Monday, January 08, 2007

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

6 Comments:

Blogger Benedict 16th said...

Good to see you back.

so does the 11 causes of anaemia include Arsenic poisoning?

10:34 PM  
Blogger Foilwoman said...

Ooh: Depression-related Christmas thoughts. I love the medieval carols: I Saw Three Ships, The Cherry Tree Carol, The Friendly Beasts. I can sing them and play them on the guitar. I was playing them and thinking of all the horrible things done in the name of Christianity in England and elsewhere in Christendom at the time those songs were sung: the burnings of the Cathars, the murders of entire Jewish communities in England, the Crusades against anyone who wasn't, well "us", etc. Those were the people who sang those songs. Yup. Cheery Christmas spirit. I'm sure there were dead children there too.

I hope you feel better soon. Despite the tone of the posts, I am very heartened that you are posting.

4:35 PM  
Blogger Juanita J. Sanchez said...

In case you ever wonder if your reflections on mood disorders are of any use: I wish I had read them in time to help a friend of mine. Your words would have made a difference, I believe that. And you never really know when you'll get a second chance. So thank you. It can't be easy.

2:51 PM  
Blogger Bronze John said...

Hail all,
Gradually catching up on these comments.

Bene' (to whom I owe a lot for recent events) - all I know about arsenic poisoning is they used to use it for make-up and it's one of those syndromes that starts with mild, vague symptoms that anyone can have, so every mild headache could be arsenic poisoning.

And I think it's one of those poisons where you can build up a tolerance to it by eating small amounts - Mithridates of Pontus style.

The only thing useful I remember about anaemia is it's a symptom, not a disease, usually a symptom of being anaemic. After that and if they aren't bleeding in front of me I run out of ideas.

John

10:14 PM  
Blogger Bronze John said...

Hail FW,
Been excellent reading your stuff too. Mention me when you get your book contract.

With regard to the Christmas thing, our Christmasses were always occasions where the whole family got together and murmured poison about each other. I went to Sarah's once and it was very different - more of the throwing of glassware and shrieking abuse at each other.

My uncle pointed out once that our (largely German) family's seasonal lunacy was completely in accord with the ancient carol "God rest ye Jerry mental men".

10:22 PM  
Blogger Bronze John said...

Juanita,
Thasnks again for this and the other of your comments. I am very sorry to hear about your friend. When the extremes of mood get someone, things like friendship, family, etc. seem to dwindle away. I do think that having supportive and understanding friends can help prevent things get too far, I know that without my friends (and I include Sarah foremost here) I would have got sicker faster and with an ultimately different result.

Anyway. Enough about me, I will go off and read other people's stuff.

John

10:28 PM  

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