Mistakes and Misunderstandings 1

One night on call at the psychiatric emergency department, I had once again seen a large number of patients. Some came voluntarily, while others arrived with the police and had to stay involuntarily. One patient followed the next, and I worked as quickly as I could. Just before six in the morning, I lay down after clearing the emergency room and had just closed my eyes when a nurse called from one of the wards. I had been awake for 24 hours.

“The patient you admitted yesterday is feeling worse. Can I give more Stesolid?”

“Yes,” I mumbled, barely aware of the question. We talked a little about how many tablets the patient had already received.

I dozed off for a few minutes and was then called again by the same person. It was unclear how much time had passed.

“Something isn't right; the patient is feeling worse. Can you come up and check on them?”

I went up to the ward and examined the patient. She had been admitted with what I interpreted as severe alcohol withdrawal and early delirium. I had conducted a quick examination and started a heavy treatment with benzodiazepines. Now the patient was somewhat better but perhaps more anxious and tachycardic than expected. Had I missed something? What would I have done if I had been on call at the internal medicine clinic, as I was six months ago? Or now that I’m training in neurology? I felt how tired I was and how sluggish my thoughts were. Suddenly, I became worried that I had missed something. Could it be an infection? Or a pulmonary embolism? I ordered blood tests and an IV line and reported to a junior doctor on the ward. Finally, my shift was over.

Getting tunnel vision and focusing too quickly on one diagnosis or condition is not uncommon and can lead to missing something else. In the example above, I was tired and far from at my best. In such cases, handing over to a more alert colleague is valuable. When you have an acutely ill patient, you can and should treat them in a clear order, for example, using the ABCDE approach. By systematically examining and ruling out serious issues and addressing those you find, you can go a long way. You don’t need to know the final diagnosis. You can think similarly in psychiatry. Some things need to be addressed immediately, while others can wait.

• Should the patient be admitted or not?

• Should it be involuntary or voluntary?

• Do I need to start treatment immediately, e.g., for withdrawal or agitation?

• Are special precautions needed, maybe extra supervision if there’s a high suicide risk?

The final diagnosis and how the patient will be managed over the next few days will be decided by the ward doctor and isn’t something I need to think about. Below, I will go through several mistakes and common misunderstandings I have encountered during my years in psychiatry. Some I have made myself, and others come from colleagues or nursing staff.

Acute Treatment

One mistake I have seen many times is not treating severe alcohol withdrawal aggressively enough. To prevent withdrawal seizures and the development of delirium tremens, it is crucial to administer adequate doses of benzodiazepines. You shouldn’t just give perhaps 10 mg of Oxascand but go in decisively and, above all, continuously evaluate the effect. I prefer to have control over the withdrawal before admitting the patient or setting up a treatment plan. Similarly, patients with alcohol withdrawal should receive prophylactic thiamine treatment parenterally! If there is suspicion of Wernicke’s encephalopathy, a higher dose is administered directly. It’s not enough to give tablets or think that the patient has probably gotten enough on their own. Patients with severe alcohol withdrawal are also at high risk for other illnesses or injuries. Examine them thoroughly for possible pneumonia or head trauma.

Similarly, acutely agitated patients should be managed immediately. A patient who feels cornered, lacks insight into their illness, and perhaps is under the influence of drugs is considered high risk for aggression. Such a patient should receive treatment already in the emergency room and not be admitted to a ward untreated. At our facility, we typically use haloperidol and lorazepam, either as tablets or injections.

State or trait

It’s easy to mistake a person’s temporary illness for their personality. Especially in inpatient care, you meet the patient when they are at their worst, and it’s easy to be misled into thinking that this is how they usually are. A patient with depression can become very pessimistic and sullen, even if they are normally positive and cheerful. Similarly, particularly older individuals with depression can seem almost demented. Not providing potent depression treatment, such as ECT, can result in the patient remaining in depression and being diagnosed with dementia. Overall, working in different parts of the healthcare system, from primary care to inpatient care, is necessary to get a true picture of the disease panorama. It’s hard to believe that many patients with dependency or personality disorders are quite functional if you’ve only experienced inpatient care.

Under- or Over-Treatment

In general, medicine is about distinguishing the sick from the healthy. Much suffering is part of life and will pass on its own, and shouldn’t be investigated or treated. This is especially important in primary care when it comes to mental health. Poor sleep, anxiety, or feeling down are natural after separations or deaths. Not everything needs to be medicalized! There is a clear risk of doing harm by giving the patient a disease role instead of strengthening the healthy aspects of the person. With the right psychosocial support, many conditions can be managed.

On the other hand, I have often seen how particularly depression has been under-treated. Just because the first-line treatment for depression is typically CBT or SSRI doesn’t mean that a severe melancholic depression should be treated that way. Psychotic depression is most effectively treated with ECT, not with SSRI and a small addition of a neuroleptic (read my previous post on ECT)! Similarly, patients who have had several severe episodes of depression, even without mania, can benefit from lithium prophylaxis just like patients with bipolar disorder. In Gothenburg, we have had a severe shortage of resources for ECT for many years, which unfortunately means that patients are not given the best treatment.

Not All Psychosis is Schizophrenia

In the mid-20th century, schizophrenia was much more common in the USA than in Europe. This is believed to be partly due to under-diagnosis of bipolar disorder, where American psychiatrists interpreted psychotic symptoms with affective episodes as part of a primary psychotic disorder. Today, the distribution is more even, but I have still encountered several patients where no one has considered affective psychosis. A bipolar patient in an episode can present just like in schizophrenic psychosis, with auditory hallucinations and suspicion. However, if you look at the course, you often see a difference, where a patient with affective disorder often has periods without many symptoms (read more in previous posts about diagnostics). If a person is diagnosed with schizophrenia, they typically receive treatment with neuroleptics but not effective mood stabilization like lithium. ECT is also a very effective treatment for affective psychosis and should be offered early instead of prolonged treatment with only neuroleptics.

People with personality disorders or severe anxiety can express themselves as if they hear voices or seem psychotic when they are actually dissociating. A panic attack is unpleasant, and if you haven’t seen someone dissociate, it’s easy to mistake it for something else. As with all diagnostics, it’s important to consider the whole picture and the patient’s presentation or phenomenology. If it involves a clear ego disturbance with functional impairment, it’s likely a psychotic disorder, and vice versa.

Symptoms of Illness, Not Poor Upbringing

Sometimes you hear from colleagues and nursing staff that certain patients are annoying and unpleasant or perhaps manipulative. Often, this is said about people with personality disorders like borderline (read more in a previous post here). You have to remind yourself that the core of the condition is impaired emotional regulation and interpersonal interaction. It’s in the nature of the condition that the patient has outbursts, behaves dependently, or threatens suicide! It can be managed professionally, for example, by validating feelings and clearly placing responsibility on the patient. However, you shouldn’t be cold and disregard the patient’s feelings. You make your medical assessment, communicate it clearly, and then stick to your plan.

Mistakes as a Lesson

Everyone makes mistakes, and we can always learn more. In this way, the medical profession is incredibly rewarding because it is a constant journey towards becoming a better doctor. It is crucial that we create environments where it’s okay to make mistakes, but not okay to do nothing about them. We should speak up to our colleagues and also share our own mistakes or misunderstandings and view them as learning opportunities. The role of the leader is important in creating the conditions for such discussions. This could involve regular meetings where everyone shares mistakes or where incident reports are reviewed together.

These were just a few examples of misunderstandings from my own experience. What examples do you have?