Sunday 26 November 2023

Perdita: Encounters with a woman with dissociative identity disorder. Part 1: I'm asked to assess Perdita under the Mental Health Act – but is it the best way forward?


Perdita had suffered horribly for most of her life. She had been abused physically, sexually and emotionally as a child, and as an adult had gone from one abusive relationship to another. Along the way she had developed a wide range of coping strategies, including cutting, overdosing, denial of food, and dependence on alcohol and drugs.

She had also acquired a range of alternate personalities, some of whom coped well and appeared “normal”, and some of whom you would not like to meet on a dark night. Or even in broad daylight, come to that.

These personalities all had names. There was Perdita of course, with all her problems. But there was also Grendel. Grendel was extremely unpleasant. She would swear, shout, scream, throw things around, gouge at her arms, take massive overdoses, and swing her favourite weapon, a baseball bat, at anyone she happened not to like. Which was everyone.

And then there was Mavis, a very sensible, impeccably behaved woman who appeared when she had to in order to clear up the mess left by Grendel.

Perhaps more surprisingly, she also had a charming, polite and remarkably well adjusted 12 year old daughter called Ophelia. Perdita had always done her best to protect her from her behaviours, not always successfully. Children’s Social Services kept a wary eye on Ophelia.

Perdita had been involved with psychiatric services for most of her adult life, and had acquired a range of psychiatric diagnoses, most notably Dissociative Identity Disorder.

Her community nurse was a very experienced woman who generally managed to help Perdita keep her coping behaviours under control. However, a mix up with her methadone prescription had destabilised her, and Grendel was beginning to emerge. Perdita began to write a series of suicide letters, and confided to her nurse that she had been taking controlled but potentially dangerous amounts of paracetamol. Her nurse was becoming increasingly concerned about the welfare and safety not only of Perdita but also Ophelia.

After a couple of weeks, during which things continued to worsen, she arranged for a home visit with Perdita’s psychiatrist, who considered that Perdita ought to go into hospital. Perdita refused to consider this. The Crisis Team were called out to assess for home treatment, but when they visited, Grendel answered the door, baseball bat in hand, and told them to go away. Although not using those words. They went away.

That was when I was asked to get involved.

Armed with a S.2 recommendation from Perdita’s psychiatrist, I went out to see Perdita with another S.12 doctor and her community nurse.

I wasn’t sure whether it was an angry Perdita or a subdued Grendel who answered the door and reluctantly let us in. Either way, there was no sign of the baseball bat.

She was not amused when I told her why we were there. She became instantly hostile, telling us to leave with an impressive selection of insults and swear words. I continued to explain the importance of allowing us to interview her. In response she turned up the TV so loudly that it was impossible to continue.

We sat patiently for a few minutes, and after a while she turned it down. This gave me an opportunity to speak.

“Perdita,” I began, “This is really important. You’re really struggling at the moment. You’re not in control. This isn’t fair on Ophelia. We have to keep you both safe.”

I had by now concluded that Perdita was so chaotic that there was no alternative but to detain her in hospital. The doctor and I left the house and retreated to my car to complete the paperwork.

I went back in to tell her. But Perdita had switched. The aggression and hostility had evaporated. In its place was a spectacularly melodramatic level of contrition.

“I’m begging you not to send me to hospital! I’m begging you on my knees not to put me away!”

She did indeed kneel on the floor in front of me, gazing beseechingly into my eyes, tears flowing freely down her cheeks. “Please, please, please, let me stay. Look, I’ll cook a nice meal for Ophelia, we’ll sit down together and watch a DVD, and then I’ll take my medication and go to bed.”

This level of apology and contrition was actually worse to handle than her insults and aggression.

But I had made a decision. I had completed my application. She was now officially liable for detention under the Mental Health Act. The risks of not admitting her to hospital were high. She had switched once. She might switch back at any time. Surely it was too late to go back on all this.

But then again...

It seemed Grendel had gone for the time being. The threat of admission seemed to have brought Perdita back in control. She was making reasonable plans for the immediate future. And what would be the effect on Ophelia of being separated from her mother?

So in the end I decided to use the discretion given in S.6(1)(a) MHA – this gives an AMHP 14 days to complete the admission. It’s not actually used very much – in nearly all cases, especially S.2, an admission follows as quickly as a hospital bed can be arranged.

I did a deal with Perdita. She would cooperate with us. She would allow us to help her keep herself safe. She would tell us if she wasn’t managing. She would not put herself or Ophelia in danger. I would visit her the next day to see how she was doing. She agreed to all this and was embarrassingly grateful. And when I visited the following morning, despite still feeling low and sad, she was calm, collected, polite and cooperative.

I continued to monitor her closely over the next week. Things continued to improve. The crisis was over.

I shredded the papers.

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