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Healthy Beginnings for a New Psychiatrist

Healthy Beginnings for a New Psychiatrist


During the first year of my child and adolescent psychiatry fellowship, I received an invaluable lesson regarding the importance of “treating the whole patient.” I was assigned to complete an inpatient rotation on the Child and Adolescent unit at the UCLA Resnick Neuropsychiatric Hospital. I had heard from my peers that this rotation was emotionally and intellectually challenging, given the acuity of the patients on the unit. However, I was greatly looking forward to having a chance to provide psychiatric care to children, adolescents, and their families in their most vulnerable time. Little did I know, a patient I would care for would teach me the significance of the therapeutic act and about the many ways to support a patient. I would also learn that being a good psychiatrist means incorporating the skills of other medical disciplines; essentially, being a good psychiatrist means being a good physician.

Sarah was a 16-year-old female who was admitted to our unit following an argument with her family. The argument had culminated in Sarah threatening her family members with a hockey stick. According to Sarah’s mother, this was seemingly out of character for her daughter and it readily became apparent Sarah was distrustful of others’ intentions toward her.

On initial examination, the patient was agitated, and her thoughts were notably disorganized. She eventually revealed she had been hearing voices that were making derogatory comments about her. Sarah also described seeing bugs on her skin and having a sensation that bugs were in her mouth. Understandably, this was disturbing to her and she asked for a cup in order to spit the bugs out of her mouth. She proceeded to fill several cups with saliva. Sarah and her family clearly had a lot to contend with. It was also revealed that Sarah was four and one-half months pregnant.

Sarah was initially distrustful of staff and, despite my best effort, I was also not to be trusted. I was able to learn that the patient knew she was pregnant and was ambivalent about having the child. A lengthy discussion ensued regarding how to best treat Sarah, given her unborn child would also be exposed to antipsychotic medication treatment. We were concerned for the safety of the baby, given Sarah’s level of paranoid agitation. With guidance from an experienced and knowledgeable supervisor, review of the primary literature regarding successful treatment of psychosis in pregnancy, investigation of the safety profile of antipsychotic medications in pregnancy, consultation with the obstetrics service, and discussion with Sarah’s mother, it was decided that Sarah should be given an atypical antipsychotic to treat her psychosis. I spoke with Sarah and her mother regarding treatment options, and following this discussion, Sarah and her mother agreed to treatment.

Sarah began to respond to the atypical antipsychotic medication, becoming less guarded and beginning to open up regarding her life before coming to the hospital. She also began to talk more of her pregnancy and the circumstances surrounding becoming pregnant. I would like to think Sarah’s increased trust in me had to do with my consistency in providing empathetic and supportive interactions. I don’t doubt the importance of this approach to Sarah’s care; however I can’t be sure how much the atypical antipsychotic medication helped to facilitate development of the relationship, as Sarah was becoming more trusting of others as well.

The patient’s thoughts were becoming clearer and her auditory hallucinations were reduced in frequency and intensity. Despite her improvements, Sarah continued to carry a sippy cup with her around the unit in order to have a receptacle readily available in which to spit out the “bugs.” Sarah explained she didn’t feel nauseated and she had not been spitting out bugs before her pregnancy.


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