Which of us, when confronted with the daunting sight of an acutely psychotic person in full flight, has not at least mentally quivered at the knees and felt like turning and running for cover? Those eyes, with that strange all-knowing look, totally suspicious and distrustful, darting from side to side like a restless flycatcher on a winter’s afternoon; a daunting sight indeed. The arrival of the doctor brings sighs of relief all round. Lay approaches and secular ammunition seem strangely ineffectual, yet how helpless that doctor feels in such situations. Quiet conversation, logical explanations and advice seem totally unacceptable, but it is the sole responsibility of the doctor to solve the problem—truly a High Noon situation. Just as for John Bunyan’s pilgrim, so too for the general practitioner: ‘Who would true valour see let him come hither’ (Bunyan, 1927).
One who, like me, has been fortunate to live and practise in the same district for several years would find it interesting to look back on some of these difficult cases and see how the people, their situations and problems have resolved. Some such cases follow.
An intelligent 35-year-old bachelor with many talents, especially those associated with the handling and nurturing of plants, Chas loved classical music. Unfortunately, he had a severe personality disorder with associated depression as well as alcohol and drug dependence.
His dramatic episode was a violent confrontation with his brother and devoted mother. The attendant doctor was summoned to a barrage of missiles, namely the entire record collection, one by one, and eventually the record player itself; all this in a neat house with a perfect garden and furniture that was cared for.
The next day Chas was persuaded to have psychiatric treatment in hospital. His life over the years thereafter was a series of highs and lows; and in one of the lows he took a drug overdose with fatal result.
She was a lonely widow with few friends and no job, living in a dingy flat with dull and drab furniture.
This time the projectiles were cups, saucers and cigarettes, as Mrs S stood unkempt, like a true poltergeist spirit, in the corner of uncared-for surroundings. The same day she was persuaded to enter hospital for treatment for her ‘nervous condition’.
After a few admissions she settled on long-term phenothiazines into a zombie-like state. Since two major strokes and relative paraplegia, she lives friendless and penniless in a nursing home.
Liz was a hugely obese, highly intelligent ex-schoolteacher. She was in her mid-twenties. All 170 kg of her had married Tim, a young local farmer who was quiet, introspective, flat of affect, with mild schizophrenic tendencies.
They managed to conceive a son who was delivered at Easter. The hospital staff noticed then that Liz was a bit ‘high’ but paid no great attention to it. On returning home the acute psychotic episode erupted: the combination of the historic religious Easter happenings and a ‘message’ that the world was coming to an end guided Liz’s mind towards the thought of sacrificing a newborn son (and his parents). With the help of our local clinic sister, Methodist minister, general practitioner and eventually the police, the baby was removed from Liz and she was ‘persuaded’ to go to the nearby psychiatric unit.
Liz improved sufficiently to be sent home, alas prematurely as she tried to suicide by overdose and cut wrists. This time the general practitioner was successful in arranging voluntary admission.
Some months later we were summoned by the shattered husband because Liz had ‘gone high’ again. We arrived to see her cavorting naked in front of open door and windows to loud pop music, throwing furniture out of the upstairs window to crash down on the garden below. Inside, the house was a mess with graffiti everywhere, smutty and religious; the bathroom door was drawn on from top to bottom. Again she was slowly persuaded to dress and prepare for voluntary readmission.
Years later the (to date) happy ending is comforting. Now, with two children (no puerperal psychosis after the second) Liz is sensible, has good insight, requires no treatment and copes well while studying for an extracurricular high-level degree in education. She remains extremely obese but she has managed to lose an amount of weight by diet and gastric stapling.
Is the psychotic volcano extinct or only temporarily quiescent?
Sid, a man in his 50s, presented one hot, dull, sultry morning in an acute manic state. He was restless, voluble (with unsavoury language), paranoid and looked positively menacing. The episode began in the middle of a busy surgery day and ended at the exit of the premises for all to see. Police help was slow in arriving and counselling was of no avail; eventually, with the help of the tardy officers of the law, he was restrained physically by five people and succumbed slowly to intravenous sedation. His admission to the psychiatric unit was involuntary.
Despite medication, Sid continues to have his ups and downs as a manic-depressive. In the ups he has expensive, expansive, high-flying ideas; in the downs he goes back to the psychiatric unit. His wife aged by 10 years within 12 months.
This woman, mother of two boys, had a poor psychiatric family history but managed rather well, if slightly anxiously, until the children reached school age. Then she became actively psychotic with paranoid ideas about her husband, thought disorders and finally a fixation on her general practitioner, expecting him to look after her completely. When disallowed from seeing him because of the embarrassment and upheaval she caused, Mrs K bombarded her general practitioner with strange and suggestive letters.
Mrs K’s illness remains ongoing. Her family disintegrated, she is the centre of a ‘committee of care’ (social workers, GP, school authorities), and a menacing presence to her relatives, the new medical attendant and the community.
After another violent episode Mrs K was taken involuntarily to the neuro-psychiatric unit. Mrs K was discharged and is still within the same community. She lives some sort of existence with relatives in a caravan—acceptable only if she agrees to regular phenothiazine injections.
DISCUSSION AND LESSONS LEARNED
As general practitioners, what have we to offer such unfortunate people? They are so difficult to handle in the acute stage of their illness and we do not know what triggers the acute crises. Specialist psychiatric help is often difficult to obtain; treatment by force is usually necessary; and long-term results are often disappointing.
The cases described here are only a few examples from a large number; it is not an uncommon problem.
As general practitioners, specialist psychiatrists and caring communities we have a lot to learn.