Psych and Medicine

I think it's very important for psychiatrists to be trained in medicine, and vice versa. I have seen many frustrating and complicated psych patients this month at this clinic--in part because the staff knows I'm going into psych, so they'll give me the "special" patients. Joy.

I've seen quite a few patients with severe anxiety, including several with blood pressures >170/100. In my opinion, treating the hypertension alone isn't fully treating the problem, because the anxiety keeps raising the blood pressure. Of course, it's not sufficient to treat the anxiety alone, either, because we know about the acute and chronic complications of hypertension. Fortunately, my attending in this clinic is very understanding about psychiatry, and I feel like he has a great attitude towards all the anxious patients.

On the other hand, it's even more important to know when it's NOT a psychiatric problem. A patient with uncontrolled diabetes and hypertension with a history of anxiety presented with dizziness and slurred speech which resolved over a period of hours. She'd woken up in the middle of the night with symptoms, only a night after having a blood sugar of >500. She'd gone to the ER with the blood sugar only to be told to "follow up with your PCP" and sent home. When her niece called 911 for the slurred speech, the paramedics accused her of being drunk, so she refused the ambulance ride. When I saw her a few days afterward, she looked slowed down, a little confused. When my attending pointed to anxiety in her chart and asked if it was causing her symptoms (that day we'd had two other ladies with anxiety-induced dizziness and hypertension) I adamantly said no. We agreed that she was likely having TIA's and sent her to neurology.

Unfortunately, some patients are written off as being "psych problems" when medical diagnosis fails. Sometimes, there's a medical condition which is undiagnosed, but when doctors can't find what's wrong they politely suggest "maybe it's all in your head." Sometimes, there's a psychiatric condition causing physical symptoms (today, it was panic disorder causing chest pain and shortness of breath), and after the EKG, heart cath, head CT, labwork, upper endoscopy, and chest x-ray are normal, the patient is slipped a prescription for Xanax and Lexapro and told "you must be depressed."

I realize psych patients are complicated and frustrating. I'll admit, the last patient I saw today, with panic attacks and anxiety, who absolutely REFUSED to let go of the idea that some hidden physical condition was causing her anxiety, drove me crazy. I was so upset after I left her that I was having a tension headache of my own (although I did not go to my doctor and demand an MRI, thankyouverymuch). However, telling patients "it's all in your head" is demeaning and somehow suggests that their anxiety isn't real. Then, it becomes even harder to treat these patients, because they mistrust doctors and psychiatric diagnoses; they rebel against being labeled as "psych patients" and demand more physical tests. There are few things more difficult than convincing someone that it's okay that their anxiety is "in their head" and that it is also okay to need treatment for the same.

In other words, I'm very happy to be learning a lot of medicine--I hope to put it to good use over and over again, even in psychiatry. I wish more medicine doctors would learn some psych and put it to good use as well.