Falling Into the Fire: A Psychiatrist's Encounters with the Mind in Crisis (20 page)

I used McKee’s matrix as a guide in thinking about Anna and the potential risk she posed to her son. Anna was not a teenager, and she had graduated from high school. She was married, though she painted her husband in a less-than-supportive light. Still, there was no evidence of domestic violence or substance abuse in the home. Anna had referenced help from her mother-in-law and sister, though she felt guilty about turning to them for assistance too frequently. She and her husband had stable finances and employment. She had looked forward to the pregnancy and continued to express sincere desire to be a mother—a good mother—to her son.

I understood the immense importance of diagnosing Anna correctly and remained aware that a diagnostic misstep could have disastrous consequences. Still, I was feeling increasingly confident that Anna’s symptoms had certain traits that designated them as more obsessive than psychotic. First and foremost, as distressed and fearful as Anna was, she was not out of touch with reality. Over the course of our discussions, she was consistently able to realize that these thoughts were
fears
and not plans. In addition, Anna’s responses to the thoughts were characteristic of someone with an anxiety disorder like obsessive-compulsive disorder, rather than a primary psychotic disorder. She tried to avoid the thoughts, and she tried to avoid the situations that brought about the thoughts. Therefore, when Dawn suggested that Anna tell her mother-in-law not to bring the baby in for visits anymore, Anna was relieved and in utter agreement. Finally, and more important, Anna’s “visions” were ego-dystonic—that is, they were repugnant to her and to how she perceived herself. She was deeply and constantly troubled by the thoughts of harming her son, as opposed to someone like Andrea Yates who might have found comfort in a delusional plan that would grant her children eternal salvation. Anna’s visions of bending over her son’s lifeless body “so sad at what I’ve done” and of herself in jail had the feel of compensatory rituals. In the same way that a germophobe might prevent the feared infection by repeatedly washing his hands or following a ritualized pattern of cleaning, Anna seemed to be preventing herself from acting on her intrusive thoughts of harming her son by adding her own punitive epilogue to the horrifying film.

After consultation with colleagues and supervisors and multiple discussions with Anna, I began a gradually escalating course of exposure therapy with her in which she would visit with (or “be exposed to”) her son and then we would meet to discuss the thoughts and feelings she had experienced during her time with him.

I wrote orders for Anna to have structured visits with her son, first on the unit, then leaving the unit with her husband and her son for a few hours at a time, and eventually spending time at home with her son, by herself. At each stage Anna reported increased anxiety, a response that was consistent with an obsessive anxiety disorder. “The patient reports that intrusive thoughts were exacerbated yesterday during visit with son and husband,” my treatment notes read. “This was very distressing to her.” I make an additional note about her appearance during our meeting: “The patient is slightly disheveled and nervous-appearing, but cooperative. She taps her fingernails together and on the table. Her hands are tremulous.” As her visits with her son increase in duration and in independence, I note that Anna “is having an appropriate increase in anxiety level with continued exposure to her son and approaching discharge.” Meanwhile, Dawn’s nursing notes indicate that she remains dubious.

“The patient returned from a four-hour pass,” she writes. “Reports that it went fair. Stated ‘I was with the baby for a half hour and had thoughts of stabbing him.’ M.D. still plans to have patient spend time with baby alone despite these ongoing thoughts.”

There was a part of me that felt exactly the way Dawn did. I, too, feared that encouraging Anna to be alone with her son was too dangerous, that the stakes were too high and that I should err on the side of caution. And yet I also felt that in these moments I needed to internalize the very message I was trying to help Anna believe in and hold: that far more women have thoughts of killing their children than actually do; that fearing something does not make it happen; that we have, since Phil Resnick’s landmark study in 1969, begun to understand more and more about the women who
do
kill their children so that we can use clinical evidence to help us know those families who are more at risk and those who are less so.

On the twentieth day of her hospitalization, Anna was home alone with her son on a four-hour pass when he had an asthma attack.

“I went right into mom mode,” she said to me on her return, recounting the incident. “He couldn’t breathe and was gasping, and I just grabbed the nebulizer like it was second nature, hooked up the albuterol, and gave him a treatment.” She smiled. “It felt so great to help him like that.”

One day later Anna was discharged from the hospital with plans to continue treatment on an outpatient basis for obsessive-compulsive disorder. Even after Anna’s three inpatient weeks of daily observation and treatment, and her noticeable improvement, I wasn’t 100 percent sure of my diagnosis.

Defining the maladies that plague psychiatric patients is an interpretive science. Visions and voices and fear and despair cannot be captured by CT scan or measured in the amplitude of EKG waves. Try as we might, we simply cannot predict which of our patients will kill themselves, which will murder their children, and which will leave the hospital healed, never to return. The reliable portraits and profiles we do have of patients who commit horrific acts are too often, like that of Andrea Yates, available to us only in retrospect, after terrible and irreversible damage has already been done.

With that hindsight, however, we are able to begin to build a framework of understanding as to the symptoms and circumstances that lead women to kill their children. As the field of research begun by Dr. Resnick continues to deepen and expand, the act of filicide may remain unthinkable, but it can be less
incomprehensible
to those of us who see or hear about it. If we continue to respond to the idea of child murder by mothers with disgust and scorn for the woman who commits the crime, as we so consistently do, we discourage all mothers—even those who would never harm their children—from feeling safe enough to seek help from the terrifying thoughts that plague them. We cannot prevent all instances of filicide, but if women felt that their disclosure of filicidal thoughts might be met with sympathy and support rather than repulsion and shame, we might have an opportunity to help certain mothers to think more clearly, or to imagine another, better way out.

I never saw Anna again after her discharge. I took solace in the fact that I also never saw her in the headlines. Maybe that meant that my diagnosis of her was right. In any case, the discomfort I felt watching her leave the hospital with her suitcase, her husband, and her son has stayed with me. And yet I had to trust that the child would be safe. It was an awful, uncertain feeling. It somehow seemed right, though, given the fact that it was the exact uncertainty I had asked Anna to trust in and bear.

Dancing Plagues and Double Impostors

The mind has great influence over the body, and maladies often have their origin there.

—Molière

I
n my second year of residency training, I spent a month working the overnight shift in the freestanding psychiatric hospital where I am now an attending physician. In theory, my main responsibility during this time was to evaluate people who came to the ER overnight. If they needed inpatient treatment, I would admit them. If not, I would send them off with a list of resources I hoped would be helpful: names of outpatient therapists or psychiatrists, instructions for how to become wait-listed for a day hospital program, addresses and times for local AA or NA meetings.

Some of these decisions were obvious. I admitted a man so paranoid that he had not eaten for days, afraid that he was being poisoned. An alcoholic woman who had no desire to stop drinking had been dragged in by her desperate daughter. With no legal right to hold her against her will, I let her go. Many decisions were not so clear-cut. A woman who had made a suicidal comment to a friend now swore that it was hyperbole. Was she telling me the truth, and would she be safe to leave? Or was she genuinely suicidal but denying it because she didn’t want to be hospitalized? A man who routinely claimed he was hearing command hallucinations to inject rubbing alcohol into his veins requested admission at the end of every month, when his assistance checks had run out. At the first of the next month, like clockwork, he would sign himself out of the hospital, stating that his voices had miraculously abated.

In reality, my responsibilities extended far beyond being the gatekeeper of psychiatric admissions. Because this was a freestanding psychiatric hospital and therefore most of the patients were otherwise medically well, I was the only doctor in the hospital overnight. This meant that I was also responsible for any medical issue that might arise on the hospital wards. Frequently I was paged for minor requests: a patient with a headache wanted some Tylenol, or a smoker was in desperate need of a nicotine patch. Sometimes I was called to evaluate a patient with chest pain or to see someone who had taken a fall. Occasionally there were true medical emergencies. When the patients’ medical needs were beyond the basic level of care that our psychiatric hospital could provide, they had to be sent out to a medical hospital’s emergency room to be treated.

When assessing a patient who needs medical care, different doctors have different thresholds of discomfort, different hierarchies of decision making. I think of it as something like a pain threshold. My own ability to tolerate physical pain is high, a lesson I learned after enduring hours upon hours of labor without medication before our daughter was born. Yet I am also risk-averse, and I err on the side of caution when it comes to patient care. I have colleagues who pride themselves on sending only the very sickest patients out for medical treatment or on admitting only those psychiatric patients who are clearly at the most severe and imminent risk. They joke of being impenetrable “walls” in the emergency room. They hold it as a point of honor that they do not waste ER doctors’ time with psychiatric patients who will surely sleep off their elevated blood-alcohol levels or whose acute chest pain is almost certainly a ploy for narcotics.

I don’t want to waste the time of my colleagues in emergency rooms either, but my threshold for sending patients from the psychiatric hospital to the medical hospital is low. This doesn’t bother me. I see it as recognizing my own limitations. And probably it’s also partially driven by the CYA, as in “cover your ass,” school of medicine. CYA, as a philosophy, is passed down from doctors to medical students in the earliest days of medical training as a kind of inoculation against medical malpractice. It is, of course, an overtly crass and overly simplistic approach, and there are those who would disparage acting to CYA as practicing defensive—rather than clinically indicated—medicine. Nonetheless, I think the gist turns out to be a good gut check: If this ends up being something serious, could people reviewing the chart determine that I should have sent this patient out for medical evaluation? Could I reasonably be expected to have acted differently in my practice by other doctors—or by a court of law?

Sometimes when I send a patient out because I suspect he needs medical attention, I am right, and sometimes I am wrong. Once I was working on the most acute unit of the psychiatric hospital, a ward reserved for patients who were floridly psychotic, or violent, or actively trying to harm themselves. A man who was being treated for opiate dependence was sent to my unit from one of the hospital’s general-treatment wards because he had become increasingly psychotic and difficult to manage.

When he arrived on the unit, the patient spoke mumbled nonsense and required constant intervention to keep him from mistakenly wandering into other patients’ rooms. When I could understand what he was saying, he was describing women in bikinis looking in his second-story window and men with guns after him about a card game. I suspected he was delirious and sent him to a medical hospital. Delirium can mimic psychosis, with its visions and voices and false beliefs, but it arises from states of medical disequilibrium, like infections or electrolyte abnormalities. In the medical hospital, my patient’s blood was found to have precipitously low sodium levels, which had led him into a hallucination-plagued stupor. Had I not sent him out for his sodium to be repleted, he could easily have died.

One week later a homeless patient who had been hospitalized because he was suicidal complained of excruciating foot pain. I pulled off his sock to see a warm, red, and swollen foot. When I pressed my thumb into his ankle, the patient howled, and a deep indentation remained in his flesh where my thumb had been. He had a history of severe infections. I feared he had a cellulitis—a spreading bacterial infection—which could rapidly advance. I sent him to the hospital for what I imagined would be imaging and medication, possibly even admission to the medical hospital for intravenous antibiotics. Four short hours later, the patient was back without even so much as a Band-Aid. His foot, inexplicably, looked better. The somewhat brusque note sent back to me from the emergency physician cited no signs of infection, said the patient had required no treatment, and recommended Tylenol and Epsom-salt soaks should the patient complain of any discomfort. The symptoms never returned. To this day I have no idea what caused his foot’s swelling to appear, cause pain, and then recede. The etiology clearly was not the dangerous infection I had thought it to be.

For emergencies, the psychiatric hospital was equipped with a hospital-wide buzzer system. Staff members in every unit had easy access to a blue button and a red button. Pushing either button activated an alarm and illuminated corresponding red or blue lights on numbered panels positioned throughout the hospital. A red light indicated a psychiatric emergency—most frequently a patient who was becoming violent—in which case additional staff members from every unit in the hospital would come to provide extra help. All the staff members in the hospital had been trained as to how to respond to a psychiatric emergency when a patient became violent. My job in those scenarios was to talk with the patient as best I could to try to calm him and to order medications if they were needed. In the event that the situation escalated, requiring staff members to intervene physically, I was to stay out of the way.

However, when the buzzer sounded and the corresponding light flashed blue, it was to notify me of a medical emergency in the hospital. In a medical emergency, though nurses and others were available to help me, I was clearly in charge.

Some psychiatric residents were more gung ho about opportunities to provide medical care than others—those who narrowly chose to specialize in psychiatry over surgery, for instance, or those who had seriously contemplated becoming internists or emergency physicians. I did not fall into these categories. My decision to go to medical school in the first place had been in order to become a psychiatrist. Although to keep myself sane while learning about pulmonary physiology and renal pathology, I stayed open to falling in love with another field of medicine, I never seriously wavered. I felt at home during my rotations with attending psychiatrists, and the knowledge I had to accumulate was more innate to me. No matter how much I studied, the territory of the kidney and lung and heart remained opaque. Their ion exchanges, their functional equations, their vectors, and their voltage-gated ion channels—I could memorize these mechanisms and pass exams to demonstrate that I had done so. But it would be false to say I ever really
understood.

I could look at an EKG, its needle-traced line on a page, all waves and milliseconds and axes. But it took a kind of faith, I found, to see in that line the aberrant cardiac rhythm that had prevented my grandfather from climbing the stairs to his favorite restaurant. Medicine asks you to believe that an exact equation can explain why an asthmatic six-year-old who lives in a cockroach-infested apartment crosses the threshold from shortness of breath to a prolonged and catastrophic lack of oxygen. You have to live by that math while looking at her in the pediatric ICU, to trust that equation to somehow make sense of her devastated brain no longer able to generate speech, or movement, or comprehension.

In medicine these precise calculations were sacred texts held within a kind of temple that professed to show—exactly—the how and why of sickness, and death, and dying. I found myself a faithless skeptic, disillusioned by the restricted scope and the persistent fight against ambiguity. I could not worship at those tidy altars. Which is not to say that psychiatry is devoid of science. There are those who make this argument, but they are clearly wrong. Nonetheless, our knowledge of the brain is limited, and our knowledge of the
mind
even more so. I found psychiatry’s lack of certainty frustrating, yes, but also liberating, and true. There is no satisfying explanation for an eighteen-year-old’s first psychotic break; try as we might, there is no way to make sense of it. Perhaps ten or twenty or fifty years down the road, schizophrenia’s origins will be made plain. Even so, I expect that knowledge will do nothing to diminish the incomprehension that overcomes me as I try to understand what brings about the fracture of a young man’s mind.

So for some of my colleagues and friends, a blue buzzer on an overnight shift was a call to arms and a welcome chance to dive back into medicine’s fray. For me it caused a surge of anxiety—would I accurately gauge what was happening? Would I know what to do?

Some residents’ entire month of overnights went by without a single blue buzzer. Midway through my August assignment, I had three, one night after the next after the next. The first night a woman who had come in after an overdose suddenly fell down on the unit and was unresponsive. The second night a man had a heart attack. Both times, despite my nerves, I administered medicines and oxygen and sent the patients out by rescue to be treated at medical hospitals—all the correct courses of action. By the third night, even when the trickle of patients into the psychiatric ER slowed and I was able to lie down in the call room to try to catch an hour or so of sleep before the next patient arrived, I couldn’t get my mind to settle. I kept waking, staring at the blue buzzer, expecting it to sound.

Eventually it did. I leaped up, grabbed my stethoscope, and ran, cursing what seemed to be my unending bad luck. The psych-ER staff had already sympathetically designated me as a “black cloud,” a hospital term for a young doctor on whose shifts a disproportionate number of bad things occur. I reached the unit that had sounded the buzzer, and the head nurse met me at the door. “It’s Phyllis M.,” she said. “Do you know her?” I didn’t. “She’s here in the Quiet Room.” The Quiet Room was a euphemistically named area of isolation. It was empty. There was no way for patients to hurt themselves or anyone else when they were there. There were strict rules as to how long a patient could be isolated, and the staff worked hard to be sure the patients were there only if—and for as long as—absolutely necessary. Often, patients could be walked calmly there, the door could be left open, and after ten or fifteen minutes they’d be ready to leave again. Rarely, patients had to stay in the locked room for an hour or more; even then they were constantly monitored through a window and evaluated repeatedly in person by the doctor on call. Though many patients have described horrifying experiences with restraint and seclusion in psychiatric hospitals (a particularly searing firsthand description is in Elyn Saks’s remarkable memoir of her schizophrenia,
The Center Cannot Hold
), the hospital in which I was working that night takes every measure to use seclusion only when essential and to employ it humanely and safely when it is used. The nurse explained to me how Phyllis had ended up there.

“She’s a forty-two-year-old with PTSD, terrible trauma history, comes in from time to time with bad flashbacks. She had an upsetting visit from her mother this evening. Then she kept asking us for Ativan for sleep. When we wouldn’t give it to her, she started rocking, pacing, said she didn’t think she could be safe out on the unit. We got her to settle down and walk herself to the QR, but then this.”

The nurse gestured down onto the floor of the Quiet Room, where other staff members were kneeling beside Phyllis, whose whole body was convulsing violently. Her head was arched stiffly to one side. As her body shook, her head inadvertently beat against the floor. Her eyes had rolled upward, and a guttural moan was coming from her wincing mouth. She was having a seizure.

A staff member had already stuffed a pillow beneath Phyllis’s banging head to prevent her from giving herself contusions or, worse, a concussion.

My own heart pounded while I directed the staff as to how to manage Phyllis’s seizure. “Let’s get her on her side,” I said, in an attempt to keep her airway from being obstructed by her tongue and to prevent her from choking on her saliva. “I’d like to check a pulse ox and a finger stick, please. And let’s get some oxygen going.” The mental-health workers began to roll Phyllis to her side, and a nurse scurried to the med room for the equipment we needed and a tank of oxygen. She was back in less than a minute, calling out readings from the monitors and cradling Phyllis’s flailing head to wrap the clear plastic oxygen tubing around her ears and into her nostrils. Her blood glucose was normal. She was oxygenating fine. For the time being, there was nothing more to be done.