PDA

View Full Version : What would a doctor of psychiatry be able to do?



KCT
07-04-2011, 11:59 PM
The scene: A women believes she may experience a terrifying dream during the night. Two friends stay with the woman to watch over her.

That night the woman does experience a terrifying dream. The woman's reaction to the dream manifests as her physically acting out what she sees in her dream, but only in short bursts. In other words, she thrashes about in her bed for a moment, and then at one point jumps to her knees, and briefly flails her arms violently about. But, within minutes the woman relaxes and appears to sleep in a normal manner once more.

Her friends try to wake her, but the woman curiously resists their efforts. The woman seems to want to stay asleep. Other than this, the woman appears normal in every way and sleeps normally between episodes of short duration violent activity.

There is a potential for the woman to injure herself due to her violent reactions.

After two instances of these violent reactions during the night, the two individuals watching over her call a friend, who is a doctor of psychiatry, to come and possibly help the woman. The doctor, however, is not the woman's personal physician, but he knows of the woman's proclivity for violent reactions to her dreams.

My question is what would this doctor be able to do in this situation? I assume he could call an ambulance if he felt the woman was in danger, etc., but the woman appears to sleep in a normal manner between the short violent episodes. I also assume he and the other two people could restrain the woman in some manner during her violent periods. Say, by holding the bed covers over the woman to restrict her movements. My guess is the doctor would be prohibited from doing much else at this point. Would that be accurate?

MsWriteNow
07-05-2011, 12:31 AM
Honestly, if no one is able to rouse her, an ambulance would be called and a head CT scan would be done. If she poses a physical danger to herself or others during the outbursts then yes, she could be restrained. When this happens either in a hospital or a mental facility, the use of soft restraints are not unheard of. Basically this is gauze tied loosely to the wrists then tied to the bed to prevent flailing (and potential harm to the patient).

What normally happens is the psychiatrist would have the patient transported to a normal medical hospital to rule out a physical cause (like a brain bleed) if the patient could not be woken. From the hospital the patient would either be held for observation or the psychiatrist could have them transferred to a mental facility. Legally I think a person can only be physically restrained at home during the outburst. They have to be in a health facility to be restrained otherwise.

This is what I remember from my ER days anyway :)

I'm not a psychiatrist nor do I play one on t.v. but I thought I would answer and if I am wrong I humbly apologize.

shadowwalker
07-05-2011, 12:49 AM
Couldn't tell you about restraints at home, but they're not allowed in any mental health facility.

The psychiatrist could act as any physician would until taking the woman to an ER. Frankly, not sure why they would call the friend instead of 911...

WriteMinded
07-05-2011, 12:54 AM
I'm with shadowwalker. A psychiatrist would be the last person I'd call for just about anything. Certainly not in this instance.

NDoyle
07-05-2011, 01:34 AM
Your description of the character sounds like she's suffering from Rapid Eye Movement Sleep Disorder. Googling that might provide you with some clues as to what is ordinarily done in those situations.

KCT
07-05-2011, 01:38 AM
Thank you for your replies,

I guess I need to give you a bit more background about the circumstances leading up to this scene to give you a better perspective of what is going on. There is a paranormal element involved.

The woman was receiving information by a paranormal dream and intentionally resisted the efforts of her friends to wake her up. Basically, she was experiencing a vivid nightmare. Her two friends and the doctor don't know that was happening to her at the time. They only see her brief sporadic reactions when she acts out certain parts of her dream. In between these episodes, the woman appears normal in every way. In fact, shortly after the doctor arrives, she does wake up and appears normal and unaffected. I was wanting to know what this doctor would potentially do at that time so I could write the scene with more accuracy. Your comments help me to clarify potential issues that would crop up in this circumstance so I can address them in the story.

MsWriteNow
07-05-2011, 01:55 AM
He would definitely put her under observation I would think, I guess up to you as to whether at home or a facility. Perhaps at home as long as someone stays with her? Also check the laws of the state where the character lives. In Texas, a patient can be restrained in a mental health facility under certain conditions with physician orders and lots and lots (and more) documentation as to why anything other than physical restrains wouldn't work.

PinkAmy
07-05-2011, 11:43 AM
She's probably be referred for a sleep study. Most hospitals in the USA either have them or have one nearby to refer patients toward.
In my experience she'd see a neurologist for the sleep study, before any real psychiatric intervention.
With a sleep study they will be able to tell if she sleeps properly--if she goes from stage 1 to 2 to 3 to 4 to REM and repeats this. There are certain percentage of time in each stage that is considered "normal." I had one years ago and my stages were all messed up-- I'd go from 3 to 1 to REM for one period, then 4 to 2 to 1 to 3 and skip REM (I'm just making up the numbers, I can't remember exactly.) The neuro called in REM sleep disturbance, but I'm not sure if this is a dx used today.
REM is when dreams occur (rapid eye movement).
I also had restless leg syndrome, which caused me to wake every few minutes.
I was given medication that helped by allowing me to have a deeper sleep, although I've never been retested so I don't know if the stages are exactly normal.

Realistically, psychiatrists do little more than dispense meds and do follow-ups. They aren't reimbursed by insurance companies and HMOs to do therapy. If your MC's dreams were considered traumatic, she'd probably have a psychologist help her through the dreams.
There are sleep disturbances where people get violent- one of my friends, the most gentle guy you'd ever meet gave his wife a black eye during sleep. He felt horrible, much worse that she did. She thought it was funny. There are various forms of sleep walking and even sleep eating where patients have been known to gain weight without realizing they've been eating in their sleep. At least two people have used sleep walking as a defense for murder and at least one guy got off for killing his wife's parents. Of course they had tons of psychiatric and neurological testing to back up his claims.
Research sleep disorders. You'll be fascinated.

veinglory
07-05-2011, 06:14 PM
It would look like a sleep disorder or a few similar organic problems. If there is emergency an ambulance would be needed--and in my opinion being unable to wake someone would be in itself an emergency.

One thing a psychiatrist is unlikely to do is to enter a house uninvited by the owner and restrain a sleeping woman who is not even his/her client. Easy to see how that could end up in court....

senka
07-05-2011, 06:52 PM
Did you ever hear about "night terrors" (which is a completely different thing from nightmares)?

Look at this: http://sleep.lovetoknow.com/Night_Terrors_in_Adults

This condition sounds quite like what you described, I think.
People are sitting upright in bed or even standing, eyes open, they may even talk or look at you but won't recognize you and it is usually impossible to wake them. They may become violent, try to run away, hurt themselves or others.
It is said that most people do not remember night terrors (as they also say in this article), but if you look at google for some more material you will see that there are people wo do, in fact, remember those episodes.

If your psychiatrist knows that this exists (and I guess a psychiatrist should know that) the advice would be to put the person out of immediate danger, e.g. putting things like knives out of the way, closing the door of the room so they won't fall down the stairs etc., but otherwise leave them alone until they go back to normal sleep.
As long as the person did not injure anyone or herself there will be no need for an ambulance or anything and a doctor who knows about it to be night terror will not think it necessary to put ther person to hospital or whatever.

Unfortunately I can't tell you how common this knowledge is amongst US doctors and psychiatrist (i guess the story takes place in the USA?)... maybe you know some and can ask them?

Wiskel
07-05-2011, 08:12 PM
Ok.

You have a normal woman who goes to sleep, has a nightmare or two,thrashes around a bit, can't be roused, then wakes up and is fine. I'd really really hate to get on the bad side of anyone who thinks this justifies detention in a mental health facility. We're going to need to start building some huge hospitals if this is the plan.

Many of the answers so far are spot on.

The most important thing is that she can't be roused. If you're writing something paranormal then you get to bend the rules, but you can't resist someone trying to wake you because by the time you're awake enough to know that's what's happening then you're awake. You can refuse to open your eyes and pretend you're still asleep but that's about it.....so if a doctor can't wake you then they get worried that they can't wake you.

At that point your lady is probably on her way to A&E for the medics to take a look. Epilepsy is going to be high on the list of things to exclude.

After that, once the medics say she's fine then Pinkamy is right about the sleep study....although we psychiatrists would probably want to point and stare at her for a bit for suggesting we're little more than medication vending machines :tongue......but that's another argument for another time.

Any psychiatrist out of training will know about night terrors and will be thinking this at the bedside. Generally, they're nothing to worry about and interestingly, the sufferer usually doesn't remember having them at all.

Craig

Orianna2000
07-05-2011, 09:53 PM
you can't resist someone trying to wake you because by the time you're awake enough to know that's what's happening then you're awake. You can refuse to open your eyes and pretend you're still asleep but that's about it.....

I'm not sure this is entirely true. I don't know about the actual "resisting" part, but I do contest the statement, "by the time you're awake enough to know what's happening, you're awake". I have a history of sleep/REM disorders, including sleep paralysis. Many times I've struggled to wake, even succeeding to the point where I open my eyes, only to fall back asleep again instantly. I get trapped in a cycle of dreaming, unable to wake, sort of the opposite of false awakening. It can even happen if someone is trying to wake me, such as my husband. I'll open my eyes and gasp, coming free of the nightmare, but within a second or two, I'll be asleep and dreaming again, perhaps even screaming in my sleep, and my husband will have to keep on trying to wake me. It's utterly terrifying.

KCT
07-05-2011, 10:20 PM
Thank you all for your helpful comments.

I was wondering if I was complicating the issue by having the woman not able to be woken up, and that seems to be the case.

The original idea was the woman was being kept asleep by paranormal activity, but she would later wake and appear normal in all respects.

I'm now thinking I should go with the night terrors idea so I can avoid all the more complicated issues that have been pointed out as that would send the story off into a tangent I don't want to happen. I'll have them able to wake her between the violent episodes - so it appears to them that she is just experiencing night terrors or an doozy of a nightmare.

The two friends and the doctor don't know at the time what is really happening to the woman (i.e. she is having a paranormal experience). The night terrors scenario would give the doctor a rational explanation for her behavior and therefore wouldn't necessitate further drastic intervention on his part.

Wiskel
07-06-2011, 12:25 AM
I'm not sure this is entirely true. I don't know about the actual "resisting" part, but I do contest the statement, "by the time you're awake enough to know what's happening, you're awake". I have a history of sleep/REM disorders, including sleep paralysis. Many times I've struggled to wake, even succeeding to the point where I open my eyes, only to fall back asleep again instantly. I get trapped in a cycle of dreaming, unable to wake, sort of the opposite of false awakening. It can even happen if someone is trying to wake me, such as my husband. I'll open my eyes and gasp, coming free of the nightmare, but within a second or two, I'll be asleep and dreaming again, perhaps even screaming in my sleep, and my husband will have to keep on trying to wake me. It's utterly terrifying.

I get what you're saying. I probably should have prefixed my comment with something like "in someone with a normal sleep pattern and in the absence of a paranormal complication.

I was thinking particularly about the idea of an active resistance to being woken. From within the dream the person wouldn't be aware of what was happening and once out of sleep and in a state of mind where active decision making and active resistance are possible then to my mind the person is already awake.

veinglory
07-06-2011, 12:53 AM
If she is thrashing around but can be woken up, I am not sure why they would call a doctor to her house on her behalf. That isn't even very unusual...? She can go and see a doctor of her choice during normal business hours.

I mean, who would call a doctor for a woman without asking her unless she is unable to be woken? What doctor would respond to such a call rather than just tell them to call EMPs?

It sounded far more plausible when she couldnt be woken, because that indicates a possible immediate medical issue. But even then, well, professional liability issues through the roof (assuming US setting).

Becky Black
07-06-2011, 02:23 AM
I'd think the friend who is a psychiatrist wouldn't be likely to want to be involved, barring an actual emergency where he is the only doctor to hand. He'd be treading on the toes of the woman's own doctor. They're quite possessive like that, doctors. As a specialist he'd be someone more used to having patients referred to him by general practitioners than being called in directly by a patient - or her friends! (Though that might work differently in the US, we Brits usually have to go through our GPs for referral to specialists.) Also, as she's his friend it's not generally considered a good idea for him to also treat her medically. There's potentially a conflict of interest in a doctor and patient being too emotionally involved with each other. It's hard for the doctor to maintain the appropriate professional detachment.

I'd say if the friends tell him on the phone that they can't wake her (even after the violent episode) he's going to tell them to call an ambulance. Even if he comes over after that, just because she's his friend and he wants to help out, maybe go with her to the hospital to use his doctorly powers to make sure she's being looked after properly, that's fine. But it would be very odd for him to rush over and start treating her himself in this case.

Susi
07-06-2011, 04:34 AM
No psychiatrist is going to go to someone's house. I work for one. You'd be lucky to get him on the phone. Besides...it sounds like a dream. Psychiatry is a guessing game....even with medications. Deeper sleep might stop the dreams, therefore medications such as Lunesta could be prescribed but again it's all a guessing game with symptoms given by the patient or family.

Wiskel
07-06-2011, 11:00 AM
Realistically, psychiatrists do little more than dispense meds and do follow-ups. .


No psychiatrist is going to go to someone's house. I work for one. You'd be lucky to get him on the phone. . .


. Psychiatry is a guessing game....even with medications.

Damn I must be doing it wrong. I didn't realise i was allowed to guess. That will save me some time in future.

I'll save even more time if I stop doing about a quarter of my work as home visits too. Not a single one of my appointments for today is at my office.

Perhaps I should use the extra time to take up golf, or I might even be able to work a couple of naps into my day.



Disclaimer. No actual offence has been taken in the reading of this thread. i just happen to be a sarcastic git who finds some of the misconceptions about psychiatry fascinating.


Craig

Spy_on_the_Inside
07-21-2011, 09:28 AM
A psychiatrist, for all you see on tv, really is a medical doctor. They have to go to medical school and disect human bodies just like everyone else.

What you should understand about psychiatrist is how very hard it is to see one. Most of the ones I have worked with have a six month waiting list, and because of this, most appointments only last fifteen minutes.

Most psychiatrists on work in diagnosis and prescribing medication. Some doctors do practice therapy as well, but they are a minority.