Sunday, 24 July 2011

Lenny: A Life and Death in the Mental Health System – Part 2

One day a notebook belonging to Lenny was found in his room. It was full of rambling drunken notes and tirades (“If you find me dead in the morning, it was because Jerry poisoned my Carlsberg.”) But it also contained some more alarming things. One of them was a "hit list" of named people whom he considered his enemies, mainly people connected with the hostel (I was on the list), as well as diagrams and recipes for molotov cocktails and petrol bombs, and much material outlining a universal conspiracy against him involving the IRA and Neo Nazi organisations, which included the belief that these organizations were systematically arranging for his food to be poisoned.

The hostel manager was understandably alarmed at this and wanted him to be expelled immediately. However, the committee was more sanguine. There was something distinctly Adrian Moleish about his ramblings, and we did not take them to constitute serious threats. Instead it was suggested to Lenny that he might feel more comfortable if he had his own accommodation. I helped him to negotiate with the local council, and he was offered a one bedroom flat.

He was delighted with this, but still suspicious. He seemed to manage reasonably well living on his own. He did agree to a community nurse from the CMHT visiting him, as well as a support worker. From time to time he would turn up unannounced at the CMHT and chat to me. Although he appeared to regard me with suspicion, I suppose he also saw me as offering some sort of continuity in his life.

It became increasingly clear from these informal chats with him that, now he was living alone, his paranoid beliefs were being allowed full rein, and were becoming more elaborate and universal in nature. He was convinced that food bought from supermarkets was poisoned or contaminated with noxious substances including the HIV virus. He talked about seeing members of the Ulster Volunteer Force in Charwood Post Office. He said on one occasion he had barely escaped with his life. If he hadn’t left, he knew they would have opened fire on him.

One day, I received a call from the Charwood Environmental Health Dept. They had received a visit from him in which he had given them an assortment of foodstuffs, including cans of lager, tins of food, and some vegetables, with an accompanying letter outlining the contaminants that had been added to them, and asking them to analyse them for him. We also heard that he had been writing to the manufacturers of various products accusing them of selling him contaminated goods.

We eventually managed to persuade Lenny to attend for an outpatient appointment with the CMHT psychiatrist. I sat in on that assessment. He freely talked about his elaborate delusional beliefs relating to paramilitary groups, Nazi’s, and a conspiracy to contaminate the food of the inhabitants of Charwood in order to subject them to mind control. We arranged for his GP to attend (yes, we were planning a MHA assessment). And we detained him under Sec.3.

This admission brought to light the full, and somewhat unsettling, extent of his acting on these persecutory delusions. On admission, he was found to have a knife and a sock full of broken glass in his bag (for defensive purposes). A few days later, his community nurse, who was visiting his flat in order to collect clothes and toiletries for Lenny, found that the cupboard under his kitchen sink was crammed with home made incendiary devices made from glass bottles filled with petrol. The police and the Army Bomb Disposal Squad attended and disposed of them.

Lenny’s diagnosis was changed: his symptoms were undoubtedly entirely consistent with a diagnosis of paranoid schizophrenia. Did we miss this over the years? Did his earlier diagnosis of borderline personality disorder muddy the waters? Quite possibly.

Lenny was prescribed antipsychotic medication and he did appear to improve. After a few months he was discharged back home, subject to S.117.

For a while he appeared much happier and settled. He even seemed more open and friendly. But it did not last. He gradually became depressed and his self care deteriorated. A few months later, he actually asked to be admitted to hospital. On admission, as his depression was treated, his underlying persecutory and paranoid beliefs emerged, as bad as ever. I had to detain him one again under Sec.3.

This time, however, treatment did not appear to result in any significant improvement in his paranoia, if anything, the depth and extent of his paranoid beliefs increased. He was disruptive on the ward, and so suspicious of the staff and food that it was very difficult to get him to eat anything. He remained completely insightless, and made regular attempts to escape from the ward, on one occasion trying to dig an escape tunnel in the occupational therapy vegetable garden.

In view of Lenny’s history of potential dangerousness, his unshakeable delusions and poor response to treatment, Lenny was transferred to a secure unit. He remained there for three years. During that time, my only contact with him was when I visited him to interview him for Tribunal reports, and to attend Tribunals. Whenever I saw him, he was consistently hostile. “Come to stitch me up again, have you, Masked AMHP?” he would say.

He was never discharged by these Tribunals, not because I had “stitched him up”, but because as soon as he was given the opportunity to speak, he would tell the Tribunal all about the plots by the Nazi’s or various Northern Irish paramilitary organisations to kill him. And then they would nod their heads sympathetically, adjourn for a discussion – and then would invariably uphold the detention.

However, over time, and with a change in his antipsychotic medication, his mental state did improve. One day I visited him for a S.117 review meeting, and he greeted me with a smile, shook me warmly by the hand, and enquired politely about how things were going in Charwood. Over a six month period, he had improved to such an extent that in all the years I had known him I had never actually seen him so well. The review concluded that he could be transferred back to an open ward, with an eventual plan of returning to live in Charwood in independent accommodation.

His improvement continued back in Charwood Psychiatric Unit. We started to make plans for his discharge, applying to the local council for housing. We managed to get him a nice flat surprisingly quickly. And he was discharged from Sec.3 and at last came back to live in Charwood.

Lenny was quite different this time. He engaged with support workers, happily accepted his depot injection, and religiously took his oral medication. He took an interest in decorating and furnishing his flat. He always welcomed me warmly whenever I visited him, and we have long and rational conversations. He hardly drank alcohol at all. For eighteen months he actually seemed happy and fulfilled.

Then one morning one of his support workers returned to the CMHT to say that she had been unable to get a response from him. This was not like Lenny. He enjoyed the visits from the support worker. I went out to investigate further. The flat was on the ground floor, so I tried looking in through the windows. His TV was on in the living room but Lenny was not in there. He wasn’t in the kitchen. The curtains were drawn in his bedroom. It was too early for Lenny to have gone out, and he wouldn’t have done knowing his support worker was visiting.

I called the police. They joined me at his house. We contacted the housing association, who sent a locksmith round to get in through the front door. I followed the police officer inside and we went into one room after another, looking for Lenny.

We found him in his bedroom. It looked as if he had knelt down to change the station on a portable radio on the floor. Then something catastrophic must have happened and he had collapsed backwards, folding down onto his knees, his feet trapped under his body. He was dead. He had probably been dead for two or three days. He died alone, and no-one had found him for two or three days. He was 30 years old.

There was an initial inquest, as the police suspected that he might have taken an overdose. But I didn’t believe that, and the post mortem revealed that he had had an unsuspected heart defect, and had had a heart attack.

His support workers and I attended the interment. His father and sister and a few family members were there. There was no sign of his mother. No friends attended.

Why had Lenny’s life been so bereft and ultimately so sad? What had happened during his childhood that was so bad that he once ran out of the room when I merely started to talk to him about the idea of possibly talking about it at some point in the future? And had whatever happened to him made him how he was, suspicious, lacking in social skills, reluctant to make friends or trust anyone?

Did he ever have an emotionally unstable personality disorder, or did he actually have a psychotic illness that had not been diagnosed? Did the label of personality disorder stop people from looking further? His discharge from detention the first time certainly gave him the unfettered opportunity to develop a full-blown psychosis, as a Tribunal had decided he did not need treatment, and the CMHT had had to back off, for a while at least.

Undoubtedly, his eventual symptoms were text-book signs of paranoid schizophrenia, and these symptoms eventually resolved with the use of antipsychotic medication. And when he was free of psychotic symptoms, there were also no signs of emotionally unstable personality disorder. Would he have spent less time in hospital had he been started on that sort of medication in his teens? Would he have had more of a life before his heart defect eventually killed him?

I don’t have the answers to those questions. All I know now, is that Lenny lived, and then he died.

3 comments:

  1. That is such a sad story. That poor bloke and all those years of fear and isolation. :(

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  2. Interesting, if sad, story. Very engagingly written too, I must add.

    One other random thought to throw into the mix: one of the rarer side-effects of some kinds of antipsychotic medication is that they can affect the heart. Depending on the nature of the undiagnosed heart defect, one may have potentially affected the other. It would add even more to the tragedy of the story if the very medication that was helping him become more fulfilled in his latter months was actually (partly) responsible for his passing.

    Anyway, that's just pure unfounded speculation, and I guess the story is maudlin enough without that added wrinkle.

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  3. How dreadfully sad... I guess the only comfort we can draw from it, is that whatever happened in his childhood that haunted him so much cannot haunt him any longer.

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