The boring patient. Biography and article
Brynjólfur graduated from the Medical School of the University of Iceland in 1966 and after two years of service in Iceland he started studying in his specialist field of psychiatry in Sweden and Denmark. Upon return in Iceland he started serving as a psychiatrist in Akureyri (1973-2018), mainly as a specialist at the psychiatric ER at the Akureyri Hospital, as well as running a private practice. He participated in the grass root activities of people with psychiatric disorders and cancer patients. As years went by, Brynjólfur became increasingly interested in equestrianism and writing. He published six books of poetry in the last century and translated two books from Swedish: Crisis and Development, by Johan Cullberg (AK 1978, 1981, 1985, 1990) and Conflict Treatment by Lasse Brännlund (AK. 1993). He has furthermore written various newspaper articles, education booklets and other materials on psychiatry.
The boring patient
Maybe it’s a bit too late for an old, retired psychiatrist to launch a dialogue about the boring patient.
A reflection of medical work for more than half a decade brings to mind a greater number of pleasant instances than sad or difficult ones. Medical histories do not remain very well in one’s memory; events tend to dwindle away and perhaps suppression is helpful or some other “mental protection” for putting aside boring things from the past.
Upon my first involvement in clinical work, I soon became aware of the fatigue among the doctors in dealing with patients who were referred to as querulists. In most instances these were middle-aged women although men were also in such a category. These patients seemed never to get enough of interaction with their doctors, either in their capacity as specialists or general practitioners. The complaints were basically about pain, insomnia, or constant fatigue syndrome. As a newcomer and beginner in the field I soon began wondering about the possible cause of this. Repeated research rarely yielded any workable answers. The doctors were at a loss and some found ways to avoid such patients. Occasionally, rare physical illnesses were detected after extensive search and everyone became “happy”. Most often this led to a longstanding “alliance of pain” between the doctor and the patient. I had to accept older doctors´ diagnosis of this being psychoneuroses which was literally deemed as incurable.
Later on, in my capacity as a psychiatrist, I started to examine matters and discovered that many of these patients had anxiety disorder. This changed the options of treatment and the old querulists disappeared and were replaced by “recovery phobia”. The principal symptom of this was a lack of ambition. Let us categorize the group of patients into private practice patients and hospital patients.
When I cleared out my private practice after 45 years of service, I discovered more than 10,000 names and most psychiatric diagnosis as listed in the International Classification of Disease (ICD). It goes without saying that in most instances the tasks were pleasant and in fact rarely boring. When reflecting upon the boring instances I recall first and foremost my amazement of patients’ lack of ambition when it came to negotiations and commitments. An example is a patient who had mild symptoms that were beginning to heal, however, was far from full recovery. Solitude and loneliness became the next tasks and various methods were sought. When a doctor suggested group session with other patients, i.e. grass root therapy, the response by the patient was too often “… thanks but no thanks”. Even though an offer was made to accompany the patient to his/her first group session, without any commitment in the beginning, the response was “…thanks but no thanks”. Those who thus selected to hold on to their pain, convinced me as time went by of the principal cause being an absence of ambition. After working closely in recent years with individuals with long-term mental disorders and having participated in group sessions with the users, I have become increasingly convinced about how ambition is the greatest determinator about who recovers significantly and who does not. Witnessing this can be boring, however, I find referring to these patients as boring patients a bit excessive.
The story is different when it comes to hospital patients. We cannot choose when emergency service is concerned; we just have to take what comes. As the only psychiatrist at the Emergency Ward of the FSA hospital in Northern Iceland in my first 10 years of service, I was constantly on duty and saw all the patients. There was rarely time to especially treat the patients who were categorized as boring patients. I have nevertheless come across a diary entry from 1982 which reads as follows:
A woman I slightly treated
Good bye, and let us sing a farewell-song
with happy feeling at the end of day.
A woman with the meanest, vicious tongue
in Akureyri has just passed away.
This brings to mind a long forgotten interaction with patients who were boring. The main distinctive feature of such patients is constant distortion and sophistry literally about anything being done for them. Any corrections fell into unfertile soil, and argumentation proved useless. A few focused on malicious backstabbing. I am not referring to patients with misconception or psychosis; instead more or less patients with personality disorders. The same make unreasonable demands on their doctors or the system, but very limited demand upon themselves.
Brynjolfur with Spanardis after a short ride.
Conclusively, compulsory internment must be mentioned, as well as compulsory treatment. During my first years in Iceland we, Icelanders, were way behind the Nordic countries in terms of legislation. Fortunately, improvements were made late in the last century. The most impressive measure pertained to the right of patients to appeal or have a re-assessment of a decision to place them under compulsory internment. Notwithstanding the aforementioned there were exceptions of patients never accepting such a forceful measure and launched a long-term “opposition” against their treatment. Furthermore, there were instances of unnecessary problems. I particularly remember a patient who demanded over the following 40-year period that the relevant general practitioner and the psychiatrist should be sued and dragged before a court of law. Here in our small community this could be somewhat tedious although there could be some humorous sides to individual situations. □