Wednesday, October 12, 2016
Making of a Child Psychiatrist: (50) Training in Psychiatry (3)
In the paper written by Irving Kreeger about assessment of suicide, he had made the point that all psychiatrists needed to have the ability to make an accurate formal diagnosis, particularly related to the possibility of psychotic depression (meaning the endogenous depression often associated with bipolar illness), and noted that depressed suicide attempters are often at grave risk, but on the positive side often have a rapid response to physical treatments. He then explored the range of suicidal motivation from the ‘cry for help’ through to a confirmed wish to die, noting that if the cry is not heard or appropriate action or safety precautions not taken, our patients can further lose hope and end up at increased risk. He noted other reasons for suicidal thinking in the patient, including self-punishment for perceived wrongs, but also the urge for revenge for the perceived or real wrongs of others, suggesting the power of the immediate family environment which may be a resource for good or may repeatedly exacerbate the problems.
From the perspective of doing the best for our patients he advised the need to develop good rapport, noting that our own unconscious response to a patient may affect the therapeutic alliance. He went further suggesting that if we are not aware of our own prejudices, or become irritated easily or by a particular type of person, we need to constantly re-examine our own thoughts, feelings and motives if we are not to make things worse.
I had had continued to be troubled by my experience over a year before as a casualty officer treating the man who self-injured. I had not been able to put my concerns into a language or context, and remained very troubled by the memory of the registrar who had smilingly demanded I sew John up without anaesthetic. Irving’s paper gave me the language and ideas to begin to think it through.
This was all confirmed by some research by Steven Greer who was a senior registrar and reader in the Department of Psychiatry. Steven had been trained in medicine in Adelaide, Australia, coming to Britain in 1957 to train in psychiatry at the Maudsley. His position was a joint one, shared with the King’s Professorial Department of Medicine, where I had completed my second house job, and had an interest in psychological aspects of physical illness. He was a delightful person, and a good teacher, but it was two of his pieces of research into suicidality that grabbed my attention.
The first was a retrospective study of all patients surviving possibly lethal attempts over two and a half years, and referred to King’s Casualty – before my time, but intriguing given I had later worked there. Published in 1967, the paper suggested that how professionals treated people after an overdose, might predict subsequent survival. The second paper was a prospective study of 204 self-poisoning patients coming through King’s casualty in the first six months of 1968. Even though the paper was not to be published until 1971, Steven was currently engrossed in this work, and discussed early findings and implications with some passion. The ultimate message was that those who had accepted psychiatric care did significantly better, with fewer repeat attempts and deaths. Those who had been dismissed with no follow-up (22% despite official policy), or had refused care, did badly with 39% overall repeating an attempt and 5% completing suicide. The messages were clear; every suicidal person should be treated with care and not dismissed out of hand, and all should get careful psychiatric assessment and follow-up support. My casualty registrar and his attitude had been very wrong. My ‘indignation button’ had been pushed. These issues around management of suicidality have obviously simmered over the years, becoming revived much later in my own clinical and research work with adolescents.
One of the benefits of our links with the Maudsley was that, if free to do so, we could attend lectures and seminars ‘across the road’. One of the lectures I attended was given by Isaac Marks, a psychiatrist who had a growing reputation for his work in Anxiety and Phobia Reduction. As I remember it he presented some early research comparing Desensitization with Hypnosis, where desensitization came out slightly better on the measures used. I know that we continued to discuss the ideas for the next few days.
In outpatients one afternoon I met Margaret and her husband. The referral letter mentioned social phobia, and the possibility of underlying depression. She did look miserable, but as I explored her range of symptoms, there was little to support a clinical diagnosis. In many ways she was more of a recluse, limiting her shopping as much as possible and avoiding social contact and family events. The main reason for this was that she could not bring herself to smile.
In the interview, she provided brief responses to questions, and had a mannerism of drawing down her upper lip so that her teeth did not show. When eventually this became clear, and I was allowed to see her teeth, it was obvious that she had severe dental caries of the two upper front teeth, and was deeply embarrassed. She wept while her husband told me that nobody in recent years had seen her smile. This had a consequence in that it limited the feedback she received in conversation, which in turn led to social withdrawal. She had lost friends though her repeated refusals to go to social events, and spent her days ‘moping around the house’.
I asked why she had not been to a dentist to get her teeth fixed? She had tried but, apparently, on each occasion when some instrument (even just a dental mirror) had been put in her mouth, she found herself gagging and on several embarrassing occasions had vomited. Dentists had suggested a general anaesthetic, but she had refused this option. Over time everyone had given up. “So, if I were to ask to examine your throat, using a wooden spatula to just gently hold down your tongue, to get a good view, would that make you gag?” She nodded. I was intrigued.
“So how do you eat?” I asked. “What do you mean?” she responded. “Well, how do you get food into your mouth?” “Looking confused, she said: “I use a fork like everyone else…” “Ah, so you can put some things in your mouth. What about a spoon?” “Of course!” “Do you use a tooth brush?” “Not as often as I should…” “If we could work out a way of reducing your anxiety, and stopping you gagging, would you be interested in trying?” “I suppose so… Would it hurt?” “No, I am sure we can avoid that. Let me just have a discussion with my registrar.”
He was as intrigued as I had been, and we came up with a ten-week plan for treatment. His recommendation was that we use a small dose of intravenous amylobarbitone to reduce her anxiety for each of the sessions. The plan was to begin with a spoon in the mouth, first with Margaret putting it in, and then seeing whether we could get her to trust me to do it without her gagging. Each week, taking it very slowly, we would then introduce a new object – a wooden medical spatula at week three, then a metal spatula, then a week or so later a dentist’s mirror, then some dental probes. On each occasion we got Margaret to introduce the object, and then allow me to repeat the experiment. The idea was to put the process under her control, and keep the anxiety as low as we could. About half way through the program with Margaret’s agreement we stopped the injections. Somewhere about week 6, I went with Margaret and her husband to the new dental school at King’s and the dentist talked through the process that would be necessary to get her teeth fixed. Afterwards we talked about her anxiety, and then again just before the next session. A couple of weeks later, Margaret felt confident enough to agree to a date for her dental surgery, and two weeks later she turned up with her husband at the appointed time, having told me she thought she could manage without my support. My reward was a week later when she popped into the clinic without an appointment to show me the most brilliant of smiles. The process had at times been tedious for everyone concerned, and these days we would not use amylobarbitone, would not have had so many sessions. But for Margaret, the end justified the means.