1st Edition
Psych ER Psychiatric Patients Come to the Emergency Room
Drawing on the experience of evaluating over 2000 emergency room patients, René Muller explores the important role of psychiatry in emergency room medicine. He discusses some of his most challenging cases, showing how psychiatry comes to the aid of medicine in managing the crises - real, imagined, and contrived - that are the everyday fare of clinicians who work in the ER. We are introduced to a world in which lies are exposed, manipulations revealed, diagnoses made, medications adjusted, and even very brief psychotherapy attempted.
Muller begins with patient narratives rooted in the mental disorders most commonly encountered in the ER: Depression, panic disorder, drug dependence, bipolar depression, bipolar mania, schizophrenia, and Alzheimer's dementia. These stories pave the way for more puzzling ER cases, which Muller gathers into sections of "Veiled and Bizarre Stories" and "Stories with a Medical Component." He introduces us to the meanings of ER malingering and offers hard-won insights into managing "dumps" (when patients are dumped into the ER by families, police, doctors) and "stumbles" (when patients' bizarre behavior lands them in the ER).
The stories patients tell - and the questions these stories raise - drive Muller's text. A young man has seriously overdosed, but with what? Why has a successfully medicated schizophrenic suddenly begun hearing voices again? And what are we to make of a patient who is willing to risk death attempting to "drown" his hiccups by drinking up to 12 liters of fluid a day? For these and equally fascinating questions, Muller is a sure-handed guide, working his way through one ER challenge after another with psychiatric acumen and a balanced appreciation of the medical, custodial, socioeconomic, and legal dimensions of ER work. An intriguing account of the competing agendas that enter into the handling of emergencies, Psych ER is also a compilation of evocative patient stories about the subjective experience of being ill.
1. Depression: The World Pushing Down
2. Panic: The World Coming Apart
3. Borderline Personality: A Brittle World, A Labile Mood
4. Multiple Personality: Taking on the World with More Than One Identity
5. Alcohol: Chemically Altering One's World by Mouth
6. Drugs: Chemically Altering One'sWorld by Nose and Vein
7. Bipolar Depression: The World Too Low Down
8. Bipolar Mania: The World Too High Up
9. Schizophrenia: Being Unable to Share the World with Others
10: Alzheimer's Dementia: The World Dissolves as the Glue of Memory Cracks
II. Complex Stories
11. Panic Disorder Fed by Emotional Dependence
12. Histrionics Mistaken for Schizophrenia
III. Veiled and Bizarre Stories
13. Malingerers and Manipulators
14. The "Dump"
15. The "Stumble"
16. Murder and Mayhem, Maybe
IV. Stories with a Medical Component
17. Why Is This Schizophrenic Patient Hearing Voices?
18. How a Stomachache Turned a Head
19. A Serious Overdose, But of What?
20. A Closed Head Injury Leads to Paranoid Psychosis
21. A Patient Who Risked Death Trying to Drown His Hiccups
22. Delirium Missed as the Reason for Psychotic Symptoms
V. How Patient's Stories Lead to a Psychiatric Diagnosis
23. The Narrative in Psychiatric Diagnosis: It's the Story, Stupid!
24. Alexithymia: When There Is No Story To Tell
25. Renegotiating the "Contract for Safety"
26. Jean-Paul Sartre in the ER
Biography
Rene J. Muller has evaluated over 3,000 psychiatric patients in the emergency room and recounted the stories told to him there in numerous articles for Psychiatric Times, the most widely read psychiatric publication in North America. He is also the author of Doing Psychiatry Wrong: A Critical and Prescriptive Look at a Faltering Profession (Analytic Press, 2007).
"This book is a 'must read' for clinicians learning to treat psychiatric emergencies. With the gripping immediacy of well written short stories, Muller captures the lived experience of troubled and troubling people who present major forms of mental illness as psychiatric emergencies. A sophisticated and humane clinician with a novelist's voice and an existential philosopher's ear, Muller teaches the reader how to understand and treat these most challenging clinical conditions."
- Robert Alan Glick, M.D., Professor of Clinical Psychiatry, Columbia University
"René Muller has done excellent work in the care of patients and in the descriptions of their problems. He brings a fresh eye to the emergency room and to the service of the mentally ill, as one can see reading these essays."
- Paul R. McHugh, M.D., Psychiatrist-in-Chief Emeritus, Johns Hopkins
"Psych ER, an easily readable, slim volume, emphasizes the narrative perspective of the life story of the individual. The power of the stories that emerge grip the reader and make it a valuable addition to our literature. The cases that are discussed come alive through such storytelling and offer many useful clinical pearls through these extended vignettes. Each individual's subjective experience beautifully demonstrates the pain and suffering such individuals experience, and gives us an empathic view that should help in managing such problems. The book is excellent reading for any mental health care professional because of the clinical wisdom embedded within it, but would be even better for hospital administrators to review and see if they themselves can answer the question of why emergency services are so poorly supported when they are so essentially needed."
Thomas N. Wise, M.D., Psychiatric Times
"Psych ER is an excellent book for the medical reader who wishes to become better acquainted with DMS-IV diagnostic criteria and develop understanding of how a savvy psychiatric clinician navigates the nuances to make these diagnoses."
- Fiona Gallahue, M.D., Academic Emergency Medicine
"I found it a heart warming book and compelling reading with reminders of how we listen to patients' stories and how they present problems. Refreshingly readable and engaging, I fail to see how any emergency nurse will not find it useful."
- Bob Write Hon. MSc, RGN, RMN, Accident and Emergency Nursing
