The Patient Was…

The patient was in their mid-eighties when they consulted me for symptoms suggesting a disorder of their heart rhythm, that is, the regularity of their heartbeat. Heart rhythm abnormalities, often called arrythmias, are very common, and the prevalence increases markedly with age. For example, the well-known arrhythmia atrial fibrillation (or A Fib, as it is popularly called in television ads), affects about twenty percent of people in their eighties.

Another common category of heart rhythm disorders consists of those affecting the normal transmission of electrical impulses throughout the heart. These are conditions in which the electrical signals that normally traverse the heart, generating contractions of the heart muscle, are partially or completely blocked. This is, in fact, called Heart Block. When this occurs, the heart muscle doesn’t get its normal electrical stimulation, resulting in a failure to contract and pump blood.

 If this is an infrequent occurrence, or the signals are only delayed but not completely interrupted, there may be only minimal consequences. But if blockage of the cardiac electrical signals is complete, and frequent or permanent, the results can be life-threatening. I have previously written about a physician colleague of mine who developed complete heart block, refused treatment, and died as a result.

The treatment for complete heart block is what is called a “pacemaker.” This is basically an electrical device, usually battery-powered, implanted within the body, that generates an electrical signal. There are several different types of pacemakers and electrical conducting systems now available for use in various types of disorders of the heart’s normal electrical system; in essence, they all perform the same basic function.

The patient in this instance was medically trained and specialized in an area we might designate as mind-body connections. They were well regarded in the field and were, in fact, often consulted by other specialists in that area. The patient was highly intelligent, knowledgeable, and quite opinionated. They tended toward directing or pontificating, rather than discussing. Their visits to my office were stimulating.

When the nature of their problem was explained, they seemed to understand fully. And the proposed treatment, implantation of a pacemaker, was accepted. Arrangements were made at the hospital, and one of the cardiac interventionalists placed the device without incident.

The first post-procedural visit to my office was uneventful. The pacemaker was functioning normally, and the patient’s heart rhythm was completely regular and appropriate. There were no symptoms or signs of anything amiss.

All was well  —  until it wasn’t.

A few weeks after their initial visit following the pacemaker implantation, they returned to my office rather agitated. What followed was something I had never encountered in my years of clinical practice as a cardiologist. And pacemakers were a specific interest of mine, as I was in charge of the Pacemaker Clinic at our hospital, and had spent time during my medical training with the physician who developed the first technique for inserting pacemakers through the venous system (veins).

“This thing is alive and malevolent,” the patient said. “It has to come out!”

For a moment, I was speechless. Alive. Malevolent. What did that even mean?

Finally, I said, “What do you mean, ‘This thing is alive’? It’s working, if that’s what you mean. It’s live in that sense. Like a live electrical connection.”

“No,” said the patient. “I mean it’s alive like a living being, a living organism inside me. And it’s evil, it’s malevolent.”

Now, through my clinical experience and knowledge of the medical literature I was aware of the psychological or emotional reactions that developed in some patients after implantation of a pacemaker. Anxiety and depression were not too uncommon, both stemming from the same realization that their lives were dependent on a “machine,” so to speak, and it was out of their control. Anxiety because the device might break or stop working, depression for the same reason that their very existence depended on a piece of metal and some electric connections inside them about which they could do nothing.

All that I knew and understood. But “alive and malevolent” was new to me. And there were only rare and fragmentary allusions to anything like it in the scientific literature that I could find.

The belief that external beings have entered into and taken over someone’s body is not new or even rare. In various religions, the idea that evil spirits of some kind reside within someone is well known. These spirits are not inanimate objects, however, but are human-like figures.  The casting out of such spirits or demons can be a sort of exorcism.

A recent newspaper article discussed a rare disorder called Delusional Infestation, in which patients believe that insects or parasites are living within their bodies, causing intolerable symptoms. Most cases are thought to be due to psychiatric conditions or, less commonly, medications, but some remain unexplained. In these cases, though, the culprit entities are believed to be living creatures.

Perhaps anthropomorphism, the attribution of human characteristics to non-human entities, is a better categorization of the patient’s ideation in my encounter. Anthropomorphism occurs when non-human entities are given human characteristics, behaviors and emotions. It is a common technique in certain fields, such as advertising, where brands are represented by human-like figures, often animals, that may speak, dance, and perform (think Tony the Tiger, for a cereal brand). The non-human entity need not always be an animal; the Michelin Man, made of stacked tires is an example. Another example of rampant anthropomorphism is in children’s literature, which is filled with non-human entities, again often animals, with human characteristics.

With anthropomorphism such a widespread phenomenon, when does it become pathological? Can it be anything but abnormal when a patient ascribes malevolent behavior to a piece of metal with batteries and electrical wiring? And must it not be pathological when they demand the removal of this inanimate device which keeps them alive?

Repeated rational arguments with my patient fell on deaf ears. Life was intolerable with this “malevolent”  —  the description never changed  —  entity controlling their life. Recommendations for psychological therapy were rejected. Pharmacological treatment was dismissed out of hand. To the patient, removal of the device was the only solution. To me, and the physician who actually implanted it, this was an unacceptable solution.

Finally, at some point in our meetings, the patient issued a vaguely worded statement that amounted to, “I’ll take care of it myself.” They didn’t contact or visit me again. And some time later, I learned that they had died in a remote location.

I suspect they had, indeed, taken care of it themself.