1 Boring Old Man

While I’d always been a data hound, I ultimately gravitated to the world of long term psychotherapy. I preferred what might be called the "case study" model to the statistical grouping of many patients. It felt like research to me. So most of what I learned firsthand was from lots of data on a smaller number of people. That model went way out of vogue in psychiatry along with the old guys who promoted it [Adolf Meyer, Sigmund Freud, Harry Stack Sullivan]. It was sarcastically called n=1 science – generalizing from a few cases. There’s merit to that criticism, and plenty of shoals in the model. But that’s true of any model – strengths and weaknesses. When I read the editorial in this month’s American Journal of Psychiatry [Early Intervention for Schizophrenia: The Risk-Benefit Ratio of Antipsychotic Treatment in the Prodromal Phase], the case I began describing in the previous post came immediately to mind.

As it happened, her parents began to see me when she refused to come herself. I had only seen the patient a couple of times in the situation where all she wanted to talk about was leaving the hospital, so I didn’t have a lot to go on, but I guessed that this was the lead-in to a Schizophrenic Illness. The parents went through a period of mutual blaming in their agitation over the state of her daughter – focusing on events and family traits they felt might be responsible for the problem. So what we worked on early was keeping them from taking out their frustration on each other. One of their hypotheses was that their daughter had inherited a grandmother’s Manic Depressive Illness, and that formulation never died. I told them of my concern that this was the trema of Schizophrenia [pertinent to this discussion, she had taken a course of neuroleptics before I met her without any noticeable effect]. We also spent some time talking about their high standards for performance in their five kids, and how that wouldn’t help their daughter now. But those weren’t the central themes in the months when I saw her parents. They were running a mental hospital in their home, and we mainly brainstormed about how to do that.

Their daughter was polite, formal, and as compliant as she had always been. She was distraught at letting her parents down, obsessed with money, spending her time balancing her checkbook. She spent hours in her room. At other times, in the morning they found her asleep at the foot of their bed. She resisted all attempts to get help, politely. Then one day, I went to the waiting room and she was there with an older sister. She was grossly psychotic, and the three of us walked across the street to the hospital where she [gladly] signed in voluntarily. She responded quickly to medication and replaced her parents as the patient. I referred them to someone else. I never saw them again after that, though there were a few phone calls when there were problems – always with their daughter’s permission. I saw her for around twenty-five years sometimes weekly, sometimes every few months, sometimes even less. She was my only long-term patient with Schizophrenia [thus from n equals one]. Over the years, she began with a menial job, then moved to working in a hardware store – a job she loved. By the time I retired, she was managing the medical record department of a large group practice. She married and she and her husband built a "farm" where they lived an isolated life. They were equestrians going on long group trail rides. They tried raising mules, but after she was thrown, she put mules behind her except as pets.

I worried about tardive dyskinesia, and tried at first to wean her from neuroleptics altogether, but that was unsuccessful. She had several subsequent decompensations with hospitalization, so she stayed on a low dose maintenance. About ten years into things, she had some mouth movements suggesting TD, and I sent her to a colleague that ran a Schizophrenia Project who managed her medications after that for a while. She was on a variety of different drugs, ending up on another neuroleptic. Whatever the case, she didn’t go on develop TD.

The reason for bringing the case up is the things we talked about over the years. Early on, She talked about what it was like to have three high performance older siblings in a high expectation family. She was plenty smart and a good student. She involved herself in school activities as had her siblings, but it was painful. The main thing she recalled enjoying was riding and being at the stables grooming the horses. Everything else was suffused with tension. As a kid, she took long walks and found "hidie-places" to feel some solitary comfort. All of her fantasies were about finding places of peace. Much of our work was modeled after the "lecture" mentioned in the last post – helping her figure out how she felt and discussing the abstract meanings in the communications of others. She became adept at identifying things that "triggered" her discomfort. She had numerous flirtations with psychosis. So for a time, we met erratically – when she felt "it" happening. Her way of describing the danger signal was "special meanings." She meant that when she felt like something happening was a communication meant uniquely for her. Those things always went back to either emotional ambiguity or confusing abstract meanings – always. Later, when she began to date again, the nuances of that arena were really hard and she had a break with another hospitalization. The man she finally married was a loner who needed a lot of "space" himself – which was absolutely fine with her.

Over the years, she talked a lot about her childhood, and it was clear to both of us that her illness did not begin at the time we met. As far back as she knew, she had been tense, worried, confused, felt like she was "faking it." She was "different" and couldn’t let it show. She used her siblings as a template for how to be. The most helpful was her brother, and she followed him to his college where he watched over her. In her junior year he was gone off to professional school and she was "lost at sea." She spent a lot of time alone, developed an eating disorder, and spent away a moderate inheritance buying clothes she didn’t want. As graduation approached, she had no idea what to do next. Her family saw she was in trouble, and an older sister visited frequently as an emissary. On one visit, her sister gave her a legal pad and said, "Let’s write down all the things you’re interested in." Looking at the page, she had no idea what to write, and had the thought, "That’s what I am – a blank page."

As time passed, I was awed by her ability to slowly "learn" how to approach things others know intuitively – sometime with my help, but later mostly on her own. She developed a compendium of warnings and triggers over the years she called tools [a term she coined in her later Hardware Store days]. I saw nothing that looked like an intrinsic deteriorating course, quite the contrary. For what the observations in one case study are worth, I thought that whatever Schizophrenia is, in her case, it was always there from as far back as she could remember. Like many others, I concluded that the manifest illness seemed precipitated the confusing issues of identity and adult interpersonal relationships – not some change in the underlying process.