George Case Study

 By the time he was admitted to the hospital, George Lawler was talking a mile a minute. He harangued the other patients and ward staff, declaring that he was the coach of the U.S. Olympic track team and offering to hold tryouts for the other patients in the hospital. His movements were rapid and somewhat erratic as he paced the halls of the ward and explored every room. At the slightest provocation, he flew into a rage. When an attendant blocked his entrance to the nursing station, he threatened to report her to the president of the Olympic committee.

He had not slept for 3 nights. His face was covered with a stubbly growth of beard, and his hair was scattered in various directions. His eyes were sunken and bloodshot, but they still gleamed with an intense excitement.

             His life had taken a drastic change over the past 2 weeks. George was 35 years old, married, and the father of two young children. He worked at a small junior college where he taught physical education and coached both the men’s and women’s track teams. Until his breakdown, the teams had been having an outstanding season. They were undefeated in dual competition and heavy favorites to win the conference championship. The campus was following their accomplishments closely because it had been many years since one of the school teams had won a championship. In fact, track was the only sport in which the school had a winning record that season.

             This was not the first time that George had experienced psychological problems.  His first serious episode had occurred during his junior year in college. It did not seem to be triggered by any particular incident; in fact, things had been going well. George was playing defensive back on the university football team.

He was in good academic standing and fairly popular with the other students.

Nevertheless, during the spring semester, George found that he was losing interest in everything. It was not surprising that he did not look forward to classes or studying. He had never been an outstanding student. But he noticed that he no longer enjoyed going out with his friends. They said he seemed depressed all the time. George said he just did not care anymore. He began avoiding his girlfriend, and when they were together, he found fault with almost everything she did. Most of his time was spent in his apartment in front of the television. It did not seem to matter what program he watched because his concentration was seriously impaired. He kept the TV on as a kind of distraction, not as entertainment.

            When he did not show up for spring football practice, the coach called him to his office for a long talk. George told his coach that he did not have the energy to play football. In fact, he did not feel he could make it through the easiest set of drills. He did not care about the team or about his future in sports. Recognizing that George’s problem was more than a simple lack of motivation, the coach persuaded him to visit a friend of his—a psychiatrist at the student health clinic.

George began taking antidepressant medication and attending individual counseling sessions. Within several weeks, he was back to his normal level of functioning, and treatment was discontinued.

             George had also experienced periods of unusual ambition and energy. As a student, he had frequently spent several days cramming for exams at the end of a semester. Many of his friends took amphetamines to stay awake, but George seemed able to summon endless, internal reserves of energy. In retrospect, these periods seemed to be hypomanic episodes (i.e., periods of increased energy that are not sufficiently severe to qualify as full-blown mania). At the time, these episodes went relatively unnoticed. George’s temporary tendency toward excess verbosity, his lack of need for sleep, and his ambitious goals did not seem pathological. In fact, his energetic intervals were productive, and his behavioral excesses were probably adaptive in the competitive university environment.

             There had been two subsequent episodes of depression with symptoms that were similar to those of the first episode. The most recent incident had occurred

8 months prior to his current hospitalization. It was September, 2 weeks after the start of the fall semester. George had been worried about his job and the team all summer. Who would replace his star sprinter who had transferred to the state university? Would his high jumper get hurt during the football season? Could they improve on last year’s winning record? Over the past month, these concerns had become constant and consuming. George was having trouble getting to sleep; he was also waking up in the middle of the night for no apparent reason.

He felt tired all the time. His wife and children noticed that he was always brooding and seemed preoccupied. Then came the bad news. First, the athletic department told him that he would not get an increase in travel funds, which he had expected. Then he learned that one of his assistant coaches was taking a leave of absence to finish working on her degree. Neither of these events would have a drastic effect on the upcoming season, but George took them to be disasters.

            His mood changed from one of tension and anxiety to severe depression.

Over several days, George became more and more lethargic until he was almost completely unresponsive. His speech was slow and, when he did say more than a word or two, he spoke in a dull monotone. Refusing to get out of bed, he alternated between long hours of sleep and staring vacuously at the ceiling. He called the athletic director and quit his job, pointing to minor incidents as evidence of his own incompetence. He believed, for example, that the assistant coach had quit because of a brief argument that he had had with her 6 months earlier. In fact, they had a positive relationship, and she had always planned to return to school at one time or another. She was leaving earlier than she had expected for personal reasons. George seemed to be blaming himself for everything. He apologized profusely to his wife and children for failing them as a husband and father. His despair seemed genuine. Suicide appeared to be the only reasonable solution. He threatened to end it all if his family would only leave him alone.

             George’s wife, Cheryl, called the psychiatrist who had treated him during his last episode (2 years earlier) and arranged a special appointment. The psychiatrist decided to prescribe lithium carbonate, a drug that is used to treat manic episodes but that is also an effective antidepressant.  Although George had never been hospitalized for a manic episode, the psychiatrist suggested that his past history of “maniclike” behavior (increased energy, sleeplessness, inflated self-esteem, and so on) and his positive family history for this disorder (his uncle Ralph) were both consistent with the diagnosis. The lithium seemed to be effective. Three weeks later, George was back at work. Maintenance doses of lithium were prescribed in an attempt to reduce the frequency and severity of future mood swings.

             His first fully developed manic period began suddenly near the end of the next spring track season. The team was having a good year, and a few team members had turned in remarkable individual performances. Two days before the conference meet, Cheryl noticed that George was behaving strangely. There was a driven quality about his preparation for the meet. He was working much longer hours and demanding more from the athletes. When he was home, he talked endlessly about the team, bragging about its chances for national recognition and planning intricate strategies for particularly important events. Cheryl was worried about this change in George’s behavior, but she attributed it to the pressures of his job and assured herself that he would return to normal when the season was over.

             George was clearly losing control over his own behavior. The following incident, which occurred on the day of the conference meet, illustrates the dramatic quality of his disturbance. While the men’s team was dressing in the locker room prior to taking the field, George paced rapidly up and down the aisles, gesturing emphatically and talking at length about specific events and the virtues of winning. When the men were all in uniform, George gathered them around his own locker. Without Cheryl’s knowledge, he had removed a ceremonial sword from their fireplace mantel and brought it with him that morning. He drew the sword from his locker and leaped up on a bench in the midst of the men. Swinging the sword above his head, he began chanting the school’s fight song. The athletes joined in, and he led them out onto the field screaming and shaking their fists in the air. A reporter for the school newspaper later described the incident as the most inspirational pregame performance he had ever seen in a locker room. Without question, the team was driven to an exceptional emotional peak, and it did go on to win the meet by a huge margin. In fact, George was later given the school’s annual coaching award. His behavior prior to the meet was specifically cited as an example of his outstanding leadership qualities. Unfortunately, the action was also another manifestation of psychopathology and a signal of further problems that would soon follow.

             George did not return home after the meet. He stayed in his office, working straight through the night in preparation for the regional meet. Cheryl was finally able to locate him by phoning his friend who worked in the office next door.

She and his colleagues tried to persuade him to slow down, but he would not listen. The next morning George was approached by a reporter from the school newspaper. Here, George thought, was the perfect opportunity to expound on his ability as a coach and to publicize his exciting plans for future competition. The interview turned into a grandiose tirade, with George rambling uninterrupted for

3 hours. The reporter could neither interrupt nor extract himself from this unexpected and embarrassing situation.

             The interview turned into a professional disaster for George. Among other things, George boasted that he was going to send the star high jumper from the women’s team to the NCAA national meet in Oregon. He planned to go along as her chaperone and said that he would pay for their trip out of the proceeds of a recent community fund-raising drive. This announcement was startling in two regards. First, the money in question had been raised with the athletic department’s assurance that it would be used to improve the college’s track facilities and to sponsor running clinics for local children. George did not have the authority to redirect the funds. His announcement was certain to anger the business leaders who had organized the drive. Second, the prospect of a married male coach chaperoning a female athlete, who also happened to be quite attractive, promised to raise a minor scandal in their small, conservative community.

            Recognizing the sensitive nature of these plans, the reporter asked George if he might want to reconsider his brash announcement. George replied—asking the reporter to quote him—that it was not every year that he had the opportunity to take a free trip with a pretty girl, and he was not about to pass it up. He added that this might blossom into a genuine romance.

             The article appeared, along with a picture of George, on the front page of the school paper the next morning. His disheveled appearance and outrageous remarks raised an instant furor in the athletic department and the school administration.

The head of the department finally located George in his office making a series of long-distance calls. The director demanded an explanation and immediately found himself in the midst of an ear-shattering shouting match. George claimed that he had just been named head coach of the Olympic track team. He was now calling potential assistant coaches and athletes around the country to organize tryouts for the following month. Any interference, he claimed, would be attributed to foreign countries that were reluctant to compete against a team led by a coach with such a distinguished record.

             The department head realized that George was not kidding and that he could not reason with him. He returned to his own office and phoned Cheryl. When she arrived, they were unable to convince George that he needed help. They eventually realized that their only option was to call the police, who then took George to a psychiatric hospital. Following an intake evaluation, George was committed for 3 days of observation. Because he did not recognize the severity of his problems and refused to cooperate with his family and the hospital staff, it was necessary to follow an involuntary commitment procedure. The commitment order was signed by a judge on the following day, after a hospital psychiatrist testified in court that George might be dangerous to himself or others.

 Social History

             In most respects, George’s childhood was unremarkable. He grew up in a small, Midwestern town where his father taught history and coached the high school football team. He had one older brother and two younger sisters. All of the children were fair-to-average students and very athletic. George loved all sports and excelled at most. When he accepted a football scholarship to the state university, everyone expected him to go on to play professional ball.

             He was always popular with his peers. They looked to him for leadership, and he seemed to enjoy the role. He and his friends were mischievous but were never serious discipline problems. Although some of his friends began drinking alcohol during high school, George always refused to join them. His father had been a heavy drinker, and he did not want to follow the same path. After several years of problem drinking, George’s father had joined Alcoholics Anonymous and remained sober. Everyone agreed that the change in his behavior was remarkable.

            George’s uncle (his mother’s brother) had also experienced serious adjustment problems. This uncle was several years older than George’s mother, and the principal incidents occurred before George was born. George was therefore uncertain of the details, but he had been told that his uncle was hospitalized twice following periods of rather wild behavior. A later search of hospital records confirmed that these had, in fact, been maniclike episodes. Although the uncle had been assigned a diagnosis of “acute schizophrenic reaction,” contemporary diagnostic criteria would certainly have required a similar diagnosis to George.