by The Naked Lady Who Stood on Her Head: A Psychiatrist's Stories of His Most Bizarre Cases
She brightened. “Ooh. Do you think you can give him one of my spec screenplays to read some morning before the fuzz sets in?”
I laughed. “No. Now do you want to hear about this or not?” She sat on the bed and looked at me expectantly while rubbing in some hand lotion. I continued, “So I haven’t figured out the cause yet. It’s not Alzheimer’s, and he’s not having little strokes.”
“Maybe he’s depressed. Is he married?”
“Hilarious. Yes, and he’s in his second marriage, to a much younger, trophy wife. So watch yourself.” She hit me on the head with a pillow, got under the covers, and picked up her novel.
Gigi’s question made me think more seriously about whether or not Greg might actually be depressed. As a demanding studio exec, he had to keep up a tough exterior, but he might be hiding a vulnerable and depressed side. And when somebody has a clinical depression, there’s often a diurnal pattern or daily cycle to the symptoms. Patients sometimes report ruminating only at night or early in the morning. However, arguing against depression was Greg’s complete lack of a sleep disorder or weight change.
A diurnal pattern could often be a clue to a psychiatric diagnosis, and not necessarily depression. For example, anxious people have trouble falling asleep while those who are depressed wake up in the night and can’t fall back to sleep. We are all diurnal by nature—more active during the day than the night. And beyond that, most of us consider ourselves either morning people or night owls. Our levels of alertness throughout the day are determined by our biologically driven circadian rhythms, reflecting peaks and valleys in hormone levels that cycle during a twenty-four-hour period and are influenced by our daily habits, including sleep patterns, diet, exercise, and medication use.
Greg’s symptoms came on at the end of the day and the evening, a clear diurnal pattern. I wondered whether a physiological condition was initiating these symptoms as the day went on. Perhaps a twenty-four-hour cardiac halter monitor would reveal an arrhythmia that could have been causing decreases in blood flow to the brain. But I also had to consider the possibility that an external event was setting off his mental fatigue. His anxiety about the competition at work had become a theme in our sessions. Maybe some daily stressful situation, an interpersonal conflict with a co-worker, a particular meeting with a junior executive or even his boss, could be triggering mental fuzziness in the afternoon and evening.
Wednesday rolled around and I was still mulling over Greg’s differential diagnosis. I got a call from his assistant, Tracey, saying Greg had a late meeting and wondered if they could send a car and bring me to the studio for our five-thirty appointment. And of course, I would be duly compensated for my time.
I immediately thought of the benefits of seeing Greg in his natural habitat, which might give me some clues as to what was causing his stress. I also have to admit that the idea of cruising up to the studio in a limo and rubbing shoulders with movie stars was appealing. As I considered running home and changing into something more hip, I snapped myself out of it and replied to Tracey, “That can work, but I won’t be free until five-fifteen.”
Most people get excited in the presence of celebrities and other important people, and psychiatrists are no exception. In 1964 a psychiatric journal first described the challenges of caring for the rich and famous in an article on this VIP syndrome. Whenever VIPs—whether they’re rock stars, politicians, or other well-connected individuals—seek medical care, they don’t always get the best. In fact, often their care is substandard. Important patients may attempt to micromanage their physicians, and some doctors may be too starstruck to disagree with the patient. There have been doctors of VIPs who have been known to overmedicate, underdiagnose, and even get lured into their patients’ social lives.
At that point in my career, I had taken care of enough VIPs to know about my own emotional reactions to them and the importance of remaining impartial and professional. And even though some VIPs impressed me—after all, I am human—I simply didn’t let those feelings affect how I dealt with my patients.
At 5:45, my town car pulled through the studio gates and my driver simply waved to the guard as he drove me toward the main building and parked in front. There were huge soundstages scattered behind the main offices, and lots of people hurrying about. The driver told me Mr. Wiley’s office was on the third floor, and he’d be waiting for me when I returned.
Once I entered the building, it was quiet. I rode the elevator up to the third floor, and the doors opened into a large sitting area with several sofas, overstuffed chairs, and coffee tables strewn with industry magazines. Tracey jumped up to greet me and offered coffee, tea, or water. I asked for water, and she brought me a chilled glass. She said Mr. Wiley was on his way up and would arrive in a moment.
I glanced at the Hollywood Reporter and noticed that Total Recall was still grossing big at the box office. The elevator opened and Greg sprang out in his racquetball clothes. He was sweating profusely and taking the last swig from a large Evian bottle. He motioned for me to follow him into his office and tossed the empty bottle into the trash. Tracey closed the doors behind us.
As I looked around the office, I was impressed by its size and its Art Deco décor. He grabbed another water bottle from the fridge in his bar and invited me to sit down on a couch. He sat across from me on another.
“I really appreciate your coming over here this afternoon.” He paused to wipe his face and neck with a towel and swig some more water. “I’m sorry for the late notice, but it’s been a crazy day.”
“No problem, Greg.”
“Man, I had an incredible game today. I kicked the asses off two guys from development.” He leaned forward and spoke in a quieter voice, “But I have to tell you about this weird feeling I got on the court today.”
“What kind of weird feeling?” I asked.
“You know how I said that sometimes I can beat my boss but I don’t?” I nodded and he continued, “Well, I got the feeling today that these punk development guys were letting me win. There were a couple shots that were gimmes, and they didn’t take them. You think they’re trying to push me out?”
Was Greg’s suspiciousness escalating to paranoia? I recalled strolling around the golf course with Larry Klein because of his suspicions about others listening in, but in Greg’s case, his fears seemed to be intensifying rapidly—was he going off the deep end?
“Look, I’m not in show business, Greg, but it seems unlikely that somebody from development would have a shot at your head-of-production job.” I was trying to give him a dose of reality, but he didn’t seem to hear me as he guzzled down more water.
He toweled off again as he walked over to the closet and changed his shirt, almost as if he’d forgotten I was there. He sat back down and asked, “What were we talking about?”
“Your racquetball game.”
“Oh yeah? Forget it,” he said. “You know, I’m feeling a little bit slowed down right now. What do you think is causing this mental fogginess?”
“I was wondering if you have a regular afternoon meeting with somebody who gets under your skin and that may be triggering your episodes. You’ve been talking about your stress and competition at work, and your mental lapses always occur later in the day.”
He thought for a long moment, “Sorry, Doc, it’s this brain haze slowing me down.” He paused, then continued, “Actually it’s my morning meetings that are really stressful. That’s when we look at the numbers and see how the pictures are performing. And Mondays are the worst, right after the weekend, or Tuesdays if it’s a three-day. In fact, I have the least stress in the afternoons—that’s when I play racquetball.” Greg tilted his head back and finished off his Evian.
Something suddenly occurred to me as Greg put the empty bottle on the coffee table. “How many of those do you drink a day?” I asked. He had a blank look in his eyes and didn’t respond. “Greg? Greg, can you hear me?” I was worried. He was having difficulty focusing on our conversation. “Greg?”
I practically shouted.
“What?” he asked.
“I said, how many bottles of water do you drink a day?”
“I don’t know,” he finally answered. “I drink a lot when I play ball. I sweat like a pig.”
As Greg walked over to the bar to grab another water bottle, my leading diagnostic theory for his mental lapses suddenly shifted from work-stress to polydipsia, also known as compulsive water drinking. The relatively rare condition can lead to water intoxication or poisoning. What happens is that the amount of water that the patient ingests exceeds the amount the kidneys can excrete. As a result, the body’s sodium level dives, which can lead to a variety of symptoms, including confusion, disorientation, and psychotic behavior. If left untreated, the mental symptoms escalate to acute delirium, drowsiness, and even coma. When severe, the illness can be fatal. During my residency in Boston, I treated a chronic schizophrenic who had psychogenic polydipsia. We had to watch her constantly so she wouldn’t sneak over to the water fountain and suffer an episode.
Greg’s water intoxication was different and associated with over-exertion and heat stress. Some athletes are at risk for water poisoning, but they can usually avoid it by consuming sports drinks with added electrolytes rather than straight water during practice and events. It’s critical to recognize the condition quickly to prevent severe hyponatremia, or low blood-sodium levels, which can cause cerebral edema or brain swelling.
Once I realized the potential danger Greg could be in, I knew I had to act quickly. I followed him to the bar and said, “Stop, Greg. Don’t drink that water. I think I know what’s causing your brain fog.”
He was holding another chilled Evian and said, “Great, I want to hear all about it. I just need another sip of water—I’m thirsty as hell.” He lifted the bottle, and just as he was about to drink, I grabbed for it and knocked it out of his hand. It spilled everywhere.
Greg backed away. “What the hell is your problem?”
“It’s the water,” I said. “You’re drinking so much that it’s poisoning your brain.”
He laughed as he grabbed a dry towel. “That’s the craziest thing I’ve ever heard. Water’s the healthiest thing you can drink.”
“Do you have a clinic or infirmary here at the studio?” I asked.
“Of course we have a medical clinic.”
“Okay, prove me wrong. Let’s get you a blood test right now and see if your sodium level is low.”
He picked up the phone. “Tracey, get the nurse over here right now. I need a blood test, stat.” He put down the phone and smiled. “I always wanted to say that. I’m kind of tired, Gary. I think I’ve got to lie down on the couch for a few minutes.”
His fatigue only worried me more since it’s another sign of low blood sodium. “Once we get your blood drawn, we should get some salt in your system right away.” I opened the door and asked Tracey to get us some chips, pretzels, and Gatorade from the commissary.
As I waited for the nurse to come, Greg remained spaced out on the couch, eyes open but not speaking. In what seemed like much longer than the five minutes it actually took, Tracey finally escorted in a studio nurse carrying a blood-test kit. I motioned her toward Greg, and she quickly tied a tourniquet around his upper arm and drew ten cubic centimeters of blood into a test tube. I gave the nurse my card and instructed her to have the lab call me with his electrolyte results as soon as they became available, probably a couple of hours later. Tracey placed a basket of assorted chips, crackers, and pretzels on the coffee table, along with four bottles of Gatorade, as she left with the nurse.
I opened a pack of saltines and urged Greg to eat a few. After downing a pack of crackers, he sat up and grabbed some pretzels. Halfway through the bag, he said “Man, Gary, that was one of the worst episodes I can remember. You came all the way over here for a session, and I completely spaced out.” He took a sip of Gatorade and made a grossed-out face.
I was relieved that Greg had snapped out of his fog. His rapid turnaround convinced me that my diagnosis was correct, but we’d have to wait for the blood results to know for sure. It was getting late, and I wanted to head home. I told Greg to take a break on the water and the racquetball for now.
Later that evening, I got a page from the lab with his blood results. As I had suspected, his sodium level had been abnormally low. His medical records hadn’t shown any abnormalities because his earlier blood tests had never been taken after one of his games when he drank water excessively.
I felt triumphant—I had finally figured out the cause of his mental lapses. The clues had been there, but I just hadn’t pieced them together until I saw him after a game. I had to actually witness my patient in the midst of a potentially fatal episode of water intoxication before the correct explanation came to me and I took action. Had I been too distracted in my search for an elusive interpersonal trigger, some kind of work stressor, when I should have been digging deeper for a medical cause?
Earlier in my career, I probably would have been tough on myself about taking so long to discover Greg’s polydipsia. But my years of practice had given me some perspective. I knew that cases like Greg’s were complex. Sometimes we never do figure them out. When I discussed the outcome with Larry Klein, he patted me on the back and praised me as if I was some kind of diagnostic hero. It felt good.
A FEW WEEKS LATER, GREG RETURNED TO my office for a follow-up visit. Dressed in his racquetball clothes and carrying a duffel bag, he was clear-eyed and eager to get started.
“Gary, believe it or not, thanks to you, my game has gotten better,” he said.
“That’s great. You look pretty focused for having just finished a game. Any more brain-fog symptoms?” I asked.
“No, thank you very much, and you know how I was throwing games with my boss? Well, guess what? I just beat him, badly, and he loved it. He even hugged me after the game.”
“I guess he really is your friend,” I said. “How’s it going with those junior executives?”
“I don’t even care anymore. No one can do my job like me. Eventually, one of those guys will take over when I become head of the studio, and I wish them luck because it’s a hell of a lot of work.” Greg pulled a towel from his duffel and wiped his perspiring brow. “Man, I’m parched.” He reached into his duffel bag and I winced, worried that he’d fallen off the wagon with his water-drinking problem, but he pulled out a bottle of Gatorade, took a swig and said, “This stuff actually grows on you.”
Later that evening, I was stuck in Coldwater Canyon traffic as I tried to call Gigi to tell her I’d be late for our Thursday-night dinner. As usual, I couldn’t get a phone signal in the canyon. Typical for L.A., the priciest, most exclusive neighborhoods had the worst cell phone coverage. Twenty minutes later, I showed up at La Loggia. Gigi had ordered me a glass of cabernet, and the bread basket was completely empty.
I took off my coat and sat. “Let’s have a toast.”
We clinked glasses. “What exactly are we toasting, Dr. Small?”
“I think it would be more appropriate to address me as Associate Professor Small,” I announced with a big grin on my face.
She stood, put her arms around me, and gave me a big kiss. The waiters applauded. “You know,” she said, “something about that associate professor title makes you really hot. Why don’t we get a pizza to go?”
As we finished our drinks and waited for the pizza, I told her how I had responded to each of the promotion committee’s queries and relished every detail of my victory. Larry Klein’s advice—never rule out the simplest possibilities—had paid off with my achieving tenure. It was also the answer to finally diagnosing my patient’s drinking problem. Over the years, I’ve kept that little mantra in mind, and it’s served me well.
CHAPTER ELEVEN
Dream Wedding
Spring 1997
IT HAD BEEN A DRY WINTER in L.A., but finally in late March we got some rain. As usual, Southern California drivers went crazy as soon as the first drop fell fr
om the sky. Thanks to a fender bender on the 134 freeway, I was stuck in traffic after giving a lecture in Pasadena. I hadn’t eaten anything all day and was just hoping to make it back to the office by the time my new patient arrived at 1:00 P.M.
I whipped into my regular UCLA parking space, hopped out, and grabbed my umbrella. As I opened it, a gust of wind bent it backward and broke it, so I tossed it into a trash can and ran for the building. As I passed the cafeteria, I checked my watch and decided to grab a sandwich on my way up to the office.
I unlocked my office door and hung my soaking raincoat on the hook behind it. I had moved into a bigger space after making associate professor and getting tenure. I had larger windows and more light, a sitting area with a couch and three chairs, and my kids’ drawings decorating the walls. I also had an outer office with an assistant answering my phones.
I still had a couple of minutes to wolf down my sandwich, so I squirted some mustard on it, which went directly on my tie. Holding my turkey and Swiss with one hand, I took a giant bite as I pulled off my tie with the other. My intercom buzzed and my assistant announced my new patient, who, of course, was right on time. I asked her to show him in.
The patient was Dr. Bruce Rifkin, a prominent Beverly Hills plastic surgeon. From our brief phone conversation a week earlier, I’d learned that he wanted to meet because he was having trouble sleeping. He also mentioned that he was forty-eight, had never been married, and was now engaged.
“Hello, Gary. I’m glad we were able to get together so quickly. My schedule is crazy, and I’m sure yours is too.”
We shook hands and I motioned to the couch. “Please, have a seat, Bruce.”
He laid his designer raincoat over the back of a chair and sat down. He was lean, tall, and wore a pin-striped suit, complete with cuff links, pale-blue dress shirt, and matching pocket handkerchief—he looked as if he’d stepped straight out of GQ magazine.
“My internist tells me you know your psychopharmacology, and I understand that you also do some geriatrics. As a plastic surgeon, I guess that’s one of my specialties too.”