Sunday, December 13, 2009

I was pretty sure my resident didn't like me. On my team at the hospital, the main players were my attending, the resident, and a medical student. The attending has the highest rank- she was the one on the team who'd graduated from medical school and who'd finished residency. Dr. Mia, the resident, was lower on the totem pole. She'd graduated from medical school two years prior to my stay, and was working her way through a Psychiatry residency. The medical student was what I was supposed to be. She was doing her third year clinical rotations.

Mental patients, particularly those with personality disorders, do something called "splitting." This basically means that they either really like someone or really dislike someone. As an example, if I really liked the nurse on the night shift, and really disliked the nurse on the day shift, for no apparent reason, this might qualify as splitting. Those lucky enough to bask in the light on the positive side of a split may be showered with compliments. But, this may be short lived, as the splitter can very easily move someone from one category to another. Someone who is wonderful one day, may be terrible the next from the point of view of the splitter. This usually causes problems, because the splitter often complains about certain people on the team, and when the behavior isn't recognized, the splitter may succeed in manipulating those trying to help her.

I was certain that Dr. Mia didn't like me. But I actually can't say that for sure- I do know that I didn't like her. She told me that I shouldn't worry about not returning to medical school, as many people are successful with college degrees. I didn't really NEED to become a doctor. Leaving medical school wouldn't be such a problem. This caused my eyes to fill with tears, and I answered her questions grudgingly, staring at her shoes during our sessions. Would Dr. Mia be happy if her dreams of becoming a doctor evaporated? I wondered bitterly. Her words swirled around my head and I became angrier and more resentful towards her as the days continued. I liked the attending and the medical student. I worried that my obvious dislike of Dr. Mia would be contrasted with my feelings towards the medical student and attending, and that my team would decide I was "splitting."

Patients who split are considered more difficult so I tried valiantly to hide my feelings.

"Splitting" is most notably associated with Borderline Personality Disorder, a label that is often a euphemism for "I don't like this patient." Personality disorders are also called "axis II" disorders. When evaluating the psychiatric patient, a doctor tries to fill each of 5 categories, called the 5 axes. Axis I disorders include Bipolar Disorder, Schizophrenia, and Major Depression, among others. These are generally considered "not the patient's fault" or sometimes "biologically based." Treatment is generally covered by insurance. Axis II disorders include anti social personality disorder, borderline personality disorder, and dependant personality disorder. Axis II disorders are usually considered to be lifelong, and related to a patient's character. Someone with an "Axis II" problem is often considered to be someone with undesirable character traits. Axis II disorders are usually not covered by insurance. Axis III includes any medical problems, such as pneumonia or diabetes. Axis IV includes any social stressors the patient may have. Being a medical student might go in this category. Axis V is denoted by a number, from 1 to 100, which reflects the patient's over all function. A patient who is a 10 is likely confined to a hospital. Someone who scores 100 is able to function in the world.

When a psychiatrist speaks of someone with "axis II issues" he or she usually means someone with "undesirable character traits." I learned in a subsequent psychiatry rotation that tattoos, sitting cross legged in a chair while speaking to a doctor, and attachment to a stuffed animal past the age of 15, are all indicative of axis II issues.


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