Inpatient, Ward 1A, Royal Ed

For a long time, I tried forgetting the psychotic episodes I'd experienced during my 20s. If anyone mentioned my spell in the Andrew Duncan clinic, I'd mention rehab. Not a breakdown. Deciding I wanted to share my story, I requested a copy of my psychiatric case file. These abridged notes detail how the medical staff assessed me during the summer of Madchester and Italia '90, an inpatient in a psych ward suffering a hypomanic episode. Staff names amended for privacy.

June 1990

Mark entered the ward following outpatient contact today for assessment. Prescribed chlorpromazine 200 mg nightly and PRN (when required) chlorpromazine. According to Dr Erskine, Mark has the potential of becoming quite unwell.

Although initially appearing restless, has seemed to settle into ward: pleasant and obliging on approach. On occasions heard talking when in bedroom alone. Spent time reading, listening to music on Walkman, but posing no management difficulty. Accepted PRN medication. Said he knows when he “needs to be drugged up.” Mentioned to colleague he “did not know you could go up as well as down.” On several instances heard talking to himself, e.g. when walking along the corridor or in the kitchen. Is aware, due to explanation by colleague, of what CLOSE OBSERVATION means.

Overnight largactil 100 mg. Slept until 8:30 am.

When asked question, anxious to answer, then get on with something else. Thought process jumbled. Is placing his state of health upon the fact the colour red ‘protects’ him from a further breakdown. Largactil 100 mg 12:15. Did not settle till after 02:00.

Remains disorganised, dominated by themes of Nazis, World War II, and the colour red he believes can cure him if he touches. PRN dose 100 mg chlorpromazine given 12:20 to clarify thought content. Mark has clear difficulty in concentrating and is unable to settle for any length of time. Did sit still for a short period to do some writing. Speech content remains confused and disordered. Easily distracted during conversation, moving from subject to subject in response to stimuli. Visited by parents today, father expressing concern about their son’s mental state. Out twice today with myself for short walks. Mark‘s conversation focused on his drug abuse and the issue of child abuse. Said, “last time I took drugs was before a church service.” Described his reaction to drug – cannabis? – as a ‘downer’ and this was the usual effect drugs had on him. Talked of the colour red and how touching something red can ward off "bad feelings" and showed me a red object he was holding in his pocket.

Mark remains on CLOSE OBSERVATION due to risk of unpredictable behaviour. Restless. Largactil 20 mg given 12:40 with no affect. In and out of bed. Largactil 100 mg given 02:30. Did not sleep till 04:30.

Very disorganised both in speech and in behaviour, forgetting where he's put things laid down a moment before. 100mg PRN chlorpromazine dose 07:00 and 09:20 with negligible effect. Duty doctor contacted re. regular regime of chlorpromazine. He came and assessed Mark, prescribed 100mg chlorpromazine tablets 08:00, 13:00, and 18:00, and maintaining present 200mg chlorpromazine @ 22:00 and PRN dose if necessary. Content of speech centring around freemasonry and Nazis, using neologisms frequently and flight of ideas prevalent. Behaviour and speech content bizarre and confused. Mark adopts unusual postures and actions. Unable to settle and concentrate for any length of time - frequently walking the corridor and at times talking to himself. Has changed his shirt a few times this afternoon offering no reason for this.

This evening Mark ran out of cigarettes and staff were unable to supply him as he had no cash. Mark became irritable and threatening in voice and manner at prospect of having no cigarettes. Given £1 from ward funds on the understanding this was a loan. Cigarettes bought by fellow patient. Mark has since appeared more settled. On CLOSE OBSERVATION. PRN largactil 100 mg 12:15. Settled 01:00 until 03:15. Bizarre behaviour since. PRN largactil 100 mg 03:40. Did not settle and sleep till 05:15.

Behaviour remains very bizarre, posturing continuously, speech content confused and difficult to follow. Extremely restless throughout day, dancing and running about ward, having to be cautioned about over-activity and limits set by staff. Has responded to setting of limits amenably, although due to level of confusion quickly forgets. Giggling inappropriately but appears to be at own thoughts. Kardex chlorpromazine increased and PRN droperidol added to prescription. Mark slept for early part of afternoon and has been drowsy and ‘slowed up’ throughout evening. Still needing limits set on certain behaviours e.g. twice he put his hand in the fish tank to try and catch one. Gesturing a lot when speaking and at times exhibiting bizarre postures e.g. holding left arm out in a twisted position as though he was doing an ‘Egyptian sand-dance,’ also using odd facial grimacing. Visited by mother this evening, out for a 10-minute walk.

This evening Mark became increasingly restless, pacing the ward, and intimidating he may hit someone e.g. as Ali Johnston was speaking, Mark held his slipper and gestured he was going to hit her on the back of the head, and going to hit Adrian McCandlish on the bottom. Duty doctor contacted as it was noted in Mark’s notes he had an acute dystonic reaction to droperidol and required IV procyclidine. She wrote him up for chlorpromazine, 200mg PRN (up to 1g in 24 hours.) Thus, 200 mg chlorpromazine PRN given at 20:20. Dr Erskine contacted IPCU and advised them of Mark’s mental state in case he needs to be transferred during the night. M Wonacutt (acting nursing officer) informed to ensure adequate nursing cover tonight and to inform her of Mark’s mental state at present. CLOSE OBSERVATION continued. Settled and slept after 22:00 medication.

Given PRN procyclidine as advised by medical staff. Behaviour becoming increasingly inappropriate i.e. head held close to a bedroom door, peering around doorframes, hunching down in corridor, giggling, content of speech inappropriate - given PRN chlorpromazine as prescribed. Said his friends’ voices “in my head” are calling him different surnames, but don’t say anything else. Claims he says he has control over voices, which he experiences all the time. Went for a short walk around hospital grounds with medical student.

Continues to exhibit bizarre behaviour, posturing and walking strangely down corridor. Continuously overactive, dancing at times, continues to misrepresent people, and it’s difficult to follow his thought processes. Some disinhibition displayed. Enjoyed sitting out on the verandah during the afternoon. Restless but more appropriate in behaviour. Slept from midnight.

Continues to be overactive and carries out ritualist gestures. A little grandiose in speech, but not as pressured and no flight of ideas. Overall conversation appropriate and concentration improved, though occasionally appears restless, wandering about ward. Spending time on verandah with Ward 1 patients and watching TV. Visited by a friend this afternoon and family later in the evening. Remains on CLOSE OBSERVATION.

Slept until 07:30. On rising, appeared restless, often gesticulating. Said he’s hearing voices but would not discuss content. Often appears preoccupied but unwilling to discuss. PRN chlorpromazine had minimal effect. On one occasion was about to go to shops with patient from Ward 1 without informing nurses. Has been advised that due to his present condition must have a nurse escort if going out of ward. Appears to be interacting well with fellow patients. Settled in afternoon. Concentration level fluctuations most of the shift. Restless and admitting to auditory hallucinations. PRN chlorpromazine 200 mg given 01:30 with no effect until 3:30.

Constantly active all morning, walking about in and around ward. Conversation often inappropriate. Gesticulating. Appears to be eating and drinking a great deal. Mixing with fellow patients but unable to settle for any length of time, becoming irritable on occasion. His whereabouts and activities need to be constantly monitored. Tending to lay his belongings in a variety of places around the ward. Concentration poor. PRN chlorpromazine given as per Kardex has minimal effect, if any. Dr Erskine suggested chlorpromazine PRN be given, if needed. Has been restless this afternoon. Encouraged to rest on the bed after lunch for an hour and before tea for half an hour. Speech in the main appropriate, though at times has been seen to gesticulate facially and with limbs in a bizarre manner.

Asking at times he can go out on his own, explained that due to CLOSE OBSERVATION he cannot. Managed out for a while this evening with his sister and a friend. Mark is eating large amounts of food, but to no ill affect. Restless and inappropriate conversation, laughing and muttering to himself. PRN chlorpromazine 200 mg at 23:30. Eventually slept from around 02:00. Remains on CLOSE OBSERVATION due to inappropriate behaviour.

Rather disorganised this morning needing close observation for unpredictable behaviour. Out for a walk to Morningside with occupational nurse. Mark needed much supervision due to his disorganisation. Needed PRN chlorpromazine 200 mg at 11:50 for restlessness and apparent response to auditory hallucinations. Has been reasonably settled, speech content in the main has been appropriate. Mark has managed a short sleep this evening. Went out for a short while with a friend and later with his sister. Appreciates getting outside.

​Still requires CLOSE OBSERVATION for unpredictable behaviour. He also has been rather disorganised and forgetful - left running tap with plug in the basin at which he seemed embarrassed. Fairly settled evening although appeared confused on occasion and quite tired. Retired at 23:30 and appears to have slept well overnight. Remains on CLOSE OBSERVATION due to unpredictable behaviour.

Very impatient awaiting visit to shop for cigarettes. Quite appropriate when out, and although overactive and confused at times, certainly appears improved and has said so himself. Restless at times, flitting from one activity to another showing poor concentration. Also complaining of being bored but has made a friendship with a Ward 1 patient. Speech content in the main has been appropriate and he says he is pleased with the apparent improvement in his mental state. Remain somewhat disorganised, sometimes forgetting where he has left things. Out for a short while with his parents this evening. Remains on CLOSE OBSERVATION. PRN largactil 200 mg, procyclidine 5 mg given 12:30, settled and slept.

Spent most of morning wondering around the ward, needing limits set on behaviour. Rather more appropriate in speech. Has appear reasonably settled throughout the afternoon, not requiring PRN medication. At times forgetful as to where he has left things such as his coat. Frequently asking to get out for fresh air on his own, explained not possible due to CLOSE OBSERVATION. PRN largactil 200 mg given 12:30. Settled 03:30.

Still needing limits set on certain behaviours e.g. twice he put his hand in the fish tank to try and catch one. 

Very disorganised and pacing constantly along the ward. Out for a spell on verandah. Remains on CLOSE OBSERVATION and disorganised manners. Communicating inappropriately. Slightly anxious about commencement of his treatment. Mark told he can go for unaccompanied walks around the grounds, but not to shops as behaviour remains unpredictable. Mark appears to have had a reasonably settled morning. Reduced to STANDARD OBSERVATION, although requires to be accompanied outside of hospital grounds. Remains disorganised and confused at times, although overall more settled. Remains muddled overnight. Unable to make decisions. Slept until 05:00 and has been restless since.

Noted to be missing from ward at approximately 10:30, not having inform staff he was going out. Search made and not found. Received phone call from his father at 11:30 to say Mark was at a friend’s house. Dad brought him back. Appeared very muddled and confused, distracted, denying he had been asked not to leave the ward without informing nursing staff. Returned to CLOSE OBSERVATION and must be accompanied by a nurse. Mark appeared to accept this in an abstracted manner. Restless when he had no cigarettes - this remedied as soon as he bought some from Morningside (accompanied by a nurse.) Retired 23:00.

Weekend pass withheld due to Mark’s unpredictable behaviour. Is now to receive another 5 mg procyclidine 18:00. Slept until 07:30. Said he felt better for having had a long sleep. On the whole, has appeared generally settled at times. Had a routine ECG as he has commenced lithium - yet to be seen by medical staff but appears normal. Went out with mum and dad for a run in the car and on return to ward appeared much more settled, although confused at times. Has been talking about going to the pictures with his sister tomorrow. Remains on CLOSE OBSERVATION. Settled and appropriate during evening. Settled approximately 11:30 and slept well since.

At times easily distracted. Concentration poor. Enjoyed trip to pictures with sister. Collected by parents. Mrs Fleming thought Mark has proved quite a lot over the past couple of days. CLOSE OBSERVATION continued. Settled and slept.

Pottered around the ward and very supportive to another patient who was distressed. Much more settled this afternoon. Chatting away. Gone out for the afternoon and evening with a sister. Due to return at 19:30. CLOSE OBSERVATION continued.

Appropriate speech on behavioural approach me to talk about lithium and his ‘illness.’ Mark appears to have insight into his need to take time off from work prior to recommencement. Out with a sister and a friend this evening settled at time of report.

Out to shops with friend Emma for half an hour and now on STANDARD OBSERVATION. Out of ward from time to time for short periods and telling staff firstly where he is going. Has spent time with visitors and appears settled. Looking forward to pass Friday to Sunday. Out with his parents for the afternoon and evening for his mother’s birthday party - due back in ward 20:30. Returned to bedroom 23:00. Slept well.

Quite bright in the morning, out to Morningside with fellow patient, EmmA. Out with parents for afternoon and evening - has 18:00 medication, due back at 20:30. Sat watching TV retired to bed around 11 pm. Slept well, up at 05:00.

It was discussed and agreed Mark can go out on a day pass from 10:00 to 20:45 tomorrow with his family. Also discussed chlorpromazine will be stopped on discharge, gradually, but lithium maintained, and importance of lithium explained. A good morning, out to Morningside with Emma, says he feels “much better now” and realises the odd thoughts he had on admission were not real but down to his illness.

Up early this morning, appeared settled. Is out for the day with family, due to return around 20:00, supplied with medication. Continues to tolerate lithium therapy. Pass agreed Friday to Sunday, due back at 20:00. Watched TV all evening and slept.

A quiet morning, out to Morningside with Emma. Collected by his dad this afternoon. Mark has gone on a pass until Sunday evening. Return from pass at handover. Settled on ward and slept well. Has gone out with mum and dad for the afternoon, due to return by 21:00. Dad has appointment to see Dr Erskine tomorrow at 14:00. Out with parents this afternoon, due back on the ward at 20:30. Present on ward at changeover. Improvement maintained, slept well, up for breakfast. Spent much of the morning out of the ward. Out for the afternoon and evening with friends, due back 22:00. Returned to the ward and is asking if he can have permission to go for a pub lunch with his parents tomorrow as it is his birthday.
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Procyclidine discontinued as it no longer deemed necessary. Mark spoke with Dr Erskine about his discharge. Advised to take 3-4 weeks off work to convalesce. Is planning to visit the office with his father to make contact again. Going out for a bar lunch today with his parents for his birthday. Kardex for discharge, bright and settled around the ward. Out of the ward all afternoon, due to return at 21:30. Quiet and appropriate around the ward. Making plans for discharge this afternoon. Went home at 14:15.