Psychiatric Casebook: The Worst Call in the World

The policeman was respectful. He knew something was very wrong, just not what he was led to believe. I stayed on the line with the 911 dispatcher, sickened and shaking. Emergency services took very seriously a psychiatrist who felt that a patient was in the midst of a suicide attempt. After the police entered the patient's apartment, I was patched into their radio communications.

"Doc, I don't know what to tell ya. The guy's in a suit havin' a cup 'a coffee. He says he's gettin' ready for a job interview." They gave the patient the radio. His rage was in full force. I imagine the NYPD stood there, embarrassed as they listened to him unleashing his profane invective.

"What the f*ck do you think you're doing!!? You're a f*cking asshole, you know that!? I can't believe you called the f*cking police, you f*cking stupid f*ck..."

The pounding of my heart in my ears now became complicated by an additional phenomenon: disorientation. I was getting an acute, intense, bewildering barrage of auditory information, the visualization of which created a Kafkaesque scene. Somehow, probably because the whole thing was playing out over the phone, I never lost my cool, even though I'm sure I looked dazed. Finally, mercifully, the cop took the radio back.

"Whaddya want us to do, Doc?" He sounded like he felt sorry for me. I instructed them to take him to the hospital. The patient exploded in anger anew. is screaming faded as they led him away: "You're fired! You're f*cking fired! Do you hear me asshole? You're fired!..." The adrenaline took a long time to subside. No matter. I now felt like an idiot.

This strange case unfolded over a few short weeks. The initial call came from the director of HR of a large, well-known company. They had an employee who made a suicidal statement to his supervisor. He was placed on medical leave and needed an evaluation. I was early in my career and took it as a stroke of good fortune that my name came to this HR director. She worked for a high profile company that could be the source of further referrals. I needed to do a good job on this case.

Four days after the call from HR I met the patient. He was a slight, bookish man in his late 20s. Casually dressed for the consultation, his meticulous grooming and crisp polo and khakis suggested a man who took his appearance seriously. I started things off by explaining that I had two goals: to help him get treatment to feel better, and to help his company determine when he could return to work.

He began, "Monday afternoon I said I had enough with stuff in my life. I wanted to put a gun to my head." I twitched, then squinted. "In a manner of speaking," he added, after a pause.

He launched into the problems. He'd had headaches, fevers, seizures and "partial paralysis" for months. A CAT scan, initially read as brain cancer, terrified him. A follow-up MRI was clean. Despite extensive testing that showed no pathology, he continued to have seizures, headaches and fevers.

His wife left him nine months ago, while he was sick with fever. They had been married about a year. He began to suspect infidelity because of her "inconsistent responses." He gave her an ultimatum: "take care of me or leave." She left the next day.

This man was losing control: of his body, his marriage, his family. He acknowledged being depressed, but also that he detaches from his feelings. Indeed, the interview was remarkable for his controlled, dispassionate explication of the narrative. It was what we called having an affect incongruous to content. This attribute did not inspire confidence in my ability to read his state of mind.

Although not entirely surprising, it did not help to discover he had virtually no social supports. Not one to "let people get close," he cited his estranged wife as his only support. He weakly added his company as a source of support- an awkward reference to his supervisor and HR I supposed.

My concern for his condition was tempered by a specific feature of the account. His seizures and paralysis did not adhere to episodes governed by the rules of neuroanatomy. They sounded more like ataques de nervios, fits of spastic writhing seen among certain Latino populations, and thought to be a response to stress. At least he didn't have the misfortune of serious neurologic disease on top of all the rest.

I was very concerned for his safety nevertheless. He was a socially isolated male, separated from his main perceived support, experiencing debilitating physical symptoms without known cause, depressed, and removed from his work. He carried numerous risk factors for suicide, although thankfully he denied feeling suicidal at the moment. We spoke about starting an antidepressant. He agreed to stay out of work for a week, live with an aunt, and allow me to contact his other doctors for information. We were to speak by phone daily and meet again in three days.

Communication proved problematic. The patient had disconnected his phone and his aunt had changed her number, so there was no phone check-in. One doctor couldn't locate the records and the other didn't remember the patient, so there was no medical clarification. The patient did show up for his appointment. Nothing had changed. He had had no seizures and no suicidal thoughts. I asked him if he had any thoughts about our initial visit. He responded with the single word, "Indifference." He wanted to return to work next week and I thought the distraction would do him good. I discussed starting Prozac and he agreed. We were to meet again after the weekend.

I met the patient three days later, the morning of his return to work. He was sharply dressed, but otherwise emotionally flat and unreadable. He told me the first dose of Prozac had produced a nausea so complete that he spent the entire day in bed unable to function. When I asked why he didn't call me, he replied, "What's the point?" The subsequent doses produced no problems. He again endorsed no changes in clinical status, denied feeling suicidal, and was ready to return to work. We set up two meetings for the following week.

He was a no-show for both visits. His home phone was still disconnected and he wasn't answering his cellular. Before I could reach him at work I got a call from the HR director. She had been contacted by a psychologist who, unbeknownst to me, had seen the patient prior to my initial evaluation. Apparently, the patient had also not shown for follow-ups with this psychologist. When she finally saw him for a second visit he described worsening suicidal thoughts. The psychologist called HR and recommended the patient be hospitalized.

My call to the psychologist was quite illuminating. The patient had given us very different stories about his history, and had kept us secret from each other. His diagnosis, always puzzling, became simultaneously more clear and complicated as a result of his now undeniable personality disorder.

It was early afternoon on Friday. The three players in the patient's treatment: myself, the psychologist and the HR director, had just realized they were being played. But to what end? I decided the best course of action was to meet with the patient and the HR director that afternoon. We would confront the patient about his deception and manipulation, and hopefully uncover his motives. The HR director would inform the patient about this mandatory meeting and bring him to my office, with security.

I opened the waiting room door at 5 p.m. to discover the HR director and her security staff person. The patient, once again demonstrating who was in charge, had fled his office after getting wind of this appointment. We had our meeting anyway. It was agreed that the patient would eventually show up at work and we would eventually have our three-way consultation. His behavior called into question all of the "facts" of his story. What was clear was the process: he mobilized alarm and action in us, perhaps as the end itself. By focusing on his process we found ourselves less alarmed by his content, and certainly less interested in initiating action. In this way we convinced ourselves that he was not likely to be a real suicide risk and we could just wait for next week.

Another thing became clear in this meeting, namely the company's metrics for the patient's work performance. I found it quite ironic that after my effort to go the extra mile on this VIP case, with a patient who turned me from psychiatrist to detective, in the end the company's main focus for this patient's fitness for work was addressing his lateness and personal phone calls at the office. In that moment the whole affair became a kind of farce: the stoic patient discovered to be an untreatable manipulator, the caring employer discovered to be clueless and banal, the ardent psychiatrist discovered to be hapless and duped.

I was glad to have the weekend off from this case. I took it as an intermission. The performance would resume sometime next week. I was in the habit of checking my voicemail periodically during weekends, with the final one on Sunday evening before I went to sleep. For some reason, that Sunday, I forgot. I called in for messages Monday morning, upset with myself for having forgotten to do it the night before. That's when I got it. He left it Sunday at 7:30 p.m.

"By the time you hear this, I should be dead."

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