Speaker 1: 0:10

G'day everybody. My name is Elliot Waters and you're listening to the Dysregulated Podcast. As always. Thank you for tuning in.

Speaker 1: 0:17

Today's episode is the next in this ever-evolving story. This is the discharge papers the discharge papers from my most recent presentation to the Marta Mental Health Hospital. So a bit of background, a bit of context. There's an episode I did a couple of weeks ago called Back to the Marta. I think it was searching for answers. So that episode saw me sitting out the front of the hospital at the bus stop, talking into my phone at whatever time it was like 1am or something explaining to you guys exactly what was going on. So this episode is the next part of that night. So when I go into the hospital and present and then speak to the psychiatrists and come up with some sort of plan moving forward. So this is very much intrinsically linked with that episode. So if you haven't listened to the Back to the Martyr episode yet, I would suggest listening to that first, then listening to this Now.

Speaker 1: 1:12

Can I just say no other podcast I'm sorry, no other podcast on the internet goes to the depths and to the vulnerabilities of mental ill health like this one. If you can find me another podcast that will talk and do episodes live from the hospital through my phone at my most acute moments and then go through the discharge papers later on. There's no secrets here. This is an open book. This is mental ill health and I'm telling you all about it and this is my story, and my story, unfortunately, is well, not unfortunately, but it's still evolving over and over again. And this is my story and my story unfortunately well, not unfortunately, but it's still evolving over and over again, and I hate to say it, but there could be more discharge papers coming, which is good for podcast content, but not so good for poor old Elliot. Anyway, enough about that, let's get into it. This is the discharge papers. This is what the psychiatrists and the nurses were thinking upon my presentation to the Mater Hospital during my most acute moments. All right, here we go. So if you can hear this rustling noise, that is because this is literally the papers that they gave me when I left the hospital. Literally, it's not a copy, it's not a printout, this is literally it. This is exactly what I was given, and now I'm giving it to you. Anyway, enough enough, elliot, come on, stay focused. All right, let me just get microphone in position because these episodes are pretty, you know, pretty big. I've got to relax, got to get ready. All right, here we go. James Fletcher Martyr, mental Health Service Discharge, referral Emergency Department Discharge Refer referral paper. Mr Elliot Thomas Waters, that would be me. Okay so, nurse triage notes 34 year old male, presents voluntarily with suicidal ideation, worsening anxiety and general frustration and anger and that's been a theme of the podcast over the last couple of months general end of my head space.

Speaker 1: 3:03

Lots of frustration, lots of anger. He has a history of attention deficit, hyperactive disorder, obsessive compulsive disorder, borderline personality disorder, autism, anxiety disorders. Okay so, presenting problem. This is now the psychiatrist presenting problem and significant events 34-year-old male presenting with acute, chronic suicidal ideation in context of chronic psychosocial stresses and a lack of meaning on a background of complicated psychiatric and developmental history. Lots of chronic will be mentioned throughout this because this is chronic. This doesn't leave me alone, unfortunately. Has a history of borderline personality disorder, potential bipolar affective disorder. Type two has attention deficit, hyperactive disorder, autism spectrum disorder, high functioning obsessive compulsive disorder, severe anxiety disorders that are lifelong, generalized anxiety disorder, social anxiety disorder and caffeine use disorder.

Speaker 1: 4:06

Elliot is cooperative, of course, and appropriately reactive throughout the interview. Hell yeah, I'll switch it on. He is very here we go, coming in a critic, let me say it. Let me say it in a critic. He is very articulate and clearly intelligent. Of course I am. He has an impressive amount of insight into his mental health struggles. He is help-seeking and future-focused. He feels as though he's on substantial amounts of medication with minimal benefit and he is seeking a long admission, not necessarily with us in brackets, to help wean and rationalize medication under supervision. So when it says not necessarily with us, that's because the MARTA is an acute care setting, mental health setting. You don't get any long admissions there. It's usually a couple of days at the most. So the MARTA is not where I want to end up, but the MARTA can help me end up where I want to get to, anyway, moving on. So he wants to rationalize medication under supervision, ideally removing all medications and starting with a clean slate.

Speaker 1: 5:15

His GP has already referred him to IJMU, which of course is the Intermediate Stay Mental Health Unit, which I've had two admissions at before for six weeks at a time. That's all on the podcast as well, anyway. So he's been referred to Ishmu and to Dr Cyriac Matthews in the community. Dr Cyriac Matthews I haven't seen for years but funnily enough he's in the public system so it's hard to see him. He's like the head of psychiatry or something now for Hunter, new England, new South Wales Health, but he is the one that actually diagnosed me with BPD, adhd and the potential bipolar disorder. All right, moving forward. So I've been referred to Syriac Matthews in the community mental health team. He's had a previous admissions to IJMU with some benefit, his most recent being January 2024.

Speaker 1: 6:04

Elliot feels as though in inverted commas, that he's about to blow. He has anxious affect, that's affect as in sort of emotional presentation affect with an A. Anxious affect appropriately reactive when discussing legitimately stressful topics. His speech is normal, which is interesting, because a side effect of ADHD in particular is this pressured speech where you you know I'm doing it a little bit now, I think as well where I'm really trying to push out what I'm trying to say and sometimes I'd stumble over some words and stuff because you know, it's like this bottleneck. There's all these thoughts that I want to get out there for people to hear, but you can only say so much at such a time and I would have thought that I would have shown some pressured speech signs and usually I do when I'm at the emergency departments. Usually that's a big part of what happens, but I'd say what happened this time, remembering back, was that I was so depressed that I was talking probably normal speech just because I was so depressed and just out of it and just bleh. So anyway, moving on, no evidence of psychosis denies perceptual disturbances. So I'm not saying things, I'm not hearing things. His insight is intact and judgment good enough that he is seeking help. All right.

Speaker 1: 7:21

Suicidality describes having some degree of chronic suicidality for most of his adult life. Feels as though suicidality is worsening lately and is concerned as he feels, as though for the first time it's his logical mind rationalizing suicide as an option due to a reasonable analysis of his in my words and it's written here it looks sort of funny shit life. This is a very professional document that has got shit life, but that's exactly what I said my shit life. He feels his life is not good enough. He's lacking meaning and purpose and has identified key goals such as functional relationships, children, a mortgage and own home as potentially not feasible. He denies prior suicide attempts or current plan, which is interesting because I have had a previous attempt many years ago now I must have forgot about that one. Anyway, obsessive thought spirals with constant negative comparisons to others, regret and retroactive jealousy oh man, I'm keen to do this retroactive jealousy episode it's going to be so good.

Speaker 1: 8:26

Describes chronic feelings of worthlessness, inability to shut off his inner critic, constant fear of not being good enough or that things will eventually, as always, go wrong, even when there is overwhelming positive feedback from his external environment. He suffers from low energy, waning motivation. Over many months struggles to exercise despite identifying it as a beneficial activity to his mental state. He eats poorly, has chronic poor sleep, constant ruminations of shame and substantial history of rejection sensitivity, which is a big one for ADHD and BPD. A lot of you guys listening will be like, yeah, rejection sensitivity I've heard that that is a big one Denies forensic history so I haven't done any crimes or history of aggression towards others, that's right, it's all aggression turned inwards. He has teenage trauma. Is currently engaged in EMDR therapy as well as internal family systems therapy. Has a childhood history of very high anxiety from a very young age, which sounds consistent with cluster C personality vulnerability. So I'll interrupt briefly there.

Speaker 1: 9:38

Cluster C Now. This has come up before, but this is probably the most clear. That has been stated. So cluster C is a which are categorized. So cluster C, there's three of them avoidant personality disorder, dependent personality disorder and obsessive compulsive personality disorder, which is not to be confused with OCD, is a group of personality disorders which have a high degree of anxiety associated with them. So for me, the one that he's referring to this psychiatrist for me is avoidant personality disorder and that's consistent with my severe levels of social anxiety and rejection, sensitivity and not trusting others, all that sort of stuff. I've never been formally diagnosed with a cluster C personality disorder such as avoidant personality disorder, because I think at this point who cares? At this point, honestly, I could have everything. Who knows? It seems like I've got everything. I've got Elliot Disorder. That's just the way it is. So I don't know if there's much utility in adding another label to already a cluster of many, many labels. But it is interesting that Cluster C has come up. It's come up before but, as I said, not this clearly written in the paperwork like it is here. Very important and so important. I may do an episode, I think, on avoidant personality disorder soon, because that one is not just big for me, it's big for quite a lot of people as well. All right, moving on, where are we?

Speaker 1: 11:11

He has noticed some abnormal movements, that's bodily movements like my T-Rex arms, and he's concerned for tardive dyskinesia. So tardive dyskinesia, very quickly is a condition where you get it's sort of like motor tics of the face, but to a higher degree and it's coming from a different way, a different pathway, because it's a side effect of long-term antipsychotic use. Now I have been on antipsychotics for a long time now a couple of years, probably more than a couple of years both quetiapine and olanzapine previously olanzapine but quetiapine currently. So that's why I was a little bit concerned because my tics seemed to be getting worse. Now my tics could be getting worse because I'm more anxious. My tics could be getting worse because my sleep's getting worse, but it could also be these facial tics in particular because of this tardive dyskinesia. So the thing is it's got something to do with your dopamine levels and how any psychotics go for D2 neurons in the brain and all this sort of stuff. That's dopamine and it plays havoc with all those circuitry and then your face sort of shows it to the external world.

Speaker 1: 12:21

Tardive dyskinesia is scary because if you stop any psychotic use it doesn't matter, it can stay with you still forever. So once you've got it often, you've got it for life, that's it, and it's all about managing the symptoms. So tardive dyskinesia is scary stuff and that's why I brought it up with the psychiatrist. Interestingly enough, he doesn't think that I've got it, which is great, great news, but definitely something to keep an eye on. Even if it's not tardive dyskinesia, my chronic motor tic disorder is getting worse and that's causing a lot of problems. All right, moving on. Jeez, ellie, come on, let's stay focused.

Speaker 1: 12:55

Identify strongly with many features of borderline personality disorder yes, I do, and in particular an unstable sense of self rejection, sensitivity there it is again Black and white thinking, emotional dysregulation and unstable personal relationships. He's also noticed some word finding and concentration difficulties of late. Yes, I'm feeling dumb, more dumb than normal, but I've got my theories as to why that might be. But anyway, moving on, that's for another time. Elliot identifies his anxiety as a core feature of his misery. He feels as though depression, low mood, seems to be secondary to anxiety. Yep, and that's the symptom giving him the most burden. He also experiences regular panic attacks when overwhelmed. I've lost my place. See, there's the concentration difficulties there, right there. What was I saying? Experiences regular panic attacks when overwhelmed and this has been happening more often at work as of late, requiring him to hide in the toilet until they pass.

Speaker 1: 14:02

Elliot denies any illicit substance use, which is half true, but has tried many supplements previously, as well as substantial caffeine burden. He's described as having worsening anger towards himself. Presently he lives with his parents. He works at Bunnings Warehouse, but he does identify this role in the associated social burden as a key stressor for him. At present he's exhausted after every shift, has large financial instabilities, which is also identified as a key stressor, feels trapped in his job to pay for therapy and feels like it's a losing battle. He has a psychology degree yes, I do with honours that he hasn't utilised due to fear of failure. Yep has been withdrawing socially and isolating himself over the last couple of months. He has had five prior admissions to the emergency department since 2019 for mental ill health, each with the flavor of BPD in crisis and functional emotional impairments.

Speaker 1: 15:01

Elliot has tried many medications with minimal benefit and is currently on chlamypramine, 250 milligrams, clonidine 100 micrograms, vivance, 50 milligrams. Dexamphetamine 10 milligrams. Pregabalin, 150 milligrams twice daily. Propanolol, 40 milligrams twice to three times daily. Quetiapine, 100 milligrams Viagra PRN, used as required, uses various supplements, including CBD oil, which I don't anymore because it's too expensive but, as we're about to find out, that doesn't matter because we don't want to be on it. Elliot has previously completed a six-month group dialectical behavior therapy course with benefit DBT. Everybody DBT is great has engaged in cognitive behavioral therapy, but with minimal benefit, which makes sense because cluster B and C personality types usually don't do much with CBT or CBT doesn't do much with it. And when I say cluster B, that's BPD, is cluster B, no private psychiatrist currently, as he's struggling to afford it. Elliot is very open-minded to trying anything and I am and noted that he felt better even over the course of our long conversation, feeling more hopeful.

Speaker 1: 16:14

It was long, oh dear, impression. This is good stuff. Here we go Now can I just mention I'm sorry I'm interrupting again, but I haven't actually read this document through until now. So a lot of this stuff, like the cluster C stuff, is interesting because, yeah, it's the first time sort of reading of this occasion of going to the Mater Hospital, so I'm learning a lot about myself in real time with you guys here today and, once again, no other podcast, I'm sorry, goes this deep into the world of mental ill health, all right.

Speaker 1: 16:47

Impression. Borderline personality disorder with cluster C, personality vulnerabilities. Chronic buildup of stresses without identifiable acute source, easily modifiable stresses Sorry, without easily modifiable stresses, that's right. They're pretty locked in. Much of what Elliot needs is not likely to be available here, that's at the Marta Hospital, and a prolonged inpatient stay in a facility like this comes with substantial risk of deterioration. It does. There is plenty of merit to rationalising his medications and stimulant use, as they may contribute to a considerable portion of his symptom burden. I worry that a long admission in a facility like this again the MARTA emergency department comes at the cost of losing access to regular therapy and additional risks associated with the restrictive environment. That's right. I don't want to end up long-term at the MARTA.

Speaker 1: 17:39

The MARTA is for acute stay only mostly. You know, a couple of days a week, two weeks at most, is sort of what you're looking at. People with schizophrenia may take a bit longer until the antipsychotics sort of work, assuming that's the path that they go down. But generally speaking, the martyr is all about acute. If someone's suicidal, let's stop them from being suicidal, get them back in the community where they should hopefully feel comfortable and then they can do the rest in the community. That's the plan. Or you get referred to another ward like IJMU Intermediate Stay or an Extended Stay ward, like this, bloomfield, which I'll be talking more about in episodes coming down the track, but let's move on for now.

Speaker 1: 18:22

So, despite all of his struggles, elliot comes across as a reasonably well put together person who has traditionally functioned exceptionally well given his challenges. Can I say that again? I'm going to read that out again to my inner critic, because this is huge. Elliot comes across as a reasonably well put together person who has traditionally functioned exceptionally well given his challenges. Yes, I bloody have, because I'm tough, I'm resilient and I am not giving in. I am not giving into this fight, no way. Okay, he may benefit from a long-term inpatient stay at somewhere like IJMU or another facility and may benefit from case management. Yes, I would in the community.

Speaker 1: 19:05

Due to his functional impairments, caffeine could be contributing to a substantial part of his anxiety load and should be addressed. Okay, okay, a conversation with on-call psychiatrist whoever this is. She suggests. This is what the on-call, this isn't the registrar, this is the top dog she suggests for me. Moving forward Again. I haven't read this before. So this is interesting. This is very interesting.

Speaker 1: 19:28

Let's see Acute inpatient admission not advisable and likely more harm than good if there is not a substantial need for containment, which there doesn't appear to be, despite some ongoing risk of self-harm, primarily related to static factors that are not amendable to an acute inpatient stay. No, the martyr is not built for what I need Suggestion to wean off caffeine as slow as needed. Suggestion to cease CBD oil, which I've already done because it's too expensive and didn't really work for me. Anyway. Await ishmmu or community referral, triaging for assistance with medication review. So wait for these other wards to see my, you know, see my referral and go. Okay, we're going to do something for this bloke, you know. And I thought, yeah, I was sort of hoping that, you know, going to the martyr would put a bit of. Not that I went up there for this case. I went up there because I was at my wits end, but looking back now, I would have hoped that going to the martyr might have helped push my case forward a little bit, but it hasn't appeared to be the case. Okay, continuing Could consider a referral from a GP to Hunter Primary Care.

Speaker 1: 20:37

I've done that before, didn't really do anything. But I could try again. A GP to a hunter, primary care. I've done that before. I didn't really do anything, but I could try again. Consider a GP referral for consideration of esketamine, likely after reduction in caffeine and medication rationalization.

Speaker 1: 20:48

Now ketamine's great. I'm all for having ketamine. That is one avenue that I haven't gone down before. It's only pretty new here in Australia and I think it's pretty new globally as well. The problem is it's so expensive and hard to get on it. It's not just like here's a script for ezketamine, go for it. You got to book in with a psychiatrist or, I think, maybe a psychologist. You got to do therapy while you're doing the treatment. It's a huge, huge thing and I'm all for it. Don't get me wrong. Let's go, let's bring it on. But it takes a lot of sort of background work to get to the point where you're in that clinic having the ezketamine and that's where I struggle because I'm not good at the background work because of this ADHD. Anyway, moving on. So this is the plan, moving forward. So discharge home, which is what happened. Gp follow-up within one week. Tick, that's the next episode coming.

Speaker 1: 21:41

Await outcome of community ishmu referrals, which I'm still waiting GP to kindly consider referrals for TMS, which is transcranial magnetic. What's the S stand for? See, this is part of the problem with me not being able to remember words. This keeps happening. This is very concerning. So let me Google TMS, which is R-TMS, because it's repetitive transcranial magnetic stimulation. Maybe Is it stimulation, it is. Ellie, got it right, you'll be all T, oh dear, all right, okay, so, yeah, so that's TMS.

Speaker 1: 22:20

So TMS, very quickly, is like the newer version of electroconvulsive therapy, ect, where they shock the brain, but this is a much more targeted sort of target specific brain areas. It doesn't go across the whole brain. You don't lose memories, that sort of stuff Anyway. So TMS again is a newish sort of therapy, or not therapy, but it's a newish sort of intervention in Australia and again, it's expensive and there's a lot of work goes into having to get it. So it's not as simple as just saying, yep, here's your referral for TMS. Go there, have a good time. Here's some mesketamine, give that nasal spray. Go, happy days. It's not that easy, or else I'd be doing them already.

Speaker 1: 23:07

Trust me, continuing, please, elliot. Please wean off caffeine. Based on symptom burden, it is likely to be contributing to baseline anxiety. Cease CBD oil. Please continue with psychotherapy, emdr therapy and internal family systems therapy and try to manifest some behavioral adjustments such as regular exercise and trying to improve social engagement, which is difficult, is very difficult If your condition now it's talking to me.

Speaker 1: 23:32

If your condition worsens it's funny how this is obviously someone else has written this part, because this is the it's gone. What third person to first person. If your condition worsens or have any other concerns, please seek medical attention. If you become acutely suicidal, we are always available for containment-focused admission, kind regards and all the best. Calvary Martyr Hospital. All right, so that's the story.

Speaker 1: 23:59

There's a little bit more info here. A lot of it's sort of rehashed. There's not much there. I'll read it out. So the whole document's read out. It's just sort of rehashing what we already know. But primary diagnosis borderline personality disorder, severe generalized anxiety disorder, social anxiety disorder, autism, adhd, ocd, potential bipolar disorder. There are cluster C personality vulnerabilities.

Speaker 1: 24:23

At least Discharge medications. There were none. I was not given any benzodiazepines, which is a good thing. This time I didn't need them, which is great, because although they work so well for anxiety, they're dangerous. They're so dangerous. No changes to medications during admission. Changes to existing medications discussed with patient discharge medication list was not provided, but action plan was given to patient slash carer, which is me, and that my friends. Can you hear that? That is me.

Speaker 1: 24:56

Turning to the last page of the discharge papers for this episode, fair dinkum, I'll tell you this story just grows and grows and grows. And, yes, it's good for podcast content. It's great for podcast content, I'll give it that. But I'll tell you I'm getting tired, I'm getting worn out and I really, really, am desperate for the New South Wales public mental health system to please get me on board, not as a job but as a worker, as a patient, and help me fix these medications so I can change careers and live the life that I want to live and start earning some real money and all that sort of stuff.

Speaker 1: 25:36

It's just, it's so difficult because usually people when they go to admissions to like this and go to instrument stuff, it takes a while for the patient to get on board with things you know, because usually the patient has got you know, at the very least, anxiety and depression sort of manifestations. So with the depression you're thinking what's the point of this? Ain't going to work anyway. Life's Life's meaningless and I may as well end it now. Sorry, I shouldn't talk like that, but you know what I mean. That's what depression does. You're on the back foot straight away. It's like no mate. No, this is a complete waste of time. Don't worry about it, brother. Don't worry about it. We'll just mope around like normal. And then the anxiety is saying we shouldn't do this, because this is scary. Something big and bad is going to happen, something catastrophic. These medications are going to change who I am blah, blah, blah, blah.

Speaker 1: 26:24

But the thing is, I went through that process years ago. As I said, my first admission was 2019. It could have been a lot earlier than that, but 2019 was my first admission when I come back from the United Kingdom, which was great because that's where I got a lot of my diagnosis and things sort of happened. And it was also great because that's where I finally discovered that, yes, there is something wrong, elliot, but we can do something about it, and I was committed to the cause. If you want to hear more about that, that first initial inpatient stay of mine at the Marta Hospital I was there for two days or something.

Speaker 1: 26:58

The first episode of this podcast, the cycle with Diane and me that is from that time period back in 2019. Great episode, great episode. What a way to kick things off. But the thing is, what I'm trying to say is my fighting the system, fighting potential ways forward, all that sort of nah, it's not going to work. It's not going to work. I'm too scared to do it anyway. This is freaking me out. You know, I've got rid of that, that's all gone. I am the most willing patient that you will find.

Speaker 1: 27:27

It's said in there that Elliot is open to trailing anything and it's true. I said to him give me electroshocks. If that's going to help, I don't care, I'll lose some memories, whatever, because I cannot keep living like this. Shock me brain, let's go. You know a little side point my grandfather he had I'd like to do some episodes on me Pop actually he's not with us, unfortunately, anymore but he had a very complex mental health history as well and you can sort of see the connections between me and him. He had ECT a few times, got quite a few of those electric shocks of the brain, and it worked really well for him. So I said this I'm like, hey, I know that's sort of a last resort thing now because there's some potential downsides big time, but I'm willing to do anything, let's go. Oh, it's so frustrating, so so frustrating.

Speaker 1: 28:15

But anyway that, ladies and gentlemen, that is the discharge papers. Again, that's the latest, or it's almost the latest on my story. There's a bit more still to come. So I've been to the gp very recently and that was a big, big one there, and I've got a few bits of paper to read out about that as well. They're not quite discharge papers, but heading in there, I don't know. It highlights quite well how difficult things have been for me and like how I sort of need help. You know what I mean. My GP is big on board, the martyr's on board.

Speaker 1: 28:44

The problem is the New South Wales mental health system is in turmoil at the moment because, well, if you want to hear about that, I've done an episode on the New South Wales mental health system. Search for it, it'll come up. But it is on its knees at present and unfortunately people such as me and it ain't just me, there's plenty of people out there are falling through the cracks because the system just cannot hope. All right, that's enough. I've said too much. You can tell that the dexamphetamine has sort of kicked in. Pressured speech remember I was talking about pressured speech earlier. There's plenty of that going on at the moment, but that's all for now.

Speaker 1: 29:18

Thank you for listening. If you're enjoying the show, feel free to like, subscribe, give us a great rating, because it's really good for the algorithm and you can share the show around with your mates. You can follow me on Instagram at elliotttwaters, and now, I'm happy to say, you can also follow the podcast on Facebook. Just search the Dysregulated Podcast. All the info is there. I've just kicked it off, so it'd be great if you would give us a follow and stay up to date with how things are going. All right, thank you, everybody. I'll catch you next time here on the Dysregulated Podcast. You.