Law and Order: Psychiatry Unit

Crime dramas on American television are known for loosely adapting actual news stories "ripped from the headlines" and calling them fiction. Law and Order: Special Victims Unit is especially known for this pattern. For instance, in one episode last year a much beloved basketball coach who runs a charitable foundation was found guilty of sexually abusing his young players over the course of many years.

In another episode, a well-known politician's long-kept secret is finally revealed after 13 years: the child he fathered with the family housekeeper.

I thought I would do SVU executive producer Dick Wolf a favor and present a unique psychiatric case study that can be adapted for the small screen.  Since it's unknown to the American viewing public (and most everyone else), it will seem like a more original idea.


Patient Presenting with Stockholm Syndrome Ultimately Diagnosed with Münchausen Syndrome and Dissociative Identity Disorder

{SPOILER ALERT: it ends badly.}

A troika of unusual and spectacular psychiatric disorders was observed in one Dutch patient, as reported by Spuijbroek et al. (2012):

A young female of indeterminate age called a crisis hotline several times in the course of a month, giving accounts of severe sexual abuse, kidnapping by her father, and membership in a sect in the recent past. She spoke by preference to male staff members, was difficult to understand, and used a high-pitched, childlike voice. She provided different names and addresses that proved to be wrong. “God,” “men and women,” and “good and evil” were regular topics...

After a few weeks, she expressed suicidal feelings, saying she wished to go to God, and she agreed to be admitted to a local psychiatric hospital. She left, however, after 1 day. One month later, she was hospitalized again, using a different family name. She stated that she was 19 years of age and claimed to have been severely abused by her father and other sect members. ... Her isolation from the outside world, the power imbalance, her sympathy for her abusing father, and her unwillingness to escape the life-threatening situation were consistent with the clinical picture of Stockholm syndrome.

In cases of Stockholm syndrome, a person held hostage or captive comes to strongly identify and bond with her captor. Here, the patient claimed she was kidnapped into a religious cult and sexually abused, yet she felt sympathy for her abusers (which included her own father). However, it soon became apparent that she was not telling the truth:

At first, the personal information provided by the patient could not be verified. After several weeks,  however, her identity was revealed by police detection. The patient turned out to be a 27-year-old woman who had been reported missing 3 weeks earlier by her family. The patient had been receiving mental health care since childhood; she also had financial debts and was at risk of losing her housing. She had wandered about for several years, presenting regularly at various hospitals with a variety of somatic and psychiatric symptoms. She also frequently contacted the police with very detailed and alarming stories that were impossible to verify...

The patient at first seemed unaffected by the disclosure of her identity, but after some days she showed concern. She was uncomfortable at the reunion with her parents. Gradually her behavior changed: she answered to her own name now, and she would speak with female staff members. A few weeks later, the patient said that she could not remember anything about the period when she was admitted to the hospital...

Thus, paradoxical elements of both Münchausen Syndrome (deliberately fabricating an illness) and a dissociative disorder (involuntary rupture of memory, awareness, identity and/or perception) were observed. The diagnosis of Stockholm Syndrome was withdrawn, and psychotic disorders were ruled out:

...The patient did not report hallucinations. While her stories were often improbable, they were never bizarre, and no cognitive impairment was found. Given the many moments of acuity and social responsiveness displayed by the patient, the picture was inconsistent with schizophrenia. The family reported that the patient had fabricated fantastical stories since she was a little girl. Fugue-like states with periods of unexplained peregrination or wandering may have occurred as well. Nevertheless, the patient was regularly able to contact others, continuing her telephone calls to mental health workers and other health care professionals, in a very consistent way. After her identity was disclosed, “Munchausen syndrome,” with imitation of both mental and somatic conditions, turned out to be the most likely description of the patient’s condition.

An additional examination of the patient was conducted by specialists from a regional psychological trauma center... their assessment revealed the following cluster of severe dissociative symptoms: derealization, fugue, depersonalization, amnesia, identity confusion, pseudoepileptic seizures, sleep problems, and self-damaging behavior. Although it was recognized that the patient was suffering from pseudologia fantastica [pathological lying], her dissociative symptoms were regarded as serious and authentic...

The court ordered the patient to be hospitalized for 6 months. During this time she was prescribed a series of medications (including antidepressants, antipsychotics, and benzodiazepines), none of which were effective. She became suicidal. Although her suicide attempts were characterized as "ambivalent", it was unfortunate that she ultimately succeeded while in hospital:

After several months, suicidal tendencies and a desire for euthanasia were a regular topic of conversation for the patient. Several times during her hospitalization, she demonstrated overt suicidal behavior: two medication overdoses, once walking on railroad tracks, and twice putting a plastic bag around her head. These attempts seemed ambivalent, since the chance of detection by staff members was relatively high. The patient was placed in seclusion because of heightened suicidal risk several times, leading to increased fear and tension within the therapeutic relationship. After 7 months, the patient suicided on the ward by suffocation with a plastic bag...

The clinical case discussion ends with COMMENTARY by David A. Kahn, MD [imagine a voice-over by Rod Serling]:

Why have I been haunted by this case report of a mysterious, unfortunate woman who was never truly knowable? The treating staff was ambivalent in its diagnoses of both Munchausen syndrome, which is the intentional feigning of illness, and DID [dissociative identity disorder], or the unintentional adoption of two or more personalities or identities. These appear to be in contradiction, ironically a most accurate reflection of the emotions evoked by the patient who appeared both manipulative but also helplessly unable to control herself and tell a true story. Who was she? Did she know or not know? Was she putting them on, or was she actually unsure of who she really was? Her final act of suicide was a forceful if equally ambiguous communication, as non-verbal as her others, but the authors suggested that it indicated both a growing attachment to the first treatment team that would be lost with transfer to a specialized trauma program, and terror or rage at feeling either found out, or held captive. The first explanation, loss that could not be expressed in words, supports dissociation—an unconscious reaction to immense pain. The second explanation, exposure and entrapment, might suggest antisocial traces more consistent with Munchausen syndrome.

The expository feature of post-episode commentary by a medical expert would distinguish Law and Order: Psychiatry Unit from other series in the franchise. Or the show could be taken in a more haunting and profound direction, which would be a clear departure from the usual police procedural. The Psychiatric Twilight Zone, perhaps?


Reference

Spuijbroek EJ, Blom N, Braam AW, & Kahn DA (2012). Stockholm syndrome manifestation of Munchausen: an eye-catching misnomer. Journal of psychiatric practice, 18 (4), 296-303. PMID: 22805905