There is silence. The 70+ years old patient is looking at me reluctantly while I read his files. His doctor left a note justifying the request for my psychiatric examination: “Nightmares. Dementia?” That is a weird combination.
The patient didn’t want to talk to me initially. The nurses convinced him. He briefly tells me he’s on Carbamazepine for 2 years (a mood stabilizer). Why? He doesn’t know why. I ask him if the drug was prescribed by a psychiatrist and he says yes. I explain to him that this drug is often given for anger, for irritability, and he confirms that he was restless at that time, 2 years ago. Did the drug help him? He says no. Then why did he continue to take the drug? He acknowledges that it was his inertia; he just followed the treatment despite the lack of efficiency. Interesting…
– But why are you angry? And since when?
– I am angry for many years…
– For how many years?
– For 12 years.
– What happened 12 years ago that made you so irritated?
The patients changes in an instant, his face turning red, and bursts into tears:
– My son died.
Then, in a matter of seconds, he controls himself. A deep silence lingers between us for a couple of seconds.
– I guess you have nightmares since that moment, right? Did you see a psychologist for counseling during these 12 years?
– No. Just the psychiatrist who prescribed the drug 2 years ago.
Depression is not only about sadness. Depression can also be anger if you can’t afford to be weak or you feel that life is unfair and has taken from you what you believe it is your right or what you valued most. So, as a rule, I always investigate further every time I encounter anger; it may be depression. In this case, a type of adjustment disorder also known as bereavement or grief. A pathological grief, something that lasts more than one year – the statistical limit for “normal” grief (as if one can decide how much time one must mourn a loved one).
The discussion advances and the patient begins to trust me. I am not, as he might have presumed, an idiot, but someone who cares to listen. I am somehow surprised by that note left by his doctor about dementia, so I do the memory and attention tests. The patient responds brilliantly. So no, he has not dementia. I conclude that he might have what we sometimes call “masked depression”. I refer him to a psychologist (for his grief), diminish his Carbamazepine and start an antidepressant and a sedative who will also, hopefully, act on his nightmares. However, out of curiosity, I ask him what he did in his professional life.
– I am a university professor with a PhD. And I still supervise others in my field. And I still do research. [for confidentiality reasons I can’t provide additional details]
He smiles while I recover from the shock. Depression looks different when the patient is an intellectual or is sufficiently intelligent. Forget about the generally known criteria! For a correct diagnosis you need to see beyond the facade. Fueled by curiosity, I dig deeper:
– But what happened to your son? Was it something unexpected?
– My son went shopping at the mall and he accidentally broke a china vase in a shop. He was scared by the guys in the porcelain shop who told him to wait until they call the police. He offered money to pay the vase but they refused. Finally, he had a panic attack and ran to the door, opened it and went out. The problem was that he had mistaken the window for a door, so he rushed through it. Another problem was that the shop was at the 7th floor of the mall… He died instantly.
The patient begins to cry as if this happened a week ago… and not 12 years ago. The pain is vivid. There is no resignation, there is no emotional acceptance, nothing. Only a huge pain due to his loss, a pain that fills up the room up to the ceiling. There is really nothing I can say to him. Some wounds heal slowly. And some wounds never heal.
I am back in my office and I’m still meditating on this patient. He has touched me deeply. You would believe that his story is accurate, as he has no reason to lie. Yet, I don’t believe he is saying the truth. Psychiatry goes by the principle that everybody lies, consciously or unconsciously. How stupid can someone be to mistake a window for a glass door?! And how stupid can the owners of the mall be so as not to secure any possible exits at the superior floors?!
The real question here is not if the patient tells the truth. The question is what he wants to believe it really happened.
Psychologically, it is very hard to accept that your son has committed suicide. He had a good life and suddenly he flies through the window of the 7th floor of the mall. It’s absurd. It’s unbearable. So you change reality. You change the facts. You unconsciously use a psychological defense mechanism called denial. You don’t deny that your son has died, but you deny the way he died. For you, it was just an accident. It is tolerable, it is bearable to be so, so that you don’t have to deal with the absurdity of this event and perhaps kill yourself. Probably, the fact that the patient is still professionally active well into his retirement age is another defense mechanism: being immersed in study, focused on something else, running from himself and his realities.
You’d probably think that I confronted him on this. No, I didn’t. I didn’t discuss this and I pretended I believe him. Why? Because denial works as an emotional painkiller and I didn’t want to crush his defense mechanism, hence increasing his pain. Before breaking a wall it is always important to make sure you know why it was erected there in the first place.
Read also my article on defensive mechanisms.