Tuesday, 3 December 2013

Case Study 1: Greg and The Wicker Man

(Greg has given me permission to tell his story on my blog.)

Greg is one of the people on my case list. I’ve been seeing him for about two years.

Greg is in his 50’s. For the last 40 years, he has been experiencing vivid and terrifying visual and auditory hallucinations. However, he has been under the radar of secondary mental health services for most of that time. That is, until 2 years ago, when he stabbed himself and was admitted to a medical ward.

Why did he stab himself? Because he could no longer tolerate his hallucinations. He would have spells, sometimes lasting days, sometimes just a few hours, of exceptionally vivid hallucinations, when he could both hear and see a number of menacing men, who would threaten to kill him in horrible ways. Most of the time, these figures would stand outside his window, looking in at him. Sometimes, they insinuate themselves into his house.

So one day, after a number of hours of enduring the threats and taunts of these figures, who were telling him they were going to burn him alive like The Wicker Man, he decided that the only way of escaping this awful fate was by killing himself. So he went into the kitchen, inserted a knife into his ribcage, and leaned against the wall, using his weight to push the knife deep inside.

Fortunately, his wife found him in time, called an ambulance, and was able to get him to hospital.

But although they were able to patched Greg up and saved his life, he was still experiencing the hallucinations, and the ward appropriately asked for a psychiatric assessment.

It nearly unravelled at that point. This is because Greg had been self medicating with alcohol for many years. The psychiatrist who assessed him noted his history, diagnosed alcoholic hallucinosis, and decided that no further involvement was necessary from mental health services.

When he was discharged, however, his supportive GP made a referral to the Community Mental Health Team. I started to look through his records, such as they were. This is when I found that he had had a brief psychiatric admission 15 years previously. And unfortunately his history of alcohol use was held against him, and he was discharged with no follow up.

I discovered that Greg had actually stopped drinking completely a few months before he stabbed himself. But there had been no reduction in his experience of hallucinations. So alcohol abuse could not have been the cause. Speaking to Greg, it became clear that he had been using alcohol in an attempt to manage the hallucinations, rather than the hallucinations being a consequence of his alcohol use.

I was allocated as his care coordinator, and the team psychiatrist prescribed him an antipsychotic.

I began to visit Greg regularly, and got to know him well.

Greg is a fiercely intelligent man, who despite suffering from these tormenting hallucinations, succeeded in a variety of jobs, ranging from car salesman, to wine merchant, to a care worker rehabilitating offenders. He is very creative, and had at one point won £5000 in a national poetry competition. But since the breakdown that precipitated his hospital admission 15 years previously, he had not worked.

It was hard to know what to make of his hallucinations. They were exceptionally vivid, but Greg did not present with other symptoms of psychosis. He also had full insight – he knew that the voices and images weren’t real, although that did not reduce the horror for him. Neither did the hallucinations appear to be depressive in origin.

So it was difficult to make a formal diagnosis of schizophrenia, and it was also difficult to diagnose psychotic depression.

Greg revealed that he had been sexually abused by a teacher when he was a child. Did this give a clue? Hallucinations, often very vivid, can certainly be a feature of Borderline Personality Disorder. But these hallucinations usually centre around hearing or seeing the abuser, and again the nature of Greg’s hallucinations did not fit this formulation.

Whatever the origin, the antipsychotic he was taking, while taking the edge off these experiences, did not stop them occurring.

One day, Greg described having a sense of when the hallucinations were going to begin. The quality of the light changed, and he always smelled coffee.

Could this be a clue? Could Greg be describing the aura some people experience immediately prior to having a seizure? Could Greg have a neurological disorder, such as temporal lobe epilepsy?

There were other clues. One day, I took a detailed life history from him. Greg described a life of transience, moving frequently, and never staying in the same job for more than a year or so. He also said that he always threw himself completely into any job he took, aiming to be the best he could, but getting bored quickly. He also described long periods when he would be intensely active and creative. I had also become aware of occasions when I visited when he would be calm, polite and friendly, while at other times he would be agitated and extremely irritable.

Could Greg have a mood disorder, such as bipolar affective disorder?

Greg had an EEG, but this was inconclusive. Nevertheless, the psychiatrist decided to prescribe carbamazepine, which is both a mood stabiliser and anticonvulsant.

Although here was no immediate change, over a period of months, the intensity and duration of Greg’s hallucinations reduced markedly. At the same time, his mood became much more stable, and he was always cheerful and affable during my visits.

I discussed with him ways in which he might manage the hallucinatory episodes. The commonest hallucination was seeing people peering in through his living room window. He did not have any curtains on this window. I asked him if it might help if he put a blind on the window, so that he could shut the images out.

He tried this simple expedient, and reported delightedly the next time I saw him that it had worked! If he begins to see anything outside, he closes the blind, and although he can then still hear voices, the intensity is much more manageable.

With these improvements, his creativity returned. He began to write poetry again. This poetry was accepted and published in a range of poetry magazines. He began to write a children’s book. When he finished it and sent it to a publisher, it was accepted and published.

Writing serves two purposes for him. He found that the act of writing could distract him sufficiently from the hallucinations that he could exclude them entirely from his awareness. He therefore took to writing if he was ever troubled by the voices or images. The success he achieved in writing also improved his self esteem, and provided a shape to his day. He began to look forward to getting up in the morning, so that he could get on with his writing.

In order to prepare himself for his writing day, he spontaneously began jogging first thing in the morning. This improved his fitness, and set him up for the rest of the day.

From being adrift in a sea of hopelessness, with no motivation to do anything, and dreading the day ahead, Greg now has days full of anticipation and achievement.

I do not know to what extent Greg’s improvement is due to the change in his medication, and what is due to my regular visits and support. I suspect it is a combination of the two. I also still do not know what diagnostic label to give Greg.

Which is probably just as well. Greg after all is a person first. The important thing is that, with some assistance from mental health services, who are at last supporting him rather than ignoring him, Greg is leading a life full of meaning and enjoyment. He no longer thinks about killing himself. His “symptoms” have not gone away completely, but Greg now knows how to accommodate them within his life rather than them being his life.

1 comment:

  1. I would recommend a book by Oliver Sacks called Hallucinations - it is a really interesting book on all the different experiences we might have of hallucinations that are not connected to psychosis, e.g. hallucinations through neurological disorders such as epilepsy. I have sometimes wondered if people might get misdiagnosed with something like schizophrenia, when actually it is something else.