My First Psychotic Patient

I can’t write everything about Mr. J in one post, nor do I wish to. For one I spent four weeks following him, and for another the more I reflect upon him and our relationship the more I learn. The title of this post is not hyperbole; he is psychotic. He suffers from schizoaffective disorder. And he also has cancer. What kind of karma sucker punch puts you in a life where you not only don’t always know what is real and what is not, but then lays cancer on top of it all?

Of course you feel for him. This is objectively a sad situation. But more than his thought disorder, more than his cancer was something else, something tipped his whole situation from sad to really sad. He was lonely. Lonely because his family is hundreds of miles away while he lives in a hospital room in a city with no family and labeled with this disorder that automatically makes people shy away from you. I can tell with some of the staff, how they talk about him, that preconceived notions exist and flavor some of the care he receives. Everyone exhibits this behavior at some point. I did because there’s societal programming that makes you have a certain response when you hear schizo- anything. But then I talked to Mr. J. I got to know him, and I became struck by how intelligent and high functioning he is. He knows way more about his diagnosis, treatment, and physiology in general than most people would in his situation. We had a long conversation about physiology, and he talked about classes he took years ago in college. I remember most clearly him waxing upon his fascination with human biology. The conversation struck me for the clear evidence of a drive and passion to learn. I had off the cuff assumed a baseline cognitive functional impairment due to his diagnosis. Yet I came in one day to find Mr. J more anxious than normal. Upon questioning he tells me that he couldn’t get food stamps, which is why he was anxious. Not food stamps for himself, but food stamps for his mother. He fills out her application so that she can purchase an adequate amount of groceries every week. Mr. J actually pays the bills and runs the whole household. From hundreds of miles away. While battling cancer. With a thought disorder. A little piece of my heart broke when I heard that. Auditory hallucinations, visual hallucinations, and paranoia could not keep him from doing everything he could to keep his household running. And he did it better than some mentally “healthy” people I know.

We don’t really know what causes psychotic disorders. A relationship with increased dopamine in the mesolimbic track correlates to the so-called ‘positive’ symptoms (hallucinations, delusions, bizarre behavior, disorganized speech) and inadequate dopamine activity in the mesocortical track correlates to ‘negative’ symptoms (blunted affect, anhedonia, apathy, alogia, lack of interest in socialization). Lifetime prevalence is 1% for schizophrenia. Only 40% risk of inheritance if both parents have it. Twelve percent risk of expressing the trait if a first-degree relative is affected. Generally the disease does not present before age 15 or after age 55. More statistics exist to quantify the incidence and prevalence and risk factors of the disease, and generally when reading a text book about any disease those stats appear first, then an explanation of the disease process comes next and after that comes the section on treatment. Standard medical textbook chapter format. But when you get to the section where schizo- is the prefix for the conditions, the explanation of the disease process drops to a paragraph at most. You don’t need to go further than that to realize just how poor of an understanding we have of the underlying mechanism of thought disorders. But we quantify whatever we can to make ourselves feel better about this scary, life-changing thing that can happen in our brain. Oh, and there’s just a standard 1% lifetime risk across most populations. One in a hundred seems like a huge amount of risk for a condition that distorts a person’s perception of reality, potentially permanently.

Two weeks in to his stay, receiving intrathecal chemotherapy (the chemo going straight to the space in the spine that is continuous with the brain), his cancer relapses. Mr. J is not leaving the hospital anytime soon. He sits there as he talks about his stressors, about the generalized pain that plagues him every day, about being lonely. He sits there and he says, “But you know, I shouldn’t complain. You have a much harder life than I do. All the things you have to memorize about all the organ systems and all the tests you have to take. All the drugs you have to memorize. It’s so amazing that you’re going to be a surgeon. Your life is much harder than mine and I shouldn’t complain.”

I honestly did not have a response to that. I could not respond to that. I felt ashamed for all the struggles that I let take an occupying role in my own life, for all the little things that keep me from my responsibilities because I rationalize my way into thinking I deserve a break. That my life is hard and I have every right to let things slide here and there. My time with Mr. J makes me want to be better beyond anything else I have experienced. I want to be deserving of the praise he gave me, to be the person he perceived me as. If only we as a society could perceive the people suffering from mental illness for the people they are behind their diagnosis.