A Quiet Brain

Phillips, Laura

I used to see him in the office only once or twice a year.

Then two years ago his psychiatrist retired and he came to see me regularly to renew his psych meds. He never liked those pills and often told me, his words spoken with restrained frustration.

A few years earlier, not long after I’d become his family doctor, he had come in asking to be taken off his antidepressant and mood stabilizer. He complained that they were dulling his intellect, ruining his academic work, and had caused him to pack on 50 lbs. He hated it all.

I listened to his complaints that day with hesitance. He was still new to me so I called the psychiatrist he’d been seeing for a decade and asked for advice. She was sympathetic but firm. Bipolar patients often want to stop their medications, but their risk of suicide is much greater than that of depressed patients. Bipolar patients go manic, make serious mistakes, and then as they drop towards depression, they realize the damage they’ve done and are at significant risk of self-harm.

I called him back in and expressed my concern for his health if he stopped his medications. I asked him to carefully consider everything he’d be putting at risk. He swallowed on.

Despite the tension of prescribing the pills he so openly despised, I enjoyed his visits. As I opened the exam room door I would see him, hair falling forward into his face, eyes poring through a thick novel. We would banter, chat and joke. At the end of one visit he asked when he was due for his annual "Well-Woman's Check" which made me laugh out loud. He was a quarter of a century older than I was, almost as old as my father, but he never failed to speak to me with the respect of a peer. We stood on level ground.

The undercurrent was different; when he spoke about how the pills had torn strips from his life, his words had an acidic edge. There was anger behind his eyes, controlled but shouting.

It never rested. It was never quiet.

Then early last year, he came to talk to me again about coming off his psych meds. This time, he wasn’t asking, he was insisting. I could see that I couldn’t defy his determination and that marked the beginning of a fantastical ride.

The ride began with a question for which I wasn’t prepared: would I prescribe medical marijuana for him? He was reassuringly nervous as he explained that marijuana calmed him, more effectively than the prescription meds, in fact. He had started using it back in his first year of college, and it helped him to focus on studying. Prior to that, throughout his school years, he was so scattered and restless that his teachers would send him out on errands just to get him out of the classroom. His performance in college improved dramatically with marijuana and he graduated with superior marks. He got married, worked as an editor, but he still felt a persistent restlessness. At 38, he returned to university to start his “mid-life crisis” - a doctoral degree. Shortly after his second year exams, his wife of 22 years died from ovarian cancer. Not surprisingly, her death sent him into a situational depression. After grief counselling and starting a teaching position, the depression continued and he was referred to a psychiatrist. He was started on Prozac almost immediately. He went manic, crazy, even had a run-in with the police. He was diagnosed with bipolar disorder and a mood stabilizer was added. He later remarried and still worked, somewhat successfully, but never felt at peace. Time broiled on. Out of desperation he started seeing a psychoanalyst. After two years of weekly visits, she told him he wasn’t bipolar, but rather that he was living in a state of hyperawareness and anxiety. Now he decided it was time to stop the pills.

We talked about the uncertain path ahead. He should start slowly weaning his antidepressant. Then he could wean off the mood stabilizer but there had to be constant reassessment - by himself, his wife, his analyst and me. I warned him about the need to be honest with himself; he wanted so strongly to come off the pills but what if he flared? Was he prepared to go back on pills again, if we tried something new?

Or what about looking at a different diagnosis - maybe ADHD given his early inattention problems? He didn't want to see a psychiatrist anymore; he wanted us to do this together. So we sat down with a list of adult ADHD symptoms and read them aloud. As we did this, it was as if we read aloud the inner emotions of his whole life.

I was suddenly aware that I felt uncomfortable. I had never diagnosed an adult with ADHD and never started anyone on stimulants. I was honest with him; I told him it would be a bit of an experiment and he would be the lab rat.

He agreed, and so did I. Our crazy collaborative decision.

That was when the ride took an abrupt turn. By the time he was off the antidepressant and alternating days on his mood stabilizer, he was feeling things he hadn't felt in a long time. There was weeping, rage, very little sleep. He was intensely sped up, his mind going like crazy. His impulse control rapidly disappeared. Looking at his wildness, his unrestrained anger and loud pressured speech, I hardly recognized him. It was scary just being in the room with him - I had no idea what he would do.

We were flying along the ride upside down and all the blood was rushing to our heads. I was deeply fearful that we had made a terrible mistake.

There was the niggling chance that this was right, though. There was the possibility that this irritative aggression and anger was actually a necessary checkpoint on the path to a new diagnosis. I started him on Ritalin, just a small short-acting dose.

We were right.

At his next visit, he was calm, focused and present. There was no more rage, no more irritability. He felt an incredible need to be productive. He was hardly using marijuana anymore because it took away his brightness. There were suppressed emotions and experiences that were overflowing, but he could cope. He and his wife were having the best conversations of their decade-long marriage. It was a struggle not to get caught up in anger over his lost decade of life, but he just focused on finding out who he was again, redefining himself.

At the end of that visit, I left the room flushed with joy. I was so thankful for his insistence and courage. I was so grateful for the trust that existed before we began. I was thrilled by the rush - we had been on a high-speed rollercoaster and were just now gliding up to the platform at the other end, stepping off slightly dizzy, but exhilarated.

"My brain is finally quiet," he said, at the age of 62.

Theme: Patients | Patients
Theme: Physicians | Médecins
Theme: Relationships | Relations

Stories in Family Medicine | Récits en médecine familiale [Internet] Mississauga ON: College of Family Physicians of Canada. 2008 -




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