A Mind In Crisis

September 12, 2013, 12:52 pm
Caring for a Mind in Crisis

By PAULINE W. CHEN, M.D.

One afternoon at a school not far from the hospital where I was working, a teacher opened a utility closet and found a staff member passed out on the floor. He was clutching a small bloody mass in one hand, a sharp knife in the other, she reported, a red stain spreading rapidly at his middle.

He had amputated his genitals.

Once he’d been brought to our emergency room and resuscitated, the man refused further treatment. Doctors and nurses, concerned that if they waited any longer to reattach the severed part the surgery might not work, took the necessary steps to deem him mentally incompetent to make such decisions. “The guy was seriously nuts,” I remember one of the doctors saying afterward. “He kept screaming that he didn’t want ‘it’ back.”

For days after the successful operation, the gruesome story was all anyone at the hospital could discuss. Most of us chalked it up to his being “certifiable,” and several wondered if maybe they should have skipped the surgery. “After all,” said one clinician, “isn’t that what he wanted?”

But in all the chatter none of us mentioned a key part of the patient’s story: the unbearable suffering that must have pushed him to commit so brutal an act. In fact, anyone overhearing our conversations might have been hard pressed to find any of the warmth and sensitivity we routinely displayed toward patients with cancer, AIDS or heart disease.

I remembered the man and our reactions this past week while reading “Falling Into the Fire: A Psychiatrist’s Encounters With the Mind in Crisis,”a thought-provoking new book by Dr. Christine Montross.

Of all the afflictions that fall upon us, few remain as misunderstood and stigmatized as those that affect the mind.

Despite efforts from advocacy groups and individual patients to increase awareness — as well as empirical evidence linking psychiatric disorders and treatments to biologic changes in the brain — there’s the nagging sense that many psychiatric diagnoses may be arbitrary and subject to social conventions, or that many affected patients could, with a little willpower and hard work, get better. As a result, patients suffering from illnesses like bipolar disorder and schizophrenia must tackle not only their diseases but also the discrimination that often prevents them from getting the care they so desperately need.

How these patients and their psychiatrists navigate those bitter vagaries is the subject of “Falling Into the Fire.” And Dr. Montross, an assistant professor of psychiatry at the Warren Alpert Medical School of Brown University who specializes in inpatient psychiatry, has plenty of cases under her clinical belt to illustrate her points.

There is the man who cannot afford the necessary psychiatric treatment he needs for his severe body dysmorphic disorder, so spends all his earnings instead on painful but unnecessary dermatologic procedures. The uninsured woman who can not get more than four appointments per year at the overextended publicly funded mental health center, so is repeatedly hospitalized for ingesting everything from light bulbs and pens to batteries and razors. And the mother who must be discharged from the hospital before her psychiatrist is fully confident that she will not buckle under unrelenting thoughts of killing her 15-month-old son.

The list is a mind-boggling inventory of psychiatric pathologies that could, in less able hands, become the literary equivalent of a carnival sideshow. But Dr. Montross, an award-winning poet before attending medical school, is passionate about her work and her patients’ plight and so scrupulously avoids falling into simple sensationalism.

Just as many of her patients have the “uncanny ability to detect — and then broadcast — a person’s most exquisitely sensitive vulnerabilities,” she can articulate many of the most uncomfortable questions that plague the rest of us. Are psychiatric diagnoses capricious? Is madness necessary for divine visions and artistic genius? Is there some element of volition in even the most irrational delusions? She addresses these issues with intelligence; and by deftly intertwining her patients’ stories with historical facts, current research and ethical quandaries, she presents a moving and nuanced picture of the psychiatric patient and doctor relationship, and a riveting and thought-provoking look at mental health care.

References to delusions abound; but they are mixed, thankfully, with some well-placed levity. Psychiatry, Dr. Montross deadpans at one point, is a specialty where “it’s not unusual to meet someone who claims to be Jesus.” One such patient is Colin, a young man admitted to the psychiatric ward in the throes of a spiritual euphoria after a month-long trek in the mountains with an Indian guru, who “actually looked the part.” Unshaven, with long flowing tresses and dressed in a stained white tunic, he walks around the psychiatric unit proclaiming that he can see love everywhere, even in the metal filing cabinets and plastic hospital chairs.

With medications, Colin becomes more lucid and subdued; but there is a new solemnity about him. “I’m not sure about this existence,” he tells Dr. Montross. Suddenly the fascinating ruminations a page earlier on the historical connections between mental illness and religious epiphanies become irrelevant. If Colin’s psychosis stems from schizophrenia, and not incipient bipolar disease as Dr. Montross first suspects, he will be condemned to a life marked by delusions, increasing isolation and paranoia. He will also be at higher risk of killing himself.

Schizophrenic patients early in the course of their disease are acutely aware that they are losing their grip on the stable life they once had; they are like the sparrow from Dr. Montross’s childhood that dies in the struggle to free itself from the netting on her grandmother’s blueberry bushes. The bird “must have understood how the more it moved, the more tangled its feathers would become.”

While the image of the struggling sparrow lingers long after one finishes her book, at times the passages of personal memoir Dr. Montross weaves in to contrast her relatively normal life with those of her patients feel jarring and unnecessary. But that may be because with each patient story, she has brought us closer to understanding how flimsy is the veil separating us from them, how tenuous is the illusion that we are invulnerable and cannot be touched by a catastrophic accident, diagnosis or death. “Mental illness pierces the veil,” she writes at the end of her book, “and those who suffer from it dwell with their fragility in plain view.”

It is a haunting reversal of roles, one that like the book itself emphasizes neither their madness nor our sanity in the face of mental disease, but our fragile and shared humanity