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

by Montross, Christine

  b.Beverages are to be given in a single Styrofoam cup with refills to occur outside patient room.

  c.Plastic or metal utensils are NOT allowed.

  d.Immediate removal of tray/plate when meal has been completed.

  5.Staff must only bring essential items into room at point of care and remove once completed:

  a.IV poles, tubing, labels, fluid bags, flushes, etc.

  b.tape and/or dressing supplies, etc.

  6.All new Constant Observers/Security Officers are to be educated by nurse about patient’s status prior to entering room.

  a.All nonclothing objects are to be removed (badges, clips, keys, pens, etc.).

  b.Patient’s mouth must be in view and observed at all times.

  c.Patient must have one arm visible above the sheets/blankets at all times.

  d.Patient is not allowed to hide mouth with gown, blanket, sheet, etc.

  7.Patient may not leave designated room unless for an ordered test/procedure.

  8.Patient must remain in hospital attire for her entire stay, undergarment briefs allowed, bathrobe belts/ties not allowed.

  The implications of the list were startling to read. Styrofoam trays, plates, and cups prevented Lauren from breaking a ceramic plate or a plastic tray into jagged pieces to swallow. Even bringing a plastic bottle or pitcher into the room to refill her drink posed a risk. If curtain rods had been broken into sharp shafts and swallowed, then IV poles could be, too. The costs of these admissions were also unquestionably staggering. Two guards had to be paid hourly for the entire hospitalization, simply to sit in Lauren’s room and watch her.

  As I turned the pages of her chart, I came across a range of surgical notes and consultations. Brief blurbs by surgical residents revealed that they had put the trauma surgery team on alert, in case one of Lauren’s swallowed objects obstructed or perforated her gut, necessitating emergency surgery. Previous psychiatric consultations focused on the acuity of Lauren’s mental state. Was she currently having urges to swallow objects or to otherwise hurt herself? Was she suicidal?

  The pages of notes also delineated the psychiatric medications that Lauren had been prescribed prior to her admission and whether or not she’d been taking them reliably. At various times Lauren had been on medications from almost every class of psychopharmacologic agent: antidepressants and mood stabilizers, sedatives and antipsychotics. Frequently she was prescribed more than one at a time: an antidepressant to improve her mood and a sedative to treat her anxiety, for example. During one series of admissions, the plan was to target her impulsivity with a mood stabilizer and an antipsychotic that had recently shown promise for behavioral dyscontrol in a clinical trial. Judging from the frequency of Lauren’s admissions and the similarity of her symptoms on arrival, no specific medication seemed to make much of a difference.

  All of medicine is plagued by the whims of the body and the variability of the human experience. The most effective diabetes regimen is useless if the patient to whom it is prescribed binges on candy bars and soda. A vegan marathoner may still have stubbornly high cholesterol or be genetically predisposed to coronary artery disease. Psychiatry’s particular struggle is that it is so often impossible to separate our patients’ psychiatric symptoms from the social circumstances and stressors that exacerbate them. There are many frustrating consequences of this dilemma.

  A common critique of psychiatry is that our medications do not work or that, if they do, they only subdue and sedate. This misperception has sometimes led psychiatry to be cast as a sinister science, beholden to pharmaceutical companies that wish to unnecessarily medicate the masses for profit. The antipsychiatry movement perpetuates this characterization of psychiatry as a scienceless discipline. Dr. Thomas Szasz, a famed critic of psychiatry who happened to be a psychiatrist himself, deemed the field “pseudoscience” and likened it to alchemy and astrology. Scientology has taken particular aim at psychiatry (as Tom Cruise demonstrated in his cruel and absurd rants against the existence of postpartum depression), even funding a hyperbolically named “museum” in California called Psychiatry: An Industry of Death.

  Dr. Lawrence Price, my friend and mentor who has been at the forefront of the study of mood disorders for thirty years, more appropriately identified some of the issues that give rise to mistrust of psychopharmacology in a 2010 letter to the editor of the New York Times. “Antidepressants do work for people who are really depressed,” he writes. “They don’t for people who aren’t. Depression is frequently diagnosed in people who don’t have it, and frequently not diagnosed in those who do. Medications that work for depression are commonly misused, and types of psychotherapy that work for depression are commonly not used at all. The reasons for this state of affairs include mistrust of authority, stigma, big-stakes health care economics, cross-discipline rivalries and simplistic thinking (within the mental health care field as well as the general public). The excesses of the media and the perverse incentives of our current health care delivery system make things worse.”

  Dr. Price was writing specifically about the treatment of depression, but the obstacles he identifies are germane to the current treatment of most psychiatric illnesses. As I looked through the long list of psychiatric medications that Lauren had tried—and that had failed to improve her condition—I found that many of these confounding variables were at play. It was possible that medication could be of help to Lauren. Depression or anxiety could underlie her swallowing. If those illnesses were treated, she might be more able to cope in healthy ways when she was distressed. And yet even the most perfect medications cannot help if they are not reliably taken. Some of the notes indicated that Lauren had run out of her medication and lacked the means to obtain more. Others reported that she had discontinued a treatment regimen because she found the side effects intolerable. Still others mentioned that she had been drinking or using drugs that had the potential to interfere with her medications.

  Nearly every note made mention of Lauren’s “lack of coping mechanisms,” as well as a litany of seemingly insurmountable social stressors—poverty, unemployment, family discord, lack of social supports. No pill we could prescribe would address any of these issues, all of which were constant pressures upon Lauren in her daily outpatient life.

  In Lauren’s charts, interspersed between the consultations and the daily progress notes by her medical team, were the images from her many, many endoscopies: healthy tubes of bright pink flesh that terminated in a glint of metal knife blade or the white plastic cap of a giveaway pen.

  Under normal circumstances, when endoscopic procedures yield biopsies or polyps that have been removed from the body’s depths, these specimens are sent to the hospital’s pathology department for description and evaluation. Lauren’s specimens followed protocol. A surgical pathology report: “Received fresh”—as opposed to in formalin, as would be true for many anatomical specimens—“are silver metal, focally rusted scissor blades with a small amount of attached orange plastic handle. The specimen measures 14.3 × 3.0 × 0.8 cm.” As if to justify the fact that the pathologist had not microscopically evaluated the scissors, the report continues, “Gross diagnosis only, consistent with foreign body.”

  This terminology, “foreign body,” crops up again and again in the medical assessment of Lauren. Each time she comes to the hospital, X-rays are done, to enable us both to look at what is inside her and where and to make sure that none of it has perforated the critical barrier between the messy, bacteria-laden contents of the human gut and the sterile body cavity that holds our internal organs. “Foreign body in the stomach/esophagus,” reads a typical abdominal X-ray report in Lauren’s chart, “14 cm in greatest dimension. Multiple other small foreign bodies, unspecified.”

  The language is meant not to be evocative but rather efficiently dichotomous. Classifying an object on a medical image as “foreign” is a way of differentiating self from other. A
child inhales a button, or a game piece, or a nickel, and a “foreign body” is visible in the airway on a chest X-ray.

  There are sometimes objects that are of the body that nonetheless don’t belong: a cyst, a tumor. Yet as much as my mother might have thought of her breast cancer as an invader, as something “other” than her body, the cells were her own, built by her DNA, errant as it might have been. Neither the unwelcome tumor in her breast nor the cancerous cells in her axillary lymph node—despite their unmistakable invasion of her healthy tissue—could medically be classified as “foreign.”

  And yet in describing Lauren’s medical and psychiatric plight, this recurrent phrase—“foreign body”—seemed profoundly correct. Was there some way in which Lauren was disconnected from her body? Some separation that enabled her to swallow scissors and steak knives?

  Most of us are unable to intentionally inflict injury upon ourselves, let alone understand what would lead someone to do so. This may be because of a reflexive response to pain or the result of an innate survival drive. It may be because our sense of personhood is so inextricably tied to our bodies that it is often impossible for us to separate our identities from our physical selves. Self-injury is even less comprehensible to us than suicide. Suicide at least can be cast as a desperate attempt to end torment and pain. How do we make sense of behavior whose very intention is to bring about damage and pain and yet survive? Over and over in Lauren’s chart, she describes swallowing objects in an attempt to relieve stress, not as a means of killing herself. Though she does occasionally express thoughts of wanting to die, those instances are very rare in comparison to the relentless constancy of her dangerous ingestions.

  What, then, is this disconnect in Lauren and in others like her who chronically and persistently struggle with what psychiatry calls “nonsuicidal self-injury”? Why is it that simply reading about the wounds she has inflicted upon herself causes many of us to wince (barbecue skewers? a bedspring?), while Lauren and others who chronically harm themselves not only can tolerate inflicting these actions upon themselves but may indeed find some sort of relief in doing so? Could it be that her body is not inseparable from her sense of self but rather foreign to it?

  • • •

  Dr. Armando Favazza is a leading expert on self-mutilation. Favazza, a professor of psychiatry at the University of Missouri, developed a system for categorizing deviant self-harm. He classified self-injurious behavior as falling into one of three types: major, stereotypic, or superficial/moderate.

  Major self-mutilation comprises rare and extreme cases—people who, for example, cut off their own limbs, castrate themselves, enucleate their eyes. These patients are most often psychotic. They may be commanded to act by hallucinations or religious delusions; they may feel they have been explicitly instructed by God to harm themselves. There are multiple references in the psychiatric literature to people who have removed one of their eyes, citing a passage in the biblical book of Matthew in which Jesus commanded, “If thy right eye offend thee, pluck it out.” Deliberate eye mutilation is a severe act, but it is not altogether uncommon. Favazza estimates that in the United States alone, about five hundred cases of intentional eye enucleation occur every year.

  Many episodes of major self-injury—whether to eyes or other parts of the body—are in response to sexual perseverations or themes. In Bodies Under Siege, Favazza describes an example reported in the Journal of Clinical Psychiatry by J. E. Crowder in which a forty-four-year-old man tried to gouge out his eyes with his fingers because he felt guilty for having gone to topless nightclubs. Three years after this first attempt, he felt that a statue of the Virgin Mary commanded him to remove his eyes from his body and thus cleanse himself of sin. He attempted to do so, this time using forceps. He failed and was psychiatrically hospitalized, where he repeatedly tried to take out his eyes, eventually succeeding in jamming a pencil into one of them during psychological testing.

  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.