by The Naked Lady Who Stood on Her Head: A Psychiatrist's Stories of His Most Bizarre Cases
Psychoanalysis has helped many people with their neuroses and personal problems, but it’s difficult to prove scientifically that it works any better than just talking with someone who is empathic and supportive, although systematic studies have demonstrated the effectiveness of a similar treatment approach, psychodynamic psychotherapy. Also, psychoanalysis is not for everyone, particularly patients with severe depression or psychosis. With the development of antidepressant and antipsychotic medicines that often improve mental symptoms more rapidly, the medical community seemed to warm up to psychiatry. And many psychiatrists turned away from pure psychoanalytic approaches and took a more eclectic strategy combining both talk therapy and medication. This medicalization of psychiatry gave the field more credibility and acceptance by other medical disciplines; however, antipsychiatry sentiments persisted, particularly among older physicians.
For many doctors and lay people, fear drives their prejudice against psychiatry. Sometimes in denial about their own mental struggles, people avoid or attack psychiatrists in an attempt to keep them from somehow recognizing their secret psychological issues—as if the psychiatrist had some magical powers to do so.
But with Ralph Porter, the antipsychiatry jabs felt personal. I was just starting out as a card-carrying psychiatrist and wanted to be taken seriously. He had a way of making me feel instantly insecure. When he directed his antipsychiatry barbs at me, I admit I even momentarily doubted my career choice. Luckily, my anger toward this jerk overtook my insecurities and spurred me to prove my worth to him. Public humiliation does have its upside—it can motivate people to push themselves to prove a point.
THE NEXT MORNING I RETURNED TO HEATHER’S room to begin my formal consult. The TV was on, and Heather was staring blankly at the screen. I introduced myself and sat down in a chair next to her bed. She didn’t acknowledge me in any way, and the only reaction I could get was an eye blink when I clapped my hands in front of her face.
I did another neurological exam. Her reflexes were still symmetrical and brisk. I gently lifted her head off the pillow and flexed her neck—there was no stiffness there at all. Finally I got around to what I had really come to do—I lifted her arm above her head and let go. I let it stay there for about five seconds, then I gently moved her arm to a horizontal position and it stayed there as well. After nearly thirty seconds, it slowly floated down to her side.
I tried her other arm and got the same result. I felt like one of those hypnotists in a Las Vegas lounge act who gets audience volunteers to freeze in weird postures while in a hypnotic trance. This whole time Heather had been staring at the TV. It was eerie.
I had never witnessed waxy flexibility before, but I had read about it in medical school. It was defined as a lowered physical response to stimuli and a tendency to maintain an immobile posture. When you move the arm of someone with this condition, he keeps it in that position until you move it again. In other words, the extremity responds as if it was made of wax. It was originally described in patients with catatonic schizophrenia, who have extensive loss of their motor skills and sometimes hold rigid poses for hours. In rare, untreated cases, victims have been known to die from exhaustion.
I was about to check Heather’s pulse when someone entered the room, “Excuse me, are you a real doctor or just another med student?”
I turned and saw a slightly older version of Heather standing in the doorway.
She went on. “I’m sick of this teaching hospital. Are you even old enough to be in here?”
I had no gray hair in those days, and even though I was approaching thirty, I looked young for my age. I stood and extended my hand, “I’m Dr. Gary Small. I’m a psychiatrist consulting on Heather’s case.” She didn’t shake my hand, so I let it drop.
“Oh, great, a shrink,” she said. “Are you doing some kind of silent treatment therapy? Have you noticed that my sister’s not talking?” She put her purse and coat down and started tidying up the room.
“I know the medical doctors have diagnosed your sister with encephalitis,” I said. “But sometimes a psychiatrist can help when a patient stops talking or doesn’t respond.”
She sighed and began brushing Heather’s hair. Her anger shifted to resignation. “Why not a psychiatrist? We’ve seen just about every other specialist in this hospital.”
“What’s your name?” I asked.
“Andrea. I’m Heather’s older sister, and I’m the one who could use therapy. This whole thing with Heather has been a nightmare.”
“I’m sure it’s been tough on you,” I said.
“It was unbelievable how fast this thing happened. One day Heather had the flu; the next thing you know, she’s like this.”
“Have you noticed any improvement at all in the last month?”
“Not really,” Andrea said. “I mean, some days she seems a little more with it—I think she enjoys it when I brush her hair—but most of the time she’s completely out of it.”
Even though Heather seemed unaware of our conversation, there was an outside chance that she was listening to us. I asked Andrea to please step into the hall with me. We walked to a couple of chairs at the end of the hallway and sat down.
“What was Heather like before she got sick?” I asked.
“She’s an amazing artist. Mom always said she got the talent in the family and I got the brains.” She laughed bitterly.
Normally I would use that as an opening to delve into their sibling rivalries, but I decided not to go there. I needed more background on Heather.
“I understand she paints. What kind of paintings does she do?” I asked.
“It depends on her mood,” Andrea answered. “When she’s really energized, she’ll go for weeks doing incredible, colorful abstract canvases, one after the other—they’re huge. I don’t know how she can be so productive and still find time to sleep.”
“Really,” I said.
Andrea went on. “But other times she locks herself in her studio for days and does these dark, moody self-portraits. It’s almost like someone else is painting them.”
It sounded like Heather was suffering from classic manic depression, also known as bipolar affective disorder. The illness afflicts about 1 percent of the population and is characterized by episodes of elevated mood or mania, interspersed with periods of depression. When in a manic state, bipolar patients don’t require much sleep; they are productive, energetic, often euphoric, and fun to be around. However, if the mania escalates, their grandiosity can get them into trouble. They can also develop rapid speech, hallucinations, delusions, and aggressive behavior.
When bipolars switch to a depressed state, they are usually lethargic and often sleep through the day. Sometimes people have a mild form of the condition and rather than full-blown manic episodes, they have hypomania—they experience euphoria and productivity without the irritability and psychosis. And their depressed states are less severe or barely present at all. Because of the seductiveness of this hypomanic state, many bipolar patients “forget” to take their lithium, a drug that can stabilize their mood and reduce the frequency and intensity of the swings.
During their hypomanic and manic episodes, people with bipolar disorder often have bursts of extraordinary creativity. It’s no surprise that some of our most famous artists, writers, and musicians have suffered from this illness, including Vincent van Gogh, Paul Gauguin, Jackson Pollock, Mark Twain, Ernest Hemingway, William Faulkner, Ludwig van Beethoven, Robert Schumann, and Brian Wilson.
“It sounds like Heather has mood swings. Has she ever seen a doctor or therapist to help her with that?” I asked.
“Why? Everybody has mood swings. And Heather’s an artist. That’s just how she expresses herself,” Andrea answered defensively.
“Anyone else in your family have mood swings?”
She shook her head.
“Do you know if any relatives have ever seen a psychiatrist or perhaps taken lithium?” I asked.
Andrea thought for a moment. “Our p
arents died in a car accident when we were in college. But I remember my grandmother telling me about a sister of hers who spent years in some mental institution on the East Coast. I don’t know what was wrong with her or if she took anything.”
I wondered if this maternal great-aunt was a manic-depressive. She might have spent years in an inpatient facility without ever receiving medication. The FDA didn’t approve lithium as a treatment for mania until 1969. Until then, a variety of treatments had been used, ranging from insulin shock therapy to psychoanalysis. Because manic-depressive illness tends to run in families, Heather’s possible family history supported my hunch that she had an undiagnosed bipolar illness.
“Andrea, as far as you know, have any of your relatives ever had problems with alcohol or drugs?” Sometimes bipolar patients self-medicate by abusing substances, especially alcohol.
“Look, Dr. Small, you’re obviously searching for some psycho answer to my sister’s encephalitis. She needs an infectious-disease specialist, not a shrink, okay?”
“I agree with you—input from an infectious-disease specialist is critical. But Heather’s condition has stumped all the doctors so far, and I think we should keep our minds open to all the possibilities.”
Andrea slumped into a chair. “I guess so. I mean, she’s the only family I have.” She suddenly appeared very sad. Was it possible that Andrea too had manic-depressive tendencies? Sometimes the condition cycles up and down rapidly, from moment to moment.
“It must be tough for you to see Heather like this,” I said.
She looked at me tearfully. “Heather’s always been tough. I love her but I never know which Heather I’m going to find—the reclusive, moody one or the bubbly, creative one. And now she’s like this.”
“I can see it’s painful for you,” I said.
“Yeah,” Andrea said. “But it’s not about me, it’s about my sister. She’s just got to get better.”
I could see Andrea wasn’t ready to go any deeper into her own feelings at this point, and I wanted to follow up on my theory about Heather’s illness. “Let’s give all the specialists some time to put the pieces together,” I said. “I’ll let you go back to your sister, and I’m going to speak with Heather’s other doctors. I hope that we can talk some more later.”
The next day I knocked on the door of Dr. Porter’s seventh-floor office.
“It’s open,” he said gruffly.
I entered the spacious, standard-issue, metal-desk-and-file-cabinet office with a view of the 405 freeway. The walls were covered with Perma Plaqued diplomas and awards—documentation to back up his oversized ego. He looked up from the slides he was sorting, “What is it, Small? I’m busy.”
Although I had walked in prepared with my articles and arguments, it only took a moment for him to make me feel like an insecure idiot. Fortunately, I had already learned how to push on despite momentary humiliation.
I blurted out my thesis, “I’ve had a chance to examine your mute patient on Four North, and I think her encephalitis is complicated by a catatonic syndrome brought on by manic-depressive disorder.”
Porter looked up from his desk and laughed. “Really? Did she suddenly snap out of it and tell you all this?”
My anger kicked in and spurred me on. “The patient’s sister gave me a lot of background. Heather Phillips has a clear history of mood swings and a family member who may have had bipolar affective disorder. Also, when I examined her, she demonstrated classic waxy flexibility—”
Porter interrupted, “Waxy what? The woman has viral encephalitis for God’s sake. Didn’t you see the labs? She has elevated white cells in her cerebrospinal fluid. What’s clear about this case is your naïve insistence that there’s something mental going on here. Now could you please leave?”
I was seething. The patient needed to be treated for bipolar disorder, and this jerk was blinded by his antipsychiatry bias and stubborn arrogance. I wanted to pull one of his stupid plaques off the wall and hit him over the head with it. “Dr. Porter, I’m not saying she doesn’t have encephalitis, but she might also need to be treated for bipolar disorder.”
“That’s absurd,” he said. “And what would you suggest we do, anyway? Force-feed her lithium?”
“No. At this point, the safest and most effective treatment would be electroconvulsive therapy—ECT,” I answered.
“Look, Small, I’m not going to give shock treatments to a patient with a brain infection.”
“Could you just take a look at these articles I copied for you?” I asked.
“Leave them on the table there. I’m giving a lecture in ten minutes, and I have to get my slides together.” He went back to the slide carousel on his desk as if I no longer existed. I dropped the articles on the table and left the office.
One of the articles was Alan Gelenberg’s classic “The Catatonic Syndrome,” which describes both waxy flexibility and the psychiatric differential diagnosis for catatonia. Gelenberg showed that mania was a more common cause of catatonia than any other psychiatric condition—even schizophrenia. The other articles described the safety and benefits of modern ECT, debunking the old perception from the media and movies like One Flew Over the Cuckoo’s Nest, which depicted ECT as a punitive rather than a therapeutic intervention.
After leaving Porter’s office, I headed back to my own cubbyhole. My office had a window as well, but the view was of the medical-center trash bins. Fortunately the window was paint-sealed shut.
It was frustrating that here I was, already an assistant professor, and still not taken seriously by guys like Porter. Being ignored felt worse than being ridiculed. There was an outside chance that Porter might glance at the articles I left, but it was unlikely that he’d come around to seeing things my way. I needed an ally at his level or higher, and I knew just the guy.
Dr. Larry Klein was an icon of American psychiatry, and I had sought him out as a mentor as soon as I arrived at UCLA. He was five feet five inches tall, but with his booming voice, insightful wit, and political savvy, he dominated any room he entered. As I waited in his office for our meeting, I stared at his infamous and incomprehensible blackboard, trying to decipher his scribbles. They were either genius or madness, which also described the man’s charm.
The door flew open as Larry whisked by me. He simultaneously sat in his chair, lit a cigar, and plopped his feet on his desk. “Gary, I like the new haircut—very Steve McQueen.”
“Thanks, Larry,” I said. “I see you’re still into bow ties.”
“Always, Gary. Can never be too formal,” he said. “Now, what’s this urgent matter that couldn’t wait?”
I filled Larry in on Heather’s case and Porter’s resistance to my diagnosis and treatment recommendation. Larry listened as he puffed his cigar. He was not only a world-class psychopharmacologist but a card-carrying analyst as well.
“I know this character Porter,” Larry said. “He’s an insecure, obsessive internist—probably compensating for inadequacies stemming from an overbearing mother. And I know just how to handle this schmuck. By the way, your assessment sounds right on the money. You did good, kid.”
I felt a wave of pride—here was the idealized father figure praising my work. My own father would have asked why I hadn’t made the diagnosis sooner. I knew that Larry would get Porter to fall into line now, but I also felt a bit infantilized. At this stage of my career, I would have liked to have handled this case on my own. But at least the patient was going to get the proper care.
Larry put his cigar down in his giant ashtray. “Let me get this idiot on the phone right now.” He shouted into the other room, “Janet, can you page Dr. Ralph Porter, please?”
We wasted no time taking the stairs up to the patient’s room. As Larry performed a neurological examination on Heather, Ralph Porter entered. Larry turned and said, “Ralph, that editorial you wrote for the Archives was brilliant.” I was impressed by Larry’s seamless political savvy.
Ralph beamed. “You’re too kind, Larry.
And Dr. Small, thank you for bringing Dr. Klein in on this most interesting case of mine.”
What a kiss-ass, I thought. “My pleasure,” I said.
I demonstrated Heather’s waxy flexibility for them, and Larry quickly piped in, “Fascinating, isn’t it, Ralph?”
Ralph said, “Yes. It certainly fits in with my original suspicion that something besides encephalitis is going on here.” How full of crap could he get?
Larry smiled knowingly at me. “So we’re all in agreement that this catatonic syndrome may be complicating her encephalitis?”
I nodded and Ralph said, “I guess so.”
Larry went on. “The way I see it, we’ve got nothing to lose by buzzing her with a little electricity. Gary, how quickly can we get her on the list for a therapeutic trial of ECT?”
“If her sister signs the consent today, I’ll get her on the schedule for the morning,” I said.
“So you think that’s the best course to take at this point, Larry?” Ralph asked.
“Absolutely. There’s enough in her history to point to bipolar disorder, and even if we don’t get a response after a few ECT sessions, we can stop it and just let the infection run its course. The ECT won’t affect it.”
“Then I completely agree,” Ralph said officiously. It was hard to keep from laughing.
“Great,” Larry said. “Gary will follow up on the details.”
Although I had been relegated to errand boy, I got some satisfaction watching Porter kiss Larry’s ass.
As Larry turned to leave the room he winked at me and said, “By the way, Ralph, I recall reading that one or two percent of the population has unexplained white cells in their spinal fluid. Do you think it’s possible that this encephalitis is just a red herring?”