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Monday, October 10, 2016

Making of a Child Psychiatrist: (49) Training in Psychiatry (2)

Betty was a faded looking elderly lady in her mid 60s. She was unable or refused to speak, and sat disconsolately in the upright chair across the desk from me. Getting a history was painfully slow with me asking questions and Betty writing her responses in an elegant copperplate on sheets of paper. She wasn’t sure how her inability to talk came about, but had woken one morning to find that she could not speak. She had had no sore throat, and there was no build-up to the problem; it was just there. She did try to mouth answers in a breathy and slightly gruff manner, but it seemed to make her angry with herself and the narrative would falter. Writing was quicker, albeit laboured.
Betty could think of no reason for her problem, but thought she could have had a cold. Otherwise she was well, with no major illnesses, and had always considered herself to be a healthy person. Her husband had died some years prior, and she seemed to have managed her grief, and subsequently living alone, well. She had one daughter who lived in Bristol and had a busy work and family life. There was also a sister who lived across the other side of London, whom she had not seen for many years. They normally caught up with a phone call once a week, but this ritual had been curtailed by her problem. She had been examined by her local doctor, and a doctor at the local general hospital, but no-one could discover or suggest a physical cause. I repeated the systems examination concluding she was very fit for a woman in later life. A registrar from the Ear, Nose and Throat clinic came up to the ward and examined Betty briefly, but could find little amiss.
At the ward round, all the staff confirmed the voice was severely limited and its quality had not changed since admission. One of the nurses had gently explored the relationship with the sister and discovered that over the years there had been discord, with a suggestion the that younger sister may have taken over one of Betty’s young male friends in their courting days.
In my next session with Betty, I began gently to explore further her relationship with her sister. There were subtle changes in the way she sat, and she did frown rather a lot – at odds with her demeanour on the ward; she seemed quite uncomfortable. I discussed this with the consultant, and he felt the most likely diagnosis to be ‘Hysterical Aphonia’. He suggested I do some hypnosis to see whether we could find out more, to which my rather gauche response was: “How do I do that?” “It’s easy,” he said “you just read a script in a quiet gentle manner, and when she is ‘under’ you suggest that on waking her voice will have improved. I’ve got a book in my office that may help. Come downstairs with me and I will find it.”
Bemused, I followed him and was handed a tatty paperback by someone called Herbert Marcuse. The book ‘Hypnosis: Fact and Fiction’ had originally been written in 1959, and this copy had definitely been well used. “So here we are, page 59. See here you just follow this and then slowly count down from ten to one. When you have finished, you slowly count back up from 1 to 10, and she will come round.”
Back in the office, I thumbed through some of the background, and prepared some ideas for the next day, writing my own short script. Betty was amenable to the hypnosis, and with the book on the desk open to page 59, I began. I could not believe the response as Betty’s breathing slowed and her head drooped, sitting in the high backed chair. Taking it slowly, I lowered my voice to read out my short speech, suggesting some ideas about the origins of her loss of voice, and about her voice returning. I repeated the last phrase a couple of times, and then began the count. After some deep breaths, Betty looked up and smiled. She nodded when I asked if she felt OK, and we closed the session confirming the next day at 10am.
Betty was still smiling when we met up next day, and in the consulting room she began hesitantly in a slightly gruff voice to tell me all about her sister and how mean she had been over the years, and how awful it felt to be angry and disappointed with your own sister. A couple of sessions later she told me how she had recounted some episode from her daily life during their last phone call, and the sister had laughed and abused her. Betty felt a surge of hatred, and admitted she had wished her sister dead. And then had hated herself. The next day her voice had disappeared. Over the next week, we discussed some strategies about how to handle the next phone call. Apparently, the two sisters had cried through the whole call.
Amazing. How could reading a script, where my patient could patently see that I was reading from the book and my notes, have such a profound effect? And how did it give her the confidence in me to be able to talk about what had happened? Me, with my obvious youth and inexperience. Thank you Mr. Marcuse.
But four months down the track, I was to learn a harsh lesson that was to stay with me throughout my professional life. I can’t remember how we got to discuss Betty, but I was told that she had been diagnosed with a laryngeal carcinoma, and the possibility of cure was somewhat remote. How was this possible? How had we missed it? How had my consultant been so confident in his diagnosis of Hysterical Aphonia?
So here is a truth. Hysterical presentations are common in younger people, and usually do not presage an organic illness. However, in anyone older than 50, hysterical presentations always have an organic basis; you just have to find it. I think I, and a large number of patients over the years, owe a debt to Betty. I have never forgotten.
Bit by bit I began to learn from my patients that anger, whatever its origins, can cause havoc with our internal world. Bottled up chronic anger can eat into who you are and destroy your life. Perhaps it is not so much the anger itself, but rather the conflict over how to deal with it. In part this depends on how we were brought up, how our parents managed tantrums when we were young children, and whether there were memorable sequelae from our being angry (for us as individuals, or for the person with whom we were angry). But there are also societal pressures against us being angry, and doing something with it.
A case in point is John who presented over a couple of months to many different doctors and clinics with a ‘useless’ right arm. He simply could not will any part of it to move; it hung apparently lifeless. It was warm and healthy, and moving it passively did not cause any problem; sensation was normal. This is unusual, in that if the problem had been organic there might have been pain, and it would have followed a specific pattern of damaged nerves to muscles that might have affected some particular movement, but not the whole arm. Everybody had agreed that this was a ‘supra-tentorial’ problem (an odd pseudo-technical way of saying ‘all in the mind’); it was not organic, it was related to John’s history.
The immediate history was that John drove vans for a living. On this occasion, he was behind a van when someone got into the driver’s seat and ,instead of putting it into 1st gear, they put it into reverse and squashed John and his arm against a loading bay. He was in pain, and felt a murderous rage toward the young driver. He physically could not act on this impulse, being squashed, but the feelings returned again and again once he had been to the hospital where it was determined he had no substantial bony, muscular or nerve damage. He was still in pain, felt that his life had been in danger, and wanted to act on his impulse to damage the driver. It was as if his mind resolved the issue by ‘paralysing’ his arm. He could not hurt anyone with his arm paralysed, but this was only conscious in part. It ran deeper than that.
Having gained this understanding over some days, we then had the problem of working out how to resolve the issue. Acknowledging John’s rage as ‘normal’ in the circumstances did little. Either the consultant or the senior registrar suggested we try ‘abreaction’, a term borrowed from psychoanalysis, meaning the reliving an experience to purge it of its emotional value, a catharsis. John’s problem was not totally unconscious, but rational discussion was just not working.
The day was planned, and two male nurses were rostered on with the registrar and I. A number of pillows were brought into the treatment room to protect both John and us from any physical reaction. John was given enough thiopentone sodium (pentothal) to make him a little sleepy, but not deep enough o be sleeping. We began to take John back through his experience, slowly examining each moment in as much detail as we could evoke, repeating the exercise until we were all clear about the feelings attached to the events.
John became more animated and distressed as we got closer to the moment he had been squashed. Again we slowed the pace of discussion to evoke maximum feeling. When we reached the moment of the accident, John exploded both verbally and physically lashing out and we had to gently but firmly hold him down while either the registrar or I took him back to that moment again and again. The storm eventually receded, with John and all of us somewhat worse for wear, bruised and sweaty – but perhaps triumphant. John slept, and we debriefed. In the cold hard light of the next few days John was able to tell his story in all its complexity but with muted emotion; the storm abated.
This was to be one of the most dramatic experiences of my first year in psychiatry. Some would argue that when you force the mind to confront such depth of conflict it can be damaging, but I was never to experience that. All I noted a week later was a man who was at peace with himself, having weathered the experience. As far as I know his arm was to not trouble him again after both he and we, the audience, had experienced and accepted his murderous feelings.

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