He was a 45 year old unemployed man living in a lower middle class joint family home in an urban area. He was referred for psychiatric evaluation by a private practitioner because he was depressed and irritable, he complained of sleep disturbance, and he described a constant clicking sound arising from the middle of his head. The last mentioned symptom evoked much interest, and I, the then junior resident in the unit, was instructed to present this unusual patient at the clinical psychiatry rounds.
Patients with psychiatric problems do not always tell their story well, and clinicians often need to draw on their experience to find coherent strands in a narrative. Thus, my fellow residents understandably saw in this patient what they had been accustomed to in previous patients. The consensus was that he was phenomenologically experiencing elementary extracampine auditory hallucinations, and that his irritability and mood disturbance were perhaps epiphenomena of a paranoid illness, the symptoms of which I had failed to successfully elicit.
I, however, had an ace up my sleeve. Unknown to my colleagues, during my exchange with the patient, I had asked, “Can other people hear the clicking that you hear inside your head?”
“I suppose so,” he replied, a little doubtfully. “I'd need to open my mouth, and they'd need to put their ears really close up.”
“Open your mouth,” I suggested. The patient opened wide, and I thrust my ear next to his mouth. Surprise—I, too, heard the clicking sound.
The patient had palatal myoclonus. This was the reason for his poor sleeping; and his insomnia, and the disbelief that his symptom evoked in all and sundry, were doubtless responsible for his irritability and depression.
Nearly 20 years have passed, but I have never forgotten the lesson: that I should always listen to my patients and test the goodness of fit of their beliefs before I try to fit them into my scheme of the universe.
Footnotes
We welcome articles up to 600 words on topics such as A memorable patient, A paper that changed my practice, My most unfortunate mistake, or any other piece conveying instruction, pathos, or humour. If possible the article should be supplied on a disk. Permission is needed from the patient or a relative if an identifiable patient is referred to.