by The Naked Lady Who Stood on Her Head: A Psychiatrist's Stories of His Most Bizarre Cases
Brenda believed that the early death of her father was at the root of all her problems. He had a malignant brain tumor and died when she was twelve, and her mother went into mourning for the next forty years. No doubt her father’s death had an impact on her, but I suspected that her mother’s inability to feel empathy for Brenda was an even more powerful force behind Brenda’s psychological isolation and low self-esteem.
The description of her mother’s narcissism and withholding personality was striking. I remembered Brenda telling me about an incident when she was seventeen. She came home a half hour late from a date, and her mother was so furious that she didn’t speak to Brenda for a week. During our earlier therapy, Brenda was not ready to grasp her mother’s contribution to her problems. It was all about her father dying and her mother’s heartbreaking loss, and then Brenda’s bastard husband not understanding.
“How does your mother feel about Richard?” I asked.
“Well, she loves that he’s a high-profile lawyer. In fact, he’s really the first man in my life she’s ever approved of. And she’s always excited if he gets on the news or something. She brags about it to all her friends. But if I tell her we had a fight or something, the first thing she says is ‘What did you do now, Brenda?’ I hate that. It’s as if Richard is all great, and I’m just lucky to have him. She thinks marrying Richard is my finest achievement in life. She doesn’t even acknowledge my work.”
It looked like Brenda was welling up with tears, so I handed her the box of tissues. She took it from me, appearing embarrassed to have revealed her mother’s power over her.
I was beginning to get a sense of what Brenda considered her crisis. She was finally getting her mother’s approval through Richard, but her marriage was on the rocks, and now she feared losing that approval. This crisis might be an opportunity for her to understand why she had issues getting close to people—whether it was her husband, her mother, or her therapist. She was in enough pain to be motivated to get help, and it was my job, actually my challenge, to offer that help without frightening her away.
During the rest of the session, Brenda reassured me that her eating struggles were over—she had been at her current weight for the past five years. We discussed a therapy plan and found two regular times to meet each week.
Saturday morning after breakfast, I was getting my son, Harry, ready to go to his friend’s house for the day. Gigi showed Rachel the purse she had gotten at the Gap as a birthday present for Caroline. Rachel thought it was cute. They wrapped it together and made a card. I left with Harry to drop him off and did some errands for the house—bought lightbulbs, dog food, and new hedge trimmers. I stopped by the office to catch up on my e-mail, and before I knew it, the day had slipped by.
When I returned home, I stepped into a crisis—Rachel was crying in her room, and Gigi was slamming cabinets in the kitchen.
“Honey, what’s going on?
“Well, Rachel went to the party and everything was fine. Caroline opened up her present and loved the Gap purse. But the next present she opened was a Coach purse,” she said.
“Aren’t those sort of expensive, grown-up purses?” I asked.
“Yes, it’s a ridiculous gift for a twelve-year old,” Gigi answered. “But that seems to be what the kids are giving each other on the Westside. So of course, Rachel was embarrassed by her present, and now she’s mad at me. I tried to explain to her that the Coach bag was inappropriate, but she doesn’t care. She has no clue about value and prices, and she just wants to fit in with her peers.”
“Is that so bad? Don’t we all want that?” I asked.
“Sure, but she goes to this fancy private school with a bunch of spoiled rich kids, and she has to understand that we don’t have that kind of money—and that money isn’t everything.” Gigi poured a glass of wine and sat down at the table. “Maybe it’s our fault for sending her to that school.”
“This kind of thing happens at every school,” I said. “We’ve got to teach our kids this lesson sometime. Why not now?”
“I guess, but I’ll never give a Coach bag to a twelve-year-old, no matter what.”
I was surprised at how early in life shopping becomes an issue, especially for girls. They learn that brand recognition as well as high price stands for greater status, even if it’s not a better product. Of course, it’s true for men too—show me a guy who doesn’t want to wear an Armani suit and drive a Ferrari. We’re constantly bombarded by ads with beautiful models using or wearing the coveted items—no wonder even kids want them.
WHEN BRENDA ENTERED MY OFFICE THE following week, she was wearing another designer outfit and black alligator pumps. She didn’t waste a minute before complaining about her husband. “Look, I can see Richard for who he is—essentially, an emotionally immature micro-manager.”
“Did you have any clue of that when you married him?” I asked.
“Of course not. I was in love with him. He treated me like a princess; he never criticized me. But now he doesn’t stop with the criticisms.”
“That must be hard to live with,” I said.
“It can be, but I know how to handle him.”
“What about your mother? Does she try to micromanage you?” I asked.
“Of course not. She’s just eighty years old and lonely. Is that a crime?”
Brenda was still unable to see any faults in her mother. For some reason, she needed to keep her mother on a pedestal.
“Brenda, it strikes me that you have a hard time seeing any flaws in your mother, as if you have to protect her.”
“What are you getting at, Dr. Small?”
“You know, she was very critical of your first husband, and eventually the two of you broke up,” I said.
“We broke up because he was a jerk. It had nothing to do with my mother.” She started to fuss with her scarf. “By the way, what do you think of this cashmere wrap? I was early, so I stopped at the mall and did some shopping. Isn’t it gorgeous?”
It seemed like every time we were on the brink of an insight, Brenda changed the subject, usually segueing into a recent shopping adventure—likely a smokescreen for the real issues that disturbed her. Throughout the initial weeks of therapy, I went easy on my interpretations; probing her unconscious too deeply might stir up more anxiety than she could bear. Instead, I acknowledged her difficulties and frustrations in order to gradually build a therapeutic alliance. Brenda seemed to have no awareness of how she kept people from getting too close, but her ways of maintaining distance were becoming clear in our therapeutic relationship. If she didn’t run away from intimacy, she maneuvered others to keep away.
A couple of weeks later, Brenda barged in ten minutes late for her Tuesday-afternoon appointment. She was out of breath and balancing several large department-store bags in her arms. She collapsed on the couch and apologized for being late.
“I actually was early,” she said, “so I popped into Neiman Marcus for a few minutes.”
“Tell me, Brenda, when you went to Neiman’s, how did it feel? What does it feel like when you’re on a shopping spree?”
She looked at me quizzically. “Well…It feels good. I feel powerful…energized. I’m the one in charge, and everybody around me is waiting with bated breath for my decision. And I don’t have the responsibility of an entire ad agency looking over my shoulder. Sometimes I buy things I don’t even like just to get that giddy feeling of control over all those sales-people. And when I really want something, it’s even better. When I touch it and look at it and try it on, I get goose bumps. There’s the thrill of the hunt and the catch. It’s like sex, but better, at least sometimes.” As she spoke, she was entranced. Her face had a far-off look. It reminded me of an alcoholic describing his first drink.
“Does the feeling last?” I asked.
“Well, no, not really. Not after I get home and put the things in my closet. If I wear something new and sexy for Richard, he just wants to know what it cost. I actually end up taking a lot of my purchases
back, but it’s embarrassing, even though I often feel relieved.”
“Really,” I said.
“Well, yes, those thrilling catches quickly lose their luster,” she said.
I figured that all this shopping and returning must have taken up hours of Brenda’s free time and had become an effective way for Brenda to avoid her underlying psychological problems. Apparently, Brenda had replaced her eating addiction with a shopping addiction. The technical term is oniomania, derived from the Greek onios, “for sale,” and mania, “madness.” Her impulsive and obsessive behavior traits had latched onto a new objective—shopping and returning. Brenda was not yet aware of how her addictive tendencies had landed on a new target. The next step in therapy was to help her recognize and understand the pattern. I didn’t want her to bolt from therapy again, but I had to go for it and push her a little.
“So, Brenda, do you see any kind of pattern here?” I asked.
“What do you mean?”
“Well, you’re no longer overeating, but it seems like you have a new preoccupation—overshopping,” I said.
She shifted in her seat, “What are you talking about?”
“You’ve replaced one addiction with another,” I said tentatively.
She looked at me, angry. “You know, you’re sounding like one of those TV shrinks. Don’t you think your theory is a little too pat, Dr. Small? When I start hearing psychobabble, I just want to quit therapy again.”
“I don’t think that would be a good idea, Brenda.”
“I am not a shopaholic, or whatever you call it. It just relaxes me.” She reached for her purse, and I thought that was that, she was leaving, but she pulled out her cigarettes instead. “Screw your no-smoking rule.” Her pack was empty, so she crunched it up in frustration and shoved it back into her purse. She fished out some gum and started chomping on a couple of pieces.
I was relieved that she hadn’t left the office, and not surprised by her defensiveness. Brenda had admitted that she left therapy the first time because of my so-called psychobabble, not because she was cured. Perhaps we had a chance to make some headway here.
“It’s hard for any of us to honestly look at ourselves. I think for you, Brenda, it may be tough to admit that you have control struggles. It comes up in many areas of your life—food, clothes, work, relationships.”
She looked amused. “You really think you know what makes me tick, don’t you?”
“It’s worth a shot to consider what I’m saying. Your description of what drives you to shop is a sense of control, but the feeling doesn’t last. It doesn’t matter what we call it: shopaholism, addiction, compulsion. The first thing to do is admit you’ve got a problem.”
She shook her head and walked to the window. I continued, “Do you see this getting better…or worse?”
Brenda put her gum in a tissue and started to pace. “I don’t know…Of course, Mommy and Richard don’t approve. It has that going for it.”
“In my experience, people don’t deal with addictions until there’s a crisis and they’re forced to. Do you want to wait until you’ve driven Richard away, you’re in debt, and you’ve possibly put your career at risk?”
Brenda stopped pacing and said, “Of course not. I’m just a worrier and shopping relaxes me. But I admit that when I get home, I feel bad, remorseful even, and I want it all to go away. Richard gets so down on me about my shopping. I figure if he’s going to give me so much grief about it anyway, I might as well just shop. Well, that’s how I feel with this stupid shopping and Richard’s reaction to it. It’s gotten to the point where I have to sneak bags into the house. He thinks every minute I’m not working, I’m shopping. And you know what? Maybe it’s true.” She sat back down on the couch, looking defeated. “I guess I am messed up. I need help, Dr. Small.”
I was relieved. Brenda had finally admitted to her addiction and had asked for help. Now we could start working. Within the next two weeks, she began attending a Debtors Anonymous twelve-step program. She told me that at first the meetings seemed hokey, but after a while, talking with other shopping addicts made her feel understood. The others in the group really grasped the highs that came from shopping, as well as the shame and then relief that came from returning. Some of them, like Brenda, had suffered from other addictions, like alcohol or food, and had moved on to shopping. In addition to group meetings and therapy with me, I started her on a low dose of the antidepressant Wellbutrin, which helped lift her mood and quell some of her obsessive behaviors.
The neural pathways in the brain that reinforce dependence on alcohol or drugs also control compulsive behaviors focused on nearly any source of pleasure, including food, sex, shopping, and gambling. When something would trigger Brenda’s urge to shop, her brain and other organs would automatically react to the image of the coveted purse, shoes, or dress—her heart rate would slow and brain blood vessels would dilate, a physiological reaction that focused her mind on the object of desire.
Brenda’s shopping had all the trappings of a full-blown addiction—just describing a spree brought on a pleasurable rush. These euphoric feelings are linked to brain chemical changes that control all addictive behaviors and involve the neurotransmitter dopamine, a brain messenger that modulates both reward and punishment. The addict compulsively seeks, craves, and re-creates the sense of elation. Dopamine transmits messages to the brain’s pleasure centers, causing addicts to want to repeat actions over and over again, even if they are no longer experiencing the original pleasure and are aware of negative consequences. And as any addiction takes hold, the brain’s frontal lobe, responsible for decision making and judgment, loses ground. My goal in therapy was to provide Brenda with enough insight and reason to hold the dopamine pleasure centers at bay.
As Brenda’s therapy progressed, we delved more into the stressors in her life that made her anxious and triggered her impulse to shop. She also began to see how much she craved her mother’s approval, and Richard’s as well. Brenda stuck with her twelve-step program, her symptoms improved, and she even quit smoking. I suspected the Wellbutrin helped with that.
It still wasn’t clear to me why Brenda’s shopping obsession was so extreme. Many women love to shop. I know Gigi certainly enjoyed shopping, and even my preteen daughter was getting into it. But they didn’t shop beyond their means and usually only shopped when they needed something. To some extent, they must have felt some of the highs and lows that Brenda described, but they weren’t addicts—as far as I knew.
ABOUT EIGHT WEEKS LATER, I TOOK MY regular Wednesday walk into Westwood to have coffee with Charlie Simon. We had been friends throughout our UCLA geriatric psychiatry training, but Charlie had decided to go into private practice. We got together periodically over the years and often reminisced about our earlier, carefree days, when we both had more time and less responsibility. It also gave us each a chance to catch up on what was going on in our respective worlds—private practice versus university life.
Charlie was waiting for me at Starbucks, reading the L.A. Times sports section. His neatly trimmed gray goatee matched his thick white hair. He never seemed to age, in part because his hair had turned completely gray in his early thirties.
He took a sip of his coffee. “It’s sad…this is my midmorning indulgence—a nonfat latte with Sweet’N Low to wash down my Lipitor. I miss those days when we’d sneak off to the Apple Pan, inhale hickory cheeseburgers, and chase them down with pecan pie à la mode. We drank real Cokes back then.”
“Charlie, you were already a Tab drinker when I met you. I remember, you liked the chemical aftertaste,” I said as I put my briefcase on a chair next to his and went to order an espresso. We chatted about the good old days, family, work, and vacation plans. Charlie pointed to an ad in the paper. “My wife will definitely be hitting this Robinson’s sale. She’ll probably run into my new patient there, too.”
“Oh yeah?” I said.
“I’ve been treating this shopping addict for the past few weeks,” Charl
ie said.
I flashed to Brenda before she had gotten help with her addiction.
Charlie continued. “This woman shops and returns the stuff like crazy, and still manages to hold down a full-time job.” Now I was intrigued. Was there an epidemic of Westside shopaholics hitting Rodeo Drive after work?
“That’s weird,” I said. “I have a patient who was hooked on shopping and returning stuff after working at her ad-agency job.”
Charlie looked me in the eye. “Okay. Ad agency. But did she have an eating disorder before she had a shopping disorder?”
“Oh, man,” I said. “You think we’re treating the same patient?”
We didn’t discuss her by name but exchanged descriptions of Brenda’s physical attributes. The similarities were unmistakable.
“Holy shit,” Charlie said. “It’s got to be the same person.”
I couldn’t believe it. Brenda was “cheating” on me with another psychiatrist, and not just any psychiatrist, but my old buddy Charlie.
Getting a second opinion during psychotherapy can be helpful when there’s an impasse, but this is usually done with the awareness of the therapist. What else was she doing behind my back? My mental ramblings sounded like those of a jilted lover. Brenda was obviously still having trouble facing the truth. But now she was holding it back from me and from Charlie.
“This is definitely a first for me,” Charlie said.
“I think I need to have a little discussion with my patient.”
Charlie smiled. “Fine, you first.”
Walking back to the office, I felt like calling Brenda that minute and confronting her. No wonder Richard and Mommy called her all day. I was learning about yet another one of her ways of manipulating the people around her.
As I crossed the street from Westwood Village onto the UCLA campus, I took inventory of my reactions to Brenda’s dual-therapy stunt. I felt angry, used, and like my time had been wasted. She was full of it about her twelve steps to sanity, and she was pulling the wool over our eyes. I knew my responses were coloring my take on Brenda’s deception. This was all part of her way of dealing with her discomfort—she would create emotional turmoil in those around her, getting them all worked up about her behavior. In that way, she got them to show concern about her, and she didn’t feel so alone.