A wonderful story by the physician Glen Tompkins about an encounter with a homeless person with schizophrenia in an emergency department. It appears as comment #8 on a post of the indispensable Crooked Timber blog, so scroll down to find it.
Starting with the smile, even a beginner such as I was found it fairly easy to build up a picture of a very, very well-compensated schizophrenic. He was on his meds, which he could name and recite dosage schedules for without error, and his meds were obviously working. His affect was somewhat flattened, but less so than the average General Surgery resident, if slightly more than the average Ob-Gyn. Yes, he did believe that people, especially a distant relative and former college roomate from his immediately pre-psychotic days, were plotting against him, and he did have his delusional system, centered, as was almost always the case with schizophrenics in New Orleans at that time, on religion (Even here he showed unusual coherence for a schizophrenic, in that he felt confident enough to discuss the theological underpinnings of his system. I recall that he explained the animus to the former college roommate as arising from his commission of the one unforgiveable sin, which he identified correctly, I mean, correctly if you follow the Baltimore Catechism, as the Sin Against the Holy Spirit.) But he was able in his current state of compensation to set those concerns on a back burner, and grew most animated in our conversation when describing such practicalities as the recent loss of his home, and the discomfiture this had caused him. Most impressively, he was able to admit, without putting it in so many words, that he was really there that night to get out of the cold and damp. The ability to tell a white lie, and more than that, the tacitly admitted white lie, with grace and tact, may not seem like much of an accomplishment, but it is a social skill beyond, say ,the average Academic Internist, and quite an achievement for a schizophrenic. Even I, in my then beginner’s state of training, could recognize a schizophrenic who was very well compensated and clearly not a danger to self or others, well except maybe at danger from the weather, so I would triage this patient to 24 hours of observation. That’s plenty of time for a New Orleans cold front to pass.
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