Friday, 16 September 2011

The Dark Side of Love 1: Adjustment Disorders

When Neitzsche said: “There is always some madness in love. But there is also always some reason in madness” he wasn’t referring to the British 70’s/80’s pop/ska band.

It is certainly true that love and relationships can at times give rise to bizarre and irrational behaviour. Indeed, it has been argued that since the definition of a delusion “is a sustained belief that cannot be justified by reason”, then being “in love” with someone could itself be regarded as a delusional state. But I’m not going to plumb those murky depths today.

There are a number of well defined psychiatric conditions that could be said to arise from, or are manifested as, love and issues with relationships. Some of them are sudden and intense but fleeting, while others may be persistent, insidious and difficult to resolve. Either way, they can present as acute psychiatric emergencies requiring formal assessment under the Mental Health Act.

I would divide these disorders roughly into two types: adjustment disorders, and delusional or psychotic states.

Adjustment Disorders
A good definition of an adjustment disorder is “an emotional and behavioural reaction that develops within 3 months of a life stress, and which is stronger or greater than what would be expected for the type of event that occurred”. This can frequently be precipitated by the ending of a relationship, and in my experience, seems to occur more commonly among men.

Everybody can feel upset, bereft, or even suicidal when a loved one wants to end their relationship. Most people can fairly quickly accommodate and adjust to it, but some people have extreme and bizarre reactions, or develop a complete refusal to accept the reality of the situation. Here are a few examples from my personal experience.

Carl worked on a pig farm. One day he presented himself at Charwood police station in a state of agitation and distress, saying that he had killed his wife. The body could be found on the farm, buried in a heap of pig slurry. He confessed that he had been clearing the slurry when his wife’s body had emerged. Although he had no memory of it, he concluded that he must have killed her.

The police immediately investigated, searching through tons of pig manure, but did not find the body of Carl’s wife, or indeed anyone else.

They eventually did manage to locate her. She was safe and well, having left Carl a few weeks previously and gone to live somewhere else in the country. Nothing untoward had happened between them.

It was as if Carl found the idea of his wife being dead more bearable than the fact that she did not love him any more. When Carl was confronted with this, he began to recall what had actually happened, and his distress gradually abated over the next couple of days.

Colin had been married for 15 years. One day, his wife unexpectedly told him that she did not love him any more and wanted to leave. He went off to work as usual, but when he returned home in the evening, he was shocked to find teenage children in the house whom he did not recognise. He also did not recognise his wife. He demanded to know what they had done with his young wife and infant children.

His wife called the on call GP and he was sedated.

I saw Colin with his wife the following morning. The crisis was over by then. It appeared that his brain’s response to the news of the end of their relationship had been to develop a form of hysterical amnesia, where he had “lost” the previous 10 or so years, taking him back to a golden past in which he and his wife had young children and a happy marriage.

Overnight, the amnesia had worn off, and he was reluctantly beginning to accept the reality of the situation.

Christopher presented to the Accident & Emergency department one day with global amnesia. He did not know his name, or where he lived. He had no memory of his past. He was unable to give any information about himself.

He was examined for head trauma, but he had no injuries of any sort, and was admitted to Charwood psychiatric hospital.

After a cpouple of days a police trawl of missing persons revealed who he actually was, and his mother visited him on the ward. He did not recognise her.

Over a period of about two weeks, his memory gradually returned, and the story of what had actually happened emerged. And guess what? It was all about the ending of a relationship. His girlfriend had told him she wanted to finish with him. His immediate reaction was one of rage, and he literally picked his girlfriend up off the ground and hurled her across the room. Fortunately, she was shaken, but not otherwise physically harmed. He then stormed off – and promptly wiped everything from his mind, including his entire life history.

These three cases featured forms of amnesia as a way of coping with intolerable news. Other people will simply refuse to accept that anything has changed, and will attempt to carry on despite all evidence to the contrary.

I was asked to assess Charles by his GP. Charles was a man in his 40’s who had been married for about 20 years. The couple had two teenage sons. 3 or 4 months previously his wife had told him that she wanted a divorce. She asked him to leave, but he refused. Since then, he had been living in the dining room. He had put locks on the inside of the door and only left the room in the middle of the night when the rest of the family were in bed. Then he would creep out and use the kitchen to prepare food for himself.

His wife had initiated formal divorce proceedings and had decided to put the house on the market. When she told him about this, he vacated the dining room one night and moved into the garage.

I went out to try and see him. His wife let me in and showed me photographs of the dining room that she had taken after he had vacated it. He had constructed a network of tunnels using cardboard boxes and blankets that had filled the room.

I went out to the garage, which had an up and over door which was closed. A car was in the garage, and he appeared to be living in that. There then followed one of my more unusual attempts to interview “in a suitable manner”. I could not induce him to open the door so that I could talk with him face to face, and had to make do with talking to him through the door.

During the interview I was unable to elicit any overt signs of psychosis, and he generally answered questions rationally, although avoided any discussion of the impending divorce. I concluded that despite the unusual circumstances, there was no evidence of risk that would merit obtaining a magistrate’s warrant under Sec.135. He was simply in denial, and unprepared to accept reality.

I advised his wife to get legal advice about evicting him from the property, and subsequently heard that after a few weeks he left of his own volition.

None of the above were actually detained under the MHA. In other cases, precipitated by rejection and the end of a relationship, people can self harm or become suicidal and present with high levels of risk. But do they actually have a mental disorder that makes them liable to be detained?

One such example was the man I wrote about in a previous post (Should People Be Stopped From Committing Suicide?) who eventually successfully committed suicide, more through petulance than mental illness. In practice, in the case of most adjustment disorders, the presenting aberrant behaviour will either quickly resolve, therefore not requiring the use of the MHA, or it is sufficiently difficult to establish the existence of a mental disorder sufficient to warrant detention that the MHA cannot be used.

Next time: Psychotic or delusional disorders named after people: Othello Syndrome and De Clerambault’s Syndrome

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