A History of the Present Illness

by Louise Aronson

  In BBD sufferers, a marked and persistent belief that personal value depends on professional reputation is often present.8 This may be evidenced by tendencies to give in to patients/ clients (and even colleagues) if not doing so results in disappointment or anger and doing so leads to praise and affection for the professional.9

  Ethical lines often appear unclear,10 a desire to please is prominent, and performance-related affective instability is common.11

  BBD is characterized by subtle and varied presentations including: inability to turn off pager and/or cell phone even while vacationing;12 receipt of copious presents from patients absent any traditional gift-giving occasion (i.e., holidays—Christmas, Chinese New Year, Mardi Gras—and/or following the successful diagnosis/treatment of a potentially serious medical condition);13 and inability to let go when treatment termination is in the client/patient/family’s best interest.14

  Associated features: Frequently this disorder is accompanied by Overachievement Disorder,15 the Good-Girl Syndrome,16 and a variety of subsyndromal anxiety, depressive, sexual, eating, and substance abuse disorders.17

  Impairment: Affected individuals often, if not always, run late in both social and occupational arenas.18

  Complications: May include but are not limited to attempts to buy love and abolish disappointment with excessive gifting.19 Premature death (i.e., suicide) is rare because of primal fears of letting others down.20 More common is a change to an alternate career of equal or greater social utility but with intrinsic boundaries.21

  Sex ratio: The disorder is much more common in females than in males.22

  Prevalence: Recent data suggests increasing prevalence and widespread underdiagnosis.

  Predisposing factors and familial pattern: There is some evidence that firstborn children are particularly susceptible,23 as are those professionals with a predilection for low-status, low-reimbursement, patient-centered specialties such as social work and community psychiatry.24

  Differential diagnosis: In Overcompensation Disorder, residual type, there is a history of a clear medical25 mistake followed by a sudden change in practice style that may resemble Blurred Boundary Disorder in some aspects, but the key distinguishing feature of OD (not to be confused with OCD) is a tendency to order frequent and unnecessary services, tests, and specialist consultations. Not uncommonly, professionals with Borderline Personality Disorder also meet the criteria for Blurred Boundary Disorder, but the instability of identity, interpersonal relationships, and affect, the self-damaging impulsiveness, inappropriate anger, and recurrent suicidal threats or self-mutilation so common to those with Borderline Personality Disorder26 will not be manifest in those with pure BBD.

  Yours sincerely,

  Noemi Kadish-Luna, B.S., M.D., M.A., M.P.A./H.S.A.(c)27

  Vital Signs Stable

  A chunk of wet clay on a linoleum floor, a pair of black suede pumps with leather mignons and two-inch heels, a scream. At ninety-eight—her bones like a frivolous dinner set from early in the last century, the china still functional but thinned to near translucence, its pieces prone to shattering as might an heirloom dropped on the ground from even the modest height of four feet, ten inches—Edith Picarelli had been shrinking for decades.

  “I heard it,” said the nursing home’s art-room assistant. “This sound, like chimes?”

  “Too many pieces for counting,” commented the radiologist in New Delhi by teleconference.

  “Damned heels,” said the English administrator when informed. “Her right hip, I’m afraid,” she explained to Frank Picarelli’s answering machine when she called Edith’s son with the news.

  It was a cool summer Saturday morning in San Francisco. From his cell phone at the window table of a popular brunch café, the on-call physician told the nurse to send Edith to the hospital. After he hung up, he put a spoonful of scrambled eggs in his toddler daughter’s mouth and said to his wife, “Sweet. That was easy.”

  An hour later, a teenager smoking in the designated area outside the University Hospital ambulance bay said, “Yo, what’s that noise?”

  The ambulance attendants lowered the gurney to the asphalt and push-pulled it up over the curb and through the sliding glass doors of the Emergency Department. “Hang in there, dear,” one of the attendants advised, patting Edith’s shoulder as her screams intensified and they parked her in the hallway near the triage desk.

  The nurse pretended to cover her ears with her hands. “Gee thanks, guys,” she said while sizing up Edith’s arm to decide whether she’d need a small-adult or a child-size blood pressure cuff.

  “On our way,” the paramedic with Edith Picarelli’s paperwork in his back pocket said into his radio as he and his partner disappeared back through the sliding doors. They’d just had a call about a near-fatal accident on Nineteenth Avenue and had to hurry.

  Quentin Chew, the new intern in the emergency department, didn’t know what to make of the almost feral cries or the fact that no one else seemed troubled by them.

  “Stand back, stand back! Coming through!” shouted an orderly who couldn’t see over the supply cart he pushed down the hall.

  Quentin flattened himself against the wall to avoid being hit by the cart. He’d heard similar awful screeching only once before, while watching a documentary on the great migration of herbivores across the Serengeti. The film consisted mostly of sweeping vistas and the occasional mother and baby shot, so he’d grabbed Ralph’s arm when, without warning, the action cut to a group of trophy hunters shooting into the herd. They missed their target, an impala with massive spiral horns, and hit a wildebeest instead. As the herd dispersed, the angry and frustrated hunters took turns shooting the injured wildebeest, aiming anywhere but the head or the heart. The animal, down on its side, its hide soaked with blood, made surprising high-pitched cries that Quentin, watching years later and continents away, had felt on his skin and in his gut. The same feeling he had now.

  He reached for the next chart in the “to be seen” box.

  The chart contained no information except “Picarelli, Edith, room 5” and the patient’s vital signs.

  “Why’s she here?” Quentin asked the triage nurse, hoping for the sort of problem that required suturing or some other procedure.

  “You should lose that and most of those,” the nurse said, pointing first at Quentin’s chewing gum and then at the pockets of his pressed white coat, which bulged with equipment readily available in each Emergency Department patient-care room.

  “About the patient?” Quentin asked.

  The nurse smiled. “Ancient, not accompanied by family. You figure it out.”

  In room 5, Edith Picarelli lay perfectly still, her eyes closed. But for the tiny trail of saliva on her lower lip and her crescendo-decrescendo wails, Quentin would have diagnosed the old woman as dead.

  He started his exam at Edith’s head and finished at her toes, careful not to miss any part in between. This seemed a surefire strategy for avoiding error while maintaining the clinical independence expected of him now that he had his M.D.

  An hour and a half after picking up the chart, he presented Edith’s case to the supervising physician. Two hours after that, following an impressive array of nonspecifically abnormal tests and several injections of psychiatric medications that quieted but didn’t eliminate the wails, a nurse suggested that Quentin call the nursing home to ask why they’d sent Edith in.

  “Oh shit,” he said when told of the broken hip. “Oh shit, shit, shit.” He ordered morphine and X-rays. And then, vaguely light-headed, he paged ortho.

  “Not with a ten-foot pole,” said the consulting orthopedist.

  Quentin called the general medicine team.

  “No freaking way,” said the admitting medical resident. “This can and should be managed at the sniff.”

  “Sniff?” asked Quentin.

  “Her nursing home. Skilled nursing facility. S-N-F. Sniff. How the hell do you get to be an intern and not know that?”

  “But�
�” Quentin began. And then for nearly twenty seconds he listened to a dial tone.

  “Very well then,” said the home’s English administrator when Quentin informed her of the plan. A realist, the administrator didn’t argue. Edith Picarelli wasn’t the first of their patients to fail to capture the interest of the fancy university hospital doctors, and she wouldn’t be the last.

  So Quentin sent Edith back.

  “If she was comfortable when she left, what difference does it make?” Ralph asked when Quentin paged him. Midway through his first continuity clinic at the New Israel Care Home as a primary care intern, Ralph seemed distracted and impatient, so Quentin didn’t tell him about the wildebeest or how many hours had passed between Edith’s arrival and her diagnosis.

  “Sorry,” Ralph added. “But she got good care, right? Time to move on.” Then he softened his voice and added, “Q , I’ve got like fifty old ladies just like her here in my clinic, and anyway, if you let things like this get to you, you’ll never survive residency.”

  Late that afternoon, Quentin jogged along the Crissy Field promenade without paying much attention to the dogs frolicking on the beach or the windsurfers leaning low on their boards off Fort Point. Since Ralph was on call and not coming home, he reheated leftover spaghetti for his dinner and curled up on their bed with a textbook to study the surgical management of hip fractures. He would have liked to read about the nonsurgical management of hip fractures as well or, more important, about how to approach patients who can’t talk, or what to do when you’ve made an inexcusable mistake, but his book didn’t have chapters on those topics.

  * * *

  At the nursing home, Edith Picarelli shared a semiprivate with a woman young enough, at seventy-four, to be her daughter. In one half of their room—Edith’s half—sculptures rested on every flat surface, poked out from beneath the bed, and stood like barricade soldiers against the walls. There were tropical plants with bladelike leaves and ostentatious flowers, miniature replicas of each of the Picarelli family’s now-deceased forebears and four-legged companions, and an abundance of child-size chamber music instruments, many in the orange brown of clay that had been fired but not glazed. In the other half of the room, across the statuary demarcation line and surrounded by white, unadorned walls and blond institutional furniture, her young-old roommate slept in an oversize wheelchair before a blaring television.

  Earlier that afternoon, shortly after Edith’s return from the hospital, Frank Picarelli had noticed the blinking light on his answering machine. Now Edith’s family gathered around her bed.

  A nurse came in. “Hello!” she said, smiling first at Frank and then at the children. “But so many people. You did not need to come all at one time!”

  Edith’s grandson, Frank Junior, who went by FJ, rubbed his beard with two fingertips. “I called the hospital. They said she might die?”

  “Oh yes, of course,” said the nurse. “But it is very slow at this age.”

  All eyes turned toward the bed. Already the necessary painkillers had made Edith smaller, paler, flatter. She’d forgotten even the basics, such as who they were and how to stay awake.

  Still scratching his beard, FJ itemized the changes. “Seems quick to me,” he said.

  “You will see,” said the nurse. She looked at her watch. “I come back after.”

  “After what?” asked Lily, Edith’s ten-year-old great-granddaughter.

  FJ put one hand on the top of his daughter’s head and another across her mouth. “Terrific,” he said to the nurse. “We’ll see you then.”

  “What’d I do?” asked Lily once she’d wriggled free.

  When nobody replied, Lily walked over to her nana. Close, but not too close. Not scary close. And Nana was scary today, even more so than usual, but in a different kind of way. Usually Nana might say, Come here, and grab Lily’s ponytail and pull off the elastic band and start brushing Lily’s hair in a way that hurt at first (that was the scary part), then felt kind of good. Next, without discussing what Lily wanted (that was the other scary part), she’d put in some bobby pins with bows and flowers on them, and when she’d finished, Lily would see in the mirror that she looked better, maybe even pretty, but she wouldn’t get to stay that way long because as soon as they left Nana’s room, her mom would sigh and look at her dad and pull out the bobby pins and remind Lily that Nana had used those exact same pins and bows on the little white fluffy dogs she always had until she moved into the home.

  “You didn’t do anything, honey,” Melissa said now, and as if she’d read her daughter’s mind, she ran her fingers through Lily’s bangs and tightened the elastic band on her ponytail.

  On Edith’s roommate’s television, a man’s voice said, We’re getting word now of hundreds, maybe thousands, of refugees driven to the border and forced at gunpoint . . .

  “Oh joyous, happy world,” said FJ.

  Lily’s younger brother, Frankie, lifted a small cello from the clay string quartet on Edith’s dresser. For the first time in his six and a half years as a member of the Picarelli family, no one said, Don’t touch. He threw it up into the air, caught it, and looked around. Then he grinned and slipped it into his pocket.

  An aide coming into the room talking rapidly into a pink cell phone saw the Picarellis, shoved the phone into her smock pocket, and pulled a curtain that split the room in two. “For more private,” she said, bowing slightly and backing out the door.

  . . . and in local news, a drive-by shooting left two teenagers . . . Edith sighed.

  “I couldn’t agree with you more, Gran,” said FJ.

  Frank signaled to his wife to turn off the television, but Edith had gone back to sleep, so Jean pretended she didn’t notice Frank’s outsize gesticulations. “Once,” she said, glancing at her mother-in-law, “years ago, after the first hip fracture, when I took care of Edith for two months, she gave me a sculpture. A Yorkie that looked just like our Maxie, who’d died the year before. This was back when she still painted them, and she knew the little dog with his shiny black nose was my favorite. She gave it to me the afternoon she moved out of FJ’s old bedroom and back to her apartment, but the next morning she called to say she needed it back.”

  Frank laughed. “She can never part with them.”

  “It was the only sculpture of hers I ever liked,” said Jean.

  “Gran sure does like to have her things around her,” Melissa said, trying as always to keep the peace. She opened Edith’s closet door to reveal three double racks of high-heeled slingbacks, pumps, and sandals. “Look at this one.” She blew dust off a steeply sloped wedge. “Such a fabulous red—and those feathers over the toe!”

  . . . I just turned away for a second. One minute she was there playing with her doll and then . . . Oh my God, this can’t . . .

  FJ jumped up, threw open the curtain, and turned off the TV. Edith’s roommate opened her eyes. She stared first at the blank screen and then at FJ.

  Frankie moved so that his mother stood between him and the roommate.

  “Sorry,” FJ said. “I thought you were asleep.”

  The roommate looked at the adult Picarellis one at a time. Then she unlocked her wheelchair and rolled out of the room.

  A while later, an aide appeared and saw the red shoe on the bedside table where Melissa had left it. “Many times, we try to take them,” she said, “but her feet too crooked, like this—” She tilted her arm so her elbow pointed at the ceiling and her fingers at the baseboard of the opposite wall. “She walk not good in normal shoes.”

  The family stared at the aide, Frankie captivated by the excursions of the woman’s exceedingly bushy eyebrows, FJ because even though he didn’t want Melissa’s feet to end up like his gran’s, just thinking about her legs and ass in high heels turned him on, and Frank senior mystified because his hearing wasn’t what it used to be and he’d understood only a few words of what the aide said.

  Eventually, as promised, the nurse returned. She and the aide leaned over the bed. “Edith
! Wake up! You want something please?”

  “Scotch on the rocks,” said FJ.

  The nurse looked at him, squinted, then turned back to her patient. She repeated the question, louder.

  Eyes opened, stared, blinked, and blinked again.

  “Hello, Mother!”

  “Hi, Gran!”

  “Nana, Nana, Nana!”

  “We’re all here, Edith,” said Jean.

  The response from the bed: a grunt, an almost smile.

  “We sit her up,” said the nurse. She nodded at the aide. The covers came down. Together, they lifted, one on each side, their fists curled around a sheet that had been folded twice and laid perpendicular to the bed.

  The body wobbled. One hand shot out—a flash of pale, cobbled knuckles, a gold band with a small diamond solitaire, long pink fingernails.

  “Aya!” yelped the aide, and the transfer sheet jerked to her side before it was lowered hastily back onto the bed. A second later, they all watched as three parallel red lines bloomed on the brown background of the aide’s slim, hairless forearm.

  The nurse took a long, audible breath. “Lucky,” she said. “No blood.” And then she and the aide exchanged a glance in which they agreed on a call to the evening supervisor and an early end to the aide’s shift, with full pay but no incident report.

  That settled, they returned their attention to Edith. Leftside down was exchanged for faceup, the head was elevated, the pillows were puffed, and the heels were floated. Finally, from one of the large front pockets of her smiley-face-patterned scrub top, the nurse produced first a syringe of pain medication, then a squat purple box into which she inserted a thick white straw. She extended her arm, rested the bottom of the box on the ruffled collar of Edith’s pale yellow nightgown, and carefully positioned the straw.

  The mouth opened, a fault line between cracked lips. Edith drank.

  “Atta girl,” whispered Frank.