I wrote about Perdita in my post “The Section 2 That Wasn’t” in January 2010. She has a diagnosis of Emotionally Unstable Personality Disorder and Dissociative Identity Disorder. She has several alternate personalities, including Grendl, who is extremely wild and destructive and angry, and Mavis, the “normal” one, whose job is frequently to clear up after Grendl.
Since that MHA assessment, a change of staff in the CMHT meant that I became Perdita’s care coordinator. Perhaps surprisingly, in view of that event, she did not object to this. In fact, she told me that because I had handled the situation in the way that I had, she felt she could trust me.
I’ve got to know Perdita quite well. Splitting her self into several discrete personalities appears to be her way of managing the intolerable emotions which arose as a result of her severe childhood abuse. There are certain triggers to her “checking out”, as she describes this process of extreme dissociation, during which one or more of her other “parts” manifest themselves. These usually involve stressful situations which she finds impossible to cope with, as they touch raw nerves relating to betrayal: anything to do with being let down, or an event that is likely to provoke extreme anger, can trigger these episodes.
Dissociative Identity Disorder (which used to be known as Multiple Personality Disorder) appears to be far more common in the US that in the UK, at least, if published literature is anything to go by. The DSMIV definition requires “the presence of two or more distinct identities or personality states”. These identities or personality states must recurrently take control of the person's behaviour. The patient must also experience an “inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness”. Physiological causes, eg. epilepsy, or the effects of drugs or alcohol, have to be ruled out. In my professional career I have only encountered three people with this diagnosis.
I used to be somewhat sceptical about the reality of this disorder until I actually started working with people with this mental health problem. Having seen Perdita displaying these different personalities, I am convinced that she is not putting on these episodes, and genuinely has no control over what happens when the other parts manifest themselves. I have met Mavis, who is charming and polite, and a pleasure to work with. I have also met Mary, who is a small child, who can be mischievous and playful. I had heard all about Grendl, the really angry and destructive one, but had fortunately not actually met her.
I work with Perdita on the basis of damage limitation. I try to help her to manage the mood swings which are a feature of emotionally unstable personality disorder. We work together to identify and avoid triggers for her dissociative episodes. We especially try to keep Grendl under control.
But things don’t always work out.
One morning, I had a call from Perdita.
“I’m afraid,” she said. “I’ve been let down big time by someone.” She told me the details. It sounded bad. I had a sinking feeling. “I can feel myself going. I’m afraid I’m going to check out. I’m afraid Grendl’s going to take over.”
We talked this through for a few minutes. I suggested a range of risk management strategies that we had put into her care plan. But I had the feeling that “checking out” was going to be unavoidable.
A few minutes later, I got another call. This call consisted entirely of maniacal laughter. I guessed that it must be Perdita, having checked out. I tried to get through to her, but the chilling laughter went on and on and on. After about 10 minutes, I realised I was not going to get any sense out of her, and put the phone down.
The phone rang again. More scary laughter. The caller then introduced herself.
“It’s Grendl here,” she said. “It’s such fun. I’m having a great laugh here! I’ve really cut the bitch to pieces this time!” Then she hung up.
I didn’t bother to try and get hold of a psychiatrist. It would cause too much delay. I went out immediately, dragging one of my somewhat reluctant colleagues with me, just in case. It was going to be necessary to concentrate on limiting potential damage – damage to Perdita, damage to her house, damage to her daughter, damage to other professionals…
We could hear the laughter from outside the house. The front door was ajar. I went in without knocking, and we cautiously entered the living room.
Perdita was sitting on the sofa, rocking backwards and forwards as she whooped with laughter. She had an open pair of scissors in one hand, and her other arm was covered in lacerations. There was a fair amount of blood, so it was hard to see how serious the cuts were.
“Give me the scissors, please, Grendl,” I said as calmly as I could.
“You’ll have to give me three good reasons!” Grendl replied, and slashed several more times at her arm.
I realised I was going to need assistance. I wanted to avoid a hospital admission if possible, but I did need back up. I used my mobile to ring emergency services, and asked for an ambulance and the police to attend. I tried to explain as objectively as possible what was happening, but it wasn’t easy with Grendl’s intolerable laughter filling my ears.
Give me the scissors, Grendl,” I repeated, while I waited for the ambulance and police to arrive.
“Give me three good reasons!”
“I’m not getting into any games. Just give me the scissors.”
I waited nervously, keeping at a safe distance, until the ambulance arrived, and two paramedics came into the room. The police arrived almost at the same time, and the room was soon full of people in uniform.
Grendl loved it. “You’re very tall, aren’t you?" she said seductively to one of the paramedics, who was indeed exceptionally tall.
He asked to look at her arm, but instead, she slashed away at it again, occasionally holding the blade against her throat, as if she were holding Perdita hostage.
“Give me the scissors,” I said again, in as gentle and unthreatening a way as I could manage in the circumstances. The police and paramedics kept quiet, waiting to see what would happen.
“You’ll have to give me three good reasons!” she said again.
I was going to have to play her game after all. “First, you’re hurting Perdita. Second, Ophelia will be upset if she finds you like this.” (Ophelia was her 14 year old daughter, who was still at school.)
“That’s only two reasons!” Grendl cried, giving her arm a few more slashes.
“And third, you’re scaring the hell out of me!” Being honest often works well in these situations.
She thought about this for a moment.
“Okay, fair enough,” she replied, and threw the scissors onto the floor. Grendl could be reasoned with, after all. I kicked them away, and one of the police picked them up.
“Grendl, I really need to speak to Perdita.”
“Perdita’s gone away. You’ve got me!”
“I need Perdita. We need to get your arm sorted out. And Ophelia will be home from school soon, and I don’t want her to find all this.”
There was a pause. Perdita’s face sagged and went blank. Her head leaned forward. Then her head snapped up and the eyes of a small lost child stared into mine, tears running down her cheeks. She looked absolutely terrified, staring with fear at the room full of people.
“Hello there,” I said gently. “Can I see Perdita. Or Mavis. Either of them would be good.”
Her face went blank again and her eyes closed for a moment. Then her face changed. She opened her eyes.
“Oh, hello, Masked AMHP,” she said, a little surprised, looking around and taking stock of things. She looked at her arm. “Is it Grendl? Has she been out?”
I recognised Mavis. She would do. She would be able to sort things out. She rolled herself a cigarette and then smoked it while she allowed the paramedic to examine her wounds, and clean and dress them. “My, you’re tall, aren’t you?” she observed. After all, Mavis had not seen him before.
“Masked AMHP,” she said. “It’s so nice to see you again.” It was uncanny, but Perdita’s face, mannerisms, and even accent, were quite different when Mavis was in charge.
I negotiated with her. I asked her to stay in charge until Perdita could return. I told her that I would come back later in the afternoon when her daughter was due home, to see Ophelia and explain what had been happening (she was, sadly, used to these episodes), and to check that Perdita/Mavis was safe and in control. Mavis listened to me obediently, making meticulous notes from time to time.
My analysis of the situation went something like this. It made a sort of sense. Once Perdita or "Mavis", the sensible one, can be induced to return, the crisis is usually over. "Mavis" herself was confident that she could remain in control. Her wounds were examined and did not require hospital treatment. Hospital admission is best avoided during these crises, and the Crisis Team also have little role to play in these situations, once the immediate crisis has passed. It would not be appropriate to use the Mental Health Act, and would undermine any trust Perdita had in me. The police would notify Children's Services of the incident, who could be mindful of Ophelia’s needs. Ophelia could stay with her father if required, but would invariably prefer to stay with her mother, and would be under less distress if she was with her mother. It would not be in the immediate interests of Ophelia to separate her from her mother.
The police and ambulance crew withdrew. I said goodbye to Mavis and reminded her I would be back later to check up on the situation.
And in the midst of mayhem and madness there is (unintentional) humour.
As Mavis pulled deeply on another cigarette, she said to me: “Masked AMHP, when you see Perdita next, could you see if you can persuade her to give up smoking? It is such a disgusting habit.”