Bill ran his own business; he was a busy man who didn’t like taking time off. Time for Bill was money, and that, perhaps, was a part of the problem. He wanted money, lots of it, and he never took any time off. He hired out mechanical diggers, excavators, bulldozers and the like to building firms across the country. He’d always loved mechanical diggers. He collected them when he was a little boy, yellow die-cast models with articulated arms and mechanical scoops. He spent hours manoeuvring them around the sandpit his dad built in the garden at the back of the house. Then he moved on to building the models himself. He spent countless hours designing and building the models when he ought to have been doing his homework. He wasn’t a scholar, but he was gifted with mechanical things, so when he left school at the age of sixteen he trained as a mechanic, and then started a small business hiring out tools.
That was when he discovered he had a knack for making money, but rather than spending it he re-invested in his business so he could buy bigger and better equipment. Then, in his mid-twenties, he obtained a bank loan and bought his first diggers and bulldozers. He was really excited, like the small boy who once pushed little yellow models through the sand. In a world of his own he began to dream up bigger and better plans. ‘Why stop at excavators and bulldozers?’ he thought, and he began to hatch plans to buy and hire out lorries, big lorries, black and white with a red dragon logo on the cab side, just like the ones he had drawn and then coloured by hand as a child. These were distinctive lorries that would travel all over the roads of Britain, and across the continent. Lorries had to be black; diggers were yellow, and sports cars, his other passion, red.
At first he was simply engrossed in his ideas, then he became so excited by them he couldn’t sleep. Every night was Christmas Eve. He’d close his eyes as he settled down in the dark next to his wife Zoe, but his mind was aswarm with ideas and excitement. With his eyes shut tight, he could not only see convoy after convoy of black and white lorries with red dragons, but now they had BTS written on the side, Bill’s Transport Services. He could hear the whine of their gearboxes, sense the bed shake with the rumble of their engines, feel the choking exhaust warm against his cheek.
One night he realised he had nowhere to keep all the new lorries he planned to buy, but as the convoy set off and he followed the leader down the road outside his house, it passed the old garage that was for sale just down the road from where they lived. He jumped out of bed. He had to buy it there and then! It was perfect. It had five acres of brown field land that he could turn into a secure parking lot. He’d do all his own servicing to save cash, and why stop at lorries? He could move into exotic car hire, like the Ferrari Dino he’d once been given a ride in at a rally when he was a teenager. Over the coming nights and days a procession of red Maseratis, Lamborginis and Ferraris joined the lorries.
This continued night after night for weeks on end. He started to get up while it was still dark to write new business proposals for the bank. He redesigned the layout of the derelict garage, park and servicing facilities. He planned and designed a new super truck with a ten litre supercharged petrol engine capable of pulling a twenty ton trailer down the autobahns at 200 kilometres an hour. He’d first had the idea when he was a small boy, but his new-found financial success meant that it could become a reality.
But his plans took over his life to such an extent that he wasn’t able to run his business properly. He began to lose money, and was finding it difficult to keep up with the payments on his bank loan and mortgage, but it didn’t matter. He’d simply overcome this by making his bigger and better plans work. He fell deeper into debt as he became more preoccupied with his new plans, until one morning, exhausted by his sleeplessness, there was a letter from the bank foreclosing one of his loans. At this point Zoe took him to see the doctor who arranged for a psychiatrist to see him. They admitted him to hospital and started him on neuroleptic drugs.
At first he went along with the idea he was ‘ill’, as the doctors put it. The pills seemed to calm him down. He slept better. He could focus more clearly on the task in hand, and begin to think about what he had to do to get his business back on track after he had been discharged. But when he got home he was horrified when he discovered that the pills made it impossible for him to make love to Zoe. He hadn’t been warned that this might happen, so he stopped them suddenly, and just as suddenly he found he could no longer sleep, and the lorries and cars were racing across the screen of his closed eyelids, and the ideas and plans were pulsing through his mind, and he ended up back in hospital.
In this way he became tied to a revolving wheel over which he had no control. Each time he worked himself to a standstill he couldn’t sleep, and he became more and more wound up. He became more irritable and excitable, and he began to think of increasingly elaborate plans to expand his business. Sometimes he managed to persuade his bank manager this would be a good thing, but this only increased his debts putting him under more pressure. Eventually he’d crash to a halt unable to sleep or work, and his thoughts racing so it was impossible to understand what he was saying. Only his long-suffering wife seemed to know, but by that time she needed a breather so he ended up in hospital on medication.
This cycle had been going on for at least fifteen years when I became his consultant, and although he quickly recovered once he was started back on medication in hospital, he would stop it suddenly once he was discharged, and so it went on. What was worrying both Bill and Zoe was that as time progressed the periods between his admissions were becoming shorter. Whereas in the beginning he would have had a year or two out of hospital, he was now fortunate to be out for three or four months. This was having serious effects on his life and business. He also became badly dispirited when two years earlier a doctor had told him he would have to remain on medication for the rest of his life. We had to do something to try and break out of this cycle.
One of the greatest strengths in Bill’s life was Zoe. She was a strong woman, practical, who wasn’t easily thrown into a panic. Whenever things got out of hand, she’d take over the running of the business and deal with customers and the bank. She had a great sense of humour which Bill shared, so even though times could get tough she would crack a joke so they were both able to smile. But she also understood how important the business was for Bill, so she knew exactly when to step down and let him take control again.
Inevitably he was readmitted shortly after I became involved in his care. It only took a couple of weeks to settle him down again on five mg of haloperidol a day, and just before he was due to be discharged we had an aftercare meeting with his wife to plan what would happen after his discharge. Although they worked really well together as a team in adversity, they had strongly differing views about the role of neuroleptic medication. Bill hated it, although out of preference he took haloperidol. Even on relatively low doses (five mg a day) he felt lethargic and unable to concentrate, so he was unable to run his business. He also put on weight, and it reduced his interest in sex and interfered with the mechanics of love-making. Other drugs he’d tried were even worse, so he would agree to take haloperidol in hospital only to stop taking it more or less as soon as he left. His wife’s view was different. Although she too disliked the impact it had on their love life, she thought that medication definitely helped to calm him down and, most important of all in her view, it helped him to sleep. She believed that things really started getting out of hand for Bill when he couldn’t sleep. That was where the downhill spiral began. Bill agreed. In the past his family doctor had tried to settle the sleep disturbance that occurred when he came off neuroleptics with short-term benzodiazepines, but unfortunately these hadn’t helped. The only thing that seemed to work under these circumstances was haloperidol. The medication seemed to help him to sleep and this was useful, but he wasn’t prepared to take it once he started feeling better, because it made him feel so lousy in other ways.
In the discussion they expressed their different perspectives on the problems they faced, and we all agreed that it was necessary to try a different approach. Neither Bill nor Zoe saw him as suffering from a ‘mental illness’. Both saw the problem in terms of Bill’s naturally enthusiastic personality, coupled to his difficulty in keeping a sense of perspective on his plans and ambitions. Both were convinced that in some way or another his frequent ‘relapses’ were something to do with the medication he had been taking for so many years. In support of this view I outlined some of the theories about receptor supersensitivity syndromes. This enabled them to make sense of his current predicament without having to see it as illness.
They both found this helpful in thinking about his problems. In addition, it offered a more positive way of trying to manage the situation by making small, gradual reductions in his medication rather than stopping it suddenly. We agreed that after discharge Bill and his wife would slowly reduce the dose of haloperidol either until Bill was well and off the drug altogether, or until there were early signs of something going wrong, such as sleep disturbance, in which case they would put the dose of the drug back up to the level it was at prior to the reduction.
This appeared to work well. As an outpatient over the next six months they gradually reduced the dose right down to 0.5 mg a day, the lowest available dose in single tablet form. However, a few days after stopping the 0.5 mg tablets he experienced sleep disturbance. Bill and his wife discussed the situation, and as a result he decided to go back on 0.5 mg a day. They phoned for an appointment and a few days later we met in the clinic. By this time Bill’s sleep was back to normal and the problem had been nipped in the bud. Zoe confirmed that Bill was functioning well running the business. This time we agreed that when they felt the time was right, he would reduce the dose down to 0.5 mg on alternate days.
The next time we met in the clinic he had kept well on this minute dose for over three months, and they were keen to make a further reduction. I said that this sounded like a good idea, although to all intents and purposes he was on such a minute dose that it seemed improbable that it could be having any significant physiological effect upon him. But that wasn’t important. What mattered was how Bill felt on the dose, not what the books or my experience said. He felt fine in himself on half a milligram on alternate days, was sleeping well, didn’t feel drowsy or tired, was able to concentrate and had a good libido without any sexual dysfunction. We agreed that he would reduce the dose by taking 0.5 mg on every third day.
Three months later they came to see me in the clinic. Bill said that about a week after reducing the dose down to every third day, his sleep began to deteriorate. He couldn’t get off to sleep as his eyes were filled with visions of sports cars.
‘No lorries, then?’ I said, somewhat facetiously.
‘No, just a little red sports car, an Alfa Spider.’
‘So what did you do?’ I asked.
‘Simple, just put the dose back to half a milligram every other day and I’ve been fine since.’
‘That’s amazing’ I said ‘All the evidence says that such a low dose is ineffective. But I’ve occasionally seen it before in other patients, usually people who have been on drugs like you for many years. I suppose the theory is that they change the sensitivity of the receptors in your brain, and it takes a long time to turn that down again. Perhaps sometimes it never returns to normal, so you just need a very low dose.’
‘I don’t know about that’ said his wife. ‘Go on, tell him!’
Bill smiled sheepishly, a seven-year-old’s smile, a seven-year-old who had done very well for himself.
‘Have you got a moment, doc? Just come outside.’
I followed them into the car park. Bill walked up to a stunning little red Alfa Romeo convertible. ‘I’ve always wanted one’ he said, opening the door for his wife ‘ever since seeing that film. You must remember it, do-do-do-do Mrs. Robinson?’
‘Yes’ replied Zoe. ‘We saw it on our first date. He’d always hankered after one. After he bought it two months ago he stopped the pills completely, and he’s been fine since.’