MARY QUITE CONTRARY



MARY QUITE CONTRARY

Mary Kendall is a 35-year-old social worker who was referred to a psychiatrist for treatment of chronic pain caused by a reflex sympathetic dystrophy in her right forearm and hand. She had a complex medical history that included asthma, migraine headaches, diabetes mellitus, and obesity. She was found to be highly hypnotizable, and quickly learned to control her pain with self-hypnosis.

Mary was quite competent in her work, but had a rather arid personal life. She had been married briefly and divorced 10 years earlier, and she had little interest in remarrying. She spent most of her free time volunteering in a hospice.

As a thorough psychiatric evaluation continued, she reported the strange observation that on many occasions, when she returned home from work the gas tank of the car was nearly full, yet when she got into car to go to work the next day, it was half empty. She began to keep track of the odometer, and discovered that on many nights 50 to 100 miles would be put on the car overnight, although she had no memory of driving it anywhere. Further questioning revealed that she had gaps in her memory for large parts of her childhood.

Because of the gaps in her memory, the physician suspected a dissociative disorder, but it was only after several months of hypnotic treatment for pain control that the explanation for the lost time emerged. During a hypnotic induction, the physician again asked about the lost time. Suddenly a different voice responded, "It's about time you knew about me." The (alter) personality with a slightly different name, Marian, now spoke and described the drives that she took at night, which were retreats to the nearby hills and seashore to "work out problems." As the psychiatrist got to know Marian over time, it was apparent that she was as abrupt and hostile as Mary was compliant and concerned about others. Marian considered Mary to be rather pathetic and far too interested in pleasing, and said that "worrying about anyone but yourself is a waste of time. "

In the course of therapy, some six other personalities emerged, roughly organized along the lines of a dependent/aggressive continuum. Considerable tension and disagreement emerged among these personalities, each of which was rather two-dimensional. Competition for control of time "out" was frequent, and Marian would provoke situations that frightened the others, including one who identified herself as a 6-year-old child. The subjective experience of distinctness among some of the personality states was underscored when one rather hostile alter personality made a suicide threat. The therapist insisted on discussing this with other personalities, and she objected that to do so would be a "violation of doctor-patient confidentiality."

The memories that emerged with these dissociated personalities included recollections of physical and sexual abuse at the hands of her father and others, and considerable guilt about not having protected other children in the family from such abuse. Mary recalled her mother as being infrequently abusive, but quite dependent, and forcing Mary to cook and clean from a very early age.

After 4 years of psychotherapy, Mary gradually integrated portions of these personality states. Two similar personalities merged, although she remained partially dissociated. The personality states were aware of one another, and continued to "fight" with each other periodically.

MY FAN CLUB

During the course of a routine physical examination, Nick, a 25-year-old single, African American man, suddenly started crying and blurted out that he was very depressed and was thinking about a suicide attempt he had made when he felt this way as a teenager. His doctor referred him for a psychiatric evaluation.

Nick is tall, bearded, muscular, and handsome. He is meticulously dressed in a white suit and has a rose in his lapel. He enters the psychiatrist's office, pauses dramatically, and exclaims, "Aren't roses wonderful this time of year?" When asked why he has come for an evaluation, he replies laughingly that he has done it to appease his family doctor, "who seemed worried about" him. He has also read a book on psychotherapy, and hopes that "maybe there is someone very special who can understand me. I'd make the most incredible patient." He then takes control of the interview and begins to talk about himself, after first remarking, half jokingly, "I was hoping you would be as attractive as my family doctor."

Nick pulls out of his attache case a series of newspaper clippings, his resume, photographs of himself, including some of him with famous people, and a photostatted dollar bill with his face replacing George Washington's. Using these as cues, he begins to tell his story.

He explains that in the last few years he has "discovered" some now famous actors, one of whom he describes as a "physically perfect teenage heartthrob." He volunteered to coordinate publicity for the actor, and as part of that, posed in a bathing suit in a scene that resembled a famous scene from the actor's hit movie. Nick, imitating the actor's voice, laughingly, and then seriously, describes how he and the actor had similar pasts. Both were rejected by their parents and peers, but overcame this to become popular. When the actor came to town, Nick rented a limousine and showed up at the gala "as a joke," as though he were the star himself. The actor's agent expressed annoyance at what he had done, causing Nick to fly into a rage. When Nick cooled down, he realized that he was "wasting my time promoting others, and that it was time for me to start promoting myself." "Someday," he said, pointing to the picture of the actor," he will want to be president of my fan club."

Nick has had little previous acting experience of a professional nature, but he is sure that success is "only a question of time." He pulls out some promotional material he has written for his actors and says, " I should write letters to God, He'd love them!" When the psychiatrist is surprised that some materials are signed by a different name than the one Nick has given the receptionist, Nick pulls out a legal document explaining the name change. He has dropped his family name and taken as his new second name his own middle name.

When asked about his love life, Nick says he has no lover, and this is because people are just "superficial." He then displays a newspaper clipping in which he had letterset his and his ex-lover's names in headlines that read: "The relationship is over." More recently he has dated and adored a man with the same first name as his own; but as he became disenchanted, he realized that the man was ugly and was an embarrassment because he dressed so poorly. Nick then explains that he owns over 100 neckties and about 30 suits, and is proud of how much he spends on "putting myself together." He has no relationships with other homosexual men now, describing them as "only interested in sex." He considers heterosexual men as "mindless and without aesthetic sense." The only people who have understood him are older men who have suffered as much he has. "One day, the mindless, happy people who have ignored me will be lining up to see my movies."

Nick's alcoholic father was very critical of him, was rarely around, and had many affairs. His mother was "like a friend." She was chronically depressed about her husband's affairs and turned to her son, often kissing him on the lips, until he was 18, when she started an affair of her own. Nick then felt abandoned and made his suicide gesture. He described a tortured childhood, being picked on by his peers for looking odd, until he began body building.

At the end of the interview, Nick is referred to an experienced clinician associated with the clinic, who charges a minimal fee (10 dollars), which he can afford. However, Nick requests a referral to someone whowould offer him free treatment, seeing no reason for paying anyone as the therapist "would be getting as much out of it" as he would.

UNDER SURVEILLANCE

Mr. Simpson is a 44-year-old, single, unemployed, white man brought to the emergency room by the police for striking an elderly woman in his apartment building. His chief complaint is, "That damn bitch. She and the rest of them deserved more than that for what they put me through."

The patient has been continuously ill since age 22. During his first year of law school, he gradually became more and more convinced that his classmates were making fun of him. He noticed that they would snort and sneeze whenever he entered the classroom. When a girl he was dating broke off the relationship with him, he believed that she had been "replaced" by a look-alike. He called the police and asked for their help to solve the "kidnapping." His academic performance in school declined dramatically, and he was asked to leave and seek psychiatric care.

Mr. Simpson got a job as an investment counselor at a bank, which he held for 7 months. However, he was getting an increasing number of distracting "signals" from co-workers, and he became more and more suspicious and withdrawn. It was at this time that he first reported hearing voices. He was eventually fired, and soon thereafter was hospitalized for the first time, at age 24. He has not worked since.

Mr. Simpson has been hospitalized 12 times, the longest stay being 8 months. However, in the last 5 years he has been hospitalized only once, for 3 weeks. During the hospitalizations he has received various antipsychotic drugs. Although outpatient medication has been prescribed, he usually stops taking it shortly after leaving the hospital. Aside from twice-yearly lunch meetings with his uncle and his contacts with mental health workers, he is totally isolated socially. He lives on his own and manages his own financial affairs, including a modest inheritance. He reads the Wall Street Journal daily. He cooks and cleans for himself.

Mr. Simpson maintains that his apartment is the center of a large communication system that involves all three major television networks, his neighbors, and apparently hundreds of "actors" in his neighborhood. There are secret cameras in his apartment that carefully monitor all his activities. When he is watching TV, many of his minor actions (e.g., going to the bathroom) are soon directly commented on by the announcer. Whenever he goes outside, the "actors" have all been warned to keep him under surveillance. Everyone on the street watches him. His neighbors operate two different "machines"; one is responsible for all of his voices, except the "joker." He is not certain who controls this voice, which "visits" him only occasionally and is very funny. The other voices, which he hears many times each day, are generated by this machine, which he sometimes thinks is directly run by the neighbor whom he attacked. For example, when he is going over his investments, these "harassing" voices constantly tell him which stocks to buy. The other machine he calls "the dream machine." This machine puts erotic dreams into his head, usually of "black women."

Mr. Simpson describes other unusual experiences. For example, he recently went to a shoe store 30 miles from his house in the hope of getting some shoes that wouldn't be "altered." However, he soon found out that, like the rest of the shoes he buys, special nails had been put into the bottom of the shoes to annoy him. He was amazed that his decision concerning which shoe store to go to must have been known to his "harassers" before he himself knew it, so that they had time to get the altered shoes made up especially for him. He realizes that great effort and "millions of dollars" are involved in keeping him under surveillance. He sometimes thinks this is all part of a large experiment to discover the secret of his "superior intelligence."

At the interview, Mr. Simpson is well-groomed, and his speech is; coherent and goal-directed. His affect is, at most, only mildly blunted. He was initially very angry at being brought in by the police. After several weeks of treatment with an antipsychotic drug failed to control his psychotic symptoms, he was transferred to a long-stay facility with a plan to arrange a structured living situation for him.

MARTIAL ARTS

John Marshall, a 32-year-old, single, white man, was referred for psychiatric evaluation by juvenile court prior to termination of his parental rights for his 7-year-old son, Richard. Mr. Marshall had been involved with child protective services and in dependency and neglect proceedings for 7 years. During that time he had one charge of physical abuse of children other than his son, and two charges of spouse abuse brought against him. He has had no other legal involvement.

Child protective services initially worked with Mr. and Mrs. Marshall when their son was living with them. However, by the time he was age 3, Richard was afraid of water, not toilet-trained, extremely withdrawn, unable to play, and had bilateral optic nerve damage, which was thought to be related to repeated, severe shaking as an infant. He is now legally blind. At 3, Richard was placed in foster care. It was discovered that his father had locked him in closets for long periods of time and had prevented his mother from caring for him. Since Richard has been in foster care, his father was expected to provide child support. Mr. Marshall is regularly employed, but has paid none of the child support and has not bought any gifts for his son at any time. He is known to have some discretionary income, which he tends to use to buy magazines, such as Soldier of Fortune, or to otherwise indulge his continuing interest in the martial arts. He is fascinated by guns, knives, and other weapons, which he describes as "tools of status." He enjoys these "toys" and finds that they "make his adrenaline flow." He fantasizes becoming a mercenary and joining the Foreign Legion.

Mr. Marshall freely admits beating up two children, ages 6 and 7, for whom he was baby-sitting and giving them bruises and a black eye. He believes this was justified because one of the two children lied to him. He addresses his son as "brat" or "rug rat" during visits. In front of Richard he describes in great detail his own abusive upbringing and plays with sharp knives during these discussions. When he was sent to parenting classes to improve his relationship with Richard, he distracted the class by telling long, dramatic stories about various devious deeds like breaking the necks of geese in the city park. He was eventually asked to leave parenting classes.

Mr. Marshall met his common-law wife when she was working in a massage parlor. She attempted to leave him at various times, but he followed her whenever she moved out and caused such a disruption at her new place of residence that she was evicted. He also harassed her at work and threatened repeatedly that if she left him, he would get her fired. He did, in fact, precipitate her being fired on several occasions. He would call her workplace, telling her boss that he was a detective investigating her for embezzlement, fraud, or child abuse (all of these allegations were untrue). Shortly after she left him for the last time, Mr. Marshall met a new girlfriend at parenting class. He became abusive of this woman soon after moving in with her, and she filed charges against him. He continued to harass her, following her to work, calling her there, and being very disruptive. On one occasion he followed her into her workplace, cornered her in a room without windows, and "karate-chopped" at various supplies, saying that he would do the same to her. He did not actually touch her.

Mr. Marshall is the eldest of six step-siblings. He had no contact with his natural father. His stepfather was a career military man, and the family therefore moved frequently during Mr. Marshall's childhood. He denies observing any spouse abuse in his own home when he was growing up, but says that his stepfather had a violent temper and sometimes beat him for no reason. These beatings frequently resulted in bruises and cuts. Mr Marshall became interested in karate at age 14 as a means of defending himself against his father.

He denies any conduct problems at home or at school during childhood or adolescence. He obtained a B average in high school and was involved in various sports. Nevertheless, he never felt he won acknowledgment or praise from his father. Following high school, Mr. Marshall attended college for 2 years, studying police science.

Mr. Marshall does not have a drug or alcohol problem, and there is no family history of drug or alcohol abuse. He is not aware of having been depressed at any time in his life, and has made no suicidal gestures He feels unjustly treated by the child protective services and juvenil court. Although Social Services reports that he frightens the foster mother the social worker, and his own grandmother, he perceives himself as being picked on by child protective services.

He believes that the allegations against him are insignificant or false and that he will eventually get custody of his son. He laughs when he describes being told that his son has significant visual problems and will never see well enough to drive.

During the interview, Mr. Marshall was somewhat demanding, at tempting to manipulate meeting times for evenings or weekends. He was demeaning of the Social Services worker in this case and of his ex-wife, but not of the interviewer. Formal mental status testing indicated normal cognition, abstractions, concentration, and fund of general information, with poor judgment.

SLIME

A psychiatrist with a special interest in the long-term effects of childhood traumatic experiences first saw Linda Darby when she was 26. She was a paralegal who had many physical complaints for which no clear etiology could be found; she was also chronically depressed and anxious. Her family doctor, who made the referral, had been unsuccessful in treating her with medication. He noted that she was exquisitely sensitive to medications (e.g., she would go into a daylong sleep after taking 5 mg of an antianxiety medication, diazepam; she would develop severe side effects on 25 mg of an antidepressant, amitriptyline.)

The psychiatrist noted that at age 26 Linda lives with her parents and brother and feels that she needs to stay around in order to minimize the constant threat of family violence. She frequently thinks of suicide, and has engaged in self-mutilation, using a razor blade on her breasts and thighs, which she claims helps her feel "like myself' and restores a sense of calm after an upsetting experience. At work her performance is exemplary. She is assigned the most complex cases and often stays late doing library research. She also volunteers as a fund-raiser for a charitable organization on weekends. Even though she seems to possess adequate social skills, she has no real friends and no social life.

She began treatment with the psychiatrist and gradually revealed a history of chronic family violence and incest. Her father was only occasionally employed, often in illegal activities. He had recurrent alcoholic binges, and used to beat up his two sons regularly, to the point that they both had been hospitalized with broken bones.

Linda remembered first having sex with her father at age 8, when she and her father and two brothers were snowed in while her mother was in the hospital. She was terrified by her father's breaking open a locked door and forcing her to have intercourse with him, but also remembers feeling that she now had become "special" to her father. These episodes of sexual abuse continued until she moved out of the house to go to college when she was age 18. She recalled her relationship with her father with much self-loathing, convinced for many years that she was to blame for the incest, which made her feel like "slime" and "a bag of shit."

Throughout her childhood, Linda's mother was often ill and Linda took care of many of the routine household duties. She always suspected that her mother was aware of the incestuous relationship.

She did not remember much of her childhood, and described episodes of "spacing out" during which she found herself in places without knowing how she got there. Despite the fact that she had a lot of attention from men, she avoided dating. She felt terrified when a man showed any interest in her. Any sexual feelings appeared to be associated in her mind with thoughts of violence. Probably her greatest source of shame was the fact that she was sexually aroused by thoughts of sexual violence.

After 2 years of supportive psychotherapy, Linda gained enough courage to move into an apartment of her own. At once expressing fear of intimacy (for fear that people might find out what a despicable person she is) and a longing for care, she adopted four stray cats and two dogs, which she considered her family. The presence of her animals, she claimed, help her deal with her frequent nightmares about being sexually assaulted. She entered a woman's psychotherapy group in which she proved to be extremely insightful about other people's problems, astounding them with her insights and her capacity to put her finger on the crucial issues. When it was pointed out that she only helped others and avoided talking about herself, she became angry and threatened to leave the group.

Two years later she was raped in her apartment in the inner city. She lived on the ground floor, and the rapist entered through a window without a grate. She had talked to her therapist about the lack of safety in her apartment, but had been unable to confront her landlord about it. After the rape, she moved back home, forfeiting 2 months' security deposit. Although shaken by the assault, she claimed that it just compounded her sense of living "in hell already-the hell of my memories."

Through judicious use of small amounts of medications, Linda's symptoms gradually subsided. She is now able to sleep through the night, and has lost her pervasive sense of psychic numbing. At work she sometimes feels so enraged about real and imagined slights that she thinks expressing her rage would have cataclysmic results. On the other hand, she has become Big Sister to an abused 10-year-old girl, and has some social contacts with cousins. In dealings with her family, she continues to feel that she has no rights and is still financially exploited by them. She continues to avoid all contacts with sexual implications. She `still has no sense of having a future that she can influence and that has personal meaning. Her medical bills, aggravated by three fender-benders during the past year, the result of "spacing out" while driving, continue to mount. Her work performance is still exemplary, and she does not mutilate herself anymore.

LEATHER

A 35-year-old married writer sought consultation because he feared he might kill someone by acting upon sexually sadistic impulses.

The patient has been married for 15 years, and during the last year has had sexual intercourse with his wife approximately every other week. The patient's fantasy life is predominantly homosexual, however, and has been so since age 9. He has felt sexually attracted to males since childhood, but resisted acting on these impulses until mid-adulthood, long after he married. Before that, he felt sexually aroused by homosexual pornography (to which he was exposed from mid-adolescence), particularly by pornography with sadistic content. Although somewhat responsive to heterosexual pornography, his interest in it was much less than in homosexual pornography, and he was never excited by heterosexual pornography with sadistic content.

The patient had married for reasons of social propriety, and also because he consciously hoped that initiation into regular heterosexual activity would lead to diminution of his sadistic homosexual impulses. This was not the case, however. These impulses continued periodically to form the basis of the patient's masturbation fantasies. Typical masturbation fantasies were of a man bound, tortured, and killed. Sometimes the men in his fantasies were people he knew, such as colleagues or teachers, and sometimes movie stars or strangers. These fantasies were more intense at certain times than at others. The patient recalls, for example, that he was "wildly" aroused when he read about a homosexual lust murder as described in a detective magazine. Immediately following this, he masturbated many times a day, always with sadistic homosexual fantacies. After a few weeks, this period of intense arousal subsided, but the patient used scenario events described in this magazine in subsequent masterbation fantasies.

About 8 years ago, the patient went to a gay bar with an associate from his office. At the time, he was under much pressure, and his work was being closely supervised by an aggressive, demanding, male superior. The patient's associate was openly homosexual, and the patient allegedly went to the bar with him "as a lark." En route to the particular bar they visited, they passed other bars that, the patient's friend told, him, were for "the leather crowd who like S and M [sadomasochism]." The patient had a brief homosexual encounter with someone he picked up in the bar they visited, following which he "put sex out of [his] mind."

Some months later, however, following a week of intense work at his office, the patient impulsively sought out one of the "S and M" bars he had previously walked past. There he met a man who was sexually aroused by being beaten, and the patient engaged in pleasurable sadistic activity with the understanding that the severity of the beating, administered with a belt, was under the control of his masochistic partner. That incident, occurring when he was age 28, was the first episode in a series of sexually sadistic activities, ultimately leading to his consultation. About once a month the patient would frequent a homosexual sadomasochistic bar. He would dress in a leather jacket and wear a leather cap. Once in the bar, he would seek out a masochistic partner and engage in a variety of activities, all of which the patient experienced as sexually exciting. The activities included binding the partner with ropes, whipping him, threatening to burn him with cigarettes, forcing him to drink urine, forcing him to "beg for mercy." The patient would experience orgasm during these activities, usually by "forcing" his partner to commit fellatio.

During the year before the consultation, the patient's wife had become progressively dissatisfied with their marriage. She was unaware of her husband's homosexual interest and of his sadistic tendencies. She felt, however, that his sexual involvement with her was desultory, and she wondered whether he had a mistress. She became confronting and also more hostile and demanding toward the patient. He realized that he "needed" his wife, and he did not wish the relationship to end, yet he felt unable to deal with her dissatisfactions directly. He avoided her as much as possible and argued with her when she insisted on talking to him. The patient's work pressures increased; he found, to his dismay, that the intensity of his sadistic impulses also increased.

On one occasion the patient convinced a partner to agree to being burned. Afterward, he felt guilty and ashamed. Just before the consultation, he bound a partner and cut the man's arm. At the sight of blood he experienced a powerful desire to kill his partner. He restrained himself and, alarmed that his sadistic impulses were out of control, sought psychiatric consultation.

CRY ME A RIVER

A 38-year-old clerical worker described to a psychiatrist how she had been experiencing a disabling sleep problem for a year and a half. She usually goes to bed at 6:00 P.M. and sleeps straight through until 7:00 A.M. The reason that she comes for help now is that last month her driver's licence was suspended after she fell asleep while driving her car out of a parking lot and hit a telephone pole. As a result, she now has to arise at 6:00 A.M. to use public transportation to arrive in time for work at 8:15 A.M. Upon arising she typically feels groggy and "out of it." During the day she remains sleepy. She frequently falls asleep on buses, missing her stop. She recently took a sales job after work, from 6:00 P.M. until 10:00 P.M. two nights a week, in an attempt to remain on her feet at least some of the time that she is away from her office job. On weekends she remains in bed asleep all day, arising only to go to the toilet or for meals, except on an occasional Saturday when she does her routine chores.

The patient does not believe that she snores during sleep (as would be likely in a Breathing-Related Sleep Disorder), and she denies nightmares (as in Nightmare Disorder), sleepwalking (as in Sleepwalking Disorder), or sudden loss of muscle tone (cataplexy) or feelings of paralysis upon awakening, both symptoms of Narcolepsy.

Before the onset of her sleep problem, the patient generally required only 6-7 hours of sleep a night. During the first year of her “sleepiness”, she began to treat herself with caffeine, drinking up to 10 cups of coffee and 1-2 liters of cola daily.

In addition to the sleepiness, the patient has had severe, recurrent periods of depression since approximately age 13. For several months before the evaluation, she was having crying spells in her office. These sometimes would come on so suddenly that she had no time to run to the rest room to hide them. She acknowledged trouble concentrating on her job and noted that she was getting little pleasure from her work, which she used to enjoy. She had been harboring angry and pessimistic feelings for the past several years, and noted that these were more severe recently as she had allowed her diabetes and weight to get out of control. She felt guilty that she was physically damaging herself and slowly dying in this way. She sometimes thought that she deserved to be dead.

She had been treated from age 18 to age 33 with psychotherapy, during which time her depression gradually worsened. More recently she had been given trials of antidepressants, including imipramine, desipramine, and fluoxetine, which had each made improvements in mood and wakefulness that lasted several months. She tended to fall asleep during evening group psychotherapy sessions.

The patient's diabetes was diagnosed at age 11. She first lost control of her weight and her blood sugar during her teenage years, regained it, but has frequently lost control since then. At this evaluation she weighed about 30% above her ideal weight, was on 52 units of insulin daily, but neither kept regular mealtimes nor tested her blood or urine. Results of recent random blood sugar determinations were abnormally high. Significant diabetic retinopathy had developed, compelling her to use a magnifying glass for reading. She had mild hypertension without apparent diabetic kidney disease, and took one diuretic tablet daily.

The patient had done poorly in high school, and had gone to business school for 4 years but had failed to graduate. She had had some hope of a romantic relationship, but never had a steady boyfriend. She lives at home with her mother and has no close friends outside her family. On close questioning, it became apparent that the onset of the sleep problems and the beginning of the most recent period of depression had coincided.

The patient's family history revealed that one of her five siblings took a nap each afternoon and slept 7 hours nightly. Otherwise, there was no history of Sleep Disorder, diabetes, or treatment for depression in the patient's family.

As the patient described her problem to the psychiatrist, she gazed continually downward and conversed in a low monotone. She answered questions dutifully, but without elaboration. She shed copious tears.

The patient was admitted to the hospital for studies. Nursing observations documented that the patient slept 12-15 hours daily. She was much impaired in tests of vigilance, which involved her pushing a button whenever the letter "X" appeared in a series of letters visually presented at one per second; she averaged 4% correct responses during two trials, compared with a normal score of 66%-78%. She had an average multiple sleep latency (i.e., onset of sleep after lights out) of 8.5 minutes during four polygraphically recorded daytime naps, a result consistent with only mild sleepiness. Nocturnal sleep monitoring revealed an abnormally short REM latency of 2 minutes and an abnormal increase (42%) in the amount of REM sleep. The nocturnal sleep monitoring revealed no other abnormality. The patient had only 2% wakefulness, much less than expected in a prolonged recording; this was consistent with her daytime sleepiness. She continued to sleep for 91/2 hours, until she had to be awakened so the laboratory could be used for daytime purposes.

I COULD BE DYING

Bill Ainsworth awoke in the middle of the night, gasping for breath, sweating, shaking, and experiencing palpitations. He felt his pulse; it was 120. He thought, "I could be dying." It was his third attack of the week, and at least his tenth that month that had awakened him from sleep. The problem, which had begun 2 years previously when he turned 50, was getting much worse: not only was he having trouble staying asleep because of similar attacks, but after such nights he felt tired all day. He decided to take a friend's advice and seek help from a psychiatrist who specialized in sleep problems.

The psychiatrist elicited this additional history. Attacks of panic occurring during the day had begun at age 12 and had recurred every few months since that time. They did not begin to occur during sleep until the patient turned age 50, 2 years earlier. A few months ago the attacks had become much rarer, after the patient had discontinued drinking the 8 to 10 beers he had drunk every weekend for most of his adult life. His weight had fallen from 227 pounds to a mildly overweight 181 pounds, and the mild hypertension he had had for several years disappeared.

In addition to the recurrent attacks, for most of his life the patient had also felt anxious in anticipation of particular situations, including being shut inside airplanes or elevators or traveling in the middle lane of a road. On a turnpike he counted the exits until he could leave, fearing that he would have a panic attack.

He described a fear of falling apart if he ever got too far from his “support system,” his term for a beer cooler, which he carried with him always, although he rarely drank the beer. In anticipation of an airplane flight, however, he would drink six to eight beers. He almost always had a company employee, his son, or a friend accompany him, and paritcuarly disliked plane flights when he was not with a familiar person. The night after he drank, the anxiety attacks almost always occurred, awakening him from sleep.

Mr. Ainsworth ran a successful auto parts business and consulted for several others. Recently, however, anxiety had prevented his accepting a huge government contract to set up an international distribution system retail stores on military bases. He felt he would be too exposed to scrutiny and would therefore fail. He also worried that some long plane rides would be unavoidable.

During the interview Mr. Ainsworth was highly verbal, informative, cheerful, friendly, and engaging. He talked about uncomfortable subjects frankly and productively. He had two sisters and two daughters who had "agoraphobia"; one of the daughters was housebound.

Initially, the patient was thought to have sleep apnea (recurrent periods of not breathing during sleep), on the basis of the loud snoring that he reported and the awakening provoked by drinking alcohol relieved by weight loss, and the presence of mild hypertension. (These symptoms are commonly seen in sleep apnea, and are presumably related to the pulmonary hypertension that develops from insufficient breathing and oxygen desaturation. No evidence for this emerged from results of sleep laboratory recording, upper airway examination, or daytime vigilance testing.)

SOMETHING OF VALUE

Eli Wolfe came into the emergency room of a New York hospital complaining of malaise, fever, and a cough. An upper respiratory infection was diagnosed. As the doctor was writing out a prescription, Mr. Wolfe tearfully revealed that he had no home to go to, was depressed, and felt that life was not worth living. A psychiatric resident was called to see the patient and obtained the following additional information.

For the past month Mr. Wolfe had been living in the basement of his apartment building, eating in restaurants, and using a health club for showers. He was eating and sleeping poorly. His own apartment was so full of newspapers, magazines, and books that he could no longer get in the door, but he could not bring himself to get rid of any of his "stuff."

When he was 12, Mr. Wolfe began collecting baseball cards and then books and magazines. His parents were poor immigrants from Eastern Europe, and the idea of holding on to things that might someday be valuable was not strange to them. Eventually, however, the apartment became so cluttered that they threw out much of his collection. He retrieved it from the garbage, and from that point on his "collecting" became a focus of conflict with family and employers.

Mr. Wolfe does not go out of his way to obtain things, but once he has a newspaper, book, or magazine, he cannot throw it away because "there might be something of value written in it." The thought of throwing things out makes him extremely anxious, and, in the end, he simply cannot do it.

For many years he worked as a doorman in elegant apartment buildings, but invariably was fired because he brought his "stuff" to store in his workplace, and sometimes got into fistfighrs with the building maintenance people who tried to throw it out. He was married for 10 years, and has a 25-year-old son. His wife finally left him, unable to tolerate his behavior. He rarely sees his son.

Mr. Wolfe first entered treatment not because of his collecting, but because, at age 20, "my mood took a turn for the worse. I had a breakdown." He stopped doing virtually everything-working, eating, sleeping. "It was an effort even to lift my leg." He began seeing a psychiatrist as an outpatient, and over the years has been in therapy much of the time, treated with a variety of antidepressants and anxiolytics.

After his divorce, 10 years ago, he moved some of his collection into his own apartment and rented storage space for the rest. Gradually his new apartment filled up with newspapers, magazines, and books, and it became a struggle just to get in the front door and make his way to his bed. Finally, last month, he injured his shoulder trying to push things aside, and then abandoned the apartment for a cot in the basement of the building. He understands that his inability to throw things out is irrational, but the thought of starting to do it makes him intolerably anxious.

HAIR

Celeste, now age 25, had always thought she was unique. When she was a teenager, her parents made her feel as though nobody else had ever pulled out her eyebrows until there were none left. This had been going on since she was age 12. And her eyebrows had not been the worst of it over the years there had been quarter-size bald patches on her head. There was a 1-year period (about 5 years ago, when she was a sophomore at college) when she was practically bald.

It always amazed her how "together" everyone thought her to be. She got good grades; she got into law school. "If they only knew," she often said to herself. But through careful brushing of whatever hair she still had, artful use of scarves and, at one time, a hair "piece," and avoiding all gym classes, not a soul ever found out. The eyebrows were easy; she just drew in new ones.

It was a merciless habit. It went on every day. Usually she would be sitting in front of the TV, distractedly watching reruns, and then she would notice her fingers were in her hair, rummaging about, looking for a hair with a nice thick shaft. Then she would rapidly tug with an expertise gained from long experience. Out would come the hair, root and all. She would then notice the little pile of hairs accumulating on the arm of the sofa and realize she must have been doing this for many minutes already. She would try to stop, but the nervousness would escalate, and the hair-pulling would recommence and go on until the urge just wore itself out. On good days this would be 10 minutes. On bad days, it could last for an hour.

She might never have known that other people had this habit until a month ago when a sudden rainstorm messed up her strategically coiffed hair, exposing the large ratty patch just above her left ear. Horrified that she was now revealed to her co-worker, Sylvia, she was surprised when she heard, "You're a hair-puller too?" Three days later Sylvia took Celeste to a self-help group where she met seven other "pullers," five women and two men. She thought she was hearing her own life in other people's words:

I felt like I must be an awful person, with no self-control. That's what my parents said.

High school gym terrified me. I was constantly afraid of my wig coming off.

I figured, who could ever want to marry me. First of all, I'm scared to have any real sex. I know my hair will come undone. And what if someone does fall in love with me? How would he react when he realized I did this thing? I had one boyfriend whom I told that I got messed up by a chemical reaction to a bad permanent. But I wouldn't be able to say that forever.

I thought I was the only one in the world.

NO FLUIDS

Ann, a 32-year-old medical secretary in Dublin, Ireland, is referred to a clinic for treatment of depression. She confides that the reason she is depressed is that for the last 5 months, she has been afraid that she will urinate in public. She has never actually done this; and in the safety of her own home, she considers the idea that it will actually happen to her to be nonsensical.

When Ann is away from home, the fear dominates her thinking, and she takes precautions to prevent its happening. She always wears sanitary napkins, never travels far from home, limits her intake of fluids, has stopped drinking alcohol, and has had her desk at work relocated near a toilet. For the 2 weeks before the consultation, she was unable to go to work because the fear had become so intense.

Ann vaguely recalls that her deceased father also had a fear of urinating in public. Before leaving for work each day, he urinated several times and avoided taking any fluids. Her younger sister has been successfully treated for a cleansing ritual.

Ann had psychiatric treatment 10 years ago when she began to fear that she had contracted syphilis, even though there was no clinical or laboratory evidence of infection. Up until 5 months ago, she had never feared that she would urinate in public. In addition to these specific fears she has always been an anxious, insecure person, considered by her family to be overly cautious and perfectionistic. For the past year she has been upset about her boyfriend's impending return to his home country after completing his medical studies in Ireland. She was divorced 5 years previously, and is now living with her 7-year-old-son and mother. Her mother disapproves of her boyfriend, and Ann has felt increasing pressure to end the relationship. She believes that the onset of her current difficulties coincided with the stress of her relationship with her mother and the threat of her boyfriend's departure from the country.

When interviewed, Ann is visibly anxious. She remarks that she has been feeling despondent about her problems. She has trouble sleeping and has no energy during the day. Although her appetite is poor, she has not lost any weight.

ROLLER COASTER

When Emest Eaton's desperate wife finally got him to agree to a comprehensive inpatient evaluation, he was 37, was unemployed, and had been essentially nonfunctional for several years. After a week during which he was partying all night and shopping all day, Mrs. Eaton said that she would leave him if he did not check into a psychiatric hospital. The admitting psychiatrist found him to be a fast-talking, jovial, seductive man with no evidence of delusions or hallucinations.

Mr. Eaton's troubles began 7 years before when he was working as an insurance adjuster and had a few months of mild, intermittent depressive symptoms, anxiety, fatigue, insomnia, and loss of appetite. At the time, he attributed these symptoms to stress at work, and within a few months was back to his usual self.

A few years later an asymptomatic thyroid mass was noted during a routine physical exam. One month after removal of the mass, a papillary cyst, Mr. Eaton noted dramatic mood changes. Twenty-five days of remarkable energy, hyperactivity, and euphoria were followed by 5 days of depression during which he slept a lot and felt that he could hardly move. This pattern of alternating periods of elation and depression, apparently with few "normal" days, repeated itself continuously over the following years.

During his energetic periods, Mr. Eaton was optimistic and self-confident, but short tempered and easily irritated. His judgment at work was erratic. He spent large sums of money on unnecessary and, for him, uncharacteristic purchases, such as a high-priced stereo system and several Doberman pinschers. He also had several impulsive sexual flings

During his depressed periods, he often stayed in bed all day because of fatigue, lack of motivation, and depressed mood. He felt guilty about the irresponsibilities and excesses of the previous several weeks. He stopped eating, bathing, and shaving. After several days of this withdrawal, Mr. Eaton would rise from bed one morning feeling better and, within 2 days, be back at work, often working feverishly, though ineffectively, to catch up on work he had let slide during his depressed periods.

Although both he and his wife denied any drug use, other than drinking binges during his hyperactive periods, Mr. Eaton had been dismissed from his job 5 years previously because his supervisor was convinced that his overactivity must be due to drug use. His wife had supported him since then.

When he finally agreed to a psychiatric evaluation 2 years ago, Mr. Eaton was minimally cooperative and noncompliant with several medications that were prescribed, including lithium, neuroleptics, and antidepressants. His mood swings had continued with few interruptions up to the current hospitalization.

In the hospital results of his physical examination, blood chemistry, blood counts, computed tomography scan, and cognitive testing were unremarkable. Thyroid function testing revealed some laboratory evidence of thyroid hypofunction, but he was without clinical signs of thyroid disease. After a week he switched to his characteristic depressive state.

ON STAGE

Harry is a 33-year-old man who lives in Seattle with his wife. He has been employed as a salesperson for an insurance company since graduating from college. He came to a private psychiatrist, recommended by a friend, complaining of “anxiety at work.”

Harry describes himself as having been outgoing and popular throughout his adolescence and young adulthood, with no serious problems until his third year of college. He then began to become extremely tense and nervous when studying for tests and writing papers. His heart would pound; his hands would sweat and tremble. Consequently, he often did not write the required papers and when he did, would submit them after the date due. He could not understand why he was so nervous about doing papers and taking exams when he had always done well in these tasks in the past. As a result of his failure to submit certain papers and his late submission of others, his college grades were seriously affected.

Soon after graduation, Harry was employed as a salesperson for an insurance firm. His initial training (attending lectures, completing reading assignments) proceeded smoothly. However, as soon as he began to take on clients, his anxiety returned. He became extremely nervous when anticipating phone calls from clients. When his business phone rang, he would begin to trembles and sometimes would not even answer it. Eventually, he avoided becoming anxious by not scheduling appointments and by not contacting clients whom he was expected to see.

When asked what it was about these situations that made him nervous, he said that he was concerned about what the client would think of him: "The client might sense that I am nervous and might ask me questions that I don't know the answers to, and I will feel foolish." As a results he would repeatedly rewrite and reword sales scripts for telephone conversations because he was "so concerned about saying the right thing. I guess I'm just very concerned about being judged."

Although never unemployed, Harry estimates that he has been functioning at only 20% of his work capacity, which his employer tolerates because a salesman is paid only on a commission basis. For the last several years, Harry has had to borrow large sums of money to make ends meet.

Although financial constraints have been a burden, Harry and his wife entertain guests at their home regularly and enjoy socializing with friends at picnics, parties, and formal affairs. Harry lamented, "It's justwhen I'm expected to do something. Then it's like I'm on stage all alone, with everyone watching me."

USEFUL WORK

An 85-year-old man is seen by a social worker at a senior citizens' center for evaluation of health-care needs for himself and his bedridden wife. He is apparently healthy, with no evidence of impairment in thinking or memory. He has been caring for his wife, but has been reluctantly persuaded to seek help because her condition has deteriorated, and his stregth and energy have decreased with age.

A history is obtained from the subject and his daughter. He has never been treated for mental illness, and in fact has always claimed to be “immune to psychological problems” and to act only on the basis of rational thought. He had a moderately successful career as a lawyer and businessman. He has been married for 60 years, and his wife is the only one for whom he has ever expressed tender feelings, and is probably the only person he has ever trusted. He has always been extremely careful about revealing anything of himself to others, assuming that they are out to take something away from him. He refuses obviously sincere offers of help from acquaintances because he suspects their motives. He never reveals his identity to a caller without first questioning him as to the nature of his business. Throughout his life there have been numerous occasions on which he has displayed exaggerated suspiciousness, some times of almost delusional proportions (e.g., storing letters from a client in a secret safe deposit box so that he could use them as evidence in the event that the client attempted to sue him for mismanagement of an estate).

He has always involved himself in "useful work" during his waking hours, and claims never to have time for play even during the 20 years he has been retired. He spends many hours monitoring his stock market investments, and has changed brokers several times when he suspected that minor errors on monthly statements were evidence of the brokers attempt to cover up fraudulent deals.

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