Shrinks (32 page)

I was asked to consult on Jenn when she was brought to New York Presbyterian Hospital–Columbia University Medical Center after a violent incident with her mother, prompted by Jenn’s belief that her mother was trying to keep her from seeing her boyfriend. When I evaluated Jenn, her appearance was disheveled and her thinking seemed disorganized. She had been out of school for five years and was unemployed and living at home. She repeatedly voiced the conviction that a friend was trying to steal her boyfriend, and she explained to me that she and her boyfriend needed to immediately escape to New Mexico if they wanted to stay together.

After talking with Jenn’s family, I learned that in reality the object of her affections had no interest in her. In fact, the young man had actually called Jenn’s mother to complain that she was harassing him and threatening his real girlfriend. When Jenn’s mother attempted to explain these facts to her daughter she became enraged and knocked her to the floor, prompting her current hospitalization.

During our conversation, Jenn seemed disengaged and distracted, behaviors commonly associated with schizophrenia—but they are associated with other conditions, too. Her false beliefs were not systematic delusions; they simply reflected unrealistic appraisals of her relationships with others. She exhibited a full range of emotions, and while her feelings were often intense and erratic, schizophrenics more typically exhibit emotions that are constricted and flat.

Although the diagnosis assigned to her upon admission was schizophrenia, my clinical intuition was telling me that something else was going on. But intuition must be supported by evidence, so I started gathering additional data. When I asked Jenn’s parents about her early medical history, nothing much turned up—except for one fact. Her mother reported that Jenn was born prematurely and had a breech birth. That alone wouldn’t account for her bizarre behaviors, but breech births and other forms of trauma during pregnancy and delivery are associated with a higher incidence of neurodevelopmental problems. A traumatic delivery can produce complications in the infant’s brain, including a lack of oxygen, compression, or bleeding. In addition, due to an (Rh) incompatibility of blood types between her and her mother, she was born with anemia and required an immediate blood transfusion. As a consequence she had low Apgar scores (the ratings given by pediatricians to newborn babies to summarize their general physical status), indicating some birth distress, and she was kept in the neonatal intensive care unit for one week prior to going home.

I asked Jenn additional questions about her life and activities. She answered automatically with brief responses and seemed to be confused by the questions. She also exhibited limited concentration and poor memory. These marked cognitive impairments did not match the ones that usually occur in schizophrenia patients, who do not seem confused or forgetful as much as preoccupied and distracted, or engaged with imaginary stimuli. I began to wonder if Jenn’s volatility and bizarre behavior may have been provoked by her environment rather than her genes.

I asked about her drinking and drug use. Eventually, she admitted she had used marijuana since the age of fourteen and cocaine since age sixteen, and while in college she smoked pot and snorted coke almost every day. A hypothesis began to take shape in my mind. I suspected she had sustained some mild form of brain injury from her birth trauma that caused a neurocognitive deficit, which was then exacerbated in adolescence by her heavy drug use, producing these quasi-psychotic behaviors. One piece of evidence supporting this diagnostic hypothesis was the fact that the antipsychotic drugs, which had previously been prescribed for her, did not have much of an effect on her condition.

I ordered tests that would help to assess my hypothesis. Neuropsychological test results revealed a significant discrepancy between her verbal and performance scores. With schizophrenia, verbal and performance scores tend to be similar even if lower overall than the population average. Performance scores are believed to be more sensitive to brain dysfunction than verbal scores, and the fact that Jenn’s performance score was markedly lower than her verbal score suggested that she had some kind of acquired cognitive impairment. An MRI revealed markedly
asymmetric
enlargement of the lateral ventricles and subarachnoid space, an asymmetry more often associated with trauma or a vascular event (like a stroke) than mental illness (in schizophrenia the ventricular enlargement is more symmetrical). The social worker assisting me developed an extensive pedigree of Jenn’s family using information provided by her parents that revealed a complete absence of mental illness in the family history. The only related condition in her biological relatives was substance abuse in some siblings and cousins.

I now felt confident about my diagnosis that her pathology was due to developmental injury and substance-induced toxicity. Her prior diagnoses of schizophrenia, schizoaffective disorder, and bipolar disorder had been reasonable guesses since in reality she suffered from a “phenocopy” of mental illness, meaning that she was exhibiting symptoms that mimicked a
DSM
-defined illness without suffering from the actual illness.

If Jenn had been admitted to a psychiatry ward thirty years ago when I started my training, she would have likely been committed to a long-term stay in a mental institution and almost certainly been given very powerful antipsychotic drugs that would have all but immobilized her. Or, she may have been subjected to months or years of psychoanalytic therapy exploring her childhood and especially her fraught relationship with her mother.

But in today’s world of psychiatry, Jenn was swiftly discharged from the hospital and given intensive substance abuse treatment and rehabilitative cognitive and social therapies, along with a low dose of medication to help stabilize her during her course of treatment. The quality of her life gradually improved and today she is focused and engaged and expresses gratitude for the help she received in turning her life around. And while not living independently or professionally successful or married with children, she works part-time, lives peacefully with her mother, and has developed stable social relationships.

Jenn’s modest recovery—one of a growing number of success stories—illustrates how clinical psychiatry has changed as a result of the brain revolution and the myriad scientific advances over the past decades. But there was one final breakthrough in the annals of psychiatry that helped shape the modern face of my profession—a breakthrough that may be the most overlooked and underappreciated discovery of them all.

Chapter 8

Soldier’s Heart: The Mystery of Trauma

We don’t want any damned psychiatrists making our boys sick.

—G
ENERAL
J
OHN
S
MITH
, 1944

Military psychiatry is to psychiatry as military music is to music.

—C
HAIM
S
HATAN
, MD

Air Conditioner Anxiety

In 1972 I was living in a shabby brownstone near Dupont Circle in Washington, DC, a sketchy neighborhood back then. One morning as I was about to leave for my physiology class at George Washington University, I heard a hard knock on my apartment door. I opened it to find two young men staring straight at me with intense black eyes. I immediately recognized them as neighborhood toughs who often hung out on the street.

Without a word, they pushed me back into my apartment. The taller man pointed a large black pistol at me and growled, “Give us all your money!” My brain froze, like a computer encountering a file too large to open.

“Hey! I said
where is your goddamn money?
” he shouted, pressing the muzzle of the gun to my forehead.

“I don’t have anything,” I stammered. Wrong answer. The shorter man punched me in the face. The taller one smacked me on the side of my head with the gun. They shoved me into a chair. The shorter man began rummaging through my pockets while the taller man went into my bedroom and began yanking out drawers and ransacking closets. After a few minutes of searching, they cursed with frustration; apart from the television, a stereo, and thirty dollars in my wallet, they weren’t finding anything of value… but they hadn’t checked my dresser.

Tucked away in the top drawer beneath a stack of underwear was a jewelry box containing my grandfather’s Patek Philippe watch. I couldn’t imagine losing it. He had given it to me before he died as a gift to his firstborn grandchild, and it was my most treasured possession.

“What else do you got? We know you got more!” the taller man shouted as he waved the gun in front of my face.

Then, a peculiar thing happened. My churning fear abruptly dissipated. My mind became calm and alert, even hyperalert. Time seemed to slow down. Clear thoughts formed in my mind, like orderly commands from air traffic control: “Obey and comply. Do what you need to do to avoid getting shot.” Somehow, I believed that if I just kept my cool, I would escape with my life—and possibly the jewelry box, too.

“I don’t have anything,” I said calmly. “Take whatever you want, but I’m just a student, I don’t have anything.”

“What about your roommate?” the intruder spat, motioning toward the other bedroom. My roommate, a law student, was away at class.

“I don’t think he has much, but take everything… anything you want.” The taller man looked at me quizzically and tapped the gun against my shoulder a few times as if thinking. The two thugs looked at each other, then one abruptly yanked the thin gold chain off my neck, they hoisted up the television, stereo, and clock radio, and casually ambled out the front door.

At the time, the home invasion was the scariest experience of my life. You might expect that it shook me up, giving me nightmares or driving me to obsess about my personal safety. Surprisingly, no. After filing a useless report with the DC police, I replaced the appliances and went right on with my life. I didn’t move to a new neighborhood. I didn’t have bad dreams. I didn’t ruminate over the intrusion. If I heard an unexpected knock on my door, I hopped up to answer it. I didn’t even flinch when, months later, I saw one of them on the street on my way home. To be honest, I can no longer recall the details of the robbery very well at all, certainly no better than the details of
The Poseidon Adventure
, a suspenseful but unremarkable movie I saw that same year. Though I believe the gun was large and black, it could very well have been a small metal revolver. To my youthful mind the whole experience ended up seeming kind of thrilling, an adventure I had bravely endured.

Twelve years later, another dramatic event produced a very different reaction. I was living in an apartment on the fifteenth floor of a high-rise in Manhattan with my wife and three-year-old son. It was early October and I needed to remove the heavy air conditioner unit from my son’s bedroom window and store it for the winter.

The unit was supported on the outside by a bracket screwed into the wall. I raised the window that pressed down onto the top of the air conditioner so I could lift the unit off the windowsill—a terrible mistake. The moment I lifted the window, the weight of the air conditioner tore the bracket from the outside wall.

The air conditioner began to tumble away from the building toward the usually busy sidewalk fifteen floors below. The machine seemed to hurtle down through the sky in a kind of cinematic slow motion. My life literally flashed before my eyes. All my dreams of a career in psychiatry, all my plans of raising a family, were plunging down with this mechanical meteor. I could do nothing but uselessly shriek, “Watch out!”

“Holy shit!” the doorman yelped as he frantically leapt away. Miraculously, the air conditioner smashed onto the pavement, not people. Pedestrians on both sides of the street all whipped their heads in unison toward the crashing sound of impact, but, thankfully, nobody was hurt.

I had escaped a high-stakes situation once again—but this time I was shaken to the depths of my being. I couldn’t stop thinking about how stupid I was, how close I had come to hurting someone and ruining my life. I lost my appetite. I had trouble sleeping, and when I did I was plagued by graphic nightmares in which I painfully relived the air conditioner’s fateful plunge. During the day I could not stop ruminating over the incident, playing it over and over in my mind like a video loop, each time reexperiencing my terror with vivid intensity. When I went into my son’s room, I wouldn’t go near the window, for the mere sight of it triggered disturbing feelings.

Even now, decades later, I can viscerally recall the fear and helplessness of those moments with little effort. In fact, just moments before I sat down to write about this incident, a Liberty Mutual Insurance commercial came on television. As the wistful song “Human” plays and Paul Giamatti’s mellifluous voice expounds upon human frailty, a man accidentally drops an air conditioner out his window onto a neighbor’s car. The ad is innocuous and witty, yet as I watched, I winced in fearful remembrance. Some part of me was instantly transported back to that terrifying moment watching my life plummet down fifteen stories…