Nadine had come from the oncology unit upstairs. Proudly, she flashed a hospital badge with her picture and the word Volunteer printed in bold, black letters. She had two reasons for coming to the ER. She needed prescriptions for paroxetine (Paxil), trazodone (Desyrel) and levothyroxine (Synthroid); her psychiatrist was not due back from vacation for two weeks, and she had only enough medication for six days. The second reason was because, as she put it, "the children started coming out." These "children," as far as I could tell, were several of the more immature facets of her identity-the "alters"-who tended to cause trouble for the major identity, "Nadine" (a name she chose, not her legal first name).
Whoever was speaking for the ensemble of labile identities constituting the consciousness of this patient, ostensibly Nadine, gave an agreeable and often cogent interview. Much of what she said made sense, but some of what she said did not and was clearly bizarre. Both the cogent and the bizarre were put forward with equal conviction, making me think she could not distinguish one from the other.
Nadine was hyperalert, knew who she was (i.e., "Nadine"), the name of the hospital and the date. Her speech was rapid, had a stop-and-start quality and was loud with poor modulation. Asked about her mood, she said she felt sad, but denied any disturbance of sleep or appetite, weight loss, anhedonia, psychomotor retardation (she had been agitated earlier, most likely because of anxiety, but was relatively calm during the interview), extended disturbance of daily routine (she had come to us directly from her volunteer work) or thoughts of being better off dead. She denied any intent or plan to hurt herself or anyone else. She insisted that her father had abused her physically and sexually.
Four months earlier, Nadine had been discharged from a state mental institution following a one-year stay. She lived in a group home for two months after that, but was asked to leave when the staff could no longer provide the attention she needed ("to control the children," she said, referring to the immature alters). Currently, she was living with a female friend.
Nadine told me she wanted to get the prescriptions for her medication and go home. She assured me she could manage on her own. She denied any history of alcohol or substance abuse (the toxicology screen was negative). Her physical health was currently good, she said, though she did have asthma and was taking Synthroid for hypothyroidism.
Almost parenthetically, Nadine let it be known that while she was in a bathroom just a few feet from the seclusion room "a man shoved garbage up me." I did not take her claim literally, though I repeated the remark to a physician assistant, who immediately said "No" to her own unspoken thought of doing a pelvic examination.
When I finished the interview, I spoke with the ER attending physician, who agreed the patient could be given the prescriptions she asked for and discharged. We were busy that evening, and Nadine had to wait for me to write follow-up orders for her discharge form and for the attending doctor to sign it. She sat on one of the high stools that ring the nurses' station, taking her place among several of the ER staff, talking confidently with them. When I brought her the discharge form to sign, Nadine repeated what she said during the interview about garbage being inserted into her while she was in the bathroom. When I did not respond, she quickly become agitated and refused to sign the form. "You promised to help me with this," she said, not saying who made the promise. Later, she insinuated it was the technician who had spoken to her in the seclusion room.
Agitation quickly gave way to hysterics. The patient (whatever facet of her dissociated, fractured identity was paramount now, possibly not Nadine) was screaming, and drawing the attention of the ER staff, as well as other patients being evaluated or waiting to be seen. In a few seconds, she went from what appeared to be a composed young woman (Nadine?) to a hysterical child, (one of the "children" who "started coming out" just before she came to the ER? Or, alternatively, simply an hysterical adult), screaming that we were not giving her the attention she needed and was promised.
