“Doctor, someone is trying to kill me” says the incredible-hulk like creature, clearly with a penchant for anabolic steroids, sitting unnervingly close to me during our new patient clinic consultation. I glance down at the brief referral, as much to break eye contact as anything else. I’m a bit freaked out within the first minute and my exit is very clearly blocked. I look up and smile, what else is there? Back to my med school tactic….smile and nod…
“I’m sorry to hear that”, there is no right answer here. It’s a lame offering I admit but better than the “oh” which first came to mind. There are all sorts of opening gambits within the initial meeting between a doctor and patient, this was one of the more unusual offerings. I’m pretty sure this wasn’t covered in my consultation skills course and not even touched on during my psychiatry induction. Now I know what you’re thinking, this man has paranoid ideation, well described in the texts and even has a neat ICD-10 classification for paranoid personality disorder. This is after all what I have been requested to assess him for, an “expert opinion”, of which my 11 weeks spent in the specialty will have to suffice.
Deep breath and I just go for it. Something doesn’t sit easy with me, I tend to use my gut instincts quite a lot as I find these are more reliable than my recall for the idiosyncratic presentation of these often insidious psychiatric presentations. I’m still pretty green round the edges, far less so than when I started out but green nonetheless. This is no bad thing because greenness tends to be replaced with cynicism and this is equally limiting in large measures.
So this man describes somewhat evasively how he has a long-standing suspiciousness and general mistrust of others. He habitually relates to the world by vigilant scanning of the environment before moving into it. He is a keen observer, and reporter of others actions. He thinks his life is in danger, someone is trying to kill him. Of this he is certain.
Does he meet the criteria, is this a diagnosis sold. Not even close. Whilst telling the story he begins sweating perfusely, starts to become restless, agitated even, fists clenching and unclenching. I’m sweating too, my pulse is racing. This can’t be counter-transference, this is fear, plain and simple.
“I’ve started wearing a bullet proof vest, I’m wearing one now, you know just in case”. Funnily enough I don’t know. Just in case of what? We’re sitting in an uncomfortably small clinic room in some middle-of-nowhere provincial town but a man has just held a gun to my patients head a mere 5 hours earlier. A giggle comes from nowhere. It’s mine. I make no apology for it as if I open my mouth I may vomit.
There is only one question that’s going to get me out of here, what does he want. I’m suspecting drugs and quite willing to be held to ransom for a fist-full of blues. Hell he can have whatever he wants.
He doesn’t want drugs. Though he has played the game well. He wants a red card, the mad card, the get out of jail card. He’s not a mad man, he’s a bad man. A very bad man.
And with that he is gone. I’m left wondering if this really happened or am I part of some hilarious experiment for the sequel of the Truman Show .
As an aside can I just say thankyou to everyone continuing to read this and follow me on twitter. And also thankyou to Nick, the brains behind memorable medicine who has been kind enough to let me use his site as a further platform for this blog.