Tannenbaum

There are, of course, days when you aren’t going to feel that good. Days like today.

I am sitting in my room at Clearwater. Outside I can see the sunlight-dappled trees, the ivy on the red brick of the next door’s building. Inside there is the drone of a therapist’s voice, talking to the woman whose marriage "won't survive this”. Inside my room is the slow whirr of the laptop, the taste of coffee in my mouth, the hard seat beneath me.

The thoughts in my head, the pressure in my chest.

The thing was, panic attacks, when someone came into the ED with panic attacks, the first thing to rule out was a heart attack. Panic attacks and heart attacks may feel the same: the same pressure behind the breast bone, the same fluttering in the chest, the same sensation of needing to breathe, needing to get air in. Oddly, heart attacks may present with or without the textbook "sensation of impending doom", while panic attacks by definition present with.. panic.

Panic, by the way, is a word with an interesting etymology. The Greek god Pan was a wild god, primal and untameable, older than the more restrained deities who were worshipped at Olympus. He had the hindquarters of a goat and a horned head and leering face, and was apparently fond of terrifying lonely travellers through the woods - hence panic.

Anyway, in the absence of leering deities, and without even a single nymph, I panic by myself. Technically it is not a panic disorder, more a severe "low" with features of agitation, but still, I feel it.

I am trying to calm myself by looking at myself as a patient, seeing myself and my fairly run-of-the-mill symptoms as a psychiatry case. Helps keep things in proportion.

Psychiatry, of course, remains a body of knowledge defined by exclusion.

You note the fear and the breathlessness, rule out PE or APO and any of a dozen other acronyms, and what you might have, eventually, is panic.

You note the slowed movement, the depressed mood, the lack of energy, rule out hypothyroidism, each of the eleventeen separate causes of anaemia, you might end up with depression.

You note the irritability, the racing thoughts, the psychomotor agitation, the patient's barely concealed fury at what is in his or her way, rule out thyroid storm or the possibility that any of many drugs – licit and illicit – have turned against you, and you have mania.

So, you progress by exclusion. The mistake that could and often is made here, by junior ED doctors (and from the contemptuous expression on his face, the ICU registrar the morning I was extubated) is to consider this sequence to be a hierarchy of gravity, from the most grave to the least, rather than a simple diagnostic process. It is not that we exclude the most serious illnesses first, and in the end are left with merely the psychiatric illnesses.

The most disabling of the psychiatric illnesses, what our American readers would call the major league pathologies (schizophrenia, unipolar and bipolar depression, the more prominent of the anxiety and eating disorders)… they hurt. I would much rather that, say, a thyroid disorder was causing my patient (or me) to hear voices and to feel the thoughts of the women next door radiating into her bones than to have that caused by schizophrenia.

Surgery, by the way, has close to 100% chance of curing hyperthyroidism. The psych nurse attending me today has a scar across her throat, ten centimetres long. This suggests almost certainly a partial or total thyroidectomy. Surgery is less successful in the treatment of psychosis, although in untreated psychosis the incision may be similar.

And one last thing, something I am writing down so that I can remember it later and say "This is how depressed people think". A day or so after I arrived at Clearwater I was having lunch in the dining room, and I saw the Christmas tree was still up - a tinsel tree with a few gaudily wrapped packages underneath it. The packages were still there, although by that time I had worked out it was a few days after New Year.

"Why haven't the children opened their presents?" I asked myself.

"The children are dead" I said.

And I had to sit there and reason out that there were no children, that there was no evidence that any children had died, that it was just one of several squillion left-over Christmas decorations around the globe.

So. That is your brain on olanzapine, valproate and inadequate amounts of several key neurotransmitters.

Thanks for listening,
John