Decompensated Schizophrenic Patient in the ER

Known as "the cancer of mental illness," schizophrenia can core a life, robbing a previously well-functioning person of what made the person uniquely them. Often, someone with chronic schizophrenia loses the capacity to cue into the basic signals of everyday life. The bizarreness so often evident with these individuals may be due to the lack of relatedness to others and the world that is rooted in this flaw, as much as it is due to the more obvious psychic perturbations caused by delusions and hallucinations.

For patients with schizophrenia, the most common signs of relapse are auditory and visual hallucinations, delusions, bizarre and sometimes violent behavior, paranoia, and insomnia, as well as decreased social interaction, poor hygiene, apathy and the inability to attend to the basic tasks of daily living.

From the many patients with schizophrenia I evaluated in the emergency room, I elected to tell Kim's story because it shows what this devastating psychiatric disorder can do to a person. How someone once healthy and highly functional can, during the gravest exacerbations of this illness, be reduced to thoughts, feelings and behaviors that are barely recognizable as human.

Kim was brought to the ER late one evening by the police on emergency petition. Several weeks earlier, the house she lived in and owned was damaged by a fire caused by an electrical short. It was October, but Kim had been living in the house without phone service, electricity, heat or hot water. Earlier that evening, a neighbor who knew of Kim's chronic mental illness, and had observed her during periods of relapse, noticed a candle burning in a darkened window. Thinking that the open flame might lead to another fire, the neighbor called the police.

Kim, 38, was born in the United States to Chinese parents, who returned to Taiwan after her father finished his medical training. Kim and her siblings remained in the United States. She graduated from a prestigious women's college and earned a master's degree in human development. Her marriage to an Asian man ended in divorce. She had not been employed for some time.

Kim was first hospitalized at the age of 26 with what was diagnosed as a psychotic mood disorder. It is not clear when the schizophrenia diagnosis was made. The records available to us did not provide any information about the early course of her illness, but they noted hospitalizations in 1992 and 1994, as well as admissions to our hospital in May and August of 1995.

When I entered the room to begin the evaluation, Kim was sitting on a gurney with a sheet pulled up around her. Her appearance belied what she was soon to reveal about herself. She was short with dark shoulder-length hair that was well cared for. This young woman was in no apparent distress and would have stood out in a crowd only for being attractive. Ontically cored, her outer shell seemed intact.

Kim knew who she was, where she was and the date. Asked about her mood, she replied that she felt "fine" and denied being depressed. She also denied having any intention or plan to hurt herself. Her records made no mention of any past suicide attempt. She had no significant medical history or current medical problems. She denied abusing alcohol or ever using illicit drugs.

Kim stopped taking her medication, she told me, because she had died in the recent fire and had been reborn with a new body and a new head, so she no longer needed to take the medication that her former body required. (In fact, she was not injured in the fire.) She told me that God speaks to her directly, not offering any further details. "I can see Europe," she said. "I have very different eyes." Her answers to even the simplest questions revealed strong underlying psychotic processes. "I am an Oriental woman. I eat and I sh*t. I don't know about American women." I cannot recall what question I might have asked to elicit that response.

I contacted the psychiatrist who had been following Kim for some time. He pointed out that her behavior in the ER was not very different from her recent baseline behavior. None of the neuroleptic medications tried, including fluphenazine (Prolixin), perphenazine (Trilafon), risperidone (Risperdal), pimozide (Orap) and clozapine (Clozaril), had benefited her significantly. Lithium was added to several of these neuroleptics, also with little effect. After her recent hospitalizations, Kim had been quick to go off whatever medication she was started on. The reason she gave me for doing so this last time was clearly delusional.

Kim had not responded noticeably to individual psychotherapy or benefited from the therapeutic opportunities offered by her most recent hospitalizations. She seemed drawn into a fragmented world out of which no intervention had any power to draw her out.

In spite of her obvious psychotic state, Kim's psychiatrist felt it was doubtful she would benefit from being hospitalized at this time. (She had come to the ER solely on a neighbor's assumption that a lighted candle in a house without electricity portended danger.) The psychiatrist felt she could be discharged, and he agreed to see her the next morning. He planned to restart her medication.

A man described as Kim's boyfriend came to the ER and volunteered to escort her home. He claimed to be negotiating with the insurance company on her behalf for a settlement on the fire damage to her house and to be making arrangements with contractors to have repairs made. A notation in the chart, however, raised questions about this man's integrity and stated there was reason to believe that he had already stolen 23,000 from her.

Three weeks after I discharged Kim from the ER, she was hospitalized on the inpatient psychiatric unit. And again five weeks later, and eight weeks later, and 12 weeks after that. Following each discharge from the hospital, she would stop taking the medication that was restarted.

The records showed that Kim was more grossly psychotic during these hospital stays than when I evaluated her in the ER. More withdrawn. More delusional. More hallucinatory. More disorganized. More thought-disordered. Asked a question, she seemed to respond to another question. She could still speak in full sentences, but the words made no sense.

Here are some of the delusional statements attributed to Kim during the four inpatient psychiatric admissions that followed in close order after my ER evaluation: "I am the Virgin Mary" (She then added, "The one thing I really enjoy is sex." Her pregnancy test on the admission five weeks after my ER evaluation was positive, and she had an abortion shortly after.); "God was downstairs in my house"; "The Virgin Mary [i.e., Kim] doesn't need electricity, heat or phone service [all absent from her house after the fire] because she lives on a higher plane"; "I am a Jew [her chart notes she is Presbyterian]"; "George Bush keeps running into my house"; and "I'm so superior to everyone."

During the hospitalization 12 weeks after the ER visit when I evaluated her, Kim reported these hallucinations: "Jesus told me I'm his mother"; "God touched me in my sleep"; and "I have communications with Joseph, and he tells me I'm his wife."

Prior to this hospitalization, Kim was seen begging for food from her neighbors. It was clear that she could no longer take care of herself. Adult Protective Services was called to investigate and was asked by the staff on the inpatient unit to look into the possibly exploitive relationship between Kim and her boyfriend. Other instances of Kim's disorganized behavior documented in the chart months earlier included her planting flowers in neighbors' gardens (without being asked to do so) and running nude through the alleys of her neighborhood.

During her last admission to our hospital, Kim was restarted on clozapine. She remained grossly psychotic, delusional and thought-disordered. It was felt by the staff that she needed intensive, long-term inpatient treatment, and she was transferred to a state mental hospital.

References:

Further Reading1. Andreasen NC (1999), Understanding the causes of schizophrenia. N Engl J Med 340(8):645-647 [editorial; comment].
2. Arieti S (1974), Interpretation of Schizophrenia, 2nd ed. New York: Basic Books. Carpenter WT Jr., Buchanan RW (1994), Schizophrenia. N Engl J Med 330(10):681-690 [see comments].
3. Kasanin JS (1964), Language and Thought in Schizophrenia. New York: WW Norton & Co.
4. Vonnegut M (1988), The Eden Express. New York: Dell Publishing.
5. Winchester S (1998), The Professor and the Madman: A Tale of Murder, Insanity, and the Making of the Oxford English Dictionary. New York: HarperCollins Publishers.
6. Wyden P (1998), Conquering Schizophrenia: A Father, His Son, and a Medical Breakthrough. New York: Alfred A. Knopf.