Substance Disorder Case Study

Dear Doctor

Myrna Field, a 55-year-old-woman, was a cashier in a hospital coffee shop 3 years ago when she suddenly developed the belief that a physician who dropped in regularly was intensely in love with her. She fell passionately in love with him, but said nothing to him and became increasingly distressed each time she saw him. Casual remarks that he made were interpreted as cues to his feelings, and she believed he gave her significant glances and made suggestive movements, though he never declared his feelings openly. She was sure this was because he was married.

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After more than 2 years of this, she became so agitated that she had to give up her job; she remained at home, thinking about the physician incessantly. She had frequent, intense abdominal sensations, which greatly frightened her. (These turned out to be sexual feelings, which she did not recognize as she had never been orgasmic before.) Eventually she went to her family doctor, who found her so upset he referred her to a male psychiatrist. She was too embarrassed to confide in him, and it was only when she was transferred to a female psychiatrist that she poured forth her story.

Myrna was an illegitimate child whose stepfather was excessively strict. She was a slow learner and was always in trouble at home and at school. She grew up anxious and afraid, and during her adult life consulted many doctors because of hypochondriacal concerns. She was always insecure in company.

Myrna married, but the marriage was asexual, and there were no children. Although her husband appeared long-suffering, she perceived him as overly critical and demanding. Throughout their married life she had periodically abused alcohol and, during the past 3 years, had been drinking more heavily and steadily to try to cope with her distress. She could not confide in her husband about her “love affair”.

When she was interviewed, Myrna was very distressed and talked under great pressure. Her intelligence was limited and many of her ideas appeared simple; but the only clear abnormality was the unshakable belief that her physician “lover” was passionately devoted to her. She could not be persuaded otherwise.


Disabled Vet

The patient is a 32-year-old man who admits himself to a mental hospital in 1982 after attempting suicide by taking sleeping pills. He says that nothing in particular prompted this attempt, but that he has been very depressed, with only minor fluctuations, ever since he returned from Vietnam 10 years earlier.


He describes a reasonably normal childhood and adolescence. “I never in my life felt like this before I got to Nam.” He had friends throughout high school, always got at least average grades, and never was in trouble with the law or other authorities. He has had many girlfriends, but has never married. After high school, he went to technical school, was trained as an electrician, and was working in this occupation when he was drafted for military service in Vietnam. He loathed the violence there; but on one occasion, evidently swept away by the group spirit, he killed a civilian “for the fun of it.” This seems to him totally out of keeping with character. The memory of this incident continues to haunt him, and he is racked with guilt. He was honorably discharged from the army and has never worked since, except for 3 weeks when an uncle hired him.  He has been living on various forms of government assistance.


In the army the patient began to drink heavily and to use whatever drugs he could get his hand on, abusing most of them; but in the past few years, he has turned to alcohol almost exclusively. He has been drinking very heavily and nearly continually for the past 10 years, with blackouts, frequent arrests for public intoxication, and injuries in bar room brawls. He has acquaintances, but no friends. Whenever he “dries out,” he feels terribly depressed (as he also does when he drinks); he has made four suicide attempts in the past 7 years. For the month before his latest suicide attempt, he had been living in an alcohol-treatment residence, the longest dry period he can remember, all previous attempts at cutting down on his drinking have failed.


The patient presents as a very sad, thoughtful, introspective man with a dignified bearing, an in informal conversation appears to be of at least average intelligence. He is not interested in anything and confides that when he sees others enjoying themselves, he is so jealous he wants to hit them; this urge is never evident from his unfailingly courteous behavior. There is no evidence of delusions and no history of hallucinations except during several bouts of alcohol withdrawal delirium in the past. His appetite is normal, as is his sex drive, “but I don’t enjoy it.” He has trouble falling asleep or staying asleep without medication. He is not psychomotorically slow. He complains of “absentmindedness.”


After 2 weeks, the patient still has trouble finding his way around the ward.  He seems very well motivated to cooperate with neuropsychological testing and is extremely distressed by his disabilities. Testing reveals impaired immediate and long-term memory, apraxias, agnosias, peripheral neuropathy, and constructional difficulties; his IQ is measured at 66.


The patient has not responded to antidepressant medication. He is sorry that his suicide attempt did not succeed, and he says that if things aren’t going to get any better, he definitely wants to die.



Empty Shell

The patient is a 23-year-old veterinary assistant admitted for her first psychiatric hospitalization. She arrived late at night, referred by a local psychiatrist, saying, “I don’t really need to be here.”

Three months before admission, the patient learned that her mother had become pregnant. She began drinking heavily, ostensibly in order to sleep nights. While drinking she became involved in a series of “one-night stands.”  Two weeks before admission, she began feeling panicky and having experiences in which she felt as if she were removed from her body and in a trance. During one of the episodes, she was stopped by the police while wandering on a bridge late at night. The next day, in response to hearing a voice repeatedly telling her to jump off a bridge, she ran to her supervisor and asked for help. Her supervisor, seeing her distraught and also noticing scars from a recent wrist slashing, referred her to a psychiatrist, who then arranged for her immediate hospitalization.

At the time of hospitalization, the patient appeared as a disheveled and frail, but appealing, waif. She was cooperative, coherent, and frightened. Although she did not feel hospitalization was needed, she welcomed the prospect of relief from her anxiety and depersonalization. She acknowledged that she had had feelings of loneliness and inadequacy and brief periods of depressed mood and anxiety since adolescence. Recently she had been having fantasies that she was stabbing herself or a little baby with a knife. She complained that she was “just an empty shell that is transparent to everyone.”

The patient’s parents divorced when she was 3, and for the next 5 years she lived with her maternal grandmother and her mother, who had a severe drinking problem. The patient had night terrors during which she would frequently end up sleeping with her mother. At 6 she went to a special boarding school for a year and a half, after which she was withdrawn by her mother, against the advice of the school. When she was 8, her maternal grandmother died; and she recalls trying to conceal her grief about this from her mother. She spent most of the next 2 years living with various relatives, including a period with her father, whom she had not seen since the divorce. When she was 9, her mother was hospitalized with a diagnosis of Schizophrenia. From age 10 through college, the patient lived with an aunt and uncle but had ongoing and frequent contacts with her mother. Her school record was consistently good.

Since adolescence she has dated regularly, having an active, but rarely pleasurable, sex life. Her relationships with men usually end abruptly after she becomes angry with them when they disappoint her in some apparently minor way. She then concludes that they were “no good to be with.” She has had several roommates, but has had trouble establishing a stable living situation because of her jealousy about sharing her roommates with others and her manipulative efforts to keep them from seeing other people.

Since college she has worked steadily and well as a veterinary assistant. At the time of admission, she was working a night shift in a veterinary hospital and living alone.

The Innkeeper

The innkeeper, aged 34, whom I am bringing before you today was admitted to the hospital only an hour ago. He understands the questions put to him, but cannot quite hear some of them, and gives a rather absent-minded impression. He states his name and age correctly….yet he does not know the doctors, calls them by the names of his acquaintances, and thinks he has been here for 2 or 3 days. It must be the Crown Hotel, or, rather, “mad hospital.”  He does not know the date.

He moves about in his chair, looks around him a great deal, starts slightly several times, and keeps on playing with his hands. Suddenly he gets up, and begs to be allowed to play the piano for a little at once.  He sits down again immediately, on persuasion, but then wants to go away “to tell them something else he has forgotten.” He gradually gets more and more excited, saying that his fate is sealed; he must leave the world now; they might telegraph to his wife that her husband is lying at the point of death. We learn, by questioning him, that he is going to be executed by electricity, and also that he will be shot. “The picture is not clearly painted,” he says; “Every moment someone stands now here, now there, waiting for me with a revolver. When I open my eyes, they vanish.”  He says that a stinking fluid has been injected into his head and both his toes, which causes the pictures one takes for reality; that is the work of an international society, which makes away with those “who fell into misfortune innocently through false steps.” With this he looks eagerly at the window, where he sees houses and trees vanishing and reappearing. With slight pressure on his eyes, he sees first sparks, then a hare, a picture, a head, a washstand-set, a half moon, and a human head, first dully and then in colours. If you show him a speck on the floor, he tries to pick it up, saying that it is a piece of money. If you shut his hand and ask him what you have given him, he keeps his fingers carefully closed, and guesses that it is a lead-pencil or a piece of India rubber. The patient’s mood is half apprehensive and half amused. His head is much flushed, and his pulse is small, weak and rather hurried. His face is bloated and his eyes are watery. His breath smells strongly of alcohol and acetone. His tongue is thickly furred and trembles when he puts it out, and his outspread fingers show strong, jerky tremors. The knee-reflexes are somewhat exaggerated.

Our patient has drunk hard since he was 13 years old….At last, by his own account, he drank 6 or 7 liters of wine a day and 5 or 6 stomachic bitters, while he took hardly any food but soup. Some weeks ago he had occasional hallucinations of sight- mice, rats, beetles, and rabbits. He mistook people at times, and came into his inn in his shirt. His condition has grown worse during the last few days.


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