The sailor who won’t follow orders
Mr. L is rehospitalized 9 times in 3 months but repeatedly fails to adhere to outpatient treatment. What is the cause of his exasperating behavior?
In retrospect, Mr. L’s seeking repeated inpatient psychiatric hospitalizations is consistent with poor planning and problem-solving skills. He has a limited repertoire of adaptive behaviors and has learned that suicidal gestures lead to admission and caretaking. These are important to him because he is frequently homeless. His lack of insight is seen in his unrealistic plans for employment in jobs requiring specialized technical skills.
Mr. L’s case emphasizes the importance of considering brain injury as an etiologic factor in personality changes. It also highlights the complex—and seemingly nonoverlapping—functions and dysfunctions of the frontal lobe, including:
- source memory
- working memory
- sustained attention
- conceptual fluidity
- imaginative thinking
- impulse regulation
- planning and problem-solving skills.
Documenting Mr. L’s cognitive deficits and acquired dementia diagnosis changed our staff’s perception of his behavior, enabling us to overcome negative countertransference (Box 2). We no longer regarded him as deliberately manipulative and refer him for appropriate treatment.
Countertransference can interfere with optimal workup and treatment of patients with character changes related to traumatic brain injury and neurodegenerative processes. When we interpreted Mr. L’s suicidal gestures and hospitalizations as manipulative and deliberate, we failed to appreciate the limited number of things he could do to obtain a safe and protective environment. We also failed to recognize that his poor planning and problem-solving skills—as well as lack of insight into his illness—prevented him from adhering to outpatient treatment.
Originally, we attributed Mr. L’s egocentricity, lack of empathy, and lack of adherence to axis II pathology.
Our staff’s hostile feelings toward Mr. L led us to insufficiently consider his history—which is consistent with cognitive decline—during biopsychosocial evaluation and treatment planning. Mr. L’s status as a frequently homeless, unemployed person reflects a sharp decline for a highly educated person who served as a Navy officer and performed radiation inspections on nuclear-powered vessels.
Outome: Residential placement
We realize Mr. L needs cognitive rehabilitation—including assistance with planning and problem solving—and arrange for his placement in a residential facility for this specialized rehabilitation. Mr. L receives supportive psychotherapy and cognitive remediation from a psychologist. He also is involved in incentive work therapy with a vocational rehabilitation specialist.
Related resource
- Silver, JM, McAllister TW, Yudofsky SC, eds. Textbook of traumatic brain injury. Washington, DC: American Psychiatric Publishing; 2005.
- Divalproex • Depakote
- Quetiapine • Seroquel
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
