August 28, 2012 | by Maureen Miller
According to every epidemiological study of medical-student mental health ever published, a large percentage of us suffer from, well, something. The discussion sections of these research papers generally propose we educate one another in mental hygiene. They suggest we should practice more “mindful medicine.” And, good students, we oblige. A medical student may not come into med school knowing how to handle a “high-functioning” anxious type in clinic, but the diagnosis doesn’t require an office pamphlet. It’s visible right there in the room.
At my school, we first learn to integrate this understanding of acute and chronic anxiety into clinical practice via the required six-week psychiatry clerkship. Six weeks of immersion in “ICU psychiatry,” the psychiatry faculty argues, is not enough time to master the management of anxiety disorders, but at least it is something. Third-year medical students spend six weeks on one inpatient psychiatry ward as well as several night shifts in a CPEP (Comprehensive Psychiatric Evaluation Program), the ER for the ill at ease.
In these settings you learn to triage threat and fear until you know from anxiety. There you learn the difference between anxiety and agitation. Panic-attack patients stay in the ER for a while for cardiac and thyroid workups. Anxiety in the CPEP counts as psychosocial stressors, or Axis IV on the DSM-IV: losing your edge, losing your family’s support, your job your benefits, your place to live. Maybe you will have an adjustment disorder on Axis I, or existential anxiety that keeps you off your axis. Agitation is losing your cool, and sometimes losing your hospital gown if you’re especially feisty. For anxiety there is benzos and SSRIs; for agitation, benzos and antipsychotics and sometimes four point restraints. They call the agitation cocktail a 5+2, for 5 milligrams of Haldol and 2 milligrams of Ativan, though I saw one “frequent flyer” get a 10+4.
The ICU psychiatry setting is, of course, high stress. I spent a few days decompressing from my six-week stint in it at my parents’ house. Mom and Dad live in a studiously bucolic gated community near Colonial Williamsburg. The décor is restrained. It is a few miles from Eastern State Hospital, one of Virginia’s sixteen state mental-health facilities. Eastern State is an upgrade from the old mental hospital, built in 1773, which was destroyed in a fire in the 1880s. I have never been to Eastern State, because I once went to the reconstruction of the colonial mental hospital, which was completed in 1985. It riled me up so much I never went back to a psychiatric ward again until I had to go for class. Avoiding triggers is easier than flooding or turning them over to the long-term management they deserve, I have learned.
There is not much time in the six weeks to discuss psychotherapy modalities—for anxiety management, we hear a lot about cognitive-behavioral therapy (CBT)—but my specific phobia of the mental hospital merits a more psychodynamic orientation. When I was five or six years old I was just coming off a pretty willful bender as a toddler. I was either developmentally delayed or selectively mute, and I refused to talk from the time I was less than a year old until I was three-and-a-half, instead electing to communicate with actions like hiding behind shopping racks and marching my classmates out of Gymboree at a local mall. By the time I snapped out of it, I began to worry, rather belatedly, that my parents had been concerned about me. I started to worry constantly: about the midshipmen who danced with my sister instead of me at my cousin’s wedding, the neighbor who put cicadas on her head, the mismanagement of the Dukakis campaign, the results of the track and field heats at the Seoul Olympics, the fall of communism. Fear of the dark didn’t do it for me, but the mental hospital did. I think it played to my persistent fears about entrapment in politics (a major issue at the time) which sounds savvy for a five-year-old until you know that I did not actually understand the context of any of these news events that so haunted me. What I understood is what I saw: a mental hospital with iron locks and white walls and no sociocultural stimuli.
To a child who is unfamiliar with words like cupola, every building in Colonial Williamsburg looks the same: red brick, white panes.The mental hospital is virtually indistinguishable on the outside from the Capitol or the Wren Building, except it is a little off the main tourist drag, Duke of Gloucester Street. Lord Fauquier, the royal governor of the colony, founded the place to add scientific innovation to mental-health care. It was the first facility of its kind in Virginia. I still kind of remember the particulars. The sample patient room had a chamberpot and a coarse mattress with a few straws loose. I saw worry lines inscribed on the painted brick, white on red brick, reproduced for the one room they chose to put on show. Essentially I saw life alone, and the horror of that was enough to induce hand-flapping and whinging on a dramatic scale. My parents took us out of there stat, and they never looked back—for my sake, they said. We drove by it a lot in later years. Actually, I remember a lot of looking back.
They joked in those years about how I might fare as a doctor, given this episode. Now that I am one, or close to it, that sensitivity has not ebbed. Often it is the underlying worry that nips me in the hall. When I visit public hospitals I am always struck by how small the bedrooms are. On the wards, then, it is comically easy to get anxious, for if you are not delirious or stuporous you are in the antsy, angsty majority wrangling with your state-issued sheets. I imagine those patients’ experiences as nothing if not understimulating, double negative to emphasize the nothing doing in recovery.
That anxiety is multiplied in the patients on a public psychiatric inpatient ICU ward, where patients pace, either for exercise or time in thought or as a medication side effect (akathisia, or restlessness). They have too many Axis IV stressors on the outside, and so we do not have as much time to get into their subacute ruminations. We learn about that anxiety on the fly, on the job. As such we are left with the inevitable churn in ourselves, and our own memories of being in hospitals with backed-up viscera. The psychiatry faculty is right: six weeks isn’t enough. We hear about CBT candidate hand-wringers like us in daily seminars, because we are what we study.
Maureen Miller is an MD-MPH student based in New York. She has written for n+1, McSweeney’s and Amazon.com Kindle singles (A Taste of My Own Medicine).