If books have destinies, as Terentian Maur taught us, other beings have them too. Even the books we study intensively are not exempt from them. The dishonorable disease syphilis was called the Spanish disease, the French disease, or some other one, depending on who found it convenient at the time. Even today, every patient speaks with pride about diseases of their heart (or better, hearts), while modestly hiding a poor condition of their prostate. No one will boast that when, in the tavern Na růžku, he complained of bloating, he was given this advice: if you have it, then smoke it! There are few men willing to have their successfully expelled urinary stone set into a golden ring and to present this jewel to the woman of their heart, as the hero of Maupassant’s short story did. That cost him his life as well. When a girl threw a gift toward the canal in the street, she felled him on the spot with a stroke; today, this would be called a cerebrovascular accident, with the same outcome.
It is even more complicated with patients, because besides being carriers of honorable or dishonorable diseases, they are owners of various personalities, which are often further altered by illness to the detriment of their carriers. Some time ago, with Michal Anděl and Vláďa Brodan, we conducted a study1 focused on which patients were pleasant to female colleagues, male colleagues and nurses and with whom they would work well. The nurses still allowed anxiety and a certain disorder, but doctors and psychiatrists saw their ideal patients as ideal partners for a pleasant Saturday evening (there was no television then worth watching either).
Psychiatric patients suffer a certain amount of discrimination among somatic colleagues, whether diagnosed and treated somewhere, or merely looking that way. By way of example, I once sent a woman with depression to ENT for assessment of swallowing difficulties. In the referral (parere) I stated verbatim that this was not a functional problem, because the patient swallowed fluids without difficulty while solid food stuck. She returned with the diagnosis "psychological overlay," without anyone having looked at her throat. I therefore took her by the hand and went to the ENT department to another colleague with whom I had and still have a good relationship; he confirmed it was an esophageal stricture burned by a previous suicidal attempt involving drinking a product intended for clearing a blocked drain, probably with caustic additives.
If we take as a starting point that ancient Greece regarded beauty as the equivalent of health, we may ask what beauty is—the thing that has attracted all of us throughout human existence. It is the maximally averaged person. If we overlay, in a computational sense, fifty faces on one another, beauty starts to emerge; with a thousand, an ideal appears. Mona Lisa can go and bury herself! What instead repels us is the fact that differs from the average by more than two standard deviations. Whether this is a dishonorable disease, appearance, or behavior in bulk and/or some of its elements. Patients who trigger our amygdala, activate an orienting reflex, and ignite the first sparks under an alarmed stress reaction are those who move outside the bounds in which “respectable people” normally move. And let us not pretend that, despite professionalism and willingness to perform activities that most people fear or find disgusting, it has not freed us from prejudice in the standard social sphere. The exception is surgeons, who do not have a patient but an operative field.
When bullying began to be observed and researchers took it up from kindergarten, they found that the targets of attacks were children with non-standard motor expression, especially those with the then-valid diagnosis DMO. In the 1980s, social psychologists installed a camera in Central Park in New York and filmed an hour of activity at peak time. They cut out blind spots; this became a half-hour screening, during which American criminals went about in every direction, and after showing the film they asked pickpockets whom they would choose as a victim. They almost unanimously agreed on several people. Further analysis showed these people moved in some non-standard way. In the same way, a hawk circles and, with sharp eyes, watches how mice move, and when it finds one slower or clumsier, it dives down on it and knows it cannot escape.
Drug users are far down the informal hierarchy of likability, especially if they are also homeless. In evaluating them, the moralizing view of the lower middle class triumphs over professionalism. They brought this on themselves! Not only did they behave extremely irresponsibly in pursuit of experiences and ecstatic states, they also got money for drugs through every route except honest work (while we, fools, toil from dawn to dusk). Their neurotransmitter systems are worn out, and from this arise differences in their behavior in the broadest sense, from the way they enter through a doorway, through tone of voice, inappropriate emotions, and even if minimally and only subconsciously, reduced coordination. On first contact with anyone we swiftly assess two characteristics: warmth and competence. In both, they are far below average, yet they do not evoke sympathy but something between existential anxiety (ecce homo), fear (who knows what all of it they are tainted with), disgust, and, to be safe, because they are unpredictable to me, hidden aggression. The amygdala quickly oscillates between the two emotions it knows. They are more than 2 SD below the standard patients with whom we routinely deal. Most of this, however, usually does not cross into consciousness; there is just an unpleasant feeling and a desire to get it over quickly.
As for the most general etiopathogenesis, that is, the path to misfortune, it does not differ in essential elements from that of type 2 diabetics. The extent of violating rational recommendations and bold reliance on God’s mercy, which will save them from treatment, is comparable. But diabetics did this within the valid petty-bourgeois rules, even in agreement with the “wisdom of the age,” which at its core was consumption and growing prosperity, which they fulfilled. At 200% level, but fundamentally as obedient citizens. Consumption had been recommended by all political structures as the engine of well-being. Drug users, unlike them, did not consume but “enjoyed themselves,” or at least wanted to.
Our attitude to “otherness,” especially the kind we evaluate as bad, contemptible and dangerous, is subconscious, therefore unconscious. In the same way, we do not like people with depression, because emotions are, by their developmental nature, “infectiously transferable,” and a clever test that captures a row of seats in a theater will simply reveal the degree of inner fears. In your mind, you place the person whose photograph the experimenter shows you on seat number 1 and ask on which seat in the same row you would sit. Distance is the measure of our inner anxiety. Translated into the professional sphere, this means we do not like anxiety in our work.
This is good to realize not only with drug users and addicts (I know this is an incorrect term, but—let us be honest—what else do we call them in our minds?), but also with other patients who do not “sit well” with us and whom we have labeled as difficult, problematic, even annoying. Primarily this is a communication problem, and it is precisely that, rather than lack of knowledge, that is most often translated into professional mistakes. Communication with people who are problematic for us is demanding, and the sooner we learn to handle it, the sooner we will benefit from it and enjoy it. We all know how exhausting a meeting with a person who is unpleasant to us can be. Four such patients in one morning represent a respectable stress load. If we learn to cope with the type of patients with whom we still struggle and who bring more negative emotions, we become more mature internally ourselves. As a starting point, this can be overcome by telling ourselves: Better this drug user than some psychopathic politician!
MUDr. Radkin Honzák psychiatr Author’s blog: http://blog.aktualne.cz/blogy/radkin-honzak.php
1 Honzák R., Anděl M., Brodan V.: What personality traits do we expect in patients. Čas. lék. čes., 1982; 121: 410-411.