Falling Into the Fire: A Psychiatrist's Encounters with the Mind in Crisis (5 page)

Examples abound in religious literature of men who, having failed in their strivings to attain purity through abstinence, castrate themselves. Interestingly, very few documented cases of psychopathological female genital self-mutilation exist. Though insertion of all manner of objects into the vagina is not uncommon, Favazza reports that there are only six cases in the psychiatric literature in which mentally ill women have intentionally mutilated their own genitals.

Which does not mean that women do not grievously and graphically harm themselves in other ways. I recently treated a middle-aged psychotic woman who repeatedly injured herself, believing that her suffering was penance and had been mandated by God. She was sent from a medical emergency room to the psychiatric hospital because her torso was covered with blistered burns from cigarettes that she had ground into her skin. Obtaining information from her was difficult because she spoke of herself in the third person, as if the voice coming from her lips were God’s. “I have allowed Patty to afflict her body in my service,” she would intone. “I have granted her the gift of doing penance, and you see the results before you.” Then she would seamlessly segue into describing why one of the other patients—in this case, a highly anxious young man with a tendency toward paranoia who kept looking fearfully at Patty—had been chosen as her “supreme pope” and under whose hospital bed she claimed her cat, Daffodil, was hiding. It was only after a lengthy interview, which required me to constantly redirect Patty’s God-voiced proclamations, that she revealed to me she had inserted scissors into her rectum and “opened and closed them at every station of the cross.” I sent her back to the medical hospital, where a sigmoidoscopy revealed multiple internal lacerations.

Favazza notes that not all acts of self-mutilation classified as major are committed by patients in the throes of psychosis. Some may occur in states of drug- or alcohol-induced intoxication. Heartbreaking accounts exist of men who have amputated their penises or testicles as a result of being tormented by their homosexual desires. Episodes of self-castration or of breast amputation have been noted as desperate measures taken by transgendered people.

One might think that the extremity of pain and danger inflicted by these wounds would shake even psychotic people into a state of alarm. In fact, the opposite is frequently true. Of people who commit major self-injury, Favazza has been quoted as saying that “despite the severity of their wounds, [they] feel little pain at the time or regret afterward. . . . It is as if their action has resolved the conflict within them.”

In contrast to major self-mutilation, stereotypic self-mutilation occurs most frequently in the context of intellectual or developmental disability—in some forms of what we have historically called mental retardation, for example, or in more severe forms of autism. It may even occur in very severe forms of Tourette’s disorder or obsessive-compulsive disorder, in which the sufferers tragically recognize the self-injury as irrational but are unable to refrain from carrying it out nonetheless. Patients who stereotypically harm themselves may rhythmically bang their heads, requiring protective helmets; they may hit or bite themselves. I treated one such patient who compulsively gouged and tore at her face, leaving angry wounds that festered and would not heal. Each time even a preliminary scab formed, the young girl would, once unattended, desperately claw at her cheek or lip or chin, reopening the wound.

The most common category of self-mutilation—with sufferers found across the globe and in every socioeconomic class—is the superficial/moderate type. Though Lauren’s chronic swallowing of objects seems neither superficial nor moderate, it is into this group that she and her symptoms fall. In her company would be a comparatively tame crowd who compulsively pull their own hair, bite their nails, and scratch their skin. Others, with symptoms more analogous in severity to Lauren’s, repeatedly cut and carve their skin, burn themselves, stick needles into their bodies, and break their own bones. Burning and cutting are the most common types of self-injury, with experts currently estimating that as many as 2 million Americans intentionally engage in those particular acts each year.

For many of these 2 million, occasional, episodic self-harm becomes progressively more frequent, reinforcing an unhealthy feedback loop in the brain. A person turns to self-injury, and the act of cutting or burning or swallowing provides a release. Not unlike what happens with a person who turns to drugs or alcohol in distress, an insidious pattern develops. It is for this that Favazza has described the behaviors associated with superficial/moderate self-injury as “morbid forms of self-help.” Tracing the skin with a blade, holding flame to flesh, or, in Lauren’s case, consuming something dangerous provides distraction from distress and relief from emotional discomfort. Yet this relief is impermanent. The distress returns, and without a lasting means of addressing the unease, Lauren and others like her continue to seek temporary reprieve in reenacting their rituals of self-harm.

If the feedback loop takes hold, Favazza explains, the harmful behaviors “become an overwhelming preoccupation and are repeated over and over again,” coustituting what he has termed “the repetitive self-mutilation syndrome.” People with this syndrome may truly feel as though self-injury is an addiction, and in severe cases their pattern of turning to it in times of distress may last for decades. Even when it remits, it is typically not without consequence. Favazza describes the “normal course” of repetitive self-mutilation syndrome as “ten to fifteen years during which the self-mutilation is interspersed with periods of total quiescence [as well as periods of] impulsive behaviors such as eating disorders, alcohol and substance abuse, and kleptomania.”

For family members and clinicians who care for self-injurers, the act of self-harm is frequently incomprehensible and the impulsivity associated with it can be infuriating. The primary response evoked in caregivers is often one of anger and resentment. After I first saw Lauren, I went from the emergency room up to the hospital floor where she was to be admitted so that I could see the preparations taking place for her admission. Nurses and other staff members were busily removing medical equipment from the walls, taking away all loose objects, and covering over fixtures. I stood in the doorway. The only other times I had seen this many hospital employees in a patient room, a code had been called because someone was in cardiac arrest and needed resuscitation.

“Wow,” I said astutely.

A nurse walked by me, carrying parts of a metal IV pole. “Yeah, wow,” she said with a sarcastic snort. “As if I’m not busy enough, I gotta waste time pulling all this apart for our most frequent flier every time she decides she wants a little attention. It’s not like there are other patients of mine who are . . . I don’t know, actually
sick
or something. God forbid I spend my time doing things for them.”

As the nurse passed, I stood there, amazed at the chaos that one person’s self-directed actions could cause. Each time Lauren swallowed a potentially dangerous object, she wielded her power to cause institutional upheaval and widespread personal disequilibrium. She angered nurses and surgeons; she sent administrators into flurries of paperwork; she prompted special case conferences and grand-rounds debates; she ignited infighting between medical disciplines eager to disclaim primary responsibility for her care. While hospitalized, she was rude and unappreciative at best, provocative and hostile at worst. She cost people time and money and patience. During one particular period, there was even a superstitious policy among medicine residents: They refused to say Lauren’s name aloud, lest doing so should conjure her to appear in the emergency room later that shift.

I was not immune to Lauren’s maelstrom. Once she was admitted, I visited her room daily, attempting to engage her in any way I could. I tried to connect with her, at first naïvely and pridefully, hoping
I
could penetrate her caustic exterior and, in doing so, truly steer her toward health. During one visit I tried to offer her a chance to talk about the experiences that had led to her behaviors; during the next I proposed that we discuss coping strategies she could utilize when she felt the urge to swallow something. Despite the lengthy list of medications she’d tried, I went through them one by one with her, struggling in vain to discern whether any one of them had been more helpful than another. Each time I saw her, I endeavored to cajole her into seeing the benefit she would reap from committing more fully to the outpatient treatment that she would have after she was discharged. Perhaps, I imagined, my empathetic ear could succeed where so many others had failed. This fantasy, of course, was fleeting. Some days she ignored me; others she tore into me in a fit of rage.

Lauren met each of our encounters with derision. Although I typically felt composed and in control during clinical meetings with patients, working with Lauren made me feel inept. I couldn’t even reasonably call it “working with Lauren.” I was floundering, and I was sure she could see it. No matter how steadily I attempted to keep my cool, I began to feel that Lauren could sniff out my discomfort. As a psychiatrist, I felt confident in my ability to make patients feel calm and safe in my presence. But Lauren’s turmoil wouldn’t steady. Rather than providing her with security, I felt as though I were absorbing her unease. And the more wobbly I felt, the more emboldened and unwavering her aggressive stance became. My savior fantasies vanished, and I began to dread my daily obligation to round on her.

One day Lauren was particularly nasty to me. Early in my psychiatric training, I learned that mentally ill people can harbor an uncanny ability to detect—and then broadcast—a person’s most exquisitely sensitive vulnerabilities. During my first week as a psychiatry resident, I shuddered as an agitated, psychotic woman screamed a series of vile racial epithets and accusations at the security guards who had restrained her and were carrying her to the seclusion room. A month or two later, I treated a demented man who routinely approached a nurse who, unbeknownst to him, was a rape survivor; he ranted through a litany of aggressive and explicit sexual acts he said he intended to force upon her while she slept. A friend and colleague of mine, besieged by guilt after his depressed mother committed suicide, had a therapy patient who knew nothing about the death and yet began leaving my friend daily voice-mail messages saying that she was going to kill herself and, if she did, that it would be my friend’s fault because he did not save her.

A mentally ill person’s accuracy in hitting the mark could be mere coincidence. Or there may be a kind of perceptual acuity that sharpens in the dangerous throes of madness, as hearing or eyesight might in a life-or-death chase. Without excluding those possibilities, I have come to think of this form of cruelty as a combination of disinhibition and powerlessness. The social filter that prevents a person from saying wildly inappropriate things can dissolve when the mind is sick. And any animal, when it perceives itself to be cornered and in mortal danger, desperately lashes out in the way most likely to make its aggressor retreat. And so in the cases of people who are psychiatrically ill, the ferocity is not so much a character trait of the person doling it out. The ferocity is rather a symptom, brought about by the stark territory of mental illness and its lonely, fearsome landscape.

In Lauren this vitriol came at me after days of the silent treatment. Dutifully, if halfheartedly, I knocked on her open door one late afternoon. “Lauren? It’s Dr.—”

“I know who the fuck it is,” Lauren interrupted. She sat up and began to address the two security guards at her bedside, gesturing toward me. “This fuckin’ Amazonian joker comes in every day with her overgrown, ugly-ass eyebrows and talks to me like I’m a two-year-old just so she can feel like she’s saving the world and write some bullshit nonsense in my chart about how my psych meds need to be changed.” My stomach—within my six-foot-tall frame with its badly untended eyebrows—dropped.
Had
I been condescending to her?
Had
I gotten carried away with narcissistic fantasies?

“She has no fuckin’ clue what to do with me, so she goes all rich-girl-who-went-to-Brown, ‘Let’s talk about some healthy ways to handle your feelings’ so she can get out of here, dope me up on more of those horse pills, and tell everybody she’s a fuckin’ regular Dr. Phil!” The guards looked toward me sheepishly for a response.

“Well . . . at least you’re telling me how you feel,” I stammered, trying to gauge whether or not I was blushing. I wondered if Lauren and the guards all thought that I was as inept as she was making me out to be, as inept as I suddenly felt.

“‘At least you’re telling me how you feel,’”
Lauren mocked in a whining singsong. “Get the fuck outta my face, Amazon Brown.”

I felt both humiliated and relieved. She was giving me a way out. “I’m not going to force you to talk to me, Lauren,” I replied.

“No, you sure as hell are not,” she shot back.

“But I really am trying to be helpful to you,” I said, turning to leave the room, “and I’m happy to talk later if you’re feeling more up to it.”

As I passed through the door, she let loose with a final arrow. “Don’t hold your breath. Maybe use the time instead to get you some tweezers.”

As I walked away, I heard one of the guards whistle softly and let out a giggling “Damn!”

•   •   •

D
uring my third year as a medical student, a notoriously demanding and demeaning surgical attending physician had gathered a group of us together to ask for feedback on our experience of the surgical clerkship. Though we had all found it both unnecessarily grueling and poorly organized, my peers dutifully offered enthusiastic praise as the attending went around the table, soliciting comments. When he reached me, last, I offered constructive criticism that was honest and fair. He was silent for a moment and then responded.

“I don’t know what you’ve heard about how you’ll be graded in this clerkship,” he began quietly, and then gestured to his shoes. “But these are the feet that are connected to the legs that are connected to the ass that you should be kissing right now.” He paused for effect, then continued. “Do you want to rethink your feedback?”