Now Boarding...for the Flight of Ideas

One of our roles as emergency physicians is to perform medical screenings for patients with primary psychiatric problems. I’ve always been fascinated by what really goes on inside the heads of people with mental illness. (I know the members of the Socrates Fan Club are now saying, “Know Thyself,” but I don’t hear you. Neither do I.) And I’ve also been intrigued as to why people go into psychiatry. After considerable thought, I think that people go into it because they are either truly interested in how people think, or they’ve got their own problems and are looking for cheap self-help. This latter perspective was reinforced by a good friend of mine from medical school who had always wanted to be a psychiatrist. For the record, he was probably not the most stable guy himself…I recall an incident with a fire hydrant, but who doesn’t steal some municipal property in college? So we were all pretty stunned when he dropped out of his psychiatry residency and went into internal medicine instead. When asked why, he simply noted of the teaching staff, “They’re all f…..g crazier than me.”

More…much more… about Emergency Department psychiatry another time. What brought me to this introduction was a very strange thought process I had on driving back from Tampa this evening. One of the things we look for as a diagnostic clue in psychiatric patients is the pattern, or “flow,” of thought. There are a host of adjectives that are used to describe varied patterns as verbally expressed by patients. Two of the easiest to identify, and ones we’ve probably all experienced, include perseveration of thought and flight of ideas. Perseveration of thought is when one word, phrase, or theme recurs over and over, and the patient seems unable to move beyond it. Examples of this include “Hope,” “Change,” “Hopey Changey,” “Who Dat?’ and “Oprah.” (This is also like when part of a really bad song…like the Frito Bandito jingle, or wrapping up a feminine hygiene product while being blinded by the light…gets stuck in your head and never leaves).

Then there’s flight of idea which can be defined as a sequence of loose associations or extreme tangentiality where the speaker goes quickly from one idea to another seemingly unrelated idea (“Thought Disorders,” Wikipedia). That’s what happened to me tonight, and it was such a classic moment…right out of the textbooks…that I wanted to share it with you.

To set the stage, it’s the end of a long day of driving across the State of Florida. The Saab screams along at 75, The Child is fast asleep in the back seat, and I’ve spent the last three hours listening to a book on tape that shall remain nameless just in case I ever get a book deal and it turns out I have the same agent whose client I’m about to trash. This entire chain of thought occurred in less than two minutes, from mile marker 129 on I-4 Eastbound approaching Daytona Beach to mile marker 131, where I-4 hits I-95 and I have to pay attention to the road again as it make a sweeping north turn.

“This is awful. He’s got no talent. I can write, and I guess that’s a talent. But I’d want a different talent. I want to sing. Not lead. I want to sing backup, like in a Doo-Wop group. Or a Pip. I want to be a Pip. I want to sing about trains at midnight and move back and forth and shout “Woo Woo” at the right times. Or maybe sing in a folk group. A funny one, like The Limeliters. Or The Folksman. I really liked “A Mighty Wind.” Mitch and Mickey were the best. I love that scene at the end where Mickey is singing about urinary hygiene. How’s that song go? Oh, yeah, that’s right:

“When urine thoughts are in....
They will make your patients grin...
Sure Flo..... Sure Flo......
Don't leave them cold and damp.....
Use our buttock drapes and penis clamp....
Sure Flo..... Sure Flo…..”

I wonder if she would sing that on QVC? That would be quite a show, wouldn’t it? “Betty from Huntsville, you’re on the air.” “Oh, Mickey, I just adore your urinary appliances. I have them in all the colors so no one can tell them apart from my clothes.” “Oh Betty, then you’re going to love our newest collection. And our new color is lilac.” Sort of like that lady who called QVC one night and talked about how she had 40 different purses all by that same Kathy Von Zeeland person. The latest purse was supposed to represent travel, with a bunch of fake stickers on it. One said, “PURE LUXE”, which means nothing. The other was a circle that up close said “Fifth Avenue New York” but from far away looked like a target that said “I’m an American. Please Shoot Me.” Kind of like the look I got from that old man years ago who would try and say something, but his wife would leap in front of him and shout, “SHUT UP MOHTY! I’M TAWKIN TO THE DOCTAH!” Honestly, I would have put him down with a bang stick. But if I really wanted to shoot him, maybe they should place me under an involuntary psychiatric hold. But Roberta the psych screener has already told me that she’ll never put me under a hold because she needs me around to clear the psychiatric patients. She says I have knack for it, a real talent. I can write circles around this guy. But I really wish I could sing.”

(The very best example of literary flight of ideas is a small book called “The Mezzanine” by Nicholson Baker. In brief narrative and a host of footnotes, it tracks the thought process of a man going up one flight on an escalator during his lunch hour. Interestingly, his protagonist is named…Howie.)

I think I’m telling you this story because it’s moments like these that I realize how thin the line really is between mental health and mental illness, and that all thinking occurs in shades of gray. Maybe we all tend to drift towards the border from time to time, and perhaps all of us…myself certainly included…should try to be more patient and more understanding of those battling psychiatric problems. Or maybe I’m just writing because it’s the one talent I have, and if I do this I can suppress my desire to sing for yet another night.

If you’ve ever heard me sing, you’d encourage my writing, too.