“If I’m ever angry at a psychiatrist, I will refer that doctor a patient with a first episode of psychosis.”
A psychiatrist whose brother suffers from a psychotic disorder once said this to me. She was joking, but—in a way—she was totally serious. The serious part relates to her experience as the loving family member of someone who suddenly and inexplicably became devastatingly ill. She and her family wanted to know the diagnosis, yet were afraid to find out. They alternately wanted to—and didn’t want to—discover a physical cause behind the illness. They blamed themselves, then resolved not to blame themselves.
They were educated and reasonably well informed; they thought they understood what serious mental illness was about. But when it came to confronting it in a loved one, they ultimately realized they knew nothing. In retrospect, they viewed their psychiatrist as pretty good, but at the time they had nothing good to say about him. Patients and their families often feel unhappy with the psychiatrist who treats a first episode of psychosis.
All physicians have the burden of helping patients and families come to terms with terrible, unexpected, and incomprehensible illnesses. That task is doubly difficult for psychiatrists, because of:
- the stigma attached to the illnesses we treat
- the subtlety of some early symptoms
- and peoples’ belief that a psychiatric illness cannot happen to them or to their loved ones.
First-episode psychoses may pose our greatest challenge as clinicians. In “First psychotic episode—a window of opportunity”, Christoph Correll, MD, and Alan Mendelowitz, MD, adeptly describe the many challenges we face in this clinical scenario: differential diagnosis, communicating the diagnosis, encouraging the family and patient to engage constructively in treatment, and getting the patient, attendants, and externals on the same page.
Nowhere in medicine is Hippocrates’ first aphorism more relevant: “Life is short, the art is long; the occasion is fleeting; experience fallacious, and judgment difficult.” I would probably say “help the patient … cooperate,” rather than “make the patient … cooperate,” but other than that, despite everything we have learned in medicine in the last few millennia, I would not change a thing.