by Barbara Ebel
In her opinion, the main thing Mr. Blake thought about was delusions. She checked her DSM and, sure enough, the diagnostic criteria for the paranoid type of schizophrenia was mostly that. She went over to the nearby shelf of books and found a dictionary. How would it describe delusions and did he fit the description perfectly? It said, ‘A false belief regarding the self or persons or objects outside the self that persists despite the facts and occurs in some psychotic states.’
He fits the exact mold, she thought, as evidenced by his verbal taunts in the movie theater and this morning in his room. He believed in nearby snakes and cockroaches and aliens and villains.
She went back and checked the DSM again. The other criterion was hallucinations. Wow, she thought, he exhibited those right under their noses. Although at some level she had understood it, now it made more sense that toward the end of their visit he was hallucinating. They realized he listened to two voices that were giving him different commands. This is interesting stuff, she thought, and enjoyed figuring it out for herself.
A half hour later and with a decent H&P written, Annabel got up and stretched. She was alone and hadn’t eaten lunch. Plus, they all had duty in the afternoon at the outpatient clinic.
Dr. Keeton bustled into the room. “I’m assuming you compiled Mr. Blake’s medical information. Come on over here with it and we’ll order his first-line treatment.”
Annabel grabbed the chart and stepped briskly to join her at the table.
“So, you should have been challenged to formulate your first reasonable diagnosis on Victor Blake. Now you’ll start on the psycho-pharmacological meds and non-somatic modalities of his care.” She began contemplating her orders. “Ten years ago, I’d be talking to you about haloperidol. I think even lay people know about Haldol. But nowadays we mostly use the newer, atypical antipsychotics. We’ll put him on risperidone.”
Dr. Keeton put down her pen. “Tomorrow you will tell me the most dreaded complication of the atypical drugs. Always know the positive effects as well as the negative effects of the drugs you prescribe.” Closing the chart she added, “Now go get yourself some lunch and we’ll all meet at 1 p.m. on the second floor of the emergency care center.”
-----
Annabel munched on a small salad and sandwich but paid more attention to reading about the drug Dr. Keeton had just prescribed. The PDR or official Physician’s Desk Reference was a compilation of prescribing information on prescription drugs and since it was a monster-sized book, most students didn’t have one. She could find out about the antipsychotics from her psych books but, at the moment, she could check it out on her cell phone on a downloaded abridged PDR version.
“I didn’t think you’d beat me to lunch,” Bob said. He put his tray down while Annabel looked up. “I’ve been hard at work with Dr. Washington and here you are checking email.”
“I’m reading about an antipsychotic.”
“On your phone?”
“Sure. Just download the mobile app.”
He eyed her suspiciously. “You’re holding out on me. I had no idea.”
“Get with it, Dr. Palmer,” she said mischievously. “In essence, we should be a super-bright generation of upcoming doctors. We have more tools available to us.”
“I disagree. There is more to learn as knowledge increases, and yes we’ll know more, but our human brains are no different than they were for doctors and Homo sapiens fifty or a hundred years ago.”
She contemplated that and frowned. “Since we work closely and you’re half of the medical student baggage on our team, I won’t debate you.”
“We could be closer.” He smiled and then sprinkled parmesan cheese on his pasta.
“I know you don’t mean it most of the time,” she said, “but for the record, your occasional teasing brightens my day.”
“I thought it was flirting,” he said, twirling spaghetti around his fork.
“Whatever. But I can’t say anything more since I already committed to no verbal sparring.” She put her phone back in her pocket. “Dr. Keeton and Dr. Washington don’t want us seeing outpatients alone yet today. How about we take turns with each of them … if they allow it?”
“Good idea. I’ll hurry. It’s almost one o’clock.”
-----
Annabel and Bob emerged on the second floor of the emergency psychiatric care building that was much more informal and decorated than the other clinical areas they’d been in. A lobby with several colorful birds in an enclosed glass case and a few potted plants dotted the corners. They noticed a few patients waiting for appointments as they both went to the desk, introduced themselves, and asked a woman where to go.
“New students,” she said. “Welcome. They’ve started afternoon clinic, so head on back.”
Annabel and Bob opened the door to a U-shaped hallway lined with pictures. When they walked to the left they found Dr. Washington thumbing through a chart.
“Welcome to the outpatient clinic,” Joshua said. “I hope you grabbed a bite.”
“I’m fed up; food wise that is,” Bob said. “Annabel researched a drug during lunch.”
“I’m impressed,” the resident said.
Annabel rolled her eyes. “Don’t listen to him,” she said.
“Okay,” Joshua said. “Since it’s your first time here, this is where we see a variety of patients: some follow-ups from hospital admissions, some referrals from other doctors, or some people just call in and make an appointment for an issue they think is psychiatric. Dr. Tilson, you can go over to Room 4 on the other side. Dr. Keeton just went in to see a patient and is expecting one of you.”
“Okay.” She smoothed the collar of her white coat and made sure her cell phone was turned off before knocking on the door of Room 4. Inside, Selina sat at a small desk near the left wall and a patient sat on a cushioned chair in front towards the window. Annabel made little noise closing the door and lowering herself into the one on the right.
Dr. Keeton and the patient glanced at her. “Mr. Ward, this is Dr. Tilson, a young student doctor. If it’s okay with you, she accompanies me to see my patients.”
A man in his early thirties looked back and forth at them. “That’s fine with me,” he said with a flick of the wrist. “I’m just here to get this over with because of a deal with my girlfriend.”
“Deal?” Dr. Keeton asked.
“We had a big fight but compromised. I told her to quit hinting for us to have sex so much and she made this appointment for me to see somebody because she says I’m hung up on anti-gay talk. So here I am.”
“It’s nice you both came up with a solution,” Dr. Keeton said.
This is off to a bizarre start, Annabel thought. She studied the patient more carefully. A bag lay on the floor, not a duffel bag or gym sack or something recognizable, but a soft cotton bag; maybe a reusable shopping carrier. He sat with his knees crossed, one leg swaying back and forth like an energetic young girl. The patient wore high-quality trousers with a pressed look and her impression was that his lean legs showing at the bottom were shapelier than most women’s.
“Yeah, well,” he said. “Sometimes we argue like we’re siblings.”
“Do you like her more like a sister?” Dr. Keeton asked. “Especially since you’re wanting less or no sex with her?”
“I don’t know, but that’s not why I had to come.”
“I see.” With her refined style, Selina sat tall and reassuringly gave him eye contact. “So what does that mean about your friend saying you’re hung up on anti-gay talk?”
“There are gay guys all over the place and they’re in your face. Like the other day eating wings in a restaurant bar; two seats down was this high-pitched man talking with his hands and trying to impress the queer next to him. Why do they have to be so obvious; did they learn it as they grew up or did they come into this world like that?”
Annabel almost gasped at his bold talk but Dr. Keeton didn’t flinch.
“What do you think, Mr. Ward?” sh
e asked.
“No man is born like that,” he said, his voice getting more pressured and passionate. “Men are men. Those types learn this stuff as they go along as children and it rubs off on other kids that are susceptible. Before you know it, they’re grown up and practically want to wear stockings and get married to each other.”
“So, although they don’t do anything to you or bother you, you are annoyed with their presence?”
“Of course!” he lisped. “What if all men were like them?”
“It’s a huge planet, Mr. Ward. And the types of human beings on it are as vast as the species of fish.”
“But they need to go back in the closet,” he said, making a big display as he talked with his hands.
The more Terrence Ward spoke, the more confused Annabel became. He certainly had feminine qualities himself so why did he harbor such a vehement attitude towards homosexuals?
“It does seem like this subject is on your mind quite a bit,” Selina said. “Which is what, perhaps, your friend is concerned about.” She leaned forward. “I have a suggestion. Since I am a medical doctor specializing in psychiatric problems which often need heavy-duty prescription drugs, I don’t think I am the perfect person to talk with you. I know the perfect person who is and I think it would be wonderful for you to discuss these concerns with her. There may be a reason why you have these strong feelings and getting to the bottom of them will give you great relief. You are probably more stressed than you are aware of.”
Mr. Ward draped his hand on his knee and he sunk further back into the chair’s upholstery. Annabel heard him take a relaxed sigh and wondered what he’d say next.
“So I can tell my girlfriend her appointment was a waste of time. But you seem like a nice doctor and I trust you.”
Selina wrote down a name and a number on a piece of note paper and handed it to him. “I will take that as a yes,” she said with a small smile. “I will advise her you’ll be calling for an appointment.”
“Okay,” Mr. Ward said. “Can I go?”
“Yes. It was nice meeting you.”
He shoved the woman’s information into his bag while he got up. “Thanks,” he said, and shook hands with her. On the way out, he nodded at Annabel.
Chapter 4
When Terrence Ward left, Dr. Keeton wrote a patient note in a thin folder. Annabel didn’t grasp what had transpired and, even if she knew more psychiatry, she still would have been at a loss as to what to do with him.
“Just like an ER doctor,” Dr. Keeton said, “I never know what’s going to come through that door. However, I referred Mr. Ward to a psychologist who also has therapists in her clinic. Some of them deal quite often with gender-identity issues.”
Annabel leaned forward, with her chin on her knuckle. “But I don’t understand,” she said tentatively. “The patient appeared to be homosexual and apparently doesn’t get that, but he’s belittling them in an exaggerated way, almost obsessed with talking about them in a negative manner. I suppose his so-called girlfriend was bothered about that, too.” She shook her head. “These days even same sex couples get married so why is he so melodramatic about the issue?”
Dr. Keeton eyed Annabel and smiled. “Precisely. You just witnessed a classic conversion reaction.”
Annabel flicked her hair back and sat tall. “I’ve never heard of it.”
Selina brought out a candy from the desk drawer and peeled off the wrapper. “He’s an emphatic and dramatic individual. His opposition to gay men is his psychological defense mechanism to hide his own desires. He spends a lot of time and energy convincing himself and others that the opposite is true, especially since in the past being homosexual was socially frowned on. It’s a behavior which falls under a reaction formation.” She put the mint in her mouth and waved at Annabel to follow her.
“You see,” she continued, “he finds every opportunity he can to condemn them in order to demonstrate that he is ‘normal’ and not gay.”
Annabel tracked her into the hallway as if following her contagious inner zest. “Do you think his reaction can be simmered down if he goes to the psychologist like you recommend?”
“It can be difficult to crack,” she said, and stopped next to Dr. Washington and Bob. “His response to homosexuals causes him great anxiety, so Terrence’s reaction has become compulsive and difficult to control. He’s inflexible about his feelings and shows the same response every time so that his ‘truth’ is never revealed.”
Dr. Keeton glanced at Bob. “A patient with a reaction formation,” she said as he rubbed his chin.
Dr. Washington turned to Annabel. “It’s very common,” he said.
“Really?” she asked.
“Sure,” Dr. Keeton said. “When someone can’t stand another individual, that’s where the saying came from: ‘Killing someone with kindness.’ A person is extremely nice to someone to hide their true feelings that they dislike them. Telling someone the truth about how they feel would make them anxious or uncomfortable.”
“That’s why you’re so nice to me,” Annabel said to Bob. “You actually find me difficult to tolerate.”
Bob rolled his eyes. “Not a fat chance,” he said.
-----
In the middle of the afternoon, staff escorted Victor Blake down the inpatient ward to the recreation room. Other patients were in their hospital rooms taking naps or in group therapy so the rec room was uninhabited except for Victor’s mother, Marilyn. They placed her there to visit with her son.
Marilyn Blake was thirty-five years older than her son and in terrible medical condition. Having chain-smoked most of her life, she now had end-stage COPD. Her chronic obstructive pulmonary disease - mostly the emphysema type – made it difficult for her to expel air from her lungs. It was harrowing to watch her breathe in and out.
Notably debilitated, she often functioned from a wheelchair and collected social security disability. She sat in her ‘rolling pair of legs,’ the nickname she used for it, and wheezed almost rhythmically. Her hair appeared dried out and her skinny fingers occasionally played with the nasal cannula hanging from her nostrils and attached to a portable oxygen tank hanging from the side of her chair.
Marilyn and Victor lived in the same house and were co-dependent on each other. However, residing on two different floors gave them the space and privacy they both cherished. A housekeeper came in once a week and mostly tidied up the main floor for Marilyn but, when she rarely cleaned the basement, she’d come upstairs and shake her head at Marilyn.
“That son of yours is living in chaos,” she would say. “I can’t really touch the plethora of piles down there to thoroughly clean. Just letting you know.”
Victor walked into the room and suspiciously eyed his mother parked on the tile floor. She cleared some mucus after a small cough and expelled it into a tissue.
“They told me what you done,” Mrs. Blake said. “You shouldn’t have scared the movie theater people.”
Victor peeled his eyes away from her and stared at a lumpy grocery bag.
“I brought ya some clothes,” she said following his gaze, “and I’m supposed to talk to your doctors.”
Inside his head, Victor only superficially listened to her let alone believed what she said. Besides his own thoughts, a running dialogue took place between the two other voices in his head. They were arguing and, as their bickering went on, the more he paced before the table and his mother.
‘She’s lying. You know black and brown and green snakes are coiled inside that bag. You tell him.’
‘He won’t do a thing about it,’ the other voice said. ‘Look at him; too busy with an old lady. What is he? Mama’s little boy?’
The first voice laughed. ‘Yeah. He’ll even accept her gift of snakes. They’ll strike him if he touches it.’
‘Here comes one now.’
Victor stopped in his tracks, his eyes bulging as he focused on the loose end of the bag where the two flaps seemed to flitter. He twisted his hands in a knot and
then flew them up to the side of his head. He considered what to do next: leap at the bag or squish the voices in his head.
‘Good call,’ the first voice continued. ‘What do you think? Is it a copperhead or a rattlesnake?’
‘It is a black-shaded rattlesnake.’
‘Is Victor just going to stand there?’ the first voice asked.
Victor stared at his mother going blah, blah, blah. He had no idea what she was talking about or to whom. Her thick black shoes on the foot pedals of her wheelchair caught his attention.
‘Yes, you idiot,’ the second voice said.
The shoes and the pedals became one as Victor gasped at the imaginary coiled snake. The forward part of the body raised and the rattle buzzed. It was going to strike!
‘Strangle it!’ demanded the first voice.
In a panic, Victor reached for the perfect weapon; just what he needed to defeat the rattler. He yanked the oxygen tubing out of his mother’s nostrils and off of the tank. Holding on to the two ends, he leaned over to her one foot where the ready-to-strike snake was and looped the hollow cylindrical device around her foot again and again.
“Stop! Stop!” Marilyn managed to cry out. She gasped for more oxygen. Exhaling took too long so the time to inhale and grab oxygen became less. And all the while she couldn’t do a thing about the insane event taking place at the bottom of her wheelchair.
Victor wouldn’t stop and his eyes grew more intent.
“Help! Help!” Marilyn cried with difficulty.
-----
As Annabel, Bob, Dr. Keeton, and Dr. Washington finished their discussion of conversion reactions, a text message came through for Selina. She wasted no time.
“Dr. Tilson, follow me. It’s about Mr. Blake.” She turned to Bob and Joshua. “The two of you see the last three patients. Call me if you’re not sure of anything.”
Selina turned and headed away. Annabel kept pace and they went through the security door. “Mr. Blake’s mother is here but they told me to come stat,” Dr. Keeton said.
