Posts Tagged ‘mania’

Shared delusions and eggs over easy

April 25, 2018

It’s called a folie a deux

When delusions are shared by two

Or possibly more

But who’s keeping score?

When our breakfast we’re trying to chew.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, and a friend’s funeral, I have returned to British Columbia.  Any identifiable patient information has been included with permission.

During my work time here, I get housed in a hotel a short kilometer walk from the clinic. The accommodations comprise what amounts to a 1 bedroom apartment.  We have a small kitchen, a stove with a real oven, and a decent-sized refrigerator.  The bedroom has a door that closes.

But the room also comes with a continental breakfast at a nearby restaurant. You can’t call the meal fancy, but we can get eggs cooked to order.

The hotel business runs light at this time of year, a far cry from last summer when one could hear loud conversations around the building all night. We haven’t had to share the breakfast room since before Bethany got here.

Today I greeted another breakfast guest as we walked in; he promptly said, “You look like an old professor.”

“I like to teach,” I said, “but that’s not what pays the bills.”

We nodded at another patron as we put bread in the toaster.

The owner by now starts my two eggs, over easy, as soon as I walk in the door.

As we sat down, the two other customers started an animated conversation, in volumes large enough to fall far from the bounds of what could be called a restaurant voice. In short order, I recognized the linguistic tells of mania (rapid speech, flight of ideas, grandiosity) for one and schizophrenia (in plain English, he didn’t make tracks) in the other.  But they found each other’s conversation fascinating.

We didn’t interrupt or join in. We just listened.

The manic customer very quickly convinced the schizophrenic customer.

You can find bipolar disease at the same frequency in every population in the world. My opinion runs something like this: in the manic state the bipolar functions as an irresistible leader with an uncontrollable libido.  He or she can convince the group to go places where, literally, no man has gone before.  On arrival, that person leaves a disproportionately high number of offspring with the same propensities.

At the restaurant, I listened to the founding of a folie a deux. Where insanity usually runs a solo game, a folie a deux relies on a two person delusional system.  Such cases notoriously resist treatment.

But I did not serve as their physician and thus cannot claim them as patients. They spoke loudly in a public place.  And, after all, such a scene almost certainly played out in more than one venue today.

So I can write about it. Rules of confidentiality do not apply.



Learning to say no, but still saying yes.

June 4, 2011

My maturity is starting to show

I tell you I’m learning but slow

     If the patient’s deranged

     Their mind can’t be changed

But I’m starting now to say no.


Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to dance back from the verge of burnout, I’m having adventures and working in out-of-the-way places.  Right now I’m living in Amberley, and just finished working a four-week assignment in Waikari, less than an hour from quake-stricken Christchurch, in New Zealand’s South Island. 

I worked this last month so the regular doctor could go back to the UK to get married; I wanted to leave an orderly desk so I arrived early.

The office staff booked me light for my last day.

In midmorning a patient came in for the first time since November requesting prescription refills.    When a person has press of speech, flight of ideas, over-detailing, and tangential associations, the differential diagnosis (the list of possible diseases) narrows down to mania, hyperthyroidism, and abuse of drugs like speed.  I told the patient my concerns, politely declined to renew his prescriptions, and sent him across the hall to get his blood drawn.

After lunch I stopped at the hospital on the way back to the clinic.  I signed off medications and drew blood.  The charge nurse told me there’d been a glitch in getting a patient transferred from Christchurch, and wouldn’t I be happy to do the admission?

I firmly and politely declined twice, but third and fourth time I said no I quit smiling.  So, she asked, should I phone them and tell them not to send the patient?

I wrestled with that one.  I could have succumbed to the guilt tripping.  But I didn’t.  I nodded.

Even though with the long holiday weekend, the Queen’s Birthday and all, she won’t get here till Tuesday?

I nodded again, and this time I smiled.

The afternoon went well.  I had breaks between patients.  The last person had eye irritation from a phlyctenule (she gave her permission to use this information).   I’ve written before about this rare eye disorder that comes from an infection in another part of the body.  I explained the problem, phoned the ophthalmology resident in Christchurch and wrote a prescription.

I had my computer shut off, my coat on and my hand on the doorknob when the receptionist stopped me with a message from the patient whose refills I’d declined.

I had a bad feeling about the call, but said yes.

His already rapid speech had accelerated; he made his anger clear, and held me responsible for his problems.  I walked across the corridor to the nurse and held the phone up so she could listen to him ramble.  After two minutes of non-stop diatribe, on her advice I said, “If you don’t let me speak I’ll terminate the call.”

Never argue with a crazy person, a drunk, or a woman in labor.  Pointing out logical inconsistencies to a person out of touch with reality does no good.  After interruptions and threats to ring off, I pointed out that he could talk to his regular doctor next week.

By the last minute of the conversation his mood had changed to friendly, he wished me well six or seven times.

I added unstable mood to the list of findings, but it didn’t help me make the diagnosis.

Bipolar disease unmasked by the Christchurch earthquake

May 3, 2011

When the ground starts to tremble and shake

The people and buildings might break

     And after the panic

     A soul could go manic

In the aftermath of a big quake.

 Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical and backing from the brink of burnout, while my one year non compete clause ticks away, I’m having adventures and working in out-of-the-way places.  Currently, I’m working in Matakana, on the North Island of New Zealand.

This weekend Bethany and I took a road trip north from Matakana.  Our first stop, to Bennett’s chocolate factory in Mangawai, left us euphoric.  We visited David and Ursula, who live in the area.

An electrician, David has helped a great deal in Christchurch since the earthquake on February 22.

The familiar news photos show the destroyed central business district, and fail to depict the drama and irony of the day-to-day human situation.

The temblor cut communication to the eastern suburbs; telephone, electric, sewer, water, everything.  Flying his own helicopter at his own expense initially, a local man delivered load after load of hot food to parks until the Red Cross took over (some would say they didn’t do as good a job).

Disposal of waste became an immediate problem.   Portaloos got shipped in by the thousand, but the limited supply meant some people faced a walk of a kilometer.  Fights broke out over access to basic facilities. 

Two plumbers in their early 20’s sat down in a garage, and in the course of an evening figured out how to turn five gallon (twenty liter) plastic buckets into toilets at a cost of $20 each, assembling jigs and putting together instructions.

David and his son James were asked to help with the project, mainly with obtaining the money required (by way of donation) and the organisation of the production of the emergency toilets.  In the process of assembling 4800 of the devices, David has made a few trips to Christchurch and has a lot of observations about what really happens on the ground in the wake of a disaster.

Many people have quit the city, some forever; some have left the country.  Rebuilding will require more than ten years.  Earthquakes pose immense technical barriers to sewer, gas, and water service. 

And the earthquakes haven’t ended.  Aftershocks of 5.3 on the Richter scale continue, robbing the night of peace and stealing rest from the inhabitants.  You can see it on their faces, he said, and some have snapped.

He described a woman who abdicated all accountability to her family and now flies around the country with no particular goal.

I said, “She starts a sentence, and by the time she finishes you’ve lost track of what it was she was trying to say.” 

David got a strange look on his face, as if to ask if I’d been in the room.

“In the business,” I said, “we call it press of speech, flight of ideas, and tangential associations.”

“You’ve just described her to a T,” he said.

I turned to Bethany.  “What’s your diagnosis?”

“Bipolar disease, manic phase,” she said, and grinned.

Avoiding pedantry, I let Bethany do the talking.  By now she has acquired an immense fund of knowledge by watching the disease progress in so many people.

A wave of mania and depression, and uncovering of bipolar disease, in the wake of severe stress followed by sleep deprivation, makes perfect sense to me.

Ursula said, “And compared to Fukushima, can you imagine what they’re going through?”

For David, the work in the disaster area has been a life-changing event; he and Ursula agree he’s a lot easier to live with.  “He doesn’t sweat the small stuff anymore,” she said.  “It puts things into perspective.

 My thanks to David for his help with this post.

After a bad Christmas on call.

December 27, 2010

While the snow outside piled deep,

Inside sometimes I’d sleep.

      But through the thin and the thick

     The people came sick,

To laugh, perchance, then, to weep. 

If you want to make a psychotic rat, you put EEG (brain wave) electrodes on it, wait till it gets to rapid eye movement (REM, or dream) sleep, and wake it up by ringing a bell. 

Christmas call did not go well.  I felt like a rat in the psycho experiment.

With reasonable volume and intensity the pace stayed steady through the night, and every time I got to REM sleep the phone went off.  Ripped from very pleasant dreams, time after time, I drove through the bracing cold the half mile to the hospital.  With one exception, the patients were sick human beings who just wanted to get better, and who had come at the right time.  I can look for no one to complain or whine to; my job snatched me from sleep’s warm and healing embrace so many times that I gave up and slept in the call room at the hospital.

Most hospitals have one place for doctors to sleep, and another for doctors waiting for a baby to deliver.  Van Buren County Hospital has both; the better room, called the ‘Doctors’ dictation room,’ near the inpatient nurses’ station, has a refrigerator, sink, and shower.  Nicer by a  long shot than the studio apartment I lived in my senior year of medical school, the mattress there provides the foundation for a good night’s sleep.  I just didn’t spend enough time on it.

My fellow human beings in distress kept seeking my training and experience so that they could feel better.  I can write about things in general without writing about people in particular.

For two of the pediatric patients I worried more about the parents than about the kid.  For another patient, inherent stubbornness provided more of a challenge than the diagnosis.

I had to dialogue with the sheriff about another patient.  After I certified neither a danger to self nor others, the sheriff made sure the person got to the other side of the county line and notified the next agency.

Three quarters of the work came from the destructive influence tobacco smoke has on human tissue. 

One quarter of the time apparent alcoholism served as smokescreen for the real problem. 

Our CT machine stopped working, won’t be functional till tomorrow, and I had to send a patient up the road to Fairfield. 

When a person comes in with press of speech (talking fast), flight of ideas (giving voice to racing thoughts), and tangential associations (can’t keep track of what they’re talking about), only four diagnoses come to mind: hyperthyroid, cocaine use, meth use, and mania.  But that person hadn’t come to see me, rather to accompany the patient.  I made the recommendation to check with their habitual doctor and ask for a thyroid test.

Putting pressure on a wound stops the bleeding almost always; elevating the bleeding part above the level of the heart speeds the process.

Shortly after a human being turns into a man, stupidity takes over and only slowly releases its grasp, if ever.    

The accumulated sleep deficit has piled up since Thursday.  My appetite control has evaporated; carbohydrates lurk near me at their own risk.  (See my post entitled Rage, Hunger, Lust, and Sleep.)

I’ve fallen asleep twice at the keyboard since I started this post.  Good-night.

Three bipolar patients, two of them out of control

April 21, 2010

I have a story I’ll tell

Bipolar depression is hell

     I’ll justify panic

     If the patient goes manic

And I might prescribe Seroquel


Back from four days in Florida, a mini vacation, and I’m feeling wonderful and well rested.

Care Initiatives Hospice will graduate another patient; removing Seroquel from the medication list has done a world of good.

Seroquel does well for certain phases of bipolar disease, but not so well when used, way off label, in the elderly who flip out and hit the people. 

The makers of Seroquel brought  a very good speaker to Sioux City a few years ago. They paid for a fine meal and drinks at Bev’s On The River, one of Sioux City’s four upscale restaurants.  I abstained from the drinks, and I listened and learned a great deal about bipolar disease from the lecture.

I prescribed Seroquel a lot right after that talk.  Since that time I’ve used Seroquel less and less, in favor of some of the older seizure drugs like Depakote and Lamictal.  I use lithium as a last resort.

Bipolar used to be called manic-depressive.  Mostly hereditary, found in all societies, it doesn’t hit any particular group harder than any other.  I’m not convinced of the accepted division between the more severe form, Bipolar I, and the less severe form, Bipolar II; I think of the disease as a spectrum.

During the manic phase the patient feels great.  They don’t need much sleep, they get a lot done.  But they engage in a lot of risky behaviors like gambling, drugs, drinking, and promiscuity.  They spend a lot of money and they tend to delocalize geographically.  Sometimes they lose contact with reality and become psychotic.

In the days when I hitchhiked I got picked up by a lot of manics.  In 1971, I rode from one end of Kansas to the other with one person who talked so fast I couldn’t understand him.  About every fifteen seconds I had to say “Yeah” to prove I was listening but aside from that I couldn’t get a word in.  He grew hoarser and hoarser till he let me off in Julesburg.

Those who cycled into mania have a lot of regret afterwards.  Having to have a spouse bail out your credit card debts every seven years is bad, but not as bad as having to come crawling back to your spouse after a six-week affair, or explain to a judge why you alone survived a suicide pact. 

The depressed phase of bipolar illness sinks the patient to the bottom of the blackest pit.  Partly the patient has tremendous remorse, seeing what a mess they’ve made of their lives, but mostly the biochemistry of their brains lets them down.  The majority of suicides turn out to have been bipolar. 

But the Seroquel speaker made me more sensitive to the less severe forms of the disease.  My touchstone question is:  “Have you ever had an episode lasting at least four days when you felt great, got a lot done, slept less than four hours a night, and didn’t miss the sleep?”

An awful lot of depressed people turn out to bipolar, and need to NOT be on SSRI’s like Prozac and Lexapro.  The tend to do much better on seizure drugs than on antidepressants, and a lot of epilepsy pills have been approved by the FDA for use in Bipolar I and II.

Vitamin D deficiency, a recurring theme in this blog, turns out to be very important in both seizures and bipolar illness.

This morning I saw three Bipolar I patients.  One takes the prescription as directed and the others don’t.

The one spent more years hospitalized than not till a psychiatrist started the patient on Depakote twent- five years ago.   After coming to terms with a disabling disease, the patient rejoined a strong social structure.  Generally coming in every year to get some blood tests, the patient hasn’t needed hospitalization for a very long time

Another patient readily admitted missing doses two or three times a week, and asked for something stronger.  After a bit of consideration we agreed that forgetting to take a more powerful pill brings the same result as forgetting to take a less powerful pill.

A third patient, smiling, was very up front about not taking the medication.  He was pleasant, and told me how great he was sleeping, awakening feeling rested an hour or so before the alarm went off.

Those last two patients were cycling into mania.  Telling them they’re not thinking straight does no good, though I told them anyway.  Then I told them they needed to take their prescriptions as directed.

I didn’t argue with them.

Never argue with a drunk, a crazy person, or a woman in labor.