Part 1

Alice was sitting in an emerald-coloured armchair in front of a fireplace that gently crackled. She knitted using two silver needles attached to a thread which unfurled from a purple ball of yarn. Alice was a lady in her sixties, with neatly trimmed short grey hair, dressed in a flowery nighty and a beige cardigan. Her slight frame barely filled the armchair. She faced the fire and the warm glow lit up her pale complexion. She stopped knitting, her melancholy blue eyes looked toward a wooden table, and she laid the needles down with tremulous hands. As she picked up her teacup, the rattle of ceramic on ceramic echoed throughout the living room. Alice took a sip and let out a sigh. 

She resumed her knitting and melted into her seat. Despite Alice’s age, her fingers hadn’t lost their dexterity. Years of handling fragile fragments and forgotten things had given her a nimble touch. She thought back to her time living in the English town of Bath many years ago. A time when she was young. A time when she was a bold, brave, and daring woman who travelled the world uncovering the buried secrets of the past. Her mother had always told her it was a career that only foolish people pursued. Why would anyone want to spend their time dusting old vases in strange remote locations? Well, that was all Alice had ever wanted to do, to discover, to learn and explore. She always came home with wild stories to share with her brothers and sisters, stories about her adventure-filled expeditions. Alice recalled a strange expedition she had taken to the spiritual and colourful land of India. 

The expedition began in the 1980s in India in the state of Uttar Pradesh. The team aimed to dig deeper and further than ever before in the City of Elephants, Hastinapur. It was a legendary city with direct mentions in both the Mahabharata and the Ramayana, yet it continued to have modern day inhabitants. Three archaeological digs had already uncovered important historical findings from early settlers. They had found vast beautiful artwork and rich lengthy works of writing. However, they withdrew from an expedition of what they believed to be a temple. As a young archaeologist wanting to make a name for herself, Alice had convinced her team that this expedition would be one for the history books. 

Alice was standing over an aged map, which was spread out onto a wooden surface. An excited audience surrounded her, and she was the majestic performer. With a wave of her hand here and a point of her finger there, she explained the expedition plans as if she was a conductor leading an orchestra. "And that is how we will uncover the dome of the temple and make our way in. Questions?"

There was silence in the room. Alice smiled. She was finally going to uncover something big. A deafening uproar filled the room as Alice's colleagues whooped and applauded. She made eye contact with a young Indian woman who looked no older than eighteen. The young woman looked back with light brown eyes and played with her long-braided hair. "Kairavi, let's get the camels packed and ready to head to the expedition site. We have ten minutes if we want to stick to schedule," said Alice.

Kairavi nodded. Her sky blue lengha twirled in the air as she turned away, heading towards the encampment. Alice followed her shortly after and began preparing her camel for the trek.

Kairavi spoke in Hindi to a small group of Indian men and women who sped up their preparations. She grinned as she approached Alice. "Thank you so much Ma'am, they will be ready in very few minutes." Her English wasn't perfect, but she was always grateful whenever she could practice it. As a youth, she had spent all her free time studying English and could not believe her hard work had paid off. She received very little for her work, but to Kairavi, the money was gold dust. They rounded up the team and began their trek to the excavation site. 

The air in the excavation site filled with a low rumble. In the distance, around 30 individuals rode on camelback towards the site. Alice pulled up to the stables, and a middle-aged Indian man helped her off her camel. The early afternoon sky dazzled her eyes and scorched her skin. She took a breath and coughed as the humid dirt-filled air irritated her lungs. Alice covered her mouth with a loose scarf that was tied around her neck, then looked proudly outward as she saw the progress that her team was making. 

There were several large vehicles with various attachments; some drilled, some scooped, and some pushed. There were hundreds of residents removing excess dirt with shovels and wheelbarrows. At the centre of the excavation site, a dome-like shape was taking form. The time. The travel. The money. It was all coming together for Alice. Since she was a little girl, Alice had looked up to the great explorers of the world. She often fantasised about joining them by making a discovery herself. All she wanted was to see her name up in the stars Alice Hargreaves: a discovery that will astonish the world, she thought to herself, looking up into the clouds. Imagining the eventual recognition of the British Museum for her work filled her with a childlike glee.

As Alice looked onto the excavation site, a sizeable amount of dirt fell from the top of the dome, revealing a large piece of artwork painted on the side. Alice grabbed her binoculars. She could see a painting of a muscular humanoid shape with dark grey skin and red eyes. He had six arms which were covered in a dark fiery aura, and crimson garments wrapped around him. He appeared to be riding on top of a bull, or perhaps a buffalo. In his hands were various items, but Alice could only make out a mace with a spike protruding from its top in one hand and a noose made of rope in another. 

Despite the distance between her and the dome, Kairavi noticed the image instantly. She fell to her knees, brought both hands together to pray "Om Yamaya Namaha." Kairavi tightly shut her eyes. All around the excavation site, there was a building chorus of chanting. People stopped in their tracks and fell to their knees, all reciting the same three words. Alice looked around and raised an eyebrow. Her Sanskrit wasn't the strongest, but she did recognise one word. Her mouth gaped open as the chanting rose to a crescendo. She fixed her eyes on the painting and glaring red eyes stared back. The eyes of the deity of death. Yamaraj.

With a sudden jolt, Alice was back in front of the fireplace. Lost in her thoughts, she had let out an unintentional screech. That was when Alice saw it again. Fiery black hands rose from the ground. The hands wrapped around her ankles. No. Not again, thought Alice, as she looked at her feet. The smell of smoke filled the air and the hands gripped tighter. "It's happening again!" yelled Alice. She got up, her heart pounding in her chest, her head spinning, her breathing fast and shallow. She felt the warm hands now grip around her arms and wrap around her body. Each dark, flaming hand pulled her towards the ground. She felt heavier and heavier as a great pressure forced her down. The world blurred around her. Everything went dark, and Alice landed on the floor, eyes shut. 

Part 2

Alice was floating, lost somewhere in the clouds, no longer weighed down by gravity. She was free. She felt at peace and for a moment even felt joy as the soft fluffy clouds brushed past her. There was a knock at the door. The door handle turned. Alice tried to grab onto the clouds, yet she awakened from her dreamlike state. A brown-haired lady in a blue tunic popped in around the door and smiled. "Y'alright there lovely, I've got a cuppa tea here for you with a couple of biscuits," said the nurse in a Yorkshire accent. She looked at Alice with a kind smile. Alice looked around her room. She recognised this place immediately as MacArthur Hospital. The teal bed sheets meant she was on Peacock Ward. 

The nurse placed a cup of tea on a nearby table. "I see from your records you've been here before, but I ain't never met you. My name is Sarah. If you need anything at all, don't you hesitate to push that buzzer there and I'll come right away. Good night, Alice," said the nurse as she walked out the door and gently closed it behind her. Alice said nothing. She felt a fire burning in her belly, a fire of frustration. How many admissions does this make now? She had lost count. She closed her eyes. She wrapped herself in her blanket and held herself. She could feel her heartbeat racing. Every second of the clock ticking boomed in her ears. She closed her eyes more tightly and tried to imagine herself on the clouds again. 

There was a knock on the door, and Sarah walked in cheerfully holding some towels. "Morning Alice, shall we get you in the shower? Then I can change your bedsheets for you," asked Sarah. Alice nodded. She yawned and stretched her arms. It had been a tough night, filled with tossing and turning. Alice yawned again. She twisted herself on the bed and let her legs dangle towards the floor, then shuffled forward. As her feet touched the ground, she felt the all too familiar warmth. The fiery black hands clasped around her ankles once more. She shut her eyes, took a breath in, stood up, and took a step forward. The mental and physical strength to move one step forward was draining. An unbearable weight came over her, crushing her from above. The fiery black hands continued to pull. Alice collapsed onto her knees and began wailing. The force above her was a dark grey cloud and her tears were the pouring rain. 

A crowd of hospital staff soon surrounded Alice. They tried to lift her up from the floor, but they couldn't. Alice remained on her knees, silent and helpless. "Alice, you need to help us get you up," said one member of staff. They thought she was resisting. They didn't understand. She couldn't help them. Alice looked around the room, she could hear them talking about her. "I can't move because of the hands. They're everywhere. I can see them on my legs. They won't let me walk. They're pulling me down." Alice said frantically, her eyes darting around the room. A blonde-haired young man stepped forward and put his hand on Alice's shoulder. Soon, several other cold hands were on her arm and shoulder. She flinched and cried out. A lady walked toward her with a needle and syringe. She felt a pinch on her upper arm. A slight stinging sensation. A few moments later, her eyes felt heavy, and she lost herself in the endless abyss of her unconscious mind. 

A tall man dressed in blue scrubs and a white coat looked on from the doorway. He scratched his head and walked to another room. Sitting down in the doctor’s office, he looked up at a computer screen. He clicked on a tab, on the top left-hand side, titled ‘Progress Notes’. He typed. 

Background

Alice is a 62-year-old elderly Caucasian lady known to our services with a previous diagnosis of depression with psychotic features. This is usually well managed with olanzapine, risperidone and mirtazapine. She is a retired archaeologist who spent most of her career in India and has struggled with major depression since the 1980s. 

Current progress

She has now presented to us with low mood, hallucinations, and delusions. Her carer found Alice on the floor following an episode where she seemed to be hallucinating. Previous entries show she has a delusional belief that a Hindu God, Yamaraj, whose temple she discovered in the 1980s, is trying to ‘pull her down to the underworld’. Therefore, Alice believes she feels an extra weight or heaviness compared to others. Alice feels a burden of guilt relating to her British Museum exhibit. She believes she should not have taken these items out of India and so she is now being punished by Yamaraj. It is possible that this heaviness is a psychosomatic manifestation of her guilt. Her delusions could also be rationalisation for her catatonic symptoms. Perhaps there is some element of mobility disturbance secondary to her depression as well. She continues to have a poor diet with a minimal intake of food and water. Her sleep continues to be disturbed. 

Mental state examination

Alice is unkempt due to not being able to meet her own hygiene and toileting needs without support. Several members of staff are required to move Alice into the bathroom for showering and toileting. When trying to move Alice’s legs or arms, there is a strong resistance felt as Alice will not allow us to move her. She makes poor eye contact and does not easily build rapport. Her speech is clear, with normal rate and tone, but is often not coherent. Her mood is subjectively and objectively low, as evidenced by moments of tearfulness. Alice displays clear delusional thoughts and hallucinations. Alice does not appear to have any insight into her condition. 

Risk

Because of her current vulnerable state and high level of dependence on staff, there is a significant and imminent risk of harm to herself through self-neglect, but a low risk of harm to others and the community. Her low mood is a risk factor for suicidality, and this is something we will monitor for. 

Recommendations 

Our working diagnosis is a relapse of psychosis. We will arrange for a Mental Health Act assessment to have a Section 2 in place for Alice, as she currently lacks capacity. As Alice appears to be noncompliant and continues to display resistance to staff, we have increased her lorazepam. We believe that because of her current level of polypharmacy and current level of risk, it would be appropriate to consider her for a short course of electroconvulsive therapy.

The psychiatrist clicked save and shut down the computer. He hesitated and looked back at the screen. For a moment, in the reflection, he thought he had seen a face with dark grey skin and red eyes. Yet only his own reflection stared back at him.