The Case of Sam: Multidisciplinary Perspectives

Samuel Adams Mercury (Sam) is a 38-year-old Caucasian man who has never been married. He was born, grew up, and continues to live in a small city in a Mid-Atlantic state. Generally, he is casually but appropriately groomed and dressed, and he has no distinguishing physical characteristics other than small tattoos on his right and left forearm that say "Left" and "Right," respectively. He has a history of marked fluctuations in his adult weight, which has varied from 115 to just under 200 pounds.

Present status. Sam is currently a long-term resident in a short-term transitional residential program. By all accounts, he is "stuck"; providers are unsure about how to proceed.

Psychiatric history. In high school Sam was an excellent, involved, and active student. However, near the end of his high school career, he began to have difficulty concentrating, his grades plummeted, and he became isolated. He managed to complete high school, and he entered college. During his freshman year he experienced greater problems with concentration, and he began to report being "fatigued"—a description of himself he uses to the present day.

Sam had his first hospitalization when he was 18 years old, after he came to the emergency department complaining of extreme fatigue. Medical and neurological workups found no organic basis for his fatigue. A psychiatric consultation was obtained, and psychological testing found evidence of a major depressive episode. Sam was given a tricyclic antidepressant, to which he responded well.

After discharge, Sam stopped taking his medication. He became more isolated, withdrew almost entirely from contact with his family, and became preoccupied with religion. Unable to keep up with his work at college, he was put on academic probation, saw another psychiatrist, and started another tricyclic antidepressant. He became hypomanic in response to the second antidepressant. Soon he was found dazed and wandering across the campus, barely clad, in subfreezing weather. Sam was sent to a nearby state hospital for his first psychiatric admission. After a brief stay, he was transferred first to one and then to another general hospital psychiatric unit.

In a consistent pattern over the next 20 years, Sam was admitted to hospitals for similar problems and discontinued his medication after discharge. During his first psychiatric admission, he was diagnosed as having bipolar disorder, manic phase with psychotic features. This diagnosis followed him for the next 20 years. No assessment has found evidence of substance abuse. Sam has accumulated more than 40 psychiatric admissions in 20 years.

During those years Sam was offered extensive outpatient psychiatric services—some of which he used. The services he used included case management, crisis services, outpatient psychiatric medication follow-up, outpatient psychotherapy, electroconvulsive therapy (ECT), crisis beds and respite beds, a supported apartment program, ancillary outreach services, and other, similar services. Sam was also offered partial hospitalization, day treatment, and clubhouse and vocational rehabilitation, all of which he repeatedly refused.

Throughout this 20-year period, Sam's medication regimen has consisted of antipsychotic drugs, including trials of conventional and atypical agents—clozapine, olanzapine, and quetiapine. Antidepressant medications were also prescribed—initially tricyclic antidepressants and later selective serotonin reuptake inhibitors. At various times Sam has also received mood stabilizers, including lithium carbonate, carbamazepine, valproate, and lamotrigine. These classes of drugs have been used alone and in various combinations.

Since his diagnosis, Sam has consistently denied the possibility that he has a psychiatric disorder. Instead, he has insisted that there is an organic basis for the symptom that he perceives as his major symptom, namely fatigue. He believes that his disorder falls within the realm of chronic fatigue syndrome or fibromyalgia. His denial of any psychiatric disorder has led providers to believe that Sam is not capable of giving informed consent to take psychiatric medications. Thus court authorization through guardianship has been obtained for the administration of psychiatric medications. When ECT was used, a medical guardianship was obtained with specific authority to approve ECT.

Sam's tenures in psychiatric inpatient settings have usually been brief, consistent with current patterns of inpatient psychiatric treatment. In some general hospital psychiatric units, his stays have been more prolonged, which has led to his characterization as an "outlier" in terms of length of stay in these units. Sam has also had several prolonged stays in what are meant to be temporary community housing placements, mainly because providers were unsure about what to do with him.

During Sam's long tenure as a psychiatric patient, no assessment has found evidence that he is a danger to others. However, he has often been deemed a danger to himself because of his depressed state and the recurring manic phase of his illness. The behaviors that endanger Sam include prolonged exposure to subfreezing weather, delusional firesetting, delusional self-injury, long periods of self-starvation, and significant periods of mutism.

Currently Sam is in a respite bed, to which he was discharged from his most recent psychiatric hospitalization. He is about to be discharged back to his supervised apartment. In the apartment program, staff ensure that Sam takes his medication twice daily. They transport him to all appointments and take him weekly on food shopping trips and planned social outings. Program staff are available for any crisis, from 8 a.m. to 9 p.m.

The same case manager has worked with Sam for more than ten years. Weekly, for the past 20 years, Sam has seen one outpatient psychotherapist—a psychologist. Sam also sees an outpatient psychiatrist monthly. The psychiatrist has managed Sam's medication for about seven years. In addition, Sam is seen by a crisis team, staffed by many workers who know him well. The team is available 24 hours a day, seven days a week. The program provides access to crisis and respite beds close to where he lives. All of the mental health professionals in Sam's life provide him with support and guidance to become more involved in community life.

Family history. Sam is the second of four children. No mental illness is known in his immediate family. Two relatives on his father's side have been diagnosed as having a major mental illness; however, neither has been given a diagnosis of bipolar affective disorder.

Social history. Sam spends most of his time alone and involved with music, a long-standing hobby to which he is committed. He has never been married but has had a number of girlfriends. Sam typically becomes involved in relationships when he is hypomanic. However, his usual contacts are with his numerous care providers.

Mental status examination. Sam's mental status is characterized by remarkable fluctuations. When euthymic and not psychotic, Sam is a taciturn, somewhat guarded individual with a capacity for dry wit; his affect, however, is generally flat, and the paucity of his verbal output can sometimes be painful to care providers. Sam is typically unresponsive to conversations and not likely to initiate them. When he is psychotic and either manic or depressed (mixed states are common), Sam's behavior can become what many of his caregivers have called "bizarre." Such behaviors include jumping among various pieces of furniture, snaking along the floor, and crawling while braying like an animal. Sam's verbal output can be so disorganized that the best description is word salad.

As noted, no assessment has documented overt homicidal or suicidal ideation. However, Sam's delusional ideation has put him in situations where he has been at risk of serious harm or even death. Sam's judgment has been extremely variable, from reasonable to virtually nonexistent. His insight is consistently poor.

Diagnosis. Sam's diagnosis is as follows: Axis I: bipolar I disorder, most recent episode mixed; eating disorder NOS. Axis II: schizoid personality disorder. Axis III: overweight. Axis IV: uncertain living arrangement; undefined future mental health services. Axis V: current GAF 35; range in GAF during past year: 15 to 45.

Treatment plan. The consensus among Sam's care providers is that his course has been one of slow but steady deterioration. A debate has been ongoing about whether Sam's current mental health services—maintenance in the community—should continue or whether he should be placed in a hospital for a long-term stay with a focus on psychosocial rehabilitation. For years Sam has had a stable cadre of professional caregivers maintaining him in the community, largely through provision of care. Is it time to provide a rehabilitation push in an effort to treat Sam and attempt to reverse his progressive decline?

Sam meets the criteria for civil commitment largely because he is unable to safely care for himself. However, will taking Sam out of his community and transferring him to a hospital lead to an improvement in his quality of life? On the other hand, will leaving him in the community do any more than facilitate his progressive isolation and dependence on the care system? Does continuing the current treatment plan mean that Sam is really in the community only because he sleeps in an apartment rather than in a hospital bed?

Dr. Geller is professor of psychiatry and director of public-sector psychiatry at the University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, Massachusetts 01655 (e-mail, [email protected]).