Reaching Down the Rabbit Hole (11 page)

Albert V is a twenty-six-year-old right-handed man, a graduate of a well-known liberal arts college in rural New England. He is well-read, currently works as a chef at a trendy restaurant in Boston. He is thin, pale, freckled, and has reddish-blond, thinning hair.

“Can you make anything of this tremor, Albert?” I ask. Maybe he’s not telling me something. What he
has
told me so far is that he had awoken about three months ago to find that all of his limbs were shaking. At first, he thought he might be having a chill, and paid little attention to the problem, even going to work that day. Over the next several days, the tremor got bigger and bigger, to the point where his arms flapped when he held his hands in the air, and his hands slapped the bed when he was lying down. Legs and arms were involved, but no limbs moved synchronously. He had been seen at several hospitals, including one near his home on the Connecticut coast, and he was told he probably had Lyme disease. He is now getting intravenous antibiotics, and is unable to work because of the tremor. It affects his limbs less when he walks, and he finds that he can reach out and touch objects without much tremor.

His speech is normal, and in particular, there’s no slurred speech to match the ataxia (his wild and awkward arm movements). His eye movements are also normal. He can walk a straight line, as in a sobriety test, his reflexes are normal, and he seems otherwise fine.

“It’s totally baffling to me, Doctor,” Albert responds. “It’s been getting worse, but there are times during the day when it’s much better. My girlfriend tells me I don’t have it when I’m sleeping. Is there a chance it’s psychological?”

“There’s always that chance, but let’s see.”

With his hands held out in front of him, his arms, elbows, and wrists dart up and down or side to side, arrhythmically but smoothly, like a Hindu devi. When I ask him to put his arms to his sides he looks pretty much like a windmill.

I take his left hand in mine and hold it tightly. The tremor suddenly becomes exaggerated at his elbow. I grab his hand, wrist, and forearm so that his elbow can’t move, and now his shoulder goes wild. When I ask the resident to hold his shoulder fixed, Albert’s head begins to jerk from side to side. We have essentially chased the tremor up his arm and into his torso. When we let go, the whole arm resumes its crazy up and down, circular and sideways motions.

Next I ask him, using only his right hand, to touch his thumb to his third, fifth, index, then fourth finger, in that order, repeatedly. At first he is unable to do it, but when I take the hand and hold it up in front of him, he starts to make the requested finger motions. As he does so, the tremor in his left hand disappears.

He is an educated and articulate young man. Could this be so opaque to him that he doesn’t know what’s going on? Could he really think that I don’t know what’s going on?

A month later, I hear that another neurologist has told Albert that he doesn’t have Lyme disease, and the antibiotics are stopped. His parents bring him to a major neurological institute in New York, where they are told that this is a functional problem that requires psychological treatment.

“I’m not saying you’re crazy, just that something is bothering your brain in a way that is beyond your control.” This is the basis of all non-Irish appeals. “The brain learns these patterns, sometimes they’re hard to unlearn, but it’s important to know that there’s no damage to your brain going on.” It doesn’t blame the patient, doesn’t give a psychodynamic explanation, but does give the patient an out.

“This pattern can be unlearned. It is within your power.” That’s
the moderate tack, not necessarily the American one, because the American sensibility obliges us to add: “Why don’t we sit down and find out why you are doing this.”

If you pick up any conventional psychiatry book, it will advise you that there is a psychodynamic explanation, or there is a genetic susceptibility, and that by identifying the underlying psycho-problem, talking about it, getting it out in the open, and realizing what it has done to you, you can get rid of the symptoms. If the psychiatrists want to handle it that way, fine by me, but I’d rather not. Besides, most of these patients would rather see a neurologist than a psychiatrist anyway. In their minds, they are sick but not insane. Most of all, they resent the implication that they have a weak character, that they are faking an illness because they can’t deal with their lives. I happen to think nothing of the sort, but how do I tell
them
?

Jessica M is a twenty-nine-year-old right-handed woman, who was taken by ambulance from her workplace downtown, unable to move her left side. She is about five foot four inches tall, blonde with dark roots, wears business dress and well-applied makeup. Her right arm is tucked through the handles of her sizable pocketbook.

“I’m so sorry this has happened to you,” I say. “Can you tell me how it started?”

“Well, I was coming out of the bathroom and ran into my coworker Nancy. We talked about going out tonight, and I told her I couldn’t because I had promised to visit my two aunts who had come to town to see my mother.”

“Yes, but how did the problem with the left side begin?”

“Oh! . . . I reached down to pick up my pocketbook, and my arm felt sort of weak, so I asked Nancy to help me sit down on the swivel chair near her desk. Then I felt sort of weak all over, and she told her supervisor to call nine-one-one because she didn’t like the way I looked.”

“Okay. So your weakness began then?”

“When the EMTs came they told me to grab onto their arm to help me onto the stretcher, but I couldn’t grab anything with my left arm.”

“What about your leg?”

“When we got here, I noticed that I couldn’t stand on it.”

The senior resident interrupts: “Dr. Ropper, let’s get her going for the CT scan so we can start her TPA.” He’s referring to tissue plasminogen activator, a powerful clot-busting drug given to stroke victims. Because it is a blood thinner, it poses a serious risk of hemorrhage.

“Give me just another minute,” I say, “and I might save us a few hours.”

“Show me how you raise your right arm in the air . . . Good. Now your right leg . . . Very good. And you can’t move your left leg at all?”

“No.”

As she lay on her back, I put my hand under her right heel. “Now push your heel down into the bed really hard . . . terrific.”

I move to the other side of the bed, and with my hand now under her left heel, I ask her to try to lift up her right leg while I try to resist. When she does this, I can feel downward pressure in her left heel. In order for anyone to lift one leg up, they have to begin by pushing the other leg down, by way of bracing. This is called Hoover’s sign. She is using her left leg without realizing it.

I explain this physiological fact to Jessica, but before I can finish, she exclaims that she feels her left side getting stronger.

I tell the residents not to bother with a CT scan.

In many cases of hysteria, the ideal treatment would be hypnosis. We used it when I was a resident, and it worked, just as it worked for Sigmund Freud and his teacher, the French neurologist Jean-Martin Charcot over a century ago. It worked because patients with hysterical symptoms are suggestible, and, having fooled themselves
into
the
symptoms, they can be fooled out of them. Deception works, but in the modern age, in the age of informed consent, we are not allowed to fool patients about anything, even if it is the only way we can help them.

Victor P is a twenty-seven-year-old Russian émigré, an on-and-off student, and peripatetic barfly. He has been seen in the Emergency Department by the neuro-consult team, and is still there, awaiting a diagnosis.

At 7:30 a.m., I call the residents to order at morning report. “What have we got?”

“Victor,” Hannah says. “He’s been in the emergency room since about five a.m., when the EMTs brought him from his apartment down on Huntington Ave. His roommates said he was having weird movements and foaming at the mouth.”

One of the junior residents, obviously thinking back to his college fraternity days, adds: “Can you believe it? This started at about three a.m., but these jerks thought it would be fun to watch him do this for a while. I think they’re BU graduate students.”

“Just now, when I left the ED,” Hannah adds, “he was shaking all over with wild, rhythmic movements that lasted for about forty-five minutes. We’ve already tried Valium IV two mg, Dilantin IV up to a gram, and they’re breaking out the Versed.”

“Hold it,” I say, “that’s pretty potent stuff. What makes you think that forty-five continuous minutes of shaking and shimmying has to be a seizure? Did he bite his tongue?”

“No.”

“Was he incontinent?”

“No.”

“Look, seizures stop themselves after a couple of minutes. The cells exhaust themselves and use up all the ATP, so it’s almost impossible to convulse for this long without stopping and starting again. Is his back arched?”

“Yes.”

Elliott, seated to my right at the conference table, suddenly stands up and walks out of the room without a word. He returns almost immediately with a rubber stamp in his right hand, reaches over my shoulder, plunks an inkpad onto the table, inks the stamp, smacks it down next to the case number in the log book, and sits down in a huff.

It’s a little red turkey.

Pseudoseizures, or P-NES, are probably the most common form of hysteria or conversion symptom seen in a neurology ward. The majority of them occur in patients who have genuine epilepsy. They know what a real seizure should look like, and are pretty good at producing fake ones. The siblings of patients with epilepsy, who have seen plenty of real seizures, also account for a significant number of cases.

Victor had no previous epileptic history, but we have to admit him to the ICU and take continuous EEG recordings for a day or two just to confirm that nothing shows up on the recordings. Nothing does. Moreover, he “wakes up” from his long convulsive sessions perfectly lucid, a virtual impossibility after a true epileptic spell. The facts are duly noted in his record for the benefit of the next hospital that has to deal with Victor.