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Introspections   |    
Balance Beam
Lloyd Benjamin, M.D.
Am J Psychiatry 2006;163:979-980. doi:10.1176/appi.ajp.163.6.979
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“Do I hold it like this or like this, I was kind of thinking…,” he says, pointing his fingers at various angles toward his head, motioning as to how he was considering shooting himself. “But, I was just thinkin’ that, you know, I was not going to do anything like that, but then I think that she saw me and thought that I kind of was…,” referring to his 14-year-old granddaughter who spotted him pointing his old revolver and called the police. He is 92 years old and telling me how he was referred to the psychiatric unit, having been thought suicidal after the death of his wife of 57 years a day prior.

It had all occurred rather suddenly, going from her pneumonia to a broken hip and hospitalization all within a few days, and then, she was gone. “Oh, my son came out of the hospital that night and just told me, and I, you know, just looked up at the stars and bawled my eyes out, but the next day, I thought that I needed to just kind of go back to my art studio in the garage.” And while there, after drinking his morning beer, the only one he drinks for the day he assures me, he discovered a very old gun he’d had for years, the name of which he did not quite recall. No, it was not a Colt .45, but it was a Colt-something, he remembered, feeling that it was so archaic, and with but one bullet in the chamber, that it could not possibly work. But for a brief moment, in considering his enormous loss, just for a moment, he’d thought of joining his wife, not really sure he could go on without her. As he is telling me all of this in our first discussion, I notice that he is rather thin, marginally groomed, quite alert, and verbally engaged in the discussion but somewhat withdrawn, motorically restless, verbally driven, and circumstantial, though his affect was locked into only a somber expression. At times, he wells up a bit, but then it all just was to get sucked back in, with another verbal barrage of just how things went in the art studio. Does he have an earlier history of depression? Has he experienced anything akin to hypomania? No, he says to all of this, insisting that he was merely reacting to the death of his wife, the toying with the gun but a speculation of what it would be like to no longer exist.

I find myself struggling with just how to diagnose him, a particularly troublesome task given my pathos for his dilemma. I know that he is terribly defended, with intellectualism and affective isolation and that I should not overidentify with him. But I keep resonating with what he’s told me, the precipitous loss of his wife after 57 years and the impossibility of this not being profoundly sad. How was the marriage? “Oh, wonderful,” he tells me, “really a good marriage.” “Fifty-seven years…,” he reiterates softly. And in our daily discussions for the short time he’s in the hospital, he lives his sadness so thoroughly. It is all in his eagerness, if not desperation, to see me—the intentness of his gaze, the anxious licking of his lips, the jostling his cane, and the shifting uneasily while recounting the events surrounding her loss and his garage musings, staving off tearfulness each time. I leave our sessions feeling very sad. Could he really just flirt with the idea of killing himself? And his restlessness, verbosity, and circumstantiality, as well as the “morning beer,” clearly not mainstay breakfast fare—what to make of all of this? Might he really suffer from bipolar disorder, heretofore undiscovered, now uncapped with the death of his wife? I’m in a quandary. What is the diagnosis? If I merely diagnose him with putative bipolar disorder, I’m ignoring his true grieving and hypomanic defense, and if I only diagnose him, so to speak, as grieving, I’m possibly ignoring potentially nascent bipolarity. I do not want to ignore either one, but I am struggling. No, says his son, never before has he been depressed or hypomanic. They both feel that he doesn’t warrant medications, and, for the moment, I’m not convinced about the need for such either. In the interim, I’ve diagnosed him with depressive disorder, not otherwise specified, though I’m not a proponent of not otherwise specified diagnoses in general.

His hospital treatment consists of brief psychotherapy, and as his initial commitment is winding down, he assures me that he is “over” whatever level of devastation he initially felt, ready to return home and to his art studio. He appears marginally brighter and a bit less circumstantial, quickly ascribing most of the prior concern about him to his son who he describes as a “real softy.” The gun has been taken away, and, no, he will “never” drink more than one beer a day. But in between our sessions, I sometimes pass by his room, finding him lying on his bed, quite still and quiet, looking up at the ceiling as if looking up at the stars, trying to find his special one among them. I am lost, he seems to be saying; I am so utterly lost. In our last session, as he walks out with his cane, he apologizes for his slowness in rising, saying, “I used to have someone help me with this…,” trailing off with a deflated note, welling up but slightly. Yes, I think; yes, you very much did. There is no diagnosis for saying goodbye.

+Address correspondence and reprint requests to Dr. Benjamin, University of California Davis Medical Center, Department of Psychiatry, 2230 Stockton Blvd., Sacramento, CA 95817; lloben@earthlink.net (email).

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