The Naked Lady Who Stood on Her Head (11 page)

When bipolars switch to a depressed state, they are usually lethargic and often sleep through the day. Sometimes people have a mild form of the condition and rather than full-blown manic episodes, they have hypomania—they experience euphoria and productivity without the irritability and psychosis. And their depressed states are less severe or barely present at all. Because of the seductiveness of this hypomanic state, many bipolar patients “forget” to take their lithium, a drug that can stabilize their mood and reduce the frequency and intensity of the swings.

During their hypomanic and manic episodes, people with bipolar disorder often have bursts of extraordinary creativity. It’s no surprise that some of our most famous artists, writers, and musicians have suffered from this illness, including Vincent van Gogh, Paul Gauguin, Jackson Pollock, Mark Twain, Ernest Hemingway, William Faulkner, Ludwig van Beethoven, Robert Schumann, and Brian Wilson.

“It sounds like Heather has mood swings. Has she ever seen a doctor or therapist to help her with that?” I asked.

“Why? Everybody has mood swings. And Heather’s an artist. That’s just how she expresses herself,” Andrea answered defensively.

“Anyone else in your family have mood swings?”

She shook her head.

“Do you know if any relatives have ever seen a psychiatrist or perhaps taken lithium?” I asked.

Andrea thought for a moment. “Our parents died in a car accident when we were in college. But I remember my grandmother telling me about a sister of hers who spent years in some mental institution on the East Coast. I don’t know what was wrong with her or if she took anything.”

I wondered if this maternal great-aunt was a manic-depressive. She
might have spent years in an inpatient facility without ever receiving medication. The FDA didn’t approve lithium as a treatment for mania until 1969. Until then, a variety of treatments had been used, ranging from insulin shock therapy to psychoanalysis. Because manic-depressive illness tends to run in families, Heather’s possible family history supported my hunch that she had an undiagnosed bipolar illness.

“Andrea, as far as you know, have any of your relatives ever had problems with alcohol or drugs?” Sometimes bipolar patients self-medicate by abusing substances, especially alcohol.

“Look, Dr. Small, you’re obviously searching for some psycho answer to my sister’s encephalitis. She needs an infectious-disease specialist, not a shrink, okay?”

“I agree with you—input from an infectious-disease specialist is critical. But Heather’s condition has stumped all the doctors so far, and I think we should keep our minds open to all the possibilities.”

Andrea slumped into a chair. “I guess so. I mean, she’s the only family I have.” She suddenly appeared very sad. Was it possible that Andrea too had manic-depressive tendencies? Sometimes the condition cycles up and down rapidly, from moment to moment.

“It must be tough for you to see Heather like this,” I said.

She looked at me tearfully. “Heather’s always been tough. I love her but I never know which Heather I’m going to find—the reclusive, moody one or the bubbly, creative one. And now she’s like this.”

“I can see it’s painful for you,” I said.

“Yeah,” Andrea said. “But it’s not about me, it’s about my sister. She’s just got to get better.”

I could see Andrea wasn’t ready to go any deeper into her own feelings at this point, and I wanted to follow up on my theory about Heather’s illness. “Let’s give all the specialists some time to put the pieces together,” I said. “I’ll let you go back to your sister, and I’m going to speak with Heather’s other doctors. I hope that we can talk some more later.”

The next day I knocked on the door of Dr. Porter’s seventh-floor office.

“It’s open,” he said gruffly.

I entered the spacious, standard-issue, metal-desk-and-file-cabinet office with a view of the 405 freeway. The walls were covered with Perma Plaqued diplomas and awards—documentation to back up his oversized ego. He looked up from the slides he was sorting, “What is it, Small? I’m busy.”

Although I had walked in prepared with my articles and arguments, it only took a moment for him to make me feel like an insecure idiot. Fortunately, I had already learned how to push on despite momentary humiliation.

I blurted out my thesis, “I’ve had a chance to examine your mute patient on Four North, and I think her encephalitis is complicated by a catatonic syndrome brought on by manic-depressive disorder.”

Porter looked up from his desk and laughed. “Really? Did she suddenly snap out of it and tell you all this?”

My anger kicked in and spurred me on. “The patient’s sister gave me a lot of background. Heather Phillips has a clear history of mood swings and a family member who may have had bipolar affective disorder. Also, when I examined her, she demonstrated classic waxy flexibility—”

Porter interrupted, “Waxy what? The woman has viral encephalitis for God’s sake. Didn’t you see the labs? She has elevated white cells in her cerebrospinal fluid. What’s clear about this case is your naïve insistence that there’s something mental going on here. Now could you please leave?”

I was seething. The patient needed to be treated for bipolar disorder, and this jerk was blinded by his antipsychiatry bias and stubborn arrogance. I wanted to pull one of his stupid plaques off the wall and hit him over the head with it. “Dr. Porter, I’m not saying she doesn’t have encephalitis, but she might also need to be treated for bipolar disorder.”

“That’s absurd,” he said. “And what would you suggest we do, anyway? Force-feed her lithium?”

“No. At this point, the safest and most effective treatment would be electroconvulsive therapy—ECT,” I answered.

“Look, Small, I’m not going to give shock treatments to a patient with a brain infection.”

“Could you just take a look at these articles I copied for you?” I asked.

“Leave them on the table there. I’m giving a lecture in ten minutes, and I have to get my slides together.” He went back to the slide carousel on his desk as if I no longer existed. I dropped the articles on the table and left the office.

One of the articles was Alan Gelenberg’s classic “The Catatonic Syndrome,” which describes both waxy flexibility and the psychiatric differential diagnosis for catatonia. Gelenberg showed that mania was a more common cause of catatonia than any other psychiatric condition—even schizophrenia. The other articles described the safety and benefits of modern ECT, debunking the old perception from the media and movies like
One Flew Over the Cuckoo’s Nest,
which depicted ECT as a punitive rather than a therapeutic intervention.

After leaving Porter’s office, I headed back to my own cubbyhole. My office had a window as well, but the view was of the medical-center trash bins. Fortunately the window was paint-sealed shut.

It was frustrating that here I was, already an assistant professor, and still not taken seriously by guys like Porter. Being ignored felt worse than being ridiculed. There was an outside chance that Porter might glance at the articles I left, but it was unlikely that he’d come around to seeing things my way. I needed an ally at his level or higher, and I knew just the guy.

Dr. Larry Klein was an icon of American psychiatry, and I had sought him out as a mentor as soon as I arrived at UCLA. He was five feet five inches tall, but with his booming voice, insightful wit, and political savvy, he dominated any room he entered. As I waited in his office for our meeting, I stared at his infamous and incomprehensible blackboard, trying to decipher his scribbles. They were either genius or madness, which also described the man’s charm.

The door flew open as Larry whisked by me. He simultaneously sat in his chair, lit a cigar, and plopped his feet on his desk. “Gary, I like the new haircut—very Steve McQueen.”

“Thanks, Larry,” I said. “I see you’re still into bow ties.”

“Always, Gary. Can never be too formal,” he said. “Now, what’s this urgent matter that couldn’t wait?”

I filled Larry in on Heather’s case and Porter’s resistance to my diag
nosis and treatment recommendation. Larry listened as he puffed his cigar. He was not only a world-class psychopharmacologist but a card-carrying analyst as well.

“I know this character Porter,” Larry said. “He’s an insecure, obsessive internist—probably compensating for inadequacies stemming from an overbearing mother. And I know just how to handle this schmuck. By the way, your assessment sounds right on the money. You did good, kid.”

I felt a wave of pride—here was the idealized father figure praising my work. My own father would have asked why I hadn’t made the diagnosis sooner. I knew that Larry would get Porter to fall into line now, but I also felt a bit infantilized. At this stage of my career, I would have liked to have handled this case on my own. But at least the patient was going to get the proper care.

Larry put his cigar down in his giant ashtray. “Let me get this idiot on the phone right now.” He shouted into the other room, “Janet, can you page Dr. Ralph Porter, please?”

We wasted no time taking the stairs up to the patient’s room. As Larry performed a neurological examination on Heather, Ralph Porter entered. Larry turned and said, “Ralph, that editorial you wrote for the
Archives
was brilliant.” I was impressed by Larry’s seamless political savvy.

Ralph beamed. “You’re too kind, Larry. And Dr. Small, thank you for bringing Dr. Klein in on this most interesting case of mine.”

What a kiss-ass, I thought. “My pleasure,” I said.

I demonstrated Heather’s waxy flexibility for them, and Larry quickly piped in, “Fascinating, isn’t it, Ralph?”

Ralph said, “Yes. It certainly fits in with my original suspicion that something besides encephalitis is going on here.” How full of crap could he get?

Larry smiled knowingly at me. “So we’re all in agreement that this catatonic syndrome may be complicating her encephalitis?”

I nodded and Ralph said, “I guess so.”

Larry went on. “The way I see it, we’ve got nothing to lose by buzzing her with a little electricity. Gary, how quickly can we get her on the list for a therapeutic trial of ECT?”

“If her sister signs the consent today, I’ll get her on the schedule for the morning,” I said.

“So you think that’s the best course to take at this point, Larry?” Ralph asked.

“Absolutely. There’s enough in her history to point to bipolar disorder, and even if we don’t get a response after a few ECT sessions, we can stop it and just let the infection run its course. The ECT won’t affect it.”

“Then I completely agree,” Ralph said officiously. It was hard to keep from laughing.

“Great,” Larry said. “Gary will follow up on the details.”

Although I had been relegated to errand boy, I got some satisfaction watching Porter kiss Larry’s ass.

As Larry turned to leave the room he winked at me and said, “By the way, Ralph, I recall reading that one or two percent of the population has unexplained white cells in their spinal fluid. Do you think it’s possible that this encephalitis is just a red herring?”

Ralph took his foot out of his mouth and said, “Anything’s possible, Larry.” I’m not sure Larry heard him—he was already halfway down the hall.

The ECT suite was a large converted conference room on the first floor of the medical center. It contained four gurneys separated by curtains at one end, while the other side of the room had a crash cart, two ECT machines with paddle electrodes, an electrocardiograph, medication bottles, and anesthesia equipment. The ECT attending physician, Tom Reynolds, was a stocky, muscle-bound psychiatrist who was rumored to use steroids to augment the effects of his weekend-warrior workouts at Gold’s Gym.

Real-life ECT is very different from the so-called shock treatments seen in the movies where helpless, screaming patients are strapped down, hooked up to electrodes, and thrown into frightening grand mal seizures. In fact, the curative element of ECT is not muscular spasms at all but instead the seizure that results from the electrical stimulation of the nerves that control those muscles. To avoid the potential dangers of a full muscular seizure, the unconscious, anesthetized patient is injected with succinyl choline, a drug that temporarily paralyzes the muscles.

Heather was being prepared for her treatment, and I was there to observe and assist as needed. After she was injected with a short-acting anesthetic, Tom pumped a blood-pressure cuff around her opposite arm to cut off the circulation to her forearm. In this way the succinyl choline would not reach her forearm, and we could observe it shaking, to ensure the rest of her body was experiencing a neural seizure.

He placed one electrode on Heather’s forehead and the other on her right temporal area. The nurse then set off the electrical impulse, which lasted only a second, and Tom pulled away the electrodes. We watched Heather’s left forearm and hand shake for about thirty seconds. Tom took off her blood-pressure cuff and we wheeled her gurney to the other side of the room. I pulled the curtain around her and stayed, waiting for the anesthesia to wear off. I was jotting down notes in Heather’s chart as Tom started to prepare the next patient.

As I finished my charting, I heard someone say, “What’s going on?”

I looked outside the curtain to see if somebody needed help.

“Where am I? Who are you?”

I quickly turned and saw Heather sitting up as if she had awakened from the dead. She was
really
looking at me for the first time.

“You’re in the hospital, Heather,” I said, “at UCLA.”

She lay back down, weakened by her ordeal. “I’m really thirsty.”

I was ecstatic. “Let me get you some ice chips.”

For the next half hour, while in the ECT recovery area, Heather remained relatively clearheaded and responsive. I was able to fill her in on some of what had happened to her over the previous month and how she had gotten here. She asked to see her sister but then drifted off to sleep. By the time she got back to her room, she was again in her unresponsive, catatonic state.

After each subsequent ECT treatment, Heather’s episodes of clarity lasted longer, and by the sixth treatment, the catatonia was gone. Her successful response to ECT confirmed that the cause of her altered mental state was acute mania, not encephalitis. She was transferred from her medical ward to a psychiatric inpatient unit. We started Heather on lithium to stabilize her mood and discontinued ECT after twelve treatments.
I found an outpatient psychiatrist in Santa Monica who could see her for therapy and medication monitoring once she got home.