CASE: He bares it all
Police have arrested Mr. L, age 62, 3 times in 36 hours after spotting him walking naked in public. With the county jail jammed to capacity, police bring him each time to our hospital’s emergency room.
After his first arrest, Mr. L matter-of-factly tells us, “I want to walk naked and starve myself to death.” His self-harm exhortations amplify with each visit until—at the third presentation—he reports that he has not eaten for at least 2 days.
Mr. L had been living on the streets for nearly 1 month. Before that, he had been in jail for approximately 1 month after attacking a nursing home patient. He has been hospitalized twice in 5 months for severe depression and personality disorder and has engaged in numerous disruptive behavioral episodes and feeble suicide attempts. At this latest presentation, he appears disheveled and lacks judgment and insight into his condition.
The authors’ observations
We readmitted Mr. L with working diagnoses of:
- major depressive disorder with psychotic features, based on his suicide threats and complaints of depression
- personality disorder not otherwise specified, based on his behavioral episodes, apparent desire to be cared for (Table 1), and refusal to “get better” during 2 recent hospitalizations.
A troubled life: Mr. L’s history
| Period | Mr. L’s difficulties |
|---|---|
| Childhood | Has no friends in school; his mother—Mr. L’s sole source of emotional support—continues to wash his laundry, buy his food and clothes into his 20s |
| Adult life | Keeps ‘goofing off’ at work and has trouble staying employed; depends on wife to manage his life |
| 2 years ago | Shows depressive symptoms (amotivation, lack of concentration, increased fatigue, decreased appetite) after shoulder injury Develops irrational fear that household appliances will malfunction Becomes hostile toward his wife of 34 years |
| 5 months ago | Hospitalized after threatening to kill wife; has depressive symptoms and is disruptive during month-long hospitalization |
| 4 months ago | Discharged from hospital to homeless shelter because estranged wife won’t allow him back home; is readmitted after shelter staff find him banging his head on an iron gate; again behaves disruptively |
| 3 months ago | Discharged from second month-long hospitalization to nursing home |
| 2 months ago | Attacks patient at nursing home; police arrest and incarcerate him on disorderly conduct charge |
| Past month | Released from jail after 1 month and spends weeks on the streets; lands in ER after police repeatedly catch him walking naked in public |
HISTORY: His best friends
As a child, Mr. L had no friends. His father was physically present but emotionally distant, so he relied on his mother for emotional support. Throughout his teens and early adulthood, his mother continued to do his laundry, buy his food and clothes, and run his life. When he married in his early 20s, his wife assumed this role.
Mr. L avoided psychiatric care for most of his life but did not socialize outside the house, lacked ambition, and seemed content to depend on his wife. He worked primarily as a janitor or housekeeper but was constantly getting fired and drifted from job to job. His wife told us that when he was supposed to be working, he spent hours staring at the walls and watching TV.
As the shoulder pain intensified, Mr. L quit his job. While out of work, he stopped attending physical therapy sessions when his depressive symptoms began to offset the shoulder pain. He suffered loss of concentration and motivation, increased fatigue with hypersomnia, and decreased appetite. He lost 10 to 12 lb in 1 year.
Mr. L also started having trouble “focusing on reality” and developed obsessive fears of malfunctions around the house, such as the furnace blowing up, the stove catching fire, or the toilet backing up. At one point, he began urinating and defecating in his pants to avoid using the toilet. He began to feel hopeless and several times tried to suffocate himself by placing a plastic bag over his head.
He also grew irritable, angry, and aggressive—mostly toward his wife, who increasingly feared him. He started blaming her for “everything wrong in my life” and began contemplating stabbing her to death or striking her head with a hammer.