And now we come to a curious case involving a Seattle patient, henceforth to be identified as Patient S, who had sought my help because he had recently developed an identity crises which created symptoms of depression. Apparently, the antidepressants his internist had prescribed (including a-adrenegic receptor antagonists and serotonin reuptake inhibitors) were no longer helping to maintain homeostasis.

By the standard metrics of professional and personal success, Patient S had every reason to be content, especially with the help of an effective combination of antidepressants. He held a well-paying job with the federal government in the highly sought field of environmental enforcement and had worked his way up to a position of authority through promotion and graduate education. Patient was gay, and was involved in a long term live-in relationship with a successful and supportive partner. As a matter of routine, patient attended cultural events in town such as the Art Walk and the Seattle Symphony, and could afford to dine out at trendier restaurants on a weekly basis. He travelled, kayaked and played soccer. However, none of new medications which I prescribed (monoamine oxidase inhibitors, tricyclic antidepressants , selective serotonin reuptake inhibitors and Viagra) were successful in harmonizing what the patient perceived as a personality “fissure” which he was unable to reconcile.

Oddly, he claimed to be increasingly attracted to women. Notably, patient stated that he had always felt attraction toward the opposite sex and simply “fell into” homosexual relationships because it provided an intelligible social self-definition. It was agreeable, as contrasted with disagreeable. However, lately he had begun to fantasize about women while performing sex with his partner, and also during casual encounters with strangers including encounters in public restrooms. Lately, he was unable to achieve an erection without thinking about women he knew from the office. When asked about the details of these fantasies, patient stated that they always involved marriage and included unprotected sexual intercourse (Weatherby and Rawls, Neuroreport 2000;11:23-29).

Disturbingly, patient stated that he purchased a firearm (Figure 2) and had become proficient in the use of a handgun. He stated that he was interested in a hunting rifle and had started carrying a handgun in his car, a Nissan Leaf. Patient S insisted he had no violent thoughts and reassured me that there was no cause for concern for the safety of anyone due to this recent preoccupation with guns.

Patient had taken to watching John Wayne movies on DVD, beginning with the middle “Red River” period and then moving into the later “Big Jake”/”McQ” oeuvre (Maltin, Classic Images 1983; 04:9-14) and said that it was too bad that Wayne had not lived longer and had made more movies despite uneven quality. When asked what he liked about these films, patient simply shrugged his shoulders and said, “just do.”  When asked if he would have liked to be more like John Wayne, patient began muttering that George W. Bush was a “war criminal,” stared at the ceiling and asked whatever happened to the electric car. Patient then stated that Cuba has the best healthcare system in the world and it’s free. At this point he slumped in his chair, placed a toothpick in his mouth and looked at the floor.

At a subsequent session, patient stated that he doubted the economic viability of the risk analysis cost assessment curve for the work he did in the environmental field. When I suggested that these thoughts might provide an unnecessary source of emotional dissonance, patient became very agitated in a manner similar to the first session and again stared at the ceiling, in this instance pulling his knees to his chest while pronouncing that corporate criminals were destroying planet Earth for a profit. He then rocked in his chair and sang Dave Matthews songs to himself until the therapy session was over. At which point he stood up, stated that he had an appointment with some “buds” to go to the Drift-on Inn and meet some “babes.” He then expelled flatus and ignited the gas with an American Eagle motif Zippo lighter.

In my post-session notes, I ruled out the possibility of a multiple personality disorder at this juncture and instead pursued a line of diagnosis related to unprocessed childhood experiences causing a series of crises related to repressed emotions and manifesting themselves in conflicting identity graphs (Table 3).

At our next meeting I made a point of discussing his sexual performance dynamics. He indicated that his problems had become so acute that he could only maintain an erection during anal sex (Howard JD, Arch Gen Psychiatry 2002; 60:261-269)  while watching Maureen O’Hara movies from the 1940s and 50s. He indicated that his partner was beginning to become suspicious, even stating to Patient S that he preferred not to be considered “just a body”. Patient then queried me regarding helpful mental exercises for this problem and I suggested self-hypnosis strategies involving gay porn.

At our final session, patient arrived chewing tobacco and carrying a “spit cup.” When I asked how the self-hypnosis strategies were working he said, “they didn’t and it’s too late anyway.” When I asked him what he meant he simply shrugged his shoulders and spit into the cup. We sat in silence for two or three minutes until he asked me if I had any opinions about God. When I informed patient that I was not a believer, patient then asked, “how do you know, I mean, how does anyone know for sure?” When I said that he was right, that no one really knows for sure, but science provides the most reliable guide, he replied, “‘science’, I’ll tell you about ‘science’” and once again spat into the cup. We then sat in silence for several more minutes.

“I pray the rosary,” he said.

“How interesting,” I replied.

Patient then discussed a recent kayaking trip on the Wenatchee River. Patient had been portaging his kayak around a set of rapids accompanied by his partner and two friends. Patient stated that he came upon a flowering shrub which he found to be of interest. He then related the following series of events, which I will take this opportunity to recount in his own words:

“…we were portaging on this deer trail and I saw a shrub with pretty lavender flowers on it and I thought it was the most beautiful thing I’d ever seen. More than that, I thought that it had the power to make me whole. It was a very strange idea, I know, but for some reason I thought that it would and that I was like some kind of red man who had seen that flower for the first time, and I stopped and held it in awe. So, Conor, one of our kayaking friends, is into the gardening in a big way, I mean his garden has been in magazines. Anyway, Conor told me that it was a Cutleaf penstemon. And when he told me that something inside me snapped for some reason. It was as if being told that flower was a Cutleaf penstemon made me angry. I had never been so angry in my entire life. But, I didn’t say anything, I just started walking. And then everyone else started walking fast with their kayaks, or maybe I just thought that everyone was walking fast and I wanted to slow down because I was really enjoying myself even though I wanted everyone else to die. Then I put down my kayak and hit Conor with my paddle and then pushed the other two guys into the water and then threw rocks at them, big rocks. Like I said, at that moment I wanted them to die even though I don’t want them to die anymore. And it wasn’t because they were all fags who tried to fuck me in my tent, I wanted them all to die because Conor knew what kind of flower it was and I’d never seen that kind of flower before. But, what really made me mad was that he told me what kind of flower it was.”

Patient then informed me that this was the last session and thanked me for healing him and called me the Annie Sullivan of psychiatrists. He then asked if I was interested in “going out sometime” and insisted that he was “clean.” When I informed him that I could not date him due to the professional code of conduct, he said that he would call me in six months. When I stated that I was a lesbian in a long-term relationship he replied that it was a “damn shame.” He then asked whether it had to do with “lighting farts,” and I insisted that it did not. Patient then asked me if I owned a three-legged dog and I indicated that I did not. “I do,” he said, and then stated that three-legged dogs were never in a hurry when going on hikes. He also stated that it would be wrong to surgically remove a leg from a four-legged dog “just because you want a three-legged dog,” and that one needs to check with the pound on a regular basis and wait patiently. Strangely, he asked me whether I believed it would be wrong to surgically remove a leg from a four-legged dog and I answered that I believed that it would. He then asked me why I thought so. I replied that I would have to think about that. “Please do,” he said and thanked me for my time.

Conclusion: Upon further analysis, subject exhibited bipolar II depression related to reduced regional orbitofrontal activation and diminished connectivity in the fronto-temporal lobe which affected emotional learning. Amygdala hypoactivation is also a factor and resulted in euthymia and mania. Going forward, I advised a regime of norepinephrine reuptake inhibitors, norepinephrine-dopamine releasing agents and tricyclic antidepressants