Evaluating psych patients in emergency room settings, with Rob Tarzwell - People Who Read People: A Psychology Podcast

On this episode, I talk with Dr. Rob Tarzwell, a psychiatrist and psych researcher. I talk to him about his 15 years as a psychiatric doctor in emergency room (ER) settings. We talk about some of the strategies and processes involved in trying to distinguish psych conditions from other types of conditions in the ER, and Tarzwell talks about some interesting cases that posed evaluation challenges. And we talk generally about the nature of mental illness and personality disorders. A transcript is below.

We also talk about a topic that I talked about in my recent interview with Dr. Timothy Jay: how there can be psychological or brain-disorder factors behind some instances of widely-shared/viral bad behavior, including racist behavior. We talk about a specific case involving a woman who was caught in three separate videos saying racist things to people of Asian descent, and what conditions might help explain her behavior. We also talk about a poker YouTube personality who had had some clear mental health struggles and who died earlier in 2020, and what could help explain his behavior.

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TRANSCRIPT

Zachary: Hi, I’m Zachary Elwood and this is the People Who Read People podcast, where we talk about understanding and predicting human behavior. You can read summaries of past interviews at readingpokertells.video/blog.

Today’s episode is an interview of Dr. Rob Tarzwell, who I talked to on August 6th, 2020.

This is the second time I’ve interviewed Dr. Tarzwell. A few episodes back, I talked to him about his work analyzing SPECT brain imaging and correlating brain imaging with conditions affecting mental health.

In this interview, I talk to Dr. Tarzwell about his 15 years experience as a psychiatric doctor in emergency rooms. Topics we discuss include:

Strategies for evaluating emergency room patients and distinguishing psychological conditions from other conditions
Interesting experiences he’s had attempting to evaluate patients
The nature of psychological illnesses, including how the surrounding environment and culture can influence delusions
The nature of self and consciousness, and how that relates to mental illness
How meaningful the names and categories we assign to various mental conditions really are, and the impacts of the language we use to describe these things.

In my last interview for the podcast, I talked to Dr. Timothy Jay, an expert on cursing, about offensive and abusive behavior and the lesser known factors that can be behind that. In this talk with Dr. Tarzwell, we talk about this topic, too. We talk about some specific examples of people behaving badly, and Dr. Tarzwell talks about mental health factors that can influence people to behave in offensive ways, including personality disorders and what exactly those are.

Okay, here’s the interview…

Zachary Elwood: Okay, here’s the interview.

Hey, Dr. Tarzwell, thanks for coming on again.

Dr. Rob Tarzwell: Hey, thanks for having me back.

Zach: What kind of situations did you see that were the most common, was there a pretty consistent breakdown in the types of cases you saw? And what did that look like?

Tarzwell: The broad categories of cases that would get referred in emergency room psychiatry, I’d say the majority would be an individual who is referred for suicidal ideation. That’s the bread and butter of emergency psychiatric work. Along with that, there’s referrals from individuals who have either acute, emotional, or behavioral disturbances. So, acute psychosis is a common reason for referral. And then the third broad category would be individuals who have expressed violent intentions towards other people. Quite often, psychiatry gets involved in those cases where it’s not clearly a police matter, or even sometimes if it is a police matter, then psychiatry might still get involved if it’s thought to be an expression or an outflow of an acute psychiatric emergency. Then after that, there’s the broad mix of individuals in various types of crisis, or individuals who are still intoxicated and behaviorally disturbed, but there’s no acute medical emergency so they are cleared by the emergency room but not yet safe for discharge. And so they often end up in the care of psychiatry for reassessment once in a state of sobriety to determine whether there is a safety issue and then sent on their way either on their own or off to rehabilitation or recovery services.

Zach: It would seem, with all the conditions that you’d be diagnosing or evaluating, there’d be a good amount of overlap between different conditions, you know, between maybe substance abuse and a psychotic break, or between I was reading about hypoglycemia and how that can look like, catatonic depression or things like that. I know this probably is a pretty broad question, but what were the strategies you would use to try to evaluate someone quickly for these kinds of common behavior areas?

Tarzwell: The approach always tends to follow the same format. It’s a bit like when you go flying, you never know what to expect but you always have the same checklist. So the individual will come in to the front door and there’ll be seen first by the triage nurse who will make a preliminary assessment whether the individual is in any medical distress or whether this is a psychiatric crisis without medical implications, and then the possibility existed of being directly referred to our service. Or it would really depend on the physician’s own comfort level. Some psychiatrists were comfortable taking patients directly from triage. I didn’t mind that. And then there were other psychiatrists who were more like, “Well, let’s follow the usual pathway. Let’s make sure this patient gets assessed by an emergency physician before we get involved.” My thought on that was, I didn’t go to medical school, I think if it’s apparent to me that there’s something that looks like a medical emergency arising, I can get preliminary bloodwork going and I can refer back to the emergency physician as needed. Ultimately, it may typically result in a patient being seen by a physician more quickly than if they would sit in the emergency room. Because one thing in Canadian emergency rooms, there’s a triage score ranging from immediate life-threatening emergencies that come in that get seen right away. So, that’d be an individual in respiratory arrest or cardiac arrest. They go immediately to the front of the line. That would be what we call a CTAS 1 or a Canadian Triage Assessment Score. And then down to three and four. And most individuals in psychiatric crisis, there’s not an immediate threat to life or limb once they’re in a contained environment so they would be triaged either a three or a four. So I’d be sitting in the psychiatric consultation office and I could see out into the waiting room the patients waiting to be seen by psychiatry, and so it just made more sense to me, “Well, all right, why don’t I just get started with the preliminary workup? And if something arises, then we can get the emergency room physician involved.” Did I answer your question? [laughs]

Zach: Yeah. Well, I’ll follow it up. How often would you say it was that you were uncertain about what someone’s issue was, and unclear whether it was due to substance abuse or intoxication or organic disease? How often was that confusion present?

Tarzwell: Probably fairly regularly when I was a resident. That’s in the phase of learning. Over time, you develop a much better train to gestalt for the manifest ways that drug intoxication or drug plus alcohol intoxication can manifest, or drug withdrawal. You get a sense of what a primary psychiatric disorder looks like, versus a psychiatric disorder complicated by substance use versus say a psychiatric disorder, either primarily the result of substance use or a general medical condition. Or the whole mix. You’re juggling all these balls all the time. And at some point, it becomes internalized and you just kind of get this mouse in your pocket. And every once in a while, the mouse crawls up your back and it breathes on the hairs in the back of your neck and you get to learn to listen to the mouse and you say, “Mhh, you know, why don’t we get some blood work cooking on this individual?” Or, “Hey, maybe this isn’t a panic attack. Maybe we should get an EKG.” Things like that.

Zach: Kind of a sixth sense.

Tarzwell: Yeah. And more often than not, it ends up being a false positive. The blood work’s negative and it’s just yet another unusual manifestation of a psychiatric disorder. Because we certainly haven’t seen all the varieties and combinations of human behavior, but once in a while you make you make an important catch and you’re sort of like, “Okay, I’m really glad we caught that one.”

Zach: When you have those sixth sense feelings of, “Oh, it’s this or that,” do you feel like it’s always something you can logically put your finger on and explain after the fact and say, “Oh, it was due to this thing that I noticed, even if I didn’t notice it consciously,” versus do you feel like sometimes it’s just unexplained and there was something you had a sense of that you couldn’t actually find categorized later?

Tarzwell: Yeah. Retrospectively, cases just about always end up making sense. There are still a few that years later, I just scratch my head and wonder what was going on and still don’t know. But 999 times out of 1000, retrospectively, it all makes sense. It’s prospectively, that’s where you’re really relying on intuition. And that comes down to very important fundamental steps that you just never want to miss. So, did the patient get a set of vital signs from the triage nurse? Was there any preliminary blood work? What tests did the emergency physician order? Have those all come back yet? Did I take a careful history? Did I miss any aspects of the history? And often, that’s where you’re going to get tripped up. It’s missing the fundamentals. A lot of times you can take shortcuts, and part of the path towards becoming a consultant is that sense of what you can omit, at least for now, in the interest of efficiency. Because the emergency room is often a very busy place. So, that multi-layered approach from the triage nurse to the emergency physician to the psychiatric nurse who does a preliminary assessment, then to the psychiatrist, you have a lot of layers to sift what the clinical issue or issues are before having to make a final disposition.

Zach: Did you ever have any instance where you had kind of a sixth-sense feeling about something very early on and you wondered why you felt that way, and then you turned out to be right and you were surprised?

Tarzwell: I would have to say that does come up once in a while there. There are cases where something is just not adding up. I think one of the most spectacular examples I can think of was when I was in training, there was an individual… I was in Nova Scotia. There are two bridges that cross the harbor from Halifax to Dartmouth. And quite often, whether you were at the Nova Scotia Hospital in Dartmouth or whether you were at the QEII hospital in Halifax, you were assessing people who were brought in from the bridge. One morning, just the most weird case came in. This was a guy, he came in and he was wet. He claimed he had jumped from the Macdonald Bridge, swam to shore, and walked to the hospital. When we asked him why he had done that—it was the day Christopher Reeve had died—and he said, “I just couldn’t imagine living in a world without Superman.” That was really… Something about that I found very moving. But also, he said, “Yeah, and my ankle’s kind of sore.” What was interesting is he’d kind of gotten brushed off by the emergency doctor because he was clearly walking around and he was doing fine, right? And I’m like, “Ah, Macdonald Bridge! That’s about 10 storeys before you hit the water. That’s a long way! Why don’t we get an x-ray?” And it turned out this guy had absolutely shattered his ankle.

But one thing that’s really unexplained but clinically really interesting is individuals in acute psychotic states often have very different pain perceptions than you or I might have or that they might have when they’re in a state of recovery. It turned out that this guy needed emergency orthopedic surgery. The hardest part then ended up becoming persuading him to just stay off his ankle because he just wanted to keep walking around because he was somewhat agitated. He did ultimately get that surgery and then he was able to be safely admitted to the psychiatric unit. Or another time, a patient got referred to our service and one of my resident colleagues at that time noticed that there was just something not right. And then she observed him more closely and noticed a very subtle, asymmetrical facial droop and pulled out a reflex hammer and like, “Hey, I think this guy might be having a stroke.” And into the CT scanner, he went. And sure enough, there was bleeding in his brain. So he called back, “I agree he’s behaviorally disturbed, but I think he needs to see a neurosurgeon, not us yet.” So once in a while, those kinds of things do happen.

Zach: In that case of the guy with the foot, could that also be the adrenaline of jumping off the bridge combination or something?

Tarzwell: Well, maybe. But the distance he had to walk to our hospital was about 10 kilometers or six miles in Yankee talk.

Zach: Oh, wow!

Tarzwell: Yeah, and a lot of it is uphill.

Zach: On a shattered ankle.

Tarzwell: Yeah. And he just did it. [laughs]

Zach: Well, that’s the amazing thing about psychosis and schizophrenia-type symptoms. Most people don’t realize how much the pain perception can be just completely non-existent.

Tarzwell: Right. Yeah, completely altered. And then just as a flip side, I remember when I was a junior resident on the inpatient service, there was a patient I was working with on my six-month rotation. She was there the day I arrived, she was there the day I left. But there was this amazing window of about eight weeks in the middle of her admission, she fell and broke her hip as sometimes happens to an elderly person– hospital floors are hard. And through the process of surgery and recovery and physiotherapy, a completely different person emerged. She was no longer psychotic. She was organized, she was rational. She was participating with physiotherapy, she was doing her exercises. As her hip recovered, she slowly sank back into her really disabling disorganized psychosis. I remember one time having the most insightful conversation with her and I can’t duplicate her lovely Scottish accent, I said, “So, what’s the reason that you think you’re here in the hospital and have been for such a long time?” And she just looks at me with these very compassionate eyes and says, “Oh, don’t be silly. It’s because I’ve got the skits. I’ve had it for years.” [chuckles] I mean, that was the most direct conversation I ever had with her. After she went back into her disorganized state, she was sort of gone again in that sense.

Zach: That’s wild how people can have that awareness mixed with going back and forth with not being aware.

Tarzwell: Yes, and I’ve noticed this several times and I think a lot of psychiatrists would report this—I’m sure it’s been studied, it’s not something that I’ve looked into the literature about—but psychiatric patients who get into desperate medical crisis, it’s somehow able to exert an organizing or rallying type of an influence. I worked with a patient for a while who was convinced that he was Satan and that he had to die in order to save the world. Otherwise, he was going to do something absolutely terrible. Unfortunately, one day while he was on a pass, a limited pass within the hospital that has a rooftop– or not a rooftop, but an upper-level kind of courtyard, which is at the top of a parking garage that’s four stories up, he took the plunge over the side and completely shattered both of his legs and somehow survived. And he needed the intervention of multiple surgical experts. He needed orthopedics, urology, neurosurgery. He had just badly fractured his legs and his pelvis. Thankfully, he was young, he came through. But he was another guy who, while he was in the wheelchair, while he was recovering, cooperating with care, completely rational, and again, just watching him just rally but then descend back into the psychotic state after his injuries were in the clear and he was on his way in terms of the rehabilitation, it’s heartbreaking and fascinating at the same time.

Zach: One thing I haven’t read much about but I wonder if you have a thought on it, it seems like the awareness of your strange mental condition can coexist with delusions and be present at the same time. Because it seems like when you look at people with really scary delusions, if they actually fully believe those delusions, there’d be much more instances of them hurting people or hurting themselves. But there’s a coexisting of some level of them realizing, well, I shouldn’t go too far with this. You know? I don’t know if you have thoughts on that.

Tarzwell: Yeah, we subdivide that in psychiatry and we make a distinction between insight, which is how connected you are with reality, sort of the consensus reality world that we all tend to operate in like, “Oh, that’s a table over there, it is raining outside, I need money in order to pay for goods and services.” Being in contact with reality, or realistic, we call it, but not in the usual sense of realistic. And distinct from insight is judgment, and judgment is the quality of your decisions. You can have intact judgment despite having impaired insight or even completely absent insight. Of course, we all know people who have good contact with consensus reality and make absolutely atrocious decisions. So you can have very poor judgment and be very well connected to reality in some sense. So when we describe an individual’s mental state, we comment on their insight, and then we comment on their judgment and whether their judgment is influenced or not influenced by their psychotic mental contents.

Zach: Two dimensions. Yeah, that makes sense. I’ve never heard that talked about but I’ve often wondered. It’s kind of amazing when you look at the sometimes terrifying delusions and beliefs that some people have that worse things haven’t happened to them.

Tarzwell: Right, yeah. One thing that a lot of people have heard about, and it’s the so-called ‘sexy psychotic phenomenon’ would be command hallucinations, which is a voice telling you to do things. One of my favorite conversations about this was with a forensic psychiatrist who was a mentor of mine. He said, “Well, the thing about command hallucinations, it’s sort of like any idea. The less outlandish it is, the more likely you are to do it. If you have the command hallucination saying, “Pick up the salt shaker and put it over there,” you’re probably just going to do that. But if you have the command hallucination telling you to assassinate a major political figure, you might be less inclined to go along with that. Just because it’s there in the mental furniture doesn’t necessarily mean that you’re going to be especially obligated to rush out and act on it.

Zach: Another aspect that I don’t see talked about much too is there can be an element of a person not actually believing the thing fully. And I think the reason it doesn’t get talked about much is because it might imply that they’re faking it or choosing to do things despite knowing it’s not real. For example, I talked to someone who had a psychotic experience episode and he described it as basically choosing to go down this rabbit hole where, for whatever reason, he basically was doing a what-if scenario like, “Oh, what if I live my life and make these decisions as if this thing were true?” In a sense, he obviously wasn’t in the best mental state, but it was also where he was acting as if this thing were true and entertaining the idea that it were true in this in the hopes that it would lead to something else. And I think there can be all sorts of scenarios that don’t involve someone completely believing in a delusion that still makes them behave in unusual strange ways.

Tarzwell: Right. Or the flip side of that was an individual I encountered multiple times. He had perfectly preserved insight but would encounter such disturbing hallucinations that would drive him to almost immediate suicidality. Typically, he would say to me, “Look, I nearly drove my car off the road. I really think you need to admit me to the hospital or I’m going to do something really regrettable.” And he was right, so we would bring them into the hospital and help them get back on the path to recovery. That was the most striking example of preserved insight in the face of an onslaught, and yet, feeling as though he had significantly diminished capacity in terms of action. So it can be anywhere from zero to 100 on the insight and the judgment axis, and there’s a loose correlation, but there are so many exceptions.

Zach: For all of us, it’s like we all contain multitudes of viewpoints, and I think sometimes there’s this desire to boil it down to these simplistics like, oh, this person has these X beliefs or delusions. But I think for all of us, we have combinations of viewpoints. We might try to kill ourselves and then all of a sudden not want to do that, you know? It’s like we have these competing views a lot of times.

Tarzwell: Yeah, I like the way the philosopher Daniel Dennett puts it. “Yes, we have souls, but they’re made of many tiny robots.” I mean, we have full conceptions of ourselves as an internally coherent self and that there’s a single narrative thread that can describe it, but that’s the convenient user illusion that we have about ourselves. I think the reality of ourselves is vast and complicated, and individuals in various states and psychiatric crisis really show us where the edges of that simple smooth appearing surface actually are when those edges start to come apart.

Zach: Right. I really liked Dennett’s “Consciousness Explained” and it really changed my way of thinking about consciousness and mind. I can really see examples of his theories when you just get these inklings with your own mind sometimes of how arbitrary sometimes a memory is, and how it’s just like this boiling down of all these competing things. It’s not this one truth, it’s a boiling down of all these competing narratives that are going on in your brain and all these activities in your brain. It’s a great book.

Tarzwell: Yeah. I sort of take from that that this is probably in part the power of psychotherapy, which is to help individuals essentially rewrite their narratives from malignant towards more benign kinds of narratives that they’re then less tortured by their own histories, and able to function more effectively in the present.

Zach: The more I read about schizophrenic symptoms and psychosis, it really seems to me that these are disorders of existential disorders. I know that’s a controversial idea and I still believe there’s genetic components too, but I think there’s a logic under the hood in the sense that there’s these existential, you know, for example, not having a very coherent model of self, not having a coherent model of reality. And even if there’s genetic components too and people are predisposed to it, the way they play out really seems like there’s some logic there under the hood in the sense that people are striving to make sense of these models that we take for granted that have ceased working for them. You know, models of of how their self relates to the outside world and relates to others.

Tarzwell: Yeah, I think a simple way of thinking about this… One year, it was a really strange year, but I had three separate patients unknown to each other, over the course of the year, all convinced that they were the illegitimate love child of a former Canadian Prime Minister, Pierre Trudeau. His son Justin Trudeau is the current Prime Minister of Canada. One thing that’s problematic about that is if you attempt to approach a member of the Trudeau family, you’re going to be intercepted by an RCMP officer and it’s not going to go well for you. And you’re going to end up in front of somebody like me, which is what ended up happening in two or three cases. Problem is, I’m the guy that comes along and then starts treatment, anti-psychotic medication, then attempting to kind of re-situate you back in the reality of your world. And undeniably there’s something really… I mean, how amazing would it be for you to wake up tomorrow morning and realize that you were, say, a blood relation of Barack Obama? That’d be like, “Wow, that’s trippy!” At the very least, that’d be really cool. Right?

Zach: It’s ego boosting. It’s appealing in various ways. Yeah.

Tarzwell: And it’s novelty, right? So there’s this novel aspect of it as well. So I’m coming along and my job is to take away this thing for you that is very organizing, it injects your life with meaning. Those parts I don’t have a problem with. The problem is when you get influenced by that belief to the point where you’re a public nuisance, or you are a nuisance to a particular family out in the community. That’s where we kind of have to step in. But one thing that we’re learning more and more—and this is in particular, there’s a colleague I work with and she does a lot of qualitative research with individuals in the bipolar community—is that lots and lots of individuals with, say, bipolar disorder– and I assume this is probably true across many psychiatric disorders– they don’t want their symptoms to be completely relieved. There’s an aspect of mania that is a source of joy. It’s a source of energy. It’s a source of ideas and creativity. But if also unchecked, instead of becoming a breeze that turns a wind turbine that creates electricity, it’s a tornado that rips apart a city.
There’s this fine balance that she’s discovering that a lot of individuals are wanting to live with. They don’t want to be completely squelched out by medication, they want some aspect of that. There’s an aspect of that’s fuel, even though the flip side is the depression and the terrible dysphoric moods. I had an individual once described to me who had visual, not hallucinations, but illusions. And the difference is hallucination is not linked with a percept, whereas an illusion might be you hear a fan or somebody switches on a fan and you hear a conversation. So actually there is objective stimulus that then gets confused or rearranged in some way that we don’t fully understand. So there was an individual who I was working with who had visual illusions, that, for instance, when she would look at playing cards, the kings, queens, and jacks would come to life and would begin engaging with her, and would just sort of see magic everywhere; leprechauns and fairies. And to an extent, that was benign and she didn’t want to have that go. But unfortunately, the treatments we use, to some degree are blunt tools. And they do tend to take those things away, or they can anyway.

Zach: One thing I’ve often wondered is, how many mental conditions or emergency episodes are due or influenced by lack of sleep? Because I know I’ve read that lack of sleep, obviously, can have very disorienting effects on people. And I know that dealing with various types of mental distress can make you lose sleep. So, what’s your opinion on that connection?

Tarzwell: I certainly have seen no shortage of individuals who are experiencing insomnia. That often seems to be part of the final common pathway leading to the emergency room presentation– when an individual is getting to the point where they cannot sleep anymore. Sleep maybe starts to go a little bit off early on, but then by the time it’s completely gone, then yeah, individuals who can’t sleep are often not having a good time. That greatly exacerbates everything. So if you’re depressed… Well, depression is kind of an interesting exception. There’s some interesting research that if you sleep-deprived somebody who’s depressed overnight, they’ll feel better in the morning. But as soon as they sleep, they wake up and they’re depressed again. Under research conditions, that’s true. But lots of individuals who are depressed and a bit anxious and stressed out and the boss is on their case and they are having friction with their families, when they can’t sleep, that’s kind of like, “Oh boy, now I’m in real trouble. Now I need help.” So there are individuals who their presenting complaint to the emergency room will be, “I just can’t get sleep, and I need to get sleep.” They may not initially be identified as psychiatric emergencies but as the emergency physician takes an interview, he recognizes, “Oh, wow, this is a big pile of stressors.” They’ll work their way over to us. And certainly, some of the most effective early interventions that I can offer somebody is to give them a good night’s sleep. It doesn’t sound like much. But wow, your perspective can change dramatically if I give you a mild sedative and we can turn the lights down, and you wake up in the morning and you’re like, “Hey, you know, maybe I can find my way through this problem.” It’s nice when a simple intervention like that can have such an effect. Even individuals who are in more significant states who need to be admitted, the very first thing that we address is sleep-wake cycles, chronobiology, sleep-wake reversal is often really common with psychiatric disorders. It’s certainly common with a lot of substance-induced psychotic disorders like, say, from crystal methamphetamine. We’ll have individuals coming in who maybe haven’t slept in 21-28 days on a really long crystal meth run. And okay, soon it won’t be a problem for you asleep, but we’re going to have to get you to sleep for now. And that’s the beginning of recovery for, I would say, just about everybody.

Zach: Yeah, just speaking from experience, I’ve dealt with major anxiety and depressive episodes and I’ve had panic attacks, and I’ve also gone through periods when I had really bad insomnia. And just the fact that insomnia alone, sleep deprivation can get you pretty close to or even lead to a psychotic break on its own, it just seems like that could be a cycle of making things worse for someone who’s close to that anyway. And then they don’t sleep for a while, and then they have a psychotic break, and then it just seems like a total cycle possible there.

Tarzwell: I’ve lost count of the number of times I’ve heard the story. “Yeah, I took a lot of pills. I hadn’t slept in four days. I just needed to sleep, and I didn’t care how it happened.” There can definitely be individuals, who from sleep deprivation and the suffering that induces, lose the will to live. Or they’re not necessarily wanting to die, but are absolutely willing to accept that risk. “If half a bottle of sleeping tablets will get me to sleep… If I don’t wake up, oh, well, but I must sleep.”

Zach: They’re so desperate. Yeah.

Tarzwell: Yeah. Yeah, sleep is absolutely important. I can even remember myself when I was on basic officer training in the ’80s. In my previous career, I was in the Air Force in Canada. And by about the third day out in the bush, logs are becoming enemy soldiers or morphing into friendly soldiers, and you talk to them and they don’t talk back and you look again and it’s a log and you’re like, “What is happening?” Yeah, yeah.

Zach: Well, when you’re sleep deprived, the world quickly becomes pretty menacing. And just from sleep deprivation, you can get a sense of what some of the schizophrenic feelings of persecution or delusion are like just from sleep deprivation. When it comes to trying to distinguish if someone’s under the influence of drugs, was it usually the case that people were pretty forthcoming and honest about that information?

Tarzwell: Yeah. Well, it really depends. Because if an individual’s paranoid, they may or may not tell you what they’re using. But in a lot of cases, if you are non-judgmental, you will just go ahead and ask them. The emergency physician, often if an individual’s mental status looks impaired in some way and you can’t get an adequate history, they’ll just send off a urine drug screen. In Canada, that’s a $2 test. In America, that’s a different story. Right?

Zach: Right, you’re going broke.

Tarzwell: Yeah, exactly. It’s a $2 test and it’s paid for by the public. The public doesn’t mind paying $2 for a urine drug screen, especially if it reveals something that’s really important, especially relating to not only the individual’s current mental state, but what we can expect as they head into withdrawal from a particular substance. And then a lot of it just ends up being clinical. You get to know what different substance impairment syndromes look like. But there, I should say, I never once had seen somebody who was intoxicated on classical psychoactive substances, so LSD or psilocybin for magic mushrooms. But then in one summer, I saw three. And it was a weirdly similar presentation in all three cases. One case, an individual was high on mushrooms and just felt compelled to just jump through the living room window. I didn’t see that person in the emergency room because they needed a lot of emergency surgery, I saw them up on the surgical floor while they were recovering and got this story. Another individual suddenly felt really confined in a car and had this overwhelming urge to jump from an overpass. Luckily, it was a low overpass, like only an 11-12 foot one, and so they shattered an ankle but otherwise they were okay. And then a third person, a very similar situation. Just this urge to jump. All three of them had endorsed being at different music festivals. Because the Lions Gate hospital not far from us is Squamish Whistler, and it’s just music festival heaven all summer long. It was the first time I’d ever seen anyone. And then one thing that’s really nice is if you have relationships with people and you’re non-judgmental, I was able to kind of reach out on an informal network and get information back from a friend of mine who uses and sells, and said, “Oh, yeah none of the dealers are touching the mushrooms this year. They’re all super potent.” And I’m like, “Okay, that’s really interesting!” Yeah, it sort of helped me get towards a partial explanation, but it definitely didn’t solve it.

Zach: One thing I was curious about with psychedelics and people doing bad things like the things you just described, would that almost always be people who it was their first time, you think? Because it seems like having had that experience once, you’d be more likely to restrain yourself the next time, knowing what the psychedelic experience is like. Do you have any thoughts on that?

Tarzwell: In terms of the cases I saw, I don’t know whether these were first-timers or not. Those details escaped me now. These cases are a few years old now. I honestly don’t know, but I’ll definitely kind of pause and say, “Hey, kids, if you’re going to be a psycho or not, don’t fly alone. Make sure there’s somebody there who’s not using who can kind of be the guy.”

Zach: Yes, and you should doubt your ideas if you’re going to do that.

Tarzwell: Or what did Timothy Leary say? “If you think you can fly, start from the ground.”

Zach: Yeah, test it out when you’re sober. Something I’ve often wondered about mental conditions in general is they seem to me to exist on such a multi-dimensional spectrum. The names that we give to the various conditions are such a rough attempt to capture what are just the surface-level descriptions.

Tarzwell: Yeah, yeah.

Zach: Would you agree with that? And is there too much belief, do you think, in the public sphere that these are actual things? That the names that we use for things, that these things are tied to very concrete conditions? Does that make sense?

Tarzwell: No, I hear exactly what you’re saying. Suppose you come to me and you’ve got, or I diagnose depression. Well, that means that you either have sustained low mood or loss of interests, or both, plus three or more of the remaining seven symptoms. So this is already a combinatorial nightmare. There are 128 ways to be depressed for DSM. Do we see all 128 types of depression in nature? Well, no, we don’t. So just to look at the depression example, one thing that’s interesting is all right, we’ve got this construct of depression. These constructs come from years and years of clinical observation and research. But what are the true natural kinds of depression? What’s the kinds of depression that we see out in the wild? And is there even such a thing as depression in the wild or generalized anxiety disorder in the wild? Or are these categorizations we are roughly applying to things that are not natural kinds? There’s a constant discussion that’s never going to go away, or certainly, I don’t see how it ever gets resolved because I think it’s fundamentally irresolvable, and it’s the approach to psychiatry. Do you fit in this bucket or not? So, here’s the depression bucket, here’s the anxiety bucket. Or do you have a number of symptoms to varying degrees so we diagnose you along various spectrums? Clinically, it’s much much much easier to work with buckets. From a research perspective, it’s much much much easier to work with scales. But when I’m saying in the emergency room setting, it’s probably good enough to say, “Okay, this individual is depressed with some agitation.” I know roughly what that means, I know what to expect broadly, I know what my approach is going to be. The psychiatric nurses know how to formulate an approach to that, the inpatient psychiatric unit knows how to approach that. Whereas, say, a psychological researcher who might come along and want to administer detailed scales over a several-hour interview might say, “Well, there’s three out of 10 on symptom one,” and so forth and so forth.

And in a sense, what’s interesting is as we look further and further, it does seem that there are some disorders which do tend to kind of cluster, and there are some disorders which if you kind of get too close to them, they seem to almost disappear like fog. Personality disorders is one thing that’s really interesting. Borderline personality disorder, which is frequently seen in the emergency room because individuals with borderline personality are very frequently or easily triggered into crisis. And they are often struggling with anxiety, with depression, with agitation, with substance use disorders, with chaotic relationships, with dangerous situations… All the reasons that somebody might come in the front door of the emergency room. That’s a disorder that does seem to cluster. It does seem to exist as a natural kind. Bipolar disorder seems to exist as a natural kind. And we can say broad things like depression, there’s mild, and there’s moderate, and there’s severe kinds of depression. But we can’t even really separate the depression of major depressive disorder—which is just kind of normal mood, depressed mood, normal mood, depressed mood—from bipolar disorder, which has depressed mood, maybe normal mood, then hypomania or mania. Those depressions are completely inseparable– the depression of major depressive disorder, from the depression of bipolar disorder. So we have this category that we call depression. And yet we know that one in six times we toss someone in the depression bucket, that’s probably a bipolar disorder. And if we put them on antidepressant medication, we’re going to make them a whole lot worse. So it’s actually a really clinically urgent question, how do we separate these folks? And no one has a good answer yet. But it’s a constant source of investigation at a neurobiological level, at a clinical level. “Well, what about this symptom? Is this symptom the clue and we haven’t yet found it?”

Zach: The reason this interests me is because it seems like there can be a tendency for the people suffering from these conditions to think of those labels or those condition names as representing very precise or definitive states. For example, it would be the difference between someone saying, “I am a schizophrenic,” versus, “I have suffered from schizophrenia.” Or someone’s saying, “I have borderline personality disorder,” versus saying, “I’ve exhibited behavior that is described as borderline personality disorder.” I was watching a documentary about borderline personality disorder and I think people crave labels. They’re comforted by having a label to assign themselves. That struck me in that documentary I watched where someone was saying, “I have borderline personality disorder.” But I think a healthier way to view it is to recognize that we can all exhibit these traits and conditions throughout our lives. We can change. I might become something resembling a personality disorder later in life. You know, these things don’t define us, but they’re states that we’re passing through. I’m wondering if you think there’s power in the way that people use language in that way.

Tarzwell: Absolutely. And I think psychiatry shares some degree of the blame here. I think one of the really positive movements in mental health and in health overall is person-centered language, which I think arose from the disability movement. So, “I am not a schizophrenic. That’s not the end of who I am. I am a person who has schizophrenia and sometimes I have active psychosis, and that manifests in these particular ways.” I think that’s one shift, in my own thinking over the last 10 years, that’s been really helpful and very de-stigmatizing as well. Because it is. It is a completely normal phenomenon for individuals to encounter various kinds of cognitive, emotional, or behavioral disturbance in their lives. Right? By the time we scatter your ashes to the winds, there’s a one-in-two chance that you will have had a psychiatric episode over the course of your life. These things are as common—not quite as common as cold viruses, but nearly. So, that’s been an important piece as well. Because I think there’s maybe a tendency within society where it’s, well, if you are a schizophrenic, then you’re over on that side of this great chasm. And the chasm separates the scene from the insane. And the reality is, we’re all somewhere on the high wire on the opposite shores. Right? So person-centered language has been one thing that’s been really helpful. Also, an analogy that I like to use with individuals in a therapeutic way if I get the sense that they may be relying on a label in a way that’s going to be maladaptive for them or dysfunctional is like, “You know, it’s like diabetes. Diabetes is a chronic lifelong condition and you got it. The question now is, what are you going to do about it? Are you going to measure your blood sugar? Are you going to exercise? Are you going to do your best to make healthy diet choices? Are you going to follow up with the nurse and take your insulin as prescribed? And would you, if you were that diabetic person?” And eventually, someone gets to the point where they’ll go, “Yeah, of course.” And I say, “Well, here’s the good news. You don’t have diabetes. You don’t have a disease that’s going to take 10 to 20 years off your life and maybe cost you your kidneys and your leg and your retinas. You have X. You have depression, or you have bipolar disorder or Schizoaffective disorder, you name it. It also is a chronic condition and it’s exacerbated by stress and it’s relieved by recovery, and we have a program where you check in with a nurse and you take medication and you participate in recovery. But none of that can happen unless you take ownership of the thing, right? If we care more about your recovery than you do, you’re never going to recover. So, it doesn’t matter what you call it, it doesn’t matter how strongly you identify with it, the real question is, what are you going to about what are you going to do about it? And what is the rest of your life? What do you want it to look like within the bounds of what’s possible for you? And what can we do to help you hit those targets?”

Those kinds of conversations end up being really common to try and grant individuals autonomy and power over their conditions in the same way that an endocrinologist would try and grant autonomy to a 17-year-old with a new diagnosis of type one diabetes,

Zach: You referenced to the power of the word schizophrenia, for example. There was a great book by Nathan Filer—I guess that’s how you say his last name—it’s called “Heartland: Finding and Losing Schizophrenia”. He makes a really strong case that, like you said, these are spectrums that are part of human nature, in a sense, and can just be on the more extreme side for people with… He calls it ‘so-called schizophrenia’ and that’s the approach he takes in the book. He makes a really strong case for how these things we like to treat as this condition, this set thing, and the language that we use for it, whereas it’s really this spectrum of various things that can go wrong with people. And they, maybe all to an extent, deal with some of it, but obviously, it’s just much more extreme for some people. That book was really great and changed my way of thinking about a lot of mental health. I think he changed the title of it, because initially one of the titles for it was This Book Will Change the Way You Think About Mental Illness, I think that was the initial title.

And then I meant to bring this up earlier when we were talking about the role of culture in the environment on delusions, when you mentioned the people who had the similar delusion of Trudeau being their father. There’s a great book called “Suspicious Minds” by Joel and Ian Gold, they’re brothers. It’s about the role of culture and environment on our delusions. They talk about The Truman Show delusion, which gained prevalence probably due to our modern environment of always being surveilled, cameras everywhere, and feeling like we’re being watched. That book was really good, too.

Tarzwell: Well, what’s interesting is if you look at nation-level studies of individuals with chronic psychotic symptoms or chronic delusions, these vary country by country. And so here we are in North America where we’re used to hearing about paranoid delusions, persecutory delusions, and in a sense, it’s reflective of culture at large. I think America and Americans in particular are pretty famous around the world for hating the government, being very suspicious of each other, carrying guns… There’s a very leave-me-alone-or-else kind of valence, earned or not, that’s kind of an American valence. And it’s not too surprising that this ends up getting reflected in persecutory ideation of government surveillance is really common. Whereas if you go to India, a lot of an individual’s delusions are things like you should be more helpful in the family, you should do the laundry. These collectivist ideas about pitching in. Don’t get me wrong, individuals who have psychotic disorders– these are disabling disorders, they’re chronic disorders– they wax and wane, but often they are lifelong disorders. But there are aspects of them that are different that make for different kinds of management issues in different countries.

Zach: You’re saying some present a harder-to-handle more aggressive problem than how they would present it in a different culture?

Tarzwell: Right.

Zach: This is probably a good segue into the last person I interviewed for the podcast, it was Dr. Timothy Jay, and we talked about verbally aggressive and offensive behavior. And I imagine as an ER doctor, you’ve dealt with your fair share of people behaving in aggressive ways towards you.

Tarzwell: Yeah, yeah. The nice thing is, as the emergency psychiatrist, often I’m sort of the last person in a chain. And by the time I get there, the police have been involved and gone home, the emergency physician has sedated the person, they’ve ended up with chemical restraint, maybe physical restraint and so forth. And by the time I’m seeing them, they’re waking up, they’re groggy, they might still be partially restrained to a bed, and they’re often in a much different headspace than they were the night before. Which is kind of entirely appropriate anyway, because I can’t assess somebody who is simply just screaming and fighting. I’m not going to just get very… I’m not going to get anywhere with a psychologically oriented interview. But that being said, I’ve certainly encountered my share of unpleasantness. And yeah, [laughs] what was the question? Sorry. [laughs]

Zach: Oh, yeah, I was kind of leading into another question. Well, I was just curious what was the sedative of choice that you or your department used?

Tarzwell: It really depends on where you go. When I worked in Nova Scotia, there was fairly rapid adoption of intramuscular olanzapine. That’s a medication that came out in the late ’90s and is strongly favored even by individuals who get asked about their sedating experience. A lot of emergency physicians still like haloperidol which has been around since the early ’70s. It’s got a very long track record, very long safety record, it’s got predictable pharmacological effects. But individuals who get sedated or restrained with Haldol uniformly report it’s an absolutely terrible dysphoric experience. Whereas olanzapine can be given as monotherapy or as a single drug. Olanzapine often needs to be combined with a benzodiazepine, usually Ativan or Lorazepam. And then here in Vancouver, for some reason, I guess there must have been an extraordinarily successful drug rep back in the ’70s but the medication of choice here is one that’s called loxapine, which it’s heard of and it’s used in other places, but here it is as common as soup. And that ends up being the go-to anti-psychotic for acute chemical sedation, often given together with Lorazepam.

Zach: The reason I was asking you about the aggressive behavior. The thing that led me to interviewing Dr. Jay for the last podcast interview was you see a lot of bad behavior and viral videos online, including racist speech, and some of these people in a few cases seem to be suffering from some mental brain thing going on based on incoherence or whatever illogical behavior and illogical speech. And pointing this out online, I’ve had people say to me, “Well, even if they’re suffering from some sort of condition that causes them to behave this way, they still must be fundamentally deep-down racist in order to say racist things.” I’m curious, what is your thought on that? Because to me, there seems to be situations where you wouldn’t be able to attribute such things to how they really feel and it’s the disease, but I’m curious what you think of that.

Tarzwell: Yeah, I’ll put it into a less contentious framework that might help make some sense out of it. When I was working in a forensic setting, there was an individual who was admitted on forensic remand because he had begun communicating online that he had an intention to assassinate the President of the United States. And believe me, that gets you noticed rapidly. He was a guy that would just go to work, he would turn wrenches, and he would go home. And he would get online and he would just start making threats against then George Bush. Ordinarily, these kinds of threats would just get you landed in some kind of criminal problem, but it became really clear when he got in front of a judge and he was giving an account of himself that once he got into this world—where he was talking about specifically about the President—his reason and his rationale just fell apart. He became completely incoherent, his sentences didn’t make any sense, his thought forms didn’t make any sense. But then you get him back out of this–

“Well, where do you live?”

“Oh, 123 Lancaster Avenue.”

“Okay, how old are you?”

“I’m 26.”

“What do you do for a living?”

“I’m a heavy-duty mechanic.”

“Okay. Now, tell me again, what’s the problem with George Bush?”

And he would just collapse. So it’s this kind of fascinating police interrogation. And so at some point, somebody says, “Okay, maybe there’s a psychiatric issue here.” So he ends up in the Forensic Service. And as he’s recovering from his psychotic episode, which is just this very purely discreet, delusional, disorganized delusional complex around George Bush, he becomes as mystified at this as everybody else. He becomes horrified by what he’s done and the circumstances that it has landed him in as he regains his insight. So when an individual is saying or doing something in a state of psychiatric crisis, all bets are off. I think I remember seeing one video that you and I discussed. It was this little old lady somewhere in California, I think, who was approaching people and just saying jaw-droppingly terrible racist things. You see her do this once and you think, “Wow, that’s really shocking and terrible.” But then another video emerges a few days later of her doing this and it’s almost the exact same script. She even at certain points starts speaking the same kind of nonsense words and syllables when she gets to certain levels of agitation. And she’s making the exact same kind of comments like, “Oh, you’re filming that? Yeah, you go ahead and film that. Put it on Facebook. Show it to the whole world.”

Zach: She even said… I include that audio in the last podcast. She even says something like, “We play games where we fuck you to death,” or something. It just doesn’t make sense. You know? She just sounds very incoherent.

Tarzwell: It’s over-the-top foul language, and it’s logically incoherent. There’s certain aspects when I’m approaching an individual, I try to imagine, “Okay, can I imagine myself in this set of circumstances? What would it take for me to end up in this set of circumstances?” If I was an elderly person, if I was somewhat frail and I had any shred of rationality, if I hated you with an undying hatred, I would also at the same time recognize how incredibly vulnerable I am in a situation. And I certainly wouldn’t march up to strangers, all of whom are probably larger and stronger than I am, and begin saying, “He’s incredibly…” over the top inappropriate, shocking, incoherent things. So there’s an aspect there of a complete loss of insight, in addition to just dreadfully bad judgment, plus the same kind of impairments in thought form and speech form, and then the same kind of collapse into the strange nonsense syllables at certain points in the interview. And at that point, I would be like, “Okay, is this a dyed-in-the-wool hardened racist who feels emboldened by the general rise of white nationalist sentiment in the US? Or is this an individual who is in some significant psychiatric distress and is rising like a boat in the tide?” After seeing the second video… The first video, I got a little suspicious. The second video, I was willing to bet everything I owned on it. And then a few days later, out comes the article “Yeah, this is an individual who because of the Coronavirus lockdown hasn’t been seen at her mental health clinic and has been off medication.” And I’m like, “Not surprising at all.”

Zach: I always err on the side of uncertainty. There’s just so many types of psychological and brain disturbances and strange obsessions that people can have related to that. So even if that video had shown just a clip of a more coherent sentence that she had said, my fundamental stance on all these things before I know more is like, I’m not going to jump to a conclusion of… You know? Even if one sentence she said or several sentences sounded coherent, we just don’t have enough information. And like you said, there’s other clues that can be present, too. I definitely noticed that she was getting in people’s faces and she wore a strange smile which was almost friendly and bantering in a way. There’s many indicators that can be present. But even without those indicators, we just don’t know enough. And that’s what bothers me about these reactions to these videos online. No matter what it is, we hardly ever have the context to know all the factors that are present. Whether that was… It could be… And I’m not just talking about racist behavior, but any behavior. It could be something that happened before the video that we don’t know about, it could be an angle of the video that makes it look like something happened but it didn’t, it could be mental condition. It’s just these unfiltered videos and audio that we get that everyone reacts to and it almost seems like wasted emotional and intellectual effort. How many man-hours are we spending on reacting to things that we don’t have the context for? You know?

Tarzwell: Right. And in a case of that individual or an individual behaving in that way, a big part of say treatment is going to be, “”So, what is your recollection of what you said and what motivated that? And what do you think would happen if you did that to the wrong person?” That’s to try and gauge whether they recognize the potential peril they’re creating for themself, and you hope that that improves over time. It reminds me of a case that I saw– it’s the only time I had to admit an individual under involuntary circumstances to the hospital. Not because he was a threat to himself or because he was a threat to others, but he was panhandling so aggressively for several weeks in front of a biker-controlled bar that eventually they said if somebody doesn’t do something about this guy, we’re going to kill him. That’s not exactly suicidal ideation, it’s not exactly homicidal ideation, but clearly this guy couldn’t be out on the street. And I was quite willing to take that to the review panel if it came up to it. But we had to bring this guy into the hospital and it took weeks and weeks and weeks to get him down and he never gained insight. So ultimately we had to arrange for him to have accommodations in a different part of the city so that he wasn’t near that place where he was in grave peril.

Zach: Speaking of the woman we talked about, who was in those videos, she specifically was focused on talking to Asian people and saying horrible things to Asian people. What kind of, if you had to guess, what kind of condition would lead to that focused obsession on Asian people, for example?

Tarzwell: Without commenting specifically on her case, but clinical details of that nature would tend to make me think of a chronic psychotic disorder. So, something like chronic schizophrenia or a schizoaffective disorder or a delusional disorder. If I had to settle on one diagnosis, it would probably be along the lines of schizophrenia with paranoid features. And so it would come to pass somehow that she had some sort of obsession with Asian people through whatever her delusions or belief systems led her to. She had some sort of obsession. Yeah. Or maybe just didn’t. Maybe in the state of recovery, she just had no thoughts whatsoever about the Asian community or Asian individuals.

Zach: So it could have been a random reaction of some sort that doesn’t really make any coherent sense.

Tarzwell: Yeah, ultimately the explanations are always vague. There’s biological factors. You know, she had been off medications. There’s psychological factors, she was probably not able to see her family, not able to see her recovery team. There’s social factors. There’s the big scary virus going around, there’s no shortage of right-wing demagogues in the media quite happy to call it the ‘China virus’ quote-unquote, or the ‘Wuhan virus’ quote-unquote.

Zach: Oh, right. So it’s the environment. Yeah. I think that’s what’s lesser known, too, in society. It’s the way that culture and the things in the environment can be absorbed by people with mental issues. For example, I was walking downtown in Portland a couple of years ago and heard a homeless person talking to themselves having some mental issues, and they were basically mumbling about racial slurs and words for Hispanics and saying things like that. I think there’s this interplay between the environment and people with mental issues. They absorb these things. And I think there can be a misunderstanding of the upswing in things, say from people suffering or mental issues. The reason they’re talking about those things is because it is in the environment more. Like you said, maybe this woman watched some TV and heard people mentioning China virus or whatever. There’s this interplay. And it doesn’t mean that… I think it’s linked to philosophies in general being popular, but these instances are more due to the environment and these people latching onto things they hear, you know?

Tarzwell: Yeah, we all do it. We’re all susceptible to being influenced by culture, otherwise culture wouldn’t be a thing. Right? We wouldn’t all have wanted Air Jordans in the ’90s to date myself somewhat. Or there wouldn’t be such a thing as a pop star if we weren’t susceptible to more benign forms of cultural contagion.

Zach: Or just our conversations getting rougher and ruder because of Trump, you know? I even had a conservative friend tell me that when she found herself saying things that she would never have said before, that’s when she kind of turned the corner and realized, “Wait, Trump is really affecting my speech and my thought patterns,” you know? And that’s what made her into an anti-Trump person.

Tarzwell: Right. Right. Yeah, that’s a great example. And this is just natural. We are, at least in some respects, a hierarchical species, and we sort of look to cultural examples, we look to politicians and celebrities. As much as we say we don’t and as much as we hate ourselves for it, we do it. I do it, you do it, we all do it.

Zach: They’re seductive. Yeah, they affect us. I was thinking about a poker personality who actually died last month, but he had a YouTube channel where he talked about poker. And it used to be a pretty normal channel. He was a coherent guy, and then he obviously was suffering from some mental disturbances. Basically, he documented his kind of downward spiral on YouTube and he was going out and basically harassing people and he would also say pretty horrible things about people on his YouTube channel. He got arrested for making threats eventually, and he just kept getting worse and worse and people were talking about it on the poker forums and stuff. I don’t have a lot of knowledge about… I imagine it’s something you would classify as a personality disorder, I guess, and I’m curious how you see… Because it’s hard to understand how someone can go from going down that path. Would you care to talk about what personality disorders are and how they can come and go?

Tarzwell: Sure. From what you’re describing, and I don’t have any direct knowledge of it, I would think it would probably be less likely to be a personality disorder because personality disorders tend to be stable maladaptive patterns that are usually present by late adolescence or early adulthood, and they often have predictably unpredictable ways of maladaptive coping in various kinds of situations. So, an individual who was a particular way well into adulthood and then suddenly starts turning a corner, that’s where I start to think, “Okay, is this a new onset psychotic disorder? Is this a new onset mood disorder? Is this a psychiatric disorder secondary to a hidden substance use disorder? Is there a medical condition at play that’s driving this that’s also not detected?” Those are all very live possibilities for an individual. But to get to your main question of what is a personality disorder, basically it’s a maladaptive and somewhat rigidly maladaptive way of adapting to the normal stresses of life that we all experience. So, it’s sort of like having… We all have a tool belt of coping strategies to deal with interpersonal conflict, to deal with internal conflict, to deal with difficult emotions, so we all regulate our emotions with a set of tools. We regulate our impulses with a certain set of tools. Your boss tells you to do something at the last minute and involves staying late, and you have this flash of anger at your boss and maybe you have a mental fantasy of punching him in the face… Well, you don’t do that! Right? If you want to retain employment and your civil liberty, you refrain. Freud talks about this in “Civilization and Its Discontents” and putting away base impulses is the bargain we all make with each other in order to have civilization. And the one thing that we mustn’t do is to completely bury our impulses and that we’re all given to neurosis. You’ve got to kind of let things off the chain once in a while in safe and adaptive ways. That’s civilization, it’s discontents in a very thumbnail sketch.

The personality disorder is somebody whose tool belt is really, really limited. And they have maybe a certain limited number of ways of coping that get applied in lots of different situations. So somebody, say, with obsessive-compulsive personality disorder is going to be the person who copes by breaking anything down into the detailed steps that have to be undertaken so that it can be undertaken perfectly. The problem is the plan gets so detailed and so bogged down that nothing gets done and it ends up being a disaster. And it ends up being this kind of repeating cycle of failure because of excessive obsessionality. Now, there are times where you need to be obsessive. If you are going on a long trip and you take medication, you check that two or three times to make sure you have enough medication and maybe some extra. And maybe you carry a prescription with you, and maybe you have some phone numbers if you lose your medication, right? There’s adaptive levels of obsessionality. But if you get obsessive about, “Okay, well, should I ask this person out on a date?” And you list all the reasons why you should and you list all the reasons why you shouldn’t, and then you start deeply interrogating all of those reasons, and it’s two years later, and meanwhile, that person is just now happily married to somebody else living the good life, well, you missed the boat there, Charlie. And it’s that tendency to bring that limited coping set into different situations.

And we break the personality disorders into what we call clusters. So, cluster A, which would be the odd and eccentric personality disorders. This is where we would have paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder. Cluster B are sometimes referred to as the dramatic and erratic personality disorders. This is where we find narcissistic personality disorder, which is that kind of excessive preoccupation with the self. And the self must be guarded and protected and valued above all other things at all costs. Then there’s a histrionic personality disorder: I must be the center of attention at all times, or else I have unendurable anxiety. And the only way I can cope with the anxiety is by re-seizing the spotlight. Borderline personality disorder also is in cluster B, and it’s focused around attachment. There’s intense fear of abandonment, and it’s flight into and flight out of relationships, which become inappropriately deep way too quickly. And then also would be antisocial personality disorder, which is… That’s a personality disorder that doesn’t tend to cluster very well. It’s just this mixed-grabag of basically criminal traits all put together and called a personality disorder. But it’s not clear that that survives validity analysis. And then in cluster C, which we would sort of refer to as the sad personality disorder cluster, that’s where we have dependent personality disorder. That’s the individual who is just completely dependent on other people, can’t make major decisions, has trouble with autonomy, with independence… In there would be the obsessive-compulsive personality disorder.And then avoidant personality disorder, which is the kind of the polar opposite of the dependent personality disorder. This is the person who completely shuns and avoids attachments and doesn’t bother, and is very loathed to make any kind of connection with other people. You can think of it as either inverse of dependent or inverse of borderline, depending on which aspects of attachment you’re kind of wanting to characterize.

Zach: So for someone, say, that was kind of going downhill and becoming more antisocial and incoherent suddenly in their 30s or 40s suddenly, I’ve had a hard time understanding how people go from being fairly coherent to not being coherent.

Tarzwell: Yeah, the fact that there was that coherency to begin with suggests against a characterological trait. Because traits are longstanding, and again, present by late adolescence or early adulthood. Right? So if this is an individual who was a particular way and then really seems to turn a corner, that’s when you want to start thinking about acute psychiatric syndrome. So, is this a primary psychiatric syndrome, or are there secondary drivers? And the two big secondary drivers are substances and other medical conditions. Somebody, especially say in their mid-30s, I’m going to be wondering about, “Okay, is there a medical condition that hasn’t been detected here?” Because often, that’s an unusual age for a new primary psychiatric diagnosis to come out of the blue. It does happen, but it’s just less common. So as somebody in that situation, I’d be wanting to work them up pretty thoroughly. So, what’s going on with your liver? What’s going on with your kidneys? What’s going on with your thyroid? What’s going on with your electrolytes? And then do you use substances? What do you use? How much do you use? Is that changing over time? Are you being honest with me? Are you being honest with me? And then once that’s all excluded, then say, “Okay, well, this is probably—if that is not there—then okay, this is maybe an atypical manifestation of a kind of late or a later onset psychotic disorder.”

Zach: And I guess you never know, there could be… Well, I guess they’d find a brain tumor or something like that.

Tarzwell: If there’s an autopsy, yeah. Yeah. That’s certainly something to think about as well. Yeah, it’s part of a comprehensive workup. If somebody’s paranoid, that’s one thing, but if they’re paranoid and they’re like,
“Oh, I get these vicious headaches!”

“Oh, really? Tell me more about the headaches. Wow, you have one eye with a pupil slightly larger than the other. Is that longstanding or is that new?”

“Oh, I don’t even know.”

“Well, let’s pull out your driver’s license photo and have a look.”

There’s just different ways that you kind of go down the path towards finding the diagnosis.

Zach: There’s just so many things that can be true. I imagine it’s… Do you like that show, Dr. House MD?

Tarzwell: House… [laughs] I mean, I like House, but I don’t like the… I like House because it’s good television. It’s good drama. I do not like House because of the medicine. It’s not always lupus, A. And it’s just not the case that you have this very tiny group of super-talented residents who are doing absolutely everything on their own. “We’re going give the radiotherapy, and we’re going to do the brain biopsy, and we’re going to do the abdominal surgery…”

Zach: It’s chaos.

Tarzwell: Yeah. [laughs]

Zach: They just do whatever they want.

Tarzwell: Yeah, yeah, yeah. And eventually, it ends up becoming something really weird. At the end, House is like, “Aha, red paint chips!” And I’m like, “What?”

Zach: Yeah, this guy gets the weirdest patients, you know? Where do all these people come from?

Tarzwell: Yeah, yeah, yeah.

Zach: All right. Well, I’ve taken enough of your time. It’s been great talking to you. This has been Dr. Rob Tarzwell. What’s the best way people can get in touch with you if they wanted to?

Tarzwell: I’d say get a hold of me at Twitter, @Rob_Tarzwell.

Zach: Great. He’s got a picture of a brain scan there. It’s impressive. Yeah, it’s an impressive image. Okay. All right, well, thanks a lot for your time.

Tarzwell: You’re welcome.

Zach: Thanks for listening to the People Who Read People podcast. If you enjoyed this, please leave it a rating or review on the platform you listen on, if that’s possible. If not, if you could share an episode you like on social media, that’s much appreciated also.