Jessica Jeffrey, MD, MPH, MBA

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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 

. 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 

 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 

. 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.

I was not prepared to hear what Sarah would communicate as her thoughts became less disorganized. Although she wished to remain pregnant, Sarah described the sadness, confusion, and worry she felt 

. She described feeling pressured to have sex with a friend. She did not have romantic feelings for the child’s father and, furthermore, explained he did not seem to care about her or their unborn baby. Sarah lived with her mother and several siblings in a lower income area. Although money was tight at home, Sarah felt supported by her mother. Her mother told me she would help Sarah raise her child, and had actually helped several of Sarah’s older siblings raise their children. The patient did not endorse symptoms of PTSD; however, her psychotic symptoms began to take on new meaning for me as I learned more of Sarah’s history. I could not help but wonder, “What is Sarah trying to get rid of with her spitting? Are the bugs she is spitting out symbols for her unborn baby?”

Over the course of several months, paranoia diminished. Something had shifted in Sarah during this time period. She began to spit with reduced vigor and frequency, no longer carrying a sippy cup with her at all times. Sarah also began to ask questions regarding the changes in her body during pregnancy and, although anxious, she began to get excited about becoming a mother. She also became interested in learning how to care for a baby.

I had completed my third-year medical school clerkships 6 years ago, and I did not anticipate I would have to revisit the field of obstetrics as a psychiatric fellow. Although Sarah was closely followed by the obstetrics service at the hospital, many additional questions arose for her at times in between their visits. Being Sarah’s primary provider, and having the luxury of spending time with her daily, I reviewed my medical school textbook on pregnancy and delivery. I searched for pregnancy workbooks and other materials to educate Sarah about her pregnancy and to prepare her as well as I could to help to care for her baby.

Sarah enthusiastically participated in discussions about nutritious eating in pregnancy and she was relieved to learn the body changes she was experiencing

such as increased need to urinate and low back pain

were normal in pregnancy. Together we practiced caring for a baby, and Sarah exhibited pride when she learned to place a diaper on a baby doll successfully. The patient was notably less anxious. She was preparing to be a mother, and she and her baby were doing relatively well.

Late one night I received a call from the nursing station on the inpatient ward. Sarah had gone into labor at approximately 37 weeks’ gestation. I rushed to the hospital to be at Sarah’s side for the delivery. Sarah’s mother and an older sister were also present in the delivery room, and I felt welcomed by the family. There were no complications during delivery and, although fatigued the next morning, the patient reported that she was happy and proud to be the mother of a healthy baby girl. During my assessment the following morning, I did not observe Sarah spitting-intriguing, in light of my dynamic interpretation that this symptom may represent her feelings about the pregnancy.

Sarah’s treatment required me to step out of a more traditional role of a psychiatrist and incorporate services generally provided by obstetricians, nutritionists, nurse educators, and social workers. The therapeutic act for Sarah included not only medication management and therapy, but also education and preparation for delivering and nurturing a baby.

I think of Sarah and her beautiful baby girl often. I am thankful they were both healthy on discharge and hope they may be a little more prepared for the challenges that lie ahead as a result of healthy beginnings.

The details of this case were changed in order to preserve patient anonymity.

Dr Jeffrey is a Child and Adolescent Psychiatry Fellow at the Resnick Neuropsychiatric Hospital, UCLA, in Los Angeles.

Articles

During the first year of her child and adolescent psychiatry fellowship, this psychiatrist received an invaluable lesson regarding the importance of “treating the whole patient” in this case, a 16-year-old patient who is pregnant.

Author | Jessica Jeffrey, MD, MPH, MBA

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