by The Naked Lady Who Stood on Her Head: A Psychiatrist's Stories of His Most Bizarre Cases
“Look, Dr. Small,” Lauren said. “There’s no way we’re getting back together, so just what is it you want to know?”
Kenny looked stung by her comment, and her directness threw me as well. We were barely out of the gate, and she had put me on the defensive.
“Lauren, I wanted you to come in today because I thought it might help us understand what’s going on with Kenny,” I said. “If either of you would like to talk about your feelings toward each other, we can do that too.” She looked down and fidgeted with her purse. “Did you know Kenny has injured his wrist three times this year?” I asked.
Lauren laughed. “No shit. I’m not surprised that he banged it up again last week. He’s been obsessed with his left arm for years. If he paid as much attention to me, I might not have kicked him out.”
Kenny jumped in. “That’s not fair. I give you plenty of attention, but nothing is ever enough for you.”
Lauren rolled her eyes.
“So I’ve had a couple of accidents,” Kenny said. “I’ve been working really hard, and I’m under a lot of stress.”
“That’s not the problem. You’re always working, and even when you’re not, your mind is somewhere else. And admit it. You’ve had this thing about your left hand way before all these injuries started.”
“What kind of thing with his hand are you talking about?” I asked, thinking that if she directed her comments to me, it would take some of the heat off Kenny.
She turned toward me and said, “It seems like ever since I’ve known him, he’s walked around with his hand in his back pocket.”
“Lots of people do that,” Kenny said. “What’s the big deal?”
She glared at him, “It’s not normal, Kenny. It’s like a nervous tic for you. And it really bugs me.”
“Fine,” he said. “If that’s your big problem, I’ll stop.”
She snapped back, “Don’t try to make it my problem. What about Halloween?” She turned to me. “His costume was perfect. He went as the one-armed man from The Fugitive.”
“I thought it was a funny costume,” Kenny said. “It’s ridiculous that you’re even bringing that up.”
As I watched the Millers’ bickering escalate, I felt a need to calm the situation, but I also wanted to know more about this Halloween costume. “Kenny, let’s give Lauren a chance to talk,” I said.
“Thank you, Dr. Small.” She looked smugly at Kenny. “I admit the costume was kind of funny at first. Kenny used to have a sense of humor. Anyway, the first time he wore it, that was fine.”
“The first time?” I asked.
Kenny broke in. “Why are we talking about this?”
Lauren ignored him. “After Halloween, he started wearing the costume around the house, even when friends came over.”
“It was just a joke,” Kenny said in exasperation.
“Yeah, Kenny, real funny,” Lauren said sarcastically. She looked at me. “He seemed pretty serious when he started going out of the house with this so-called costume on. He’d wear it to the movies, out to dinner. It wasn’t funny; it was ridiculous.”
I figured that the costume was a link to why Kenny kept injuring his left hand, but I hadn’t pieced it together yet. Whether accidental or deliberate, his injuries were self-inflicted and at some level a cry for help. That brought up a short list of possible psychiatric diagnoses, which I began to check off in my mind. He didn’t seem depressed, and his injuries weren’t consistent with suicidal gestures. Sometimes people with borderline personality disorder will injure themselves to experience physical pain to replace the emotional pain they are trying to escape.
“Kenny, were you aware of how much your costume joke was irritating Lauren?” I asked.
“If I had known that,” he said, “I would have cooled it.”
“How could you not know?” she said, annoyed. “I told you ten times a day!” She looked at me and said, “It was embarrassing me.”
“So Kenny wasn’t hearing you. How would you like it to be with Kenny?” I asked.
“I’d like it to be the way it was when we first got married. We were always laughing, and when something was bothering me, he listened. He would comfort me and hold me.” She paused and her eyes teared up. I handed her a box of tissues, but she waved them away.
“Kenny, do you remember those times?” I asked.
“I loved when we would just hang out and laugh.” He turned to Lauren and said, “And I still want to hold you and comfort you.”
Lauren looked like she was about to reach over and hug him, but instead she snapped, “But only with your right arm.”
The fact that Lauren had come to the session suggested that she might be interested in giving the relationship another try, but she seemed too hurt to let Kenny in again. As the session continued, they seemed to get beyond their bickering. I learned that for the last few years they had been debating the idea of starting a family, but Kenny was less interested in it than Lauren. As the session ended, I got them to agree to come back for another appointment—a minor victory for me.
After they left, I made some notes. I could understand Lauren’s frustration with Kenny’s hand obsession and his reluctance to have a baby. Despite her anger and frustration, she still seemed to care about him. If we could bring back the old Kenny, the guy who made her laugh and knew how to comfort her, I suspected she might give him another chance.
LATER THAT WEEK I HAD MY NOON supervision meeting with Dr. William Browning. I wanted to discuss Kenny’s case with him because of his expertise in psychosomatic medicine—the subspecialty that interfaced mental and physical conditions. Will also had a fascination with Sherlock Holmes and solving mysteries. Among other peculiar talents, he could look at the details and design of a sailor’s tattoo and figure out the person’s original port of embarkation—something he picked up while in the navy.
Will’s office was prime Harvard hospital real estate. Overlooking a grassy area just outside the Bullfinch Building, it was spacious, airy, and decorated with memorabilia from his world travels. I sat down in a comfortable chair, and he sat behind his desk.
“What’s up?” he asked.
“I saw a twenty-eight-year-old carpenter in the E.R. last week,” I answered. “The surgical resident asked me to step in because the patient had self-injured his left wrist three times in less than a year.” I took a long sip of my orange juice.
“That’s it?” Will asked.
“No. While they were putting on a brace, he asked the resident if he would need hand surgery. The resident said it seemed like the guy wanted surgery.”
“Interesting,” Will said. “What else did you get?”
“He agreed to come back to see me for a session with his soon-to-be ex-wife, and she said he’s been obsessed with wearing a one-armed man costume since Halloween.”
Will put down his sandwich and asked, “Does he have a tendency to neglect or hide his left hand or arm?” I was amazed. How did Will know that?
“Yes,” I said emphatically. “For years he’s had a habit of keeping his left hand in his back pocket.”
Will said, “I wonder if this is a case of hemispatial neglect.”
Hemispatial neglect commonly results from a right-hemisphere brain injury, which causes visual neglect of the body on the left side. It usually results in a sensory deficit, and it might cause a victim to pay less attention to sensory input. Kenny clearly had sensation on his left side, so this condition was ruled out.
“I don’t think so,” I answered. “His neurological exam was normal.”
“This talk about surgery, though, could just mean he wants attention,” Will said.
“He did get a lot of TLC in the E.R. from his mother and—”
Will interrupted, “Do you think there’s a sexual component to this one-armed-man thing?” Will loved delving into possible sexual explanations when trying to understand and diagnose complicated cases.
“I don’t think so,” I said. “But I didn’t really get a ch
ance to go there. The two of them were arguing so much that I barely got them to agree to come back in again.”
Will smiled. “So they still have feelings for each other.”
“Yes,” I replied, “but this hand thing is too much for her to take. Also, her biological clock is ticking, and he’s reluctant to start a family.”
“My guess is your patient’s hand obsession is just a distraction to keep them from dealing with the real problems between them. Try and get them to talk about their underlying issues. Also, ask him directly what he’d like to see happen with his hand.”
THE FOLLOWING WEEK, KENNY AND I WERE waiting in my office for Lauren, who was late. He was jumpy and kept checking his watch. “I don’t think she’s going to show up,” he said angrily.
“That’s okay. You and I can get started. How have you been feeling this week?”
“Like crap,” he said. “I thought Lauren and I made a connection last week, but now she won’t return my calls. My parents are driving me crazy—I can’t live with them much longer…” As Kenny spoke he absently pulled his jacket downward to cover the sling on his arm.
“You know, when you were in the emergency room, you asked the doctor about surgery. Why did you bring that up?” I asked.
“I don’t know,” he said. “Sometimes they have to put in metal pins and stuff. They might even have to amputate for all I know.”
Whoa. How did he get from a broken wrist to amputation? Was he kidding, or did he have some kind of unconscious wish to get his hand amputated? Maybe he was psychotic.
“Don’t you think amputation is a little extreme for a wrist fracture?” I asked.
“How the hell should I know?” he snapped. “I’m not a doctor. Besides, I can work just fine without my left hand. I’m right-handed, you know.”
Maybe his amputation wish was not so unconscious after all. At that moment, his face seemed to shift from anger to sadness. It was so apparent that I thought I should comment.
“You seem sad, Kenny.”
He grunted and shrugged his shoulders.
“Tell me what’s going on,” I said.
He sighed. “I just feel alone. I always do. There’s nobody I can talk to.”
“You can talk to me,” I replied. “Why don’t you tell me what you really want to happen with your hand.”
Kenny looked up at me, worried. “If I told you, you wouldn’t understand. I don’t even get it.”
“Try me.”
Kenny stood up and walked to the window. He stared outside for a few moments and then said, “I’ve never told this to anyone before. It’s embarrassing, Dr. Small.”
“Maybe you’d feel better if you told me,” I said.
Kenny sat back down and said, “I get the craziest feelings sometimes. Like my hand isn’t supposed to be part of my body—like it doesn’t belong. I never told Lauren because she’d freak out, but she knows I have a secret and that drives her crazy.”
Kenny’s secret feelings helped explain his bizarre behavior. He could be psychotic, but it sounded more like he had a rare form of distorted body image. Kenny’s feelings were similar to those of anorexics who starve themselves because their normal body size feels wrong to them. In Kenny’s case, instead of a skinny body, he wanted one less hand. I felt an urgency to learn more about this condition before Kenny actually found a surgeon who would agree to cut off his hand.
“I can understand why it’s hard to talk about these feelings,” I said.
“Lauren would never understand. She’d think I was some kind of freak.” Kenny got agitated again and kept nervously pushing his left arm back, away from him. “Sometimes these urges get so intense that I’m afraid I might go down to my table saw and chop it off myself.”
That comment changed the whole situation, and I was suddenly concerned that he was in danger. “What keeps you from doing it, Kenny?” I asked, trying to remain calm.
“I always thought it would be safer if a surgeon did it. I don’t want to die, I just want to get rid of this stupid hand—it shouldn’t be there.” He looked down at the floor and continued, “But I don’t know. What does it matter? Lauren won’t accept me either way.”
At this point I was worried that Kenny was at risk of seriously hurting himself, and I knew I would have to hospitalize him—whether he liked it or not. To keep him from bolting, my next move was crucial. While Kenny was staring at the floor, I used the old make-your-own-beeper-go-off trick and paged myself. Kenny looked up as I checked my pager and said, “Will you excuse me a second, Kenny? This is an emergency.” He shrugged and I left the office, shutting the door.
I quickly told the clinic secretary to page security because I had to put my patient on a seventy-two-hour hold over at Lindemann. She said she’d buzz me on the intercom as soon as they were stationed outside my door.
I went back into the office and sat down. “Sorry about that.”
Kenny looked distracted and said, “Whatever. Look, Doc, I know I must sound crazy, but I’ve had these feelings a long time and I do just fine.”
“You’re not concerned that you might act impulsively at some point,” I asked, “and maybe try it yourself?”
“They’re just thoughts, Dr. Small, I haven’t done anything yet, have I?” he said with an edgy tone. To my relief, the intercom buzzed. I picked up the phone and asked them to wait.
“But you’re having a tough time right now, Kenny,” I said. “Your marriage is in trouble, and living at home with your parents is driving you crazy. And you’re talking about possibly cutting off your own hand. I think you might be better off going into the hospital for a little while until we sort this out.”
“You mean the loony bin?” he sputtered. “Not a chance in France.”
One of the difficult decisions a psychiatrist is sometimes forced to make is whether to hospitalize patients against their will. There are essentially three reasons for involuntary commitment: a patient is acutely suicidal, homicidal, or perceived in some way to be a danger to himself or others. Often it’s a psychiatrist’s judgment call as to whether self-destructive thoughts or feelings pose an imminent danger. Some people might feel chronically suicidal and talk about those feelings constantly but never act on them. Others engage in chronic suicidal behavior, destroying themselves at a gradual pace through starvation, drugs, alcohol abuse, or smoking. However, these people are not perceived as acutely dangerous; they are rarely committed.
Part of a psychiatrist’s training involves putting together what a patient says, his history, and his current behavior to make this critical decision. The methods for potential self-harm that patients discuss will influence the doctor’s decision. A man is more likely to shoot himself, whereas a woman would sooner opt for an overdose of pills. If a depressed and lonely woman mentions a large stash of sleeping pills at home, that would heighten a psychiatrist’s concern. And if a carpenter who’s obsessed with cutting off his hand mentions a table saw in his basement…
“I’m sorry, Kenny, but at this point it’s not up to you,” I said. “I’m going to have to admit you for observation to make sure you don’t hurt yourself.”
Kenny stood up suddenly. “No fucking way. I trusted you, you asshole.” He swung open the door and stepped out as two burly security guards grabbed his arms. “Hey, easy on my sling, you jerk,” he said.
THE NEXT DAY, WILL BROWNING WAS ABLE to squeeze me in for half an hour. He wasn’t surprised by what had happened with Kenny. “You had to do it, Gary,” Will said.
“I know. I just feel bad that I’m the first person he’s ever trusted with his secret, and he thinks I’ve screwed him over.”
“You probably saved his life, and now you have a chance to really help him.” Will went to his file cabinet and pulled out some papers. “Check out this article.”
I read the title out loud: “Apotemnophilia: Two Cases of Self-Demand Amputation as a Sexual Preference.” I scanned the abstract describing these unusual cases of male patients who had a sexua
l obsession with their own amputated stump.
“Gary, I think you’ve stumbled upon a very rare condition. Kenny finally told you what he wants—amputation of his left upper extremity,” Will said. “Did you find any sexual connection to his wish to amputate?”
“I don’t think there is a sexual component to his obsession,” I answered.
“Then it could be a form of dysmorphophobia, where the patient perceives himself or part of himself as grotesque, even though he looks perfectly normal.”
“That sounds closer to what he’s got,” I said. “But I don’t think he sees his hand as grotesque. He just feels it doesn’t belong there—like he won’t feel normal until it’s gone.”
Dysmorphophobia was first described by an Italian psychiatrist, Enrico Morselli, in 1886. Today we call it body dysmorphic disorder, which describes people who seek body modification to rectify some perceived physical imperfection. The condition has some similarities with obsessive-compulsive disorder, and patients often suffer from both illnesses simultaneously. Sometimes these people appear to be addicted to plastic surgery, and the results can be irreversibly grotesque. Usually they don’t pose an immediate danger to themselves, unless their symptoms become extreme.
Kenny had some of these symptoms but actually suffered from a related and extremely rare condition that today we term body integrity identity disorder (BIID). Patients suffering from BIID believe their bodies don’t match the image of themselves they have in their minds. They might feel their unwanted limb is not necessarily ugly but makes them incomplete or disabled. They’re often jealous of actual amputees and experience such shame about their feelings that they rarely discuss them. They are typically not suicidal but just want the limb gone, so they seek out surgeons for elective amputation. Occasionally BIID victims will damage the unwanted limb to the extent that it requires amputation. In one reported case, a man rigged his car with automatic hand controls and then froze his unwanted legs in dry ice until they were unsalvageable. He then calmly drove himself to the hospital, where his legs had to be amputated.
