THE WASHINGTON POST – Fans of the medical-mystery television series House will find arresting parallels – and striking differences – in the absorbing collection of real-life psychiatric case histories the distinguished British neuropsychiatrist Anthony David recounts in Into the Abyss: A Neuropsychiatrist’s Notes on Troubled Minds.
Both feature patients whose enigmatic, even bizarre symptoms defy ordinary clinical explanation, baffling one specialist after another. As the patient fades, fears rise and suspense reigns. Can the intuitive diagnostician called in to consult resolve the crisis and restore the patient to health?
Well, no one can second-guess the ornery, arrogant Dr House. By contrast, the compassionate, philosophical Dr David can’t help second-guessing himself, and that’s only one reason his case histories are so compelling.
As a neuropsychiatrist, David treats patients whose symptoms cross borders between the mental and the physical. His daily struggle is figuring out how the two supposedly distinct systems of mind and body have conspired with – or perhaps against – each other to land his patients in such calamitous predicaments.
How does it happen, for instance, that as a victim of traumatic brain injury recovers his ability to walk and talk, he becomes possessed by psychotic delusions? How to explain a patient’s physical paralysis when no organic reason can be found? Is another patient’s eating disorder a rational “lifestyle choice,” as she asserts; a reaction to an assault she has tried to bury in memory; or something else altogether?
The mind-body link at the centre of each of these cases runs contrary to traditional medical assumptions about their independence from each other, and that is also David’s theme. His patients experience, and suffer from, a range of neurological pathways and interconnections that the medical and psychiatric professions are only on the cusp of exploring and understanding.
One case in point: While conventional wisdom might dismiss some ailments as existing “all in the mind,” David shows that we – and physicians in particular – do so at our peril, lest we miss a significant clue that if spotted in time might save a life. David learnt that lesson when one of his patients, whom he thought was on the upswing from an episode of severe depression, deliberately stood in front of an oncoming car and died instantly.
Only in retrospect could David see the boldly waving red flag that he had not paid attention to before. The patient, long a devout Christian, had in his despair abandoned his faith, which led in turn to the loss of the sense of purpose it had given him. No longer perceiving a reason to continue his life, his patient had ended it. An acute observation, but in a case like this second-guessing just doesn’t cut it.
David also admits to being forced to engage in a kind of educated guesswork. Many of his cases present so unusual a confluence of symptoms and syndromes that, search as he may, the medical-psychiatric research literature contains few precedents to guide him. That is what he was up against when he met Jennifer, a 30-something artist whose medications had previously kept her schizophrenia under control, but who had now been hospitalised in a near-catatonic state. A battery of neurological tests suggested that her antipsychotic medications had, in a rare side effect, also triggered the onset of a severe case of Parkinson’s disease. But what was the next step? As David and his colleagues began nudging and tweaking various combinations of medications to treat both conditions at once, not really knowing what might work, he could not disagree with Jennifer’s observation that she had become a human guinea pig. But in time she did recover enough physiological strength and psychological calm to start practicing her art once again.
David believes that the neuropsychiatrist’s job requires looking beyond the data, to see the fuller canvas of an individual’s life history and to trace the damaged, tangled threads in need of healing in both mind and body.
For him, he writes, “the real challenge is finding the right level of explanation along the biological, psychological and social continuum.” But life’s messiness can make it difficult for patients and their families to discern just how inextricably connected all these components are.
With 15-year old Christopher’s autistic younger brother commanding all his parents’ attention, his mother and father at first paid little attention when a chest infection started to morph into a neurological disorder that robbed him of movement in his arms and legs. Then, when an incompetently executed medical procedure seemed to paralyse him completely, his parents were consumed with guilt and brought him home to care for him as devotedly as they did his brother.
The problem was that, even though not a single diagnostic or neurological test showed any physical cause for this disability, his parents declined to pursue further treatment. For David, the case had the markings of what’s known as a “conversion” or functional neurological disorder, in which an emotional conflict that cannot be articulated (in this case Christopher’s desire for his parents’ attention) manifests instead as a physical disability – in this instance, paralysis, a result made to seem all the more plausible by the trauma of the botched medical procedure.
It was a narrative, however, that the family would not willingly accept. David does not make clear why they changed their minds, but when Christopher was 18 he finally did return for further treatment, his long years without movement now requiring intensive physical therapy, in addition to psychotherapy, to help him gain independence in his mind as well as in his body. Within four months, Christopher was able to get around on his own again; just as important, he felt he was being treated, for the first time, as an individual worthy of respect.
This is David’s happiest ending, and it comes as a relief after some of more wrenching cases that are never fully resolved. I wish he had provided more details about the state of our still-unfolding knowledge of the neurological and other channels through which mind and body communicate with each other. That may be for another book, however. In the meantime, he has given us a gripping overview of the dilemmas that the traditional binary medical mind-set has yet to fully explore or grasp.