A 28-year-old man with HIV and hepatitis C presented to the hospital for a complicated cellulitis and abscess of hand and forearm that developed after an altercation. The emergency room physician performed an incision and drainage and admitted him to the hospital for intravenous antibiotics. The patient acknowledged occasional nasal heroin and cocaine use but denied addiction. At the time of admission, the attending ordered oxycodone 10 mg every six hours as needed. The health care team suspected that the patient was homeless when he refused to provide a telephone number or family contact.

During multiple prior admissions the patient had displayed such hostility that nurses limited their interactions with him. The nurses reported the smell of tobacco smoke near the patient’s bathroom, but he declined a nicotine patch. He left the floor to smoke and often returned appearing sleepy and intoxicated. He received escalating doses of intravenous (IV) narcotic medication from cross-covering clinicians. The day team did not appreciate that his night time extra doses amounted to a significant escalation of his opiate use. His readmissions precluded follow-up with his primary care physician from another hospital network. Multiple attending physicians during his monthly hospitalizations further disrupted continuity of care.

On hospital day 2, the patient refused his dressing changes without IV narcotics. The nurse reported that she tried to coax the patient to undergo a dressing change with oral opiates but that he started yelling obscenities at her. Extremely irritable, the patient was alternately pleading and demanding IV pain medications. He threatened to leave if “the people here don’t start treating me with respect.” This patient’s hostility made his primary nurse feel defensive and uncomfortable.

THE ROLE OF LIFE EXPERIENCES AND ASSUMPTIONS

At this point, a psychological and social history revealed that the patient had grown up in east Baltimore under the worst of conditions. His physically abusive father abandoned his family. His mother was largely unreliable due to substance abuse. After asking numerous questions about his past medical experiences, we determined that the patient had received medical care only in “institutional settings,” and his experience with white male authority figures had been dismal.

We discussed his history of negative interactions with health care in institutional settings, and how his “assumption” that he will be mistreated leads to antagonistic behavior toward nurses and doctors, who respond in turn with hostility.

After commenting on how unfortunate these experiences must have been, we informed him that we would like to start with a clean slate. We reinforced our commitment to getting him better and to trying to make his stay as comfortable as possible while still doing what would be medically justified by the risks and benefits of treatments.

We negotiated with the patient that if he wore a nicotine patch, cooperated with dressing changes, and restrained from foul language, one of us would accompany him outside to smoke twice a day. Although he could not receive IV opiates, he would receive his preferred opiate orally, hydromorphone (Dilaudid) in equianalgesic dosing to the oxycodone he had been prescribed.

THE BENEFITS OF INITIATING TREATMENT OF DEPRESSION IN THE HOSPITAL

His behavior improved. The diagnosis of depression would not have been made had it not been for the extended exposure to the patient in the setting of walking him outside. While smoking, he described his life as miserable and meaningless. He stated that he could not sleep at night and felt “hateful” all of the time. He said he often thought he would be better off dead and admitted that he sometimes hoped someone, “like a police,” will shoot him. We offered him medications for sleep and depression and described major depression to him. The treatment of his depression allowed the forging of a better relationship as we discussed the way his depression had interfered with his life.

PATIENT EDUCATION ABOUT WHAT IS GOOD AND BAD ABOUT EXTRAVERSION

We told our patient that he needed to choose between being Martin Luther King Jr., who had rules he followed even when he was angry, sad, or felt like he was not getting anywhere, and being Marion Barry, who, when he got caught smoking crack with a prostitute said “it wasn’t me.” I described to the patient that he had “special abilities to persuade people” so that he usually got his way, but that he was using those powers to harm himself and those around him. He was able to expand this and engage with the idea.

NONJUDGMENTAL RECOGNITION OF ADDICTION

On day 3 he was much more irritable, with nausea and flulike symptoms. We diagnosed him with opiate withdrawal and offered to treat him for his withdrawal with higher doses of opiates followed by a slow taper. We described how addiction can sneak up on people. At this point, we also introduced the idea that some people have very little emotion, most people have an average amount of emotion, but that he had a very large amount of emotion, using the term “two scoops of feelings.” We explained that this was a form of being “gifted,” but for him it had been a curse. We clarified that his belief that he should be having a better life was actually accurate, but that no one had helped him learn to manage his intense feelings. We offered to help him with this over the several subsequent days. We added a long-acting opiate to stabilize him on a regimen. During the remaining days of his admission, we slowly tapered his opiates and offered to refer him to an outpatient program if he wished. The medical team saw him twice a day, often confronting him gently on the way his feelings cause him problems and with suggestions on how to behave during intense feeling states in order to be more effective.

THE IMPACT OF THE DOCTOR–PATIENT RELATIONSHIP AND SYSTEM OF CARE ON OUTCOMES

Consider the example of our patient, who had multiple readmissions to a tertiary hospital outside of his network. He seemed to benefit from hospitalization as a possible way to obtain temporary shelter and food, receive intravenous narcotics that made him feel better, and perhaps experience fewer restrictions than in the city hospital where he was enrolled in care. When asked why he did not go back to the hospital of his primary care physician, he responded, “They do not treat me right.” The challenge for the clinicians taking care of him was how to change the behavior resulting in monthly readmissions. We determined that the plan would be most successful if directed by one primary care physician. We ascertained through communication that his primary care physician would accept him back and manage his HIV and other medical issues as well as his substance abuse. Because he would likely benefit from the direction of one individual, he was transferred to the hospital of his primary care physician. Although not customary practice, this may have been the only way to break the cycle of readmissions so that appropriate resources could be put in place to provide him with the help he needed.

• Behavior disturbances have multiple causes—those due to underlying medical illness, those due to major psychiatric illness, and those related to interpersonal styles. The management strategy begins with a history and physical examination, including a neurologic assessment, so as not to overlook delirium or other underlying medical illness that requires emergent treatment, a review of all medications and dosages, and a toxicology screen in patients suspected of substance abuse. Patients with cognitive deficits may be easily confused by a change in environment; may be susceptible to medications with anti cholinergic properties, steroids, and analgesics; and may exhibit paranoia or delusions due to a developing delirium. Patients with stroke, Parkinson’s disease, and traumatic brain injury may exhibit features of apathy syndromes, such as lack of motivation and inability to initiate behavior even though they are not depressed or delirious. Alcohol and other substance withdrawal may also account for the observed behavioral disturbances.

• Patients with major psychiatric illness such as major depression, bipolar illness, schizophrenia, and substance abuse are at risk for receiving suboptimal care due to mental illness. The first step in treating their medical illness is to collaborate with their psychiatrists or seek hospital psychiatric consultation.

A man with schizophrenia had the persistent delusion that the VA in Florida was shooting radio waves into his abdomen. He presented with worsening abdominal pain and a seemingly stable 4 cm abdominal aortic aneurysm. For two weeks his complaints were attributed to his paranoia despite low-grade fevers and a rising white blood cell count. He died of massive internal hemorrhage shortly after a gallium scan correctly diagnosed his mycotic aortic aneurysm.

Physicians often approach clinical interactions with the preconceived notion that all complaints by patients with schizophrenia are generated by the illness, or that they will be unable to follow treatment recommendations—an assumption that is often incorrect.

Dysthmic patients

This quote from Winnie the Pooh is illustrative:

(Eeyore the donkey) “Hallo, Pooh. Thank you for asking, but I shall be able to use it again in a day or two.”

“Use what?” said Pooh.

“What we were talking about.”

“I wasn’t talking about anything,” said Pooh, looking puzzled.

“My mistake again. I thought you were saying how sorry you were about my tail, being all numb, and could you do anything to help?”

“No,” said Pooh. “That wasn’t me,” he said. He thought for a little and then suggested helpfully: “Perhaps it was somebody else.”

“Well, thank him for me when you see him.”