What if someone with “prescriptive privileges” looked at superficial symptoms only, and ordered antipsychotics without considering the bigger picture?
Everyone’s mother reminds them to wear clean underwear (well, almost everyone’s), but I doubt if anyone’s mother tells them that clean underwear will save their lives. Yet that is exactly what happened in New York City quite a while ago. Let me tell you that story so that you can see for yourself.
Many, many years ago, a large hospital stood in the center of Greenwich Village. It was Saturday night, and my turn to cover the ER. The Village was still “the Village” back then, filled with artists and poets and flooded by tourists and transients.
As I rushed to the psychiatry section, which consisted of 2 little rooms in the corner, the neuro resident grabbed me. He pointed toward a gurney in the center of the medical section. “That one’s for psych,” he announced. “Probably a chronic schizophrenic. Needs to be admitted.” Then he waltzed away, not to be seen again until the next day.
A young man stretched out on the gurney. He was making a ruckus, but was making no sense whatsoever. As I moved closer, I saw some nicks on his knuckles, but he was moving all extremities and did not appear to be in pain. There were scrapes on his forehead, which I presumed to be the reason that they called neuro first. A nurse was still holding the chart. She looked up and said, “Tox screen negative. Vital signs stable. He’s been here for hours. Time to move on.”
Drugs were the first suspects when it came to bizarre behavior, especially on a Saturday night in the Village, but the negative toxicology screen lessened the likelihood. No history was available, except for a brief note left by the police in the squad car who found him sitting on the sidewalk, shouting.
In New York City, in those days (and maybe even today), there was no shortage of individuals with chronic schizophrenia who wandered the streets or stumbled into the ER. Still, no reasonable doctor posits a diagnosis without some sort of exam. Ordinarily, one starts with a history, but we had no history. All we had was what we saw (or heard). So I listened to the patient, as he spoke like a character from Lewis Carroll’s Jabberwocky.
Something didn’t make sense, but that something went beyond his lack of sentence structure. It was his clean underwear. His crumpled clothes were piled beneath the gurney, his body covered by the obligatory bed sheet. When he kicked off the sheet, his clean white underwear was in clear sight.
His speech had no meaning, but his grooming said a lot (as it always does). It said that he was conscientious enough to find clean clothes that morning. Schizophrenics who speak in word salads do not have such habits. Besides, his nails were clean and cut-not a typical trait of a street person. He made eye contact when I spoke, not menacingly, as sometimes happens with patients in psychotic states. I couldn’t call him by name, because he had no name. He arrived without a wallet. The unnamed man struggled to respond, but his efforts failed. He spoke louder and louder as I looked more and more quizzical, but he did not speak in sentences I could understand.
Not ready to write this off as psychosis, pure and simple, I opted for aphasia testing. I asked him to raise his right arm. He complied. I asked him to blink. He blinked. I told him to hold up 2 fingers, then 3. He did exactly that, making no errors whatsoever. When I asked, “What is this?” as I pointed to my eye, he tried to answer-but coined a nonsense word instead. That quick bedside test suggested expressive aphasia!
I scurried to find the senior ER resident, who perked up when I shared the specifics of aphasia testing. In what seemed to be the blink of an eye, he had the patient whisked off for a CT scan, where a bleed was confirmed. Just before dawn, the neurosurgery team evacuated a growing subdural hematoma. By the time we made rounds in the morning, we heard that John Doe’s family had contacted New York City police because he was missing. They said that he and his frat buddies were spending a long weekend in New York City. Together, they hit the town. Then he disappeared.
A medical degree isn’t needed to know what happens when tourists “hit the town”-although a little ER experience drives the point home. Greenwich Village was dotted with bars, some of them immortalized by literary icons, such as Norman Mailer and Dylan Thomas. Some were just dives. There were jazz bars and blues bars, gay dance bars and piano bars with torch song singers.
The buddies appeared well after my ER shift had ended. At morning rounds, when we reviewed the events of the evening before, the report said that they confirmed that all 3 went out drinking on arrival. Their pal-our patient-had staggered and stumbled, fell to the ground and hit his head, but rose up again, as if nothing had happened. Hence, no action was taken at the time. The neurosurgery service reported that the patient was doing well and was expected to recover.
It all made sense in retrospect. Subdural hematomas are high on our list of differential diagnoses. They are nowhere near as common as chronic schizophrenia, but identifying their presence, and acting on that information, can be lifesaving and can prevent permanent damage.
The friends and family did not know that subdural hematomas bleed gradually, sometimes taking months before their size increases enough to put pressure on the brain and change behavior. In this case, the bleed was still circumscribed and caused expressive aphasia alone.
It’s always fun to reminisce about good cases. I can’t help but think of the present and the future, when many think that psychiatry is all about writing prescriptions and practicing psychopharmacology. In this case, it was the medical differential diagnosis that made the difference. As psychiatrists, we rotate through neurology. We get certified by the Board of Psychiatry and Neurology (and not by the nonexistent board of psychiatry and psychopharmacology). What if someone with “prescriptive privileges” looked at superficial symptoms only, and ordered antipsychotics without considering the bigger picture? By dawn, the patient would have been dead.
I confess: the real lesson is not about clean underwear and doing what mother tells us. Clean underwear was simply another sign to consider while evaluating the total patient. The real lesson concerns differential diagnosis, the mainstay of medical practice. This case highlights one more reason why psychiatry is a medical subspecialty and why prescriptive psychology misses the mark.
Dr Packer is Assistant Clinical Professor of Psychiatry and Behavioral Sciences at the Albert Einstein College of Medicine, Bronx, NY. She is also in private practice in New York City. She is the author of Superheroes and Superegos: The Minds Behind the Masks (Santa Barbara, CA: ABC-Clio; 2010) and several other books, for which she receives royalties.