Читать книгу My Body Is a Book of Rules - Elissa Washuta - Страница 13

University Health Center

University of Maryland

College Park, MD 20742

July 24, 2007

Campus Psychiatrists

Hall Health Center

Mental Health Clinic

University of Washington

Seattle, WA 98195-4410

To Whom It May Concern:

The patient requested her medical records as proof of her diagnosis and treatment as she prepares to move from Maryland to Seattle. We agreed that some of the contents of her medical records, especially notes on her mental state recorded by myself and her therapists, may be troubling to the patient. Therefore, I agreed to write this letter, which she can carry with her wherever she travels. These recollections have been gathered from my records and memories following our final appointment. Please use the following information as you wish.

The patient was first seen at the University of Maryland Mental Health Clinic in August of 2006 for symptoms of severe depression and anxiety. After completing a mood inventory upon her first visit, the patient scored 36 on the Beck Depression Inventory, indicating severe depression. We prescribed Lexapro.

The patient had consulted with a campus counselor in the spring of 2006 to deal with issues stemming from a sexual assault in January of 2005 (“Acquaintance rape”). The patient maintained a relationship with the young man despite his abusiveness. The patient exhibited no symptoms suggestive of PTSD. The patient discontinued counseling sessions due to concerns that her counselor failed to take her problems seriously (his primary suggestion for avoiding late-night meltdowns was to create an hour-by-hour schedule for evening activities [which, I agreed, was a flawed suggestion]).

We assigned her to one of our clinic therapists who, despite her training, cried when the patient detailed her wrung-out existence. The patient felt that the therapist’s miniature Zen rock garden stationed next to the patient’s chair, complete with sand and a tiny rake with which to move it around, was insulting to her emotional intelligence. The patient excelled in her English classes and maintained a 4.0 GPA.

The patient visited my office almost weekly while we worked to stabilize her moods. The patient was a regular fixture at the clinic. She saw me for drug adjustments more often than most patients see talk therapists. Although the patient’s knowledge of psychopharmaceuticals could have caused concern that she may have been “medication-seeking,” I instead saw this as a remarkable desire to understand her own drug regimen and possible future treatments. The patient was med-compliant to a nearly unmatched degree, exhibiting a complete willingness to improve her mental state through drug treatment. I disclosed to the patient that she was my favorite patient. Upon hearing this, the patient nodded and reported that she was only ever sane in doctors’ offices.

The patient exhibited no developmental problems. The patient had no family history of psychiatric disorders. The patient grew up in a loving family. The patient had many friends on campus. The patient reported no prior history of alcohol or substance abuse, but, on occasion, she came to my office straight from class, stinking of booze. When I asked her about it, she replied that she had come from her creative writing workshop, and I had to admit that some of the greats were drunks.

The patient’s mood gradually improved over the weeks following the use of Lexapro; however, following a setback, we added Wellbutrin for mood, low motivation, and daytime sedation. In addition, we added PRN Ativan for episodic anxiety.

The patient described nightly treks across campus to sit in a tunnel. The patient also described walks toward dangerous neighborhoods, cut short by fatigue. The patient described Ativan as somewhat helpful in cutting these “meltdowns” short by inducing sleep. The patient said that sleep would not save her forever. To hug her would have been unprofessional.

The patient’s daytime sedation and low motivation began to interfere with her studies. As a result, we added Ritalin as needed in order to allow her to complete her senior year schoolwork. Although insufflation is always a concern when prescribing psychostimulants to mentally ill patients, I had to disregard any far-out notions about what abuses she might be doing to the linings of her nostrils in favor of keeping the sheen on her GPA.

The patient witnessed an episode of elevated mood and confidence. As a result, we made a decision to discontinue Lexapro and add Lamictal. After a difficult month-long titration period, during which the dosage was increased in weekly intervals of 25 mg, the patient improved and returned to baseline affect and function.

Every other week of the winter, the patient crossed campus in maroon plaid flannel pants with the hems worn and torn and stained with snow. The patient collected hooded sweatshirts and wore them under a puffy coat. I did not notice that the patient had lost 35 pounds and become underweight until she informed me.

We began to reduce Wellbutrin with the aim of discontinuing it, as we continued to be concerned about the likelihood of the patient having a bipolar spectrum disorder. Her original diagnosis of unipolar depression was based on her answers to questions asking that she catalog her moods at that moment. This method of scoring darkness has its limitations. For example, it asks that the college students we treat—most of whom are paying tens upon tens of thousands of dollars to take classes they report to be “fucking lame” in order to earn degrees that often prepare them for prestigious unpaid internships—sit in a waiting room and circle numbers on sheets fastened to a clipboard that correspond to statements like, “1.) I don’t feel I am being punished. // 2.) I feel I may be punished. // 3.) I expect to be punished. // 4.) I feel I am being punished.” We add up the numbers and decide whether we believe the students feel hopeless. We decided that the patient hated herself. We diagnosed her with “severe unipolar depression.” While that was true at that moment, in other moments, she thought she was a rapper so famous she didn’t need the ability to rap. The patient’s apparent hypomania, associated with the use of antidepressant monotherapy, as well as known mood instability in bipolar patients resulting from antidepressant monotherapy (meaning, putting a bipolar patient on antidepressants will send them into ultradian [multiple cycles per day] cycling), led us to discontinue.

The patient’s level of composure and charisma during office visits made it difficult to believe she was so fucked up.

After Lamictal was increased to 125 mg, the patient’s mood regained stability. However, the patient developed a fever of 103, followed by a rash on the torso, upper arms, and legs, indicating that the patient may have developed Stevens-Johnson Syndrome, a rare and potentially fatal reaction. The patient would have been in the less-than-one percent of all patients on Lamictal who develop SJS.

The patient visited my office, stating that there was an emergency. After I closed the door, the patient lifted her shirt to reveal a rash on her stomach. The patient twisted her spine to show a rash on her back. For the first time, she cried in my office. “I know I have to stop taking it,” the patient said, “or I’ll die, but I don’t want to stop taking it.” I said, “I’ve never seen this before. Of all the people, I wish it didn’t have to be you. Dammit, why did this have to happen to one of my favorite people?” When I said “people,” I must have meant “patients.” I had to send the patient downstairs for a benadryl injection that would knock her out until she would be kicked out of the clinic at closing time.

We were forced to discontinue Lamictal.

We added lithium. Once again there was improvement on 600 mg of lithium, with a resulting lithium level of 0.6 mEq/L, in the normal range.

The patient’s hair kept getting shorter. Gold highlights the size of sunfish were added.

In May of 2007, the patient once again reported an episode of dysphoria with decreased social judgment. Lithium was increased to 900 mg.

The patient described a recent episode in which she had a lesbian encounter against a bathroom door and an encounter with a former partner on the lawn of a coffeehouse. The patient said, “Don’t write that down. Just put, like, ‘Manic shit going down.’” The patient could never make mental notes off-limits. When she once said hello to me outside the clinic, I pretended I didn’t know who she was.

In June of 2007, the patient had another episode of elevated mood, increased alcohol consumption, negative self-reflection, and a sense of hopelessness. The patient said it was getting hard to take out the recycling, and bags of beer bottles accumulated under the kitchen table. At this point we added 10 mg of Abilify. There was some insomnia and akathisia, for which we added 1 mg of Klonopin nightly.

The patient said that her internal organs felt as if they were being constantly unraveled and knitted into something too tight. The patient said that her brain was uncoiling and re-clenching, as her fist does during a blood draw. The patient said she was determined to stay on Abilify. This was her attitude when I last treated her, before her move from Maryland to New Jersey to Washington upon graduation and entrance to graduate school.

The clinical picture is compatible with a mixed, rapid-cycling bipolar disorder.

I missed her a lot when she left.

In conclusion, the patient’s mood has been frequently and episodically unstable. There have been episodes of depression, as well as mixed and hypomanic symptoms. There have been ten-degree nights in ten-inch skirts, nights spent going through the Ativan rations while trying to sleep under a window left open to let the murderers in, nights racking up every point on every inventory and dreaming up new ones—the Washuta Online Spending Inventory, Identification with Famous Rappers Inventory, and Facebook Posts about Self-Worth Inventory. There have been nights when she genuinely believed she could really do the rest of her life, and nights when she really thought that no drug company was ever going to make a pill that could even lessen her pain. It kills me to know that she thinks this during most of her daily activities.

Although the patient’s current course of Abilify has stabilized her mood, she does meet the criteria for bipolar disorder, mixed, rapid cycling, and will need to receive lifelong drug treatment. If anyone tells her otherwise and tells her to shrug it off and cheer up, I have promised her I will personally kick his or her teeth in. I wish Miss Washuta the best.

Sincerely,

The Psychiatrist¹

Next psychiatrist’s postscript: The patient’s akathisia, described as a constant feeling of agitation and unrest, intensified immediately after her move to Seattle. There, because no one in his right fucking mind should prescribe Abilify, that and Klonopin were discontinued and Seroquel was added. After adding 5 mg Lexapro, the patient achieved stability.

_________________

1 With edits from Elissa Washuta, 11/13/2007.