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FOCUSED LEARNING for the
psychiatry clerkship
Completely UPDATED
FOR THE DSM-5
FIRST AID FOR
THE®
PSYCHIATRY
CLERKSHIP
FOURTH EDITION
MATTHEW S. KAUFMAN, MD
Associate Director
Department of Emergency Medicine
Richmond University Medical Center
New York, New York
New York / Chicago / San Francisco / Athens / Lisbon / London / Madrid / Mexico City
Milan / New Delhi / Singapore / Sydney / Toronto
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CONTENTS
Contributing Authors v
Introduction vii
Index 217
iii
CONTRIBUTING AUTHORS
Sean M. Blitzstein, MD Kelley A. Volpe, MD
Director, Psychiatry Clerkship Chief Resident, Department of Psychiatry
Clinical Associate Professor of Psychiatry University of Illinois at Chicago College of Medicine
University of Illinois at Chicago Chicago, Illinois
Chicago, Illinois Eating Disorders
Examination and Diagnosis Sleep-Wake Disorders
Personality Disorders Psychotherapies
Substance-Related and Addictive Disorders Forensic Psychiatry
Geriatric Psychiatry
Somatic Symptom and Factitious Disorders
Sexual Dysfunctions and Paraphilic Disorders Alexander Yuen, MD
Resident, Department of Psychiatry
University of Illinois at Chicago
Amber C. May, MD Chicago, Illinois
Resident, Department of Psychiatry Psychotic Disorders
University of Illinois at Chicago Mood Disorders
Chicago, Illinois Impulse Control Disorders
Anxiety, Obsessive-Compulsive, Trauma and Stressor-Related Disorders Psychopharmacology
Neurocognitive Disorders
Psychiatric Disorders in Children
Dissociative Disorders
v
INTRODUCTION
This clinical study aid was designed in the tradition of the First Aid series of
books. It is formatted in the same way as the other books in this series; how-
ever, a stronger clinical emphasis was placed on its content in relation to psy-
chiatry. You will find that rather than simply preparing you for success on the
clerkship exam, this resource will help guide you in the clinical diagnosis and
treatment of many problems seen by psychiatrists.
Each of the chapters in this book contains the major topics central to the
practice of psychiatry and has been specifically designed for the medical stu-
dent learning level. It contains information that psychiatry clerks are expected
to learn and will ultimately be responsible for on their shelf exams.
The content of the text is organized in the format similar to other texts in the
First Aid series. Topics are listed by bold headings, and the “meat” of the top-
ics provides essential information. The outside margins contain mnemonics,
diagrams, exam and ward tips, summary or warning statements, and other
memory aids. Exam tips are marked by the icon, tips for the wards by the
icon, and clinical scenarios by the icon.
vii
Chapter 1
Respect the Patients 2 How to Prepare for the Clerkship (Shelf ) Exam 4
Respect the Field of Psychiatry 2 Study with Friends 4
Take Responsibility for Your Patients 3 Study in a Bright Room 4
Respect Patients’ Rights 3 Eat Light, Balanced Meals 4
Volunteer 3 Take Practice Exams 4
Be a Team Player 3 Pocket Cards 5
1
2 Chapter 1 HOW TO SUCCEED IN THE PSYCHIATRY CLERKSHIP
The psychiatry clerkship will most likely be very interesting and exciting.
A key to doing well in this clerkship is finding the balance between drawing
a firm boundary of professionalism with your patients and creating a relation-
ship of trust and comfort.
While anxiety and depression can worsen the prognosis of patients’ other
medical conditions, medical illnesses can cause significant psychological
stress, often uncovering a previously subclinical psychiatric condition. The
stress of extended hospitalizations can strain normal mental and emotional
functioning beyond their adaptive reserve, resulting in transient psychiatric
symptoms.
R E S P E C T T H E PAT I E N T S
R E S P E C T T H E F I E L D O F P S Y C H I AT R Y
TA K E R E S P O N S I B I L I T Y F O R Y O U R PAT I E N T S
Know as much as possible about your patients: their history, psychiatric and
medical problems, test results, treatment plan, and prognosis. Keep your
intern or resident informed of new developments that they might not be
aware of, and ask them for any updates you might not be aware of. Assist the
team in developing a plan; speak to consultants and family members. Never
deliver bad news to patients or family members without the assistance of your
supervising resident or attending.
R E S P E C T PAT I E N T S ’ R I G H T S
1. All patients have the right to have their personal medical information kept
private. This means do not discuss the patient’s information with family
members without that patient’s consent, and do not discuss any patient in
public areas (e.g., hallways, elevators, cafeterias).
2. All patients have the right to refuse treatment. This means they can refuse
treatment by a specific individual (the medical student) or of a specific
type (no electroconvulsive therapy). Patients can even refuse lifesaving
treatment. The only exceptions to this rule are if the patient is deemed
to not have the capacity to make decisions or if the patient is suicidal or
homicidal.
3. All patients should be informed of the right to seek advance directives on
admission. Often, this is done by the admissions staff or by a social worker.
If your patient is chronically ill or has a life-threatening illness, address
the subject of advance directives with the assistance of your resident or
attending.
VOLUNTEER
BE A TEAM PLAYER
Help other medical students with their tasks; teach them information you
have learned. Support your supervising intern or resident whenever possible.
Never steal the spotlight or make a fellow medical student look bad.
K E E P PAT I E N T I N F O R M AT I O N H A N D Y
P R E S E N T PAT I E N T I N F O R M AT I O N I N A N O R G A N I Z E D M A N N E R
patient feels [state the patient’s words], and the mental status and physi-
cal exams are significant for [state major findings]. Plan is [state plan].”
Many patients have extensive histories. The complete history should be pres-
ent in the admission note, but during ward presentations, the entire history
is often too much to absorb. In these cases, it will be very important that you
generate a good summary that is concise but maintains an accurate picture of
the patient.
2–3 weeks before exam: Read this entire review book, taking notes.
10 days before exam: Read the notes you took during the rotation and the
corresponding review book sections.
5 days before exam: Read this entire review book, concentrating on lists and
mnemonics.
2 days before exam: Exercise, eat well, skim the book, and go to bed early.
1 day before exam: Exercise, eat well, review your notes and the mnemonics,
and go to bed on time. Do not have any caffeine after 2 pm.
Group studying can be very helpful. Other people may point out areas that
you have not studied enough and may help you focus more effectively. If you
tend to get distracted by other people in the room, limit this amount to less
than half of your study time.
Find the room in your home or library that has the brightest light. This will
help prevent you from falling asleep. If you don’t have a bright light, obtain a
halogen desk lamp or a light that simulates sunlight.
E AT L I G H T, B A L A N C E D M E A L S
Make sure your meals are balanced, with lean protein, fruits and vegetables,
and fiber. A high-sugar, high-carbohydrate meal will give you an initial burst
of energy for 1–2 hours, but then your blood sugar will quickly drop.
TA K E P R A C T I C E E X A M S
The purpose of practice exams is not just for the content that is contained in
the questions, but the process of sitting for several hours and attempting to
choose the best answer for each and every question.
HOW TO SUCCEED IN THE PSYCHIATRY CLERKSHIP Chapter 1 5
POCKET CARDS
The “cards” on the following page contain information that is often helpful in
psychiatry practice. We advise that you make a photocopy of these cards, cut
them out, and carry them in your coat pocket.
Cognition:
Level of consciousness: alert, sleepy, lethargic
Orientation: person, place, date
Attention/concentration: serial 7s, spell “world” backwards
Memory:
Registration: immediate recall of three objects
Short term: recall of objects after 5 minutes
Long term: ask about verifiable personal information
Delirium
Investigations:
Routine: CBC, electrolytes, glucose, renal panel, LFTs, TFTs, UA,
urine toxicology, CXR, O2 sat, HIV
Medium-yield: ABG, ECG (silent MI), ionized Ca2+
If above inconclusive: Head CT/MRI, EEG, LP
Orientation (10):
Registration (3): Ask the patient to repeat three unrelated objects (1 pt.
each on first attempt). If incomplete on first attempt, repeat up to six
times (record # of trials).
Delayed recall (3): Ask patient to recall the three objects previously
named (1 pt. each).
Language (9):
■■ Name two common objects, e.g., watch, pen (1 pt. each).
■■ Repeat the following sentence: “No ifs, ands, or buts” (1 pt.).
■■ Give patient blank paper. “Take it in your right hand, use both hands
to fold it in half, and then put it on the floor” (1 pt. for each part
correctly executed).
■■ Have patient read and follow: “Close your eyes” (1 pt.).
■■ Ask patient to write a sentence. The sentence must contain a
subject and a verb; correct grammar and punctuation are not
necessary (1 pt.)
■■ Ask the patient to copy the design. Each figure must have five sides,
and two of the angles must intersect (1 pt.).
HOW TO SUCCEED IN THE PSYCHIATRY CLERKSHIP Chapter 1 7
Distractibility
Irritable mood/insomnia
Grandiosity
Flight of ideas
Agitation/increase in goal-directed activity
Speedy thoughts/speech
Thoughtlessness: seek pleasure without regard to consequences
Drugs of Abuse
(continued)
8 Chapter 1 HOW TO SUCCEED IN THE PSYCHIATRY CLERKSHIP
First Aid for the Psychiatry Clerkship, 4e; copyright © 2015 McGraw-Hill. All rights reserved.
HOW TO SUCCEED IN THE PSYCHIATRY CLERKSHIP Chapter 1 9
Psychiatric Emergencies
notes
Chapter 2
11
12 Chapter 2 EXAMINATION AND DIAGNOSIS
INTERVIEWING
Allergies:
First contact:
Developmental History:
Diagnosis:
Prior hospitalizations:
Relationships (children/marital status):
Suicide attempts:
Outpatient treatment:
Education:
Med trials:
Work History:
Housing:
Smoking: Income:
Legal History:
must establish a meaningful rapport with the patient in order to get accu-
rate and pertinent information. This requires that questions be asked in a WARDS TIP
quiet, comfortable setting so that the patient is at ease. The patient should
feel that the psychiatrist is interested, nonjudgmental, and compassionate. If you are seeing the patient in the ER,
In psychiatry, the history is the most important factor in formulating a diag- make sure to ask how they got to the
nosis and treatment plan. ER (police, bus, walk-in, family member)
and look to see what time they were
triaged. For all initial evaluations, ask
why the patient is seeking treatment
today as opposed to any other day.
TA K I N G T H E H I S T O R Y
The psychiatric history follows a similar format as the history for other types of
patients. It should include the following: WARDS TIP
■■ Identifying data: The patient’s name, gender, age, race, marital status,
place and type of residence, occupation. When taking a substance history,
■■ Chief complaint (use the patient’s own words). If called as a consultant, remember to ask about caffeine and
list reason for the consult. nicotine use. If a heavy smoker is
■■ Sources of information. hospitalized and does not have access
■■ History of present illness (HPI): to nicotine replacement therapy,
■■ The 4 Ps: The patient’s psychosocial and environmental conditions pre- nicotine withdrawal may cause anxiety
disposing to, precipitating, perpetuating, and protecting against the cur- and agitation.
rent episode.
■■ The patient’s support system (whom the patient lives with, distance and
■■ Past psychiatric history (include as applicable: history of suicide attempts, Psychomotor retardation, which
history of self-harm [e.g., cutting, burning oneself], information about pre- refers to the slowness of voluntary
vious episodes, other psychiatric disorders in remission, medication trials, and involuntary movements, may
past psychiatric hospitalizations, current psychiatrist). also be referred to as hypokinesia or
■■ Substance history (history of intravenous drug use, participation in outpa- bradykinesia. The term akinesia is used
tient or inpatient drug rehab programs). in extreme cases where absence of
■■ Medical history (ask specifically about head trauma, seizures, pregnancy status). movement is observed.
■■ Family psychiatric and medical history (include suicides and treatment
response as patient may respond similarly).
■■ Medications (ask about supplements and over-the-counter medications).
■■ Allergies: Clarify if it was a true allergy or an adverse drug event (e.g., KEY FACT
abdominal pain).
■■ Developmental history: Achieved developmental milestones on time, Automatisms are spontaneous,
friends in school, performance academically. involuntary movements that occur
■■ Social history: Include income source, employment, education, place of during an altered state of consciousness
residence, who they live with, number of children, support system, reli- and can range from purposeful to
gious affiliation and beliefs, legal history, amount of exercise, history of disorganized.
trauma or abuse.
14 Chapter 2 EXAMINATION AND DIAGNOSIS
M E N TA L S TAT U S E X A M I N AT I O N
WARDS TIP
This is analogous to performing a physical exam in other areas of medicine. It
A hallmark of pressured speech is
is the nuts and bolts of the psychiatric exam. It should describe the patient in
that it is usually uninterruptible and
as much detail as possible. The mental status exam assesses the following:
the patient is compelled to continue
speaking. ■■ Appearance
■■ Behavior
■■ Speech
■■ Mood/Affect
KEY FACT ■■ Thought Process
■■ Thought Content
An example of inappropriate affect is a ■■ Perceptual Disturbances
patient’s laughing when being told he ■■ Cognition
has a serious illness. ■■ Insight
■■ Judgment/Impulse Control
The mental status exam tells only about the mental status at that moment; it
can change every hour or every day, etc.
KEY FACT
able to define a particular vocabulary ■■ Bruises in hidden areas: ↑ suspicion for abuse.
it in a sentence reflects a person’s ■■ Eroding of tooth enamel: Eating disorders (from vomiting).
■■ Clang associations: Word connections due to phonetics rather than actual is uniquely related to patient (e.g.,
meaning. “My car is red. I’ve been in bed. It hurts my head.” a TV show character is sending
■■ Thought blocking: Abrupt cessation of communication before the idea is patient messages)
finished. ■■ Thought broadcasting—belief that
Describes the types of ideas expressed by the patient. Examples of exaggerated (e.g., Jesus talks to me)
■■ Somatic—false belief concerning
disorders:
body image (e.g., I have cancer)
■■ Poverty of thought versus overabundance: Too few versus too many ideas
expressed.
■■ Delusions: Fixed, false beliefs that are not shared by the person’s culture
and cannot be changed by reasoning. Delusions are classified as bizarre
(impossible to be true) or nonbizarre (at least possible).
■■ Suicidal and homicidal ideation: Ask if the patient feels like harming WARDS TIP
him/herself or others. Identify if the plan is well formulated. Ask if the
patient has an intent (i.e., if released right now, would he go and kill him- The following question can help screen
self or harm others?). Ask if the patient has means to kill himself (firearms for compulsions: Do you clean, check,
in the house/multiple prescription bottles). or count things on a repetitive basis?
■■ Phobias: Persistent, irrational fears.
■■ Obsessions: Repetitive, intrusive thoughts.
■■ Compulsions: Repetitive behaviors (usually linked with obsessive thoughts).
Insight
Insight is the patient’s level of awareness and understanding of his or her
problem. Problems with insight include complete denial of illness or blaming
it on something else. Insight can be described as full, partial/limited, or none.
Judgment
Judgment is the patient’s ability to understand the outcome of his or her
actions and use this awareness in decision making. Best determined from
information from the HPI and recent behavior (e.g., how a patient was
brought to treatment or medication compliance). Judgment can be described
as excellent, good, fair, or poor.
a red T-shirt. Upon her arrival at the emergency room, her behavior is
demanding, as she insists that you let her husband know that she has
arrived. She then becomes irate and proceeds to yell, banging her head
against the wall. She screams, “Stop hiding him from me!” She is unco-
operative with redirection and is guarded during the remainder of the
interview. Her eye contact is poor as she is looking around the room.
Her psychomotor activity is agitated. Her speech is loud and pressured,
with a foreign accent.
She reports that her mood is “angry,” and her affect as observed during
the interview is labile and irritable.
She is uncooperative with formal cognitive testing, but you notice that
she is oriented to place and person. However, she erroneously states that
it is 2005. Her attention and concentration are notably impaired, as she
appears distracted and frequently needs questions repeated. Her insight,
judgment, and impulse control are determined to be poor.
You decide to admit Mrs. Gong to the inpatient psychiatric unit in order
to allow for comprehensive diagnostic evaluation, the opportunity to
obtain collateral information from her prior hospitalizations, safety mon-
itoring, medical workup for possible reversible causes of her symptoms,
and psychopharmacological treatment.
M I N I - M E N TA L S TAT E E X A M I N AT I O N ( M M S E )
The MMSE is a simple, brief test used to assess gross cognitive functioning.
See the Cognitive Disorders chapter for detailed description. The areas tested
include:
■■ Orientation (to person, place, and time).
■■ Memory (immediate—registering three words; and recent—recalling
three words 5 minutes later).
■■ Concentration and attention (serial 7s, spell “world” backwards).
■■ Language (naming, repetition, comprehension).
■■ Complex command.
■■ Visuospatial ability (copy of design).
Interviewing Skills
G E N E R A L A P P R O A C H E S T O T Y P E S O F PAT I E N T S
Violent Patient
One should avoid being alone with a potentially violent patient. Inform
staff of your whereabouts. Know if there are accessible panic buttons. To
assess violence or homicidality, one can simply ask, “Do you feel like you
18 Chapter 2 EXAMINATION AND DIAGNOSIS
want to hurt someone or that you might hurt someone?” If the patient
WARDS TIP expresses imminent threats against friends, family, or others, the doctor
should notify potential victims and/or protection agencies when appropri-
To test ability to abstract, ask: ate (Tarasoff rule).
1. Similarities: How are an apple and
orange alike? (Normal answer: “They
are fruits.” Concrete answer: “They are Delusional Patient
round.”) Although the psychiatrist should not directly challenge a delusion or insist
2. Proverb testing: What is meant by that it is untrue, he should not imply he believes it either. He should simply
the phrase, “You can’t judge a book acknowledge that he understands the patient believes the delusion is true.
by its cover?” (Normal answer: “You
can’t judge people just by how they
look.” Concrete answer: “Books have Depressed Patient
different covers.”) A depressed patient may be skeptical that he or she can be helped. It is impor-
tant to offer reassurance that he or she can improve with appropriate therapy.
Inquiring about suicidal thoughts is crucial; a feeling of hopelessness, sub-
stance use, and/or a history of prior suicide attempts reveal an ↑ risk for sui-
cide. If the patient is actively planning or contemplating suicide, he or she
should be hospitalized or otherwise protected.
KEY FACT
IQ Chart
OBJECTIVE PERSONALIT Y ASSESSMENT TESTS Very superior: >130
Superior: 120–129
These tests are questions with standardized-answer format that can be objec- High average: 110–119
tively scored. The following is an example: Average: 90–109
Low average: 80–89
Minnesota Multiphasic Personality Inventory (MMPI-2) Borderline: 70–79
■■ Tests personality for different pathologies and behavioral patterns. Extremely low (intellectual
■■ Most commonly used. disability): <70
Projective tests have no structured-response format. The tests often ask for
interpretation of ambiguous stimuli. Examples are:
Rorschach Test
■■ Interpretation of inkblots.
■■ Used to identify thought disorders and defense mechanisms.
This page intentionally left blank
Chapter 3
PSYCHOTIC DISORDERS
21
22 Chapter 3 PSYCHOTIC DISORDERS
Psychosis
Psychosis is a general term used to describe a distorted perception of real-
WARDS TIP ity. Poor reality testing may be accompanied by delusions, perceptual distur-
bances (illusions or hallucinations), and/or disorganized thinking/ behavior.
Psychosis is exemplified by either Psychosis can be a symptom of schizophrenia, mania, depression, delirium,
delusions, hallucinations, or severe and dementia, and it can be substance or medication-induced.
disorganization of thought/behavior.
DELUSIONS
Delusions are fixed, false beliefs that remain despite evidence to the contrary
and cannot be accounted for by the cultural background of the individual.
P e r c ep t u a l D is t u r b a n c es
D i f f e r en t i a l D i a g nosis o f P s y c h osis
DSM-5 criteria for psychotic disorder due to another medical condition include:
■■ Prominent hallucinations or delusions. WARDS TIP
■■ Symptoms do not occur only during an episode of delirium.
■■ Evidence from history, physical, or lab data to support another medical Elderly, medically ill patients who
cause (i.e., not psychiatric). present with psychotic symptoms such
as hallucinations, confusion, or paranoia
should be carefully evaluated for
S u b s ta n c e / M edi c at ion - indu c ed ps y c h o t i c diso r de r
delirium, which is a far more common
finding in this population.
Prescription medications that may cause psychosis in some patients include
anesthetics, antimicrobials, corticosteroids, antiparkinsonian agents, anti-
convulsants, antihistamines, anticholingerics, antihypertensives, NSAIDs,
digitalis, methylphenidate, and chemotherapeutic agents. Substances such as
alcohol, cocaine, hallucinogens (LSD, Ecstasy), cannabis, benzodiazepines,
barbiturates, inhalants, and phencyclidine (PCP) can cause psychosis, either
in intoxication or withdrawal.
DSM-5 Criteria
WARDS TIP
■■ Hallucinations and/or delusions.
■■ Symptoms do not occur only during episode of delirium. To make the diagnosis of schizophrenia,
■■ Evidence from history, physical, or lab data to support a medication or a patient must have symptoms of the
substance-induced cause. disease for at least 6 months.
■■ Disturbance is not better accounted for by a psychotic disorder that is not
substance/medication-induced.
Schizophrenia
"He had nearly died, and he was all she had," replied Mrs.
Evans. "Heir to a fine property, I believe. I scarcely think that
Mrs. Caruth could be the one Joyce mentioned. Was it likely
there would be any intimacy between the daughter of a poor
country clergyman and people of position like those Caruths?"
"But not always their wives and daughters," said Mrs. Evans.
"Did you notice the name of the place Joyce's friend lived at? I
have the address of those we met at Mentone; it was Ferns—
something—crag, probably."
"I can hardly think that," replied the girl; "I could not imagine
Joyce saying an untrue word. She is not that sort of girl. And,
mamma, she is my cousin and a lady, though she is not rich. I
cannot help feeling sorry for her. If these friends of hers
should turn out to be the Caruths we met, and at some future
time we should see them again, what will they think of us for
letting Joyce go?"
"Think, you foolish girl! What can they think? Just that as she
was too proud to go to Fernsclough, she was too headstrong
to be guided by us, and went her own wilful way. You need not
trouble your head about that."
CHAPTER IV.
THOUGH Joyce Mirlees' twenty-first birthday brought some
clouds and storms, it was not wholly without peace and
brightness. More than a dozen letters reached her from
various quarters. Her uncle did not forget Joyce, but wrote
warmly and lovingly, and promised to be at The Chase before
she left it.
Other letters were from old friends at Welton, who did not fail
to send birthday greetings and simple gifts to their former
pastor's daughter. One packet, containing some beautiful
fancy articles, came to her from her Sunday scholars, who had
worked them for the dear teacher whose absence they
regretted more and more, they said. Yet it was plain that one
and all pictured Joyce amongst loving kinsfolk, and amid
luxuries of every kind, for they seemed half afraid that their
simple tokens of love would look very poor and mean amongst
her birthday gifts in her new and splendid home.
There was one more letter not named hitherto, which, though
full of kindness, brought some disappointment. The writer,
Mrs. Caruth, said all that could be expected from an old and
true friend. But there was no other message, though she
mentioned casually that her son, being quite well, had
rejoined his regiment instead of availing himself of the longer
leave at his disposal.
It was still early evening, and Joyce was in her own room,
when she heard a light tap at the door, and the words, "May I
come in, Cousin Joyce?"
"Yes, my uncle has always been kind, and I have had Sarah
Keene. Besides, I was but a stranger who had to win the
affection of strangers, though they might be relatives; and I
really believe you care for me after all!" cried Joyce, looking
up into Adelaide's face, and smiling through the tears which
her cousin's words had brought to her eyes. "Forgive me,
Adelaide. I want forgiveness, too, for I have judged you rather
hardly, I am afraid."
"No, you have not; I have never been kind, but I want to be
now." And two pairs of arms went out, and two girls' lips met
for the first time in mutual affection and forgiveness. Then
they sat down side by side, each encircling the other with one
embracing arm.
"I should not have minded about working early and late if you
had wanted help and we had worked together," said Joyce. "If
any one here had been ill, I should have thought nothing too
much to do for them, night or day. Supposing that my uncle
had been poor, and had given me a home with his children, I
would have slaved for him and them most cheerfully, and
taken care that his kindness should have cost him nothing in
the end. But you are all rich, and every wish can be gratified;
and the thought of being sent to sew under the orders of
Russell was—"
"Do not ask me, dear; I cannot take it," said Joyce.
"Yes, and I will take a gift, too, and prize it. Spend ten
shillings on a little brooch in cut steel, and I will wear it, and
never part with it while I live. And give me your likeness; I
should like to have it, though I shall always picture your face
as it looks to-night."
"You shall have these trifles, Joyce, and I will keep this, no
matter how long, until you are willing to wear it." And
restoring the ring to its case she put it into her pocket. "Now
what else can I do for you?" she asked.
"My uncle breakfasts earlier than you and the rest do. I have
been used to pour out his coffee and join him at table. I think
he will miss me at first. Will you sometimes breakfast with
him?"
"How selfish I have been not to notice this, or care for his
loneliness! Rely on me, I will breakfast with him always,
unless by some special chance I have been up very late the
night before."
But she smiled as she said it, for she was glad to think that
the father and daughter would be brought together by her
own departure.
"Then what?"
"Her son came home for a time, and she had him, and I
became more of a companion to my father."
"I believe I have seen both Mrs. Caruth and her son. Does she
call him Alec?"
"He is very fond of his mother, and she of him," said Adelaide.
"Indeed, he seems a good, noble-minded man altogether.
Augusta thought there was no one like him during the eight
weeks we spent at Mentone."
"He neither troubled himself about her nor any other girl. I
mean so far as paying special attention went. He was
everything that was kind and courteous, but the elder ladies
and the children absorbed the larger share of his time—
somewhat, I think, to the disgust of the grown-up girls. If
hazarded a guess, it would be that he had no heart left to
give, and that he was far too noble and true a man to pay
unmeaning attentions, which could lead to nothing but regrets
and pain for another. I suppose he has no sister, or he would
be a model 'brother of girls.'"
"Not now, dear. But if ever the time should come when I can
be sure you all wish for me, or if I am needed by any, I will
return."
Adelaide was obliged to be satisfied with this. The girls parted
with expressions of affection and pledges of future friendship;
and Joyce laid her head on her pillow with a lighter heart than
she had done for months past.
Mr. Evans was expected home the evening before his niece
was to leave The Chase, but in place of him came a telegram
—
Joyce was to leave the station at nine, so her uncle would not
arrive till after she was gone. Mrs. Evans declined to see her,
but sent word that when Joyce came to her senses, and was
prepared to submit and acknowledge she had done wrong,
she might write and say so.
Moved still further by the new and better feelings just born in
her heart, Adelaide declined to drive with Mrs. Evans and
Augusta, and went instead to meet her father on his return at
noon.
"That first kiss was poor Cousin Joyce's," she said. "She left it
for you, and I promised to deliver it."
"Joyce's! She is surely not gone? I thought you would all have
joined to keep her until my return. My only sister's only child
to leave The Chase in such haste!"
"She could not stay. I tried hard to persuade her, for, papa, I
am sorry I have not been kinder to Joyce. We are friends now,
dear friends, and I hope we shall always be so. I cannot blame
Joyce for going. How could she stay? But you do not know all
yet. I trust things will turn out better than they seem to
promise. I think I ought to tell you all about Joyce's birthday
and what was said, only you must promise to say nothing to
mamma. I cannot help thinking she is a little sorry now, and
she is more likely to feel regret about Joyce's going if no one
speaks of it."
Then Adelaide told her father all that had passed, and Mr.
Evans listened, not altogether sadly, for his daughter made
the most of all that had been bright for Joyce on her birthday
—the loving letters and souvenirs from Welton, Mrs. Caruth's
consideration for her cousin's safe convoy, the opening of
hearts between themselves, and the new-born friendship,
which was to bind them more closely than the ties of
relationship had done.
There was much to cheer Mr. Evans in what he heard from his
daughter, and acting upon her suggestion, he made no
allusion to Joyce's departure. His silence was both a relief and
a reproach to his wife, who expected a scene, and was
conscious that, in spite of her desire to free herself from a
sense of responsibility, she could not even excuse herself for
her treatment of Joyce.
"Now another, papa," she said. "That is for Joyce. You must
give me one every morning for her, as I am her deputy."
CHAPTER V.
JOYCE reached the station nearest to Springfield Park at three
o'clock, having had a change of trains, and a stoppage of an
hour and a half on the road. Mrs. Caruth's maid, returning
direct to Fernsclough, would rejoin her mistress before six.
Her train would not, however, start for twenty minutes, so she
was able to tell her mistress that she had seen Miss Mirlees in
charge of a grey-haired coachman, who, with two little girls,
awaited her arrival.
"Are you the young person for Springfield Park?" asked the
man.
"No doubt Mrs. Ross feels that the children are safest with
you," said Joyce.
"Just so. She has had time to know what I am, for I drove her
when she was no bigger than the least of them, and I was in
her father's service. Now you step in next the eldest one—
Miss Mary. She should have been a boy by rights, but nobody
would like to change her for one now. Your things will be
brought by that lad, who has a trap close at hand. They are all
together, I suppose?"
"Come in," cried the elder child. "We wanted to see you, so
mamma let Price bring us. I am Mary, 'papa's Molly,' they call
me, and that is Alice. She turns her face away because she is
shy, but she will be friends soon. Mamma said we must be
very good and not make you sorry, because you have no
father and mother."
Tears sprang into Joyce's eyes, which the child noted instantly,
and her own face grew sorrowful.
"Why do you cry?" she said. "Let me kiss the tears away, as
mamma does mine, if I am only sorry, not naughty."
"There, that is right. Now look how pretty the park is, and see
the deer under the trees. They feed out of our hands, and
they will know you very soon, because you will be with us."
The little girls had been taken charge of by Mrs. Ross's maid,
Paterson, and the housekeeper told Joyce that when she was
ready she was to come to her own room for refreshment.
"Here are your boxes in good time," said Mrs. Powell; and
thus Joyce was able to make the needed change in her dress.
She was about to go down, when, recollecting her new
position, she turned back for one of the aprons, ironed so
carefully by Sarah Keene's hands, and over which, as badges
of coming servitude for her darling, she had shed many a tear.
"I always have an early cup of tea," said Mrs. Powell, "and I
thought it would be the best for you, along with something
more substantial, after a journey. Your future meals will be
taken upstairs with the children. Mrs. Ross will see you in the
morning; but she and the master are away—only for the day;
they will be back to-night. My mistress trusted you to me, and
I promised to make you comfortable," said Mrs. Powell, with a
look of great kindness in her motherly face.
To Joyce this was like having her old friend Sarah Keene by
her side, and she thanked the kindly housekeeper most
heartily and gratefully for her encouraging words.
But the tea was being neglected, and Mrs. Powell turned
Joyce's attention in that direction; so, impelled by a healthy
girlish appetite, she made a hearty meal, much to her new
friend's satisfaction.
One hour after she spent with the children, of whom, however,
she was not to take formal charge until the morning. Then the
housekeeper, being at leisure, showed her through the house
and a portion of the gardens, and finally left her to indulge in
happier thoughts than she could have imagined would be
possible to her under her new circumstances.
Joyce rose early and dressed the children, the little one having
overcome her shyness, and being now willing to make friends.
She was sitting, telling them a baby-story, when Mrs. Ross
entered the nursery after breakfast, and greeted her with the
utmost kindness.
"
Springfield Park, Sept. 6th."
"After three months, dear old nurse and friend,
I can say that I am glad I came here. Every one
is good to me; the children are so sweet that it is
delightful to work for them; and I do work,
Sarah."