Chapter 1. Mental Disorders in Adults
DOI: 10.1176/appi.books.9781585622665.30109; R) }3 n; C7 k, r
: X3 I! M/ j0 L9 L. v3 l9 uBrujeria
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The interview takes place in a small, windowless interviewing room into which are crowded the attending psychiatrist, five psychiatric residents, and two social workers. The attending psychiatrist asks her to describe what happened to her, and she says she was washing dishes at her boyfriend's house, where she had been living, and began to have chest pains. Her boyfriend's mother told her to lie down, and the next thing she remembers, she was in the emergency room in chains. The family told her that she "got wild" and tried to bite people. She explains that this has happened many times before, since she was 17. Her boyfriend, who has seen many prior episodes, called the police this time because, as he told her, she had a knife and he was afraid she might kill him.
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6 a+ d5 ?; T+ R7 f7 NShe has been told that during these episodes she screams, bites, and kicks, and sometimes has tried to get a knife to cut herself. The interviewer asks her, "What do you call these attacks or spells that keep happening to you?" She then says she doesn't want to talk with all the people in the room. She could talk to two or three people, but not eight. The interviewer tries to convince her that these are all people who can help her, and the more the better. She refuses. He then asks if she understands how fortunate she is to be in a famous teaching hospital. She has never heard of it and will not budge. He tells her that these people can help her if she is able to talk to them about what's troubling her. No response. He says, "You have a lot of secrets." More silence.) [# [( {}" n) |3 t2 S2 o& i1 W4 r7 fInterviewer: Do you ever tell people about the bad things that have happened?' C( |9 m$ H* ^: R: H
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Patient: No. I don't tell nobody nothing.- k2 M. J3 n& X/ G' ^
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Interviewer: Do you dream about bad things that have happened?
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" Q' _4 _9 }( D! r3 mPatient: Yes, but in the dream it happens to my sister.
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' p* J4 t0 t5 S- WInterviewer: What happens? (Silence.) Were you very young when it happened?+ d& f7 Y3 y* `
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Patient: Yes.
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Interviewer: 12, 13, 14?
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2 C1 h7 h8 v5 K4 UPatient: No.
% a& ^2 A$ V: {}9 [- ?0 Y+ d8 k, A2 qInterviewer: 15, 16?
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Patient: No, the other direction.
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Interviewer: What did your mother do?
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' W" N: Z- i& H2 I; OPatient: Nothing., L( Z3 r- h. q* b/ ^, P& X* \# u
, f* y" K8 F( h9 M7 WInterviewer: Did you feel like it was your fault?. }9 C5 ^% ?, Q: o
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Patient: No. I dream that it happens to my sister, and I wake up crying.
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She was married at age 14 and had two children, but says that she has never been able to enjoy sex and can have intercourse only if she is high on drugs. During intercourse she often sees the face of her uncle. After her husband went to prison for selling drugs, her mother-in-law got custody of her two children. Why this happened she was unable to explain. She now says that although she loves her children, she gets "nervous" when she has to spend a lot of time with them.
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2 \! v S7 B1 |She has not been able to get her life together and finish school or stick with a job. She now lives with her boyfriend's family and spends most of her time watching soap operas. She acknowledges often being quite irritable. She frequently has trouble sleeping and often awakens from bad dreams. Since she had an abortion several months ago, she has been depressed and has had thoughts that she would be better off dead.
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DSM-IV-TR Casebook Diagnosis of "Brujeria"' p0 T9 J) E0 l9 U
' l& x8 m" X" U# m( n& cThe report that this patient was aggressive, out of control, and brought to the emergency room in restraints suggests either a psychotic episode or drug intoxication. During the interview it appears that neither is likely, and the key question is the nature of the recurrent episodes that the patient has been having for several years. The fact that her behavior during the episodes is so at variance with her normal behavior, and the fact that she does not remember much of what occurs, suggests that she is experiencing recurrent dissociative episodes, or possibly an unusual manifestation of temporal lobe epilepsy. Evidence of the dissociative nature of these episodes emerges as she tells the social worker that the face she sees is that of her uncle who repeatedly raped her when she was a child. (We acknowledge that we have only the patient's report that she was raped, yet we see no reason to doubt her veracity. She has nothing to gain from telling this story, and her distress in speaking about it seems entirely genuine.)
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) I' K; ^" V) `One wonders whether the dissociative episodes may represent a switching to another identity, as in Dissociative Identity Disorder (Multiple Personality Disorder) (see "Mary Quite Contrary"). However, that diagnosis requires that the alternate personalities have their own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self, and there is no evidence that this occurs during Ms. Vega's dissociative episodes.6 X# Z8 W# v& V! t
2 F+ i) |% W( O+ x( \* PWe are not surprised to learn later that this patient has many of the symptoms of Posttraumatic Stress Disorder (PTSD). The rapes meet the entry criterion for a traumatic event. The dissociative episodes represent the reexperiencing of the trauma (i.e., fighting off her uncle's sexual advances) as do the dreams and recurrent recollections during sex. PTSD also requires three symptoms of avoidance of stimuli associated with the trauma and numbing of general responsiveness. She clearly avoids sex, and her inability to finish school or work suggests that she may also have markedly diminished interests and a sense of a foreshortened future, which would be evidence of avoidance or numbing. Her difficulty sleeping and irritability satisfy the criterion requirement of increased arousal.$ p! L2 `( y% t( U: ?- k6 K
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The diagnosis of PTSD is easier to make when a single trauma seems to result in a markedly changed level of functioning. In this case the effect of the trauma is hard to disentangle from the other noxious environmental features of her life. We do not know whether she would have finished school, found a job, and had more satisfying interpersonal relationships if she had not experienced the rape trauma. Still, with all of this uncertainty, our best guess is that the dissociative episodes, which were the ticket to her admission to the mental health system, are symptoms of the more pervasive disorder, Posttraumatic Stress Disorder (see DSM-IV-TR).
/ ?9 G. G( u' M! t# f/ F( H7 k& {}) z- yMs. Vega was released from the emergency room to live at her sister's house and was visited the next day by the psychiatric resident, along with a social worker from the mobile crisis team. The resident arranged a family meeting with the mother, from whom the patient had really been estranged, and set up a schedule of home visits with the mobile crisis team to engage the patient in psychotherapy. For reasons that are not clear, the follow-up plan did not work, and the patient reappeared in the emergency room 2 weeks later, tearful, "nervous," and wanting to talk to the emergency room social worker. Another appointment was made for ongoing psychotherapy, which the patient never kept.