Music to accompany article: Cello Concerto in E Minor, Op. 85, Adagio - Moderato (Elgar)
Ruby was one of those determined spirits, who would rather die than admit defeat. At the age of 84, life can get quite tough, particularly for a widow with no children or friends to turn to.
The trouble started not long after her husband John had died, about two years previously. He had finally lost his battle against cancer and she had lost a faithful companion in life. John had been ill for many months and Ruby cared for him at home the best she could, but his condition had suddenly deteriorated and he had to be admitted to hospital. A couple of days later, a nurse rang to say that John’s condition was critical, and that Ruby should come to see him as soon as possible. In a rush, she slipped and broke her leg. A neighbour called the ambulance and instead of being at the bedside of her dying husband, she arrived at the Accident & Emergency Department.
Ruby was unwell for a while and could not even attend John’s funeral. The fracture healed, but her grief did not. Ruby had not only lost a man she loved, she had also lost the ground she stood on; John had always been there to support her, to calm her anxieties and assuage her heart. So when he had developed prostate cancer and had told her that he would be all right, she believed him. “Why would he have lied to me?” she asked, when I came to see her at her home.
Stephanie, a CPN (Community Psychiatric Nurse) opened the door and let me in. It was a Victorian terraced house, smelling of must and mothballs. The lounge was rather dark, even though outside the warm October sun made it feel as if summer had returned, if only for a day. A few dusty oil paintings were hanging on the walls, and a large statuette of a female dancer by the chimney place seemed to testify that once there had been joy and laughter in the house. Ruby was sitting on the sofa next to the door.
“I am a hospital doctor, a specialist. Your doctor asked me to come and see you, because she was concerned about your sleep”, I introduced myself.
“A hospital specialist? Whatever for?” she fired away with painful directness. “I don't need a hospital specialist! All I need is a good policeman”, she continued, in a louder than necessary voice, typical for people who can’t hear well. I don't quite remember how I got out of this predicament, but I couldn't possibly have revealed that her GP was at her ‘wits end’ in attending to her mental state.
Initially it was only from time to time, but lately she had been calling the police at least twice a week to deal with an intruder at night. Most evenings this mysterious man would flash his car's headlights at her windows, and then having sneaked through the front door would go straight to the spare bedroom to sleep. How he managed to do that, even though every evening Ruby made sure that the door had been locked and bolted, remained a mystery.
“Can we see this bedroom?” I asked, somewhat hesitantly.
“Sure, but there is nothing to see. He is not there now!” she reasoned, leading the nurse and me upstairs.
Just as we approached the bedroom door, Ruby paused and said, “You don't believe me really, do you?”
As expected the bedroom was empty and tidy.
“You see, he doesn’t even bother to make the bed properly afterwards”. Ruby was shaking her head with indignation.
“It looks quite OK to me”, I made an attempt to undermine her assertion.
“No it doesn’t! Not as well as I would have done it!”, she insisted. The nurse looked at me with a sense of hopelessness.
As we were about to descend back to the lounge, Ruby suddenly stopped. “I want to show you something”, and she opened her bedroom door. “See that?” She gave me an old hat made of leather.
“It looks like… like an old flying helmet… I remember seeing something like this in a film”, I searched my memory.
“You’re right. It’s a flying helmet. It belonged to John, my husband. He was a pilot, you see. I met him at the friend’s house, before the war. He was ever so handsome and he danced so elegantly. Once he took me for a flight, and I can still remember the noise and the wind, and how frightened I felt. 'You’ll be alright, you'll be just fine', he reassured me. And I was. Then the war came, and each time before taking to the sky he said to me 'everything will be alright'. And he was always right. Except... when he became ill. You know, when I put this helmet on my head at night, I see and hear nothing, and I sleep well. But then I think I mustn't sleep too deeply, in case that man comes again. I mustn't be complacent, must I?”
I held the flying helmet in my hands for a while. It had such a soft feel to it, almost skin-like. Then I looked at Ruby’s face, now lit by the autumnal sun. She had surely been a beautiful woman in her youth, with her lively features, rosy cheeks and plaited (now mostly grey) hair.
We returned to the lounge and Ruby offered to make tea. While Stephanie went to help her, I sat down in a worn out armchair to gather my thoughts. What were we going to do? The GP had already tried to give Ruby medication, considered helpful in such circumstances, but she had only taken a few tablets and refused to take any more. Firstly, it was making her ‘dopey’, and secondly, she could not see how the tablets could stop the man coming into her house at night.
I looked around and noticed several old sepia photographs on the marble lamp table, just next to me. In addition to a picture of a newly married couple, there were two others, both of handsome looking men in uniform. One of them must be her husband, I thought.
“Is this John?” I asked when Ruby returned with the tea.
“The one with dark hair? Yes”, she confirmed.
“And the other man, with the moustache?” I pursued.
“Oh, that's my father. He was a sailor. One day he went to sea and never returned. I was only six at the time. My mother raised me, and my sister Nelly. I often had dreams about him. I dreamt that he… Oh, but it was such a long time ago. Your tea is getting cold, Doctor” she ended rather abruptly.
Not knowing the best solution, I suggested that Ruby should come to the hospital, so that she (and her GP and the Police!) could get some rest. Perhaps a solution could be found, once she had had a better night's sleep? To our surprise, Ruby agreed. Stephanie offered to help her pack some essential items and take her there straightaway. Just before Ruby got into the car, she returned to collect something important she'd forgotten. I could see her putting a small rectangular object, rather nervously, into her handbag. Her husband’s photograph? – I thought.
In hospital, Ruby immediately made friends with the patients and staff. She was helpful, considerate, looked happy and, as predicted, there was no sign of the unwelcome visitor at night. Her ‘paraphrenia’ seemed to have evaporated, and without any medication! It looked as if the company of other people had done wonders. But what were we to do next? She was far too able and independent to even consider a nursing home.
During a ward round, a fortnight into her stay, she resolutely stated, “I’m very well Doctor. As you can see there is nothing wrong with me, and you have truly ill patients here who need your help. It's time I went home!” And this is exactly what she did. Just before she left, she stopped me in the corridor. “I must tell you something. I had a dream last night. I dreamed that my father came back. We were all overjoyed! One thing was strange though. He had my husband’s uniform on… But mix-ups like this happen in dreams, don’t they?” she reasoned.
For nearly a year, Ruby boldly defied the mysterious nocturnal visitor, until one morning a home help found her lifeless in bed, with the tattered flying helmet on her head.
COMMENT:
Paraphrenia has been classified as a form of late onset schizophrenia; it is often marked by hallucinations (auditory or visual) and accompanied by an element of paranoia. Whilst most of the reasoning may be intact, it falters when it comes to the core pathological premise. These patients can be, however, painfully logical in justifying their experiences. As Schopenhauer anticipated, reason can sometimes be a cunning accomplice to unreason! Paraphrenia is a form of ‘encapsulated’ madness and does not interfere greatly with everyday life, communication with other people, and the ability to form an emotional bond. It occurs later in life when the personality is well established, often in relation to some degree of social isolation and sensory impairment (of sight and/or hearing). Sometimes, as was in Ruby’s case, grief lies at the heart of it. Medication is seldom helpful, but relieving social isolation and attending to sensory deficit might be.
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