by The Naked Lady Who Stood on Her Head: A Psychiatrist's Stories of His Most Bizarre Cases
“Fine, thank you.”
“Excellent,” he said. “Ahmed, please bring us some coffee and water.” Henry put his book down and pointed to another overstuffed chair. “Have a seat.”
“Thanks,” I said, sizing him up. So far, he didn’t seem like a crazed, maniacal, paranoid psychotic.
“From what my siblings said about me, you’re probably surprised that I agreed to your visit,” Henry said.
“They were concerned about how you’re doing—they haven’t seen you for some time,” I said.
“Yes, I’m sure they expressed their deepest concern—speaking in tandem as usual. They’ve seen eye to eye for years and haven’t allowed me into their little club,” he said bitterly.
“I’d like to hear more about that,” I said as Ahmed came in with the coffee and water.
“Thank you, Ahmed,” Henry said. Ahmed left the room and closed the doors quietly behind him.
“My sister and I used to be close when we were little,” Henry said. “We had great fun playing games like hide-and-seek, or baking with Father. We made these incredible chocolate-chip cookies. I’ll never forget them. But something changed as we got older. Carolyn and William started ganging up on me, and I guess things have stayed that way ever since.”
“You must have felt pushed out,” I said.
“Yes, I felt excluded, alone,” Henry said. “But I suppose it’s typical sibling rivalry. I’m sure it happens in all families. I know Father felt sorry for me and tried to make up for it, but I think that only made them exclude me more.” He sipped his coffee and added, “They’re not really concerned about me, you know; they want something—most likely control of the estate. What did they tell you, that I was lazy? Or maybe they said I was crazy.”
“They didn’t use either of those terms,” I said. “But they did want me to try and figure out what was going on with you, to see if I could help.”
“Well, there’s definitely something going on with me, but I don’t think they have the slightest idea about it.” He poured both of us a glass of water and said, “And I certainly hope you can help me. That’s why I agreed to see you.”
I finished off my coffee. “Tell me what’s wrong.”
“It’s simple,” Henry replied. “I can’t leave this house.”
The phone rang and it was Carolyn. As Henry spoke with her, I noticed the spectacular view outside. I watched an eagle circling a large pine tree, apparently homing in on potential prey scurrying about in the snow. As I listened to Henry, I anticipated the eagle making a dive.
“Yes…he’s here now…He just arrived…Fine, I’ll put him on the speaker.”
“Hello, Dr. Small, it’s Carolyn.”
“Hello, Carolyn,” I said.
“I just wanted to make sure you got there all right.”
“Everything’s fine,” I said toward the speaker. “We’re just getting to know each other.”
“Look, Hank,” she said. “I know you must be wondering why we asked Dr. Small to come up there. It’s because we love you and we want to be sure you’re okay.”
Hank smirked, not buying a word of it. “Thank you, Carolyn.”
“Dr. Small, could you pick up, please?” Carolyn asked.
Hank motioned and said, “Go right ahead.” He went back to his book. Not the kind of response you’d expect from a paranoid psychotic.
“Yes, Carolyn?” I asked.
“I’m relieved that it sounds civil there,” she said. “But how bad is he really?”
“Carolyn, I just got here. The trip was very comfortable, and we’re getting along fine. Thank you for checking in.”
“All right, I get it, you can’t talk right now. I’ll go. I don’t want to make him any more paranoid than he already is. Call my cell if you need anything.”
I hung up and thought about her contribution to the family dynamic. It struck me that it was much more convenient for William and Carolyn to focus on Henry’s mental issues than their own. At the moment, Carolyn seemed more paranoid than Henry.
Henry put down his book and looked up at me. “Now, where were we?”
“You mentioned you can’t leave this house,” I said.
“Right. Every time I try to step out the door, my heart starts racing and I can’t catch my breath.” He paused. “I feel like I’m going to die, and I’m overwhelmed with terror. In fact, it’s gotten so bad, I can’t even go into the entry hall without hyperventilating.”
“When did all this start?”
“About a year ago. I was in a camera store in town, and suddenly my heart started pounding. I had to sit down so I wouldn’t pass out. After about five minutes I was fine. But when I went back to that store the next day, it happened again. After the second attack, I could never go back in there.”
“When did it happen next, Henry?”
“Please, call me Hank,” he said. “I’m not exactly sure when it happened next, but I remember starting to feel panicked in other places. Restaurants, the bank…the attacks seemed random. My doctor checked me out and couldn’t find anything wrong with me, so he suggested I get some rest. After a couple of weeks of taking it easy at home, I asked Ahmed to drive me to the bank. But once we left the grounds, my heart started racing so badly that we had to turn around. I haven’t been able to leave the property since. I’ve tried many times to get out, but I know I can’t leave the house without having an attack.”
Hank’s diagnosis was no mystery. He was describing a classic case of spontaneous panic attacks with secondary agoraphobia. These patients initially experience physical and emotional symptoms of panic that seem to come from nowhere and end abruptly. Sometimes there’s a physical condition that triggers the attacks, such as a heart flutter from mitral-valve prolapse. Other times the patient has a genetic predisposition for panic.
What Hank described was a typical scenario for a patient with spontaneous panic attacks. He associated the location of the initial attack as its cause, so he avoided that location and other places where attacks occurred. This learned response developed into a phobia about these places, and over time his movements became more and more restricted. Eventually, for patients like Hank, if full-blown agoraphobia develops, they become housebound. I reflected on how Hank’s photography display in the hallway gradually transitioned from expansive outdoor scenery to more restricted indoor close-ups, reflecting the progression of his phobias.
Despite their dramatic and debilitating consequences, panic disorder and agoraphobia respond well to treatment, usually to a combination of antidepressants and desensitization psychotherapy. The medication eliminates the panic attacks, and the therapy helps the patient gradually overcome his fears of the outside world.
I spent several hours with Hank that afternoon learning more about his condition and background, before he became too tired to continue. We planned to resume over breakfast the next day, and Ahmed drove me to my hotel.
I entered my luxurious suite at the lodge and saw that a wood fire was already burning. I unpacked, took a shower, and called room service to order dinner and a glass of wine. Settling back on the four-poster bed, I called Gigi to gloat.
“You’ve been skiing. I can tell from your voice,” she said, half joking but with an accusatory tone.
“That’s absurd. How can you tell that from my voice?” I asked, feeling guilty for no reason and deciding not to mention the fireplace.
“Because you’re tired. You get tired when you ski,” she said. “And do you have a fireplace in your room?”
“No, no, that crackling is just a bad connection.” She was silent. “Okay, I have a fireplace. And the room is incredible, but you should see my patient’s compound! And that private jet! Oh my God!”
“All right, I get it,” she said. “I miss you and the kids miss you. When are you coming home?”
“Hopefully, tomorrow evening.” I paused, then said, “I have to tell you, honey, all the money in the world can’t buy happiness or love.”
“Ar
e you okay?”
“I’m fine,” I answered. “But it’s sad that this incredibly wealthy family is so distracted by their money that it splits them apart and they can’t get close. They talk about caring for one another, but they let years go by without seeing one another.”
“Do you think you can help them?” Gigi asked.
“I’m going to try. I think the younger brother will get better once he’s in treatment. Whether I can help him have a real relationship with his siblings, I don’t know.”
IN THE MORNING, THE BREAKFAST ROOM AT Hank’s estate was sunny and overlooked a ski run below. The meal was a healthy mix of egg-white omelets, fruit salad, and oatmeal.
“You know, the view is spectacular from here,” I said as I realized Hank always sat facing away from the windows.
He smiled. “I used to appreciate it more, but since my attacks began, I can’t stare out the window too long or my heart starts speeding up.”
“This condition has really restricted your life,” I said.
He seemed sad. “You know, I’ve felt alone so much of my life, and now that I want to get close to other people, I’m stuck in this house. Frankly, I’m ashamed of my situation.”
“Is that why you haven’t told your family about your symptoms?” I asked.
“I suppose so. It’s humiliating. I’m a grown man terrified of stepping out my own front door…or even looking out the window, for God’s sake. If I were stronger, I’d be able to overcome these feelings.”
It has always amazed me that people feel such a stigma about their psychiatric conditions. Most people wouldn’t feel embarrassed if they had a broken leg and needed help. Despite the remarkable advances in psychiatric diagnosis and treatment, many still believe that mental illness is a sign of personal weakness and something to be embarrassed about.
The effects of these attitudes can be devastating. Patients feel self-doubt and shame, so they isolate themselves. Many who would likely respond to treatment pretend that nothing is wrong and refuse help. They are often rejected by family and friends and discriminated against at work. Health insurance companies have even bought into these biases and routinely provide lower reimbursements for mental conditions compared with physical ones. Advocacy groups such as the National Alliance on Mental Illness (NAMI) have made efforts to correct these stereotypes, but there is still a long way to go. Hank’s shame about his condition kept him from getting the help he needed.
“Hank, you’re not alone in those feelings,” I said. “But having a psychiatric illness doesn’t mean that you’re weak-willed. Conditions like yours, like any medical illness, have a significant physical component. And as you said, a part of you believes I might be able to help you.”
“Do you think you can, Dr. Small?” he asked.
“Yes. In fact, I know I can. You have a classic case of spontaneous panic attacks. And as you’ve described, they come out of nowhere and go away quickly. We can easily diminish or even cure the attacks with an antidepressant like Zoloft or Prozac.”
“But what about my fear of leaving the house?” he asked.
“That can be treated too, but differently,” I said. “What’s happened is that whenever you anticipate being in a place where you’ve had a panic attack, you avoid it. And you’ve developed agoraphobia, a fear of leaving your house, which is common in people with panic attacks. We’ll get you started on a desensitization program and gradually teach you to remain calm in normal situations.”
“I get the medication part,” he said. “But I’m not so clear on this desensitizing thing.”
“The way it works is you’ll literally make a list of places and situations that you currently fear, then rank them according to the degree of anxiety you experience with each, say, on a scale of one to ten.”
“So, if walking into my own foyer rates a five, then going to a restaurant would be off the scale, right?” Hank asked.
“Exactly,” I said. “You’ll learn relaxation exercises, and you’ll gradually be exposed to the least anxiety-provoking situations first. As you get comfortable with those, you’ll eventually work your way down the list to the scarier stuff. You’ll probably start feeling better the first week you take the medication, and soon you’ll be able to overcome the phobias.”
“So it’s psychotherapy with training wheels. Are you going to be able to stay here for this?” he asked.
“I can get you started,” I replied. “But I know of several qualified therapists close by who have a great track record with this type of therapy.”
“It’s definitely worth a try,” he said. “I can’t keep going on like this. It’s no way to live.”
“What may be more challenging,” I said, “is repairing your relationship with your brother and sister.”
“Look,” he said flatly, “I have no relationship with them. I mean, it’s complicated. I was very close with our father—he used to love it up here and visited all the time. Even when we were little he paid more attention to me. Maybe that’s why my sister and I drifted apart.”
“All families are complicated,” I said. “You said you didn’t want your siblings to visit because you were embarrassed about your condition. Maybe they felt snubbed by you.”
“How’s that possible? They’ve been snubbing me for years,” he said.
“That may be, but you are the one refusing to see them now,” I said. “You and your father were very close. Carolyn and William may have envied that connection.”
“I guess you have a point,” he said.
“In addition to inheriting your father’s artistic talent, you may have also inherited a tendency for panic attacks from him.”
Many forms of mental illness are known to run in families. Whether it’s schizophrenia, panic disorder, or major depression, complex genetic components have been discovered. Usually more than one gene is involved, and environmental triggers come into play as well. Sometimes a relative inherits only a tendency to develop the illness, which might or might not be expressed, depending on life circumstances.
Identifying a genetic contribution to a psychiatric illness can be tricky, since family members with the disease gene might not develop the illness until later in life. One of the earliest psychiatric genetic studies involved Amish families with manic-depressive illness. The Amish were considered an ideal group for genetic research, since they separated themselves culturally from the general population, making it easier to pinpoint inheritance and factor out other influences. There was tremendous excitement when the genetics were first reported, but the results fell apart years later when several of the supposedly unaffected teens experienced manic episodes.
Of the various forms of anxiety, panic disorder has undergone the most genetic investigation. The condition clearly runs in families, and twin studies have confirmed that it can be inherited. I suspected that Hank had inherited his panic disorder from his father and that perhaps his father’s eccentricities were a related form of anxiety.
“I inherited my father’s traits?” Hank laughed. “That’s a good one.”
“What do you mean?” I asked, confused.
“I was adopted, Dr. Small. My brother and sister don’t know because my father didn’t want them trying to push me out of my inheritance.”
I laughed. “You definitely know how to keep a secret. But there isn’t any controversy over the estate now, so why not tell them?”
Hank smiled. “I suppose it’s childish of me to withhold the truth, but Father didn’t want to tell, and I guess I do get some pleasure from their envy of how close Father and I were. And the fact that they believe I’ve inherited his talent and even his weaknesses probably gets their goats too.”
“But keeping this secret also serves to keep you apart,” I said.
“I hadn’t considered that,” he said.
After breakfast, Hank’s internist came by the house with a copy of his medical records for me to review. I discussed my findings with him, and he performed an electrocardiogram befo
re starting Hank on Zoloft that afternoon. I reached one of the behavior therapists I knew in the area, and he agreed to come up to see Hank the next day to begin desensitization therapy. The rest of the afternoon I helped Hank begin his list of anxiety-provoking situations, as well as determine their rankings.
At that point I considered heading home but felt we had made so much headway, that perhaps one more day would really make a difference. Also, I could meet with the new local psychiatrist and fill him in. Hank understood that his panic disorder was very much a medical as well as a psychiatric condition, and I hoped that some of the stigma he felt around it had lifted. He seemed optimistic about the treatment plan, and the timing might have been right to try to repair the family rift.
“Hank, how would you feel about Carolyn and William visiting you up here?” I asked.
“Well, I’m just starting my treatment,” he said. “Do you think it’s a good idea so soon?”
“You seem to understand that there’s nothing about your symptoms to be embarrassed about. It’s really a medical condition—your body is low in the chemical transmitter serotonin, and Zoloft replenishes that serotonin in your brain so you won’t feel so panicked.”
“That’s true,” he said.
“I think now might be a good time to have them come up and break the ice, especially while I’m still here.”
He thought for a moment, and then said, “Okay. I’ll give it a try.”
THAT EVENING BACK AT THE LODGE, I called Gigi to let her know I’d be staying another night. The phone wasn’t answered immediately, so I thought I would just be able to leave a message. I suppose I felt a little guilty because I was beginning to think about getting in a quick hour or two of skiing while I was up there.
Just as I thought the voice mail would pick up, Gigi answered. “Hello?”
“Hi, honey, how are you?” I asked.
“Good. I got a lot of work done today,” she said. “The kids and I are negotiating bedtimes. I thought you were coming home.”
“I have to stay another night, babe. I’m really sorry,” I said.
“That’s okay, I’ve got to work tonight anyway,” she said. “But listen, I’m on a deadline, and I won’t have time to get to the market tomorrow. Do you think you could stop for some milk on your way home from the airport?”