fascinoma / personality disorder

In the end, empathy - it is one of the most useful social glues and one of the most wonderful things for us to behave rightly towards each other but it’s nothing without political systems that function, without a kind of exercise against injustice, which is slightly more active than ‘I read Middlemarch and I felt so for Dorothea.' You know, there’s a limit to that kind of empathy and action. And I think the novelist should always be aware of that. You can fool yourself writing novels that you’re saving the world, you know, one by one. Opening the hearts of people so they become better. But people’s hearts can be opened extensively and they can do nothing. You have to be careful with that idea.

[...]

I just think that the English tradition of the novel as represented, the kind of apex of it, by Eliot, doesn’t always recognise that people are perverse. People are profoundly perverse. The French understand that very well. But the English, they tend not to look at things which are… certain parts of human nature they’d rather not think about.

- A Conversation with Zadie Smith

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'where did he cut?'

'both his forearms'

'which parts?'

'the uh, here. outer-'

'so the outer aspect, not the wrist or inner forearms.'

'yeah.'

'so he doesn't want to die.'

'... no I guess not'

'I'll take that. Where is he?'

It might seem cold or callous but the consultant's attitude was simply pragmatic, and he was kind enough to be frank with me about a referral that wasn't very sensible.

It turned out that my gentleman had attended A&E multiple times following intentional overdoses and other forms of self harm since the age of 16.

Medical school taught us that previous episodes of self harm and attempted suicide were indicators that they were capable of acting on their intentions and carrying out their plans, and therefore higher risk of self-harming or attempting suicide than someone who had never done so before. What I didn't understand was that if someone had been in and out of A&E a thousand times with the same presenting complaint, chances are that they will survive long enough to continue the trend. Chances are they aren't in imminent danger of dying. What are the odds that this day is unlike the other 100000 days they have done the same thing?

Patients with borderline personality disorder are characterised by a pattern of behaviour, and specific coping mechanisms which are learned, and maybe can be unlearned. This episode of self harm, probably like many others in the past, was one such coping mechanism, and wasn't an indication that his mental health had suddenly deteriorated. It was simply how he had learned to express himself - to get what he needed - which was release, and then someone to provide reassurance and care and empathy afterwards. Me calling the mental health liason team was like activating the major hemorrhage protocol for a patient with a papercut.

This wasn't an isolated incident. I have an unfortunate history of overreacting when confronted by unfamiliar situations -- especially when dealing with dishonest patients. For example, just the day before I had seen a 49 year old gentleman with a drinking problem, who had, according to him, had a seizure two weeks ago and since then had lost sensation in a small patch of his leg, and that he had cut down on his drinking for a week now. He was desperate to be admitted, to be seen by the alcohol liaison team. When I explained to him that alcohol related seizures normally occur after the detox, he changed his story, saying the seizure happened only a week ago. And that he had hallucinated his dead brother during it. "That's impressive," said the consultant. I didn't realise what he meant at the time.¹ There were a few other signs, visual field defects, abnormal sensation, diplopia - all subjective, come to think of it. All relying on the patient to be faithful with his reporting. The consultant didn't think it would show anything, but I pushed for it and we treated him to an unhealthy dose of radiation via CT scanner. I even added on B12 and folate levels. The next day I looked him up on the system. On the stroke ward where I'd put him. CT was normal, and so were his bloods. Plumb normal. I'd been duped.

Common things are common, is the adage quoted to medical students as a rite of passage, and yet I managed to complete medical school without fully digesting the aphorism. Instead I felt in my bones, without any sense of irony or mistrust, knowing my luck, all the uncommon things will happen to me. And so I spent most of urology, most of general practice and now the first two weeks of A&E being hypervigilant. Dotting my 'i's and crossing my 't's twice. Being unnecessarily meticulous. Trying to spot zebras in a herd full of horses.

Afterwards I sat in a corner, ruminating. Trying to construct some kind of argument that would justify my referral, but I gave up halfway, realising all I was doing was trying to collagen-adhese together my lacerated ego. Maybe the system was the reason he kept coming back, I thought to myself, seething quietly (which even if it were true, doesn't justify a mental health review). But I knew it wasn't the mental health team's fault that the patient kept coming back. I knew they were doing everything they could. Sometimes if a student fails, it isn't necessarily the teacher's fault. Maybe this case was the exception to the rule, an anomaly. Maybe in this particular case, as opposed to the rest of medicine, the pathology was in fact the patient's fault.²

How do you distinguish between patients who self harm the same way some people compulsively masturbate and patients who self harm because they are on the brink of ending their life? The answer is: you can't always, but it helps to appreciate that there is a dichotomy - and also, if you've heard enough horses, chances are you'll have a pretty good idea of how their hoofbeats sound.

That's the value of experience. Once you've witnessed enough chest pains that aren't heart attacks, you'll stop believing that every one is. That's also the curse of inexperience - that until you've witnessed enough, you will continue to believe.

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<sup>1. When the consultant said 'that's impressive,' what he was implying was, 'you don't get visual hallucinations with the vast majority of seizures, and even when you do it's not of dead relatives. The story doesn't make sense.' At the time I understood this. I was aware that this didn't fit into my medical school diagnostic framework, but I doubted myself more than the patient, thinking, 'but what about the tiny minority of seizures? But what if it does?' I've never been any good at being skeptical of patients. I think of them all as victims of misfortune, who can only be healed with good intentions and a pure heart.↩

2. I still find it hard to grasp - thanks to my coddled, sheltered, middle-class upbringing - that there are people who will leap at every opportunity to take advantage of the people who are trying to help them... and even then I find myself wanting to excuse them by saying - this is the only pattern of behaviour they know, and if they were lucky / privileged enough to have formative experiences that hinted to them that there was a different way to live, they would be able to choose it over this manipulative and selfish and despicable version of themselves. If they knew there was another way to be, they could stop being this way. Maybe.

If you were raised on cocaine, how could you ever desire - how could you ever believe in anything else? ↩</sup>