Mr Simpson seems to be a good example of Millon's Insular Paranoid, with its combination of paranoia and the withdrawal of the avoidant. He shows the social anxiety of the avoidant, with people making fun of him (fear of ridicule). This report shows his delusions of reference--he is the hub of the TV networks. It would appear that both the law firm of Akin, Gump, Strauss. Hauer & Feld, where my employment was terminated for mental health reasons in October 1991, as well as The George Washington University Medical Center tried to foist on others the following pathology as an accurate depiction of my disorder.
The D.C. Court of Appeals affirmed Akin Gump's depiction of my employment problems and workplace behavior as genuine and credible. Freedman v. D.C. Department of Human Rights, D.C.C.A. no. 96-CV-971 (Sept. 1, 1998).
Mr. Simpson is a 44-year-old, single, unemployed, white man brought to the emergency room by the police for striking an elderly woman in his apartment building. His chief complaint is, "That damn bitch. She and the rest of them deserved more than that for what they put me though."
The patient has been continuously ill since age 22. During his first year of law school, he gradually became more and more convinced that his classmates were making fun of him. He noticed that they would snort and sneeze whenever he entered the classroom. When a girl he was dating broke off the relationship with him, he believed that she had been "replaced" by a look-alike. He called the police and asked for their help to solve the "kidnapping." His academic performance in school declined dramatically, and he was asked to leave and seek psychiatric care.
Mr. Simpson got a job as an investment counselor at a bank, which he held for 7 months. However, he was getting an increasing number of distracting "signals" from co-workers, and he became more and more suspicious and withdrawn. It was at this time that he first reported hearing voices. He was eventually fired, and soon thereafter was hospitalized for the first time, at age 24. He has not worked since.
Mr. Simpson has been hospitalized 12 times, the longest stay being 8 months. However, in the last 5 years he has been hospitalized only once, for 3 weeks. During the hospitalizations he has received various antipsychotic drugs. Although outpatient medication has been prescribed, he usually stops taking it shortly after leaving the hospital. Aside form twice-yearly lunch meetings with his uncle and his contacts with mental health workers, he is totally isolated socially. He lives on his own and manages his own financial affairs, including a modest inheritance. He read the Wall Street Journal daily. He cooks and cleans for himself.
Mr. Simpson maintains that his apartment is the center of a large communication system that involves all the major television networks, his neighbors, and apparently hundreds of "actors" in his neighborhood. There are secret cameras in his apartment that carefully monitor all his activities. When he is watching TV, many of his minor actions (e.g., going to the bathroom) are soon directly commented on by the announcer. Whenever he goes outside, the "actors" have all been warned to keep him under surveillance. Everyone on the street watches him. His neighbors operate two different "machines"; one is responsible for all of his voices, except the "joker." He is not certain who controls this voice, which "visits" him only occasionally and is very funny. The other voices, which he hears many times each day, are generated by this machine, which he sometimes thinks is directly run by the neighbor whom he attacked. For example, when he is going over his investments, these "harassing" voices constantly tell him which stocks to buy. The other machines he calls "the dream machine." This machine puts erotic dreams into his head, usually of "black women."
Mr. Simpson describes other unusual experiences. For example, he recently went to a shoe store 30 miles from this house in the hope of getting some shoes that wouldn't be "altered." However, he soon found out that, like the rest of the shoes he buys, special nails had been put into the bottom of the shoes to annoy him. He was amazed that his decision concerning which shoe store to go to must have been known to his "harassers" before he himself knew it, so that they had time to get the altered shoes made up especially for him. He realized that great effort and "millions of dollars" are involved in keeping him under surveillance. He sometimes thinks this is all part of a large experiment to discover the secret of his "superior intelligence."
At the interview, Mr. Simpson is well-groomed and his speech is coherent and goal-directed. His affect is, at most, only mildly blunted. He was initially very angry at being brought in by the police. After several psychotic symptoms, he was transferred to a long-stay facility with a plan to arrange a structured living situation for him.
DSM-IV-TR Casebook Diagnosis of "Under Surveillance"
Mr. Simpson's long illness apparently began with delusions of reference (his classmates making fun of him by snorting and sneezing when he entered the classroom). Over the years, his delusions have become increasingly complex and bizarre (his neighbors are actually actors, his thoughts are monitored, a machine puts erotic dreams in his head). In addition, he has prominent hallucinations of different voices that harass him.
Bizarre delusions and prominent hallucinations are the characteristic psychotic symptoms of Schizophrenia (see DSM-IV-TR). The diagnosis is confirmed by the marked disturbance in his work and social functioning and the absence of a sustained mood disturbance or a general medical condition or use of a substance that can account for the disturbance.
All of Mr. Simpson's delusions and hallucinations seem to involve the single theme of a conspiracy to harass him. This preoccupation with a delusion, in the absence of disorganized speech, flat or inappropriate affect, or catatonic or grossly disorganized behavior, indicates the Paranoid Type (see DSM-IV-TR), further specified as Continuous, as he has not been free of psychotic symptoms for many years.
Discussion of "Under Surveillance" by Thomas H. McGlashan, M.D.
The common feature of paranoid patients is an overriding, watchful, suspicious interpretation of experience. These patients demand special consideration by virtue of being, without doubt, the most difficult patients to treat psychotherapeutically. They invariably enter treatment under coercion and bristling with hostility. Convinced that people always misunderstand them, they trust no one.
Mr. Simpson represents the paranoid patient par excellence and, as such, is one of the most challenging persons any psychiatrist will ever treat. The patient's clinical history, symptoms, and severe functional deficits leave little doubt as to the diagnosis of Schizophrenia, Chronic Paranoid subtype, and there are no reasonable differential diagnostic entities to consider. The patient's symptoms are continuous, and his deficits in reality testing are particularly severe. He is totally disabled functionally with regard to work and social interactions. After 20 years of active psychosis and 12 hospitalizations, he presents any treater with a daunting challenge—any treater, that is, who is willing to try.
Mr. Simpson's overall prognostic potential is slim if the goal is symptomatic and functional recovery. His expected future course is likely to be an extension of his course over the last 20 years. Mr. Simpson assaulting an elderly female neighbor might signal further deterioration. If deterioration continues, his prospects for living outside of a long-stay asylum or jail will diminish drastically. On the other hand, the past 5 years have seen only one hospitalization, suggesting that his disorder could be mellowing.
Two additional elements bode ominously with respect to prognosis. The first is that his psychotic world of delusions and hallucinations literally fills his apartment and his life. His disorder is not just persecutory, it is also interesting, exciting, and, at times, amusing and gratifying. In short, his investment in psychosis is substantial compared to his investment in "real" life and people. The second ominous prognostic element is his obviously negative attitude toward any and all efforts at treatment—an attitude that has translated into noncompliant behavior with virtually every therapeutic encounter.
On the other hand, two positive prognostic elements stand out. One is his degree of organization. His affect is intact. He has few negative symptoms (e.g., lack of motivation, poverty of speech), and most of the time he displays little disorganization, all of which is consistent with the paranoid subtype. Most strikingly, he is self-sufficient and takes care of himself. He is almost certainly unable to work, but his modest inheritance keeps him off of disability and provides an illusion of instrumental self-sufficiency. The other positive prognostic development, paradoxically, is that he has broken the law and gotten himself into treatment as a consequence. He probably denies responsibility for the precipitating assault, but, nevertheless, his behavior has added a real problem to his delusional ones, and it could be the key to "locking" him into an adequate trial of treatment for the first time in his life. Mr. Simpson may not see his delusions and hallucinations as a problem, but no matter how intensely paranoid he may be about the police, unlike his other persecutors, they are real.
Two bodies of information would be especially desirable to have in evaluating his case. The first are records of his prior treatments, supplemented with whatever observations the patient is willing to share about his career as a "patient." The history indicates that a recent several-week trial of an antipsychotic drug failed to control his psychotic symptoms. Information regarding his compliance with this medication is crucial because it determines the direction of pharmacotherapeutic treatment planning. If he did not take the medicine, the issue is familiar (i.e., willful noncompliance). If he did take it, then the issue is biological resistance and suggests considering different neuroleptics, including atypical antipsychotics (such as Zyprexa [olanzapine], Risperdal [risperidone], Seroquel [quetiapine], Geodon [ziprasidone], and Abilify [aripiprazole]) and clozapine. The second area requiring clarification is Mr. Simpson's legal status. Is he remanded by court to the long-stay institution? Who does he have to answer to, if anyone? Of pivotal importance is whether the treating psychiatrist has any leverage in this matrix. Unless the patient is required by the court to be a patient, Mr. Simpson will exercise his civil right to deny intervention. For patients like Mr. Simpson, treatment often depends on a loss of civil rights.
The treating psychiatrist's first meeting with Mr. Simpson will be crucial if the effort is to have any chance of success. The doctor should be ready to face someone who is lined up against any encounter. A conservative and supportive approach, especially in the early phases of treatment, is necessary if there is to be some chance of developing a working alliance. Because such patients often enter treatment feeling coerced and exhibiting great mistrust and hostility, they are best greeted by the therapist with a removed but matter-of-fact attitude. A high degree of professionalism and reliability, and no evident desire to be liked by the patient, will enhance the possibility of success in establishing some trust. The reality of the patient's delusions should neither be accepted nor argued, and observations should be offered as hypotheses. Attempts to modify or diminish paranoid defenses should be made only after a reasonable working alliance has been established and should be undertaken without ambitious expectations on the part of the therapist.
The doctor should explicitly address his or her understanding that Mr. Simpson is being seen under coercion—that he is here because of the police. The doctor should also make explicit his or her role in this situation and inform the patient who it was that recruited him or her to intervene, for what purpose, to what end, and with what contingencies (i.e., what Mr. Simpson has to do in order to resecure his freedom and autonomy). The doctor should be nonjudgmental with respect to the patient's guilt or innocence, or whether Mr. Simpson's behavior was justifiable or not, given his delusional conviction about his neighbor's persecution. The doctor should state that he or she is willing to explore all these issues with Mr. Simpson, with the goal being how Mr. Simpson can react so as to not have any further trouble with the police.
The doctor should be truthful and unambiguously state who he or she is, what he or she believes is going on with Mr. Simpson at this time, and what he or she can and cannot do with or for Mr. Simpson. He or she should acknowledge up front being a psychiatrist brought in by the court because Mr. Simpson assaulted his neighbor and add that Mr. Simpson's act was judged by the court to have occurred because Mr. Simpson was psychotic and delusional. The doctor may share the diagnosis given by the court (i.e., Schizophrenia) and offer to elaborate on what that means at some future time if Mr. Simpson is at all interested.
The doctor should also say that he or she assumes mental illness is involved because he or she was called into the case as a psychiatrist but that he or she is willing to listen to Mr. Simpson's side of the story, again with the aim not of assigning blame or determining whether the events were real but to help Mr. Simpson avoid trouble with the police and to secure greater personal freedom. The doctor then outlines what the process involves—regular meetings to get to know each other and to explore the events that led to Mr. Simpson's trouble.
The doctor should also be clear in the first encounter about the "rules" of this "process" (the word treatment should be avoided). The rules include a clear delineation of the limits of confidentiality in the doctor-client relationship such as limits relating to responsibilities the doctor has for reporting back to court and especially limits relating to dangerousness. Regarding the latter, the doctor should be explicit with Mr. Simpson that he or she will warn any potential victims of the patient's wrath and that he or she will inform the courts and police of any plans Mr. Simpson has to hurt himself or anyone else. If it seems appropriate, the doctor may predict that Mr. Simpson may become suspicious of him or her (or more suspicious than he already is), much like he is suspicious of just about everyone else, but that this in no way suggests they cannot work together, especially if Mr. Simpson can talk about his misgivings.
At this point, the doctor says something such as, "That's who I am and what I see myself doing here. What did you expect? I think I can be useful to you. What do you think?" Hopefully, Mr. Simpson will engage and elaborate. If he does, the doctor can elaborate further on what to expect in the sessions and, over time, include more active treatment modalities such as medication and cognitive-behavioral techniques. Before these are introduced, however, time and effort must first be invested in establishing a relationship.
Because of suspiciousness, disorganization, indifference, or ambivalence about human attachments, establishing a relationship with a patient with Schizophrenia can be challenging. Analytic strategies of passive neutrality and anonymity can easily be misinterpreted as disinterest or dislike and are generally discouraged. Consistency, straightforwardness, and an active effort to establish rapport are advocated. Within bounds, a reasonable degree of self-disclosure on the therapist's part can help to counter distortions by allowing the patient to become comfortable with the therapist as a person. A relationship should be sought on the patient's terms. If the patient initially wants the therapist only to meet some immediate need (e.g., to secure discharge from a hospital or intervene with the patient's family), this is taken as the starting point and viewed positively as a sign that the therapist is seen as potentially useful. At times, engaging in activity (walking or playing a game), finding a neutral topic of common interest (sports, music), or placidly accepting periods of silence will further promote establishing a relationship. Creativity and patience are the only rules.
The process of engagement is often hard, unrewarding, and sometimes scary. The latter, especially, should never be ignored. The aggressive patient requires great care and some experience for one-to-one interactions to be safe. The maintenance of mutual respect, firmness, and an undistorted awareness of one's own anxiety are all strongly recommended. Limit setting, ranging from verbal remonstrance to meeting in the presence of readily available help, to the use of restraints, to timely termination of a volatile session, can be instituted as the situation dictates. Very frequently, the open and candid admission by the therapist to a highly threatening patient that he or she is frightened will defuse the patient's need to be defensively attacking. In all of these situations, it is important that the therapist acknowledge his or her own difficulties in becoming comfortable with the patient. Should these difficulties prove insurmountable, the therapist should seek supervision or consider a change of therapist. It is highly unrealistic to expect oneself to be both comfortable and effective with all patients.
What could be talked about? The events surrounding Mr. Simpson's assault on his neighbor will need to be elaborated eventually, but initially, the doctor might fruitfully focus on what Mr. Simpson has done right over the last 5 years rather than focus on what he did wrong. The doctor should observe out loud that Mr. Simpson avoided hospitalization and trouble with the law (with one exception) for the past 5 years and that it might be useful to explore how he has managed to do that.
If Mr. Simpson takes up the offer, an opening into his life and experiences may be created. The doctor remains nonjudgmental and focuses on how the patient successfully coped with his delusional and hallucinatory "experiences" in his everyday life for the last 5 years. These experiences are not labeled as psychotic but are dealt with as real enough to Mr. Simpson that he probably struggled many times to keep from doing what he ultimately did to his neighbor. The doctor focuses on the times Mr. Simpson was successful in that struggle (i.e., when he remained in behavioral control) and what he did to achieve that control. The process highlights the patient's rational capacities and strengths; it provides models for successful coping in the future, and it does so without getting into contentious debates about the "reality" of the patient's experiences.
Only after a certain degree of familiarity and comfort has been established can the patient's psychotic symptoms be approached in any systematic and technical fashion. Cognitive-behavioral strategies become relevant at this point. The patient's rational cognitive capacity is called on to challenge and scrutinize his delusional realities. As outlined by Dickerson (2000), cognitive-behavioral therapy (CBT) approaches include belief modification, focusing/reattribution, and normalizing the psychotic experience, among other strategies.
In belief modification, evidence for delusional belief is challenged in reverse order to the importance of the delusion to the patient and the strength with which it is held. In Mr. Simpson's case, this might be applied to the sequence about his shoes being altered. He reported being quite surprised by this turn of events, suggesting that he might be willing to entertain alternative hypotheses about what was happening. Focusing/reattribution targets auditory hallucinations such as the voices that Mr. Simpson hears at times. The phenomenology of the voices is explored in detail: who is talking, how frequently, how loud, etc. The patient is asked to keep a daily diary of the voices' frequency and content. The patient and therapist examine the beliefs the patient has elaborated around the voices, their source, and their aim. By elaborating and embedding the patient's hallucinations in the matrix of everyday life, including the patient's concomitant thoughts and feelings, the therapist attempts to help the patient reattribute the voices to him- or herself. Asking Mr. Simpson to elaborate the details surrounding the moments when the "joker" talks, for example, may link the experience to other aspects of the patient's mental state and thereby suggest an internal rather than an external origin of the voice.
In normalizing the patient's psychotic experience, the therapist tries to put the patient's thinking in the frame of antecedent stressful events to "explain" the patient's symptoms in a stress-diathesis context. This helps to make the psychotic experience appear less bizarre and "crazy" to the patient. With Mr. Simpson, it might be useful to focus on the event bringing him into treatment—his assault of the elderly neighbor who operated one of the "voice machines." Despite countless days and nights filled with harassing voices and plots, he lost control only this once. Something different was probably happening around this event, and careful detailing of the experience might reconstruct the link between symptoms, assault, stress, and personal history. Highlighting the emergence of stress and personal history in the elaborated story can possibly help Mr. Simpson "normalize" the experience and take some personal responsibility for it.
CBT strategies, such as that described above, could be tried with Mr. Simpson's extensive paranoid delusions and auditory hallucinations should he ever be sufficiently motivated and develop a relationship with the doctor that is strong and trusting enough to manage the effort. If he proved he was able to negotiate such a sequence of exercises, sufficient rationality and alliance may be present to introduce other treatment modalities for consideration, particularly medication. It is highly unlikely that Mr. Simpson would ever reach this level. Nevertheless, should he reach the level of CBT exercises, his treatment could be regarded as highly successful, even if he remained delusional, unemployed, and socially isolated. He would have a realistic chance of achieving what is most precious to him—his freedom to resume a paranoid lifestyle to which he has become accustomed and adapted but to resume it with a greater capacity for containing it safely.