by The Naked Lady Who Stood on Her Head: A Psychiatrist's Stories of His Most Bizarre Cases
There are plenty of reasons why sex can decline in a relationship; job or money stress, children or family obligations, and health problems can diminish libido and lead to a pattern of asexuality for some couples. Depression can also decrease a person’s sex drive, and many antidepressants will boost mood and improve libido, but ironically they can also reduce the ability to reach an orgasm.
I wasn’t sure what was going on with Sharon and Steve, but I was determined to find out and try to help them. I gazed over at my girlfriend, who was snoring, which helped dampen my own libido. I tried to get back into my book but started nodding off, so I turned out the light and went to sleep.
MONDAY MORNING I STARTED PLAYING PHONE TAG with Pete Carter, and we finally spoke in the afternoon. When I asked about Steve’s rash and ointment, Pete was surprised. “He’s still using those creams I prescribed? That was like a year ago when he came in with that rash.”
“Do you remember the details?” I asked.
“Sure do,” Pete replied in his usual drawl. “He had tinea cruris, better known as jock itch. I gave him an antifungal cream for his pubic area and a corticosteroid cream to help stop the itchiness for a few days.”
“Sounds like he’s still using it,” I said.
“That could cause some problems,” Pete said. “It’s pretty rare, but occasionally people absorb enough of the steroid in their blood for it to shut down their pituitary gland and their blood sugar shoots up. More likely, if he’s really usin’ it a lot, it’ll just make his itching and rash worse.”
“Thanks for the info, Pete. They’re coming back in later this week.”
“Good,” Pete replied. “I’d like to see him again too and check out what the heck’s goin’ on down there.”
“Better you than me,” I said as we hung up. I never did like that dermatology rotation in medical school. Skin eruptions made me gag.
It was Thursday afternoon and Steve showed up at two o’clock on the dot. Before I could even say hello, he sat down and began. “She’s late, huh? Typical.”
“We can get started anyway,” I said.
Ignoring me, he went on. “Sharon has nothing to do all day except drop those kids off at my mother’s and get over here, and still she’s late. She always does this.”
“I’m sure it’s frustrating, but it gives us a chance to talk alone for a few minutes, and I wanted to follow up on something.” That seemed to get his attention.
“Oh yeah? What?”
“After you left last week, Sharon and I discussed some of your medical history. She mentioned that you’d been using a cream for a rash,” I said.
“Yeah? So?” he asked defensively.
“Are you still using it?” I asked.
“Once in a while when I need to,” he said. “I mean, you go to the gym, don’t you? Everybody gets jock itch at some point. Why does it matter?”
“Because Sharon thinks it’s affecting your sex life,” I said hesitantly, hoping he wouldn’t bolt at the mention of the word sex.
“Sex again? Sex, sex, sex. Sharon never shuts up about it. That’s all I hear—voices talking about sex.” He was becoming agitated and started rambling as if there was someone else in the room.
“Voices?” I asked. Could this guy be psychotic, having auditory hallucinations?
He didn’t answer. He just stared out the window as if in another world.
I raised my voice. “Steve! You said you were hearing voices?”
He snapped out of it. “Huh? What did you say?”
“Voices…Are you hearing voices in your head?” I asked.
“Well…not really voices. You know what I mean, she just never shuts up.” He looked toward the window again. I remembered Sharon’s comment that he seemed paranoid when she saw him in the bathroom and wanted to check out his rash. And now he just let it slip that he heard voices talking about sex and seemed to be hallucinating right in front of me. If he was having some type of psychotic experience, he was covering it up pretty well because most of the time he just seemed like an obsessive, angry, intelligent lawyer—pretty much like a lot of lawyers I knew.
I tried again to reach him. “What are you looking at, Steve?”
“Huh? Nothing,” he said. “I thought I saw something…”
Sharon suddenly came barreling into the office, “I’m so sorry I’m late, but there was a traffic nightmare on Wilshire. Some kind of protest at the Federal Building and then I had to try and park here—it’s insane! But I did finally get a space like a mile away and then ran back—”
Sharon’s incessant chatter seemed to pull Steve back from his private world, and he was able to focus his full irritation on her. “That’s enough, Sharon. You’re already late. Let’s try to salvage what time we have left.”
Sharon looked hurt. “I said I was sorry, Steve.” She started crying, “I’m doing the best I can. I just get overwhelmed.”
Steve seemed to soften with her tears. “I’m sorry, Sharon. I’m so busy and stressed out that sometimes I just snap.” He moved over on the sofa and put his arm around her to comfort her.
Though he’d snapped a moment ago, I liked the direction in which this was going now. I wanted to help them move beyond the squabbling match of the last session so we could discover what was really going on between them.
“Sharon, how do you feel when Steve comforts you?” I asked.
She sniffed. “I feel good…closer to him.”
“What about you, Steve?”
“I guess I’m a sucker for her tears,” he said. “And when we hold each other, I don’t think so much.”
She smiled. “You know, honey, it reminds me of when we used to spoon each other to fall asleep.”
“Yeah, so?” Steve asked, pulling away from her.
She went on. “So we never do that anymore.”
“And why do you think that is?” he asked.
“Because you never fall asleep,” she shot back at him. “You’re either up working in the other room or reading files in bed. And when you finally do turn off the light, you toss and turn all night and we never have sex.”
“You know, Sharon, I’ve got a lot on my mind right now. I don’t really need that much sleep, and I definitely don’t need to be nagged about sex.”
I tried to steer the conversation away from sex. “How many hours of sleep are you getting, Steve?”
“I don’t know, maybe four or five,” he mumbled.
I knew that wasn’t enough sleep for someone Steve’s age. I didn’t know what was keeping him up at night—it could have been depression, stress, or any number of things, but his behavior was pointing to an underlying psychosis. And like many psychotic individuals, he was too defensive to open up and tell me what was going on in his head.
Psychosis is defined as a loss of touch with reality. Psychotic people might hallucinate, which means they hear voices or see things when there’s really nothing there. They might also have delusions or false fixed beliefs, which come in many flavors, ranging from paranoid beliefs that Martians are monitoring their thoughts to grandiose ideas that they’re a famous rock star, say, or even Jesus Christ.
A lot of things can make a person psychotic. A psychiatrist usually rules out medical illness first, then considers various psychiatric conditions such as acute mania, psychotic depression, or schizophrenia. The nature of a patient’s delusions can help differentiate these illnesses. Depressed patients often have somatic delusions, meaning that they believe that their body is somehow diseased, abnormal, or altered. Sometimes they have exaggerated feelings of remorse, as if they have committed some horrible crime and should be punished severely. By contrast, psychotic schizophrenics have more bizarre experiences and might believe that their thoughts are being broadcast on the radio. Sometimes they’ll hear running conversations in their head between two or more people.
If Steve was in the beginning stages of psychosis, I doubted that a medical problem was the cause—Pete Carter was a thorough internist. Since
Steve was in his early forties, schizophrenia was less likely because its psychotic features usually become apparent at a younger age, in a person’s late teens or early twenties. Steve’s lack of sleep could be consistent with a manic episode, but he didn’t have the pressured speech and euphoria typical of bipolar patients when they’re in an upswing. He did show the irritability, anger, and withdrawal that can point to depression. But at the same time, his paranoia and strange behavior in my office reminded me of someone on the verge of schizophrenia. I needed to know more about what Steve was experiencing and thinking to nail down his diagnosis.
Many times a therapeutic trial of an antipsychotic medication can clear up some of the defensiveness, paranoia, and hallucinations of psychosis. It can also help people sleep better at night. I saw Steve’s sleep problem as an opportunity to prescribe an antipsychotic drug to improve his symptoms and hopefully make him more accessible in therapy.
“Steve,” I said, “a guy your age needs to sleep at least seven hours a night. I’m going to give you a low dose of a medicine that will help you sleep better. You’ll probably feel more rested during the day and less stressed out.”
I wrote him a prescription for two-milligram Haldol tablets. “Try taking one of these about a half hour before you to go to bed. If you still can’t sleep, take a second one.”
As I handed him the prescription, Sharon said, “He hates taking medicine.”
“It’s a very low dose, and it’s not the type of sleeping pill that you can get dependent on,” I reassured them. “It also helps reduce stress.”
“It’s fine, Sharon,” Steve said. “I’ll try it.”
“Good,” I replied. “Call me in a few days and let me know how it’s going.”
I didn’t hear from Steve the entire week and figured he was either doing well on the medication, or he never filled the prescription at all. I hoped I’d find out at their scheduled appointment.
The phone rang, and it was Steve. He said that they wouldn’t be able to make it in later because the twins had fevers and Sharon didn’t feel comfortable leaving them with his mother.
“I’m sorry to hear they’re sick,” I said. “But why don’t you come in alone, Steve? We both booked out the hour, and we could talk some more.”
He thought about it a moment. “I guess so. Why not?” I was surprised to hear his upbeat tone.
“By the way, Steve, how’s that medication working for you?”
“Not bad. I’m sleeping better.”
“What about during the day? Are you noticing anything?” I asked.
“Well, I’m not as tired, and Sharon says my mood’s better.” Often, the initial benefits of psychiatric medicines are noticed only by people close to the patient, rather than the patient himself. This was a good sign that the Haldol was working.
“That’s great, Steve. And listen, I have a staff meeting right before our appointment, so in case I’m running a few minutes late, just let yourself in. I won’t be long.”
“No problem,” he said.
As I walked toward the elevator on my way to the staff meeting, I started to worry about Steve. Even though he sounded better, I knew that a low dose of Haldol wasn’t going to cure him overnight. At least he was cooperating, and I was encouraged that he was flexible enough to come in on his own.
As I had expected, the staff meeting went long and I was ten minutes late for Steve’s session. Too impatient to wait for the elevator, I raced up three flights of stairs to my office. As I walked briskly down the hall, I wondered whether I had prescribed a high enough dose of antipsychotic for Steve. Maybe he needed an antidepressant as well. I wondered if his psychosis would resurface if I asked too many probing questions.
I got to my office and opened the door. I couldn’t conceal my shock when I saw Steve on the sofa. I stared at the scene in disbelief, unable to move.
Steve’s pants were down around his ankles. He was holding his penis with one hand and rubbing a cream on it with the other. He had a small, round makeup mirror wedged between his thighs so he could watch what he was doing. An open condom sat nearby on the sofa. He was so absorbed in his procedure that he didn’t even notice that I had entered the room. Was he masturbating? Perhaps he was an exhibitionist and I had missed the diagnosis completely. Was this some form of psychotic ritual? Or was there some other unthinkable yet logical explanation for his bizarre performance? I was stunned but curious, and I didn’t quite know how to proceed.
I finally blurted out, “What the hell are you doing, Steve? I’m going to wait outside while you get yourself together.”
Startled and embarrassed, Steve said, “Oh, Dr. Small, just turn around for a second, I’m almost done with my treatment.”
In a daze, I followed his instructions and turned around. I could hear him put the rubber on and zip up his pants.
“Okay, I’m finished,” he said.
I turned back and saw Steve putting the cream and mirror into his briefcase. I stumbled to my chair as I tried to regain my composure. I’ve always found that therapy sessions go more smoothly when everybody’s penis stays in their pants.
“What’s going on, Steve? I mean, the door was unlocked and anyone could have walked in.”
Steve looked at the floor, ashamed. “You know we talked about my crotch rash. Well, it was itching like crazy and I had to do a treatment.”
“But it looked like you were rubbing something on your penis, not your crotch.”
“I know,” Steve said defensively. “But it’s spread to my penis. It’s been like this for months. When I apply the ointment directly on the rash, it feels better. And the condom keeps the ointment from rubbing off.”
“Did Dr. Carter recommend this?” I asked.
“He knows about the pubic rash, but I haven’t told him about it spreading to my penis.”
I suspected that he hadn’t told anyone, especially Sharon. That could explain why he didn’t want her to see him naked or have sex with him. Perhaps the antipsychotic had helped him to open up and share this secret with me. The fact that I had caught him in the act might have helped as well.
“Anything else you haven’t told anyone?” I asked. “I want to help you, Steve, but I can only do that if you’re honest with me.”
Steve slowly got up and walked toward the window. As he stared at the building across the way, I hoped that the Haldol had put enough of a lid on his psychosis to help him organize his thinking and allow me into his private world.
Still staring out the window, he said, “Well, there is something…” I waited. Eventually, he went on, “I know this will sound crazy…but ever since the rash spread to my penis, it’s been getting smaller.”
“The rash?” I asked.
“No, my penis. I can see it shrinking,” he said.
He was finally letting me into his private world, but I wasn’t so sure I wanted to go there.
Steve continued, “It seems like the only thing that keeps my dick from shrinking is that ointment.”
I wanted to tell him to flip the mirror over to the magnifying side where objects appear larger than they really are. As soon as that tasteless joke entered my mind, I knew that it was an expression of my own anxiety about this awkward situation. Freud believed that humor was an effective defense mechanism for diminishing anxiety and repressed impulses. In a sense, laughter transforms these uncomfortable feelings into pleasant ones. In medical settings, gallows humor is common and helps physicians cope with overwhelming tragedy and illness. As long as patients and family members are out of earshot, most experts agree it is not only harmless but allows medical personnel to let off steam. As a result, doctors can be more accessible to and effective with their patients.
I also couldn’t help but think about the symbolic nature of Steve’s concern about his shrinking penis. He was trying to make partner at the firm, provide for a family of five, and satisfy his wife in the bedroom—all challenges to his potency and sense of self as a man. At an unconscious level, he prob
ably wished for a large, virile penis, rather than a shrunken, itching one.
“Steve,” I said, “I appreciate your telling me about this. I know you’re convinced that this is happening, and I’m going to work with Dr. Carter to help you get rid of this rash and feel better.”
“But can you stop my penis from shrinking? Is there a stronger medicine you can prescribe?”
I knew he meant stronger ointments, but I was thinking a higher dose of antipsychotic. “I’m going to discuss the situation with Dr. Carter. In the meantime, I want you to double your Haldol dose—I think it will help with the itching and make you less worried about it.”
We made an appointment for a few days later so I could speak with Pete and try to get a better handle on what was going on. Steve promised that he’d keep the door locked the next time he felt the need for a midday treatment.
I got Pete Carter on the phone that afternoon and filled him in on Steve’s situation. He was amazed that this apparently normal lawyer was pretty much “bonkers,” as he put it. As far as Steve’s rash was concerned, Pete wanted to see it again and consult with a dermatologist ASAP. He suspected that the long-term use of the steroid cream was sustaining the problem, causing skin irritation and itchiness, and the condoms kept the area moist instead of letting it dry out and heal. Also, some people develop a contact dermatitis from condoms, especially latex ones. As far as the penile shrinkage was concerned, Pete said there was no physiological way that Steve’s penis was shrinking—not from the rash, the creams, the condoms or anything else he might be doing.
Without a medical cause for Steve’s belief that his penis was shrinking, that left a short list of psychiatric conditions. The nature of Steve’s delusion was consistent with schizophrenia, and occasionally patients did show their first symptoms later in life. Steve also had some features of depression—trouble sleeping, anxiety, and ruminations.