Paranoia

Had a mini family vacation in Houston and then it was back to work on New Year's Day. You'd have thought that would be an easy day -- no discharges, everything is closed, docs stay home, right? I did. But I was wrong. I discharged a patient, accepted a transfer and then admitted one to the PICU. And the admission required me to do a full work-up. During the week, an admissions nurse does all that work but not on weekends/holidays. But it turned out to be interesting. (Again: details changed to protect confidentiality). The young woman I admitted was having a acute pyschotic break, her first. She was taking her cat to the vet with her boyfriend and basically did what we'd call "a freak out". She ended up pushing the vet tech to the floor (nobody was hurt) and ran into the woods behind the clinic. Boyfriend couldn't get her to come out. The police were called and brought her in to us. It seemed logical to her at the time because of paranoid delusions. Paranoia is actually pretty interesting to think about. It's such a common problem in psych, I would hazard a guess that it's the number one complaint. Most schizophrenics are "P.T." (paranoid type). People who aren't psychotic, what we might call normal (I word I don't like....I mean, who's normal?) have a little dash of paranoia, I guess we call it vigilance, skepticism, mistrust.

Personally, I can recall a time in my life where I said to myself, "gee, I feel paranoid." I was working as a aerobics instructor at a gym where the ownership changed hands from  the husband to wife following a divorce. The wife then started dating one of my fellow instructors (a guy, BTW). I noticed that there seemed to be this strange little clique develop that consisted of the wife, her boyfriend, and two of the other instructors. They worked out together, went out to eat, socialized. I wasn't part of it, but I was such a gym rat that I was around these people a lot and ended up feeling very separate. I didn't particularly like them and didn't want to be included, but I also felt at times that they looked down on me and didn't like me. My instruction style was always based on safety and effectiveness - I didn't include exercises for abs, say, that I was taught weren't effective or could strain your back. I noticed that this "clique" seemed to be more about what looked cool -- for example, make your oblique exercises with big arm movements because it looks like you're doing a lot, when actually it is easier than forcing your core to do the work. Do 50 hops on one leg - nevermind that could injure your achilles. It's more imporant to feel like a badass & scream "Alright, do FIFTY!". I got the impression that they talked about my style being uncool and boring. Did I ever hear them say that? No. I think it was more when I would enter the leg room where they were all doing squats together, they'd look over at me and get quiet. It was more expression and affect, not words. Now if I had thought I heard them whispering about me, following me, and that they wanted to kill me & take my classes, well, then I guess I'd have been a psych patient. As it was, it just made me uncomfortable and I quit. But right before I quit, they reduced my schedule of classes, and I wasn't surprised. See, my paranoia had prepared me to expect that.

We went to the Better Than Ezra show at ACL Live (Moody Theatre) the night before we drove to Houston. Good show, excellent seats, but I had a very drunk and horny youngster next to me. I had to keep out of the way of her flailing limbs. She and her date would periodically make out, his hands all over her ass, tottering next to me, I just knew I would have to catch them. And to be honest, I didn't really want to touch them. A paranoid schizophrenic I'll touch, certainly, but not some obnoxious drunk strangers with no boundaries. Ha. She did kick me once. It didn't hurt.

We had a laugh at work - as I mentioned the most common type of schizophrenia is paranoid type. The unit secretary that entered my new admit's diagnosis into the system, however, didn't quite grasp that and typed it as "paranormal type". So we had a discussion about how that could make for an interesting patient. Could they move objects? Hear our thoughts? See ghosts?

I was reminded at work of the value of just listening. I had a patient, one of the read-the-chart-and-weep variety. When he was a teenager, his abusive father gave him a head injury that rendered him mentally retarded, with a significant seizure disorder, and with mental illess. He was upset because my discharge was his roommate and he really wanted to be discharged too. He started making threats about "causing trouble". I judged that he's been in the system enough to know how to create a problem and get what he wanted. But what did he want? Anxiety medication? a shot (some patients like those)? to force someone to pay attention? So I started a conversation with him, letting him take the lead and the charge nurse (someone I normally like and respect greatly) horns in to state that he won't be discharged and why. Apparently she was assigned this patient yesterday and felt the need to remind him that his discharge was delayed. Now this just served to make him more angry. I could see it in his body language and face. He started arguing back with her, and incredibly, she just got louder. She clearly wanted to be right. (and duh - of course, she's right, but who cares?) I had to give her a look (a "shut up" look) and lead him away to talk to him privately. All I did was listen, say "uh huh" a lot. He wanted to vent. We talked ten minutes and then he was fine, didn't even need a pill.

I see this often, it's got to be the most frequent staff error. People want to be right. But you just don't argue with the mentally ill. You really can't convince them that their paranoid delusions are wrong. Sometimes they are asking for information and don't like the answer - like, how long can I be held here on a protective order? Really, 72 freaking hours?! But I know basically not to get into it with them -- let them talk. Listen more than anything. Ask them about their feelings, their behavior but don't lecture, for god's sake, about why they're wrong. It's not therapeutic! Look, I'm not a genius and I'm definitely not the best nurse there, but I did figure out early on who were the best nurses (Kathy, Curtis, and Gilbert if you want to know). I noticed they all shared this trait of letting the patient talk more -- you'll never see them making long-winded speeches to patients, showing irritation, or being insistent, unless it's insistence about delivering an emergency injection (but even then, very little needs to be said).

Yeah - paranoia, the destroyer. (apologies to the Kinks)