Another dilemma about the shrink

This week, I saw an elderly patient. He had been to the emergency room several times over the last ten days, referred by his family doctor (rightfully). The time he presented to me, the family doctor had sent him with an angry letter, saying he couldn’t understand why we didn’t hospitalize the patient, and to please deal with him.

According to the family, the patient had refused to be hospitalized. But he had continued to feel unwell, and agreed, with much convincing, to return to the emergency room.

The first thing that the patient said to me was that he was a very independent person, that he did not want to live out the end of his life very ill and did not want any invasive procedures. He said that everyone needs to be in charge of his own life and live how he chooses. He also said that the last time he was here, everyone had just jumped on him, wanting to put tubes in him, and never explained anything. I listened for a long time.

The patient has a metastatic cancer, but a slow growing one, with a good prognosis. His newest symptoms were almost certainly, in my eyes and the eyes of another doc I consulted, due to a local expansion of his cancer which was damaging an organ. It was an organ that is crucial to life and health. While he couldn’t be cured, a minor procedure could alleviate the pressure and spare the organ. He had refused.

Among the multiple documents from the prior ER visits and the family doctor and the oncologist was a letter that the patient had been sent to the local psychiatric court for a hearing to declare him incompetent, the reason being that he was “passively suicidal” by refusing treatment, and that he had said he wanted to die.

I briefly inquired – he had said, in fact, that he would rather die than lose his independence, that he “didn’t want to live like this” in a fit of frustration after one of the ER visits, that he had decided that he had lived long enough and that if this cancer complication would kill him, that would be an acceptable end to him, more acceptable than invasive treatment.

His affect was a little flat and down, and I’m sure that if I dug deep enough, I could have found some paranoia and maybe even light delusional thinking. He repeated himself a lot about his dignity, about needing things to be explained to him. There was probably some rumination in there. But in the ER, my job was to treat his physical illness according to his wishes.

I got to the point where I needed a list of his medications, which we got when his daughter called his wife at home. Nothing unexpected. But then, after that, his son said, “Wait, what about the medicine you got from Dr. Y, the psychiatrist?”

“Oh…I don’t take it.”

It was perphenazine.

Apparently, when he had come before, as soon as they had identified the impingement on the ultrasound, they had immediately wanted to put a stoma in, relieve the obstruction right then and there. He refused. This was the incident which had caused him to say that no one explained anything and they all just wanted to cut him open against his will.

My first task was damage control. I promised the patient that I would never do anything to him without his permission. Then I promised him that while I care about his health and his life, his dignity was more important to me. I explained that this was not a prison, that he was free to refuse or leave whenever he wanted.

I had to repeat myself several times. As I said, he was somewhat perservative about his fear of losing independence, being less than a man, having things done to him without explanation or permission.

Then I explained to him exactly how the pressure was damaging his organs. I explained what we could do to save his organs, showed him a sample of the kind of implant we would use, and explained exactly how it would be inserted. I called both an oncologist and an interventional radiologist to talk to him and explain. I also had to repeat this several times. I also arranged for it to be done as an outpatient procedure instead of insisting on hospitalization then and there. I did keep him longer than he wanted to try to stabilize him medically as a bridge to the procedure, but he agreed.

But in the end, he agreed to the procedure, and not reluctantly. I was afraid that if he went home, he’d change his mind, but today he showed up with no hesitation, underwent the procedure (which is uncomfortable, bordering painful), went home, and according to my conversation with his daughter after, did not swear off doctors.

I like dealing with elderly patients. I’m thinking of doing a subspecialty in geriatrics. I am sure he has some depression, and some light paranoia, and maybe even some delusional thinking. But is it really delusional thinking if he can be talked out of it? Is perphenazine treating the patient, or treating the family and the doctors? Would a lighter, antianxiety medication make it easier for him to make clearheaded decisions without his excessive fear? To be fair, since he didn’t take the med, and didn’t have it with him, I didn’t know what kind of dose was prescribed. But for a frail elderly man, this seemed excessive – like it was treating the family and doctors’ complaints that he was prickly and hard to deal with, while blunting what makes him him – his independent streak.

In the elderly, a lot of times you see some delusional thinking, a little bit of paranoia – but to me it seems like it comes from loneliness and loss of independence, and being treated like a child, combined with less cognitive reserve. I am not a psychiatrist, much less a geriatric one, but it seems to me that this is quite different than usual delusions in psychiatric illness, because it is so common, usually can be dealt with with patience at least temporarily (though it tends to return). I suppose it responds to antipsychotics, but just because it does doesn’t necessarily mean it has to be treated with them.

Here’s the real rub: Dr. Y. is my psychiatrist, the one I bitch about here all the time. Lately, the Cymbalta has been making me flat, has really harmed me cognitively, has completely destroyed my ability to write, has probably made me a worse doctor, though it has controlled the mania and the rages and the mood swings, and made me less prickly, less stubborn, less independent and fierce. I have complained about all of this to my psychiatrist, and he insists that the change in me is for the better. I kept asking him whether he is treating me or my environment. His exact words were, “The easier you are on your environment, the better it is for you.”

Until now, I had given him the benefit of the doubt, because he likes me and I do think he wants what is best for me. And that maybe I’m not the most objective judge of my own behavior and personality.

But now I see another, totally unrelated patient being treated the same way, and I think it is inappropriate, and I’m wondering. I know it is hard to judge another doctor’s actions because maybe I saw the patient on a much more lucid day or maybe things were different. I’m wondering if he is the one who referred him to the court. And most of all, I’m wondering…should I be shopping for a new shrink?



  1. Hello! You’ve raised a number of issues.

    1) As you’ve said, your patient technically didn’t have delusions since by definition a delusion is “unshakeable” but you were able to challenge them. To be pedantic, it’s most likely to be an “over valued idea” but the difference is splitting hairs. The psychopathology’s the same, it’s simply the intensity that’s different. In years gone by this muddled delusional/abberant ideational state was called “paraphrenia” but it’s a term that’s been dropped since it’s not diagnostic (and was misused, to peoples detriment).
    The real rationale for prescribing an antipsychotic here comes to two things :
    – are there elements of a psychosis, so an antipsychotic is therefore sensible?
    – is there evidence that the psychosis is adversely impacting on the person’s wellbeing (thoughts, feelings, behavioural reteptoire), so an antipsychotic is therefore sensible?
    I’m not keen on using antipsychotics unless there’re real grounds for entertaining them, as you say that’s especially true in the elderly.

    2) You said, “I promised the patient that I would never do anything to him without his permission.”
    In the UK we’d be less bold 🙂
    He has symptoms of depression. This is understandable, he has a progressive terminal illness and is in pain. If he was skipping in feeling peachy you’d be fretting he was in denial or had incongruent mood.
    The way you handled it is best, managing this informally through time and explanation and understanding.
    But there would be grounds for arguing he has a right to treatment and if he didn’t agree, and this was through mental disorder (eg depression) then compulsory admission could be warranted (and arguably it’d then be negligent not to do so).

    3) Duloxetine (cymbalta) isn’t a drug that’s widely used in my corner. I prescribe it in the management of fibromyalgia and neuropathic pains but don’t find it as wondrous an antidepressant/anxiolytic as the drug company’s studies claim.

    4) Perphenazine isn’t used at all in my corner since the benefits are modest and the side effects are legion.

    5) Choice of a shrink, well it’s all muddling to me ijn your corner since you have to pay. As you blogged here, coin can better be used elsewhere to improve your wellbeing. I do no private work at all, so all my time with my patients is invested because it’s clinically useful, not because it’s wanted (but not needed) or being paid for, so I’ve a poor understanding of the dynamics and relationships that exist in your corner.
    Depends what you want from a shrink, really. But it doesn’t look great.
    If it is just prescribing, and your drugs aren’t great, you could discuss why the shrink’s prescribing those for you when they’re causing awful side effects. If you get no sensible answers and no suggestions of options (which is key, that you’re having choice rather than someone pushing Drug X on you) I’d be parting ways.

  2. Reading this piques my confidence in the psychiatrist again.

    Every healthy person has mood swings, since we all enjoy the range of emotions that’s part of lifes rich tapestry, instead of being stuck in one mood state all the time.

    Every healthy person relates to other people at different levels which will be more successful or less successuful at different times.

    Every healthy person can look back at moments of their childhood and think, things could have been different there, and happen that would have been better.

    To look upon someone who has moods which change, has elements of fraught relationships some of the time, who’s had a childhood past that’s included imperfect elements, then formulate this into psychopathology seems a significant step to take.
    I wonder if it’s since the pshchiatrist is being paid?
    If they don’t make a diagnosis, if there isn’t a long term condition needing intervention, drugs, management, support, surveillance, what’s the psychiatrist’s role in private practice?

    I’m not savvy enough about the dynamics of mental health provision outside the UK to say anything helpful. I’d just ponder why the unhelpful consultations have been unhelpful, to consider if factors personal to the psychiatrist or necessitated through the system generated your consultations which were unhelpful to you, rather than you being the source of all blame!

  3. Yeah, I could calm down afterwards because I went and read up, and I know I’m not borderline. Without the identity confusion, fear of abandonment, and splitting, it ain’t borderline. And I don’t have any of those, for sure. I am just an angry youngish woman who is hard to deal with…it’s that shorthand again. I may point out to him that all that is angry is not borderline.

  4. i just wanted to say how amazing you were with your patient. he obviously felt calmer around you, and you made him feel like he was being heard, which seems to be lacking in his life. even though i’ve never met you, i am still proud of you! you are a credit to all of us ‘bipolars”!

  5. I also think you worked to make that patient’s experience a good one. The patience, compassion and shared decision making you displayed with him was beautiful and what we all need in a doctor.

    Which brings me to your question…I can only share my experience, but to me shared decision making, shared understanding of a diagnosis, shared understandings about what is and is not acceptable in terms of medications side effects and a shared understanding of who I believe I am are extremely important…in fact I would say for me they are deal breakers.

    I have tried almost every antidepressant and mood stabilizer out there. Nothing worked for my mood swings (not the normal human experience mood swings, but the kind that destroy my ability to participate in my environment). Out of everything I tried the mood stabilizer I was most afraid to try…Tegretol, has helped me the best, and I have no side effects. Life is not perfect for me, and I have since added Prozac, Valium and Dexedrine to my mix…but I have a sense that we are edging closer to the combo of medications that help me most.

    I know for me the search for medications to help has been a long and difficult one, but having a pdoc who’s ability, chair side manner and desire to create a shared decision based relationship has made the experience so much better than it was before.
    Take care,

  6. I was at the shrink today. Plan is to go back to my old cocktail, then slowly try lamictal. Today was not good, because he thinks I’m better when I’m actually suicidal, because I’m at least nice – he kept commenting on how friendly I was to talk to. But we also discussed consulting a psychopharmacologist. Anyway – he’s going on vacation now, so it should be a good break for me to reconsider. And I think I still don’t really forgive him for that borderline comment.

    The other follow up – patient is now in a psychiatric hospitalization (at my hospital actually, but no one told me) – I didn’t ask how much the shrink had to do with it. Turns out the whole time I was doing everything in my power to discharge him at the same time the shrink was trying to get him hospitalized. I lose, I guess. He thinks it is good because they will stabilize him medically (which is most likely the cause of his psych symptoms), but I think that for the fragile elderly, these hospitalizations are the beginning of the end.

  7. be careful of projection, it can happen to anyone. It certainly feels like theres some here.

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