Wednesday, 28 September 2011

The Dark Side of Love 2: De Clerambault’s Syndrome and other disorders

Afflicted by love's madness all are blind. Sextus Propertius

Psychotic or delusional disorders
These can manifest in two basic ways:

Morbid jealousy (also known as Othello Syndrome) is when a person holds a strong delusional belief that that their spouse or sexual partner is being unfaithful in the absence of any actual evidence.

Jealousy is a very common emotion, but when jealousy is entirely baseless then it can become pathological in nature. This can range along a spectrum between essentially normal feelings of jealousy, perhaps arising from an individual’s basic sense of insecurity or personal inadequacy, through to full blown psychotic illness.

Morbid jealousy is likely to take the form of constantly checking what the person’s partner is doing at any time of the day. The person may look on their partner’s mobile phone to see who they’ve been ringing or texting. They may interrogate them during the evening about what they’ve been doing, who they’ve been talking to.

This can be obsessional, but essentially non-psychotic in nature and therefore amenable to treatment, in which case, a talking therapy such as Cognitive Behavioural Therapy, can be effective in tackling and addressing the individual’s personal insecurities and anxieties. However, if it is truly delusional in nature, then it can be much more difficult to treat. It can also extend into stalking behaviour.

De Clerambault’s Syndrome (also known as erotomania) is a delusional belief that the person is in love with another, and that that love is reciprocated. This seems to occur most commonly in women. Usually, the subject of the person’s attention is only a casual acquaintance, and the affection is entirely unreciprocated. This belief can also lead to stalking behaviour.

(Isn’t it curious how so many syndromes and disorders are named after people with unusual or glamorous names? Gaetan Gatian De Clerambaut was a French psychiatrist practising in the early years of the 20th century who specialised in hallucinations and delusions and first described the syndrome in the 1920’s. “De Clerambaut’s Syndrome” almost onomatopoeically seems to describe the symptoms. What if Stanley Boggis had discovered it? Or John Woodcock?)

I’ve known Sian for nearly 10 years now. She provides an interesting illustration of both these disorders. Sian was in her late 20’s when she first came to the attention of psychiatric services. She has first assessed in the court cells about 12 years ago, having been arrested for harassment of her ex-husband and his partner. Although this assessment was inconclusive, there were approaching a dozen further incidents of harassment over the next 6 months.

Things finally came to a head when she was arrested after being found hiding in the wardrobe of her ex-husband’s bedroom, having broken into his house. She was arrested on suspicion of burglary, and assessed by a psychiatrist in police cells, who recommended an assessment under Sec.35 MHA. Following this assessment, she was detained in hospital from the Magistrates Court under Sec.37.

I first became involved with Sian when she appealed to the Hospital Managers against her detention. It is a comparatively little known aspect of the Mental Health Act that, although a patient cannot appeal to a Tribunal against Sec.37 in the first 6 months of detention, they do have the right to appeal to the Managers of the hospital, who can, if they wish, discharge the patient.

I had to provide a social circumstances report and appear at the Hearing. This is when I discovered her story.

Sian had led a completely normal life until her late 20’s. She was married and they had one daughter. After a few years of marriage she became more and more suspicious of her husband, coming to believe that he was having an affair. She began to check his whereabouts, ringing him up constantly to find out what he was doing and where he was, and searching through his clothes and belongings. This behaviour began to put increasing strain on their marriage. In an effort to make him jealous and win back his affection, Sian had a brief affair with a friend of her husband. This only succeeded in finally ending the marriage.

On an impulse, Sian left the matrimonial home, leaving her daughter in the care of her husband. Her husband applied for residence, which was granted. After a year or so, her husband obtained a divorce and his new partner moved in. This provoked the increasingly abusive and violent attacks by sian which eventually resulted in her being arrested, and spending a week or so on remand in prison until she was admitted to hospital.

When I interviewed Sian, she was still wearing her wedding ring, even though they had been divorced for a year and her ex-husband was now engaged to his new partner. She denied that it was possible that their relationship was over, and could not believe that her ex-husband could be having an intimate relationship. They were just friends, and Sian was certain that if she could cause a rift between him and his fiancée, then he would return to her. These beliefs were completely unshakeable.

Sian was not discharged by the Managers, and remained in hospital for about 4 months, during which time she was treated with antipsychotic medication and appeared to make a reasonable recovery, gradually realising that it was futile to believe that she and her ex-husband could ever get back together again. She was discharged from hospital with the rather vague diagnosis of “delusional disorder”.

Over the next few years Sian seemed to manage fairly well, getting a flat, and a job as a shop assistant, although she had a tendency to avoid contact with her care coordinator, and at times stopped taking her medication. At such times, she would become delusional again, invariably believing that someone she had served once or twice in the shop was in fact in love with her. She would then start stalking him, finding out where he lived and staking out his house. It was usually possible to persuade her to restart her medication, and these beliefs would then evaporate.

Sian’s most recent admission to hospital came out of the blue. She had been engaging well with the CMHT, was clearly taking her medication, and I had begun to explore with her some of the issues from her past. She had enduring guilt about abandoning her daughter, as she saw it, and I began to analyse her history and the breakdown of her relationship with her husband, in the context of the insidious onset of a psychotic illness over which she had no control. She seemed to have good insight into this, and it appeared to be reassuring her.

Then suddenly, over the course of two weeks, Sian began to behave increasingly bizarrely. She threw out all her clothes, resigned from her job, destroyed all her identity documents, and declared to her daughter, who was now an adult, that a man she had met in a pub a few days previously was her sole mate and one true love. She presented as highly distressed, agitated and tearful, with pressure of speech. Her daughter called out the Crisis Team, as it was at the weekend, and they assessed her and admitted her informally.

It took several months for her to return to normality. It took many weeks before she was able to recognise that this wonderful, perfect relationship was entirely delusional (I had checked it out and knew for a fact that she had only met this man twice, and only in the company of others, and that he had no romantic interest in her). However, antipsychotic medication, combined with an antidepressant, eventually restored her mental health, and to date, over a year on from that relapse, Sian remains stable and content. And has no irrational beliefs about any of her male acquaintances.

Friday, 16 September 2011

The Dark Side of Love 1: Adjustment Disorders

When Neitzsche said: “There is always some madness in love. But there is also always some reason in madness” he wasn’t referring to the British 70’s/80’s pop/ska band.

It is certainly true that love and relationships can at times give rise to bizarre and irrational behaviour. Indeed, it has been argued that since the definition of a delusion “is a sustained belief that cannot be justified by reason”, then being “in love” with someone could itself be regarded as a delusional state. But I’m not going to plumb those murky depths today.

There are a number of well defined psychiatric conditions that could be said to arise from, or are manifested as, love and issues with relationships. Some of them are sudden and intense but fleeting, while others may be persistent, insidious and difficult to resolve. Either way, they can present as acute psychiatric emergencies requiring formal assessment under the Mental Health Act.

I would divide these disorders roughly into two types: adjustment disorders, and delusional or psychotic states.

Adjustment Disorders
A good definition of an adjustment disorder is “an emotional and behavioural reaction that develops within 3 months of a life stress, and which is stronger or greater than what would be expected for the type of event that occurred”. This can frequently be precipitated by the ending of a relationship, and in my experience, seems to occur more commonly among men.

Everybody can feel upset, bereft, or even suicidal when a loved one wants to end their relationship. Most people can fairly quickly accommodate and adjust to it, but some people have extreme and bizarre reactions, or develop a complete refusal to accept the reality of the situation. Here are a few examples from my personal experience.

Carl worked on a pig farm. One day he presented himself at Charwood police station in a state of agitation and distress, saying that he had killed his wife. The body could be found on the farm, buried in a heap of pig slurry. He confessed that he had been clearing the slurry when his wife’s body had emerged. Although he had no memory of it, he concluded that he must have killed her.

The police immediately investigated, searching through tons of pig manure, but did not find the body of Carl’s wife, or indeed anyone else.

They eventually did manage to locate her. She was safe and well, having left Carl a few weeks previously and gone to live somewhere else in the country. Nothing untoward had happened between them.

It was as if Carl found the idea of his wife being dead more bearable than the fact that she did not love him any more. When Carl was confronted with this, he began to recall what had actually happened, and his distress gradually abated over the next couple of days.

Colin had been married for 15 years. One day, his wife unexpectedly told him that she did not love him any more and wanted to leave. He went off to work as usual, but when he returned home in the evening, he was shocked to find teenage children in the house whom he did not recognise. He also did not recognise his wife. He demanded to know what they had done with his young wife and infant children.

His wife called the on call GP and he was sedated.

I saw Colin with his wife the following morning. The crisis was over by then. It appeared that his brain’s response to the news of the end of their relationship had been to develop a form of hysterical amnesia, where he had “lost” the previous 10 or so years, taking him back to a golden past in which he and his wife had young children and a happy marriage.

Overnight, the amnesia had worn off, and he was reluctantly beginning to accept the reality of the situation.

Christopher presented to the Accident & Emergency department one day with global amnesia. He did not know his name, or where he lived. He had no memory of his past. He was unable to give any information about himself.

He was examined for head trauma, but he had no injuries of any sort, and was admitted to Charwood psychiatric hospital.

After a cpouple of days a police trawl of missing persons revealed who he actually was, and his mother visited him on the ward. He did not recognise her.

Over a period of about two weeks, his memory gradually returned, and the story of what had actually happened emerged. And guess what? It was all about the ending of a relationship. His girlfriend had told him she wanted to finish with him. His immediate reaction was one of rage, and he literally picked his girlfriend up off the ground and hurled her across the room. Fortunately, she was shaken, but not otherwise physically harmed. He then stormed off – and promptly wiped everything from his mind, including his entire life history.

These three cases featured forms of amnesia as a way of coping with intolerable news. Other people will simply refuse to accept that anything has changed, and will attempt to carry on despite all evidence to the contrary.

I was asked to assess Charles by his GP. Charles was a man in his 40’s who had been married for about 20 years. The couple had two teenage sons. 3 or 4 months previously his wife had told him that she wanted a divorce. She asked him to leave, but he refused. Since then, he had been living in the dining room. He had put locks on the inside of the door and only left the room in the middle of the night when the rest of the family were in bed. Then he would creep out and use the kitchen to prepare food for himself.

His wife had initiated formal divorce proceedings and had decided to put the house on the market. When she told him about this, he vacated the dining room one night and moved into the garage.

I went out to try and see him. His wife let me in and showed me photographs of the dining room that she had taken after he had vacated it. He had constructed a network of tunnels using cardboard boxes and blankets that had filled the room.

I went out to the garage, which had an up and over door which was closed. A car was in the garage, and he appeared to be living in that. There then followed one of my more unusual attempts to interview “in a suitable manner”. I could not induce him to open the door so that I could talk with him face to face, and had to make do with talking to him through the door.

During the interview I was unable to elicit any overt signs of psychosis, and he generally answered questions rationally, although avoided any discussion of the impending divorce. I concluded that despite the unusual circumstances, there was no evidence of risk that would merit obtaining a magistrate’s warrant under Sec.135. He was simply in denial, and unprepared to accept reality.

I advised his wife to get legal advice about evicting him from the property, and subsequently heard that after a few weeks he left of his own volition.

None of the above were actually detained under the MHA. In other cases, precipitated by rejection and the end of a relationship, people can self harm or become suicidal and present with high levels of risk. But do they actually have a mental disorder that makes them liable to be detained?

One such example was the man I wrote about in a previous post (Should People Be Stopped From Committing Suicide?) who eventually successfully committed suicide, more through petulance than mental illness. In practice, in the case of most adjustment disorders, the presenting aberrant behaviour will either quickly resolve, therefore not requiring the use of the MHA, or it is sufficiently difficult to establish the existence of a mental disorder sufficient to warrant detention that the MHA cannot be used.

Next time: Psychotic or delusional disorders named after people: Othello Syndrome and De Clerambault’s Syndrome

Thursday, 1 September 2011

Origins of the Masked AMHP: Episode 1

An occasional series

The Beginning
I think no-one has ever asked a child or even a teenager what they’d like to be when they grew up and the answer has been: “social worker”. A fireman. An engine driver. An astronaut. Maybe even a nurse. But never a social worker.

I was no exception. When I was a teenager I wanted to be either a poet or a professional actor. Preferably both. Consequently, I wrote vast quantities of incredibly bad and embarrassing poetry, and was a member of various drama groups.

In the very early ‘70’s, when I was 16, I attended a careers evening at secondary school. I went straight for the desk where the local authority’s head of drama education was sitting to ask about pursuing a career as a professional actor. He knew me, as I had been involved in various drama activities both in and out of school, some of which he had organised. He gave me the following advice:

“The best thing to do is to enrol on a teacher training course and specialise in Drama. That way, you will always have teaching to fall back on if you have difficulty finding employment as a professional actor.”

I could see the sense behind this advice. I was not so naïve as to be unaware that it was very difficult to make a living in the theatre, and the rate of unemployment among actors was very high. So I took his advice, and applied for several teacher training colleges that offered Drama as a main subject. In particular, I decided to go for courses that offered a combined option of Drama and English Literature, so that I could combine my love of the Theatre with my love of poetry.

It really wasn’t very difficult. The course I opted for, which was in the London area, only required 1 A Level (in those days the standard qualification was a Certificate in Education, which wasn’t actually a graduate qualification, so you didn’t even need 3 A Levels). Knowing I didn’t have to work too hard, I frittered away the rest of my 6th form acting in amateur productions and writing terrible poetry. I consequently only managed to get 2 A Levels.

But that was enough to get me on the course, and at the age of 18 I left home and went to college.

The course mainly succeeded in extinguishing any desire or ambition I may have had to be a professional actor. With hindsight, I suspect that the drama adviser knew I had no real talent to make a go at acting. I think if he had thought I had any real dramatic spark he would have advised me to go to Drama School.

I wouldn’t say that going on the course was a total waste of time. I did at least learn how to live independently on a small budget (my grant – yes, students had grants in those days – was £13 per week). However, the main thing I learned was that I didn’t want to be a teacher, or at least, not in any conventional sense.

So I looked around for a job I might like to do. Being an inveterate Guardian reader even back then, I fancied the idea of a career in journalism, so I wrote letters to all the local papers in the Greater London area asking to be considered for a post as a trainee journalist. I figured my training in English and Drama would stand me in good stead.

I did not even get a single interview. So I set my sights lower and started applying for jobs as a trainee building society manager, which seemed incredibly sensible, especially as I’d just got married, even though my heart sank at the prospect.

Then I saw a job advertised in the local paper for a “junior houseparent” in a children’s home. This involved looking after children in a 24 bed children’s “reception and observation centre”. I liked the sound of it. I would get to work with children, one of the few things I had enjoyed about the teacher training course, and I would be involved in managing and supporting their care and development. I got an interview, for once my Certificate in Education and experience of working with children was relevant, and I was given the job.

The home, being a “reception and observation centre”, took children, usually in emergency, anywhere between the ages of 4 and 16, although the oldest we had there was a young man of 18 with learning difficulties, whose social worker could not find anywhere else for him.

Children would arrive at the home at any time of the day or night, usually with the minimum of information. I remember one morning arriving at the start of an early shift (which started at 7.30 a.m.) to find a family of three young children asleep under a pile of blankets in a space under the stairs. Aged between 4 and 9, they had been brought in on a Place of Safety Order (as Child Protection Orders were then called) in the early hours of the morning, and the night staff, not wanting to disturb the other children, who slept in dormitories, had put them there.

One of my first tasks, within a week of starting there with no previous experience, was to take a group of children to the local fireworks display. This entailed walking with a dozen children, the youngest of whom was 6, and the oldest of whom was 15, along a busy road, in the dark, until we reached the park where the firework display was being held. It was terrifying – being entirely responsible for the safety of 12 children in the care of the local authority, all of whom were erratic or unreliable in some way, in a park full of hundreds of people, in the dark, with a large pile of explosives separated from the crowd by nothing more than a rope.

I found myself being led by the excited children, who pushed through the crowd in order to get as close as they could to the firework display. I ignored the fact that all the older children (that is, aged 12 or over) were taking the opportunity of being in a large crowd in the dark to smoke, and concentrated on the 3 children under 10, who were beside themselves with excitement. I tried to hold the hands of all of them at once, but it was futile. One of the young children was so entranced by a Catherine wheel that he pulled away from me and dodged under the rope, heading straight for it. I found myself diving after him, and managed to manhandle him to the ground just before he reached out to grab the conflagration with both outstretched hands.

“Can’t you keep your children under control?” the organiser shouted at me. No, I couldn’t.

I learned a lot, fast. I learned never to enter the girls’ dormitories without a female member of staff; I was told that a previous male member of staff had once been enticed into a compromising situation by responding to a request from a teenage girl to help her in her room. I learned to be careful how you admonished a pugilistic teenage boy, when he punched me in the face, breaking one of my front teeth. I learned to avoid distressed children when they were close to the cutlery box in the dining room, when I was showered with knives by a provoked and desperate young boy who had realised that his parents didn’t love him.

We took in abused children, young offenders, children whose foster placements had broken down, children in emergencies. The average stay was about 3 months before their social workers managed to find them a more appropriate placement. This was my first contact with social workers. On the social care career ladder I was the lowest of the low. I was not even a “residential social worker”, I wasn’t even a “house parent” (some of the younger children would actually call us “uncle” or “aunty”), I was just a “junior” house parent.

The children’s social workers would turn up from time to time, have a brief chat with their child and a brief chat with the officer in charge, and then leave again, maybe not visiting again for a month or two. They would never bother to talk to the junior house parent, the one who had spent many bedtimes telling stories to a sad and abandoned little boy, but who probably knew more about him than anyone else in the home.

Nevertheless, they were in charge of each child’s care and destiny, they made the plans that could affect a child for the rest of their life. And they only worked a five day, 9-5 week. And they were paid a lot more than a junior house parent.

I began to be drawn to the idea of becoming a social worker – not just because of the pay and conditions, but because you had more of a chance of influencing a child’s fate for the good, because you could also follow through and see a child growing up and hopefully begin to heal.

However, the Summer of 1976 made up my mind to apply for a post as a field social worker.

Those of my readers who are old enough to have lived through the British Summer of 1976 will not need reminding how extraordinary it was. For months it didn’t rain. Drought was declared. Some people were reduced to getting water from standpipes. And it was hot. I remember spending that whole summer wearing nothing more than a pair of flared jeans (come on, it was the 70’s), a T-shirt and sandals.
It was too hot for the children in the home. They couldn’t settle in the evening. As it got hotter and hotter, the children became more and more restless. One evening, at 10.30 pm, when all the children, of whatever age, should have been tucked up in bed, half of our residents had been officially reported missing, and the other half were running around in the grounds of the home throwing stones at the windows.

I arrived at work one afternoon for a late shift to find the morning staff barricaded in the office, waiting for the police to arrive, as there had been a riot during breakfast over an inadequate supply of Sugar Puffs.

My wife and I decided that it was no fun living in a London borough. I decided to apply for social worker jobs in the surrounding shire counties, in particular, the ones where it was possible to afford to buy a house.

I was offered an interview at Charwood area social services office. It was a blisteringly hot day. I drove up wearing jeans and T-shirt, then stopped in a quiet woodland area a few miles outside Charwood and changed into my only suit. Nevertheless, by the time I reached the office for the interview, I was drenched in sweat. I was then ushered into a waiting room with the 16 other applicants, who would be competing for 4 posts. We were all unqualified. In those days it was not a condition of employment, and few social workers were qualified.

The area officer was a kind man. He allowed the male applicants to take off their jackets for the interview, and even tolerated us loosening our ties.

I must have done fairly well in the interview (by this time I was beginning to have a reasonable CV), because I got a job.

To be continued…