It was a typical Monday at the Emergency department, with an air of excitement mixed with the scent of fear, apprehension and unrestrained maladies. Right from the minute he stepped into the emergency room till now, he hadn’t had a minute respite to catch his breath. Six hours of consultation and listening to the deep dark secrets of his patients had left him worn out.
He looked at the folder of the next patient he was about to call, and scanned the biodata. A 25-year-old male patient. He wondered how long it was going to take to finish the consultation and what the diagnosis would be. He had seen patients with Dementia, Seizure disorders, Cerebral Palsy and Late-onset Schizophrenia earlier. He decided that this was going to be his last patient of the day.
The patient walked in with two other people, a middle aged man, dressed in a brown Buba and trousers with a black shoe and a much older man with long, not so white beards and a tired face, dressed in a sky blue flowing gown.
After the usual exchange of pleasantries, he turned to the patient and inquired the purpose of the consultation.
“Why are you asking me?” the man replied, the tone of his voice sharp.
This is going to take a while, Dipo thought despondently. He had been hoping to spend 45 minutes to one hour tops. His stomach rumbled and he was reminded that he had not eaten all day. Taking a deep breath, he leaned back in his chair and smiled at the patient, although inwardly he was frowning.
“That is an interesting question” Dipo said “I presume that anybody that comes to the hospital usually has one complaint or the other”
“I don’t want to talk to you” the man replied and Dipo observed that he had a slight stutter.
“Are you the number one?”
“The number one of this whole establishment”
“Not at all. The head of the hospital has a different office from where you are, I am just one of the doctors working here”
“Then I have nothing to say to you”
“If I were the number one, would you have been willing to talk to me?”
“Yes, I would. Because he needs me, and I can spare him some time”
This is getting interesting, Dipo thought. He was beginning to get a feel of the patient’s perception about himself.
The way the patient talked and his dismissive attitude was beginning to point him in the direction of a deep seated sense of inflated self-esteem driving the patient’s attitude. Still, he needed to get the patient to talk.
“Why do you say he needs you?”
“I am not talking to you again. I have said all that I need to say. In fact I shouldn’t have replied you at all, because you are nobody, and you are not in the league of people that I interact with. Not that your number one is, but because of the people that are here with me, I would be willing to spare him some time, and that is because today, I have some few hours to waste”
“Okay” Dipo replied “but what if I am deputizing for the number one, would you be willing to talk to me?”
The patient turned to the elderly man, “see, I am ready to leave. Let us go”
The elderly man, the patient’s father, began to plead with him to stay. “He is a doctor, and you need to talk to him and allow him to offer you the appropriate treatment”
“This one?” the patient scoffed “this one is a nobody and I won’t waste my time talking to him”
Five minutes and the interview was not going anywhere. Dipo knew that he was not likely to get the patient to be cooperative and to give him any useful information that would help him in making a diagnosis. It was not unusual to meet the difficult patients, those who had no insight into the disease process that is eating at their minds.
“I think you should talk to me” he addressed the patient one more time “you are going to have a nice time talking to me, I am already enjoying our little chat. Aren’t you?”
A smile played at the patient’s mouth, but only for the briefest of moment. He refused to answer, but Dipo knew he had scored a major point.
It was time to get the patient’s history. He turned to the elderly man and asked him to give details about the patient’s illness.
“It all started two years ago” the father began “he was attending the state university and studying for a diploma in Islamic studies. Suddenly, he changed and became garrulous and arrogant. He became unruly and talked disrespectfully at elders and imams, something that was unusual of him. Then he started making claims to be a commander, to be the brain behind President Buhari’s presidency and other false claims.
“He declined job offers, saying they were beneath him and that he was a CEO of a company and he needs no employment. Also, he has become argumentative and he challenges everybody, especially myself to debates about history and religion”
Dipo asked and confirmed that the complaints have been present continuously for most of the time in the past two years.
“Is this the first ever episode or has he had previous ones?”
“You have no sense” the patient interjected “you must have left your brain at home before coming to work”
Silence greeted the room.
The elderly man and the other man were wide-eyed and horrified. After a moment of uneasy silence, the middle aged man turned to look at the patient and reprimanded him.
Dipo smiled. He had been caught by surprise. This wasn’t the first time a patient would be hostile to him during an interview but this was the first time he would be abused and in such a vulgar manner. He had however masked his shock and kept a straight face.
He gave himself a mental pat on the back.
You are really turning into a fine shrink, he told himself.
“So I suppose you have some reservations about the history your father narrated” He addressed the patient looking straight into his eyes. It was a battle of wits, and although he would not say exactly what he felt about the patient, he could still communicate it with his eyes.
After some seconds of stare down, the patient lowered his eyes. “Well, it is only the sufferer of an ailment that can tell you exactly how he is feeling”
“I agree. So, would you like to talk to me about it?”
“No. like I said earlier, you are not welcome”
“I am not welcome?”
“I told you that today I have some spare time to waste, and that is why I followed my father to the hospital, because he needs me. However, I didn’t get what I expected, and so I am not talking to you”
“What were your expectations?”
When the patient did not reply, he tried another angle.
“Did you really expect that when you get here, you were going to be attended to by the head of the hospital?”
“It is like saying you are going to Aso rock and expecting to be attended to by Buhari”
“That is where you are wrong” his stutter was becoming more prominent and he was having increasing difficulties with his words, signs that he was getting worked up. “if I want to see Buhari, he will come to look for me”
“Yes. Because he needs me”
“So, how does he need you, and what kind of power do you wield?”
“Why are you questioning me?”
“I am not questioning you, I am just curious. I mean it is not every day that I get to see the man that can summon Buhari at will”
“It is not only Buhari I can summon at will. There is no one in this whole world that I cannot summon and that I cannot make to do what I want”
“How are you able to do that?”
“Your time is up. I am not answering your questions anymore”
This here is one big delusion of grandeur, he concluded and ran through differentials in his head: Paranoid Schizophrenia; Delusional disorder grandiose type; Mania with Psychosis. He needed more information to clarify things.
He knew he wasn’t going to get much from the patient, so he turned to the father and the middle aged man, the uncle, who really hadn’t said much since the interview began, and started to ask further questions.
Does he smoke cigarettes or drink alcohol? What about any other psychoactive substance? What other things have you noticed that have changed about him? Does he spend excessively? Does he talk too much? Is he usually restless and hyperactive? Does he have problems completing tasks or does he leave them unfinished and jumps to another? Any irritability and/or aggression? Does he sleep well? Any change in his hygiene and execution of daily tasks and routines? Any family history of mental illness?
“Are you saying that I have a mental illness?” the patient butts in again, and this time he was really angry. “I have said it before, it is you that is mad. Who made you a doctor sef? If you don’t take time, I will slap you, yes, you are begging for it”
Before Dipo could reply, the patient’s uncle reacted again, and this time, it was with threats. The father just looked on, he was too exhausted to reply. His face was etched with sorrow and his shoulders were drooped.
“I thought you said you were a commander?” Dipo asked, his voice tinged with mirth. He was amused rather than offended at the expletives. “Don’t you know that commanders are the most disciplined? They rarely get angry and are not easily provoked; even if they are, they never show it”
“Yes, I know” the patient was more subdued. “I am not saying that I would slap you, but if you ask for it, I will give you”
“But, I never asked for a slap. Did I?”
“If you ever abuse the doctor or threaten him again, I will deal with you” it was the uncle. He was becoming inpatient. His phone had rung three times since he entered the room and he had been telling the person on the other end of the line that he was not around and to call back.
He must have a business appointment to make, Dipo thought sympathetically. Coming with the patient to the hospital was a huge sacrifice.
He thought about the close knit extended family system that existed in Africa and how it offered a good environment for recovery for patients with mental illness. Sadly, the family structure is gradually being eroded as civilization and western lifestyle becomes more pervasive.
“No amount of threat will make him stop” Dipo said. He was addressing the patient’s uncle. “His behavior is driven by his deep seated belief of superiority over others and thus he feels he can talk down on anybody. It is until he stops believing that, that he will stop acting and talking that way. I know you are frustrated, but try not to allow it to get to you”
It took another 30 minutes of history taking and mental state assessment before the interview was over.
Dipo had finally arrived at a provisional diagnosis, Delusional disorder, grandiose type. He wasn’t too sure of his diagnosis, the symptoms were diverse and didn’t fit into any distinct category but he figured, if there was any box it was closest to, then it was the diagnosis he had chosen. He scheduled the patient’s follow up for two weeks. Further interviews will help clarify the final diagnosis.
After taking the blood samples and tidying up his notes in the patient’s case note, he was done.
What a day, he thought. I can’t wait to tell the guys about this case.
It was the norm. After work, the doctors hung out at the lounge and swapped interesting stories about their days and the patients they had seen.
It was time to go.
As he stepped out of the consulting room, his bag slung over his shoulders, a woman rushed in.
“Help!” she shouted as she doubled over, panting.
“Damn” he muttered, as he returned into the room, dropped his bag and rushed out again.