Projections, page 20
There is much at risk. If including mortality from medical complications—the starvation-related organ failures—alongside the suicides, then eating disorders together show the highest death rates of any psychiatric disease. Decline and death come by failure of starving cells, all across the afflicted human body. Depression and suicide, if the first to fail is the brain. Infection, if the immune system falters. Cardiac arrest, if the electrical cells of the heart, already weakened from malnourishment, can no longer cope with the distorted salts of the blood—imbalances in levels of ions that had been set billions of years ago by the rocks dissolved in the ocean of our evolution, and now fishtailing free, diluted and fluctuating in the daily vagaries of starvation.
But for the survivors, the grip of the inner tyrant fades over time. The patient can writhe free, and impose by force new thinking and new action patterns—another layer of masking, perhaps, but still reaching at last a point, over years, when the story can be told like a nightmare.
* * *
•
Medications are just as off target for bulimia nervosa—which I suspected was Emily’s secret—as for anorexia: able to blunt some comorbid symptoms, but still missing the heart of it all. Bulimia is also a killer with ion imbalance—wild swings in potassium and heart rhythm that come with the purge. Bulimia sometimes becomes mixed up with anorexia, as in Micah, together creating even more extreme shifts in fluids and charged particles—calcium and magnesium derangements too, in traces of rocks and metals needed to keep excitable tissues like heart and brain and muscle stable. These cells that twitch and spike need calcium and magnesium to function properly; otherwise spasms of spontaneous activity result: fibrillations in muscle, arrhythmias in the heart, and seizures in the brain—some ending in death.
The purge can come in many forms: self-induced vomiting, or laxatives, or even excessive exercise—anything that drives down mass balance. The mass balance credit is then used for intake—often with binges of food, piling the plate again and again, caloric reward multiplied by the illicit thrill of loopholing, from knowing the purge is coming, that nothing can stop its rush.
I knew that bulimia rush, that excited torture, from my time working with pediatric inpatients, and seeing it here in Emily I wanted to let her know I knew. If I were right, and if we could get it out into the open, together we could form a kind of partnership—a therapeutic alliance. From there, it would be a matter of logistics: starting some foundational therapy, building some insight, and discharging when ready to the right outpatient or residential program for her.
“Will you be able to tell us about it?” I asked, finally pressing. “I can tell you need to.”
She was fully avoiding my gaze now, back to the bedspread. “I can’t, really.”
“Is it somehow related to why you can’t stay in class?” I looked briefly over at Sonia the strong. She seemed enthralled.
“Yes, it is kind of the same.”
Time to push a little harder; on the inpatient unit, we did not have the weeks or months of time that outpatient therapy would allow, and there were other patients too. “Emily, you mentioned earlier that a long time ago you sometimes would throw up after big meals.” She had described this as remote, and minor, and not connected to her current symptoms; but now it made sense as a reason to leave class. “Is it possible that’s happening again?” Her finger, which had been tracing infinities and parabolas on the bedspread, paused; her eyes remained on the bed, now fixed at a point, frozen.
“What would happen if you were alone, Emily?” I asked. She looked up at Sonia.
“I don’t know,” Emily said, to Sonia. “Maybe it would be okay. But probably not.”
I let a few more beats go by, and shifted in my seat. Sonia picked up this call and responded. “Emily,” she said, “do you want me to sit with you and talk? I think the doctor has to go see some other patients pretty soon.”
“Sure, that sounds okay,” she said. “It’s no big deal.” She sounded a bit diffident, but it was the biggest of deals; it seemed that Emily probably wanted to get better. Another page had come from ortho, I really did have to go, but I could leave Sonia behind to find out more, to work her new craft, its course now well defined. I buttoned up, fared them well, and shuffled out of the room. There was no rush now; time and space were needed for alliances to grow.
As I made my way to the orthopedic surgery unit, I pondered the contrasting appearances of Micah and Emily. Micah suffered both anorexia and bulimia, but his bulimia purge strategy involved not regurgitation but walking whenever he could: pacing, circling, and even surreptitiously clenching his leg muscles while seated—all forms of burning calories. A cryptic purge, subtle, not classic bulimia—and overall he seemed mostly dominated by anorexia. He was inward-directed, a tight little bundle of sticks.
Emily could hardly have been more different. She was strong, extroverted, energetic, at a perfectly healthy weight—though who knew, perhaps she swung from one disease to the other too. During our interview, she had mentioned some caloric restriction patterns from years earlier.
Was there shared biology, despite how different these two diseases, these two patients, seemed? Anorexia was a rigid accountant, tracking every calorie and every gram, suppressing the reward of food; bulimia was natural reward embraced, amplified, repeated furiously through a cloud of calories. Yet there was a paradoxical commonality—these two could still coexist, and even work together. Both were content to kill, but the compatibility seemed to me to be deeper yet; both achieved a toxic liberation, an expression of self as dominant over the self’s needs.
What brain but of a human being could make such a thing happen? At what moment in evolution did the balance of power finally tip toward cognition becoming stronger than hunger? There was no way of knowing, but I guessed it could not have been long before we emerged, not long before we became modern humans. Wanting such a thing is not enough. Wanting to live beyond want—that is unremarkable, and universal. The hard part is making it happen, for anything as fundamental as feeding. But the modern human mind has vast and versatile reserves standing by, waiting to engage, to solve anything—calculus, poetry, space travel.
Motive force might be drawn from many different regions across the rich landscape of the human brain. Defiance of hunger is no small task, but for a nation of ninety billion cells it is perhaps not too hard to arouse powerful million-strong ensembles. Many different brain circuits could even individually suffice for the uprising, each in its own right a massive and well-connected neural structure, each adapting its own mechanisms, its own culture, its own strengths.
And so diverse paths might be taken to anorexia nervosa in different patients, depending on each individual’s unique genetic and social environment—a complexity already hinted at by the diversity of genes that can be involved, as with many psychiatric disorders. One patient might raise an army against hunger by drafting circuits in the frontal cortex devoted to self-restraint; another might instead work through a self-taught cross-linking of deep pleasure circuits with survival-need circuits, learning to affix the attribute of pleasure onto hunger itself; still others, like Micah, with both bulimia and anorexia, working with both motion and thought, might find their way by recruiting rhythm-generating circuits, ancient oscillators in the striatum and midbrain built for repetitive behavioral cycles. Controlling the walking rhythms of the brainstem and spinal cord, via compulsive exercise, could suborn the pleasing rhythms of counting—for both steps and calories. With bulimia and anorexia, Micah would be counting both—the calories coming in and the steps going out, the tick and the tock. Micah had woven a soft repeating rhythm of the two, their rough-knit interlocked texture absorbing all his blood and salt.
Repetition is immensely compelling. Circuitry for repetitive grooming in birds—maintaining feathers in form for flight—does not need to provide awareness of any underlying rationale. Evolution just confers motivation, to loop the action without logic or understanding, front to back, again and again and again, pleasing and inexplicable. Or the digging behaviors of the ground squirrel, badger, and burrowing spider—each of these species locks the rhythm of the dig to its own specialized frequency, its tuned neural cycle from central pattern generators. Or scratching in mammals like us—every animal has a different dig—getting to the parasite and rooting it out, driven by the flush of reward that comes with the scratch as the itch is hit, once started barely stoppable, the rhythm only heightened in intensity by the necessary damage done to the skin. A full valence flip—raw pain now raw reward.
Our brains play out more complex rhythms too, spanning time and space, using the metaphor of these basic motor actions. The same frontal cortex that plans and guides our scratch with a hand, in lockstep with its deeper partner the striatum, is also an executive for planning the daily routines, the seasonal rituals, the yearly cycles. The reward of rhythm shows up across every timescale, and in nearly every human endeavor: in knitting and suturing, in music and math, in the conceptual rituals of planning and organization. Not only actions but repetitive thoughts too can become as compelling as any tic; the extension of ancient rhythms to new kinds of conceptual digging may help us build civilizations—but when the rhythms grow too strong, some of us become collateral damage: the obsessive-compulsive cleaners, the hyperaware counters, the groomers, the scrutineers, all the suffering relentless.
My pager went off again as I entered the ortho unit—it was the psychiatry housestaff office. I picked up a phone at the nearest nurses’ station and called back. It was Sonia. “She’s gone.”
“Uh…what? Gone?”
“As soon as you left, she said she wanted to sketch her problem for me.” Sonia’s voice was tremulous, fear gasping out through every intersyllable. “She asked me to get some markers, so I ran to the housestaff office, and came right back.” She had imagined the thrill of diagnosis, maybe a publishable case report, an epic win for her residency interviews. “I was only away thirty seconds, and when I came back she was just gone. She wasn’t on a hold, so nobody was watching, and none of the nurses saw her leave.”
“I’m coming back now,” I said. “Sit tight, it’s okay.” But it was not okay. I had read her all wrong. Emily had been the cagiest of the psychotic depressed, suicidal but just wary enough to snooker me. In her own hidden craft, she had set out alone. The excitement of her final liberation was what I had been picking up, not knowing, misdiagnosing. My house of cards had come down, and I was responsible. I double-timed it back to the unit, just short of a run. Weak.
* * *
•
It was a complicated situation, but Sonia was right that we had no control. Emily was eighteen and not on a legal hold. She had never expressed suicidality, and had the freedom to come and go. There was no recourse.
We buzzed around the unit, looking for clues. She had taken nothing, and she had even left her laptop and phone exactly where I had seen them by the bed a few minutes earlier. Not what someone leaving against medical advice would typically do, if she were just headed back home or to a friend’s house. There was no time, and no need, to speak our deepest fear.
We paged the attending to update him, though there would be nothing he could do either. It was on us, on me.
Only ten minutes had passed. The hospital was buttoned-down pretty tightly; even where there was no locked unit, the windows were generally sealed. If suicide were the goal, it wasn’t clear what route she could take. We were on the second-floor open unit—I knew how to get to the roof of the fifth floor, through the hidden rathole of our resident gym, but there was no way she would find her way there.
Sharp edges…the hospital cafeteria, first floor, almost exactly under our feet? Or worse, just past the cafeteria, there was a balcony, an overlook into a vast atrium—it was a long way down from that balcony to the basement floor below. She could have gotten there in thirty seconds, and anything—everything—could have happened since then.
Sonia knew the stakes and was feeling it; her face was hard and I could see, just under the surface, cracking fault lines of failure and self-doubt. “Okay,” I said, as reassuringly as I could. “She is probably just going to get a cigarette. In fact, that’s probably what this whole thing is—the school stuff too.” It was almost plausible—a flash recall brought me back to second-year residency, when I had been called in a panic by the labor and delivery unit; a new mother was demanding to leave right after her C-section and the whole floor was in a tumult. I had been called as the consult-liaison psychiatrist to—as the obstetrics resident put it—“I don’t know, place her on a hold or something.” After speaking with the patient in her mother tongue for just ten minutes I got to the real reason—she only needed to go have a cigarette, and had been too embarrassed to ask. I savored that small victory for years, in part as crystallization of a curious and recurring lifelong theme—I had noticed that truth can always be discovered just by letting people speak.
But not this time, and that wasn’t Emily. When you’re just desperate to sneak off and smoke, you don’t tell authority figures to sit with you. I kept that thought in, for now. “Hang on,” I said to Sonia. “Let’s split up. You go check the ER and the parking lot. I’ll head toward the other side of the ground floor. Don’t run.” On task, Sonia, high ponytail describing frenetic horizontal figure eights in the air, was gone.
When she turned the corner, I speedwalked to the escalator, trying to project professional calm as I headed down to the ground floor. Ten seconds to the cafeteria, twenty to the atrium. I turned right, one more hallway to go. Counting steps. Listening for screams. The only sound a ticktock, each step a small victory, each step burns calories. Each step is a win. Nobody can stop you from taking more steps—and every step is closer to death.
I had been so close, but I had betrayed my undeserved gift, the inescapable theme of my life, that people seem to unburden themselves with me—and this time, someone needing help had started to connect, and I had walked away. Why? Only because orthopedic surgery had paged me once too often about a transfer that could wait.
Here. Sharp edges around this corner, at the sunlit cafeteria entrance. I allowed myself to think: it was a beautiful day, as was every day here. Sunlight was coming, but I was ready for that darkness, for that crow shadowbird.
The sun streamed in from the cafeteria patio as I turned right again, and there she was, just an arm’s length in front of me: Emily. We nearly collided.
She had been intercepted, hustling out of the cafeteria entrance. Standing there, we locked eyes and then both looked down. She let herself giggle in relief. In her hand was a plate of food, piled high, nearly architecturally impossible. Fried chicken drumsticks, cake, pizza—an edifice of pure caloric reward.
She told me later it had been her third round-trip in ten minutes. Duck into the cafeteria, stack food, come back out through the entrance without paying—then to the patio to gorge, purge, and return. A cycle of reward and release, without consequence—yet hoping, needing, to be caught. Loopholing: victory over the body and the equations of mass balance. That was everything, and there was no stopping. But she felt it to be crazy, knew it to be dangerous, and did not want to be alone.
* * *
•
I was on call that night, and at the first quiet moment I went out alone onto the roof, through the door near the call rooms where residents could get a few minutes of sleep between admissions and consults, and onto the moonlit expanse of concrete and railings and vents. On rare quiet nights we would go out there together sometimes, two or three of us, residents or interns or students, and sit under the stars, leaning back against hard metal scaffolds in our thin scrubs.
The roof was uncomfortable but had the feeling of a sanctuary—a space apart before the next burst of calls and pages. That night it felt important to be still and alone, to consider what had happened with Emily. Something about the biology of this disordered eating felt hard and unallowable—and when that feeling comes, I have found, it is best to seek a moment to sit with the mystery.
This disorder seemed to me unique, and important, and a clue to something scientifically deep, but first I had to ask myself: how much of this strong reaction I was feeling—that neuroscience needed to learn much from this disease—was driven by my own parental sympathies, a drive to care for Emily, displaced? I relived another scene: of a father at his fourteen-year-old’s bedside on the pediatric anorexia unit, in his oil-change-shop shirt—Nick, it says above the left pocket—after her heart attack and pneumothorax. The possibility of death has been spoken, and is known to him. He’s no longer able to look at her; he is only just holding her, touch his only sense, seeing nothing, focusing only on the frail sparrowlike form of her scapula, her intermittent heartbeat felt faintly through to his chest, every two seconds, and her weak cool breath on his shoulder. No—he is remembering the sound of before she was born, the thumping whoosh-whoosh of her heart coming from the ultrasound like a war drum, filling the room, fierce and strong and fast, she couldn’t be held back, she was his and coming, and the tears crashed out through his eyes, then and now. She was, she had to be always, unstoppable.
