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News from the Johns Hopkins Department of Psychiatry and Behavioral Sciences
The fact that Lisa Tucker’s diet consisted entirely of eggs, green grapes and hot dogs wouldn’t have been such a problem except, asked to prepare meals as part of her group home duties, she refused to serve anything else. If housemates complained or she was pressed to comply, she’d burn herself with a frying pan.*
Tentatively diagnosed with schizophrenia some 20 years ago—there were hallucinations and unrealistic suspicions—Tucker left college and drifted from job to job. Her eating disorder, bound by rituals, became more ingrained with age. And though she now has the support of an able psychiatrist, a psychosocial day program and the staff of her group home in Washington, D.C., “all of them were stymied by the way her odd eating habits and recurrent burns colored her schizophrenia,” says Hopkins psychiatrist Russell Margolis. “Should they be more confrontational? Less? They couldn’t tell,” he says. And that uncertainty was reason enough to have Tucker seen at Hopkins’ inpatient schizophrenia consultation service.
Even before Margolis became head of the hospital’s schizophrenia program last year, he saw a need for broader-based consulting for patients like Tucker. “Schizophrenia is heterogeneous and complex. Its onset alone can mimic other disorders, and symptoms are so variable that early diagnosis is often difficult.” That’s especially true in a setting of substance abuse or certain personality styles or a fractured home life, not to mention other medical illness.
With the consults, what Margolis had in mind was a service for local, national and international patients that mirrors the holistic approach firmly rooted in Hopkins psychiatry. Encouraged by E. Fuller Torrey, a worldwide advocate for schizophrenia patients, and colleague Nicola Cascella, M.D., who now co-directs the resulting service, Margolis put ideas to practice.
So Hopkins consultants first search for alternate diagnoses—delusions and hallucinations, for example, occasionally have a curable cause in infection or a tumor. Psychiatrists and nurses probe for personality strengths and weaknesses, suggesting ways to play to strengths. And because patients’ life experiences can’t help but affect how they view their illness, a sharp awareness there shores up the treatment plan.
Tucker’s experience is typical. During her weeklong hospital stay, an MRI, EEG and a battery of blood tests ruled out complicating disease. Staff followed the paper trail on her hospitalizations and called for other useful records. Five faculty experts in schizophrenia or eating disorders talked with family and past care providers. And Tucker, of course, was interviewed many times.
What nurses on the schizophrenia unit saw was an extremely anxious woman. Even under mild stress, her symptoms would snowball to the point where she’d threaten self-harm. But, the nurses found, Tucker could be easily distracted and calmed if she wasn’t pushed. Meanwhile, neuropsychological tests revealed a trouble with problem solving that matched what the occupational therapist saw. Tested for ability to carry out real-world tasks, Tucker could follow only one-step directions: No wonder she roused complaints in her group home.
Advice on Tucker’s care involved shifts in medicine, changes in her environment and new behavioral techniques to damp her urge to hurt herself. And all agreed she was a prime candidate for an eating disorders program. “At the end,” says Margolis, “everyone took home something substantial.”
*For patient privacy, her name and some facts are altered.
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