You have been working with an Asian American family after their son was hospitalized on your inpatient psychiatry unit with concern for First Episode Psychosis. Your team completed the first break psychosis workup and all suggested normal. How do you share the big news to Andrew and his family?
[[Meet with the family->WHAT IS WRONG WITH MY SON]]
You meet with the father and mother in the room designated for family meetings. The father looks furious.
"What is wrong with my son? What is the point of medication? Those are all manufactured by “Big Pharma” to make us even more sick! Look at that thing my son was puffing on, and they’re calling that “medicinal marijuana” these days? That’s probably why he’s not right in the head!"
[[Mr. and Mrs. Lee, what have you noticed at home with Andrew over the last few weeks? What do you think is impacting him the most? ->WHAT HAVE YOU NOTICED?]]The father responds immediately, "He not sleeping, not talking to us, not going to school, not eat dinner with us! Just argue and smoke weed!"
The mother adds, "He not playing soccer or spending time with friends either."
[[Have you guys talked about why some of these changes have happened? It sounds like you both really value his physical health and spending time together. ->ASSESS UNDERSTANDING]]The patient's father looks down at his hands. "He says he is scared when he tries to sleep, but I tell him there is nothing to be scared of."
The mother shares, "I ask him why he is scared but he won’t tell me. I ask many, many times, and then I stop asking. He talk to himself in his room all the time, but I can’t tell what he saying. I tell him eat healthy, I make him bitter melon soup, chrysanthemum tea, red date congee, very cooling, but he refuse to eat."
The father cuts in, "If he just listen to his mom and eat, he won’t need medication! But he doesn’t listen!"
How should you respond to this?
[[There is no evidence that bitter melon soup, or these other homeopathic remedies will improve Andrew’s psychosis the way antipsychotic medications will be able to.->NO EVIDENCE]]
[[How do you think these foods will help Andrew? Why do you prefer them over medication?->WITH CURIOSITY]]You try to share your knowledge as a doctor with the parents. "There is no evidence that bitter melon soup, or these other homeopathic remedies will improve Andrew’s psychosis the way antipsychotic medications will be able to."
The parents look uneasy. They begin to whisper to each other.
[[Review learning points and try this conversation again?->LEARNING POINT: TCM]]You decide to approach the parents' concerns with curiosity. "How do you think these foods will help Andrew? Why do you prefer them over medication?"
The mother thinks back to her childhood. "When I grow up, my mom always makes me these items. He is very angry, very easy to irritate, 好燥, 好上火, this will help him calm down. He needs to eat more healthy things."
The father adds, "Yes, if he eats more cooling items, and less unhealthy junk foods, he will not need medication!"
[[I see, you’re wanting to help Andrew feel better. What is your understanding of why Andrew is talking and acting like he is now? ->LEARNING POINT: EXPLORING WITH CURIOSITY]]The father looks at his hands. His shoulders tense up. "I don’t know! He never acted like this before! Tell us doctor, what is wrong with him!?"
You share the results of his labwork. "We checked everything that could physically cause this. We checked his blood, his thyroid levels, for infection, for autoimmune causes, and imaged his brain, and the good news is that it is all normal."
How should you proceed from here?
[[Andrew has schizophrenia, a psychotic disorder, and he needs to start antipsychotic medication or he will not get better. ->HE NEEDS TO START ANTIPSYCHOTIC MEDICATION]]
[[Having thoroughly checked the medical issues that could cause this, and ruled them out, means that Andrew is experiencing a first episode of psychosis. This means that Andrew’s mind is giving him alarms that aren’t real, which is why he is hearing voices, scared at night, and feel people are against him. The good news is like medical conditions, psychiatric conditions are treatable, with the right medicine. ->MORE THOROUGH EXPLANATION]]The mother looks scared. "Psychosis?!?! So he is crazy! No, Andrew isn’t like this. He has straight As and is the captain of the science olympiad team. This is because he was smoking weed! I told him not to, but he didn’t listen to me!"
[[I can understand why you’re worried about the marijuana. Sometimes marijuana can worsen psychosis, but it sounds like Andrew was using it to quiet his fears at night and he only started using it after the voices at night had started. Many kids who have never used marijuana develop psychosis. There are ways we can help Andrew feel better without relying on marijuana, like with prescribed antipsychotics. ->UNDERSTAND WHY WORRIED ABOUT MARIJUANA]]Dad: I knew marijuana is dangerous! It probably made Andrew worse!
[[I can see you’re really worried about Andrew. Let’s talk about the ways we can help Andrew feel less scared while he is hospitalized, especially since he can’t access marijuana while he is here. ->I CAN SEE YOU'RE WORRIED]]The antipsychotics that I mentioned before, they can quiet the voices and the fear within a few days to weeks by adjusting the dopamine levels in the brain, and can be life changing. I’m curious, what makes you reluctant regarding Andrew starting this medication?
Dad: This medication is no good. It will change his personality, and he will become so slow, and not be able to think!
[[It’s true that all medications come with downsides. This medication can make him sleepy at first, and possibly increase his appetite and weight, but we can watch for each of these things and adjust or switch the medication if he has any unwanted responses. ->ALL MEDICATIONS COME WITH DOWNSIDES]]The parents talk to each other.
Ahhh, well the doctor didn’t say he can’t have my bitter melon soup. What if he tries both?
[[Continue with conversation ->I DON'T KNOW!]]