Volunteer Associate Professor of PsychiatryUniversity of Cincinnati Medical CenterJuly, 1987 to 2014

Senior AttendingGood Samaritan HospitalDepartment of Psychiatry2002 to Present

Patients with a Chronic Delusional Psychosis:What Do the Patients Teach Us?

Slides and Sources Available athttp://tinyurl.com/EnzerChronic

Charles Hart Enzer, MD, FAACAP

5599 Kugler Mill RoadCincinnati, OH 45236-2035

513-281-0074Email:  Charles.Enzer@uc.eduWebSite:  TinyURL.com/EnzerMD

Child - Adolescent - Adult - Family – Psychiatry

Privacy RulesThe Patient and I Request:

Anyone Not Familiar with HIPPA Protections for Patients, Please Leave Now

Anyone Not Bound by HIPPA Protections for Patients, Please Leave Now

Disclosures No Potential Conflicts of Interest to Report Senior Attending

Good Samaritan Hosital Practiced Psychiatry for 90,000+ Hours Board Certified General Psychiatrist Board Certified Child and Adolescent Psychiatrist Past Board Examiner Volunteer Associate Professor of Psychiatry

University of Cincinnati Medical Center

Ms Z:

Has a Chronic Delusional Psychosis Licensed Healthcare Professional Employed by a Health Care Institution Consults to Other Institutions to Prepare

for Federal Inspections Elected to Condo Board Volunteer for a Variety of Service

Organizations

Interruptions vsContributions

Questions Are Contributions Criticisms Are Contributions Comments Are Contributions

Who Is Wise: Who Learns from Every PersonSayings of the Fathers, Chapter 4, Verse 1

הלמד מכל אדם-- איזה הוא חכם

Entering the Room, You Hear Prolonged Screaming with Gasping Inhalations. Next Step?

20%

20%

20%

20%

20%1. Do nothing, further observe

2. Inquire as to what is upsetting them

3. Assess clinically, get vitals

4. Breathe and check your own pulse

5. Observe and listen

You See Tightly Clenched Fists Rapidly Flaying. Your Next Step?

20%

20%

20%

20%

20%

1. Take steps to prevent injury to both parties

2. Be supportive

3. Call security

4. Stand close to the door

5. Assure physical security

How We Began 5/23/88 Dad of Ms Z Called: “Daughter Has a Mental Problem” Family Meeting Scheduled the Next Day

5/23/88 We Called Dad a Few Hours Later to Get Face Sheet Data on Ms Z

Dad: “Do not Call Her” “You’ll Ignite a Fuse” He Got Angry “You Don’t Need the Information”

5/24/88 - Family Meeting Ms Z and Her Parents Parents Described History of “Erratic Behavior

I Recommended Rather than Request, Offer Invitations Don’t Argue Don’t Explain None of Them Are to Assume They Can Read

Minds Grant That Each Is an Expert in Their Own Skin

6/1/88 – Individual Meeting

Ms Z Complained about:

Intruders Assailants with Lethal Weapons Confusion Difficulty with Abstractions

6/1/88 – Individual MeetingMs Z’s Goals:

Having More Initiative Becoming More Independent Stop Being Vulnerable, Paranoid Being More Open Better Feeling about Psychologist Less Annoyed by Things

6/1/88 – Individual Meeting

Ms Z Described Previous Treatments:

Employment Assistance Programs Local Psychiatrist Cleveland Psychiatrist

Your Questions/Comments for Ms Z

Are you on any medications currently? Did Dr. Enzer address psycho-analytic

issues from childhood? What differences did you see with Dr.

Enzer? How often did you meet with Dr. Enzer

compared with other drs. What symptoms are you experiencing?

After Listening to Ms Z, What Is Crucial in Working with Patients?

20%

20%

20%

20%

20%1. Listen and accept

2. Listen, not judge, establish trust

3. Listen, get more insight

4. Communication

5. Availability, physical and otherwise

What Is Your Next Step?

100%

1. Enter Text. . . ..

How to Earn Distrust

See My Website

http://homepages.uc.edu/~enzerch/answers/shut_up_.html

How to Earn Trust

Suspend Moral Judgment Maintain a Zone of Safety Examine Comprehensively Inform about the Findings Make Recommendations Only When Indicated, Provide

Specific Treatments

In 10 or Less Words, What Is Doctoring?

20%

20%

20%

20%

20%1. Listening, doing the art of the possible

2. Psychological and pharmacological counseling

3. Saving lives

4. All of the above

5. Healers. . . ..

My Sources for Combining Psychosocial and Interpersonal

Therapies Flemish Town of Gheel/Geel (600 to

Present) Benjamin Rush, MD (1746 – 1813) Eugen Bleuler, MD (1857 - 1939) Manfred Bleuler, MD (1903 - 1994) The Psychiatric Day Hospital (1962) Fellowship in Child and Adolescent

Psychiatry (1970 - 1972)

Flemish Town of Gheel/Geel Since 600, Most of the Families Managed

People with Chronic Mental Disorders Fostered the Malades in Their Homes The Malades Worked in the Fields with

the Family The Malades Paid as Other Family

Members The Malades Free to Move about the

Community

Benjamin Rush, MD1746 - 1813

Signer of the Declaration of Independence Removed Coercion and Restraints Wrote one of the First Psychiatry

Textbooks Encouraged Meaningful Work Pioneered What Is now Called

Occupational Therapy Patients Recovered to Return to Society His Methodology Is Called Moral Therapy

Eugen Bleuler, MD1857 - 1939

Introduced the Term, Schizophrenia Lived among the Patients Worked in the Fields with the Patients Hiked, Played in Theatre and Danced with the Patients Introduced Psychodynamics in Research on Patients

With Schizophrenias Not A Single Psychopathological Symptom Exists

Which Is Present in Every Patient with One of the Schizophrenias

Patients with a Schizophrenia Have No Symptom Which Might Not Occur in Other Psychoses

Manfred Bleuler1903 - 1994

After 5 Years, Patients Tend to Improve After 5 Years, 75% Do Not Need Hospital

Treatment “It Is Worth Trying to Help Schizophrenics” “The Recognition That in the Schizophrenic a

Hidden, Normal, Psychic Life Continues behind the Psychotic Façade Must Encourage Us to Care for Him”

Day HospitalAlbert Einstein College of Medicine

Bronx, NY1961

A Random Double-Blind Sample of ED Patients Referred for Hospital Treatment

9am to 4pm, Monday thru Friday Patients Faired Better Than Those Admitted to

Hospital Primary Focus on Psychosocial, Occupational

and Interpersonal Therapies

What Is Wrong with the Sentence:I Am Treating 30 Schizophrenics

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20%

20%

20%

20% People not schizophrenics

Not looking beyond one diagnosis

Patients

Generalization

Helping 30 people feel doctored

Diagnoses Do Not Classify People

Diagnoses Classify Merely Disorders/Diseases

The Basics of Doctoring

Be Curious Be Thorough Enjoy Caring for the Patient

In the 2nd Century, Rabbi Tarfon said:

The day is short, the task is great, the laborers are idle, the reward is rich and the master is urgent.

It is not incumbent upon you to finish the task.

Yet, you are not free to desist from it.

והפועלים , והמלאכה מרובה, היום קצר, רבי טרפון אומרובעל הבית דוחק, והשכר הרבה, עצלים .

ולא אתה , לא עליך כל המלאכה לגמור, הוא היה אומר.בן חורין ליבטל

-- Goodies –http://tinyurl.com/EnzerGrand

PowerPoint Presentation Print Handout – Formating Choices

No Color Printer▪Change to “Pure B&W”

“2 or 4 Slides per Page Sources Consulted Inventory of Complicated Grief Symptoms

Screening Tool Taking 2 to 4 Minutes

"Prescribing Is So Easy, Understanding People

So Hard."

Kafka, Franz. (1917) A Country Doctor. The Penal Colony, Stories and Short Pieces (translated by W. & E. Muir, 1961), p. 140. New York: Shocken Books.