Unlocked

Internalisation is a process by which genes are activated to change polymorphisms, facilitating the displacement of receptors, channels or substances from the surface to the intracellular space. I probably didn't use the correct terminology to explain the above appropriately enough, but I'm sure you have understood or are familiar, to some extent, with this biological phenomenon.

Our particular subpopulation is prone to emotional and psychological trauma. It might be foolish of me to say, but we often forget that patients are sick; patients need our help. Last week Dr. KF introduced us to Matthew, one of her favourite patients. He was a man who looked 65, but was actually 51. His big, white beard seemed well-maintained for a man who was homeless, had a longneck beer in one pocket and Tally-Ho cigarette paper in the other. His clothes were torn and faded.

Matthew sat with us for over an hour, talking about his experiences in prison (over 5 years for different offences), told us about his relationships, children; but mostly he told us about his addiction to heroin. This man was well read, mild mannered and had a cognition that was intact. There was a significant mismatch between his physical appearance and behaviour; his colloquial language and intellectual descriptions. He took us through how he had organised to continue his addiction through financial means, manipulation of prescriptions and many other facets of his life.

We patiently sat there, trying to make sense of the history and piece his story together but he was a very good communicator. He went from story to story, they all seemed related and he would use one story to explain another story, which clarified another. And we did the best we could to organise the information in order to process it, well before even thinking about presenting it to a senior clinician.

I very much appreciated him volunteering his time to talk to us about his experience. It was clear to me that Matthew was a good person, a down to earth, wise human being who had been through much more than he bargained for. He was introduced to alcohol at the age of 6 by his parents and first started experimenting with illicit drugs at the age of 14, in between reading about Ancient Greece and the components of a Constitutional Monarchy. So then why the jail terms? Why the homelessness?

Being under the influence of any drug distorts the senses. They can create are called positive symptoms (ie experiencing things that are normally absent) and or negative symptoms (ie being deficient in things that are normally present). Matthew had committed crimes of theft a number of times while being "high" on heroin or speed and well, they added up. But he never meant to steal anything. There are times he did consciously to support his addiction and maintain basic human needs such as food and drink (although beer does not constitute a human need).

But what of his health? Does he look like a 50-year-old man? What of his past medical history? Did we ask him about his family history? If this gentleman is an injecting drug user, what are his medical risks? If he uses prescription narcotics routinely, does he experience the side effects? If so, how does he manage them?


Our supervisor drilled us, painting a portrait of the patient's history on the walls with our brain matter. Matthew admitted to having two heart attacks in the past. No follow-up, no regular doctor. But why? If a person had a critical illness, wouldn't they feel the need to present to the emergency department if not their doctor, or any doctor?

Imagine you're the emergency doctor and an middle-aged man presents to you complaining of chest pain for a couple of hours with shortness of breath. After you take a thorough history of his presenting illness, past medical history and all the other biological stuff, you get to the drug and alcohol history and he admits to using heroin regularly for the past 36 years. Are you going to give this man morphine for his chest pain?


Given the way Dr. KF asked the question, the answer was obvious. But the truth is, other people out there, qualified practitioners, do not see it that way. This person could very well be trying to manipulate the system to obtain narcotics to maintain his "high". Such people are dismissed in the emergency room, made to wait hours on end without pain relief; and this was all in exchange for honesty and trust in the medical practitioner considering their complaints.

Can homeless people not have strokes? Can a heroin addict not have chest pain? Who are we to judge them?

It's a disgrace. We ignore these people, avoid contact with them and change direction if we see them on the footpaths. I wanted to help. I didn't want to judge, discriminate, or dismiss. And I hope I never do.

Initially I started writing this entry because I wanted to talk about internalisation. It is fascinating because I do it consciously all the time. I look at my life and the things that should concern me on a daily basis; sometimes I stare at the world around me caving in with the demands I have set up for myself. Then I leave all of that at the automatic doors.

I have been unable to do this in Psychiatry as of yet. As in the movie Inception, we all have secrets and they are locked away in safes, hidden deep in the midst of our thoughts, clouded and distorted by surreal defence mechanisms.

There is a lock that obstructs access to these secrets, which could otherwise be discovered through a door. It is as symbolic as it is literal. We interact with each other (friends, patients, etc) and try to make sense of who they are, their hobbies, principles and morals; perhaps we dig further and find out about their family, religion, country of origin. Over time, we may be allowed to dissect deeper until to us a door is revealed. And there is a lock. Each individual who has had the privilege of being exposed to this door was also given a key unique to them. This unique key exposes to the listener, friend (and perhaps healer) to the mysteries of an individual's vulnerability that [the patient] has explicitly allowed.

Such an intimacy might take years to build. Decades to maintain. Seconds to shatter.

Psychiatry demands instant assessment of the individual. For me, this has been an unnatural experience. I am meant to start my 'examination', or perhaps analysis, from the moment I have obtained consent for the discussion to take place. I must assess their general appearance, mood, speech, thoughts and cognition; and much more. Such things the non-psychiatric clinician takes for granted. It never occurred to me to consider these factors in assessing a person's well-being and I definitely didn't think that such assessments would unlock the door to my own darkness.

So here I am, on my blog, slowly spilling out the stories one at a time.

I have been feeling down most of the day, with intermittent bursts of happiness, easily reversed. So fragile. I didn't go into the Addiction Medicine department in the guise of a 'day off for study and rest' but the truth is, I felt weak. I didn't want to face the patients with the tragic stories for fear that my own insignificant demons in comparison would be revealed in some subtle way to reflect my weakness.

My door is slowly being revealed to those around me, but also to me and I am so afraid of what I might find if I open that door myself. I can only avoid what kind of fear I would be feeling if other people could access it. And there's the catch. I'm in Psychiatry right now, surrounded by people that can analyse my appearance, speech, cognition, thoughts and every other component we are taught to assess in each patient.

So I stay quiet, in the background, occasionally suggesting this or that, trying my utmost not to dig myself a hole.

It's the second week and I really am not sure if I am emotionally ready to face what awaits me tomorrow.

As a person with Surgery in mind as the specialty of choice, I am finding Psychiatry quite frightening and I am beginning to see why surgeons are able to avoid it, ignore it and dismiss it at the times they are supposed to address it in themselves, in their friends, family and tragically, even their patients.