I. Case History
1. Background Information
The patient, R.I.P. , male, mid-40s before, mid-60s after, married to an expert in psychological warfare, two children, notable member of a rural community. Patient describes himself as “caring, happy, popular and generous”. In contrast, his wife has been known to refer to him as “idle, careless, foolish and ruinous”. No history of mental or physical disease is known, except for frequent episodes of overpowering laziness which seem to be genetically inherited, since R.I.P.'s son manifests the same tendencies. When questioned, patient admits to sometime resorting to alcohol “for comfort”. Patient's social relationships seem to be inversely proportional to his family relationships: the more cordially he is received in the community, the more his status in the family decreases. Patient attributes this phenomenon to “the terrors of a woman's tongue” and it soon becomes apparent that R.I.P. suffers from spousophobia. This phobia and the stress associated with it seem to constitute the major cause of the patient's psychotic episode.
2. Description of the Presenting Problem
R.I.P's major concern is his domestic climate, which at times becomes unbearable to him, forcing him to take to the hills accompanied by his dog. Patient exhibits the typical personality profile of abused spouses, confessing his lack of courage to face his wife's constant verbal aggression.
One one such day of crisis, patient took a stroll up the mountains. Hearing voices calling him, he discovered a little man in old-fashioned clothing seemingly needing help to carry a keg up the hill. He met more such dwarfs, but no conversation took place. However, patient drank from the dwarfs' liquor and soon fell asleep. When he awoke, his dog was nowhere to be found, his beard had grown enormously and his rifle was rusty. Returning to his village, he could no longer recall any of the sites or faces. He has since been taken in by his daughter, who believes her father is no longer safe without constant supervision.
Every time the therapist suggests that the voices and dwarfs might have been mere hallucinations, the patient becomes aggressive and angrily claims they were perfectly real.
3. Diagnosis
Although at a first glance, R.I.P.'s symptoms (auditory hallucinations, bizarre delusions, significant occupational dysfunction) may point in the direction of schizophrenia, that would not explain the sleeping disorders.
However, Idiopathic Hypersomnia fits with all of the symptoms described by the patient. The recurring episodes of excessive daytime sleepiness (EDS) are consistent with S.U. Rashid's description of the syndrome.¹ The patient also reports having difficulty waking up, and feeling extremely disoriented upon doing so. The feeling of disorientation must be emphasized, since it is the most serious such case we have encountered in our experience: not only does the patient not recognise his own family or community, he does not even find the buildings and fashion familiar, and feels that he is living in a different era.
Even the secondary symptoms fit the diagnostic criteria perfectly, making this a very easy to diagnose case. R.I.P. feels increased anxiety, especially in the vicinity of his wife, increased irritation (again sparked by the approach of his wife); extremely decreased energy, making it impossible for him to perform any work task; slow thinking and speech, as attested by the entire community; hallucinations (voices, drinking dwarfs) and memory loss.
Therefore, the patient's disorder can be, promptly and without doubt, diagnosed as Idiopathic Hypersomnia.
II. Intervention
Unfortunately, an intervention was rendered impossible by the patient's refusal to cooperate. Immediately after the psychotic episode described above, he settled under a tree in the middle of his village and now refuses to move unless coaxed with food or alcohol. Every one of the therapist's attempts to approach was rejected aggressively, the patient repeating “Be gone, you foolish shrink! Long live the King!” obsessively for the rest of the day.
¹Sheik Urbooti Rashid, “Common Mental Disorders of the Modern Age”, Cambridge University Press, New Delhi, 2011
Witch - Rip Van Winkle
