A History of the Present Illness (15 page)

The ebony man asks the psychiatrist's wife if she wants another switcher.

“Oh, yes,” she says. “Please.”

He puts her empty glass on his tray.

“Madame's vacation,” he says, “is for how long?”

“I don't know.”

For a fraction of a second, his smile wavers—there's the slightest narrowing of his eyes, a flicker along his jaw.

“Madame works?” he asks.

She looks at the pool, the palm trees, the tanned feet and pink, pedicured toenails of a passing stranger, and she shakes her head, wishing she had a scar like his, for all the world to see.

* * *

It's lonely at the top, or so the saying went, and the psychiatrist's wife used to wonder if it had to be that way, whether nice guys really always finished last while those better able to maintain the demarcation between Self and Other would—like scum—more surely rise to the top of the sweet organic mélange that sustained them.

Her husband told her it wasn't so. But that was decades earlier, when they were peers in both stature and passion, when her mind still resembled a well-organized catalog of scientific
information rather than an endlessly unfurling commemorative scroll, when she too believed that a person's profession could and should define her life.

Morbid preoccupation
, the psychiatrist said, not unkindly, in the days before she stopped telling him her dreams.

Histrionic personality disorder
, he whispered on one of his rare visits with his hospitalized mother.

Adolescence,
he recently said of their son.
No longer a child but not yet an adult.

“
Please
,” he says not infrequently, even now. His hands touching, reaching.

She had a colleague who said that sometimes, when nothing else he'd tried worked, he figured the last thing he could do was to give good death. He told families that he was sorry he couldn't move things along, but if anything happened, any little thing, he'd treat it with morphine only. No more machines, no electricity, no antibiotics. Some families fired him; others clasped his hands in theirs as if he were an angel.

“I just want to make a difference in the world,” her son said. “Why can't you understand that?”

In medical school they'd been taught the words of the great physician Francis Weld Peabody, who said, “The secret to caring for the patient is to care for the patient.” Too late, she knew that Dr. Peabody was wrong. Too late, she understood that the secret was caring for the patient—for anyone—just a little. Enough, but not too much.

The ebony man asks if the psychiatrist's wife has come for the conference. She shakes her head. “No,” she says. Then, “Yes.

My husband is there now.” The ebony man smiles. “So your husband is a doctor?”

She nods.

“That is good,” he says. “That is very, very good.”

“Why?” she had asked her son when the piercings began.

For the longest time, until after the fourth switcher, until the ebony man with his scar and his questions, she hadn't understood her son's answer, the
Look at me
followed by the stream of
FUCK YOU
s.

When her husband returns from his scuba cruise, the psychiatrist's wife sits waiting on a bed stripped of everything but a single white sheet. Her hair is stylishly short and newly bleached, a blond so pale it trifles with light and time. She's wearing an ocean-blue spaghetti-strap dress that tapers at her waist and thighs and stops above her knees. Her makeup is perfect and her suitcase is packed.

Dear Drs. Saperstein and DiBenedetto: It has come to my attention
¹
that you are, respectively, the director and associate director of the working group charged with revising the
Diagnostic and Statistical Manual of Mental Disorders
for its much-anticipated (and long-awaited) fifth edition.

Below please find (again)
²
my
³
suggestion for an addition
to the second section of the “Personality Disorders” chapter, which I heretofore will refer to as Cluster
⁴
B.

The essential feature of this disorder is a pervasive pattern of personal boundary instability exhibited by a caregiving professional,
affecting mood, self-image, and not just intimate relationships (e.g., lovers, friends, and—where applicable
⁶
—spouse and children) but also professional ones.
⁷

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 medical
²⁵
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 Disorder
²⁶
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

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.