Remember That Drive-by Shooting?

March 18, 2015

Here's how a single question I don't normally ask changed the course of one patient's life. The story highlights how widespread the effects of violence are.

Allan Tasman, MD | Editor in Chief

[[{"type":"media","view_mode":"media_crop","fid":"33102","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_6103070339869","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3486","media_crop_rotate":"0","media_crop_scale_h":"76","media_crop_scale_w":"150","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image"}}]]This month we present a Special Report on violence, which reminded me of a clinical experience I’ve talked and written about in other places, including Academic Psychiatry.1 I’m repeating it here because for me it highlights how widespread the effects of violence are. Sometimes we see the effects but we don’t recognize them for what they are.

Some time ago, I was asked to see a patient who had been followed for several months in our teaching clinic by a staff nurse practitioner and one of our best residents. The woman was not improving. Everything I’m about to report transpired in a 15-minute precepting period in our clinic

I was told that this single mother in her mid-30s with a full-time job and 2 kids met the DSM diagnostic criteria for an acute-onset paranoid delusional disorder. She had developed a fixed belief, which completely preoccupied her, that someone she didn’t know was going to break into her house during the night and kill her and her children. She was spending several hours each evening, after putting her daughter and son to bed, checking the locks on the doors and windows of her single-family home. No matter how many times she checked, her anxiety and fear were not allayed. She had no evidence of medical illness, substance abuse, or history or symptoms of any other psychiatric disorder.

An atypical antipsychotic had been prescribed for this woman. The dosage had been gradually increased over the past several months, without any positive effect.

After hearing her history, I interviewed the patient with the nurse and resident-as is our usual practice. I was immediately aware of this woman’s ability to relate to me in an emotional and personal way. I found this surprising in a woman who was diagnosed with a paranoid psychotic disorder. I decided I’d better shift gears and go back to the start to see if I could understand the precipitants of her symptoms.

I asked about changes in her family, her work, or some other aspect of her personal life. She said there had been no changes. Feeling somewhat stumped, I then asked her if there had been any changes in her neighborhood. I did not usually ask this question in those days, but as you will soon see, it is at the heart of this story.

The woman asked if I remembered reading about a 9-year-old girl who had been killed in a drive-by shooting in Louisville (where we both lived) several months earlier. I told her I had. She told me the girl who had been killed was her next-door neighbor. I felt a jolt, and said that the murder must have been incredibly upsetting. She said yes, it was even more upsetting than I might imagine because when the girl was killed, she was on the patient’s front porch playing with the patient’s 9-year-old daughter.

Everything suddenly fell into place. I said that it must have been terrible not only to lose this child in such a traumatic way, but also to be fearful that the victim could have been one of her own children, or her. The patient immediately began to cry. I asked if she had ever mentioned this to anyone, and she said that she had not because she did not think it had anything to do with how she was feeling because she hadn’t started to worry until a few weeks after the shooting.

I asked if the medication had helped her at all. She said it had only made her feel very groggy and washed out, and was interfering with her ability to take care of her children or do her work.

I told my patient that I thought she was mainly reacting to this horrible murder, and that the emotional impact on her was tremendous. I said she must be scared to death about her children and herself. She readily agreed. I told her I thought the medication she was taking was unlikely to be helpful, but that instead she needed to talk about how she was dealing with this terrible event. The patient seemed taken aback-this idea had never crossed her mind. I said I assumed that no one had asked her about this or talked with her about this, since she hadn’t brought it up. She confirmed this was true.

You can imagine how the case went from that point on. She was medication- and symptom-free within 6 weeks.

What did I do that was so different from what had been done before? Not much, but it was something that clearly turned out to be important. I used my own empathic reaction to the patient and the way she related to me was a clue to what might be going on. In retrospect, knowing she was African American and living in a high-crime area of the city sensitized me, although I had no idea until she told me that what had happened there caused her symptoms. And what I was surprised to learn allowed me to find out something about the patient that had not been discovered before and which completely changed her treatment.

What’s my point in relaying this story? It’s something we generally know that affects us all . . . but which we don’t generally think about enough. Race, socioeconomic status, family and neighborhood social structures and events, and broader societal phenomena affect our patients more than we usually have time to explore. The woman I’ve described would not be listed in a tally of victims of the violence that took her neighbor’s child-but she was certainly a victim of that violence. I’ve often wondered how many other patients I’ve seen (that all of us see) are unlisted and undiscovered victims of violence?

We have an immense problem in our country and, for that matter, in every country. Children who grow up in violent households or neighborhoods; family and neighbors who know someone who’s suffered from violence directly; the thousands of veterans who return from combat with no physical injury but who are injured nonetheless: these are just a few of a very large group of people affected. We don’t have anywhere near the resources to intervene on behalf of all those suffering from the effects of violence, but we must be sure to assess this possibility in all the patients we do see. When we identify someone who has suffered from violence (especially when that person doesn’t bring up the issue), we’ll better understand the problems he or she brings to us. And just maybe, as with the patient I’ve described here, we’ll be more helpful than we otherwise might be.

References:

1. Tasman A. Lost in the DSM-IV checklist: empathy, meaning, and the doctor-patient relationship. Acad Psychiatry. 2002;26:38-44.