Wednesday, August 16, 2006

S3 MHA 1983

Some while ago we met Carly. I speculated that her recent cutting behaviour represented one end of a spectrum, where the "self harm" was an act of frustration taken out in the infliction of a little pain with ony minor and quickly repaired damage to the self. Yesterday I was called on to visit Ed in the local psychiatric hospital. Ed is right at the other end of that spectrum.

Ed first became ill around ten years ago in his late teens. He became withdrawn, quiet, and a bit "Goth". Then he sarted not wanting to go out at all. He kept looking behind him on those rare occasions when he could be persuaded out of the house. Then he stopped eating out. Then he stopped eating. The other lads on his estate were "picking on him". They looked at him "funny". They were "trying to kill" him. So was his mum.

He got very scared and took some pills and ended up in hospital. A psychiatrist was called and he was relieved. He took some meds and got a bit better and went home. Where he stopped the meds, began withdrawing again, got ill again and needed admitting back to the psychiatric hospital again, this time under the compulsion of a "Section", that part of the Mental Health Act that can require patients to be detained in hospital to be assessed and/or treated.

Being obviously paranoid he was assumed to be schizophrenic and treated as such. He got better again. Better at covering up his symptoms enough to be let home again anyway. As I said, this all began about ten years ago. In the interim he has had two longish spells of regular antipsychotic medication. He put on lots of weight, felt very dopey, even became diabetic as a result. But he stayed "better". Except that his fixed fears about the kids he had grown up with, and even his own mum conspiring against him never went away. And the "medicines" he was being given were making him ill. Small wonder he continues to think we are trying to poison him.

Since his paranoia stubbornly refused to lift along with his other symptoms the psychiatrists began to question their diagnosis / management earlier this year, and I was called on to examine Ed with a view to him being detained in hospital whilst his medication was stopped (something of a first for both of us). In the end it became apparent that he was not willing to go in to hospital voluntarily and we had little option but to section him again. His meds were stopped. He realpsed. He went back on medication and shortly after went back home, exactly the same as he had been.

Until last month.

He cut his left wrist. As in, cut it down to the bone, taking out a couple of flexor tendons along the way. He was admitted to the general hospital, but declined repair surgery. He was re-sectioned and admitted to the psych ward. A couple of weeks later he absconded and went out to play with the traffic. The traffic won and he went back in to hospital with a couple of broken bones. Now he's back on the psych ward and today I had to visit him there to apply Section 3 of the Mental Health Act 1983. This requires him to remain in hospital, and to receive treatment, for up to six months. He and I have done this little dance a time or two now, and we both know the likely outcome even as we sit down for the interview that will "decide" the matter. This time he tells me he was distracted and didn't see the cars. And the cutting? Well that was ages ago and he'll get the tendons fixed when he's back home, no problem.

Problem is, like a latter day Yossarian, if he saw the cars he was trying to kill himself and needs sectioning for his own protection. If he was so distracted he didn't see them his illness caused an accident and he needs sectioning for the protection of others. The outcome was never really in doubt. I think he accepts this. But on the way out of the interview room he asked me to assure him that he will be allowed to see the medication he is to be given before they inject him with it, so he can know just what he is being given. It is the only thing I can do for him before I sign my copy of the section paper and I do it with a heavy heart. The problem is I know he will continue to believe the nurses are poisoning him, and in a sense he is right. We can argue it's for his own good, we can argue it is for the good of others, but it remains the only, utterly imperfect, option we have.

I stand there state appointed judge, jury and executioner, depriving a man of his liberty with a stroke of a pen. This is a far from arbitrary act, and it is entirely necessary, but these are decisions I continue to loose sleep over. And then, just to rub it in, on my way out the door to the ward is locked and the nice lady on reception is away from her post, so I buzz in vain to be let out.

For a few short minutes I get a glimpse of Ed's world for the next six months. Then it's back to the car and on to the next visit...


Z said...

Yup, don't suppose you forsaw this when you happily scanned your straight As at A level.

Sympathy to you. And I hope you have a relaxing holiday.

Alice said...

It's hard to set oneself up as a judge over the sanity of another human being. I think it's harder when the person is manic: they're happier, and they make other people happier, by being high. (Yes, then they crash.) But I found myself unable to honestly disagree when the psych patients accused me of poisoning them or "messing with their minds."

Geena said...

What kind of studies are done to find out why people get to this stage? I don't understand how a human mind can degenerate to such a point of madness with no apparent cause. But then there's so much I don't understand about life.

My heart goes out to that chap and his family. Living hell. If I were him the next cut would be across my throat. Who'd want to live like that? And if there's no cure, why prolong their agony?

I don't mean to sound callous or harsh, at all. I realise your job is to save life not to let it go but sometimes the lines seem so blurred.

Shinga said...

I've known (older people) that were sectioned. It was very difficult for the staff and the family. This is such a fraught area but it is so re-assuring to know that these decisions are recognised for their full gravity-depriving someone of their liberty and enforcing a treatment regime are not easy decisions.

I did see some proposals for extending Mental Health training to other health professionals a while ago. Among the suggestions was that OTs and similar who had taken the training (4 days at its most reductionist) should be allowed powers to section.

Sectioning - wretched. However, selfishly, I really appreciate that there are people like you who take it so seriously.

Regards - Shinga

Nutty said...

It's good to read of someone caring enough to think about what they're doing when they section someone. It's just such a pity that many psychiatric wards are such untherapeutic places to send someone. I hope that your patient shows signs of recovery soon.

Mr Angry said...

I hope you don't lose too much sleep over it.

It's a tough job, but someones got to do it...

Doctor Jest said...

z-- Nah. I didn't even get close to straight A,s, but this was back in the seventies, a Special Paper pass in Biology helped, and then there was all the shameless pleading at interview.... but no. Most students have no clue how the mental health services work, myself included.

Alice-- absolutely. I too hate having to compell manics to treatment. They're so infectious when they're up, but so vulnerable too...

Geena-- there's nothing callous in being realistic. I fear Ed will not see his three score and ten years out, but we feel obliged to try to avert an avoidable death, and to protect all those Ed might come into contact with. Not that he is willfully dangerous, just that in his recent attempts he has shown no regard for others and might inadvertently cause more harm to others than himself. It pretty much sucks, but this is what we are called on to do sometimes.

shinga-- thanks for the vote of confidence. It really helps right now.

nutty-- excellent tag. And thanks for the good thoughts for Ed. I am sure he can use them. (Thanks too to Geena similarly).

Mr A-- no I'm loosing sleep over the upcoming voyage on the high seas now ;-)

Zoe Brain said...

Someone who I care about deeply has just been sectioned under similar laws in Australia.
She hadn't slept for what, 14 days? And hadn't eaten for 8. OK, if ever there was a life-threatening emergency that was it. That amount of sleep deprivation will make anyone psychotic.

She hates the ECT. It gives her headaches. 19 down, 6 to go. She can't even read now, her short-term memory is shot, and by the time she's halfway through a sentence she's forgotten what the first part said. IQ was 160+, now... I don't know. Hopefully it's temporary.

But at least we've gotten the hospital to get her endocrinologist to see her, she has a history of severe endocrine imbalance.
I'm upset that they weren't aware of this, nor the possible biological cause of the symptoms, or even the history of pituitary lesions. I thought the latter was a contra-indication for ECT, something that would be checked for. And a complete blood series taken before starting on such drastically large doses of lithium, especially with a patient history of chronic and acute Hypothyroidism.

Things like this happen sometimes I know in emergencies. No-one's fault. But please, and I know I shouldn't have to say it, try to get a complete patient history, strictly medical problems as well as psychological ones, even in an emergency.

All the best, and remember, to err is human. Thanks for having the emotional strength to do your job, it's something I don't think I could manage, no matter how many were depending on me.