by The Naked Lady Who Stood on Her Head: A Psychiatrist's Stories of His Most Bizarre Cases
I grabbed the remote from her and shut off the TV. “Forget Entourage and turn off the lights.”
THE FOLLOWING MONDAY, WHEN I TOLD LARRY about his test results, he took it well. In fact, he didn’t seem surprised at all. That day I started him on an anti-Alzheimer’s drug called Aricept, which helps not only with the cognitive symptoms but with the mood and personality changes associated with the illness. Once he was stable on Aricept, I added a second drug, Namenda, which has similar effects and works well as part of a combination treatment. I made sure that the medicine didn’t bother his stomach—if it did I could always switch him to an Exelon patch.
Larry and I kept meeting but cut back to once a week. He became less paranoid, and he was now fine with meeting only in my office. For a while he almost seemed like he was back to his old self. After a few months, he decided to take a break from our friend therapy.
About six months later, Larry came in for a midmorning meeting. He arrived right on time and grabbed himself a cup of coffee before getting comfortable on the couch. He looked like he had lost a couple of pounds, and I wondered if his medications were suppressing his appetite. Aricept and Cymbalta sometimes did that.
“Well, Gary, the Tony Wilsons in this place will think they’ve won, but I’ve decided to retire.”
“What? When?” I asked in disbelief.
“Today. Fuck ’em.”
“Have you thought this out, Larry?”
He wagged his finger at me. “Your problem, my young friend, is you think too much. Anyway, Louise is thrilled. We’re going on a cruise.”
I laughed. “You hate cruises. You said they were like being in a prison that could sink.”
“Yeah, but with Cymbalta on board, I can pretend I’m having fun.” He smiled impishly. “You know I’m good at faking it. Besides, Louise deserves something after putting up with me all these years.”
“Larry, before you just up and retire, why not take a leave of absence, go on your cruise, and think about it when you get back. No matter what your PET scan shows, I’m sure you still have an IQ of at least 140 and a lot to contribute to psychiatry.”
“Look, you and I both know my clock is ticking. Those plaques and tangles are eating up my brain. I could be a total veg in six months.”
Hearing Larry say that suddenly made it seem real. I felt a rush of sadness, but I kept myself together.
Larry noticed I was upset and got more serious. “Look, pal, I know it’s been hard for you to take me on as a patient, but you’re one of the few people in this world that I trust.”
“I appreciate that—it means a lot to me,” I said.
“Well, I’ve been grooming you all these years, and it just happens that dementia is one of your areas of expertise. I have to confess, I suspected for a while that something like this was going on.”
I took a deep breath as his last few statements sank in. “You always were one step ahead of me, Larry.”
“But that’s going to change, and we’ve both got to come to terms with that,” he said.
“You know, Larry. You’ve always been like a father to me.”
“Well, you’ve been like a son, a psychiatrist, and a friend when I needed you most. You helped me to let go of my need to control everything. I feel like now I can move on with what’s left of my life.” He stopped and took my hand. “You have to do the same thing.”
I was overcome with sadness and didn’t know what to say.
Larry stood and said, “I love you, pal. I gotta go.”
I held back my tears as he quickly left the office.
As I expected, Larry failed to take my advice and retired from UCLA that afternoon. I got a few postcards from his Mediterranean cruise, and it sounded like he was truly enjoying it and not just faking it.
WHEN HE RETURNED, LARRY CLOSED UP HIS lab. He still showed up at faculty meetings and teaching conferences from time to time. Our strolls around the Brentwood golf course became less frequent, and I went back to being his old friend rather than his therapist friend.
Aricept and Namenda seemed to hold Larry steady for the next year, but eventually he began to decline. It was hard to watch him slip away, but in his own way, he had prepared me for it.
When I think back on my relationship with Larry over the years, and how much he taught me about my profession and about myself, I know that defining therapeutic and personal boundaries is essential. Those boundaries allowed me to be the best therapist, husband, father, and friend that I could. But in the end, my mentor taught me how boundaries sometimes have to be stretched in order to help those we care about.
What was most unusual about Larry’s case was the complexity of our relationship, which temporarily clouded my vision so much that I missed a diagnosis in my area of expertise. In fact, he was so bright that despite his impending dementia, he recognized it before I did.
In many ways, what I experienced with Larry was not much different from what many adult children go through as their parents age. They have to face the psychological confusion that occurs when their roles reverse and they need to care for their own parents. Many respond with love and empathy, but others experience anger, frustration, and guilt.
After his retirement, Larry occasionally mentioned that he still felt like a fraud, yet now it didn’t seem to bother him. It became a recurring philosophical debate for us. After a while, he came around to see it my way—that those feelings were universal. But I wondered whether I had really convinced him or perhaps his progressing dementia just made him more agreeable. Soon Larry’s cognitive impairment got so bad that we had to stop our walks and eventually Louise had to get twenty-four-hour help at the house. It became hard to visit him and watch my mentor-hero disappear before my eyes.
Even after Larry passed away, I kept his lessons in mind. Whenever I make a correct diagnosis, tolerate my own anxiety, or mentor my own students, I feel Larry with me. And no plaques or tangles will take that away—I hope.
AFTERWORD
WHEN I THINK BACK ON THE unusual cases I have dealt with throughout my career, I’m surprised by how many there were and how hard it was to decide which ones to include in this book. Some were unusual because of the rarity of the diagnoses; others were noteworthy because of the complexity of the relationships and situations. Many had an element of medical mystery, and as a young psychiatrist I sometimes found myself stumbling upon the correct diagnosis and treatment without even realizing it.
Each of these unusual cases—whether it was a mute, naked woman standing on her head or a man who thought he would be more comfortable with only one hand—also contained an element of the usual issues that we all struggle with at some point in our lives.
Of course, most people don’t obsess about chopping off an extremity, but who doesn’t occasionally feel discomfort about his body weight or perhaps how his hair looks? It’s certainly out of the ordinary to meet someone who believes she’s had sexual intercourse with you because you merely looked her in the eye. Yet many of us have had experiences with strangers or acquaintances who are intrusive. Perhaps it was someone whose gaze lingered too long or a co-worker who touched you inappropriately on the arm.
And many of us have had the uneasy experience of dealing with somebody who suddenly starts acting crazy—it could be a relative with hidden alcoholism who begins to unravel or a colleague who flips out with acute mania during a staff meeting. We all wonder how to respond during those awkward moments, how we might help the person who’s off kilter, and how we can deal with our own emotional reactions to these events.
Often our first instinct is to run, but if we can get beyond our fears and anxieties, we have an opportunity to understand their pain and show compassion. When we do express empathy and compassion, it not only helps the person who is suffering from a mental problem, but it also helps us to feel more human.
Many people who could benefit from seeing a psychiatrist choose not to because of their fear and denial. We spend years of our lives in school and colleg
e studying any number of topics, yet the idea of taking a few hours to study ourselves seems foreign to so many. It’s not surprising that we sometimes go to extraordinary lengths to escape our psychological pain in our attempts to feel accepted, valued, and loved.
Much has changed in medical education since the days of my early training in psychiatry. Doctors callously discussing cases on elevators and in hallways within earshot of families and other patients have become rare occurrences. The stereotypical “know-it-all” doctor is being replaced by the physician as a partner in healing. Medical students are now required to take courses on effective listening and empathic abilities. Although most people rank technical skill as the leading quality they seek when choosing a doctor, studies show that those technical skills are most effective when delivered with sensitivity and understanding.
The field of psychiatry continues to evolve. With continued discoveries of safe and effective medicines and growing appreciation that talk therapy works, psychiatry is moving into the future as a respected medical specialty that benefits both the mind and the body. Almost all of us will face emotional struggles during our lives. Whether we use humor, denial, or some other defense mechanism to cope with these struggles, taking some moments to reflect on how our minds work usually brings us insight and relief.
NOTES
PREFACE
In any given year, an estimated one in four adults—National Institute of Mental Health website: http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america/index.shtml.
CHAPTER 1: SEXY STARE
The term stands for young, attractive, verbal—Kimm HJ, Bolz W, Meyer AE. The Hamburg short psychotherapy comparison experiment. The patient sample: overt and covert selection factors and prognostic predictions. Psychotherapy and Psychosomatics 1981;35:96–109.
Freud took the position that the therapist should be impenetrable—Gelso CJ, Hayes JA. Countertransference and the Therapist’s Experience: Perils and Possibilities. Lawrence Ehrlbaum and Associates, Mahwah, NJ, 2007, p. 62.
He said that transference was one of the most—Goldberg ST. Using the Transference in Psychotherapy. Jason Aronson Publishers, Lanham, MD, 2006; Bloch, S. (ed). An Introduction to the Psychotherapies. Oxford University Press, New York, NY, 2006.
Borderlines are patients whose psychological state—Friedel RO, Hoffman PD, Penney D, Woodward P. Borderline Personality Disorder Demystified: An Essential Guide for Understanding and Living with BPD. Da Capo Press, New York, NY, 2004.
Her EEG revealed no evidence of temporal-lobe epilepsy—Geschwind N. Personality changes in temporal lobe epilepsy. Epilepsy & Behavior 2009;15:425–33.
CHAPTER 2: THE NAKED LADY WHO STOOD ON HER HEAD
an unfortunate but traditional rite—Small GW. House officer stress syndrome. Psychosomatics 1981;22:860–9.
I had come up with my own mnemonic—Cassem NH, Murray GB, Lafayette JM, Stern TA. Delirious patients, in The MGH Handbook of General Hospital Psychiatry, 5th ed. Edited by Stern TA, Fricchione GL, Cassem NH, Jellinek MS, Rosenbaum JF. Mosby, St. Louis, MO, 2004, pp. 119–34.
If somebody injects too much insulin—Fishbain DA, Rotundo D. Frequency of hypoglycemic delirium in a psychiatric emergency service. Psychosomatics 1988;29:346–8.
Today, on-call hours are limited—Meltzer DO, Arora, VM. Evaluating resident duty hour reforms: More work to do. Journal of the American Medical Association 2007;298:1055–7.
CHAPTER 3: TAKE MY HAND, PLEASE
He taught a small seminar entitled “Autognosis”—Stern TA, Prager LM, Cremens MC. Autognosis rounds for medical house staff. Psychosomatics 1993;34:1–7.
It helps to maintain “detached concern”—Halpern J. From Detached Concern to Empathy: Humanizing Medical Practice. Oxford University Press, New York, NY, 2001.
“Apotemnophilia”—Money J, Jobaris R, Furth G. Apotemnophilia: Two cases of self-demand amputation as a sexual preference. The Journal of Sex Research 1977;13:115–24.
Dysmorphophobia was first described by an Italian psychiatrist—Gilman SL. Creating Beauty to Cure the Soul. Race and Psychology in the Shaping of Aesthetic Surgery. Duke University Press, Durham, NC, 1998.
Patients suffering from BIID—Frare F, Perugi G, Ruffolo G, Toni C. Obsessive–compulsive disorder and body dysmorphic disorder: A comparison of clinical features. European Psychiatry 2004;19:292–8; Müller S. Body integrity identity disorder (BIID)—Is the amputation of healthy limbs ethically justified? American Journal of Bioethics 2009;9:36–43; Bayne T, Levy N. Amputees by choice: Body integrity identity disorder and the ethics of amputation. Journal of Applied Philosophy 2005;22:75–86.
Anafranil—Gitlin MJ. Psychotherapist’s Guide to Psychopharmacology. Free Press, New York, NY, 1990.
CHAPTER 4: FAINTING SCHOOLGIRLS
although these epidemics were—Small GW, Nicholi AM. Mass hysteria among school children: Early loss as a predisposing factor. Archives of General Psychiatry 1982;39:721–4.
“Essentially, the sixth-graders were”—Ibid.
In fact, he was describing typical features—Small GW, Borus JF. Outbreak of illness in a school chorus: Toxic poisoning or mass hysteria? New England Journal of Medicine 1983;308:632–5.
I studied several episodes—Small GW, Borus JF. The influence of newspaper reports on outbreaks of mass hysteria. Psychiatric Quarterly 1987;58:269–78; Small GW, Propper MW, Randolph E, Eth S. Mass hysteria among student performers: Social relationship as a symptom predictor. American Journal of Psychiatry 1991;148:1200–5; Small GW, Feinberg DT, Steinberg D, Collins MT. A sudden illness outbreak suggesting mass hysteria in schoolchildren. Archives of Family Medicine 1994;3:711–6.
Examples of bizarre explanations—Johnson DM. The “phantom anesthetist” of Mattoon: a field study of mass hysteria. Journal of Abnormal and Social Psychology 1945;40:175–86; Medalia NZ, Larsen ON. Diffusion and belief in a collective delusion: The Seattle Windshield Pitting Epidemic. American Sociological Association 1958;180.
My Boston-suburb elementary school outbreak had its own—Small GW, Nicholi AM. Mass hysteria among school children: Early loss as a predisposing factor. Archives of General Psychiatry 1982;39:721–4.
A decade later I studied—Small GW, Propper MW, Randolph E, Eth S. Mass hysteria among student performers: Social relationship as a symptom predictor. American Journal of Psychiatry 1991;148:1200–5.
Almost exactly two years after—Small GW, Borus JF. Outbreak of illness in a school chorus: Toxic poisoning or mass hysteria? New England Journal of Medicine 1983;308:632–5.
As I reported in the New England Journal of Medicine—Ibid.
CHAPTER 5: BABY LOVE
Pseudocyesis, also known as false or hysterical pregnancy—Small GW. Pseudocyesis: An overview. Canadian Journal of Psychiatry 1986;31:453–7; Sobrinho LG. Prolactin, psychological stress and environment in humans: Adaptation and mal-adaptation. Pituitary 2003;6:35–9
I continued to read up—Small GW. Pseudocyesis: An overview. Canadian Journal of Psychiatry 1986;31:453–7.
CHAPTER 6: SILENT TREATMENT
Few young psychiatrists were looking to work with seniors—Jarvik LF, Small GW (eds). Psychiatric Clinics of North America, Issue on Aging, vol. 5, no. l, 1982; Small GW, Fong K, Beck JC. Training in geriatric psychiatry: Will the supply meet the demand? American Journal of Psychiatry 1988;145:476–8
Scottish psychiatrist R. D. Laing—Boyers R. R. D. Laing and Anti-Psychiatry. Hippocrene Books, New York, NY, 1974.
Stanford psychologist David Rosenhan—Rosenhan DL. On being sane in insane places. Science 1973;179:250–8.
Psychoanalysis has helped many—Gabbard GO, Gunderson JG, Fonagy P. The place of psychoanalytic treatments within psychiatry. Archives of General Psychiatry 2002;59:505–10; Leichsenring F, Rabung S. Effectiveness of long-term psychodynamic psychotherapy: A meta-analysis. Journal of the American Medical Association 2008;300:1551–65.
The illness afflicts about 1 percent—Jamison KR. An Unquiet Mind:
A Memoir of Moods and Madness. Vintage Books, New York, NY, 1997.
Alan Gelenberg’s classic—Gelenberg AJ. The catatonic syndrome. Lancet 1976; 1:1339–41.
The other articles described the safety—Sherese A, Welch CA, Park LT, et al. Encephalitis and catatonia treated with ECT. Cognitive and Behavioral Neurology 2008;21:46–51; Fink M, Taylor, MA. Catatonia: A Clinician’s Guide to Diagnosis and Treatment. Cambridge University Press, New York, NY, 2003.
CHAPTER 7: THE SHRINKING PENIS
Freud viewed sex as our primary social activity—Freud S, Brill AA. The Basic Writings of Sigmund Freud. Basic Books, New York, NY, 1995.
Psychosis is defined—International Early Psychosis Association Writing Group. International clinical practice guidelines for early psychosis. British Journal of Psychiatry 2005;187:s120–4.
In medical settings, gallows humor—Small GW. House officer stress syndrome. Psychosomatics 1981;22:860–9.
Many patients with both mood and psychotic symptoms—Malhi GS, Green M, Fagiolini A, Peselow ED, Kumari V. Schizoaffective disorder: Diagnostic issues and future recommendations. Bipolar Disorders 2008;10:215–30.
CHAPTER 8: WORRIED SICK
A major part of any insight-oriented therapy—Goldberg ST. Using the Transference in Psychotherapy. Jason Aronson Publishers, Lanham, MD, 2006.
Although stress and diet can contribute—Marshall BJ, Warren JR. Unidentified curved bacilli in the stomach of patients with gastritis and peptic ulceration. Lancet 1984;1(8390):1311–5.
Medical studentitis—Kellner R, Wiggins RG, Pathak D. Hypochondriacal fears and beliefs in medical and law students. Archives of General Psychiatry 1986;43:487–9; Moss-Morris R, Petrie KJ. Redefining medical students’ disease to reduce morbidity. Medical Education 2001;35:724–8
Minuchin often worked with nuclear families—Minuchin S. Families and Family Therapy. Harvard University Press, Cambridge, MA, 1974.