History and Physicals:

Journal Article Summary:

For my site visit, I presented a journal article on the impact of COVID-19 on mental health functioning in adolescents, specifically those with a prior diagnosis of ADHD. I had a patient that was displaying increased impulsivity and even oppositional defiance for the past year and half, and I wondered the impact that COVID and social restrictions may have played into the change in behavior seen with him. This article shows that COVID-19 and the following stay at home orders and public health recommendations have been very impactful on adolescents and have increased the emotional dysregulation and conflict at home. Out of the patients studied, there was a significant increase in depression, anxiety, inattention, and oppositionality/defiance symptoms in these adolescents during COVID. For most, symptoms generally returned to baseline in summer 2020, but those who had poor emotional regulation prior to the pandemic were more likely to retain those symptoms for a longer period of time. I found this to be very interesting as it seems very applicable to the patient I was working with. It seems he already had struggles with emotional regulation before COVID, and the increased time at home and therefore increased opportunity for family conflict led to a dangerous outburst. Knowing patterns like these and being able to recognize them allows us to better treat these patients and create strategies to prevent these things in the future. In my patient, working on better methods to regulate his emotions and deal with conflict is critical for him, and would hopefully reduce the need for a change or increase in  medication.

Site Visit Summary:

I really enjoyed our psych visits as I felt we were able to see a variety of psychiatric conditions and really dig into the differentials and treatments that fit best for our patients. I presented on a 33 year old female who came in with suicidal threats. She had a  history of polysubstance abuse and self harm in addition to currently feeling depressed and anxious. Her history of the events that led to her admission to CPEP was remarkably different from her boyfriend, and it left me wondering the full truth behind all the events. I enjoyed this case because it really required me to evaluate the patient to determine what I thought was going on currently with her. I ended up deciding on borderline personality disorder, due to a history of emotional lability, impulsive behavior, and self-destructive actions like the suicidal threat that led to her current admission. Additionally, the patient displayed a history of impulsivity as showcased by self harm and polysubstance abuse in the past. The one thing I really learned from this case is that while one diagnosis may be the best fit, there is often overlap in conditions. In her case, while I feel the major diagnosis was borderline personality disorder, there was also likely comorbid major depressive disorder in addition to some anxiety. It helped me realize that a lot of psychiatric conditions are comorbid with each other, and it’s important to consider how those play a role in a patient’s presentation. Additionally, it impacts the medications we choose to treat our patients. In this patient, I opted to choose an SSRI like Lexapro that would provide relief for both depressive and anxious symptoms, in addition to CBT or dialectical behavior therapy. On top of that, it was critical for her to maintain sobriety. The goal is that all of these treatments would work together for the various complaints she currently had. It helped me realize the need to treat the whole patient and all the factors that play into their current condition. Dr. Saint Martin really pushed us to understand the why behind our treatment choices, which I appreciated. One thing my site evaluation really made me think further about is the reasoning for admitting patients involuntarily, and the effects that can have on patients by removing their autonomy. Psychiatry is different from many other fields because you can hold patient’s involuntarily, and it’s important to be judicious with that. He really pushed me to further question when that should happen and why.

Typhon Case Log Totals:

Reflection:

This psychiatry rotation was unlike any of the previous rotations. It was a completely different type of medicine to try to practice. The history was so much more important, so much more in depth, and always supported with collateral information from another source. The physical, which I was used to being so critical, fell more to the background as the complaints are not visibly physical in nature. It was difficult for me at first to adjust to this different perspective in medicine, but I absolutely loved it. I think it helped me better evaluate patients as I’m taking the history. It forced me to begin looking more at the mannerisms, the behavior, the affect of the patient, the speech of the patient, the words (or lack of) that they used. Instead of just taking a history and trying to develop a timeline, I learned to do that while also assessing the patient. It really pushed me to be a better interviewer in addition to a more observant interviewer. There is so much to be learned from a single interview, especially in a psychiatric setting. It’s critical to appropriately evaluate the patient as you interview, and this rotation pushed me to really become better at doing that. The mini mental status exam is something that I want to continue to think about and keep in the back of my mind as I’m dealing with other patients. I found in this rotation that often patients present to the MER with a complaint but there’s often a bigger underlying psychiatric issue present. Or, alternatively, they appear to be psychiatrically unstable but they’re really just suffering from acute delirium and need to be further medically evaluated. It was a huge learning curve to become better at interviewing and being able to evaluate psychiatric complaints, but I think I improved a lot in these things throughout my 5 weeks in psychiatry.

Related to interviewing, one type of patient I found to be particularly difficult were patients that were poor historians or those with an incoherent narrative. Oftentimes, I would have patients that were internally preoccupied and would have a difficult time providing any history. Other times, I would have patients that were acutely manic and while they attempted to answer questions, they would often continue into a new tangent or display a flight of ideas while I was attempting to obtain a history. In these types of patients, I think that’s when I really recognized how even just these behaviors were part of the history and maybe told more of the story than the actual words they were saying. Additionally, it helped me recognize how important it is to continue to follow up with these patients at different times throughout their hospital stay. While they may not be able to provide a history upon arrival, later in the day when they’re more comfortable may be a time they’re better able to provide a history.

As a result of this rotation, my perspective has changed about psychiatric patients. I have been able to see that these conditions can feel isolating, upsetting, confusing, and so many other things to the patients dealing with them. Often, it seems their actions are really their attempt to try to deal with all the things going on inside their mind. One patient that really struck me was a schizophrenic patient who told us that he believed he had a “terminal illness” and he wanted to be able to receive physician-assisted suicide as an end for his suffering. We discussed this with our preceptor Amil and talked about the autonomy he has in this situation, and if he should be able to seek suicide if he feels other treatments have been exhausted and he has lost hope. I think this patient really helped me see how chronic and debilitating an illness like schizophrenia can be, especially when the treatments don’t seem to change the course of the illness. It also helped me think further about the need for patient autonomy, and what the options should be for a patient in this type of situation. 

Overall, I absolutely loved this rotation. I learned so much about psychiatry and it challenged me to think outside of the box in terms of medical treatment, because it felt like such a different type of treatment. I learned that I enjoy psychiatry and would definitely be interested in pursuing a job in psychiatry in the future, particularly with adolescents. I also further solidified the feelings I have about the importance of teaching emotional regulation. The things I learned as a teacher – including de-escalation of conflict, emotional constancy, and making sure every person felt seen and heard – were so critical within this rotation. I feel that the skills I developed as a teacher really came into play in this rotation, and I’m excited to continue to develop those skills and potentially use them in this field in the future – fingers crossed!