The Lived Experience of Ostracism

h/t whatnot

I first discovered C. Fred Alford’s work about the experiences of whistle blowers. In it, he describes what constitutes “knowledge as disaster”, and my experiences jibes almost perfectly with this list:

“What must the whistle-blower forsake in order to hear his own story?

* That the individual matters.

* That law and justice can be relied upon.

* That the purpose of law is to remove the caprice of powerful individuals.

* That ours is a government of laws, not men.

* That the individual will not be sacrificed for the sake of the group.

* That loyalty is not equivalent to the heard (sic) instinct.

* That one’s friends will remain loyal even if one’s colleagues do not.

* That the organization is not fundamentally immoral.

* That it makes sense to stand up and do the right thing. (Take this literally: that it “makes sense” means that it is a comprehensible activity.)

* That someone, somewhere who is in charge knows, cares, and will do the right thing.

* That the truth matters, and someone will want to know it.

* That if one is right and persistent, things will turn out all right in the end.

* That even if they do not, other people will know and understand.

* That the family is a haven in a heartless world. Spouses and children will not abandon you in your hour of need.

* That the individual can know the truth about all this and not become merely cynical, cynical unto death.

Not only is it hard to come to come to terms with these truths, but when one finally does, it seems one is left with nothing.”

Now plug in this list to Smart’s diagram below.

Multimotive model of reactions to interpersonal rejection experiences.Smart Richman, L., & Leary, M. (2009). Reactions to discrimination, stigmatization, ostracism, and other forms of interpersonal rejection: A multimotive model. Psychological Review, 116 (2), 365-383 DOI: 10.1037/a0015250

That, in a nutshell, is my experience. Ostracism is a cruel death sentence where all of the means to sustain oneself are intentionally withheld. The victim is used as an object of ridicule, contempt and alienation. The dying is slow, and there is full self awareness of what’s happening. Think of open heart surgery being performed without end, night and day without anesthesia, where the surgical team continually ignores the cries for help and instead makes jokes about the patient and his plight.

That is ostracism. Alford describes whistle-blowers who are doomed, but somehow, he never connects their experiences to ostracism. He discusses living as though one is already dead. Yup, that’s ostracism, because in the eyes of those who know and those who commit it, the victim as person has been murdered and only a ghost remains. But because the ghost has a heartbeat and is still enfleshed, it’s an object used for entertainment. In this case it’s used to create a feeling of superiority and legitimacy by degrading the victim as an unworthy, repulsive “other”.

I have been an other for time out of time. There is no re-entering society. I have been a most compliant patient patient and have repeatedly tried and failed to find a job, volunteer, make a friend beyond the most superficial of acquaintance level, and find any meaning or purpose in continuing to exist this way and there is none. In writing about some of my experience, I attracted a cyber stalker nurse and her band of bullying nurses, ambulance drivers and a Texas ER doc who wrote that “if she’s still alive we can make fun of her”. I was diagnosed as having persecutory delusions because my story “reads like a novel.” The outpatient psychiatrist to whom my case was assigned – she sure as hell didn’t volunteer – is married to the CEO of a competing organization in which I had been an inadvertent whistle-blower. In that organization, the mid level manager and director paranoia ran on high octane, and ironically, I wasn’t paranoid enough to save myself.

The paranoid whistle-blower is absolutely fight (sic) that his organization is not just out to fire him, but to obliterate him or her. The whistle-blower’s paranoia is an accurate emotional reading of an emotional reality: the one who has become the scapegoat cannot just be dismissed, but must be destroyed, so that others will know.

It is this aspect of paranoia that is the most difficult of all for an outsider to come to terms with because it represents a truth that is hard to know: that if the organization feels sufficiently threatened by the individual, it will remove him or her. Not just beyond the margins of the organization, but all the way to the margins of society. The average whistle-blower of my experience is a 55-year-old nuclear engineer working behind the counter at Radio Shack.

I was so desperate for help that I eventually sought it from the mental health non-system system, knowing full well that I would be placing myself in the hands of providers who were as likely to treat me with contempt as those who ostracized me did. All of my concerns were validated. For my troubles, I was diagnosed with stigmatizing labels, received treatment which resulted in metabolic, immune and cardiac derangements, was repeatedly deceived, humiliated, degraded and dehumanized, and was coerced and threatened. Physical problems were not diagnosed and treated, but instead were recorded as being somatizations and dismissed, if they were acknowledged at all. I cannot expect to receive competent healthcare from any provider who accesses my medical record because I am permanently and prominently labeled as the “xx year old homeless patient with extensive psych history”. When I pointed out multiple examples in the medical record of that to the outpatient psychiatrist, she sent a note to some of the offenders very politely requesting them not to do that anymore, and she proudly relayed that to me. But still it continued, and having been on the provider side, I know damn well that once patients are labeled, that they are treated with contempt, do not receive even minimally acceptable care, and they suffer for it with higher morbidity and mortality rates.

I took myself off every prescribed medication as none had helped, some were prescribed to mitigate the adverse effects of others, and many had caused direct harm. I read my medical record, identified what lab and diagnostic values were abnormal, and then I did all of the self care activities that I could do with my resources to reverse the damage.

But ostracism can’t be treated with medications and meditation. It requires a real physical friend, a network of professional/work peers, and a place in the social order. None of those are available to me.

Stillman, et al, describe life without meaning and purpose:

Why should social exclusion reduce the sense of life as meaningful? The pervasive reliance on social connection as humankind’s biological strategy entails that people are deeply motivated to connect with other people as a fundamental aspect of nearly all human striving. Meaning itself is acquired socially. Hence to be cut off from others is potentially to raise the threat of losing access to all socially mediated meanings, purposes, and values.

The formation and maintenance of positive close relationships can aptly be characterized as one of the primary motivations for human beings (Buss, 1990; Maslow, 1968). This pervasive drive has been described as the need to belong (Baumeister & Leary, 1995). We define social exclusion as a perceived deficit in belongingness.

Oh, belongingness. Joiner has something to say about that:

The theory posits that serious suicidal behavior will not occur unless an individual has both the desire to commit suicide and the ability to do so. Two factors contribute to an individual’s desire for suicide, a thwarted sense of belongingness and a sense of perceived burdensomeness on others, while the ability to commit suicide can be acquired over time through habituation to the physical and mental pain involved in self-injury.

I have been cut off from a place in society. The mental image I have is the astronaut in 2001 whose oxygen line has been snipped by HAL, the malign robot. At least the astronaut suffocates quickly in the absolute freezing void of space. His awareness of his predicament is full, but brief.

Not so the ostracized, who have to find their way in a hostile wilderness which is incompatible with life. I am out of place everywhere. There is no place to escape to. There is no respite.

In my everyday world, I go places to kill time. To use up the eternal isolation. To go just for the sake of movement. There is no reason for a journey. There is no destination. I try to keep everything out of focus, like looking sideways out a car window, because any conscious realization of my plight is too excruciating to bear, even for a moment. Time has no meaning. There are no holidays, anniversaries, birthdays, wedding, births, deaths, or special events by which to measure life. There is no quality of life. Everything adds up to zero. It is exhausting purposeless, meaningless, hamster wheel work, which is unending.

The psychiatrist conflated psychological assessment with treatment (not just her – I have found this with all mental health providers across disciplines), and I find this in the literature, as well. Assessment of depression, chronic severe insomnia and suicidal ideation is intrusive and painful, and yet, that is the extent of what she did at each visit. I had nothing else to share. My story was invalidated by diagnosing it as delusional. I will not refer to it again. It is not able to be heard by anyone. And I don’t want to cause anyone distress, which this obviously does.

It reminds me of times when people who knew what was happening to me would turn away when they saw me, lest they be seen with me and thus perceived as being at risk for ostracism themselves. There’s nothing like having people literally run from you to bring home how your life is destroyed.

She asked me what I was reading, but I’d reported to her my increasingly and consistently poor ability to comprehend, let alone, remember what I’ve read. I no longer read anything longer than a headline. Culling the literature for this blog post is taking me an extraordinarily long time. It probably reads as disjointed and not terribly well-reasoned. My cognitive ability and memory stink, to use the technical term. Yet, I can’t distinguish whether my nonstop efforts to keep everything out of focus, and so to minimize the consciousness of my predicament is the cause of my ever worsening cognition or just an effect of ongoing isolation.

Except for the visits to the psychiatrist, I have not had a single substantive conversation with another person for many years. And I wouldn’t really call the content of the visits conversation. In reality, I was always on tenterhooks trying to not evince distress, lest she decide to forcibly treat me.

I’ve lost the ability to have a social conversation. I can’t relate to others because I have no social commonalities – no family experiences, no contacts with people considered friends, no work role, no social role – nothing on which to any longer identify with others. When I was still trying to regain involvement via volunteering, as soon as someone got a whiff of my isolation via lack of those connections, they would abruptly cut off the conversation. I never heard from any of them again. The psychiatrist had been told this repeatedly when she poked and prodded into why I no longer sought outside activities. That amounted to self punishment. It’s painful to be rebuffed and excluded over and over and over. I am a slow learner, but I finally got the lesson: in order to avoid inflicting pain on myself, do not try to go where you are not welcome. That would be everywhere.

But she did it herself. She’s in a position in which, if she were to go out of role, granted, she could have provided me networking referrals to jobs.

But of course, she didn’t. Boundaries, you know. I was an assigned case, a cluster of pathological symptoms. Not a person, not someone with advanced education and related professional experience, not even a plain old person. She made two specific suggestions about how she saw me being able to contribute: to serve as a personal care attendant (adult baby sitter and butt wiper) or as a pet sitter. As if that wasn’t confirmation of my deemed worthlessness. Early on I had given her a copy of my vitae, and to her credit, she read what I had offered to her via a sample of my writing and the Alford article referenced here. And I don’t believe that she conducted therapy as a rule. I’m pretty sure I was an exception and guess that she primarily practiced psychopharmacology along with her administrative duties.

In my medical record, it turns out that her sole treatment goal for me was to keep me “in the realm of suicidal ideation. Dx: existential despair, but no worse than usual.” And that was the most positive thing written in my entire medical record. How is that compatible with life?

Stupid me. If I had gotten my records earlier, I could have saved myself the repeated distress of being “clinically assessed” (read psychologically debrided without anesthesia with wounds left gaping) and left to try to forget until the next session of torture and tell.

In my world, no one returns phone calls and emails. I received a total of 6 pieces of US mail last year (not addressed to “or resident”) – all from organizations requiring paperwork and none from individuals or anyone who knows me personally. I used to keep NPR on to hear reasonable, non-violent human voices. But I finally stopped because I often couldn’t follow the patter and it became just more intrusive and irritating noise. Now I just keep a fan running to drown out gunshot season – any loud abrupt noise especially during open window weather. I exist in a noisy world but with more silence than a monastery.

I can’t get any enjoyment out of any experience. Food tastes like nothing. Everything is a tone of grey and shadow. Aromas that in the past evoked pleasant memories are undetectable, and most aromas smell foul. Music is just notes, too loud and evoking nothing. People are nothing but harbingers of pain and dread. No one has voluntarily touched me except to perform medical procedures using my body as just an object, such as blood drawing and injecting a joint, in many years. I know better than to reach out a hand or to offer a pat on the shoulder. It would most decidedly not be welcomed.

There is no reason to prolong this, but my attempts at providing my own euthanasia failed. The LD50’s weren’t enough, and I don’t have the means to provide myself with a peaceful and painless death. I’ve come to realize that a painful death is preferable to this unending dying.

Ostracism means that there is no burden to anyone. Society has already unburdened itself of me.

Ostracism is a death sentence, and every person who knows that it’s been imposed on someone and yet who does not intervene, is a member of that judge and jury.

I can’t stand the notion that the rest of my natural lifespan is going to be spent in this wholly silent, totally isolated and destitute way of existing. It’s enforced insanity. The conditions explain why most whistle blowers get sick and die early.

ResearchBlogging.org

Alford, C. Fred (2007). Whistle-blower narratives: the experience of choiceless choice Social Science, Volume 74 (1), 223-248

Smart Richman, L., & Leary, M. (2009). Reactions to discrimination, stigmatization, ostracism, and other forms of interpersonal rejection: A multimotive model. Psychological Review, 116 (2), 365-383 DOI: 10.1037/a0015250

Stillman, T., Baumeister, R., Lambert, N., Crescioni, A., DeWall, C., & Fincham, F. (2009). Alone and without purpose: Life loses meaning following social exclusion Journal of Experimental Social Psychology, 45 (4), 686-694 DOI: 10.1016/j.jesp.2009.03.007

Van Orden, K., Merrill, K., & Joiner Jr., T. (2005). Interpersonal-Psychological Precursors to Suicidal Behavior: A Theory of Attempted and Completed Suicide Current Psychiatry Reviews, 1 (2), 187-196 DOI: 10.2174/1573400054065541

Williams, Kipling D (2001). Ostracism: The Power of Silence 2001 Other: 1572306890

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National Distress Is A National Disgrace

I remember the Tuesday in September.  The morning was crisp, clear and with eye-watering bluest of blue skies.  I had already finished morning barn chores and was in the house having coffee, checking the net and listening to the tee vee.  For the next three hours, I watched the sky overhead where normally the aircraft were in their final landing pattern turnaround to the local metropolis’ airport gradually clear of all thing winged and rotored.  The silence and stillness was ominous and dreadful, even though the sounds of nature could finally be heard as intended.

The US on that day, could have moved forward by examining the hows and whys of terrorism.  It could have held steady on the solid bedrock of tolerance and inclusion, dignity and respect for all.  It could have made conditions permanently inhospitable to terrorism by not condoning and allowing bigotry, bullying and alienation.

But instead, the US was led by the nose in exactly the opposite direction by Dick Cheney, ostensibly the president in deed if not in title, George W Bush who never had a single edifying thought, but instead sought retaliation, retribution and revenge for deeds real and imagined, the Cabinet of fundamentalist Christians and lobbyist-tainted hangers-on – power and control mongers all, a Supreme Court which is firmly Corporatist and devoid of human decency, a media which is commercially bought and paid for to produce “what the viewer wants” – meaning what the viewer watches/reads that leads to advertising revenue, and a willfully ignorant citizenry which indeed paid attention to all of the above and neglected to apply critical thinking and adequate skepticism to the calls for war, violence, national paranoia, suspicion and a (permanent) suspension of the rights guaranteed in the Constitution.

Instead of building a welcoming and open society, we have let it go to wrack and ruin.  Instead of educating thinking productive citizens, we have trained a nation of gullible test takers.  Instead of building on the classical virtues, we have a nation of individuals that don’t know the first thing about voluntary cooperation, collaboration and compassion for the greater good and for our fellow humans.

We could have spent our dollars on research, new technologies, renewable energy, professional growth and development, infrastructure renewal and development and transportation growth.  We could have invested in our citizenry with healthcare, education, healthy-based communities and in the liberal and fine arts.

Instead, we have funded wars, terrorism, global arms, an enormous, off the books contracted spy industry, state-sponsored violence and government disruptions.  We have criminalized mental illness.  We have made prisons the largest growth industry in the US. We have made over one third of Americans too poor to afford necessary health care.  We have turned out a generation of Americans who are ill prepared to be engaged and informed citizens and who do not have the ability to be successful in a trade or profession.  We have neglected everything from the air we breathe to the food we eat, the water we drink to the ground in which our crops are grown.

We have gone from a two party political system to a one party, corporatocracy.  There isn’t any point in voting, as there is no one to vote FOR as a legitimate representative of the constituency.

We are constantly surveilled via cameras, data bases and undisclosed programs and organizations.  We are extolled to “see something, say something”.  Everyone has been made into an out group. We are prompted every day in many ways to be “alert, be aware” and be suspicious of everyone and everything around us.

On this day of reflection, I mourn for the lives lost on September 11, 2001, as well as for all of the lives lost in Iraq, Afghanistan, & Pakistan by both military and civilians.  I mourn for those affected by any act of terrorism.  I mourn for alienated people who react to ostracism with extremism.  I mostly mourn for the loss of the Republic.  Franklin said that it would last only “if you can keep it”.  But none of us did, and it’s gone.

What’s in its place is a worn out shell filled with a people made very weak and seemingly still without a will and the means to try to take it back.

This is a demoralized people, and more and more of its inhabitants are becoming hopeless about it because of their seeming helplessness and the betrayal by those who promised, hope, change, transparency and equality.

And as more citizens are deemed to be burdensome by politicians (failure to extend unemployment, criminalization of homelessness, retrenchment of Medicaid and SCHIP, the general promotion of ostracism), will the national collective perception of thwarted belongingness propel civil unrest or violence?

I bring this up because as the two fundamental conditions for people to choose to act on suicidal ideation, on a large scale, I wonder what actions people might take when these conditions become intolerable to bear. Kip Williams discusses the final phase of ostracism when coping has failed to produce re-inclusion and affiliation as resignation (ostensibly to one’s fate as permanently ostracized – ed).

This is when people who have been ostracized are less helpful and more aggressive to others in general,” he said. “It also increases anger and sadness, and long-term ostracism can result in alienation, depression, helplessness and feelings of unworthiness.”

Williams is trying to better understand how ostracized individuals may be attracted to extreme groups and what might be the reactions of ostracized groups.

“These groups provide members with a sense of belonging, self-worth and control, but they can fuel narrowness, radicalism and intolerance, and perhaps a propensity toward hostility and violence toward others,” he said. “When a person feels ostracized they feel out of control, and aggressive behavior is one way to restore that control. When these individuals come together in a group there can be negative consequences.”

Emotions and Social Behavior

Well, so much for keeping up with blogging.  An unexpected health insult, weeks of bedrest and sequelae of fatigue and brain fog haven’t done me any favors. But whatever, here’s a bit of catch up, even if presented through a dense fog….

Kipling Williams is one of the few researchers who is investigating ostracism.  I want to read his major opus, Ostracism: The Power of Silence, but will have to wait until I can do so in library residence, as it doesn’t circulate. (If you have a copy to lend or re-sell at a bargain, I’d be thrilled.)  The library has it catalogued under social isolation, and in a collection titled emotions and social behavior.

The latter label struck a chord, for what is suicidality but distress signaling (the emotion) which if unaddressed, leads to suicidal attempts (the social behavior)?

So when I start thinking more clearly again, I’ll try to put together some sort of framework for addressing the distress signaling:

  • alienation
  • burdensomeness (perceived)
  • demoralization
  • despair
  • grief (situational)
  • guilt
  • helplessness
  • hopelessness
  • ostracism (externally applied isolation)
  • pessimism
  • powerlessness
  • realism
  • self identity loss – externally removed (loss/denial of social roles)
  • self loathing
  • shame
  • social isolation (as opposed to voluntary avoidance and isolating behavior)
  • thwarted belongingness
  • worthlessness (perceived and externally applied)

To date, no one has studied people who have made suicide attempts or completed suicides to evaluate what behaviors they used to try to adapt to the distressors, what train of events (thoughts, feelings and behaviors) they experienced when the distress wasn’t adequately relieved, and what directly led to the suicidal ideation, the suicidal attempt, and the completed suicides. But at certainly needs must be done in order to treat suicidality upstream – preferably before the suicidality is entertained and certainly before it is acted upon.

Demoralization

This post is essentially an interim reference list. Demoralization is arguably the most important concept in suicidality that you’ve never heard of.

Demoralization and remoralization: a review of these constructs in the healthcare literature Margaret J Connor, Jo Ann Walton

Nursing Inquiry

Nursing Inquiry

Volume 18, Issue 1, pages 2–11, March 2011

The Social Separation Syndrome
Reprinted from Survival International Review Vol. 5, No. 1(29):13-15, 1980.
G. N. Appell
Brandeis University

Engel and his collaborators have been concerned with the related question: Why do people fall ill or die at the time they do? And they have identified a psychological pattern that appears associated with disease

onset that they call the Agiving up–given up complex@. Five characteristics are identified with this complex (Engel 1968): (1) the giving up affects, i.e. helplessness or hopelessness; (2) a depreciated image of the self; (3) a loss of gratification from relationships or roles in life; (4) a disruption of the sense of continuity between past, present, and future; and (5) a reactivation of memories of earlier periods of giving up.

Pubmed search for demoralization

The term demoralization was first used in the psychiatric literature by Jerome Frank in the 1970s (i.e., “the chief problem of all patients who come to psychotherapy is demoralization . . . the effectiveness of all psychotherapeutic schools lies in their ability to restore patient morale”)1(p271) and represented a persistent failure of coping with (internally or externally induced) stress; Frank believed demoralization left one feeling impotent, isolated, and in despair. This conceptualization was congruent with the psychodynamic approach of the Diagnostic and Statistical Manual of Mental Disorders, Second Edition (DSM-II),2 in which all disorders were considered reactions to environmental events. Frank defined the symptoms of anxiety and depression as direct expressions of demoralization.1
However, in 1975, Schildkraut and Klein3 defined demoralization as a state separate from depression. Whereas patients with depression experienced anhedonia, patients with demoralization lost their sense of efficacy. In the 1980s and 1990s, Frank and De Figueiredo further refined the meaning of demoralization.4 The term demoralization remained distinct from depression and was characterized by 2 states: distress and a sense of incompetence that results from an uncertainty about which direction to take. Individuals with depression and those with anhedonia cannot act (even if they know the proper direction to take).
Curr Psychiatry Rep. 2010 Jun;12(3):229-33.

Differentiation between demoralization, grief, and anhedonic depression.

Source

Department of Veterans Affairs, Central Arkansas Veterans Healthcare System, 4300 West 7th Street, 116T/LR, Little Rock, AR 72205-5484, USA. marcus.wellen@va.gov

Abstract

Demoralization is a phenomenon in which a patient reaches a state of subjective incompetence, hopelessness, and helplessness that can lead to that devastating moment in which he or she feels the only recourse left is to give up. This article reviews the medical literature regarding the current understanding, importance, and impact of demoralization. In addition, using the key characteristics of demoralization, this article attempts to compare and contrast demoralization with anhedonia and grief.

 

TO THE EDITOR: Dr. Slavney’s stimulating article, “DiagnosingDemoralization in Consultation Psychiatry,” is a valuable additionto the ongoing debate on demoralization.1 Dr. Slavney statesthat demoralization is a normal response to adversity and thathe disagrees with my proposal to substitute “demoralization”for “severity of psychosocial stressors” as Axis IV in the DSM.Although demoralization may, at times, be understandable, asin the cases described by Dr. Slavney, the view I proposed isthat demoralization is always abnormal. It is because demoralizationis abnormal that it requires treatment (psychotherapy). I proposedthat demoralization be conceptualized as involving two states:distress (which some other authors have called “demoralization,”incorrectly in my opinion) and subjective incompetence. Althougheach of these two states may be normal by itself, their overlapwould constitute demoralization, which is always abnormal. Demoralizationis thus viewed as a boundary phenomenon, that is, a state thatoccurs within the individual and at the boundary with the environment,something akin to inflammation.

World Psychiatry. 2005 June; 4(2): 96–105.
PMCID: PMC1414748
Copyright World Psychiatric Association
DAVID M. CLARKE,1 DAVID W. KISSANE,1 TOM TRAUER,1 and GRAEME C. SMITH1

When People Aren’t De-Stressed

There was an extraordinary commenting discussion about suicide as reader responses to a NYTimes column by the physician and writer, Danielle Ofri. In her essay, she laments the death by suicide of a patient and expresses frustration about the seeming non-suicidality of him making the death an unexpected shock.

Two weeks ago, I called one of my patients to reschedule an appointment. A family member answered and told me that my patient had been found dead in his apartment, most likely a suicide. This robust and healthy 54-year-old had screened “negative” for depression at every visit, despite having risk factors: being unemployed, living alone, caring for an ill relative.

Here she makes a clinical error: screening for depression and suicidality are two distinct entities.  Once does not necessarily presage the other. In terms of perceived burdensomeness, thwarted belongingness, isolation, hopelessness, helplessness and worthlessness, this gentleman was existing in a stew of toxic risk factors.

Maslow’s hierarchy of needs is old, but useful, in my view.  This person exhibited unmet basic needs – financial burdens, caregiver burdens, physical burdens, social isolation burdens.  The question becomes, where art thy neighbor?  Who is thy neighbor?

Maslow's Hierarchy of Needs. Resized, renamed,...

Image via Wikipedia

One of the risk factors for suicidality is that physicians increasingly treat rather than care for patients.  Because the care is missing, patients aren’t supported around anything other than medications, surgery and medical procedures.  One thing Dr. Ofri could have addressed is linking the patient to a home health nursing agency or to a social worker who could help him access caregiver support, perhaps home delivered meals and financial and job search supports.

The bottom line is that it appears that no one was this man’s neighbor, or brother, or fellow citizen.

Now to the commentary:

Readers addressed a wide variety of insightful and thoughtful aspects around suicide and suicidality.  The right to end terminal suffering – psych ache – is addressed quite compellingly.

Treatment As Usual: Case Report

DSCN1759

Image by Michael 1203 via Flickr

 

Submitted without comment:

Outpatient psychiatrist: Patient came to her routine psychopharm visit expressing profound hopelessness and a desire for her life to end. She described recent incidents at the shelter where she is staying, including one where another guest took an overdose of medication and she (the patient) was distraught that she hadn’t recognized this (clinically) sooner.  She repeatedly said, “I can’t survive this…I want it to end.”  In addition to feeling overwhelmed and anxious about her state of homelessness, she expressed concern that she “would never feel safe anywhere.”  She denied suicidal intent but was unable to find any reason to continue her life and made numerous self-disparaging remarks.  She became increasingly distraught, crying and almost moaning in her chair.

Impression:

Since stopping her antipsychotic medication (intolerable EPS per patient) and decreasing her antidepressant medication on discharge from the hospital (to the street), the patient is faced with the reality of limited housing options and may likely face daily uncertainty about where she will sleep once she completes her time at current shelter – and is overwhelmed, panicked, despairing and hopeless about her life.  Her paranoid ideation has increased.  She sees no meaning in anything and wishes to die.  She denies immediate suicidal intent, but mostly due to lack of energy rather than lack of desire.

Plan:

With much persuasion, patient walked with me to the A(cute)P(sychiatry)S(ervice) where she will be evaluated for inpatient hospital admission.

APS psychology fellow note 4 hours after arrival:

Patient was tearful, depressed with poor eye contact.  Patient refused to talk to writer stating “I can’t talk, go away.” Writer was unable to complete full exam due to patient refusing to be evaluated at this time.  Patient is intermittently sobbing uncontrollably, saying nothing more than “I can’t” and “you have to let me go”, refusing medication and refusing to participate in interview. Perseverating on “you have to let me go” “nothing will help”  TP – perseverative -Insight poor Judgment poor Patient requires ILOC to establish safety, containment, and aftercare planning.

36 hrs later – Psychiatry fellow and attending consultation note:

Fellow: This patient was admitted for altered mental state with bradycardia and a serum diphenhydramine level of 489 mcg/l (toxic range).  Psychiatric consultation was requested for ? suicide attempt. The patient reports that she left the hospital yesterday, returned to the shelter at which she was staying to discover that her belongings (aside from medications) had been removed.  Pt reports having felt more hopeless and ingested unspecified number of her prescribed medications.  She reports that she did not want to hurt herself but hoped that this ingestion would kill her.  She denies having anything to live for at this point, denies intent to harm herself but feels “regret” for the outcome of this medication ingestion and reportedly “want(s) to die.”   Pt does report that much of her feeling hopeless is related to lack of shelter and job.  She attributes her “life situation” to being ostracized “for being a whistleblower” (related to prior living and job situation per medical record review).

Attending: I have reviewed the events/notes of earlier this week.  At present, she explains to me that yesterday, when she left here, she wanted to die and took pills in order to bring about her death and thought the pills she took would effect that outcome.  When she realized she did not die, she felt regret.  She still feels regret because she still wants to die and kill herself. Asked why she did not acknowledge this yesterday before she left here, she said that she knew she would be hospitalized psychiatrically if she had and she didn’t want to be.  I explained to her that caretakers are able to help her only to the extent that she is honest with them.  She is pessimistic that pharmacotherapy and psychotherapy can help her deal better with her problems even if they cannot take them away.  I explained further that both can help her to be more optimistic.  She denies any thought of wanting to hurt anyone else.  She denies that anyone here is trying to hurt her.  She feels her thinking is clear and in its usual state.

Impression: Delusional and depressive disorders.  She is pessimistic, despondent, and suicidal at present and meets criteria for involuntary psychiatric admission.  Continue suicide precautions.  Continue 1:1 observation.