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Thursday, July 20, 2006

And Nothing but the Truth

A patient recently told me that his "problems" began in 1978 with his witnessing the spectacular crash of Pacific Southwest Airline Flight 182 in the North Park section of San Diego. Worse, "half my family was aboard that flight." He reports recurrent nightmares of "bodies covering me," of "my brother dying in my arms." Contributing information: he has spent 23 of the last 25 years in one prison or another; he is the meth addict's meth addict; and he pelts me with "treatment jargon," speculating as to what he believes an examiner wishes to hear. He is diagnosed with Psychotic Disorder NOS (and apparently CA prisons are one of the few places you can maintain an NOS for 11 years) with fixed delusions, and Antisocial Personality Disorder (which he reeks of like a cheap aftershave lotion). All right, delusions must include the element of possibility, but what is the probability of this tale being true?

Second case. A man appears at the public clinic late in the day while I'm on call. He identifies himself as a former patient, as the staff moves to the basement to find his records. Examining his chart, I ask him if recalls his medication history. He offers a relatively benign list of tricyclics. I turn the page to find copies of prescriptions, basically several year's worth of haloperidol and fluphenazine decanoate. I ask him and he angrily states he never took the meds. "But wasn't [doctor] your doctor?" "Yes, he was great." "But he wrote you all these prescriptions," and I show him the chart. "I DID NOT TAKE THOSE MEDICATIONS." OK. Let's change direction. I ask, "What brings you here now?" He goes on to tell me that he was working at the corporate headquarters of a major hotel chain in a neighboring county, when he was informed that his sister died in the collapse of the North Tower of the World Trade Center. The corporation graciously granted him a leave of absence and he came to San Diego. "Where are you living?" "On the street." "So you took a leave of absence from a major corporation to live on the streets in San Diego?" "You know, I have better things to do. I'm leaving." "Please wait. I'm just trying to understand the situation so I can offer you services." He leaves, and the next morning, under my provider number, the hit list says he went to the county's Emergency Psychiatric Unit, told the same story, assaulted a doctor and was arrested. Again, his story is possible, but how probable?

Third case. I sit in a silent prison housing unit on lockdown, and the control officer/gunner calls the patient's name over the PA and automatically opens the cell door. It is dark inside, with no apparent movement. She calls him again, and then again. From the cell emerges a train-wreck of a human being, seated in one of the world's oldest wheel-chairs, a rag tied on his head and askew, disheveled, no teeth, and appearing to be in significant pain. He finally rolls up to the table, greetings, and we get down to business. 3 separate times I inquire as to his disability, and 3 times he doesn't answer: "I was in Viet Nam," "I had 2 strokes in prison," "I was hit in the head with a bat." Are any the source of his disability? I don't know. Next, I spend too long listening to a lecture on "bulk laxatives, because when you're in a wheel-chair..." He declines every service I offer. "Where will you live?" "I own an apartment building?" What? "I got a multi-million dollar settlement with the city, so I bought an apartment building." "How far did you go in school?" "I have a degree in engineering and work for an engineering firm." I examine his medical chart. Neurological reports and reports of 3 MRI's: "No discernible signs of CVA." Neurologist writes, "I asked him to get out of the wheel-chair and sit in a regular chair in my examination room. He immediately complied." Discharge order from the doc at the prison from where he transferred: "This inmate is absolutely, under no circumstance, allowed to have access to a wheel-chair, walker. crutches, or a cane. He has no disability" I'm holding my breath as I turn to the psych notes. Diagnosis: Factitious Disorder. Now how often do you see that? I'm speaking with a Bulgarian colleague with a known psychoanalytic bent: hysterical neuroses, he muses. Hmm. A month later, I look on the computer for the Out-Patient notes following parole: His psychiatrist has confirmed that he won a multi-million dollar settlement, lives in an apartment building he owns, has a degree in engineering, and even spoke directly with his employer who confirmed his employment.

Apparently, there can be a fine line between veracity, delusion, probability, and personality disorder. Documented liver functions won't make you crazy; it's indisputable evidence. Truth, however, does not necessarily set you free.


Blogger Wrkinprogress said...

I've been reading your blog for a month or so now, and I just want to tell you how much I appreciate the humanity you bring to your work. Imprisoned people, the guilty and the innocent, are generally cast aside and forgotten by our society as a whole. We forget that they are actual people with actual problems, which, perhaps, is what landed them where they are to begin with -- having fallen through some other social crack.

Just thank you, Doc, for trying to do good and humane work.

July 21, 2006 10:04 AM  

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