Pyscho Drama

A young patient of mine suddenly decided to start speaking to the wall. He was angry, or so says his girlfriend who is next to him. So he yelled at the wall. This didn't seem too out of the ordinary at first. I mean, how many times, in the car do we mumble "are you kidding" to ourselves in traffic, or even worse things aloud, with no audience except an empty passenger seat and the radio. But then the yelling continued. He started to lash out at the wall, to humiliate the wall. And soon into this she realized that her boyfriend was having one of those moments, where one "loses it" and acts crazy. But in his case, the craziness continued on, and she called his mother who was unsuccessful at talking him down from this imaginary ledge.

Three weeks later this man is in my company. He spent the past two weeks on an inpatient psychiatric ward with frequent episodes like the one I described above. He was on 8 different antipsychotic medications. None worked. And after a few weeks they checked his blood labs and found, to their surprise, that many things were awry. The labs had been checked on admission to the psychiatric hospital and were normal. Now his liver tests were abnormal, and he was quickly shuttled over to my hospital for further evaluation. And after a few days of testing, including an careful eye exam which revealed the problem, and a liver biopsy which cemented the diagnosis, we had unfortunate news: there is nothing we can do for his psychosis.

The disease is Wilson's disease in which copper accumulates in tissues. This manifests as neurological or psychiatric symptoms and liver disease. Early in the disease, several treatments, most of which are geared towards chelating (adhering to and ridding the body of) copper are used. But in severe Wilson's disease, very little can be done for the brain, which can have irreversible damage.

So why do I share this story, other than its fascinating allure? For one, the patient was 23, and for those 3 weeks, while his brain worsened, he was diagnosed with schizophrenia, depression with psychosis, and several other psychiatric illnesses. And don't forget, those initial labs were normal. It is so easy, in medicine, after the fact, to start pointing fingers. This could be an essay about how the psychiatrists dropped the ball, or about how shitty things happen to young people- but really it's just an eye-opener for my readers: in medicine, one needs to fight every day not to corner people into their diagnoses. That's how we miss things. One needs to think outside the box- and be willing to be wrong. After all, it was the psychiatrists who sent him to us as soon as they realized there was more to the story: a metal accumulating in his organs, and driving him mad.