Cases That Test Your Skills

A Reverend’s tale: Too tragic to be true?

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After his pregnant fiancée dies, Reverend R is strangely jovial. He dodges efforts to verify the highly implausible history he reports. What’s going on here?


 

References

CASE: A tragic tale

Reverend R, a 62-year-old Methodist minister, is admitted to a general surgical service for abdominal pain secondary to a recurring bowel obstruction. While there, he learns that his pregnant 24-year-old fiancée was struck and killed by a drunk driver as she was driving to visit him. Her medical team was not able to save her child. The surgical service requests a psychiatric consultation for Reverend R to assist him with grieving.

Our team interviews Reverend R 3 days after his fiancée’s death. We did not have access to his psychiatric records before our evaluation, but his chart indicates Reverend R had been hospitalized for nearly 3 months after being transferred from another hospital. He has a history of colon cancer and cerebral palsy and has struggled with depression since college. He had 1 psychiatric hospitalization 26 years earlier and no history of suicide attempts. He has responded to pharmacotherapy and is taking sertraline, 100 mg daily.

Reverend R expresses grief, stating he has lost the love of his life. With prompting, he provides a few details about his fiancée but does not say much about the accident. He says he feels guilty and frustrated that he can’t attend his fiancée’s funeral because “I have a nasogastric tube.” He claims he has cried excessively in the last few days, repeatedly stating, “I soaked 4 towels.” He is profusely apologetic for expressing his grief, as if doing so was inappropriate.

Reverend R acknowledges feeling sad but denies pervasively depressed mood or anhedonia, excessive guilt, or feelings of hopelessness, helplessness, or worthlessness. His affect ranges from mildly dysphoric to jovial and witty. His thought form and content are logical, linear, and goal-oriented. He denies having preoccupations, obsessions, delusions, or hallucinations. Attention and concentration are intact without evidence of waxing and waning. Cognition and memory also are intact. His Folstein Mini-Mental State Exam (MMSE) score is 29/30. Insight and judgment are assessed to be good, and intellect is above average.

We end our interview by asking Reverend R for permission to contact his psychiatrist for additional information. He stops making eye contact, begins to stammer, and tells us he is acutely short of breath. We seek out his nurse to check him, and within a few minutes his shortness of breath resolves without intervention.

The authors’ observations

Reverend R’s presentation does not suggest that his fiancée died 3 days ago. Without prompting, he says little about her or the accident, but he provides a great deal of information about himself. He clearly enjoys our attention, several times enthusiastically asking, “What else would you like to know about me?” At times he focuses on irrelevant topics.

He does not appear depressed and, although Reverend R’s voice breaks at times, we do not observe tears. His intermittent jovial, witty manner is inappropriate, but he is oriented and his MMSE provides no evidence of delirium. He does not elaborate on his frustration at being unable to attend the funeral and seems satisfied with the possibility of watching a video of the service.

Reverend R does not meet DSM-IV-TR criteria for major depressive disorder. We feel his emotions and conduct are unusual in response to the stress and therefore, based on what we have learned so far, we believe he best meets criteria for an adjustment disorder.

HISTORY: A series of traumas

During our initial interview, Reverend R explains that his life has been characterized by a series of traumatic events (Table 1). He had been sexually assaulted twice: by an uncle during childhood and by a male nurse while hospitalized for depression 26 years ago. The nurse had HIV, but the Reverend tested negative.

Reverend R tells us he is ordained and was working for a church 15 years ago when a drunk driver hit him. Since then, he has lived in a nursing home. Although he can no longer work as a minister, he says the nursing home staff on occasion invites him to deliver sermons at the facility. He also serves as the nursing home’s public relations director and writes faith-based literature for the residents.

The day before our visit was not only the Reverend’s birthday but also was to be his wedding day. The Reverend had met his fiancée, a nurse, at the nursing home where he lives. At times, she took him on outings for dinner and other activities.

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