WILTIMS #318: A psychiatric portrait in pieces

Since beginning my psych rotation, I have been trying to find a way to represent the difficulty of piecing together a story from all the different sources we tap during a patient's inpatient stay. The best I could come up with is trying to analyze a picture only adding one color at a time. Let me take you through both a patient and a picture's story. The example patient is purely made up, but based loosely on experiences from the past few weeks.

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The first perspective we get is from a nurse or police officer who only knows what they saw the patient doing when the patient was referred to us. We might get something like "the patient was found wandering the street and talking about killing himself." Ok, so perhaps we're dealing with major depression and suicidal ideation.

In the painting above, all we can see is one color. With only the red to show us the scene, we can make out a few people and perhaps some trees. If I had to guess, I'd bet the woman in the foreground on the right was the important part of the picture.

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Next we talk to the patient himself. In the admission interview, we sit for a long time and try to get as much as we can from the patient's perspective. But this is still just one data point and, particularly with psych patients, the information we get may not be reliable. "Well sure I was suicidal; I've been depressed all my life, but when my father was killed by CIA I lost it." Huh. Now this seems like more than depression. Some of this is delusional, but how much?

In the above painting, we add green to the red. The two colors blend together and show more than either alone. Suddenly, we see details that were all but invisible before. There are way more people in the background, they don't seem important though. There's a cat in the foreground... prominent, but probably unimportant as well. What about that umbrella though?

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Now that we've had a moment to peruse the patient's old medical records, we can see that some things don't add up. We see that, yes, the patient has a history of depression and that he's been treated for suicidal thoughts before. But there's a big gap in his charted history and he's been on an antipsychotic medication in the past. Now, that seems important.

Next in the picture, we've added in the third primary color, blue. With it we've confirmed a lot of what we suspected from the beginning: the woman on the right is still prominent, there are people in front of a background of trees, and a woman with an umbrella is still seeming interesting. But suddenly there are gaps in the picture that beg to be filled in: why does the grass end on the left and, most intriguingly, what's that white blob in the middle?

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In the patient's old chart we see a phone number for the patient's brother and decide to give him a call. Suddenly everything gets a little clearer once we have context. Turns out the missing time was from when the patient was committed at another facility. The brother confirms the lifelong depression and that their father passed away right before the patient was committed, but that was years ago. Lastly the brother remembers something about hearing voices.

Suddenly the whole picture changes thanks to some increased complexity. This isn't just a scene in a meadow; it's a scene on the water. Now I know that white blob in the middle is important and I'm pretty sure I know what it is.

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We return to the patient and finally get the closest we'll come to an answer. Turns out he still hears voices. They're mean voices that blame him for his dad's death and badger him to hurt himself. The depression is and always has been there, but it's the voices we need to try to treat. We can't find everything out about every patient, but we can find the important things if we get enough perspective.

Our painting is as clear as it's going to get. There are a lot of things going on, but the item that draws the eye is the little girl in the white dress. However, we can't derive any meaning from this focus without the context provided from the scene. All of this requires layers of color and detail that blur together into a complete picture.

Part of the reason I picked this painting is because it's an example pointillism rather than realism; you simply can't see every detail because the painter omitted them, just as in psychiatry you can never know every detail of a patient's life. We must be careful, then, to give each piece of art its fair share of attention, lest we miss the details that spark our understanding.

TIL: There is a higher incidence of schizophrenia in people born in winter or early spring. It's hypothesized that some seasonal infection at a critical developmental time in utero, for instance the mother getting the flu, might be the cause. This is just one of many correlations that have been found, with genetics actually being the best predictor.