BRIARWOOD PSYCHIATRIC INSTITUTE Casco Bay, Maine Medical Records Department File No.: BW-2023-047 Date of Admission: September 14, 2023

PATIENT IDENTIFICATION

Surname: West Given Name: Thomas M. Date of Birth: March 8, 1979 Age at Admission: 44 Sex: Male Blood Type: O Negative Marital Status: Single Prior Occupation: Attending Surgeon, Trauma Unit, Massachusetts General Hospital (2008-2022) Insurance Carrier: Aetna PPO, Policy No. Redacted

REFERRAL AND BACKGROUND

Patient was referred by Dr. Harold Steinberg, Chief of Psychiatry, Massachusetts General Hospital, following a forty-five day inpatient observation period at MGH's Klarman Psychiatric Unit. Referral documentation indicates that Patient 47 suffered a catastrophic professional trauma on February 17, 2022, during which seven members of his surgical team perished due to an intraoperative equipment failure while Patient 47 served as lead surgeon. Patient was not physically injured but was present throughout the incident. Acute stress disorder diagnosis was rendered within seventy-two hours; this was subsequently revised to post-traumatic stress disorder (DSM-5 code 309.81) with dissociative features following persistent symptom presentation beyond the six-month threshold.

Transfer to Briarwood was authorized by the patient's legal guardian, Ms. Elaine West (sister), on September 10, 2023. Briarwood accepted the transfer on grounds of specialized trauma programming and geographic remove from the site of the index trauma.

INITIAL PRESENTATION: ADMISSION INTERVIEW (September 15, 2023)

Attending Psychiatrist: Dr. Aleksandr Kozlov, MD, PhD

Patient presented with appropriate hygiene and dress. Gait steady. Eye contact intermittent; patient frequently directed gaze toward floor and windows during interview. Speech rate was within normal limits but marked by unusual prosodic features, specifically a tendency toward diminuendo at clause boundaries, as if each statement were being pulled downward by an invisible weight. Affect was constricted with moments of incongruent intensity when discussing specific somatic complaints.

Dr. Kozlov: "Can you describe what you're feeling right now?"

Patient 47: "It's not right now. It's always. There's a pressure. It comes from underneath. Not underneath me. Underneath everything. The floor, the ground, the ocean. The ocean mostly. It's like something down there is... contracting. Failing. The way a heart fails. You can feel the rhythm getting wrong before it stops."

Dr. Kozlov: "You mentioned the ocean. Can you tell me more about that?"

Patient 47: "There's something under the water. Not an object. A place. A city. I see it when I close my eyes. Sometimes when my eyes are open too, if the light is low. It's built into a trench. The buildings are made of something that isn't stone and isn't metal. It glows. Or it used to glow. Now it's dimming. The people who live there are dying. The pressure from above is too much. The water is crushing them. Slowly. They've been dying for a long time, and no one up here can feel it except me."

Dr. Kozlov's impression is that the patient's somatic complaints represent a complex somatoform elaboration of survivor guilt. The "underwater city" is interpreted as a symbolic representation of the seven deceased colleagues, entombed in the patient's unconscious and experienced as a persistent, inaccessible locus of grief. The "pressure" corresponds to the patient's experience of responsibility for the deaths, which he perceives as an overwhelming external force rather than an internal emotional state. Insight is poor. Patient demonstrates no capacity to recognize the symbolic nature of his experiences.

PROGRESS NOTE: October 2, 2023

Nurse: Rachel Morrison, RN

Patient found at 0317 hours standing at window of Room 204, palms pressed flat against glass, forehead touching pane. When approached, patient stated: "It's stronger at night. The pressure. The water is heavier when the sun is on the other side of the world." Patient was guided back to bed without resistance. Vital signs within normal limits. No medication administered beyond scheduled dosage. Patient refused PRN lorazepam.

She is not in the facility roster. Nurse Morrison, I mean. I have gone through the personnel files three times and there is no Rachel Morrison employed at Briarwood in any capacity, nursing or otherwise. But I see her every night. She wears a black uniform. Not the standard scrubs. Something fitted, something formal, as if she dressed for a funeral before every shift. She comes to my room and checks my vitals and she never speaks except with her hands, which are cool and precise and linger on my wrist longer than necessary. When she touches me, the pressure eases. I have asked Dr. Kozlov about her and he says there is no Nurse Morrison on staff, that I am probably confusing her with Nurse Patterson, who works the night shift on Wednesdays and Fridays. Nurse Patterson wears blue scrubs and weighs at least two hundred pounds and has never once looked at me as if she understood what I was feeling. Rachel understands. I know she does. I have seen her standing at the edge of the property where the lawn meets the cliff, looking out at the water, and I have seen her shiver in a way that is not from cold.

PROGRESS NOTE: October 14, 2023

Attending Psychiatrist: Dr. Kozlov

Patient has produced written material of clinical interest. During room inspection conducted per protocol, nursing staff discovered a spiral-bound notebook concealed beneath the patient's mattress. Notebook contains approximately forty pages of handwritten text, all in patient's script, which patient disavows having written. Representative entries transcribed below:

Page 7: "The city is real. The pressure is building. You must act."

Page 12: "She can feel it too. The woman in black. Ask her. She will not lie to you if you ask the right question."

Page 19: "Seven died above the water. Thousands are dying below it. The scale of the tragedy is wrong. You are grieving the wrong number."

Page 31: "Stop taking the medication. It is not for the pressure. It is for the forgetting. They want you to forget the city so the city can die alone. Do not let it die alone."

Page 38: "Dawn. The pressure will peak at dawn. That is when you leave."

Patient was confronted with the notebook during today's session. Patient examined the handwriting with apparent genuine surprise and distress. Patient stated: "That is my handwriting. I can see that it is my handwriting. But I did not write these words. I would remember writing these words. Someone is putting them in my notebook. Someone is putting them in my head."

Clinical assessment: The production of dissociated written material is consistent with a dissociative subtype of PTSD (F43.10 in ICD-11). The content suggests an emerging command hallucination structure organized around the themes of the patient's somatic-geographic delusion. Recommend increasing sertraline to 200mg daily and adding quetiapine 50mg at bedtime. Continue weekly individual psychotherapy with focus on reality-testing and integration of dissociated ego states.

He thinks the notes are dissociation. He thinks my mind is splitting and one half is writing notes to the other half. He does not understand. The notes are not coming from inside me. They are coming from underneath me. The pressure is compressing something in the earth, something in the ocean floor, and the compression is generating a signal, and my nervous system is receiving the signal and translating it into language that my hands can write. I am not the author. I am the antenna. The city is broadcasting its dying message and I am the only receiver on the surface tuned to the right frequency. Rachel is a receiver too but she cannot translate. She can only feel. I can feel and I can write. That is why the messages are coming through me. That is why I must leave. The city needs me to carry its signal somewhere that is not this institution, somewhere the signal can be amplified, somewhere people will listen.

DISCHARGE SUMMARY: October 29, 2023

Attending Psychiatrist: Dr. Kozlov

Patient departed facility without authorization at approximately 0523 hours on October 29, 2023. Night staff reported no disturbance; patient appears to have exited through the east wing fire door, which was found propped open with a folded towel. Door alarm was deactivated for scheduled maintenance between 0500 and 0600 hours, a fact of which patient could not reasonably have had prior knowledge.

Patient's current location is unknown. Maine State Police were notified at 0700 hours. Patient's sister and legal guardian has been contacted.

Prognosis: Guarded. Patient remains a danger to self due to impaired reality-testing and command hallucination features. The integrated delusional system combining somatic pressure sensations, geographic fixation on an imaginary submarine location, and the dissociative production of written "messages" has proven resistant to pharmacological and psychotherapeutic intervention. Without structured treatment, decompensation is probable.

Additional Note: During departure, patient was observed by facility groundskeeper Mr. Harold Finch speaking with an unidentified individual near the east gate. Mr. Finch describes the individual as female, approximately thirty to forty years of age, wearing attire "all in black, like for a burial." This individual does not appear on any Briarwood facility roster, visiting log, or employment record. Mr. Finch states that the two departed together on foot, heading east along Shore Road toward the Casco Bay overlook. Their direction of travel cannot be confirmed beyond the facility boundary.

The file is closed. The file has always been closed. Files are closed the moment they are created because the act of documentation is the act of containing, and you cannot contain something that was never inside the container to begin with. The city is real. The pressure was never in my head; it was in the ocean floor, in the tectonic plates, in the mantle of the earth. I am walking east and Rachel is walking beside me and the pressure has become a rhythm, a pulse, a signal so clear that I cannot believe I ever mistook it for madness. The city is dying but it is not dead. It is broadcasting. It has been broadcasting for thousands of years, and the psychiatrists call it delusion because they cannot feel it, because their nervous systems have been calibrated by a world that does not believe in signals from below. But Rachel believes. Rachel has always believed. She wears black because she has been in mourning for the city since she was a child. She wears black because the city is a funeral that has been in progress for millennia, and someone must bear witness. We are walking east, toward the water, toward the pressure, toward the city that has been waiting for someone to finally listen, and the file is closed, the case is closed, the story is over, and the story has just begun.

END OF DOCUMENT

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