The Naked Lady Who Stood on Her Head (10 page)

“Did you ever get married?”

“Gordon and I have been living together for five years. We don’t believe that a piece of paper will make us any more committed to each other, and frankly, I resent that my family is more concerned about that piece of paper than they are about me.”

“If Gordon wanted to get married, would you?” I asked.

She started crying again. “I don’t know, maybe. But it would just be to get my mom off my back. Or maybe I do want it. I don’t know! But I want a baby more, and we can’t seem to have one.”

Anne went on to tell me about her miscarriages and how she hadn’t told her parents after the first one because they were so disappointed—not for her, of course, but because they were denied another grandchild. Despite her problems with infertility and concerns about Gordon possibly leaving her if she couldn’t have a baby, she still managed to keep a busy psychotherapy practice specializing in adolescents. It struck me that it was during Anne’s adolescence that her insecurities about her identity emerged. It was probably no coincidence that she chose to specialize in treating adolescents.

Many mental health professionals are drawn to the field in part to resolve their own personal struggles. I’ve known anorexic-looking psychiatrists who focus on patients with eating disorders, hypomanic psychologists who run mood-disorder clinics, and obsessive therapists who focus on treating obsessive-compulsive disorders. Some of these individuals, especially those who have overcome their personal struggles, are better therapists for it, because they have more empathy for their patients who are going through what they themselves have experienced. Other therapists, still grappling with their issues, might find that their patients’ problems are too close to their own, and it can interfere with their ability to help.

For Anne to come to terms with her insecurities and competitive feelings with her sisters, she needed to give up her adolescent need to be “the baby” and instead appreciate who she had become—an educated adult, a successful therapist, and a partner in a long-term relationship. Today’s session was a big step for her—admitting that she had not been pregnant, talking about how becoming a mother was fundamental to her sense of self, and openly expressing the competition she felt with her sisters. I suspected that this competitive drive was so fierce that it had forced her unconscious mind to trick her body into a false pregnancy. For all I knew, her two previous miscarriages had been hysterical pregnancies as well.

At a biological level, women are genetically primed to procreate. If a woman discovers that she is infertile, she might feel like a physiological failure, and the psychological consequences of that can be devastating.

Each infertile woman copes with this challenge in her own way, and
her partner, of course, plays a large part in how well she copes. Some couples eventually adopt children, while others invest in high-tech fertility procedures that have no guarantee of success. The stress of infertility can be overwhelming, and many couples break up as a consequence. Infertility has been known to drive some women mad. They can’t stand to look at a pregnant woman or a baby; they might become psychotically depressed each month when they menstruate. Pseudocyesis is an extremely rare, though temporary, solution to what is an unacceptable reality for many women.

THE NEXT WEEK I WAS HAVING LUNCH
with Jim in the hospital cafeteria. We grabbed an empty table by the wall, and I barely had a chance to bite into my sandwich when Jim said, “Check out the brunette nurse at the cash register, eleven o’clock.”

“Eat your lunch, Jim,” I said. “This isn’t a singles bar.”

“Yeah, but she’s cute and she’s smiling right at me. Do you think I slept with her?”

I looked over at her. She was beautiful—way out of Jim’s league. “I sincerely doubt it. Hey, remember that therapist patient Pam Sefton referred to me?”

He laughed. “You mean the awesome one with pseudocyesis that you let slip through your moronic fingers?”

“Whatever,” I said. “I’m seeing her weekly now. And I think there might be a really great paper in this.”

Jim stopped eating and looked at me, trying to hide his shock. “That’s great, Gary. Good luck with that.” He looked at his watch and said, “Oh shit, I gotta go.” He stood and wrapped up his sandwich. “See you later.”

I had enjoyed one-upping him, but now, as I watched him leave, I felt sort of bad. It seemed like he could dish it out but couldn’t take it. Our competitive banter was fine when Jim had the upper hand, but when he didn’t, he took off. Sadly, as my career trajectory rose, my friendship with Jim essentially ended. I’ve always wondered how much my own competi
tive issues contributed, but I realized later that a lot of it came from Jim. He had two very successful brothers—one a Wall Street financier, the other a powerful Boston litigator—both of whom Jim hadn’t spoken to in years.

As I reflected on the competition I had felt with Jim, I thought about how Anne was just beginning to acknowledge her competitive issues with her sisters. Over the next few months of therapy, we explored her need for attention through either being the baby or having a baby. She also came to realize that her position on not getting married was a defense against her fear that Gordon might not really want to marry her.

Eventually, as Anne became more secure, her relationship with Gordon solidified and he proposed. As I expected, she was thrilled and accepted. He told her that he loved her whether or not they could have their own kids, and they started to seriously discuss adoption.

I hadn’t seen Anne for over a month while she and Gordon were in Europe on their honeymoon. She walked into my office looking very tan and wore a white tunic with a turquoise necklace. Her large green eyes sparkled, and she had put back on a few pounds.

“Dr. Small, it’s so great to see you. Gordon and I had a wonderful time in Greece. The water is so blue and clear.”

“That’s wonderful, Anne. You needed a break.”

She sat on the sofa and grinned. “You know, neither of my sisters went to Europe for their honeymoons. In fact, I don’t think either one has ever left the Northeast except maybe to go to Florida once or twice.”

“Really,” I said.

“And Gordon and I have gotten so close, we’re like best friends
and
lovers. I don’t think my sisters have that kind of relationship with their husbands.”

“Anne, I’m hearing an old theme here today that we’ve discussed before.”

“Really? What?” she asked.

“Your competitive feelings toward your sisters. But now it’s about relationships and honeymoons, instead of babies.”

“Babies! You haven’t heard the best part!”

“What’s that?” I asked, growing concerned.

“I’m pregnant!”

Oh brother, I thought. Was she having a full-on relapse? I needed to tread lightly here. I said hesitatingly, “That’s good news.”

“
Good
news? Are you kidding? It’s
fantastic
news,” she said. “Why the hell aren’t you excited for me?”

“When did you find out?”

She laughed and said, “I did three more home pregnancy tests this morning, and they were all positive. Look at my stomach!” She lifted her tunic, and her tanned belly was protruding the way it had been with her last hysterical pregnancy. She went on. “You know how it is with all those couples who can’t get pregnant. They finally decide to adopt and suddenly they get pregnant? Well, ta-da!” She raised her arms in a victory sign.

“I know you’re excited, Anne, but have you seen an obstetrician?” I asked.

“What’s your problem, Dr. Small? I thought you’d be happy for me. Seven months ago I was ready to leave Gordon, and thanks to you, I’m happily married and having a baby.”

I supposed it was possible that Anne was pregnant, but the reemergence of her competitive issues with her sisters seemed like a regression, and I knew that pseudocyesis often recurs. I felt that the sooner it was proven true or false by a blood test from a real lab, the better off she would be psychologically. And I suspected that her avoidance of even discussing an obstetrician was another indication that she was in denial again. During our previous months of therapy, I felt she had gained insight and had begun to form an alliance with me as her therapist. If I pushed harder with Anne to help her face reality or at least get an official blood test, I might be able to break through her denial.

“Anne, I really hope you are pregnant, but it is possible that your mind is tricking your body again. When do you plan on getting a blood test?”

“What do you mean? You think I’m not really pregnant again?” she asked.

“I didn’t say that, Anne. But right now it seems very important to you
that I get excited about your baby, just like your family gets excited about babies. And as we’ve discussed over the last few months, that’s been a major source of self-esteem for you throughout your life.”

“You know, I hear you, Dr. Small, and I get what you’re trying to say, but I don’t really care. I know I’m pregnant. My breasts are swollen and sore, and I’m nauseous every morning. And I don’t need this negative talk. In fact, I don’t think I need therapy right now at all.”

Despite my efforts to get Anne to stay, she wouldn’t be swayed. She thanked me for helping her get over her problems and promised to keep me posted on how things went. But now that she was really pregnant, she didn’t want any negativity in her life—she wanted to stay in a positive place. When I told her that sounded like denial, she just laughed and said, “See what I mean?”

In retrospect, I had probably pushed Anne too hard, and I should have given her more support at that point. I recalled that when I first reined her in as a patient, it was by embracing her point of view and agreeing that she should get a second opinion outside of the hospital. But I also knew that she very well might have been planning to leave therapy anyway.

I have found that most patients need to be motivated to want to do the work of psychotherapy. And Anne didn’t appear to feel she had any problems to work on at that moment. Ironically, when patients are not in emotional pain or crisis, it can be the best time to do the deepest and most beneficial therapeutic work. It’s then that patients have the serenity and perspective to truly explore their psychological world.

Over the next few months, I received several phone messages from Anne, mostly after work hours. She probably didn’t really want to speak with me directly. Her messages told me how wonderful her pregnancy was going, that she and Gordon were painting the nursery and her sisters were planning her baby shower. She didn’t mention any medical documentation of the pregnancy. I called her back but always got her answering machine.

I continued to read up on pseudocyesis and started drafting the review paper I was planning to write about it. I learned of several case
reports of women convinced of false pregnancies for up to eight months. I worried that Anne might become one of those.

Her phone messages eventually stopped, but I did get a note from her about six months later. It was a handwritten card with two photos inside. The first photo was a black-and-white grainy amniocentesis snapshot of a large fetus—obviously a boy. My mind raced to the possibility that her pseudocyesis had progressed to a psychotic delusion of motherhood and that she was stealing photos from a neonatal clinic. But the second photo quelled my fears. It was of Anne and a man in his early thirties, presumably Gordon, holding a beautiful baby boy. His eyes were large, piercing, and hazel. In the note, she said that she wanted me to have copies of the first two pictures of her son. I was thrilled for Anne but a little embarrassed for myself. I had never really given her the benefit of the doubt.

As I walked into my apartment that evening, I kept thinking about Anne. I was amazed by the way her competitiveness with her sisters had driven her to believe she was pregnant when she wasn’t. But I also thought about how her rivalries mirrored my competitiveness with my friend Jim. Did my own issues interfere with my ability to help Anne with hers? Or did it make me more empathic because I was going through a similar situation?

When does healthy competition cross the line and become unhealthy rivalry that drives people to behave in psychotic ways? For my patient, it had been a lifelong struggle, and I wondered whether her having a baby would continue to quiet her demons or simply stir them back up.

I flipped on the TV. The Celtics were playing the Lakers again. Thankfully there were no Celtics fans around, so I could root for the winning Lakers out loud. I got a cold beer from the kitchen and watched as Kareem Abdul-Jabbar posted up Larry Bird and dunked over him. But Kareem was fouled on the play and fell. Larry turned and offered his hand to help him up off the floor. Those two had mastered the art of friendly competition.

Fall 1984

I STEADIED MY MUG OF COFFEE
and fiddled with the radio while waiting to turn left onto the 405 freeway south. I was commuting to work, and it was already bumper-to-bumper traffic at 7:00
A.M.
As I reached the top of the hill near the Mulholland Drive overpass, I checked my rearview mirror and saw the San Fernando Valley behind me. The Santa Ana winds had blown away the usual smog and haze, and the vista was as beautiful as it had been when I was a kid—except there were fewer farms and more buildings.

I loved being back in Los Angeles after my psychiatry residency in Boston. It was great reconnecting with old friends and family. I had taken a position in geriatric psychiatry at my alma mater, UCLA. Psychiatry for older people was just getting started there, and I saw a real need for it. Few young psychiatrists were looking to work with seniors, who were often confused and neglected, and whose cases tended to be complicated because of their multiple medical conditions.

I began building my clinical research in the geriatric area while my general outpatient and consultation practice slowly grew, but it wasn’t as
easy a transition for me as I thought it would be. During my three years at Harvard, I was one of an elite group of trainees who were handpicked from the top applicants throughout the country. I had established myself there and had a good reputation. UCLA was also an outstanding institution, but it was huge and I was once again a small, unknown fish in a big pond. It would take a while to get to know my colleagues and gain their trust.

UCLA Medical Center was as busy as Harvard’s Mass General Hospital, but like Los Angeles, it was more spread out. Built in 1953, it was considered a landmark of early modern architecture. The eleven-story brick structure of the main hospital and school had half a dozen intersecting wings that created a tic-tac-toe layout. The horizontal stainless-steel louvers over the windows protected us from the heat and direct sunlight, but from the inside they resembled bars and, depending on the direction of the sun, sometimes made it look and feel like we were working in a prison.

I was jotting down my morning consultation notes at the nurses’ station on the fourth floor when I heard a blaring voice coming toward me from the long east-west hallway. I saw a group of neurology residents following their attending doctor, Ralph Porter, out of a patient’s room as they did their morning rounds. Porter was pontificating about the patient’s stroke and hematoma. It was hard to concentrate on my notes because he was one of those loudmouthed know-it-alls who liked to humiliate the residents by asking questions he knew they couldn’t answer.

The group crowded together next to the nurses’ station, and Porter called on a shy first-year neurology resident, who had to present the patient they were about to see next. She hesitated as she began. Her insecurity was palpable—perfect fodder for Porter to chew up and spit out.

She described Heather Phillips, a young painter from Venice, the lively and artsy beach town south of Los Angeles. Heather had come down with the flu a month earlier, and her sister had checked her in to the community hospital, where she presented mute and unresponsive. A spinal tap turned up some white blood cells in her cerebral spinal fluid, suggesting meningitis, encephalitis, or some other type of brain infection. They treated her with intravenous antibiotics, but her symptoms
persisted, so the doctors figured it was viral. She remained unresponsive, and they transferred her to UCLA. Heather’s neurological exam was normal except that she still had no verbal or physical responses to questions or directions.

Something about this case didn’t sound right to me. If the patient had a brain infection, why did she go mute so rapidly and for so long? Why wasn’t she in a delirious state with episodes of clarity and confusion? Also, why was her neurological exam otherwise normal? Meningitis patients generally have severe neck rigidity.

As the team walked across the hall toward Heather’s room, I caught up with Dr. Porter and asked if I could join them on their rounds. He looked at my name tag and smirked. “A psychiatrist? Sure. Maybe we can figure out what trauma in this patient’s childhood made her catch encephalitis.”

I ignored his sarcasm. “I’ll do my best, Dr. Porter.”

We crowded into Heather’s room. She was lying on the bed by the window with her head propped up; the other bed was empty. A slim, pale brunette, possibly in her early thirties, she had a vacant expression. Porter moved beside her and introduced himself. He asked her what her name was and got nothing. He asked if she knew where she was; again no response. He tried a couple more orientation questions and then proceeded with a cursory neurological exam.

He pulled out his percussion hammer and checked Heather’s reflexes, which were brisk and symmetric. He then held her upper arm steady while moving her forearm back and forth to check range of motion and flexibility. He turned to the residents and asked for a volunteer to summarize the case. As one of the nervous young neurologists began describing the differential diagnosis of encephalitis, I observed something strange—Heather’s arm was still up in the air where Porter had left it. No one else seemed to notice. As the resident rambled on trying to impress Porter, I watched Heather’s arm slowly, almost imperceptibly, ease down toward her side.

Was I imagining this? Why didn’t anyone else see it? If I mentioned it now, would they think I was nuts? Porter suddenly turned to me. “Dr.
Small. You seem rapt by this presentation. Have you figured out the unconscious motivation for this patient’s condition?”

This guy didn’t like psychiatrists—that was for sure. I wondered what bizarre personal issues
he
was hiding. I said, “Not quite yet, Doctor. But I would like to do a formal consultation, if you don’t mind.”

Porter laughed. “Be my guest. In fact, maybe we should call in dental and see what they can come up with.” He got a few snickers from the group as I felt my face redden—I hated when that happened.

Porter wasn’t alone in his antipsychiatry attitudes. In the early 1980s, many internists and surgeons found little value in psychiatry. They didn’t understand it, and their patients feared the stigma of being labeled mentally ill. While I was in medical school, I would hear an occasional student or professor take a poke at psychiatry, insinuating that it was an ineffective specialty based more on speculation than science.

In residency, I learned more about the reasons for these prejudices. Scottish psychiatrist R. D. Laing had questioned whether mental illness should be considered an illness at all, since it had no proven physical cause. He argued that the concept of madness stemmed from political and interpersonal influences.

In 1973, Stanford psychologist David Rosenhan published “On Being Sane in Insane Places,” which described how university students pretending to be psychotic gained entrance into psychiatric facilities. Once admitted, these pseudo patients stopped feigning their madness, yet the hospital staff perceived their normal behavior as symptoms of psychosis. Interestingly, the actual inpatients knew better.

After World War II, psychoanalysis—a theory of mind investigation and treatment—dominated many medical school psychiatry departments. In Freudian psychoanalysis, patients verbalize their free associations, fantasies, and dreams to their analyst, who then interprets the unconscious conflicts he assumes are causing the patient’s symptoms or problems. When the patient gains insight from the analyst’s interpretations, the symptoms often improve, but it can take years of nearly daily treatment, which is expensive and obviously time-consuming.

Psychoanalysis has helped many people with their neuroses and per
sonal problems, but it’s difficult to prove scientifically that it works any better than just talking with someone who is empathic and supportive, although systematic studies have demonstrated the effectiveness of a similar treatment approach, psychodynamic psychotherapy. Also, psychoanalysis is not for everyone, particularly patients with severe depression or psychosis. With the development of antidepressant and antipsychotic medicines that often improve mental symptoms more rapidly, the medical community seemed to warm up to psychiatry. And many psychiatrists turned away from pure psychoanalytic approaches and took a more eclectic strategy combining both talk therapy and medication. This medicalization of psychiatry gave the field more credibility and acceptance by other medical disciplines; however, antipsychiatry sentiments persisted, particularly among older physicians.

For many doctors and lay people, fear drives their prejudice against psychiatry. Sometimes in denial about their own mental struggles, people avoid or attack psychiatrists in an attempt to keep them from somehow recognizing their secret psychological issues—as if the psychiatrist had some magical powers to do so.

But with Ralph Porter, the antipsychiatry jabs felt personal. I was just starting out as a card-carrying psychiatrist and wanted to be taken seriously. He had a way of making me feel instantly insecure. When he directed his antipsychiatry barbs at me, I admit I even momentarily doubted my career choice. Luckily, my anger toward this jerk overtook my insecurities and spurred me to prove my worth to him. Public humiliation does have its upside—it can motivate people to push themselves to prove a point.

THE NEXT MORNING I RETURNED TO HEATHER’S
room to begin my formal consult. The TV was on, and Heather was staring blankly at the screen. I introduced myself and sat down in a chair next to her bed. She didn’t acknowledge me in any way, and the only reaction I could get was an eye blink when I clapped my hands in front of her face.

I did another neurological exam. Her reflexes were still symmetrical and brisk. I gently lifted her head off the pillow and flexed her neck—
there was no stiffness there at all. Finally I got around to what I had really come to do—I lifted her arm above her head and let go. I let it stay there for about five seconds, then I gently moved her arm to a horizontal position and it stayed there as well. After nearly thirty seconds, it slowly floated down to her side.

I tried her other arm and got the same result. I felt like one of those hypnotists in a Las Vegas lounge act who gets audience volunteers to freeze in weird postures while in a hypnotic trance. This whole time Heather had been staring at the TV. It was eerie.

I had never witnessed waxy flexibility before, but I had read about it in medical school. It was defined as a lowered physical response to stimuli and a tendency to maintain an immobile posture. When you move the arm of someone with this condition, he keeps it in that position until you move it again. In other words, the extremity responds as if it was made of wax. It was originally described in patients with catatonic schizophrenia, who have extensive loss of their motor skills and sometimes hold rigid poses for hours. In rare, untreated cases, victims have been known to die from exhaustion.

I was about to check Heather’s pulse when someone entered the room, “Excuse me, are you a
real
doctor or just another med student?”

I turned and saw a slightly older version of Heather standing in the doorway.

She went on. “I’m sick of this teaching hospital. Are you even old enough to be in here?”

I had no gray hair in those days, and even though I was approaching thirty, I looked young for my age. I stood and extended my hand, “I’m Dr. Gary Small. I’m a psychiatrist consulting on Heather’s case.” She didn’t shake my hand, so I let it drop.

“Oh, great, a shrink,” she said. “Are you doing some kind of silent treatment therapy? Have you
noticed
that my sister’s not talking?” She put her purse and coat down and started tidying up the room.

“I know the medical doctors have diagnosed your sister with encephalitis,” I said. “But sometimes a psychiatrist can help when a patient stops talking or doesn’t respond.”

She sighed and began brushing Heather’s hair. Her anger shifted to resignation. “Why not a psychiatrist? We’ve seen just about every other specialist in this hospital.”

“What’s your name?” I asked.

“Andrea. I’m Heather’s older sister, and I’m the one who could use therapy. This whole thing with Heather has been a nightmare.”

“I’m sure it’s been tough on you,” I said.

“It was unbelievable how fast this thing happened. One day Heather had the flu; the next thing you know, she’s like this.”

“Have you noticed any improvement at all in the last month?”

“Not really,” Andrea said. “I mean, some days she seems a little more with it—I think she enjoys it when I brush her hair—but most of the time she’s completely out of it.”

Even though Heather seemed unaware of our conversation, there was an outside chance that she was listening to us. I asked Andrea to please step into the hall with me. We walked to a couple of chairs at the end of the hallway and sat down.

“What was Heather like before she got sick?” I asked.

“She’s an amazing artist. Mom always said she got the talent in the family and I got the brains.” She laughed bitterly.

Normally I would use that as an opening to delve into their sibling rivalries, but I decided not to go there. I needed more background on Heather.

“I understand she paints. What kind of paintings does she do?” I asked.

“It depends on her mood,” Andrea answered. “When she’s really energized, she’ll go for weeks doing incredible, colorful abstract canvases, one after the other—they’re huge. I don’t know how she can be so productive and still find time to sleep.”

“Really,” I said.

Andrea went on. “But other times she locks herself in her studio for days and does these dark, moody self-portraits. It’s almost like someone else is painting them.”

It sounded like Heather was suffering from classic manic depression,
also known as bipolar affective disorder. The illness afflicts about 1 percent of the population and is characterized by episodes of elevated mood or mania, interspersed with periods of depression. When in a manic state, bipolar patients don’t require much sleep; they are productive, energetic, often euphoric, and fun to be around. However, if the mania escalates, their grandiosity can get them into trouble. They can also develop rapid speech, hallucinations, delusions, and aggressive behavior.