When Victor Henriksen's FBI unit finally caught up with John Winchester, they weren't exactly stunned he took the coward's way out – or the madman's, from a certain perspective. Winchester was implicated in well over two dozen distinct felonies, starting with grave desecrations and working all the way up to a trio of bizarre, ritualistic murders. And that was just the crimes they could pin on him. Once they caught him, he was never going to breathe free air again, whether he was rotting in a Supermax or stuck in a secure loony bin. They surrounded his ramshackle cabin and shouted through bullhorns that he should give himself up, but they didn't much care whether he did or not. A trial would be nice, but stopping this guy would be a job well done, no matter how it went down.
Their criminal profiler had assured them that Winchester had some capacity for rational thought, but his behavior was erratic and the notes they scrounged from his abandoned lairs were frankly delusional. All in all, this was a guy who was going down, one way or another, who didn't exactly have all his marbles to begin with. So, yeah, when John Winchester put a pistol in his mouth and pulled the trigger, Henriksen felt a lot of different things, but shock wasn't one of them.
After the gunshot, it was perfectly quiet as the agents slowly approached the cabin. Henriksen put his hand on the door handle and took a deep breath. Gory scenes were a part of the job; if he prepared himself, the mess inside wouldn't throw him for a loop. He tested the door, knocked, and waited, following procedure to the letter, before he pulled it open and looked inside the decaying room, his eyes ready for the bits of skull and face he would find splattered around.
He wasn't surprised by the blood splatter. He wasn't surprised by the pages of rambling theories tacked to the walls. He wasn't surprised by the stockpile of weapons. But Henriksen was standing in the doorway, mouth hanging open in shock. He hadn't expected to see two children, filthy and silent, crouching on the floor in a ring of salt and staring up at him.
The boys were placed in foster care, names changed from Winchester to Campbell in hopes they would be able to have some sort of normal life. Everyone watched and waited, wondering how badly their minds had been damaged by their father's delusions. They clung to each other. They hoarded food. They were paranoid, especially the older boy – Dean – who was clearly his younger brother's self-appointed protector.
Dean had a hard time assimilating to school and the regular community. He got into fights and he mouthed off to his teachers. He drank, he smoked pot, and he had a panicked pregnancy scare with his girlfriend when he was sixteen. But he pulled it together. He graduated from high school with a vo-tech diploma, got a job as a mechanic, and adopted his younger brother. It turned out that responsibility was good for Dean. Once he and his brother moved into their own little apartment, Dean paid the bills, cooked, cleaned, and basically demonstrated that he was a competent adult.
The younger boy, Sammy, had always seemed more resilient than Dean. He made friends and did well in school. If he had a tendency to brood, it only made teachers dote on him. He wasn't popular, but he wasn't rejected either, and he made first string in J.V. soccer. He had aspirations of becoming a lawyer and his SATs showed he was up to the task. Everybody was looking forward to Sammy's graduation, to their little success story all grown up and off to college. But in Sammy's senior year, things began to…well, they say schizophrenia runs in families.
Dean stumbled into the kitchen, still half-awake post-shower. Sam was reading the newspaper, scissors in hand to cut out "important" articles. Dean snatched the sports section away before Sam could start snipping at it.
"Did you take your meds?"
Sam didn't look up from the paper. "I'm not five, Dean. I can manage my own medication."
Dean sighed. "You didn't answer me."
"I'll take them after breakfast. If I take the propranolol on an empty stomach, I get nauseous."
"Then eat a piece of toast now. I've got to get going. They need me at the garage early today."
Sam started cutting out an advertisement for vinyl siding. "I'm not hungry yet."
Dean rolled his eyes. Why did they have to go through this every fucking morning? "Sam, you gotta take your meds."
"I will. Later."
"No, now. Before I go. I have to see you take them."
"Come on, Sammy. When you got out last time, you promised the docs you would let me keep track of your meds. You promised."
Sam said nothing. He managed to keep glaring while opening his mouth and sticking out his tongue.
"Thank you," said Dean. He opened up the morning slot on the pillminder and handed it to his brother along with a glass of water. After Sam swallowed, Dean said, "Tongue."
Sam obediently raised his tongue and moved it to the left and right, eyes narrowed all the while. He obviously hated this little ritual, obviously found it humiliating, but Dean was confident the alternative was worse.
"All right," said Dean, "done with that. You don't have anything on your schedule today, so just relax, okay? I'll be back at the normal time." He sniffed the air. "Maybe try to take a shower, huh?"
Five years ago
"Dean," said Alice, the owner's wife, "phone for you. It's your brother's school."
Dean wiped off as much grease as he could before taking the receiver.
"Mr. Campbell?" said the voice from the other end. Dean recognized it as the vice-principal. "There's been…an incident. Your brother is on his way to the hospital right now."
Dean felt his blood run cold. "An 'incident'? What happened? Is he hurt?"
"He's not hurt. It was a behavioral incident."
"Behavioral? Sammy doesn't get in trouble."
"He's not in trouble. He's sick. I can't tell you exactly what the problem is – that's for the doctors – but I can tell you that he's been acting oddly at school, turning in assignments that make no sense, carrying half a dozen rosaries everywhere, talking to himself. Today he took a bucket of road salt from one of the doors and hid in the space under the stairwell. He was screaming and throwing salt at anyone who got close."
"He's not crazy," said Dean. "He's not. He's just, you know, the stress of senior year. He's got all his college applications and stuff." They had escaped their father's curse. Sam was almost to the finish line. He wasn't going to trip up now.
"Whatever it is," said the vice-principal, unconvinced, "you probably want to meet them at the hospital."
It wasn't until Dean was waiting in line for his stupid visitor's pass that he wondered how on earth they were going to pay for all this.
By the time Dean got home, Sam still hadn't showered, but he had printed out at least a hundred pages of internet news articles that had very little to do with one another. The articles were mostly spread across the floor, though some were grouped into piles with the previous days' "research." Dean grimaced. On the one hand, toner was expensive. Maybe he should start taking the printer cable with him to work again. On the other hand, at least this crap kept Sam out of trouble. The real solution would be to get Sam out into the community because the longer he spent alone, the weirder he got, but Sam didn't really want to socialize and the community didn't really want to welcome a crazy person into their ranks.
Case in point:
"Steve is planning on ordering the match on pay-per-view tomorrow night," said Dean. "A bunch of guys from the garage are going over there to watch it. We could go."
Sam shook his head. "I don't want to. Too many people." He glanced to the left before adding, "You go."
"Steve said you were welcome to come."
"No, he didn't."
Dean shoveled another forkful of pasta into his mouth. Sam was right, basically. Steve hadn't even invited Sam initially, and when Dean had asked, the guy had hesitated for a long while before finally extending a half-hearted invitation. The guys at the garage tried to be nice to Sam for Dean's sake, but they couldn't help being wary and awkward.
"You know what?" asked Dean. "I'm not into boxing anymore anyways. Why don't we have Cas over and rent a movie?"
"You're a grown-up," said Sam. "Do whatever you want." He turned his head to the left and winced, before rubbing his ear.
Dean furrowed his brow. "You hearing something?"
Sam put on a serene, cryptic smile. "Everything I hear is real."
Five years ago
Chief complaint: "I have to stop the witnesses. I have to stop the apocalypse."
History of the present illness: Patient is a 18YO WM brought to the ER from school via ambulance. School report approx. 3 month prodrome of decreased academic and social function, poor hygiene, and odd behavior. When psychotic break was florid, pt expressed belief that hostile ghosts were coming for him and believed salt would act as defense. When evaluated in psychiatric ER unit, pt expressed belief that the ghosts were "witnesses" to his bad behaviors and were somehow related to the apocalypse.
Personal history: Abuse in family of origin, lived in foster care from ages 7 – 15. Denies hx of alcohol or drug abuse. Prior to prodrome, excellent school performance, normal psychosocial function. Lives with brother. Parents deceased.
Family history: Undiagnosed psychotic illness in pt's father.
Mental Status Exam: Hygiene is poor. Patient is malodorous. Gait is normal. Patient is pacing. Posture is hunched. Alert and oriented x3. Speech is fluent and free of paraphasia. Mild increase in rate and pressure. Thought is disorganized. Perseveration on topics of ghosts and the apocalypse. Affect is fearful. Mood is, "How do you think I am? I have to stop the goddamn apocalypse!" With regard to symptoms of major depression, the patient endorses insomnia, delusional negative self-cognitions, and anhedonia. Suicidal ideation is weakly endorsed, with no current plan. Homicidal ideation is present only for "ghosts". With regard to anxiety, the patient is hypervigilant. With regard to psychotic symptoms, the patient endorses both visual and auditory hallucinations. He is paranoid. He has delusions that he plays a significant role in some sort of religious ghost battle. Insight is absent. Judgment is poor.
Psychotic Disorder NOS
R/O Schizophrenia, Paranoid Type
R/O Schizoaffective Disorder
R/O Bipolar I Disorder with Psychotic Features, most recent episode Mixed
Lawrence Ebling, PhD
Dean finished reading the report and set it down on the table in front of him. He didn't say anything.
The doctor tented his fingers. "This can be a lot to take in," he said.
"It's got to be one of those things?" Dean pointed to the diagnosis list. "It couldn't be something else? Like, I don't know, drugs?"
"We ran a tox screen," said Dr. Ebling. "It was negative."
"There aren't…there aren't cures for any of those things, are there?"
"No, there aren't. But there are treatments. Good ones, much better than what you may have seen in movies."
"He's not crazy," said Dean. "He's a good kid."
"I don't know about crazy, but your brother's episode is fairly classic for paranoid schizophrenia. But I'm going to do the both of you a favor and diagnose him with an adjustment disorder and you're going to go out and get him health insurance."
Dean looked confused. Health insurance he bought now wouldn't cover the ambulance or the hospital stay.
Ebling had apparently led family members through this before. "He needs health insurance because this will happen again."
Sam was sitting on their ratty sofa, staring to the left, silent and still.
"Sammy," said Dean. When Sam didn't respond, Dean repeated himself in a stern tone. "Sammy! Hey!" Dean snapped his fingers. "Come on."
Sam closed his eyes and shook his head before answering. "What?"
"The drawer where I keep my gun. Somebody opened it." Dean had been advised more than once to get rid of the gun, but he just hadn't been able to bring himself to do it. Yes, he was supposed to be the sane brother, but he had be raised paranoid and pardon him if he couldn't quite shake it.
Sam said nothing.
"What were you messing around with my gun for?"
"You made me get rid of mine." Sam sounded a little bitter.
"Yeah," Dean snorted, "for a reason."
"I wasn't going to do anything, Dean. He just wanted to look at it."
"Who wanted to look at it?" asked Dean. After five years, he was used to the verbal contortions required to have a conversation with Sam.
Sam looked up at his brother, face more vulnerable than his enormous frame should have allowed. He pursed his lips for a moment before answering: "Lucifer."
I wrote the mental status exam fairly close to what you would actually see in a hospital. Here are some terms people might not know:
Pt – patient
Prodrome – the time immediately before an individual has a first psychotic break, usually characterized by worsening social, occupational, and personal function.
Paraphasia – word errors in speech, such as 'took' for 'look' or 'towel' for 'rag'.
Anhedonia – an inability to experience pleasure.