Falling Into the Fire: A Psychiatrist's Encounters with the Mind in Crisis

by Montross, Christine

  “Joseph?” I called loudly as I stood by his bedside. He remained motionless in the bed. I took hold of his shoulder and shook it. “Joseph, I need you to wake up now,” I said. There was no response. Not even the snoring I had heard from him earlier in the morning. “Okay, I’m going to examine you, Joseph,” I said as I lifted his limbs one by one from the bed. His reflexes were normal. I lifted his eyelids and shined a light in his eyes; his pupils were the same size, and they shrank in diameter when the light struck them. All reassuring signs. I began thinking that maybe Joseph was ignoring me, simply refusing to engage. Then I remembered Henry’s sternal rub. I took Joseph’s hand in mine and held my pen crosswise against his thumbnail. Then I pushed down on it, first gingerly and then, when there was no response from Joseph, as hard as I could. He didn’t even flinch. The sensation of hard plastic pressing against a nail bed is unpleasant at best, excruciating at worst. Before a clinical-skills exam in medical school, I practiced it on my partner, Deborah, right after assessing her cranial nerves and position sense. Not having expected what was coming, she almost punched me. Joseph’s lack of response was meaningful. It made me nervous. I started to leave the room, resolved that I would send Joseph out to a medical emergency room, but then turned back to him to try one last thing.

  Doctors have tests that are specifically designed to determine whether symptoms are truly neurological in origin or whether they might have psychiatric or volitional components. Some of these tests are meant to flush out people who are exaggerating symptoms for their own gain. Disability applicants, perhaps, or military draftees. Many of these tests take advantage of basic tenets of brain functioning that are likely unknown to the general public. For example, in all but the most profound losses of cognitive functioning, people who sustain a brain injury will retain elementary facts: that a dog has four legs, for example, or that the date of Christmas is December 25. Even people with near-total memory loss know their own names. Answers to the contrary raise a flag of concern for malingering or symptom exaggeration.

  Dr. Charles Scott, a well-known forensic psychiatrist, demonstrates the coin-in-the-hand test to uncover intentionally erroneous responses on testing. “You can’t imagine that anyone would fall for this,” he says. “It’s very obvious.” Scott puts a coin on his desk and then puts his hands out in front of him, palms up, facing the person he’s evaluating. Then he explains to the examinee that he’s going to ask him or her to select which hand the coin is in. With the person watching, Scott picks up the coin with his right hand, slowly puts it in the palm of his left hand, and closes both of his hands into fists. The hands never cross; they are never out of the person’s sight. “That’s it,” Scott says. Then, with all that in plain view, the examinee is asked to count down from ten to one and then say which hand the coin is in. Ninety-plus percent of nonmalingering examinees will indicate the correct hand, Scott explains. Malingerers, conversely, will choose the wrong hand more than 50 percent of the time. They’re trying too hard to look as if they can’t function.

  There are similarly cunning tests to assess pain, sensory loss, and paralysis. And as I turned away from Joseph, I suddenly remembered the arm-drop test. I stepped back to his bedside and raised his limp arm up above him until it was over his face. Then I let it drop. The arm flopped down, landing alongside Joseph’s body. I did it again, raising the limb, holding it directly above and in line with his face, then letting it drop. Again the arm flopped to Joseph’s side. Henry and I exchanged glances. The fact that Joseph’s hand had missed hitting his face—twice—made it likely that he was changing the trajectory of his arm to protect himself. He may have been doing it unintentionally or subconsciously, but if he were totally unconscious he would have been unable to redirect his arm.

  A group of internal-medicine doctors rotates through the psychiatric hospital early on weekend mornings to do physical exams on newly admitted patients and consultations for psychiatric patients who are medically complicated. I left Joseph’s room and told Henry that I was going to page the medical service to run this by them. Now that I had seen the results of Joseph’s arm-drop test, there was nothing else on exam that made me think he needed to be sent out to a medical hospital. Still, the lack of response to painful stimuli was unnerving. Henry agreed.

  When I got the medical doctor on the phone, he had already left the hospital. “Did you check his pupils?” he asked me. Yes, I told him, and his reflexes. And his muscle tone. Everything was normal except Joseph’s lack of reaction to pain and the fact that he seemed to be protecting his face from his falling hand. The doctor listened, then thought aloud, ruling out one medical cause after another based on my examination. Eventually he paused. “What about the gag?” he asked. “Did you check a gag?” I hadn’t. Lack of a gag reflex could indicate damage to the medulla, a critical part of the brain stem.

  “I’ll try it now,” I said.

  “Call me if you need me,” the doctor replied. I hung up and headed back to Joseph’s room with gloves and a tongue depressor. Henry met me in the doorway.

  “Still nothing, Doc,” he said. “I don’t like it, but then again, he doesn’t seem that sick to me.” I understood. Joseph’s motionless endurance of two painful tests was impressive, but it didn’t add up. I put on my gloves and went back to the bedside.

  “Joseph?” I said loudly. “I’m going to open your mouth to test your reflexes. This might feel uncomfortable. You might feel like you have to gag.” He remained stock-still and silent on top of his covers. I took his face in my hands and gently pulled his jaw open. I began to slide the tongue depressor into his mouth. Well before I was close to making him gag, Joseph let out a low moan. I paused and glanced up at Henry, who looked surprised. I withdrew the tongue depressor.

  “Joseph?” I said again. “Can you hear me?” The room was silent as Henry and I craned forward to listen for several long seconds. I began to convince myself that I had heard nothing and started to take Joseph’s chin back into my hands. Then, finally, there came the slightest of sounds from his lips.

  “I’m very depressed,” he whispered, motionless and eyes closed.

  I suddenly heard myself exhale, relieved by Joseph’s response. “Okay,” I replied. “Okay. We had some trouble waking you up and had to make sure you were with us.”

  “I know where I am,” Joseph whispered, slowly and laboriously, “and I know who you are, and I just want to be left alone, because I’m terribly depressed.”

  • • •

  It’s tempting in situations like Joseph’s to read a patient’s lack of responsiveness as intentionally obstructionist, a manipulative trick. And yet the intersections between mind and body are so much deeper and more complex than that. My interpretation of Joseph’s condition was that he had symptoms of catatonia.

  Though catatonia is most widely associated with images of schizophrenic patients who adopt bizarre postures for prolonged periods of time, unresponsiveness and a lack of withdrawal from painful stimuli are indicative of stupor, a principal feature of catatonia.

  Stupor illuminates a baffling intersection of the mind and body. Here psychic conflict can somehow interrupt a body’s neural circuitry so as to render a person mute, immobile, or even impervious to pain. Psychiatry occupies just this kind of ever-shifting nexus of brain and mind. In terms of scientific disciplines, psychiatry bridges the territory between neurology and psychology. Like neurology (and unlike psychology), psychiatry is a medical discipline; practitioners of both disciplines must go to medical school, then train in a hospital-based residency program.

  Neurology claims the territory of the brain, the spinal cord, and the nerves that branch throughout our bodies. The neurologist treats the migraineur whose headaches will not abate, the stroke victim who comes into the emergency room slurring her words and unable to move an arm and a leg, the boy who dives into the shallow end of the pool and becomes a quadriplegic, the motorcyclist whose crash has left him
comatose from a bleeding brain.

  Psychiatry, in contrast, is the science of disorders of the mind: when thoughts derail, emotions wreak havoc, or behavior destroys. In this book I have written five chapters about the mind and its mysteries. The first explores the struggles that doctors face in treating patients who intentionally and repeatedly injure themselves, by swallowing dangerous objects or by cutting and burning their own flesh; who undermine the very work their doctors do to try to help them. The second examines illnesses in which people are relentlessly tormented by their ideas about their bodies. Herein is a woman who nearly killed herself by picking at a blemish on her neck and a man whose earnest plea is for a surgeon to amputate his healthy leg. The third chapter centers on the legal ability doctors have to hospitalize—and sometimes medicate—a patient against his or her will. A patient claims that love emanates from everything around him. Is it ecstasy or psychosis? Do our current views of sanity allow for the otherworldly or divine experiences historically associated with saints or mystics? The fourth chapter grapples with the very real peril that patients face if their individual illnesses are not correctly defined. When a woman is admitted with repetitive thoughts of harming her child, her course of treatment—and her child’s safety—depend upon whether she receives the correct diagnosis. The fifth and final chapter recalls Joseph and patients like him whose bodies are overtaken by the illnesses of their minds. How do we treat a woman whose seizures have no neurological cause? What possible explanation can there be when groups of men are convinced that their penises are shrinking into their bodies? The chapter asks how well we doctors, trained to act and fix, are prepared to sit with patients in—and accompany them through—the trials of their illnesses.

  Life, of course, changes how we see things. As I wrote this book, my partner, Deborah, and I were raising our young daughter and our even younger son. It turns out that parenting children and caring for psychiatric patients have their fair share of similarities. I mean that in all the ways in which that sentence can be interpreted: with love, and frustration, and gratification. With fear, and awe, and ineptitude.

  My children do not age sequentially in this book. My daughter may be four, and then she may be a newborn. I have found that I experience the pasts of my children in this jumbled way. A snapshot of a year ago and then a flowing current of their infancies and then today, with their book bags and lunch boxes and shoes that tie. I imagine that the memories will intermingle like this throughout their lives. Those memories, too, will shift with context. My son will become an engineer, and we’ll nod knowingly, claiming to have seen it coming from the years of infinite Lego structures. Or he’ll be a comedian and we’ll say, We knew because he always made his sister laugh. Hindsight is powerful in parenthood, as in medicine.

  • • •

  In its quest for effective treatments of mental illness, the evolution of psychiatry has been characterized by both inspiring and inglorious moments.

  The Bethlem Hospital to which twenty-two-year-old Charles Harold Wrigley was admitted in 1890 was founded as a priory in 1247. It became a hospital in 1330 and took the first patients classified as “lunatics” in 1357, making it the first and oldest recognized institution in the world to give care to the mentally ill. By the end of the fourteenth century, the hospital began to be used exclusively as a hospital “for the insane.” Over the centuries the hospital grew, as did the demand for the care it provided. But for nearly three hundred years, Bethlem housed only twenty patients at a time and operated as an institution for so-called short-stay patients.

  Today my colleagues and I use this term for hospital admissions whose duration is less than forty-eight hours. In the current state of health care, only the most severely ill patients are admitted to the hospital; even then the average stay is five days. Managed-care companies will phone physicians, sometimes daily, to interrogate them about their clinical decisions and treatment plans. If the insurance companies do not feel that the patient continues to meet their own narrow criteria for inpatient treatment, they will refuse to authorize additional days of hospitalization. Physicians have the right—indeed the mandate—to make clinical decisions based on patients’ needs rather than insurance companies’ pressures, but we are aware that unauthorized days in the hospital will result in staggering bills for our patients, many of whom are already in financial turmoil. If patients cannot pay, the costs of their treatments are frequently absorbed by the hospitals themselves—an obviously unsustainable practice. These factors combine to form the present reality: Today’s inpatient care is most often crisis management. Patients are discharged from our wards as soon as they begin to stabilize, once they are no longer acutely psychotic or no longer in imminent danger of harming themselves or others. This means that patients are often released from the hospital in a tenuous state of mental healing. In many cases their symptoms recur and they return to the hospital for another five-day effort at stabilization.

  In contrast, by early Bethlem standards a “short stay” was one in which the patient was discharged after twelve months or less. Even one year of treatment proved to be inadequate for many patients at Bethlem, as the hospital archives reveal. The hospital developed a means of classifying patients as either “curable” or “incurable.”

  “When a patient, after sufficient trial, is judged incurable,” an eighteenth-century hospital document explains, “he is dismissed from the hospital, and if he is pronounced dangerous either to himself or others, his name is entered into a book, that he may be received . . . [into] the house whenever a vacancy shall happen.” Despite the dangerous conditions that these patients were deemed to have, the number of patients in need of longer-term care far exceeded what Bethlem Hospital could offer. “There are generally more than two hundred upon . . . the incurable list,” the document continues, “and as instances of longevity are frequent in insane persons, it commonly happens that the expectants are obliged to wait six or seven years, after their dismission from the hospital, before they can be again received.”

  In response to this great need, Bethlem expanded yet again in 1730, adding two wings for the “incurables,” who were now permitted to stay until the moment when—or if—they recovered. One such patient was Richard Dadd, an artist who began suffering from paranoid delusions at the age of twenty-five. Dadd said he received messages from the Egyptian god Osiris and stabbed his father to death in a park, believing him to be the devil in disguise. The hospital documentation mentions that Dadd remained in Bethlem until his death, forty-two years after he was first admitted to the incurable ward.

  The expansion of Bethlem Hospital to treat—or at least contain—patients whose struggle with mental illness would be chronic and severe was not one entirely characterized by altruism. The sheer number and concentration of (often visibly) ill patients at Bethlem became a major eighteenth-century London tourist attraction. Visitors bought tickets from the hospital to gawk at the spectacles of both frenzied psychosis and the brutal forms of physical restraint that Bethlem employed. The tour began on the Bethlem grounds beneath two reclining sculpted figures called Melancholy and Raving Madness and then processed past the patients, some caged or shackled or with iron bits protruding from their mouths. Using Bethlem’s name, the witnessing public soon coined a new word for the conditions they observed: “bedlam.”

  In retrospect, “bedlam” seems an apt description both for the scenes of madness in Bethlem’s early halls and for the torturous range of “therapeutic” treatments whose efficacy was tested on the captive patients. Every spring, under the orders of one particular physician, there was a prescribed bloodletting for every patient in the hospital. At other times, depending on the psychiatric treatment currently in vogue, patients were restrained in submersible cages and then held underwater in the hopes that the near-drowning experience would shock the ill mind into a new outlook on life; they were strapped to seats that spun for hours at great speed, and treating practitioners marveled at ho
w well the induced nausea would calm the most agitated patients into more placid behavior.

  Even in that earlier era, a patient’s finances could determine the treatment he received. Bethlem’s eighteenth-century hospital physician, Thomas Monro, was called before a House of Commons committee to discuss the use of Gothic fetters—iron restraints to which hospitalized patients were frequently riveted. Monro reassured the committee that the fetters were “fit only for the pauper lunatics,” explaining that “if a gentleman was put in irons, he would not like it.”

  Though the treatments I can offer to my patients today are, thankfully, far more humane than those I find documented as I page through the nineteenth-century Bethlem casebooks, I am struck by the disquieting fact that Charles Harold Wrigley, with his exact symptoms and story, might as easily have been seen in one of the psychiatric wards on which I work today.

  I could likely guarantee Mr. Wrigley more dignity, more comfort, and more privacy than he received in 1890 in “Bedlam.” I could prescribe him modern medications and offer him appropriate psychotherapy. But in spite of the surefire treatments that have been found in the last three centuries for countless other medical conditions, I could not guarantee that my treatment would bring him relief or cure.