Case 1605: The Delusions of Patient Quixano

Case 1605: The Delusions of Patient Quixano

 

This study (in progress) analyzes Alonso Quixano, a man who was brought to our facility after traversing the country, believing himself to be a knight errant. Quixano seemed to be suffering from a psychotic break; his madness had blurred the lines between reality and fantasy. Symptoms include delusions of chivalry, enchantment, and magic. Quixano also described situations that can only be classified as hallucinations. His friends and family believe that this dysregulation was caused by obsessive reading of chivalric books; the ideas in the texts have infiltrated his reality.1 His personality is polite, intelligent, and at times paranoid. Upon intake, patient appeared to be in his fifties, though his birth year is unknown. Quixano is of Spanish descent. Patient arrived in full armor; physical restraint was necessary in the removal of his gear. Quixano appeared to be dirty, thin, and not clean shaven. Quixano was missing multiple teeth. He had numerous injuries and was covered in bruises; these appeared to be obtained through many brawls and fights.

Quixano meets many of the DSM-5 criteria for schizophrenia; though a sure diagnosis cannot be made without ruling out schizoaffective disorder, bipolar disorder with psychotic features, and autism. Quixano’s presentation of schizophrenia-like symptoms are especially interesting when speaking to him; his intelligence and true confusion are both very acute. At some points, his disorganization and incoherence is shocking, at other times, it may simply be a part of his delusion that he is a knight errant: he makes sense within his own reality, but not outside of it. He does not show social difficulties or apathy that are typical of patients with schizophrenia. In fact, he is preoccupied with favorable values, like honor; he is enthusiastic to help the people around him. Surprisingly, he believes this to be his responsibility. Quixano’s institutionalization was necessary; many of his delusions put him in dangerous situations and he was found to be a threat to himself. Treatment will include individual therapy to regulate thought patterns and delusions. Cognitive-behavioral therapy and some psychoanalytic techniques will be helpful in creating a trusting relationship between Quixano and his clinician to further understand his symptomology and origins of his disorder. With talk therapy and possible medication (pending a confirmed diagnosis), Quixano’s recovery and stability is possible.

The first portion of the patient’s treatment will begin with a close interpretation of some of his dreams. Importantly, he does not acknowledge them as dreams. He sees these visions as reality. He admits that reality looks different here, attributing all inconsistencies to “enchantments,” yet he still believes his dream occurrences to be real. In analyzing these moments, it is hoped that a deeper understanding of Quixano’s desires and values can be obtained. This dream analysis will open a line of communication to Quixano’s subconscious wishes and thinkings, once this is understood, it may be possible to unravel these ideas to their core. Then they can be challenged.

A difficulty with Quixano, and many patients with schizophrenia-like symptoms, is communicating with them that their reality is not as others see it. Quixano has constructed an explanation that, in his mind, cannot be challenged. He understands that these fantasies are not realistic, that is why he labels them as “enchantments.” In doing so, there is no way a clinician can convince him otherwise.

For a more detailed history, refer to Quixano’s case history. A full transcription of Quixano recounting the following dream can be found in chapter 23 of this history. Quixano told his team of a particularly compelling “adventure” that began with his falling asleep in the famous Cave of Montesinos (this is a real cave where an episode in a famous, and fictional, Spanish chivalric book takes place). When he believed he had awakened, he found himself in a new land of meadows and castles. An older gentleman approached Quixano and the old man, named Montesinos, explained that he had been placed under an enchantment. After his cousin Durandarte (a knight) died, Montesinos had been tasked with cutting Durandarte’s heart and taking it  to Durandarte’s wife. This was all at the request of Durandarte. Since then, an enchanter known as Merlin had trapped Montesinos and Durandante’s wife  inside the cave, along with others. Merlin’s motive for this punishment was unknown. Montesinos told Quixano that Quixano had been long awaited; the characters trapped in the cave seemed to think that Quixano’s alter ego as a knight would be able to free them from their enchantment. It is also notable that Quixano recognized “Dulcinea” in the meadow he woke up in. Dulcinea is a manifestation of Quixano’s delusional desire for love; he sees her “in her enchantment,” looking like a peasant girl, though in his reality, he believes that she is royal, beautiful, wealthy and honorable. Within this delusion, he sees her not in her “true form”–in her supposed royal form– because of a trick that was played on him. He has no knowledge of foul play; he truly believes this peasant girl is Dulcinea.

There are numerous themes throughout this dream, many of which align with Freud’s idea that dreams act as wish fulfillment. From this point on, while I am exploring Quixano’s relationship with his dream, I will engage with his delusions and use his language so that our communication may continue more productively.

There is also a great deal of day residue that can be found within his dreams. Day residue refers to the details of a dream that have no symbolic significance, they have simply been a part of waking life recently, because of this, they linger on the subconscious brain and can appear in dreams. Interestingly, this seems to be the case for Quixano’s general fixation on knight errantry. His deep reading of this genre has, in the opinion of his family, encouraged, even caused, the delusion. They believe such intense reading has interspersed his reality with the fantasies of literature.

Day residue is a major influence in the details of all dreams. His interest in visiting the cave itself can be explained by his reading a book of chivalry set there. With such a fascination with this genre of literature, and being physically, in real life, in the cave that the story occurs in, it is no wonder the characters from this book manifested into his dreams. Yet, his position in relation to these characters is astounding: Why not dream himself as a spectator, or as Montesinos? No, Quixano imagines himself to be the hero of the story;  his dream self presents as his alter ego, Don Quixote the knight. I will refer back to this point shortly.

I began today’s session asking Quixano what he was feeling during this “adventure.” This was a pleasant dream for him. He says it was “the sweetest and most delightful existence and spectacle that ever human being enjoyed or beheld.”2 We talked through the events of the dream, in a moment by moment assessment, considering the emotions the patient felt. In a typical dream analysis session, the clinician may follow this practice with a question like, “Where in your waking life do you feel these emotions?” Of course, Quixano’s situation is very special: He is unable to acknowledge this dream as being a dream. I cannot ask him questions of that sort, if I do not play along, I risk losing the openness of our conversation. Eventually, if we deconstruct enough of his delusions, my goal is that Quixano will reach this conclusion on his own. Thus, I continue. During our moment by moment assessment, instead I ask of each event in the dream, “Why did this make you feel such an emotion?”

Some of these answers are easy. He felt pleasure waking up in the meadow, for it was “the most beautiful, delightful meadow that nature could produce or the most lively human imagination conceive.”3 He felt interested and engaged while observing Montesinos and Durandarte, describing himself “gazing at the tomb in amazement.”4 He felt eager and pleased to meet such famous characters; he felt satisfied to be able to ask them if their tale was true. Most notably, he felt honored and special that it was he who was meant to save them from their enchantment.

I asked him if he had any negative feelings during his “adventure.” He began recounting the grief and empathy he felt for those inside the cave. Montesinos was “ill-fated,” Durandarte was “sore-wounded,” Belema (Durandarte’s wife) was “unhappy,” and so forth.5 Quixano’s expressions of compassion were clear and reassuring here. His sadness for the characters only further compelled Quixano to be brave and just on their behalf. He continued, saying he was also disturbed when Montesinos, in his explanation of Belerma’s grief, compared her to Quixano’s Dulcinea. Why was this so upsetting to him? Quixano explained that, as a knight, it is necessary for him to honor his woman before all else. He admitted that all his actions are done in her name; she is the object of his affections, and she is the reason he cares about justice, courage, honor. I asked, “But how did Montesinos offend Dulcinea?” Quixano explained that Dulcinea’s beauty, regality, and loveliness cannot be compared to anything, much less a woman as unhappy and unattractive as Belerma. I asked why not. Quixano became distressed at this point in our conversation; he said that it is a chivalric order. She is the perfect woman. She is his life, his inspiration. She cannot be compared to anything remotely negative. She cannot be offended in any way. A great love, he explained, is the reason for any knight to act as he does. A knight is nothing without love. At this point and still now, I am not completely certain how she has been offended, or why he is so sensitive to criticism on her behalf, but I sensed his distrust and move forward.

Next, I asked him why he believes it is his responsibility to free these characters from their cave. Keep in mind that Quixano speaks of himself as Don Quixote; I have not yet deconstructed his idea that he is a knight. He answers simply; it is his responsibility to free Montesinos and his comrades from the cave because he is a knight. When I asked him to continue, he referred back to the chivalric code of the knights-errant. He explained to me his duties to his fellow countrymen, to God, and to Dulcinea. He must be brave. He must be just. He must serve with the intent to protect and help. He must be faithful. “Why must you do these things?” I ask. Because he is a knight. “Why are you a knight?” I ask “How did you assume this role?” He seemed to not have an answer at first. After thinking for a moment, he responded: “What else would I be?”

 

Brief Overview of Symbolism in Quixano’s Dream

 

  • The knight represents self-sacrifice, bravery, loyalty, efficiency. This is how Quixano views himself in his dream. It is his responsibility to be the hero, to exercise his bravery and loyalty.
  • The damsel represents vulnerability; something in need of protection and rescue. This symbol can be extended to Montesinos and Durandante, though not the typical presentation of a damsel, they are characters in Quixano’s dream that need his help. Again, this represents Quixano’s desire to be needed, to have a purpose.
  • The cave represents something safe, hidden; something that must be explored or revealed. This dream is an opportunity for Quixano to “confirm” what he already believes is true. Here, in the cave, he is actually able to confront characters from real chivralic stories and establish their truth. This is the first thing he does upon meeting Montesinos. He makes sure that the stories published about Montesinos are true. In the cave, he is safe to explore his literature from inside it; he quite literally is able to reveal that his fantasy is actually reality. In another interpretation, The cave does not need to be considered symbolically; it is likely day residue from the story he was thinking about.
    • A dead body (Durandarte) as a representation of potential that has not been expressed in waking life. Perhaps Quixano feels inadequate in his knight-errantry, or his real life from before his “adventures.” However, Durandante’s body may  not need to be considered symbolically; it is likely day residue from the story Quixano was thinking about.
  • A dismemberment is something that being torn apart (in Durandante’s case, ripped out, and represents emotional distress. Pulling things (an organ, a heart) out of a body  represents something new that is being obtained, typically thoughts and feelings. This may represent conflict between Quixano and Don Quixote, or any tension between a subconscious that wishes to be left alone in fantasy, and aspects of reality that haunt them both. Again, it’s also possible that Durandante’s dismemberment does not need to be considered symbolically; it is likely day residue from the story he was thinking about.
  • The heart represents how one loves; injury to the heart represents emotional hurt. This may relate to Quixano’s repeated proclamations of love for Dulcinea, and his ongoing devotion. However, Quixano seems genuinely distraught that he cannot see her. Even when he does get an opportunity to see her, she appears only to him in her enchanted form. This is painful for him. Or, once again, Durandante’s heart may merely be residue from the story he was thinking about.
  • The subject of general “enchantment” and magic is open to an array of interpretations. In my opinion, any sort of enchantment that Quixano encounters is simply wish fulfillment: this excuses any breaks from reality, and allows him to continue on his quests without any thought.

Though many of his symptoms present as schizophrenia, my team has doubts of such a diagnosis. This delusion is likely caused by boredom and dissatisfaction. This does not mean it is a conscious decision; we believe Quixano truly believes himself to be this Don Quixote. His self-appointed role of knight errant is a coping mechanism that allows him to explain his want for purpose and honor. Quixano, as a mere man, does not satisfy his desire for order, for respect, for adventure. So that he is not shameful or fearful, Quixano is deluded into thinking these desires come from his identity as a knight. This is easier for him to understand. To want purpose, love, honor—and to do anything to achieve this—is more respectable for Don Quixote than it is for Quixano. I believe Quixano is, on some level, aware of this. I believe his delusions are not all-possessing. I believe he has moments of sanity, and moments where his delusions can be reasoned with. Having said this, I think Quixano’s continued institutionalization will be helpful in his regaining of reality. With scheduled talk therapy and treatment, I believe Quixano’s recovery may soon be a part of his story.

Meanwhile, my team will continue to study Quixano  thoughtfully and closely.

  1. Upon intake, I spoke to members from Quixano’s community. I spoke to his loyal friend, Sancho Panza, who enabled these delusions entirely. Panza believed Quixano to be a true knight, and believed himself to be a squire. Speaking to Panza was useful in obtaining a full history on Quixano. Members of his family, his niece and housekeepers were also necessary in constructing Quixano’s full history. Patient was brought in by Sampson Carrasco, a neighbor.
  2. Miguel de Cervantes, Don Quixote (Translated by Edith Grossman (Harper Collins, 2003), 984.
  3. Cervantes, Don Quixote, 986.
  4. Cervantes, Don Quixote, 988.
  5. Cervantes, 984.
 
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