advance into a hyperbolic state. He did not seem a danger to himself
or others, but rather bothersome and odd to be quite honest. We
sat down with Tyson as a treatment team – the residents, a social
worker, and myself – and had the same interaction as before. The
conversation was difficult to move forward; he was annoyingly
anxious and entitled but not overtly manic. Then the social worker
learned that Tyson’s father and uncle were at the hospital, and he
left to discuss Tyson’s situation with them.
When the social worker returned, he had a knowing look on his
face. Tyson’s father related that a few days prior, while he riding in
the car with his son driving, Tyson had thrown his arms up and
made some religious remarks. The father had feared they were going
to crash. When the father checked on Tyson at the apartment the
next day, he found the front door wide open with the keys in the
door. According to his father, Tyson had not been sleeping at all,
claiming he was practicing a religious sleep fast. His partner, in fact,
had locked himself in his room because of the odd behavior and
had called the father for help in getting Tyson to leave.
The uncle stated that within the past week, Tyson had driven several hours south of Louisville to buy a dog from a lady much older
than him. He told his uncle he loved her and wanted to marry her.
Within the past several days, in the middle of a lecture for a college
night class he attended, Tyson had knelt down on the ground to
pray and licked the floor.
Needless to say, the collateral information gathered from the
social worker changed our whole notion of what was happening.
Tyson was admitted to the locked psychiatric wing that night with
a diagnosis of “mood disorder – rule out bipolar with borderline/
histrionic traits.”
My encounter with Tyson provided valuable insight into how
difficult making psychiatric diagnoses can be. The diagnosis often
depends on one’s functionality as perceived by others. Before we
got the collateral information from the father and uncle, we were
leaning toward releasing him from the hospital with instructions
to seek therapy and outpatient counseling. Instead, Tyson’s life was
forever changed.
Being admitted to a psychiatric hospital is no small event, and I
imagine because of the stigma of mental illness, Tyson’s psychiatric
admission could have negative ramifications on his future job prospects, his status with health insurance companies, and his own sense
of self. At the same time, if Tyson truly is going through a manic
episode, monitoring him in the hospital while giving mood-stabilizing medications may be best for him in the long run. During
the interim period, while the social worker questioned the father,
I remember feeling the weight of the moment for Tyson – how the
decision to admit and the decision to label him bipolar hinged on
his father’s answers. Of course, neither Tyson nor his father knew
this – only the team and I did.
I still maintain that many of Tyson’s problems stem from underlying borderline or histrionic personality traits that until recently
had not manifested themselves in such a manner to be recognized
by the health-care system. The resident gave me a great clinical
pearl that night as we discussed the case: If a patient evokes negative
reactions in you, consider a personality disorder in the differential
diagnosis. Certainly, for most of the time I talked with Tyson, I felt
annoyed by his sense of entitlement, his overly dramatic answers to
my questions, and his refusal to believe anything was wrong with
him. I wished for a magical “insight pill” at many poin