When Neitzsche said: “There is always some madness in love. But there
is also always some reason in madness” he wasn’t referring to the
British 70’s/80’s pop/ska band.
It is certainly true that love and relationships can at times give rise
to bizarre and irrational behaviour. Indeed, it has been argued that
since the definition of a delusion “is a sustained belief that cannot be
justified by reason”, then being “in love” with someone could itself be
regarded as a delusional state. But I’m not going to plumb those murky
depths today.
There are a number of well defined psychiatric conditions that could be
said to arise from, or are manifested as, love and issues with
relationships. Some of them are sudden and intense but fleeting, while
others may be persistent, insidious and difficult to resolve. Either
way, they can present as acute psychiatric emergencies requiring formal
assessment under the Mental Health Act.
I would divide these disorders roughly into two types: adjustment disorders, and delusional or psychotic states.
Adjustment Disorders
A good definition of an adjustment disorder is “an emotional and
behavioural reaction that develops within 3 months of a life stress, and
which is stronger or greater than what would be expected for the type
of event that occurred”. This can frequently be precipitated by the
ending of a relationship, and in my experience, seems to occur more
commonly among men.
Everybody can feel upset, bereft, or even suicidal when a loved one
wants to end their relationship. Most people can fairly quickly
accommodate and adjust to it, but some people have extreme and bizarre
reactions, or develop a complete refusal to accept the reality of the
situation. Here are a few examples from my personal experience.
Carl
Carl worked on a pig farm. One day he presented himself at Charwood
police station in a state of agitation and distress, saying that he had
killed his wife. The body could be found on the farm, buried in a heap
of pig slurry. He confessed that he had been clearing the slurry when
his wife’s body had emerged. Although he had no memory of it, he
concluded that he must have killed her.
The police immediately investigated, searching through tons of pig
manure, but did not find the body of Carl’s wife, or indeed anyone else.
They eventually did manage to locate her. She was safe and well, having
left Carl a few weeks previously and gone to live somewhere else in the
country. Nothing untoward had happened between them.
It was as if Carl found the idea of his wife being dead more bearable
than the fact that she did not love him any more. When Carl was
confronted with this, he began to recall what had actually happened, and
his distress gradually abated over the next couple of days.
Colin
Colin had been married for 15 years. One day, his wife unexpectedly told
him that she did not love him any more and wanted to leave. He went off
to work as usual, but when he returned home in the evening, he was
shocked to find teenage children in the house whom he did not recognise.
He also did not recognise his wife. He demanded to know what they had
done with his young wife and infant children.
His wife called the on call GP and he was sedated.
I saw Colin with his wife the following morning. The crisis was over by
then. It appeared that his brain’s response to the news of the end of
their relationship had been to develop a form of hysterical amnesia,
where he had “lost” the previous 10 or so years, taking him back to a
golden past in which he and his wife had young children and a happy
marriage.
Overnight, the amnesia had worn off, and he was reluctantly beginning to accept the reality of the situation.
Christopher
Christopher presented to the Accident & Emergency department one day
with global amnesia. He did not know his name, or where he lived. He
had no memory of his past. He was unable to give any information about
himself.
He was examined for head trauma, but he had no injuries of any sort, and was admitted to Charwood psychiatric hospital.
After a cpouple of days a police trawl of missing persons revealed who
he actually was, and his mother visited him on the ward. He did not
recognise her.
Over a period of about two weeks, his memory gradually returned, and the
story of what had actually happened emerged. And guess what? It was all
about the ending of a relationship. His girlfriend had told him she
wanted to finish with him. His immediate reaction was one of rage, and
he literally picked his girlfriend up off the ground and hurled her
across the room. Fortunately, she was shaken, but not otherwise
physically harmed. He then stormed off – and promptly wiped everything
from his mind, including his entire life history.
These three cases featured forms of amnesia as a way of coping with
intolerable news. Other people will simply refuse to accept that
anything has changed, and will attempt to carry on despite all evidence
to the contrary.
Charles
I was asked to assess Charles by his GP. Charles was a man in his 40’s
who had been married for about 20 years. The couple had two teenage
sons. 3 or 4 months previously his wife had told him that she wanted a
divorce. She asked him to leave, but he refused. Since then, he had been
living in the dining room. He had put locks on the inside of the door
and only left the room in the middle of the night when the rest of the
family were in bed. Then he would creep out and use the kitchen to
prepare food for himself.
His wife had initiated formal divorce proceedings and had decided to put
the house on the market. When she told him about this, he vacated the
dining room one night and moved into the garage.
I went out to try and see him. His wife let me in and showed me
photographs of the dining room that she had taken after he had vacated
it. He had constructed a network of tunnels using cardboard boxes and
blankets that had filled the room.
I went out to the garage, which had an up and over door which was
closed. A car was in the garage, and he appeared to be living in that.
There then followed one of my more unusual attempts to interview “in a
suitable manner”. I could not induce him to open the door so that I
could talk with him face to face, and had to make do with talking to him
through the door.
During the interview I was unable to elicit any overt signs of
psychosis, and he generally answered questions rationally, although
avoided any discussion of the impending divorce. I concluded that
despite the unusual circumstances, there was no evidence of risk that
would merit obtaining a magistrate’s warrant under Sec.135. He was
simply in denial, and unprepared to accept reality.
I advised his wife to get legal advice about evicting him from the
property, and subsequently heard that after a few weeks he left of his
own volition.
None of the above were actually detained under the MHA. In other cases,
precipitated by rejection and the end of a relationship, people can self
harm or become suicidal and present with high levels of risk. But do
they actually have a mental disorder that makes them liable to be
detained?
One such example was the man I wrote about in a previous post (Should People Be Stopped From Committing Suicide?) who
eventually successfully committed suicide, more through petulance than
mental illness. In practice, in the case of most adjustment disorders,
the presenting aberrant behaviour will either quickly resolve, therefore
not requiring the use of the MHA, or it is sufficiently difficult to
establish the existence of a mental disorder sufficient to warrant
detention that the MHA cannot be used.
Next time: Psychotic or delusional disorders named after people: Othello Syndrome and De Clerambault’s Syndrome
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