Projections, page 19
I looked back to Emily. I had waited for her to continue longer than I normally would, deliberately modeling for the medical student how to let the patient declare herself—demonstrating how to not pre-frame whatever it was into something else, to inadvertently morph the underlying issue into an object of our own making.
And then the silence finally became noise in itself—negative, distracting—even a bit hostile. “All right, Emily,” I said. “Let’s talk about that.” There was no choice but to move back into the room, with my student in tow. We returned to our chairs and sat, white coats settling around us like falling marionette strings.
Not only had our history-taking failed to divine a serious psychiatric condition, but Emily’s outpatient lab tests had also been normal—no hyperthyroidism, for example, from Graves’ disease, which could have explained agitation and restlessness. With so little information, my diagnostic thoughts felt scattered and poorly formed, mostly relating to anxiety—maybe a social phobia or panic disorder. But she had not endorsed any anxiety-related symptoms. I had also considered ADHD—and had ticked through the symptoms associated with this term, one of many evolving frames we use in psychiatry for states we are still working to understand. As insights come from research, we know our models and nomenclature will be revised and discarded and replaced in a generation, and then again in another. Yet these we use because they are what we have now, helping to guide both treatment and research; each diagnosis comes with a list of symptoms and criteria. Emily was endorsing none of them.
All my direct questions probing these possibilities—and even my less direct methods, like open-ended pauses needing to be filled by the patient—had unearthed nothing substantial. She had some mild depression but never suicidal thoughts; a few hints of the eating disorder traits so common in her age group; and a touch of some obsessive-compulsive qualities. But we hadn’t been able to address the core problem, the chief complaint; we couldn’t explain why she could no longer stay in class. Only as we were headed out the door, thinking our diagnosis would have to be a placeholder only—anxiety disorder not otherwise specified—did it seem the real conversation started.
And now, with her cryptic reopening of the interview, new diagnoses sprang forward eagerly like racehorses charging from the starting gate—but then all stumbled and crashed into one another. The straightforward diagnoses were somehow even less coherent now. If she were intent on suicide, she wouldn’t want someone to sit with her. If she were psychotic, she would be less organized, more cagey. And finally, a borderline patient would not be so diffident, and might have led with abandonment more directly.
Whatever disorder lay within was both subtle and strong; she looked physically healthy and did not seem to be suffering, but something had overtaken her powerful mind. At this crucial moment in her development and education, Emily’s greatest strength had been taken away; her passport to the future had been lifted from within her, by a light-fingered entity she knew, a thief she was protecting.
As her last words hung in the air between us, something else happened to her, to Emily’s scholar-athlete self as shown to me, to her robust and brash façade. For an eyeblink, the mask flickered and fell, and in an instant, all was really real. Though she had spoken a truth as she knew it, there was also a slight twist at the corners of her eyes and mouth. She was showing me something, and it was almost funny…but not showing too much, because, well, she was still a teen, and it was still embarrassing.
“Why should you not be alone, Emily?” I asked.
She said nothing more. She was tracing shapes with her finger on the thin and tightly drawn bedspread, watching me out of the corner of her eyes. Emily had spoken something important, and yet it seemed there was also a secret joke unexplained, one that she was tempted to share. Was this all a deeply disguised malingering, from a clever manipulator of the system, working for some gain I had failed to perceive? Or was the humor darker than I could imagine—morbid commentary on a destructive side of her, with desire for self-harm—a cloaked wraith that she had been fighting but could not bring herself to disclose, at least until a social loosening brought on by the moment of our departure.
Ten seconds of silence. What next? I had an ally here, Sonia. I looked over to her.
Sonia was the medical student but also a sub-intern—advanced, and tasked to behave like a full-fledged intern, playacting at the next level as if she had MD authority to make treatment plans and write orders. Sub-I’s were expected to perform the doctorly part in each scene right up to the moment of actually signing each order—a challenging role-play, designed for medical students who have decided their specialty, heard their calling, and now are seeking a head start in experience. It’s a difficult line to walk, acting authoritative without true authority—requiring self-confidence, social smarts, and a tendency to be right. Strength.
And Sonia was strong—fearless and resourceful, quick with pen and phone, adept at making things happen. It had been obvious right away, in her first moments on the team—though I tried not to categorize people quickly or absolutely, having come through medical school in a harsher and more binary time, when swift judgments were routinely made by the team as each new member rotated onto the inpatient care service: a new face, a blank slate not chosen or known before by anyone present, but thrust into the midst of urgent life-and-death decisions. When I had been at her stage, nobody on the team really cared about how creative the new student might be, or the quality of the papers published—all of that was irrelevant. A wholly other categorization came into play that never had existed before in the life of the medical student. Unforgiving labels were everything: was the new student strong, or weak?
Teams coalesced on snap judgments, right or wrong but made quickly. Medical students generally suspected little of the importance of their first few actions upon joining the team, but in that time they would earn a label—one way or the other, spoken or not. All was not lost if things went the wrong way on any one team, since the students would rotate off the service in a month, moving on to new roles, new growth, and discovery of new strengths—but that month of time would remain frozen thus for those who were on the team, never to be undone. In low moments I wonder: in how many senior physicians’ minds am I still stored in one of these categories—as strong or weak, and nothing more? Before meeting Emily, when I was a medical student starting my clinical rotations—and front-loading the surgery rotations, since I was sure my residency would be in neurosurgery—there had been plenty of opportunity to show weakness.
My head was still in the clouds from my PhD, which had been in abstract neuroscience and so nonclinical in any sense, and I was more than a bit defiant—stubborn and unwilling to accept or work with the axioms and rituals of medicine. In my resistance I was hesitant with medical custom—and yet sometimes my style, by chance, fit the team’s interests. In an early vascular surgery rotation, I had no idea what I was doing, but happened to ask an interesting (if slightly irritating) question on the first morning. As a result later that same day, on afternoon rounds, I was introduced by the chief resident to the attending as “the new medical student, strong.” The attending said “Good.” How wrong they were, but after that nobody bothered me—I was in, it would be a good month. The student was strong. The team, now set and labeled, swept on.
Later, in my resident and attending years, I thought of myself as part of, and supporter of, a changing culture in which some complexity could be tolerated—in which doctors recognized that the world needed more than one approach to doctoring. Sonia was not weak by any measure though, so when I looked over at her, not knowing what to do, it was for any of her many strengths she could bring to this nameless domain. We had been together for two weeks on the same inpatient team, and we’d had time to get to know each other. She had the same sort of provenance as Emily: similar academic upbringing, diverse and literary, quantitative.
We exchanged a lot of information in that moment—Sonia was keeping quiet, as was I, but her slightly widened eyes, locked to mine, indicated we should explore more deeply.
Looking back at Emily, I picked up no fear, no panic, no anger. Rather, she exuded a kind of nervous excitement, as if she were getting ready to step out on a first date—or no, more like an affair—and then I knew. A representation of sorts, of Emily herself, could be projected onto others I had seen and stored away inside me, from my time long ago on the adolescent psychiatry locked unit—and with only a little warping here and there, the images aligned perfectly.
There was another being in that room with us, one that she needed, feared, and could never leave. Emily opened up and showed me because it didn’t matter, there was nothing she nor I nor anyone could do. She did have a ferocious date planned; it was happening and nobody could stop it—but she wanted it known and witnessed. This was a straightedge, unaltered, unsophisticated truth she spoke—one generation stating a hard fact to another—only telling me of the world as it was. The fact was this: she didn’t want to be alone, but I should be the one afraid.
* * *
•
By that point, I had treated many patients with eating disorders. I’d spent months on the children’s hospital locked unit, which is effectively a dedicated anorexia ward, where I had seen patients from mildly ill to near death, and heard the diverse kinds of language the teens used to describe anorexia nervosa and bulimia nervosa. Some patients on the mild side of disease even personalized the two disorders as Ana and Mia, but most patients on the severe end abandoned all pretense of metaphor for their illness.
The psychiatrists working in this realm have deep intelligence and experience, yet their constructions (as with much of psychiatry) are unmoored from the bedrock of scientific understanding, and I had found no greater mystery than eating disorders, anywhere in psychiatry or medicine. None greater in all of biology.
With Emily, I was cautiously aware of a particular priming to consider this kind of diagnosis, since at that same moment I had other such players on the open unit, other patients in the same domain. Micah, for example: art-dealer kibbutznik, eyes dark as shoeblack. He had a sharp and closely trimmed Vandyke, and was frighteningly thin, with a tube snaking up his nose and down his throat. Micah lived in a very deep and severe relationship, with both diseases at once, anorexia and bulimia. Dangerously extreme weight loss resulted, and the contradictions and conflicts were draining. It had become full-time work for Micah to meet the demands of both diseases, to give each the time needed.
Anorexia nervosa is often personalized as cruel and strong, a duchess-like mean girl, distant and stern, locking subjects in a cold tomb of cognitive control. To assert independence from a survival drive, and to reframe the drive to eat as an enemy arising from outside the self, anorexia has to become stronger than anything the patients have known or felt; and the patients start strong themselves—they would have to, in order to manifest such a thing.
With anorexia, they control the progress of growth and life—and so of time itself, it seems. Anorexia prevents sexual maturation in the younger patients, slows aging, and is not cured by medicine; no drug can liberate patients from its grip, thus forcing desperate measures. When we were most acutely worried about Micah, watching as his heart rate and blood pressure dropped to astonishingly low levels, he would allow us to insert a nasogastric tube to pour some calories directly into his stomach. But he would then rip out the tube as soon as he was alone, sometimes before we had a chance to get anything in, so that we had to go through the process of replacing the tube. I could almost hear anorexia mocking me from inside Micah’s mind as we went through these motions, as he watched impassively, all three of us knowing what I would do, all three of us knowing what he would do, the two of them secretly smiling, laughing at the tube-wielding drug-mongering chucklehead.
But bulimia nervosa is different. Bulimia brings crazily exciting reward—not suppressing food intake to the minimum but pegging it to the maximum—binge and purge, and binge again. Bulimia seems to create a more positive bond than anorexia; bulimia can scratch an itch deep under the skin, leaving the appearance of purity and health while providing the rawest of rewards. Nothing limits how much bulimia can give you, except how much potassium you have left in your frail and contorted body before you die. In all its forms, bulimia knows what you really want, will excite and hurt you more ways than anorexia, and will kill you just as dead in the end.
Mortal allies and rivals—anorexia and bulimia nervosa—are each hated and embraced, each a snarl of disease, deception, reward. They dwell further from the reach of medicine and science than most psychiatric disorders, in part because a partnership of sorts takes root between patient and disease. Sometimes crush-like, sometimes hostile, sometimes only practical—the partnership with the patient is forged, like many interpersonal pairings in the real world, from a living dialectic of weakness and strength. And though no drug can cure these two diseases, any more than a drug can erase a friend or an enemy, words can reach them as one human being reaches another.
That these disorders are strong, and can be imbued with personhood, creates a situation unlike any other in psychiatry, or in medicine more broadly. Addictive drugs—in the setting of substance-use disorders—come closest to this perception of a controlling external power, though with less personal connection. Eating disorders exert both forms of power: governing authority and personal intimacy.
The power of either anorexia or bulimia nervosa, as with the compulsion of drug addiction, still can derive from an initial, even momentary, consent of the governed. Later this authority becomes malevolent; freedom is lost as time passes, and patient and disease move close and closer—until like any stellar dyad, twin suns spinning around each other, they become locked in a gravitational well, a hole deep and dark, destroying mass with every cycle, collapsing into a singularity.
On the pediatric ward I had seen anorexia nervosa in its most severe and devastating form—a disease dwelling mostly within teenage girls, with both patients and families consumed. These were uniquely deadly dynamics I saw, mixing love and anger, with parents frantic to feed their young, full of fury at this inexplicable monster. Families would blame each other, with hints and digs and clawed swipes and violent detonations, since there was nobody else in reach, and no other way to make sense of their emaciated child, surrounded by yet refusing food. There is no clearer example in psychiatry of human suffering that would be addressed just by understanding—even without a cure.
These were children who had been so strong—stars and performers, disciplined across dimensions, utterly beloved—and yet so starved that their brains themselves were dying away, beginning to atrophy, shrinking and peeling back from the skull inside. Children who had become so fragile and cold that their hearts were slowed to forty, or even thirty, beats per minute, with blood pressure hard to measure, hard even to find—the biology of life slowed and almost frozen, maturation arrested and even reversed, the disease-patient dyad rejecting the impositions and effeminations of the teen years—age, adulthood, weight—those shared enemies, fusing into one and denied as one, rejected as a force from without. Children in mid-teen years with preteen appearance and demeanor—and yet socially smart, even in the depths of the disease still verbally swift, adept, expert navigators of cliques and culture, deft at argument, while failing at that most simple math: the basic topology of survival, the taking in of food.
Many come near death, and some die. Why, ask the families, please tell us.
Why not start by asking the patient, the host of the disease? Anything verbalized would help our understanding, even if (or perhaps especially if) in the uncomplicated language and perspective of a child. But symptoms are hard for patients to explain in anorexia, as in any psychiatric disease. We can no more expect an explanation from the anorexia patient than from a person with schizophrenia when we ask how a hand can feel under alien control, or from someone with borderline when we ask for insight into the exhilaration and release of cutting. Some people simply cannot exist as others wish.
As family and doctors try to step in, to intervene, the patient-disease pair develops deceptions and dodges, whipped hard and harder from within. Together they have reframed desire, reshaped the meaning of need—as can happen with meditation, or with faith—but unsustainably. Anorexia is strong but causes fragility, and defends itself lethally. Anorexia preaches loudly in front of the mirror, and then later, off the pulpit, still whispers relentlessly with sibilant words learned in secret—a mimic, a hustler, a charlatan within—until in the end the lie is accepted. The pretense first gains leverage for its utility, but then grows rapidly to meet the monumental scope of its task. Once commissioned, the neural mercenaries cannot be recalled, but spin out of control into a rogue army ravaging the countryside.
These are not simple delusions. In the end, the patient somehow knows but does not understand, is aware but has no control. The idea lives as a layering, a battle mask adhered, fused by fire to the face of life. It is a lie compelling to the patient’s life in every way that matters, measured in the clinic as thoughts, mass, and actions. The doctor elicits and records anorexia’s way of thinking, one of distorted self-image: the patient states and believes one thing, while body mass index reports the opposite. The patient’s actions too can be measured—reports on the restriction of food intake, which we can track as the patient does, rigorously counting all the tiny caloric ticktocks.
Immersive cognitive and behavioral therapies can help in anorexia nervosa—especially if prolonged, for months at a stretch—using words, and building insights, to slowly shift the distortions within the patient. The goal is to identify, and address, intertwined behavioral and cognitive and social factors, and to monitor nutrition with a touch of coercion. Medications are used not as cures, not to strike at the heart of the disease but to blunt symptoms; for example, serotonin-modulating drugs are typically brought in to treat depression that is often present. In some cases antipsychotic medications are provided that additionally target dopamine signals, and can favor reorganization of thinking, to help break the rigid loops and chains of the distortion; these agents can also cause weight gain, and so an otherwise-harmful side effect becomes a side benefit, to some extent.
