by The Naked Lady Who Stood on Her Head: A Psychiatrist's Stories of His Most Bizarre Cases
We had just seen Total Recall, Arnold Schwarzenegger’s new science-fiction film about a construction worker who undergoes a false memory transplant that takes him on an imaginary trip to Mars. But things go wrong, and when he comes out of it, he can’t tell what’s real and what’s imagined.
“When he first got back from Mars, there were so many signs that he was from the future that I believed it,” I said.
“But honey, before he had that memory implant done, he was perfectly happy living in the present—on Earth. Then he got all paranoid.”
“Of course he did. How do you know what’s reality if you can’t trust your memory?” I asked.
“I don’t know; you’re the memory expert. I want to go into this shop for a minute.” Gigi disappeared into a record store.
As I ate my ice cream and watched the crowds, I kept thinking about those questions. If two realities seem equally true, how would you know which version to believe? Many of my patients struggled with similar issues, whether they were psychotic, demented, or simply having memory problems.
Over the past few years, I had begun to concentrate a large part of my practice on memory issues—not just in older patients with Alzheimer’s disease but in middle-aged people who were worried about their increasing forgetfulness. My research was also focusing on early detection of dementia and age-related memory decline, and I was developing brain imaging as a diagnostic tool.
Gigi came back with a bag of CDs and said, “Let’s get the car.” Thankfully, she remembered where we had parked.
The following Monday, I got to the office early and checked my phone machine as usual. There was a message from one of my UCLA mentors, Dr. Larry Klein. He wanted me to see a VIP studio executive, Greg Wiley, who was complaining about his memory. That name rang a bell—I had just read about him in the L.A. Times business section. He had been promoted to head of production at a major movie studio.
Two days later he showed up at the office for his first appointment. He was in his mid-fifties, lean and fit, and had an air of authority. He wore an expensive suit and carried a leather briefcase. As we shook hands, he looked me straight in the eyes, but then his gaze flitted about the room, as if he was sizing up my territory. I pulled up a chair across from the sofa, but rather than sitting on the sofa as most patients did, he positioned the other chair opposite mine—he wasn’t going to let me forget who was head of production.
Greg crossed his legs, and I noticed his alligator shoes—they probably cost more than my monthly mortgage. Maybe I wasn’t charging him enough, but as soon as that thought crossed my mind, I wondered if I felt intimidated by him and was cracking jokes to myself to defend against the feeling.
I had just gotten a new Mr. Coffee machine for the office. I went to pour myself a cup and asked Greg if he wanted some. He declined and pulled an Evian bottle out of his briefcase. “Larry Klein tells me you’re the go-to guy in your field. For a newcomer, you’ve made quite a name for yourself.”
“Larry tends to exaggerate.” I sipped my coffee.
“Maybe I should hire you away from all this glamour,” he said sarcastically, gesturing around my sparsely furnished hospital office.
I smiled and said, “Larry tells me you’ve noticed some memory changes.”
Greg leaned in, suddenly serious. “Now, this is completely confidential, right?”
“Of course,” I answered.
“I haven’t told this to anybody, not even my wife, but there are moments when my mind doesn’t feel as sharp as it used to. And it tends to get worse later in the day and evenings.”
“What do you think brings on these episodes?” I asked.
“It could be overwork or stress, I don’t know.” He took a swig of his water.
“Tell me more about what you’re experiencing.”
“It’s not so much my memory—in fact, most of the time my memory is pretty good. But I have these moments of…not confusion necessarily, but my brain starts thinking in slow motion. You know what it’s like when you drive through a thick fog at night? That’s what it feels like.”
“Like a brain fog?” I asked.
“Exactly,” he said as he gulped down more water.
“Let me see if I understand this,” I said. “When you have these episodes toward the end of the day, your thinking slows down and the thoughts aren’t as clear.”
“Sort of…it takes more time to organize what I want to say, and I suppose it’s harder to remember things.”
“How often does this happen?” I asked.
“A few times a week…maybe every other day.”
My mind jumped to an inventory of possible causes for Greg’s lateday brain fog. Hypoglycemia was at the top of the list. It also could have been transient ischemic attacks or TIAs, ministrokes that don’t lead to lasting brain damage. But when I asked him about his diet and medical history, neither fit. In fact, Greg had just had a complete medical checkup, and his blood pressure, cholesterol level, and glucose tolerance were all normal. I did learn that he had a family history of Alzheimer’s disease.
“We used to just call it getting senile,” he said. “My grandmother was really out of it, and so was her brother. Now my uncle is totally confused, and his doctor says it’s Alzheimer’s. I guess that’s another reason I wanted to meet with you. Maybe I’ve inherited a predisposition for it, and it’s already starting.”
“How old were your relatives when they first showed symptoms?” I asked.
“Probably in their late seventies or early eighties.”
“Chances are, what you’re noticing now is something different. When Alzheimer’s is inherited in families, it tends to begin at about the same age. So at fifty-six, you’re way too young,” I said.
Greg’s worry about getting Alzheimer’s was typical for people with a family history of the disease. We all start noticing mild memory changes as we age—it might take longer to recall a name, retrieve a word, or find misplaced glasses or keys. And when someone has witnessed firsthand how these mild mental lapses gradually progress in a loved one, their own forgetfulness can scare the hell out of them, making them worry that they too will have to start labeling their kitchen cabinets. We know that having a close relative with the disease doubles the likelihood of getting it, but it’s not an absolute risk factor. Studies have shown that genes account for only about a third of the risk for Alzheimer’s disease. Thus, nongenetic factors, particularly lifestyle choices, have a much greater impact than most people realize.
Over the years, these kinds of issues inspired the research and clinical program I developed at UCLA. Our group was doing a lot of research with PET scan technology, and discovered a way to visualize the physical evidence of Alzheimer’s disease in living people. Through that invention, we eventually found that the disease begins gradually in the brain, often decades before symptoms begin to show themselves. These observations led us to develop a drug and lifestyle prevention program targeting people at risk in order to protect their healthy brains, rather than attempt to repair neural damage once it sets in.
“But isn’t it possible that this brain fog of mine is the subtle beginning of Alzheimer’s?” Greg asked.
“It’s possible, but not likely,” I replied. “Actually, we’re doing a study with a new kind of brain scan, positron-emission tomography, or PET. We think it may tell us if someone is going to get Alzheimer’s years before real symptoms begin.”
Greg looked excited. “Does the study need funding? I control a small family foundation, and I want in.”
As much as it killed me to tell a potential donor to put away his check-book—for now—I said, “I appreciate your generosity, Greg, but I think I can get you into the study without your funding.”
“Well, that’s a first—somebody refusing a check. I’m impressed. So what else can I tell you, Doc?”
“You mentioned that it could be stress. Tell me more about that.”
He laughed. “My job is all about stress. And it’s not jus
t stress from keeping the pictures on budget and dealing with prima donna actors. I have to deal with dozens of junior executives competing with each other and clawing their way up the ladder, basically to get my job. Showbiz is just one big party every day.”
“Have these mental lapses affected your work?”
“Not yet, but I worry that they will eventually. I mean, in the evenings there are screenings and dinners, I have to schmooze people, and I just don’t feel like I’m on my game the way I used to be.” He took a sip of water and went on. “Let me tell you, there are plenty of those young sharks coming up, kissing my ass, but really wanting to take my place. And I’ve got to keep the studio head happy too, so my movies have to make money. In my business, it’s not what you’ve done, but what you’ve done lately.”
I thought for a moment about my own business and reflected on the old joke: Why are academic politics so vicious? Because the stakes are so low. I happened to be in the midst of preparing my dossier for promotion to associate professor—the big leap to tenure. It had taken years, but I was very close now. My peers would be judging my work and making the decision by secret ballot, an old academic tradition. You never knew if someone on your tenure committee might be vying for your job and trying to keep you down. I could relate to Greg’s distrust of colleagues who might put their own self-interests before his. I knew I had to remain mindful of this parallel issue that my patient and I shared so it wouldn’t cloud my perspective and interfere with my ability to help him.
“Do you have any friends at work that you trust?” I asked.
“I have a couple of racquetball buddies at the studio who I think I can trust, plus my boss and I play together once a week. He really is a friend, and I think he’s grooming me to take over his job when he retires.” Greg unbuttoned his collar and loosened his tie. “But you know, sometimes it’s uncomfortable competing with him on the court.”
“Why’s that?”
“Well, he’s older. And even though he’s a hell of a player, there have been a couple of games when I could have beaten him, but I didn’t…I guess I was afraid.”
“Afraid of what?”
“He may be my friend, but he’s also my boss. If I piss him off, he could retaliate. He could demote me. But you know? Sometimes when he wins, it’s almost as if he’s disappointed, like he’s waiting for me to step up and beat him like a man.”
“So this studio head is your friend, grooming you for his job, and you’re ambivalent about beating him at racquetball?”
“Yeah, I guess I am, but it’s just a game, and I’ve always found that competitive sports get me out of my head and help relieve my stress. I used to play basketball, but it’s too hard to pick up a game with my schedule.”
For the rest of the session, we discussed more of Greg’s background. He had been a straight-A student, an immediate success in business, and though his first marriage failed, he got remarried to a gorgeous ex-movie star and now had two teenagers in the best private schools in West Los Angeles. But all these achievements came with a price—he constantly felt a need to stay at the top of his game and watch his back to make sure nobody took what he had worked so hard to get.
We didn’t have time that day to really explore his childhood, but I wondered what early experiences might have shaped Greg’s lifelong quest for success and control, and his pressing fear about losing his winnings. No wonder he was afraid of Alzheimer’s disease. It was the ultimate loss of control, and there was no way to beat it. We could try to detect it early, slow it down and possibly stave it off with medicines and lifestyle adjustments, but eventually, if he did get Alzheimer’s, the disease would take over his mind permanently.
I wondered if Greg’s worry about the young executive sharks was more than just normal Hollywood competition. If he really did have some type of brain disorder, he might be experiencing more than episodic mental lapses; he might have paranoid thinking. I had seen several cases of early-onset Alzheimer’s that started not with memory loss but with psychiatric symptoms. One woman complained of obsessive-compulsive tendencies that seemed to come out of nowhere; another man was referred to me because of sudden-onset panic attacks. Both turned out to have Alzheimer’s disease, and the anxiety symptoms were the first signs of the underlying neural degeneration of their mental faculties.
I told Greg I would arrange a PET scan for him. I also asked if he could have his internist send me a copy of his medical records before his next appointment.
Later that day I had a meeting with Larry Klein to help me with my tenure dossier. The first review committee had questioned whether I had enough focus in my research—I’d studied mass hysteria, psychosomatic diseases, brain scanning, and geriatric dementia. Apparently, they wanted to see a thematic trajectory demonstrating how each study led to the next. They also wanted to be sure I had become independent of my mentors as an investigator. So of course, I immediately turned to a mentor for advice.
Larry, often suspicious that others were listening in on his office conversations, had a habit of conducting consultations and supervision sessions during strolls around the West L.A. Veterans Affairs Medical Center campus. It was the main V.A. hospital affiliated with UCLA, located just west of the 405 freeway. The older buildings were sprinkled across vast lawns, and the north side of the campus had a nine-hole golf course, Larry’s favorite spot for conducting business in private. Paranoid? A little, but everybody has their quirks.
As we left the parking lot and headed toward the ninth fairway, Larry cut to the chase. “You’ve done excellent research your entire career. Now it’s just a question of spin.” We circled around the ninth hole; I could see the kids at the Brentwood School playing in the yard.
“Spin? What do you mean?” I asked.
“Look at the big picture, Gary. You’re an eclectic guy, and you have a methodical way of solving problems. It’s reflected in all of your work—whether you’re analyzing a bunch of hysterical schoolkids fainting in a recital or figuring out what causes damage to brain neurons in Alzheimer’s disease. You just need to show the committee how each question you’ve answered in your career has led to the next, and where you plan to take it from here.” He reached down, picked up a golf ball, and threw it onto the eighth green, nearly getting a hole in one.
“Great shot,” I said as I pondered what he had said.
“So what’s happening with Wiley? Have you given him your secret screenplay yet?” he asked.
I laughed. “I must be the only guy in Los Angeles who doesn’t have a secret screenplay stashed in his desk.” I found a stray golf ball and tossed it at the next hole, missing the green by twenty yards. “I’m not sure yet. He’s having memory lapses and episodes of confusion. It could be early-onset Alzheimer’s, TIAs, or some other kind of medical problem, but I don’t know. Maybe it’s psychological or just plain stress.”
“I’m confident you’ll get to the bottom of it, Gary. Just like I know you’ll figure out how to handle these promotion questions. Remember, never rule out the simplest possibilities.”
“I hear what you’re saying, Larry, and I appreciate it. But sometimes when a case is unusual or complicated, I don’t have the same confidence in myself that you seem to have.”
“Gary, becoming a good psychiatrist is not that different from getting comfortable in any role in life—banker, teacher, or whatever. Think about the first time you held your daughter—you must have felt more awkward than the first day you wore a white coat. Everybody feels like they’re faking it sometimes. The key is to move forward and make the best decision you can at the moment. Don’t be afraid of making mistakes. I’ve learned the most when I’ve made mistakes and bounced back from them.”
As I drove back to the office, I thought about Larry’s advice. I needed to take in the big picture and not overlook the obvious or perhaps simplest explanation—both with my promotion and with Wiley’s case. It was interesting that Greg seemed paranoid about his co-workers vying for his job; Klein had a paranoi
d streak in his personality; and I was worrying about my colleagues sabotaging my promotion. I wondered, when does suspiciousness and paranoid thinking escalate from protecting us from real danger to overtaking our lives and crippling our ability to function? For Wiley, I was hoping I could answer that question quickly. With Klein, I suspected I never would. In my case, I knew those bastards were out to get me.
A FEW DAYS LATER, I RECEIVED GREG’S medical records and pored over them in detail. I couldn’t find any abnormalities, not even a suspicious mole on his back. His PET scan also came back completely normal—no evidence of Alzheimer’s or any dementia—so I called to give him the good news.
“So what the hell do you think is going on with me?” he asked.
“I’m not sure yet, but we can discuss the possibilities on Wednesday.”
“Oh yeah,” he said. “Can you see me later in the day, maybe five-thirty? My racquetball game changed to midafternoon.”
I checked my schedule, “Okay, that works for me. I’ll see you then.”
I hung up and pondered the possible causes for Greg’s mental lapses. For now, Alzheimer’s was ruled out, but a normal PET scan doesn’t mean he’d never get the disease in the future—details I wouldn’t get into over the phone. In fact, had his PET scan been abnormal, I would have waited to give him that news in person as well.
At about ten-thirty that evening, I climbed into bed with a stack of journals and the best intentions of reading them when Gigi came out of the bathroom in her flying-toaster PJs.
“So what’s up at work?” she asked.
“You know, the usual: tenure freak-out, committee meetings, crazy people.”
“No, I mean it,” she said. “Any interesting cases?”
“Well, there is this patient, some movie mogul who’s getting fuzzy-headed in the afternoons and evenings.”