“he said next time it happens, I’m out,” Pinny told me.

It was a story I’d heard many times before. Maybe the husband had a drinking problem, maybe he’d raised his hand, maybe he’d spent too much of his paycheck on the lottery. Whatever it was, he’d been warned.

But Pinny seemed like a regular, pleasant fellow: an Israeli avreich of 23 from a good family, with infant twins at home, learning in a prominent Jerusalem kollel.

A brief review of psychiatric symptoms showed that he didn’t have clinical depression, anxiety, or other issues beyond the stress of a challenging marriage. So why was he on such thin ice at home?

“My wife told me I’m a selfish, terrible husband, and that I need a psychiatrist — so here I am. But I’m telling you — I’m a regular guy,” Pinny said, pleading his case. “I really don’t know what I’m doing to make my wife constantly scream at me. At 3:00 a.m. she’ll wake me up to tell me that I need to work on my middos, and that even though she reads the whole sefer Tehillim each night it doesn’t do anything to help me be a better husband. And she does this crazy thing with her eyes — they look like they’re going to pop out of her head. What am I doing wrong?”

Well, I’d met my share of embattled couples, but I needed more information. Maybe Pinny wasn’t such a mensch after all, so I asked his permission to call his rosh kollel. In fact, it was Rav Levy who told Pinny to see me in the first place. He explained that Pinny was just a young avreich who was having shalom bayis problems after the birth of his twins. Rav Levy had sat with him, encouraged him to be a more present husband, to work on his middos, to daven for shalom bayis, and had given him a few practical and inspirational seforim to read. When none of this worked, and Pinny returned with a written demand from his wife that he see a psychiatrist, Rav Levy gave him my number, “just to be sure that he wasn’t as terrible as his wife made him sound.”

“I tried to speak with his wife,” Rav Levy told me, “but she was talking a mile-a-minute. I couldn’t get a word in, so I asked her to write me a message to send along with her husband. But even the letter was written with words crammed all over the page and many exclamation points. I can’t imagine what it’s like to be married to such a woman.”

I continued to file these pieces of information away. One thing was sure, I need to see his wife as well. I wasn’t sure how Pinny would react when I called to tell him this, but in fact he was ecstatic.

“That sounds great, Dr. Freedman, because I think she’s gonna kill me sooner or later, but, frankly, I’m nervous for the twins, so I haven’t left the house yet.”

I asked Pinny to clarify, and he proceeded to tell me about how she had woken him up at 3:30 a.m. after finishing her nightly Tehillim and was screaming at him to work on his avodas Hashem, then threw her sefer at him which gashed his forehead, and stormed out of the bedroom.

Pinny was in shock and did the only thing a sensible young man could do. He called his Ima, and, like a responsible savta, Pinny’s mother packed her bags and headed for his house to help out with the babies. In the meantime, his wife had locked herself in the bathroom and was refusing to go out until “Pinny was taken away for being such a terrible husband.”

I prepared myself for the explosion as Pinny and his wife came to my office later that day. Pinny looked exhausted and had a Band-Aid on top of the lump on his forehead. But it was his wife who drew my attention. The woman was disheveled, clearly hadn’t slept more than a few hours in the previous month, and was already talking up a storm before she walked in the door.

But it was her eyes that caught me. While I’d expected to meet a young woman with undiagnosed bipolar disorder right smack in the middle of a manic episode, I was humbly incorrect.

Pinny’s wife’s eyes did in fact look like they were going to pop out of her head. But there was a fancier word for this condition: exophthalmos. And, as I looked at this poor woman as she proceeded to scream at me about her husband’s middos and how happy she was that someone would finally listen to her, I put together her lack of sleep, the manic behaviors, her eye condition, and the fact that she was sweating profusely. Here was a woman with a classic case of Graves’ Disease and hyperthyroidism.

This was the kind of story our professors had told us about during the first year of medical school. I knew about how hypothyroidism mimics depression and how hyperthyroidism mimics mania — I’d diagnosed it myself over my years in the profession. And yet this was one of the most extreme versions I’d happened upon in my own clinical practice.

“Are you listening to me?” she continued to shout as poor Pinny sat paralyzed in his chair, steamrolled by her tirade.

“Absolutely Rebbetzin,” I answered. “But I have to tell you that I’m nervous about your eyes.”

“What? They’re just big because I’m angry. I’m fine, he’s the crazy one!”

I nodded in agreement to diffuse the tension. “But I’m nervous that you have a thyroid problem, Rebbetzin, one that’s making it hard to sleep and is damaging your eyes.”

“Damaging my eyes? It’s my heart I’m worried about, and he’s killing me by making me cry so hard! But now my eyes too?” she yelled hysterically.

I needed to formulate my next words carefully. Here was a woman with a medical condition that was causing serious psychiatric symptoms and was putting both herself and others at risk. One way or another, she needed to go to the hospital.

And yet calling an ambulance to take away a patient against her will was something I wanted to avoid. I knew I had to tread carefully.

“Rebbetzin, I’m concerned for your health—”

But she cut me off. “Me too! Just call me an ambulance already, and get me healthy before his terrible middos kill me! You know what, forget it, you two are both failures!” she shouted as she took out her phone. “Hello Hatzalah? Yes! Come pick me up immediately — my husband is crazy, and my eyes are exploding!”

I said a silent tefillah as the Hatzalah volunteers came and took an agitated-but-willing woman to the emergency room. Pinny’s rebbetzin was headed down the right track toward treatment, while Pinny himself would have plenty of time to process this. Luckily his Ima had packed enough clothes to stay for a while.

Identifying details have been changed to protect the privacy of patients, their families, and all other parties.

Originally featured in Mishpacha, Issue 741. Jacob L. Freedman is a psychiatrist and business consultant based in Israel. When he’s not busy with his patients, Dr. Freedman can be found learning Torah in The Old City or hiking the hills outside of Jerusalem.  Dr. Freedman can be reached most easily through his website www.drjacoblfreedman.com.