Gary Small & Gigi Vorgan Read online

  For most BIID victims, the wish for self-mutilation begins in childhood or adolescence. Some experts think the condition results from a brain disorder that somehow disrupts body image, but a specific cause has not been pinpointed. Treatment involves both psychotherapy and medication, and though patients may continue to have thoughts of removing their extremity, they can be helped to improve their quality of life and find ways to function reasonably well with their unwanted body part. Antidepressants can reduce the obsessive thoughts, and an important aspect of therapy is helping the patient reveal his secret to people in his life who can offer support.

  I WAS WALKING BETWEEN THE HOSPITAL CLINIC buildings and saw Neil Cooper in the distance, so I shouted “Neil!” but he didn’t turn. I picked up my pace and shouted again, “Dr. Cooper!”

  His walking slowed and he shouted back, “My God, I’m hearing voices. Get me a psychiatrist. Stat.”

  I caught up with Cooper and gave him an update on the Kenny Miller case.

  “You know, Gary, this is an interesting situation. At what point do you say a person doesn’t have the right to elective surgery? Lots of people don’t like their appearance, so they change their hairstyle, get a nose job or maybe a face-lift. At what point do we call them crazy?”

  “But you’ve got to admit, Neil, wanting your hand amputated is a bit over-the-top.”

  “Maybe, but where do you draw the line? Do you set a limit on how many nose jobs a person can get? No. Plastic surgeons often do multiple surgeries on the same body part. Are you going to commit somebody for wanting her eyes done a fifth time?”

  “So you’re saying you’d do an elective amputation for this guy if he asked you?”

  “Well, it depends,” Neil said.

  “On what?” I asked.

  “How good his insurance is. I gotta go. See you later.”

  I walked on to the Lindemann Mental Health Center. Lindemann was the lockdown inpatient unit affiliated with Harvard’s Mass General Hospital. It was a modern concrete structure that from the outside could have been an art gallery but on the inside had the feel, smell, and tension of a typical psychiatric ward.

  Dr. David Keller’s office door was open. He was busy at his desk, which was cluttered with papers, files, and books. Keller was a resident in my year, with an engaging, self-effacing humor. He planned to be a psychoanalyst after residency, and he never missed an opportunity to make an analytic interpretation about nearly anything.

  “Dave,” I said, “I like the way you’ve gotten a handle on your office clutter.”

  He looked up and grinned. “Well, Dr. Small, you just can’t see the intricate organization I’ve got going here.”

  “So how’s my boy Kenny Miller?” I asked.

  “He’s a fascinating case. You were right on with the body dysmorphic diagnosis. And despite being in my care, he’s doing quite well.”

  “He was pretty agitated when I sent him over here,” I said. “Do you think he’s still in danger of cutting off his hand?”

  “Well, he claims his amputation thoughts have diminished,” Dave said. “I started him on some clomipramine. It’s been less than a week, but I think it’s beginning to reduce the obsessive thinking. He’s having a little dizziness, but I think he’ll tolerate it.”

  Anafranil, the brand name for clomipramine, is a tricyclic antidepressant often used to alleviate obsessive-compulsive symptoms. It usually takes a couple of weeks for its full benefits to take hold. Unfortunately, many patients report troubling side effects including dizziness, headache, and fatigue. Today newer antidepressant drugs known as selective serotonin reuptake inhibitors (SSRIs) such as Prozac, Zoloft, or Paxil are used because they have fewer side effects.

  Dave went on. “I think the separation from his wife really aggravated his condition. But now that she’s been visiting here, he seems much calmer and definitely more accessible.”

  “Lauren’s been here?” I asked.

  “Every day,” Dave answered. “And now that she’s in on his secret world, they seem much closer.”

  “That’s great,” I said. “I’d like to see him.”

  “Be my guest. Room 212.”

  Kenny’s room was in the low-security wing of the unit—a good sign that he was improving. As I approached his door, I heard talking. I knocked and entered. Lauren was sitting on the bed beside Kenny, and they both turned to me.

  “Hi. It’s good to see you two,” I said.

  “Hi, Dr. Small,” they both said.

  “How are you feeling, Kenny?” I asked.

  “I’m sorry that I was so pissed off at you,” he said. “I realize now that you had no choice about sending me here, and the truth is, I’m doing better.”

  Lauren jumped in. “We’re doing better too.”

  “That’s great,” I said. “What do you think is helping?”

  “I don’t feel shut out anymore,” Lauren answered. “Kenny’s finally telling me what’s really going on with him.”

  “I’m glad to hear that.” I said.

  Kenny smiled. “And when I get out of here, I’m moving back in.”

  She added, “We’re giving it another try.”

  Kenny was released from the hospital two weeks later. He and Lauren started seeing me for couples therapy on a weekly basis. It became clear that Kenny’s symptoms had gotten worse when Lauren first brought up the idea of having a baby. Kenny was worried that amputation might ruin his carpentry career and he wouldn’t be able to support a family. But instead of discussing it with Lauren, he allowed his shame to make him keep his feelings secret, so she never understood, which left her feeling shut out.

  Thanks to Kenny’s medication, he became less obsessive about his hand and better at communicating with Lauren. They even started talking about having a family again. After a few months, Lauren got pregnant and they decided to stop therapy. I tried to convince them otherwise, or that at least Kenny should continue on his own. But these two were on a second honeymoon and confident that they no longer needed my help.

  At their final session, Kenny promised that if his amputation urges ever became obsessive again, he would call me right away. He never did call. When I think of Kenny, I hope that he’s doing well and holding his children with both hands.

  CHAPTER FOUR

  Fainting Schoolgirls

  Spring 1980

  I WAS STUDYING CARL JUNG ESSAYS one May night in my chilly Cambridge flat. I could hardly keep my eyes open when the sudden hissing of the steam heater going on shocked me fully awake. Had my landlord won the lottery and decided to share the wealth by actually heating his tenants’ apartments in the spring?

  I was tired of Jung—too much theory and not enough action—so I turned on the TV to watch the eleven o’clock news. I went to the kitchen to make some tea, while listening to the headlines. A story caught my attention—a bunch of grade-school kids in a nearby suburb had been hospitalized that day because of some mystery illness. I loved mysteries.

  I ran back into the living room to watch the news coverage. A crowd of young students milled about in their school yard looking frightened and disoriented while their teachers tried to comfort them. Some of the kids were crying, others were lying on mats, holding their stomachs, and a few were being loaded into ambulances. A newsman on the scene described the mysterious outbreak: “It began in the auditorium during a school assembly. One teacher said the kids started dropping like flies. Most of the children who fell ill were taken to State Street Community Hospital and released within a few hours, perfectly well. Local health officials are still searching for a cause, and toxic fumes were among the lead culprits under investigation. However, nothing has been proven as yet.”

  I’d heard about mass hysteria—outbreaks of what seem to be physical illnesses but turn out to be group contagion of psychosomatic symptoms. This mystery illness might well fit in with that diagnosis. Even if the health inspectors found a physical cause, the events were pretty dramatic—lots of tearful children, frantic
parents, and plenty of teachers and emergency technicians running about.

  I stopped by the medical school library the next morning before clinic and found a few articles on mass hysteria. I learned that although these epidemics were pretty rare, they had been recorded as far back as the Middle Ages. Most often the outbreaks afflicted children and teenagers, girls more than boys, and fainting and hyperventilation were the most common symptoms. Occasionally the illness persisted for days; however, once the afflicted crowd dispersed, symptoms tended to disappear, because they were only contagious when new victims observed others falling ill. Rumors about the causes of the outbreaks tended to spring up throughout the communities.

  Reading about these unusual events got me charged up. They had all the elements of a medical mystery and raised some fascinating psychological questions about the power of the group and the ability of the mind to control the body.

  I had lost track of time and realized I was late for clinic. After quickly making copies of the articles, I raced off to the hospital. Fortunately, it was a light clinic day. I flew through the nearly empty waiting room and found my buddy Don Williams in the coffee area, drinking a diet soda while finishing up a note on his last patient. Don was one of my closest friends in our residency class and described himself as a tall, dark, and handsome version of Woody Allen.

  “So nice of you to saunter in at this leisurely hour, Dr. Small. Dog eat your alarm clock?” Don asked.

  “Always a comedian, never funny,” I responded. “I was actually in the library.”

  He laughed. “And I’m playing shortstop for the Red Sox.”

  “Seriously, Don, did you catch the news story about those suburban kids who fainted and were rushed to the hospital yesterday?”

  “Yeah, they’re blaming it on some toxic leak or something. Everybody’s so freaked out by the environment since that Three Mile Island thing.”

  “There’s no proof of any toxin at the school. I think there might be a psychological spin here. The kids suddenly get sick and just as quickly get better—it sounds suspicious. That’s why I was looking up mass hysteria at the library.”

  After a pause, Don said, “Could be…You know, Gary, you ought to go take a look into this. You keep threatening to get into research; here’s your big chance.”

  “I’d actually love to go down there, but I’ve got clinic all day,” I said.

  “I’ll cover for you. Go talk to the locals and find out what’s going on. Maybe you could put together some kind of study or something. You could get published. If nothing else, I’m handing you a get-out-of-clinic-free pass.” Don then went into his best Marlon Brando Godfather impression. “But one day, I may come to you for a favor…”

  “So what are you saying? I just go down there and start asking questions? On whose authority?”

  “You don’t need any authority—you’re on staff at the prestigious Harvard Medical School. Tell them you’re an expert in epidemic illness and you’re there to get to the bottom of this disturbing incident.”

  I was getting excited about the possibilities. I had dabbled in research during medical school but never had a chance to follow up on anything. Ever since I was a kid, I had loved solving puzzles. There was something about figuring out a strategy or solution to a problem that was tremendously satisfying to me. This was an opportunity to solve a real-life puzzle.

  Don was right. Whether or not I played the Harvard-doc card, I could just go down there and try to find out what went on. I might not really be a mass-hysteria expert, but I had read two articles, and probably knew more about it than any of their local doctors. As I learned later, even the Centers for Disease Control tended to overlook mass hysteria as an explanation when searching for diagnoses of unexplained illness outbreaks.

  I made a few phone calls and set up an appointment with the principal of the school where the outbreak had occurred. I typed up a one-page questionnaire for the parents and kids and made copies of it.

  Driving down Boylston Street in my 1974 red Toyota Corolla, I watched as the scenery changed from buildings to foliage as I headed out to the suburbs. I figured I would just apply the psychotherapeutic investigative approaches I had been using on individual patients, although I would probably be talking to multiple individuals. I guessed that wouldn’t be too hard as long as I was given access to the families. At the same time, I realized I would need to come up with a research hypothesis for a study.

  There exists a general bias that studies of behavior and other psychiatric investigations are somehow less scientific than other kinds of medical studies. Many reasons exist for this: the mind seems nebulous and immeasurable; there is a persistent stigma about anything psychiatric; and many people are afraid of looking at their own underlying psychological issues.

  I MADE PRETTY GOOD TIME OUT TO the suburbs and parked across the street from the school. I grabbed my notebook from the backseat. Seeing my white clinic coat there, I grabbed it and slipped it on—maybe I would try Don’s concerned, Ivy League–expert angle to help pry the doors open here.

  As I waited in Mr. Saxon’s outer office, I could hear his tired, raspy voice on the telephone. It sounded like he was trying to reassure a parent that everything was fine. He hung up and came out to greet me. A tall, imposing man, he practically crushed my hand as he shook it. He invited me into his office, and I sat across from his desk. I had a momentary flash of being called into the principal’s office in elementary school.

  “So, Dr. Small, what brings you here from Harvard?” he asked.

  “I wanted to talk about the incident they covered on the news last night.” I took out my notebook and pen and asked permission to take notes.

  “What do you want to know?” he asked.

  “Well, several of the doctors at Harvard heard about the illnesses, and we’ve…I mean, I’ve…had some experience with this kind of thing.” I had gone to the library, after all. “Could you tell me how the outbreak started?”

  “Essentially, the sixth-graders were about halfway through their dress rehearsal for their spring performance,” Saxon said. “The rest of the student body was in the auditorium watching when one of the boys onstage fainted and fell. He hit his chin against the riser and started to bleed. Everyone was startled, and the next thing we knew, other chorus members grabbed their stomachs and sank to the floor. Then it started getting out of hand, and it seemed like half the kids in the auditorium were getting nauseous, fainting, and having trouble catching their breath.”

  I was taking notes furiously. “Did you notice if more girls than boys got sick?” I asked.

  “Actually, I think there were more girls who fainted.”

  “What happened next?” I asked.

  “Well, the fire marshal got here pretty quickly—maybe less than half an hour. He thought he smelled fumes, so he evacuated the auditorium. The ambulances took about two dozen kids to the hospital, and I was just trying to calm everybody down,” Saxon said. He stood up and walked to the window. “A lot of the students were crying, but when their parents showed up, they calmed down. I think our teachers and staff did a fantastic job of keeping things together.”

  I looked up from my notepad. “Sounds like you had quite a scene on your hands. What did they find at the hospital?”

  “Not a thing. The lab results were normal. It was before lunch, and I think the kids were just hungry and tired. A couple may have started hyperventilating, and then everyone got scared. But there was nothing really wrong with our students physically, and the school followed all the correct protocols,” Saxon said defensively as he sat back down behind his desk.

  “So we still don’t really know what caused this temporary illness.”

  “We’re not worried about that, Dr. Small. They found no toxins in the auditorium, and the school is perfectly safe for the students and faculty. We have an outstanding record here and everything’s fine.”

  It seemed to me that Saxon was not very interested in digging any further to find the t
rue cause of the outbreak. In fact, he was describing typical features of mass hysteria: absence of laboratory evidence supporting a physical cause, hyperventilation, fainting, and rapid remission of symptoms once the students were separated from one another. His explanation alluded to a psychological cause, but I suspected that if I mentioned mass hysteria at that point, he’d get even more defensive. He clearly didn’t want the school, or himself, blamed in any way for contributing to the incident, but if we didn’t get to the bottom of this thing—whether it was a psychological cause, physical cause, or both—there was a risk of it happening again.

  “Aren’t you concerned about another outbreak?” I asked.

  “Not at all. It’s finished. Everybody just got overly excited. It’s never happened before, and it’s not going to happen again.” He shifted in his seat and arranged the papers on his desk nervously. Was he trying to reassure himself or me?

  That may be, I thought, but if it did recur, I wanted to see it for myself. “When are the kids doing the actual show for their parents?” I asked.

  “The Spring Sing is on Friday night, and we should get a big crowd. Why don’t you join us?”

  The invitation seemed halfhearted. No doubt Saxon was getting tired of swatting away my questions. Sensing I’d outworn my welcome, I stood and said, “Thanks for the invitation, Mr. Saxon. I’ll be here.”

  He didn’t seem thrilled that I said I’d come, and looked relieved that I was on my way out. Just as I was about to leave, I turned back and said, “You know, Mr. Saxon, there is one more little thing…” My favorite TV detective, Columbo, would have been proud.

  He looked at me, clearly annoyed. “What?”