Case Study - The Demonic and the Angelic

When leading groups, occasionally, one comes across a patient who is so interesting, or peculiar, or unusual, that the clinician literally is compelled to write a brief case study.  Such is the case with patient D. (name and all identifying data changed).  She is an English-speaking Caucasian female.  Although she kept changing her date of birth, she appeared to be approximately 35 years old.  Upon admission she was agitated, anxious, aggressive, uncooperative, confused and combative.  Her appearance was disheveled and her grooming and hygiene were poor.  She had extremely long, curved fingernails, which looked like talons on a falcon, or some other bird of prey.  She came in four-point restraints, shouting profanities and lunging at staff.  She screamed, “Leave me alone!”  For a while, it was necessary to place security personnel at her bedside.

Although records were not available, D. admitted a history of mental illness.  She also conceded a history of substance abuse, although she claimed to be clean and sober at present.  She averred she was in constant pain and that she had a prescription for medical marijuana.  Her mother was jealous and abusive; she had broken her feet in a fall, when “my mother threw me out of the house in a wheelchair.  She threatened to cut off my wrists and feet.”

On admission it was difficult to communicate with her, or even establish minimal rapport.  She was isolating and withdrawn, turning her head away on approach and refusing to make eye contact.  Although she could follow what was being asked, she refused to answer any questions about her living situation, marital history, or whether she had children.  At one point she claimed to have children, but this was a fleeting reference, and seems unlikely.  She was suffering from vaginal bleeding, as a result of having ripped out an IUD.

Her medications on admission were Abilify and Topamax.  Even though dosage was modest, she was non-compliant.  While she was oriented x4, she was unable to recall any of three items after three minutes.  She was globally impaired had no capacity to conduct activities of daily living (ADLs).  I would estimate her GAF score as low as 5.

D. became an in-patient on what is known as a “5150 hold.”  Section 5150 is a provision of California’s basic mental health law.  It permits certain specified professionals (such as members of law enforcement) to detain a person for 72 hours and have that person committed to a locked psychiatric care facility.  Grounds for a hold are that probable cause exists to believe the person detained is a danger to self (DTS), danger to others (DTO) or gravely disabled (GD), which means unable to take care of basic personal needs such as food, clothing and shelter.  Typically, the detainee has attempted suicide (in the case of DTS) or has made specific threats to harm someone (in the case of DTO).  In D.’s case, it was the latter.

Law enforcement is faced with a choice when confronted with a person who is DTO: they either can take that person to jail, or they can initiate a 5150 hold.  From a practical standpoint this is a judgment call, depending on the nature and life-threatening potential of the person’s overt acts and inferred thought processes.  Extraneous and unacknowledged factors also often come into play, such as a jurisdiction’s desire to keep its reported crime rate low, or a concern for diversion of law enforcement attention and resources away from other, potentially more impactful criminal activity.

Upon the expiration of the 72-hour period, the facility can certify the detainee for intensive treatment of mental disorder during an additional 14-day hold.  Reasons for certification include the patient’s behavior, or refusal or unwillingness to accept treatment.  The detainee has the right to contest this extension, in which case a mental health court referee will conduct a certification review hearing at the psychiatric facility.  These hearings are summary in nature.  The detainee has the right to be present.  A nurse or other qualified person on the psychiatric facility’s staff presents the case.  A hearing advocate is present to represent the detainee’s interests.  On the conclusion of the hearing, the referee either releases the detainee, or finds that probable cause exists to continue commitment, on the same grounds as the original 5150 hold (the detainee however may remain at the facility on a voluntary basis).  The referee’s finding must be backed with specific factual information upon which the referee has relied, in reaching a conclusion.  If the detainee disagrees with the outcome of the hearing, then the detainee has the right to seek judicial review.  Upon the expiration of the 14-day hold, the facility may certify the detainee for an additional 30-day hold, in which case the same procedure applies.

D. requested a certification review hearing and was certified for an additional 14-day hold.  In my judgment it is unlikely D. will experience any remission of symptoms during the 14-day intensive treatment period, and it seems likely she will be certified for an additional 30 days.  It was hard to envision a scenario under which she would be able to comply with medication, utilize treatment resources effectively, or meet even the simplest treatment goals.  At such point, she probably should be transferred to a facility specializing in longer-term psychiatric care.

I was able to interact with D. over the course of six sessions of group therapy.  Approximately a dozen people attended each group.  In my experience, a third of attendees at group in an acute care psychiatric facility are asleep; a third have nothing to contribute; and the remaining third are active.  D. fell into this latter category.  I base this note on my observations of her behavior and remarks during group.  Etymologically, “pathology” is derived from the Greek word πάθος (“pathos”), which standing alone means suffering; another derivative, “pathetic,” means pitiful.  D. aptly might be characterized under all three of these semantic dimensions.  She is one of the most floridly psychotic patients I ever have met.

From an epistemological standpoint, her insight and judgment were impaired.  Her thought process was alogical, tangential, fragmented, disorganized, even scrambled, full of non-sequiturs and cul-de-sacs.  She had difficulty expressing herself coherently, pausing for long intervals to choose words, which, when stated, made no sense.  That is, one might be able to understand the meaning of individual words, but combinations of words and phrases, when strung together, were incomprehensible.  I would characterize her thoughts as “racing,” though from a clinical standpoint there is nothing amiss with racing thoughts per se.  All of us have periods when we have extreme flight of ideas.  The problem arises when one is unable to track them, or keep up with them.  D. met this criterion.  Showing poor impulse control and complete lack of insight, D. simply would blurt out whatever ideation she was having at the moment.

From a behavioral standpoint, she was irritable, paranoid, and at times almost childlike.  She would curl up into a ball, seemingly ruminating over her thoughts.  But then, from her lair, she would fix her gaze on you, staring, almost trying to bore a hole in your skull.  I would characterize her emotional affect as highly labile.

D. appeared to be continually affected by various hallucinations and responding to internal stimuli.  She complained of nightmares, and paranoia; “People around me talk about me behind my back.”  The most interesting moment came when D. was describing a persistent, highly directive internal command.  “I have a vision,” she said.  “I am a moon goddess.  I am the one in charge of bread and wine” (which I interpreted as a reference to the Catholic sacrament of communion).  “Moon goddesses are devil worshippers.  My soul uplifts and I ascend a spiral staircase.  At the top, I bash my head into a set of drums.  I am strong.  When I find love I turn Satanic; I become the embodiment of pure evil.  It is a critical time in the world.”

Then:  “I have the power to ruin everything.”  D. repeated the phrase “ruin everything” a half dozen times, on each occasion swooping her right arm around in ever-enlarging concentric circles.

Then: the frightening part.  Her speech became precise, but temporally and audibly modulated; she spoke slowly, then quickly, placing irregular stress and emphasis on certain syllables of words.  “My soul is angry,” she said.  “In fact, I am so angry I could turn into a dragon with a red body, crow’s feet and seven horse’s heads.  I could fly across the room and end the entire world.  I am an expert at wielding a knife, and I will scar your face.”

I did not interpret this as a suicide threat, that is, she might end her own private world.  Rather, she literally believed she had the power to terminate mankind’s existence on earth.  As she said this, she became especially brittle.  I was reminded of shattered windshield glass, or the cracks that appear in newly formed ice, if it is pressured.  I was afraid of her.  I believed she fully was capable of flying across the room and transforming into the mythological creature, which she described.  Then, she turned softer.  “I can guard against this presence of evil by streaking my hair with red dye, burning incense, and putting marijuana in my shampoo.”

I should note that D. carried a Bible with her.  Nothing she said, however, made me think she was overtly religious, or, if she was, all she was able to take from her religious beliefs were theories about Satan and the end of the world.  She focused on the New Testament book of Revelations, claiming to see the numbers “666” in various floor tiles (“666” is the so-called “mark of the beast” appearing at Revelations 14:9).  She was an expert astrologist, and at one point offered detailed, albeit disconnected interpretations of a fellow patient’s astrological sign.

The specificity and precision of D.’s bizarre delusions, and their monothematic religious content, is one of the reasons why she was so interesting from a clinical standpoint.  In principle it is not possible to devise an epidemiology of bizarre delusion.  There can be no question but that they result from activity in the brain.  Just like digestion occurs in the stomach, there is nowhere else for them to come from.  The precise mechanism of how this occurs, however, is poorly understood.  A variety of genetic, neurochemical, neuroanatomical and environmental factors must come into play.

An example is schizophrenia.  A genetic hypothesis: it may result from 22q11.2 deletion syndrome, which is the absence of a small piece on chromosome 22.  A neurochemical hypothesis: it may result from hyperactive dopaminergic signal transduction.  A neuroanatomical hypothesis: it may result from abnormal myelination of white matter fasciculi in the central nervous system.  An environmental hypothesis: under the diathesis-stress model, it may result from a combination of genetic, biological and psychosocial factors.

All of these elements may be active in various combinations.  None of them, however – singly or in combination – ever will be able to account for the substantive propositional content of a bizarre delusion.  The reason why is that there is no necessary connection between the brain and the mind.  One and the same alignment of brain states and processes has the potential to result in a plethora of different lived, phenomenological experiences.  They are multiply determined or realizable.  While technologies such as fMRI enable the researcher to isolate a region of the brain where cognitive processing occurs, it never will be able to identify what those thoughts are.  As a result, there is what has come to be referred to as an “explanatory gap” between the two.

So, in D.’s case, where did they come from?  In what combination of ingredients did they originate?  Proclivity towards having bizarre delusions is genetic, neuroanatomical and neurochemical.  What they comprise, however, must be environmentally or situationally associated.  It’s hard to say for sure, and most likely we never will know.  Cases like D.’s are particularly illustrative, because their extreme nature illuminates with clarity the modality of normal, non-pathological mental functioning.

Another thought I had about D. was the interplay between Axis I and Axis II disorders.  Under Federal and state mental health laws, only a dozen or so Axis I disorders have parity with non-psychiatric medical conditions.  Thus, as a practical matter, diagnoses in acute care psychiatric facilities fall into only a few categories, such as schizophrenia, schizoaffective disorder, or bipolar disorder.  For this reason, diagnostic impressions as to any Axis II disorders uniformly are deferred.  Most patients, however, have them.  The root of most Axis II disorders is poor coping skills, whether self-induced or environmentally stimulated.  The patient is out of attunement with the requirements and demands of psychosocial reality.  In D.’s case, it would be interesting to study the interplay between these two categories, in particular, the impact of Axis II pathology on Axis I, and vice versa.

During the last session, one of the attendees was patient A.  She was as sweet and innocent as D. was enraged and bitter.  She had been admitted on the grounds she was DTS.  A. had attempted suicide on two prior occasions.  She stated: “I am a hidden angel.  I am on my way to heaven.  I am tired of dealing with the pain of this world.  I am not trapped forever in my mortal body.”  What was disturbing about A. was the contrast between her sweet and innocent personality, with her specific, theologically motivated suicidal ideations.  Her head was surrounded by a halo of dark black hair.  She spoke clearly and articulately, albeit softly.  Her thought process was logical, connected and coherent, though resulting in a distressing conclusion.  Her eyes gleamed, clear and bright.  I wish I would have had the opportunity to spend more time with her.  What impressed me the most was the juxtaposition of A. against D., particularly as they interacted in group.  The demonic versus the angelic, all in the space of a single afternoon.

Thanks to Eric Hamilton for sharing diagnostic impressions with me as background for this note.