Filler A memorable patient


BMJ 2008; 337 doi: (Published 21 August 2008) Cite this as: BMJ 2008;337:a551
  1. John Baruch, consultant psychiatrist
  1. 1Tindal Centre, Aylesbury
  1. john.baruch{at}

    My patient lives alone. She has had a long string of compulsory admissions for psychosis and has been insisting on reducing her neuroleptic against advice. On a routine visit, her community psychiatric nurse finds her distressed and distracted. She denies any problems, declines a suggestion that she increase her medication, and insists that the nurse leave. Later that day a member of our crisis team goes to her flat, but she refuses to let him in.

    This is typical of her pattern of relapse, with terrifying psychotic experiences and compulsory detention in a psychiatric hospital expected to follow. Of course, community treatment or voluntary admission would be preferable, but previous experience suggests that neither will be possible. So next day I arrange to be joined outside her flat by the social worker and a second doctor, whose agreement will be necessary for me to admit the patient against her will.

    We don’t expect her to let us in, and we talk about the likelihood of needing to get a court order allowing the police to force an entry. This is not usually as bad as it sounds, with persuasion succeeding in the end, but it can be a dreadful experience for the person involved: how would you feel if several police officers, a psychiatrist, and a social worker broke into your home while your neighbours looked on? But she has been so ill in the past that doing nothing is not a humane option.

    I knock on her door, and she asks who it is. I tell her, and to our surprise she sounds pleased and cheerfully lets us in. She apologises for her behaviour the previous day, saying that her daughter had just had an emergency caesarean and the baby had been on a ventilator when her nurse called. She had thought that the nurse might be upset if she told her what was troubling her, and it might put her off having children herself. As for the crisis team member, she wasn’t going to let a stranger into her home was she?

    The baby, her mother, and my patient are all fine now, and she thanks us for our visit and shows us out.


    Cite this as: BMJ 2008;337:a551

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