This post is part two in a series. Part one is titled "Treating the Seriously Mentally Ill."

I was called to evaluate Dorothy after she had been admitted to the ward from the ER, where her family had brought her. She stated, “These eyes have seen evil.” She believed that she needed to be punished and that if she did not succeed in pulling out her eyes then terrible catastrophes would prevail in the world—"wars, floods, plagues.”

She quoted, “For if your right eye causes you to sin, gouge it out and throw it away.” The rest of the quotation continues, “It is better for you to lose one part of your body than for your whole body to be thrown into hell.”

The loss of touch with reality signaled that she didn’t just have major depression but that she had major depression with psychosis. In psychotic depression, the idea of being responsible for evil is not uncommon. What starts as feelings of guilt with ruminations on past failures takes on an all-encompassing structure; the mind reaches into dark crevices to pull forth a transgression from long ago, connecting it to current anxieties. I sat with her and tried to connect with her but she was too agitated to engage. She was placed in a seclusion room in restraints for her own protection but there was no guarantee that she wouldn’t get out of restraints and go for her eyes. Because of the extreme danger to her health and well-being with the specter of enucleation hanging over her, we decided we needed to take........

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