you are surrounded by positive people and always share your feelings and worries with others.

Are you Ready? (This is Defeating Stigma Mindfully)

Jumping Off The Bridge

Man sitting on wooden bridge overlooking snow-covered mountains and lake

When Depression Blows Up In Your Face

Imagine suffering from depression since your adolescent years but never talking about it with anyone. Your culture considers mental illness to be a taboo and you view psychiatric medications as something that only “crazy people” take. So all that you’re left with is depressive feelings haunting you every day of your life, until you feel like jumping off the bridge.

This is how many people feel every day, especially those who don’t seek treatment. Some people do seek behavioral counseling but counseling is not always enough; as a matter of fact, it almost never is. The evidence in the literature demonstrates that both medications and therapy is the best treatment for depression; not one or the other.

The scary thing about depression is that you may have been suffering from it for years and believe that you have it under control, until it randomly blows up in your face. Depression can be like COVID-19: it can unexpectedly strike at anytime. One day you may be sad like you typically are and the next you are getting drunk and walking towards a bridge with the intention of jumping off.

Depression is not an illness to take lightly. It has the power to end your life whenever it feels like it. You may think that you have your depression under control, until it decides on a random day to try to kill you. Because you are already mentally weak from the illness, when it does decide to kill you, you may not have enough strength to stop it. That’s how many end up committing suicide and people wonder why they never saw it coming.

If you are experiencing depression, no matter how mild or severe, you need to seek treatment immediately! Do not wait until you end up in a CPEP to start seeking treatment. There is nothing to be ashamed of. Just like the coronavirus is infecting people all around the world, the same applies with depression.

Take your mental health seriously.

Are you Ready? (This is Defeating Stigma Mindfully)

Mentally Ill And Proud Of It

Abstract painting of man with tinfoil covering face

My Brain, My Choice

As each year passes, more and more people open up to the idea that having a mental illness is not the end of the world. For too long, mental health has prevailed in the underground world, only coming out at night out of fear of ridicule and embarrassment during the day. But finally, people are starting to realize that they are mentally ill and proud of it; their brain, their choice!

Times have changed; no more hiding in your bedroom suffering from a mental illness, afraid to come out to seek help. The medical environment is viewing mental health with more passion and concern; jokes such as “go see a psychiatrist” and “I’m sure the shrink will take care of you” are out the window.

Psychiatry is much more respected nowadays. Medical students have broadened their horizons and are now aggressively applying to psychiatry residencies all over the United States. Psychiatry is no longer considered an easy field to match into as a medical student. This goes to prove how the modern generation is much more interested and compassionate about mental health.

The exciting thing about mental health these days is not only that patients have more access to medications and therapy, but they are more confident to seek these resources. When confidence increases, you put yourself in a much better position to treat your mental illness, than when confidence is low while hiding in your home.

Who is mentally ill and proud of it? If you are reading this right now and you believe that you are, then you have taken the first step in the road to success: being honest with yourself. Next comes the second step: being honest with others. And finally, the third step: being honest with the world. Overall, be honest.

One thing to keep in mind is that you cannot force someone with a mental illness to get treatment; their brain, their choice! But, if a person is a danger to himself or another, then treatment should be enforced. It’s never okay to not report a suicidal or homicidal patient to the authorities. When lives are at risk, treatment is absolutely necessary!

Therefore, the more that we open up the mental health dialogue, the more access we will have to each other’s minds. And the more access that we have, the easier it will become to bridge our ideas, thoughts, feelings and patterns of behavior. And when this happens, the world will become a more connected place, universally.

Are you Ready? (This is Defeating Stigma Mindfully)

Learning More About Children

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Imaginative Play

Assessing children for psychiatric symptoms can be much different than assessing adolescents or adults. Children tend to be less patient, full of energy and interested in moving around and playing. Adolescents prefer no parents present and enjoy privacy and brief sessions. Adults are on the opposite end, ready to spill everything onto the table. Learning more about children requires a few different approaches.

For instance, children enjoy imaginative play with dolls, puppets and toys. Imaginative play is when children are role playing and acting out various experiences they may have had or that is of current interest to them. During role playing, they are experimenting with decision-making on how to behave, while at the same time, practicing their social skills.

It’s crucial to develop rapport with children, more so than with adults. Adults can compensate for less rapport, but no rapport with a child is like talking to a wall; no response or meaningful information will be obtained. The rapport with children must also be built off side-conversations that are not related to their symptoms and experiences, while with adults, you can jump straight to the symptoms most of the time.

When you have developed rapport with a child via side-conversations and imaginative play, it becomes easier to assess their psychiatric symptoms; the child has become comfortable with your presence. During role playing, you may gain essential information by talking through the puppet or toy; this is a nice technique that often works well.

Children love to get lost in imaginative play; it’s like an escape from school, parents and other children. A child can start talking to a toy as if a switch were suddenly pressed: one second he’s talking to you and the other second his voice has changed and he’s talking to the toy. But you must be comfortable role playing with a child, or else he or she will lose interest in playing with you.

Also keep in mind that depressed children oftentimes do not manifest the same symptoms as depressed adults. They will often experience irritability and somatic symptoms such as headaches or abdominal pain. It’s important to always assess their home life as well, to make sure that their parents are giving them medication and that they are safe.

It takes patience, good rapport and imagination to learn more about children, but with time, it can turn into a fun and pleasant experience, especially when they are improving from their psychiatric symptoms.

What are your experiences with children suffering from psychiatric symptoms?

Are you Ready? (This is Defeating Stigma Mindfully)