Paranoid-Yes: Dementia-No!

Diagnosis, particularly psychiatric diagnoses, are history based. We have no objective tests. We have no imaging studies. We need to listen, pay attention, gather a history, and pursue collateral information. Yes, you have known me to say this for a very long time. Now, I will tell a fictional story which illustrates my point, since the fire in me pushes me to say it again. Diedre is a 70 year-old longstanding patient who has a long family history of mental illness. Her mother was bipolar. Her father had issues with alcohol. Her mother’s mother also had bipolar illness. Both her mother and her maternal grandmother had a history of long stays in psychiatric hospitals. Diedre, although high-functioning, has, what seems to be a more mild version of her mother’s illness. She does have a history of psychiatric hospitalization, but her mental illness manifests more in paranoia than in mood swings. She has long periods of time where she is quite agitated that institutions, such as the police department, want to hurt her. As a result, I have her on an antipsychotic medication, which, as she reports, makes her “much calmer”. Diedre also has a severe alcohol and prescription drug abuse problem, which she denied for many years, but she knew that I knew that this was an issue. Over a long holiday weekend, her drinking caused a change in mental status, leading to her boyfriend calling 911, and then a subsequent psychiatric hospitalization for delirium. The psychiatric team took her off her medications and she detoxed in the hospital. Although the patient told the team to talk to me, that communication never happened, so even as her mental state cleared, where she returned to her baseline paranoid ideation, the team did not re-start her antipsychotic. Instead, they interpreted her mental state as the beginnings of dementia. They administered one test of functioning, which, by her report, she was too paranoid to cooperate with the questions, so she “failed” the test and was diagnosed with dementia. This resulted in a report to the DMV stating that she was unsafe to drive. This also resulted in them insisting that she transition to a skilled nursing facility, at the cost of many thousands of dollars out of pocket, since the team did not feel she was safe to go home. When she was discharged she returned to me. I told her to re-start her antipsychotic, to return to her previous living situation, and to get private cognitive testing in order to have documentation for the DMV. As expected, she has no evidence of dementia, and although the hospitalization was very helpful in starting her on a sober life, the increase in paranoia was tragic to observe. Histories take a long time to understand. Quick diagnoses are not only wrong, they are harmful. There is a fire in my belly.

Brain Plasticity

Schizophrenia is a problem with brain mapping, so says Sophia Vinogradov MD, a psychiatrist from UC San Francisco. As such, cognitive enhancing programs might, and she said might at least twenty times during this one hour Grand Rounds, improve the outcome of this dreaded disease. She reminded the audience, filled with psychiatrists, that it was only twenty years ago that we were all taught that the brain stopped changing somewhere around age fifteen. Now, we know that the brain changes throughout one’s lifetime, albeit at different rates of change as we age. Learning, she reminded us takes place with repetition. I think we all know that! More specifically, she taught us that the first time we learn a new skill, we are tentative, but with intensive repetition, that skill, like playing scales on a piano, becomes automatic. I think we all know that too. This automatic quality to a new skill is evidence that we have created a new “brain map”. As such, we can train our brain, if we apply intense repetition, to form new neural connections, and hence new skill sets. Little children, it seems to me, need less repetition to develop new brain maps, and hence their brains are more plastic. Aging, in other words, demands from us that we have to work harder to acquire new ways of thinking, but the good news, is that we can expand our brain, literally. Phew!

 

http://www.psychiatrygrandrounds.com/namedlectures/may.html

The First Smile: 14 Years Into Treatment

   Lilith, sixty-three, has seen me for fourteen years, since she was 49. At that time, she was convinced that every police car was after her to arrest her for a crime, she was not sure she committed, but she was certain she would be arrested. At a younger age, Lilith dropped out of medical school because the voices were intolerable. She never used drugs or alcohol, she says. She had a history of multiple psychiatric hospitalizations in her twenties. In the fourteen years that I have seen her, she has held a job, isolated from most people, and paranoid, particularly about the police. Her medications have not changed. She remains on typical psychotic medication, at low dose. She is compliant with her regimen, as she says, “it makes me less concerned about the police.”

    Normally our sessions are heavy. Lilith looks to me to reassure her that the police do not want to arrest her. She says she knows, but she likes when I say it too. Astonishingly, on a recent visit to see me, which is almost always when she is feeling particularly anxious, I saw Lilith smile. “I have never seen you smile before,” I say to her, recognizing that we have never had a relaxed feeling together. “My life is so much calmer now. Maybe it is because I am getting older. Maybe I just don’t think about the police as much, but I just feel more comfortable,” Lilith explains in a way that we have never talked before. “Did anything change with your medication?” I ask, wondering if she increased her medication without telling me, even though she has never done this before. “No, I just feel that getting older has made me more relaxed,” she says, with  insight into her condition, which she demonstrates intermittently. “It is certainly nice to see you smile,” I repeat as a result of my surprised feeling. “Yea, life is better,” she says with a lightness, so uncharacteristic of our previous visits. I wish I could say I could see this coming, or that I understood why her paranoia subsided, but I can’t. I am just happy it did.