Mr. Q in 1001 words

Dr. Kamal Artin | Exclusive to iKurd.net

One might ask about brutal leaders’ mental life. Generally, people with mental illness are more humane than many leaders. Although absentee evaluation might be medically unethical, humanity’s ethics overrides medical ethic in case of inhumane leaders.

A few years ago, I published the hypothetical case of Mr. Q. The purpose here is to remind the public about psychiatric evaluation and some leaders’ harmful behavior despite some positive qualities.

According to the inquirer, Mr. Q was an indigenous tribal leader who had died in his sixties many years ago. The inquirer was curious about the reason for his mood changes and what one should do if a descendant should go through similar changes.

Mr. Q was born as an orphan; his father had died before birth. Because of the tribal tradition, he was raised by his grandfather who died two years later. He then returned to his mother around age five who soon died too. Subsequently one of his uncles, an influential tribal leader, took care of him until he married. His romantic life started in his late teens; he fell in love and married a wealthy and influential widow twice his age. They had two sons and four daughters. Both of his sons died at a young age.

Soon the wife passed away too, after which he had become depressed and reluctant to marry again. Eventually he overcompensated and married many times including some very young girls. There was no alcohol and drug use history. His career started with working as a farmer during his teens. Soon he accompanied his uncle on trading trips; he became a skillful tradesman. He was righteous and hostile against the corrupt elite. He had refused an offer to join the elite; he become a warrior instead. By his late fifties he had become a renowned warrior and had won many fights. He established himself as a powerful fighter; yet, he had a constant worry about his rivals.

His friends knew him as a clever, trustworthy, faithful, courageous, righteous, strong, and successful fighter. However, others had described him as an ambitious, self-centered, vengeful, vulnerable, and intolerant man who would find any excuse to fight with those with a different worldview.

He has been an athlete and never complained of any physical problems. However, since his forties he has had intermittent confusion accompanied by hearing voices, suggestive of possible epilepsy.

It is unclear how he reacted to losses during childhood. As adult he became preoccupied with doing great things; he united many tribes and started leading them and fighting battles. He had many emotional ups and downs. Initially he had few followers but gradually many joined him. Some of them were very fanatic and fierce.

He started talking about heavenly experiences and messages from God. He volunteered to become a mediator between some of his tribal rivals. Later he withdrew from being an active warrior but asked his supporters to fight for his mission. He started sending grandiose messages to his rivals that they are better off following him.

His mood was not steady. After the loss of his first son, he had become depressed and isolated. He would retreat to a cabin during intermittent low mood, lethargy, and lack of appetite. He would convince his family that he needed to pray and fast in isolation. In one episode of isolation, he started hearing frightening voices in the cabin. Later he thought of them as God’s messages.

Depending on his emotions, the voices were positive or negative and different from his own thoughts. He recovered and the voices were gone for three years. When they returned, he convinced his supporters they were God’s words.

After the loss of his wife and his uncle, he became depressed and started hearing hopeless messages again. At times he became agitated, expansive, evasive with urges to start a battle. Other times he felt elated and cheerful and persuasive about his mission. He had difficulty with writing but dictated the messages to his supporters who made a manuscript out of them.

Physical Exam, Laboratory and Imaging Data, Allergies, Review of Systems, and Mental Status Exam was not available

Assessment in absentee is typically unfair. However, one might conclude that occasional isolation, fasting and sadness could be a sign of depression, and that the intervals of elation, expansiveness, grandiosity, aggression, initiation of battles, paranoia and multiple marriages could be signs of mania. Mood congruent psychotic features have accompanied both episodes of his mood fluctuations. Intermittent severe emotional changes, confusion and hallucinations might also indicate epilepsy and postictal psychosis.

Surviving many traumas and losses might be indicative of his physical and mental strengths. Loss of many family members during childhood and being raised as an orphan by different relatives might have had an impact on his development as a righteous and self-made man. The losses could have also led to self-centered behavior, aggression, preoccupation with control, expansiveness, and an intense desire for variety in satisfying his sexual needs.

Based on the information Mr. Q’s diagnosis included Bipolar I Disorder with psychotic features, cluster B personality traits, possible epilepsy, frequent losses since childhood, and variable functional level from 30 to 80% depending on episodic changes.

Treatment is not applicable in absentee. However, if any of the patient’s descendants or relatives suffers from similar signs and symptoms, one might consider anticonvulsants not only for epilepsy but also as mood stabilizers. Lithium and neuroleptics would also have a significant benefit for bipolar disorder and psychotic features.

During a depressive episode, one might transitionally add an antidepressant to help with low mood as well as impulsivity. Intensive psychotherapy to process past losses and traumas, as well as helping the individual understand his weaknesses and strengths, is essential in recovery. Some underdeveloped communities might be reluctant to doubt things for the sake of keeping traditional values; helping them to understand and seek help for mental illness is important. As developed societies have broken taboos and sacred traditions, likely developing communities will do the same.

Kamal Artin, MD; 12-15-22; Background: Kermashan Jamea High School, University of Zurich, San Diego
University of California, Johns Hopkins University, University of Southern California, and in Private
Practice for over 2 decades with his loving dog, Dr. Fluffy. Former host of Dangi Be Dangan in Zurich, former president of KAES and KNCNA.

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