Charles Balis' Journal for the Week ending 3/14/97

Saturday, March 8, 1997

Sunday, March 9, 1997

Monday, March 10, 1997

2 pm. Sixth Session with George Landau. I decided to force the issue and not allow George to continue telling me everything was all right and that he was perfectly fine. So I told him that I would excuse him, with a clean bill of health, from coming to further sessions. When George thought I was abandoning him, he opened up and admitted that he was terrified. Of what, I'm not certain. But at least we made some progress breaking through the hard shell of reserve in which he resides. George broke down and wept. Then we were able to proceed with a great deal more honesty. Since the department switched over to a new computer system, George has successfully avoided the training courses through recurrent bouts of stomach cramps and nausea. George insists that the symptoms he feels on the first Monday of each month are very real. But after he's sure of missing the training, his condition improves. He does become anxious the day before the training sessions are to begin, so there could be a physical component caused by stress, but George's malady seems likely to be primarily psychosomatic in origin. That doesn't make it any less real for George, of course. George manages three staff members and feels that he is accomplished at avoiding dealing with the computerized system. He has his subordinates retrieve the information he needs from the computer. To them, he consciously hides behind his "fuddy-duddy" image. But that's not working with Simon Taylor. During this session, George did not wear his wrist brace.

Tuesday, March 11, 1997

9:10 am. Conversation with Sylvia Bows, Rene Wolff, and Dr. Brian Malleson at the California Pacific Medical Center, Labor and Delivery ward. Rene called late last night. Sylvia's water broke and she went into labor. Rene called an ambulance and rushed her to the hospital where they were met by Dr. Malleson. Sylvia was put on an IV of Magnesium Sulfate which was successful in arresting the labor. When I saw her this morning, Sylvia was lying in bed and looking quite gray. She had an elevated heart rate and was perspiring freely. Sylvia was also attached to a fetal heart monitor, and at least one of the twins had a normal rate of 140 beats per minute. Apparently, the other twin wasn't being monitored. Sylvia hadn't had any serious contractions for the length of the strip--perhaps 3 hours. I spent most of my time talking with Rene because Sylvia seemed barely able to say hello. Rene was tired but very angry at Tom, whom she blames for Sylvia's labor. But Rene had tried to reach Tom, leaving a message with his secretary. I do hope that Tom comes through for Sylvia. She really seemed to want him there. The only time she became animated was when I was talking about the phone call I had with Tom last Friday. Sylvia was very anxious to know if I was successful in convincing Tom to reconsider his position. Sadly, I couldn't tell her that I was successful. Dr. Malleson arrived. He has that Old World charm that really cheers patients up--his bedside manner is excellent. But he was clearly concerned about the twins developing RDS. He is starting Sylvia on corticosteroid therapy. Although this is not my area of speciality, I believe that he is trying to artificially accelerate the development of the surfactant coating in the tubules of the lungs prior to delivery. But a side effect of the therapy is an increased risk of infection--particularly troubling here because the therapy won't work unless the lungs are given a chance to develop and, conversely, the delivery must take place if an infection develops after the water has broken. So Doctor Malleson also put Sylvia on a prophylactic antibiotic. Sylvia clearly needed rest and was being disturbed by my conversation with Rene, so I took my leave soon after Dr. Malleson left.

Wednesday, March 12, 1997

Thursday, March 13, 1997

12 pm. Second Session with Christina Herald. Chris arrived for the session with her hair wet, dressed in jeans and a gray sweatshirt. I thought the emblem on the shirt was a college crest until, on closer inspection, I saw that it said "Psychotic State University." I think I should put in a supply of the shirts. Christina's emotional lability was high during today's session. While maintaining her constant movements, she ranges from calm and reflective when she talks about her ex-boyfriend Kevin to disgusted and angry when she talks about her father and stepmother. Apparently, Christina initiated a break-up with Kevin, who she describes as both gorgeous and good in bed, because he wasn't intellectually challenging. However, he is clearly a trigger for some of her panic attacks and she seemed emotionally exposed when talking about him--I sense that there are some unresolved issues surrounding that relationship. He was not merely the romantic diversion that I believe she is trying to imply. Christina described her fractured family life. Christina was an only child until her mother and father divorced and her father remarried Joanne who had a daughter, Monica. Together her father and Joanne had a son, Jonathan. Christina is clearly hostile to both Joanne and Monica (she believes both to be vapid) while she feels a protectiveness towards Jonathan, who seems weaker than she. Christina was clearly proud of Jonathan when he took a rare stand against his father over his choice of career. Christina also rushed to Jonathan's defense. Her father wishes Jonathan to take up business or law--a profession that would be valuable in a corporate environment. Jonathan wishes to go into veterinary medicine. Christina describes her father--Herald the Horrible is a nickname around the office--as a soulless control freak. After the conflict with her father, Christina made it home before having another attack. We talked about the genetic basis for panic disorder and I suggested that Christina think about the possibility of somatic treatment. Christina is hesitant to take drugs. She feels that she has her quota already with caffeine and nicotine. I asked her to make an appointment with an internist and recommended Doug Halsey. I'll call Doug to make sure that he concentrates on conditions which could lead to a differential diagnosis such as hyperthyroidism, hyperparathyroidism, pheochromocytoma, diseases of the vestibular nerve, hypoglycemia, mitral valve prolapse, and supraventricular tachycardia.

4 pm. Thirty-third Session with Anna Green. Anna is still having difficulty falling asleep after her experiences with the S&M club, but it seems that the trauma surrounding that event is slipping away. Anna had resolved not to talk to Martin for a time, but he flew out to San Francisco and was able to convince the painters of an apartment building across the street from Anna's home to use the as yet unpainted side of the building as a billboard to advertise his affection for Anna. Anna was embarrassed and pleased when she saw the building emblazoned with the message: "I LUV U ANNA." She was met by Martin at the front door to her apartment. She said that the neighborhood seemed to have gathered for the event, clapping and cheering. Martin and Anna only were able to talk briefly before Martin had to fly back to Michigan, but Anna admits that she is a sucker for romance. And she says that, sexual quirk aside, she still really likes Martin. So she is toying with the idea of satisfying Martin's desires by being his dominatrix. She professes to understand that, to its devotees, S&M is more than just a role playing diversion. I tried to explain that it is often an integral part of their personality structure. But Anna sees deeper into Martin than just his sexual persona and feels that he is capable of great love and affection. Anna has started to look at people in the street differently. She remembers the man in the leather mask who was screaming that he was a lawyer in the police station, and now imagines the secret sexual lives of the ordinary people that she sees in the street. She has come to the conclusion that there are a lot of strange people in San Francisco, and I found it hard to argue. She has decided to learn more about S&M, so with a helpful clerk at a dirty bookstore in North Beach, she has gotten some reading material and is preparing herself to undergo the lash in Martin's hands. Martin describes having a sexual rush while he is being abased. Anna says that she has to understand that before she can inflict pain on him. If I wasn't a psychiatrist, I'd say that she was out of her mind. But I am a psychiatrist, so all I can do is nod and say, "Hmm." I was afraid several times during this session that my personal feelings for Anna were going to interfere with my professional judgment. I really think it would be a lot better for Anna if she dumped Martin and tried to find someone else more compatible in body and spirit.

Friday, March 14, 1997

9 am. Second Session with Jerico Freeman. Jerry is apparently suffering from full fledged persecutory delusions, although without visual hallucinatory features. He believes that he, and a small band of compadres who work in the City sewer system, are battling some form of apparently non-human entities. He believes that these entities, which he has nicknamed CHUDs after a fairly unpleasant movie of the same name, are responsible for the death of Jake, a friend and co-worker. Jake was killed in the Sea Cliff Sewer Collapse in December 1995. He was doing some surveying in the Richmond Transport Tunnel when, according to Jake, he must have stumbled upon a CHUD. Jake believes that there was an explosion, caused by the CHUD, which killed Jake and caused the collapse. The sewer collapse happened before I got to San Francisco, but I still remember the impressive television news footage of that giant Tudor house cartwheeling in seconds into a giant hole and collapsing into a bunch of boards. Jerry is still having intermittent outbreaks of the hand tremors I witnessed during our last session. He told a fairly amusing anecdote of using an unexpected occurrence of the tremors during intercourse to increase his partner's sexual satisfaction. Jerry is still not particularly amenable to somatic treatments and, frankly, I'm somewhat surprised that he came to me for treatment at all. Generally, those with delusional disorders have little insight into their own illness and are reluctant to seek care. An interesting feature of Jerry's case which I haven't resolved is how Jerry believes that a number of coworkers share the same delusions. Perhaps they have been humoring him. A treatment outline for Jerry follows: I must separate out possible physical causes including alcoholism, drug-induced states, dementia, and infectious, metabolic, and endocrine disorders. Then I must separate out other possible mental disorders which might express themselves as delusions, such as mood disorders with psychotic features, schizophrenia, and paranoid personality. But I have noticed no depressive or manic syndrome in Jerry which would tend to rule out psychotic mood disorders, and unlike schizophrenia, there is an absence of prominent hallucinations, incoherence, grossly disorganized behavior, or loss of personality. It's important that I neither condemn nor collude in Jerry's beliefs. Jerry must be assured that the doctor-patient relationship is confidential. Unfortunately, my experience is that delusional disorder doesn't respond particularly well to antipsychotic medication. The medication can reduce the concomitant anxiety and agitation, but does little to stop the underlying delusions. And noncompliance is always a serious issue. I might consider some of the subcutaneous fat soluble forms to assure proper dosage. Most importantly, time and patience is required to gain Jerry's trust and build a relationship. Once we have a good rapport, I will gently challenge Jerry's delusional beliefs and point out how they are interfering with Jerry's normal functioning.

4 pm. Second Session with Thomas Darden. Tom described for me some of the issues that stop him from having a social life. He feels that people are going out as part of an elaborate game--to impress each other rather than to have a good time. Tom found himself falling into the same trap. In fact, Tom is worried that he might be creating imaginary situations to have something to tell his co-workers. He gave me an example of having a telephone conversation with a woman who was concerned about him after she had hit his car. He turned the situation into a story about the woman calling him for a date and that he refused. The interesting part of the story was that, after telling the lie to his friends, he began to imagine that the woman had really been interested in him, that she had really been trying to get him to ask her out. He was reshaping his reality to justify the lie he had told. But the example didn't make it sound to me like his lying was an irresistible compulsion. Rather the lie was more in the nature of a fantasy about getting out of a life which is undesirable. Although he works out--to be ready in case a relationship should ever come about--he describes himself as a home body who enjoys solitary activities. In a jumble of justifications, he described how he didn't have anything to offer a woman, and how he didn't even think he wanted a relationship now because it would stifle his freedom to be crude when he wanted to be. But he also admitted that he was lonely. His response to feeling lonely is to binge-drink beer and feel sorry for himself. Tom described his early family life. His father was an outgoing, large and expansive man while his mother was a polite, passive person who Tom describes as a pushover. His father worked in a chemical plant. When Tom was 10, there was an explosion which killed 35 people instantly. But his father held on for several weeks before succumbing and was conscious during some of that time. Tom remembers being dressed up in his Sunday church clothes and visiting his father, who must have been terribly burned and was swaddled with bandages. His father was restricted to hand gestures and was unable to talk. Although his younger brother was able to talk to his father, asking him when he was coming home, Tom's more mature realization of the extent of the injuries made him shy with his father. Tom remembers holding back and not being able to go to his father's bedside, even when his father motioned for him to do so. Tom can't forget a look that his father gave him, which Tom interpreted as his father telling him that he was sorry. The funeral was such an ordeal for Tom's mother that she had a psychotic break. She snapped out of it after a few days at the psychiatric hospital. But Tom vowed never to go to another funeral. After that, the family moved around a lot, his mother getting involved with a succession of different men. She remarried two years later to a man whom Tom describes as a perfect asshole. Tom said that each member of his family had metaphoric neon signs above their heads directing others how to act towards them. Tom's sign said, "Abuse me, won't you?" Tom's brother Alex's sign said, "Ignore me." And Tom's mother's sign said, "Fuck me and leave me." When Tom said that he needed a drink during our session, I started to remonstrate, then Tom warned me not to accuse him of being an alcoholic. My guess is that Tom suffers from avoidant personality disorder. I suspect that he has strong feelings of inadequacy and hypersensitivity to negative evaluation. This has probably been a pattern from early childhood, perhaps because of his inability to live up to his image of his father. Tom is probably unwilling to get involved with someone unless he is certain of being liked. I also imagine that Tom is unusually reluctant to take personal risks or engage in new activities that could prove embarrassing. There is an overlap between avoidant personality disorder and social phobia. I have heard that some psychiatrists have had good success with benzodiazepines, short term, in helping patients reverse previously avoided behavior, and the full range of somatic treatments that are useful for treating social phobias have application here because of the strong overlap.

6:15 pm. Conversation with Sylvia Bows & Tom Bows at the California Pacific Medical Center, Labor and Delivery ward. Sylvia looked better today, even though she was still on the Magnesium Sulfate drip. She was extremely grateful that Tom had come. Sylvia wants to silently convey to Tom just how strong the bond between them still is, but she seems unwilling to actually discuss how she feels with him. When I chastised her gently for not telling Tom that she loved him, she said that she was scared that if she uttered the words and then Tom left her, that it would destroy her as a person. Tom came into the room and was his normal, businesslike, efficient self. He has educated himself about the medical procedures affecting Sylvia and was able to give me a lucid medical explanation of why Dr. Malleson wants to deliver the twins this weekend. He expects that the youngest boy will have to stay in the neonatal intensive care unit for a few weeks after birth. Obviously, with Sylvia in the room, I was not able to get a sense from Tom about how he is going to act with Sylvia once she has given birth.

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