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

by Montross, Christine

  One week later a homeless patient who had been hospitalized because he was suicidal complained of excruciating foot pain. I pulled off his sock to see a warm, red, and swollen foot. When I pressed my thumb into his ankle, the patient howled, and a deep indentation remained in his flesh where my thumb had been. He had a history of severe infections. I feared he had a cellulitis—a spreading bacterial infection—which could rapidly advance. I sent him to the hospital for what I imagined would be imaging and medication, possibly even admission to the medical hospital for intravenous antibiotics. Four short hours later, the patient was back without even so much as a Band-Aid. His foot, inexplicably, looked better. The somewhat brusque note sent back to me from the emergency physician cited no signs of infection, said the patient had required no treatment, and recommended Tylenol and Epsom-salt soaks should the patient complain of any discomfort. The symptoms never returned. To this day I have no idea what caused his foot’s swelling to appear, cause pain, and then recede. The etiology clearly was not the dangerous infection I had thought it to be.

  For emergencies, the psychiatric hospital was equipped with a hospital-wide buzzer system. Staff members in every unit had easy access to a blue button and a red button. Pushing either button activated an alarm and illuminated corresponding red or blue lights on numbered panels positioned throughout the hospital. A red light indicated a psychiatric emergency—most frequently a patient who was becoming violent—in which case additional staff members from every unit in the hospital would come to provide extra help. All the staff members in the hospital had been trained as to how to respond to a psychiatric emergency when a patient became violent. My job in those scenarios was to talk with the patient as best I could to try to calm him and to order medications if they were needed. In the event that the situation escalated, requiring staff members to intervene physically, I was to stay out of the way.

  However, when the buzzer sounded and the corresponding light flashed blue, it was to notify me of a medical emergency in the hospital. In a medical emergency, though nurses and others were available to help me, I was clearly in charge.

  Some psychiatric residents were more gung ho about opportunities to provide medical care than others—those who narrowly chose to specialize in psychiatry over surgery, for instance, or those who had seriously contemplated becoming internists or emergency physicians. I did not fall into these categories. My decision to go to medical school in the first place had been in order to become a psychiatrist. Although to keep myself sane while learning about pulmonary physiology and renal pathology, I stayed open to falling in love with another field of medicine, I never seriously wavered. I felt at home during my rotations with attending psychiatrists, and the knowledge I had to accumulate was more innate to me. No matter how much I studied, the territory of the kidney and lung and heart remained opaque. Their ion exchanges, their functional equations, their vectors, and their voltage-gated ion channels—I could memorize these mechanisms and pass exams to demonstrate that I had done so. But it would be false to say I ever really understood.

  I could look at an EKG, its needle-traced line on a page, all waves and milliseconds and axes. But it took a kind of faith, I found, to see in that line the aberrant cardiac rhythm that had prevented my grandfather from climbing the stairs to his favorite restaurant. Medicine asks you to believe that an exact equation can explain why an asthmatic six-year-old who lives in a cockroach-infested apartment crosses the threshold from shortness of breath to a prolonged and catastrophic lack of oxygen. You have to live by that math while looking at her in the pediatric ICU, to trust that equation to somehow make sense of her devastated brain no longer able to generate speech, or movement, or comprehension.

  In medicine these precise calculations were sacred texts held within a kind of temple that professed to show—exactly—the how and why of sickness, and death, and dying. I found myself a faithless skeptic, disillusioned by the restricted scope and the persistent fight against ambiguity. I could not worship at those tidy altars. Which is not to say that psychiatry is devoid of science. There are those who make this argument, but they are clearly wrong. Nonetheless, our knowledge of the brain is limited, and our knowledge of the mind even more so. I found psychiatry’s lack of certainty frustrating, yes, but also liberating, and true. There is no satisfying explanation for an eighteen-year-old’s first psychotic break; try as we might, there is no way to make sense of it. Perhaps ten or twenty or fifty years down the road, schizophrenia’s origins will be made plain. Even so, I expect that knowledge will do nothing to diminish the incomprehension that overcomes me as I try to understand what brings about the fracture of a young man’s mind.

  So for some of my colleagues and friends, a blue buzzer on an overnight shift was a call to arms and a welcome chance to dive back into medicine’s fray. For me it caused a surge of anxiety—would I accurately gauge what was happening? Would I know what to do?

  Some residents’ entire month of overnights went by without a single blue buzzer. Midway through my August assignment, I had three, one night after the next after the next. The first night a woman who had come in after an overdose suddenly fell down on the unit and was unresponsive. The second night a man had a heart attack. Both times, despite my nerves, I administered medicines and oxygen and sent the patients out by rescue to be treated at medical hospitals—all the correct courses of action. By the third night, even when the trickle of patients into the psychiatric ER slowed and I was able to lie down in the call room to try to catch an hour or so of sleep before the next patient arrived, I couldn’t get my mind to settle. I kept waking, staring at the blue buzzer, expecting it to sound.

  Eventually it did. I leaped up, grabbed my stethoscope, and ran, cursing what seemed to be my unending bad luck. The psych-ER staff had already sympathetically designated me as a “black cloud,” a hospital term for a young doctor on whose shifts a disproportionate number of bad things occur. I reached the unit that had sounded the buzzer, and the head nurse met me at the door. “It’s Phyllis M.,” she said. “Do you know her?” I didn’t. “She’s here in the Quiet Room.” The Quiet Room was a euphemistically named area of isolation. It was empty. There was no way for patients to hurt themselves or anyone else when they were there. There were strict rules as to how long a patient could be isolated, and the staff worked hard to be sure the patients were there only if—and for as long as—absolutely necessary. Often, patients could be walked calmly there, the door could be left open, and after ten or fifteen minutes they’d be ready to leave again. Rarely, patients had to stay in the locked room for an hour or more; even then they were constantly monitored through a window and evaluated repeatedly in person by the doctor on call. Though many patients have described horrifying experiences with restraint and seclusion in psychiatric hospitals (a particularly searing firsthand description is in Elyn Saks’s remarkable memoir of her schizophrenia, The Center Cannot Hold), the hospital in which I was working that night takes every measure to use seclusion only when essential and to employ it humanely and safely when it is used. The nurse explained to me how Phyllis had ended up there.

  “She’s a forty-two-year-old with PTSD, terrible trauma history, comes in from time to time with bad flashbacks. She had an upsetting visit from her mother this evening. Then she kept asking us for Ativan for sleep. When we wouldn’t give it to her, she started rocking, pacing, said she didn’t think she could be safe out on the unit. We got her to settle down and walk herself to the QR, but then this.”

  The nurse gestured down onto the floor of the Quiet Room, where other staff members were kneeling beside Phyllis, whose whole body was convulsing violently. Her head was arched stiffly to one side. As her body shook, her head inadvertently beat against the floor. Her eyes had rolled upward, and a guttural moan was coming from her wincing mouth. She was having a seizure.

  A staff member had already stuffed a pillow beneath Phyllis’s banging head to prevent her from giving herself contusion
s or, worse, a concussion.

  My own heart pounded while I directed the staff as to how to manage Phyllis’s seizure. “Let’s get her on her side,” I said, in an attempt to keep her airway from being obstructed by her tongue and to prevent her from choking on her saliva. “I’d like to check a pulse ox and a finger stick, please. And let’s get some oxygen going.” The mental-health workers began to roll Phyllis to her side, and a nurse scurried to the med room for the equipment we needed and a tank of oxygen. She was back in less than a minute, calling out readings from the monitors and cradling Phyllis’s flailing head to wrap the clear plastic oxygen tubing around her ears and into her nostrils. Her blood glucose was normal. She was oxygenating fine. For the time being, there was nothing more to be done.

  Seizures require doctors to act counter to their natures. Generally doctors tend to be action-oriented problem solvers. Don’t just stand there, do something! The medical maxim of initial seizure treatment is antithetical to this impulse: Don’t just do something, stand there. Unless a seizure lasts more than five minutes, the course of action in seizure treatment is simply to wait it out. A seizure that lasts more than five minutes may not remit—a dangerous condition called status epilepticus. Without intervention a patient in status epilepticus risks damage to her brain and other organs. Yet prior to that mark, the prescribed course of action is to wait and see. When someone is moaning and convulsing in front of you, five minutes is a long time. Imagine it. Watch the clock.

  “Staff was in here with her when she started,” the nurse said, “so we know exactly how long it’s been.”

  The mental-health worker who had been watching Phyllis when she began to seize looked down at his watch. “Three minutes and fifteen seconds,” he said.

  That sounded right, since they had hit the buzzer immediately and I’d had time to run from one end of the hospital to the other and be briefed by the nurse. I was paging through Phyllis’s chart to look for evidence of a preexisting seizure disorder, or else for medical etiologies or lab abnormalities that might explain why she was seizing. For starters, a huge percentage of our psychiatric medications have the capacity to lower the seizure threshold in a person taking them. This means that patients on certain psych meds are more susceptible to having seizures than they otherwise would be. Phyllis was on several medications that could theoretically be culprits. Other patients are particularly at risk of seizures when withdrawing from alcohol or tranquilizers, but Phyllis had been closely monitored over the five days since her admission and had shown no signs of withdrawal. She’d never had a traumatic brain injury or a stroke that might have predisposed her to seize. Nothing in her medical history stood out. Phyllis continued to groan and convulse. It had been four minutes.

  I flipped to the psychiatric section of her chart, and on the third page, buried in a paragraph about prior medication trials, was a sentence that read, “The patient has a known history of pseudoseizures.”

  “Pseudoseizures?” I asked the nurse.

  “Oh, yeah,” she said. “I’m so sorry. I forgot you didn’t know her. She pulls this kind of stunt every now and again, but of course we never know if one of them is going to turn out to be real.”

  There was judgment in the nurse’s characterization of Phyllis as pulling a “stunt,” but there was also wisdom in her assessment of the ambiguity of the situation. Pseudoseizures—more accurately referred to as psychogenic nonepileptic seizures—are, as their name indicates, seizures whose origins are psychological rather than neurological. The idea is a mind-boggling one. The body behaves exactly as it would if the brain were firing electrical impulses, causing convulsions. Yet here there are no such impulses to be found. In epileptic seizures, brain waves form recognizable aberrant patterns on an EEG. In psychogenic seizures, patients’ bodies shake, overtaken by tremors, but their monitored brain waves show no seizure activity. Their EEG patterns are consistent with an entirely alert and awake state.

  Despite this measurable distinction on EEG, the diagnosis of psychogenic seizures is a notoriously difficult one to make and to treat. As the neurologist J. Chris Sackellares writes, detection of psychogenic seizures teaches “the neurologist an important lesson in humility: even the best clinician can misdiagnose a pseudoseizure as an epileptic seizure or mistake an epileptic seizure for a psychogenic pseudoseizure.”

  While Phyllis’s body continued to shake, beating against the floor, I felt the full force of uncertainty as to whether her seizures were neurological or psychological in origin. I was flooded with a range of feelings, all of them uncomfortable. Tonight, as during each of the medical emergencies I had run to the previous two nights, I felt overcome by adrenaline’s edgy, rattling buzz. During both of those scenarios, I fell back on the mantra of a life-support checklist: Check the airway of the unresponsive woman. Ask the nurse to get her oxygen. Feel for a pulse—it’s there, and strong. Get a set of vitals. Have the staff call rescue. This man is having a heart attack. Get him oxygen and aspirin. Have the nurse get a sublingual nitroglycerin out of the Pyxis. Get an EKG going. Call rescue. Call rescue. Call rescue. When I first got to Phyllis, my mind began charting its way through seizure protocol, but a history of pseudoseizures complicated the picture and immediately shifted the course of action from clear to murky.

  Ordinarily, with a patient still seizing as the four-minute mark came and went, I would administer a sedative—rectally, so the patient wouldn’t spit it out or, worse, aspirate it or choke on it. I would call an ambulance to transfer her to the medical emergency room for status epilepticus. But Phyllis’s history made it likely that she wasn’t in status epilepticus, that she wasn’t even having an epileptic seizure. In which case emergent transfer was not only unnecessary, it was contratherapeutic. Given the fact that transfer to a medical hospital would likely mean administration of more and more sedating medications in an attempt to stop the seizure, it was also potentially dangerous.

  As Phyllis’s seizure continued, so did my unease. Her limbs and trunk thumped brutally against the floor, her head slamming over and over again into the thin hospital pillow. The staff members who stood around me shifted their gazes from Phyllis’s convulsing body to me and back again.

  “Five minutes,” the mental-health worker read from his watch. I sat quietly beside Phyllis, trying to will my stillness into her wild and unrelenting movements. “Six now,” he said. My heart was beating with such force that I felt it in my temples. I tried to reassure myself again and again, Pseudoseizures. She has known pseudoseizures. But what if this one wasn’t? What if she were having an epileptic seizure? What if I were sitting—inert—beside her while she was going into status epilepticus and I did nothing to intervene?

  “Okay,” I said. Shit, I thought. Close to seven minutes had passed. “Somebody please call rescue, and let’s give her the rectal diazepam. Who’s holding arms and who’s holding legs? The nurses are going to need some help to get it into her.” Immediately the room broke into motion. A mental-health worker ran out to make the phone call. Gloved hands held Phyllis to the floor by her wrists and ankles. A female nurse slid her hands beneath Phyllis’s nightgown.

  “In,” she said.

  “Okay, great. You can let her go,” I said. The staff backed away from Phyllis. She continued to seize.

  Another minute went by. Then three more. Then five. Phyllis was sweating badly now, her hair stuck in damp ribbons across her reddened face. The lack of effect from the medicine told me nothing; both nonepileptic seizures and status epilepticus can fail to respond to acute treatment. Finally, after several minutes more, I heard the clang of the unit doors opening to rescue’s gurney and the deep voices of the EMTs. I began to stand, to go brief them on Phyllis, her history, the length of this seizure, the steps we had taken. As I did, Phyllis’s shaking suddenly ceased. She opened her eyes and looked straight at me.

  Rather than relief that her convulsions had finally stopped, I was surprised to feel most
ly overcome by anger. I felt as though this woman had fooled me.

  The EMTs rounded the corner and arrived at the Quiet Room’s doorway. “We’re actually good,” I said to them. “We’re all set. You can cancel the rescue.”

  “Cancel it?” the lead EMT asked.

  “Yeah,” I said. “Thanks for making it here so quickly. Sorry for the false alarm.” I stood, turned toward the door, and let out a deep breath, trying to defuse my anger.

  The nurse in charge of the unit turned to me. “Well, I guess she got her benzo, huh, Doc?”

  I didn’t answer. The implication in the nurse’s comment was clear: Phyllis had pulled one over on us all. On me. I took another breath, then turned back around into the room. Phyllis sat herself up and was pushing her hair back out of her face.

  “You all right?” I asked her.

  “Yes,” she said quietly. “Yes, I’m fine. After my spells I just need a little water and some rest. Or maybe someone could bring me some ginger ale?”

  “Sure,” I said, trying to keep my voice calm so as not to show I was seething inside. “Sure. We can get you some ginger ale.”

  • • •

  The diagnostic “gold standard”—the most conclusive evidence—for psychogenic nonepileptic seizures is video EEG. In this test, patients are hospitalized, hooked up to electrodes that continuously monitor their brain activity, and simultaneously videotaped. To establish the diagnosis, the patient must seize while hospitalized and under these dual forms of observation. Then video-recorded seizure activity must be juxtaposed against the EEG reading of the same time period to show there is no epileptic activity on EEG. It’s easy to imagine an aha moment that follows, where the detective/doctor swoops in at the end to reveal to the patient that he’ll be fooled no more, the ruse is up. End of seizures, end of treatment, end of story.