Razor's Edge

Hail,

I got a letter from a Doctor Davey the other day, from Byron Bay. Byron Bay is a day's drive north of Sydney, just near the Queensland border, on the Pacific coast. That guy you know, took all those drugs, just dropped out of everything - he went to Byron. You can stand in the pure blue water at Tallow Beach and watch the smoke from the sugar-cane burning, on a good day there are humpbacks in the water.

Doctor Davey is the only methadone prescriber for two hundred kilometers – he says the town is full of “surfers and travellers and lost children.” He sounded tense and a little worn down. He was asking what I knew about Anushka Sharapova.

I wasn’t able to tell him much. We hadn’t had her for long, only a couple of months. She’d come down from Darwin, had got out of one bad relationship (ten or twelve thin, clear scars on her abdomen, stabbed with a pearling knife), and fell into another when she got here (James Firlik, one forty of methadone, during one of his increasingly infrequent interregnums between prison sentences). She'd come to see me only once, our organization two or three times. When James was picked up outside the pharmacist and led to the waiting police car, she’d disappeared, “fallen off the programme” and possibly the edge of the earth. When I read about the body of a young woman found at dawn in the parklands late last year, she was the one that I imagined.

But it hadn’t been her, and she'd gone, and there was very little I could tell him about her.

The reasons for this are complex. I had not admitted her to our programme, that had been Dr Grizzle, and before I saw Anushka I glanced at Dr Grizzle's write-up - a complete nutritional history, a few questions about body image, symptoms and signs of hyperthyroidism, a gentle but thorough discussion of licit and illicit amphetamines.

And I looked at the BMI, the starting point for discussions about issues of weight and size, and swore, and I went out into the waiting room and called her in.

Anushka was thin, frighteningly thin, the angular frame and stretched-parchment features you only normally see on an thyrotoxic, an ascetic or a cachectic, someone consumed from within by thyroid hormones or God or cancer. She sat, baggy-jumpered, flared jeans, on the chair opposite me and stared with large, dull eyes, and answered the questions about drug use history in a flat, soft voice, monotones, uncommittal, and the only time any kind of energy came into her voice and her face was when explained how she wanted to help people.

“Kids on drugs,” she said, speaking slowly. “I want to talk to them. Be a counselor or something.”

I had a vague idea, spoke almost on impulse. "Is that something you want to give your life to?" I asked.

She nodded, earnestly.

After she left - I had done pretty much the same as Dr Grizzle had done, asked the same questions, come up against the same thick stone walls - yes, she tried to gain weight, no, she didn't think she was overweight or fat, yes, she knew about bone density and tooth decay and constipation and headaches and death. She didn't want to see anyone else, she didn't think that she was depressed, she was a happy kind of person. And the food was just like for everyone else, there were no forbidden foods, no rituals, she ate pretty much everything, she loved eating and cooking food for other people.

I glanced up when she said the bit about "cooking food for other people", but that in itself is not a symptom of a mental illness, otherwise the backs of ambulances would be full of celebrity chefs. I remembered speaking to a woman with bulimia in Florey - she was hungry every hour of every day, always hungry. In the end I prescribed daily multivitamins along with her methadone and wrote her a short script so that she had to come and see me in a month.

I drove home with this vague disquiet, and strange thoughts breeding in my mind. There was a strong sense that I had done the wrong thing, that bad things were going to happen to Anushka soon, but I had no real idea - then or now - what else I could have done, how I could have made things better.

And most of all, I think I did so little because I had and have a profound sense that I had not understood Anushka Sharapova, that the chances were I had mistaken and misheard and maybe even mis-seen her, and that lack of comprehension was what paralysed me and Dr Grizzle and every other unexceptional doctor she had seen.

See, this is how my thought would go. Anushka was starving, I would think. What did she get out of starving, what did she get out of being starved? To be "successful" in suicide, one of my lecturers once said, one has to want to kill, to want to be killed and to want to be dead. It was rare for all three drives to intersect in the same person, when that happened, the person died. I used to think about that, walking the corridor down to the emergency department, rooms full of people who wanted to be dead or who wanted to be killed, but few who wanted to kill.

Anushka, I thought, wanted to starve, to punish, to deny. It's not far from that to want to kill.

And anyway - that whole "three things" thing - maybe it was just a slogan. You can argue that we are all suicides - Most people who die, die from self-inflicted wounds. We eat too much, we still smoke, we don't wear a condom, we go back to dangerous men. When you graduate from medical school, unless you are exceptional, your idea of medicine doesn’t deal well with this kind of slow, partial suicide, these kind of people, yet they are among our most common presentations. At best we see people who don't look after themselves as frustrating, at best, at worst, as morally compromised, taking up valuable resources that we could otherwise use to save people who really deserved it, really needed our help.

I don't know. Those who punish the body are not new to us. St Maria Maddalena de Pazzi lay naked on thorns. Saint Catherine of Siena drank pus from a cancerous sore. St Margaret of Cortona sought to slice through her nostrils and upper lip - Anushka's body is cut, pierced, starved. It's like those images of the Saints where the heart is visible through the rib-cage, burning and beating and crowned with thorns in an empty cage of bones.

It is of interest that as we fatten and age as a culture we focus more of our vision on the anorexic, the ascetic. S/he is a strange figure, someone who stands at the heart of our culture, someone whom we cannot face yet from whom we cannot look away. Like many of the other mental disorders, it is at least partially defined by income - Anushka and those like her must be cured, Gisele and Saint Catherine must be emulated.

I think realizing that I thought like that was why I felt considerable trepidation* in treating Anushka. I had no feeling at all that I saw "her", instead I knew I was seeing what I thought, superimposed on her, an idea that's stuck in my head. What next - prescribing sanctolytics or sanctoplegics, some prayer uptake inhibitors, a short course of diabolic steroids? When you see your own ideas, your own prejudices, your own beliefs and mystifications instead of the patient, you can't do anything for anyone. You don't see other people, obviously, you see something inside yourself, a category, a symbol, a cliché. You can't cure an eidolon, an idea.

But then what do you do?

I wonder if that was part of what was worrying Doctor Davey. I wonder, in fact, if that is part of what makes us struggle in the psych wards against the dying of these young, superficially placid and obedient women, part of what was behind the confusion, the frustration, the fear and opposition that those around Ss Catherine, St Therese di Lisieux and St Gemma Galgani felt.

Anyway, this hasn't come out right. I will try and write more coherently next time.

Thanks for listening,

John
*Current leader, clumsiest phrase or sentence in a work of fiction.

Sleep

Hail,
Been thinking about a lot of things, sleep and religion and parrots and Tycho Brahe and so on, and I might try to write this down.

There has been a bit of a hiatus in the blogging, by the way, a combination of a number of things - Sarah, packing up stuff into boxes, doing some writing, the approach of Autumn - but in a week or so I start psychiatry training, and posting should improve from then. Reflecting and thinking and writing is encouraged in psychiatry, although posting your patient's sufferings to the world as entertainment is possibly less so. Unfortunately, until then (early Feb) it's probably going to be pretty slim pickings.

First off - go and have a look at this. Shout it from the rooftops, preach it from the pulpit, print it up and put it on a bloody great tee-shirt. Whoever the author is, s/he shouldn't have typed this blog entry, s/he should have carved it on stone tablets for all eternity, because it is truly bloody glorious. Seriously. Print it out and stick it up somewhere.

But anyway. Sarah's on opiate patches at the moment, and I think we've got the right dose. Things are better than they were before, the pain is better, and there isn't so much of the early morning nausea* and vomiting that she was getting, but she says the patches make her sweat, and they affect her appetite, and, most distressing for her, they cause strange dreams.

Not strange dreams in the exciting way. These strange dreams are not ornate oneiric visions in the Edgar Allen Poe sense of the word, or Jungian strange dreams redolent with symbolism and secret meaning, they are dreams that are strange because they are so... unstrange. They are utterly mundane, confusing and occasionally embarrassing dreams that very closely resemble "real life".

Dreams where she wakes up and brushes her teeth and checks her email and then she really wakes up and has to brush her teeth and check her email again.

Wild voyages through the subconcious where she has a cup of tea, vivid multicoloured phantasies wherein she chats with her mum, delirious surrealist reveries involving paying the electricity bill. A few nights ago she either couldn't sleep and spent the night tossing and turning until just before dawn, or she slept like a log but had a dream where she couldn't sleep and spent the night tossing and turning until just before dawn.

She says it's not that whole spacey "One night the great sage Chuang Tzu dreamed he was a butterfly" stuff, either. It's more "One night the great sage Chuang Tzu dreamed he had returned the DVDS so he drove off without them and then a week later he got a hostile phone call from the DVD people and the great sage Chuang Tzu said 'What the hell's wrong with you people, I gave them back Tuesday' but it turns out he hadn't, it was just a dream" kind of thing.

Anyhow.

Speaking of sleep, an interesting article in the New York Times suggesting that what we call normal sleep - like normal eating or normal childhood - is actually a recent and historically abnormal phenomenon. Pre-Industrially it may have been that we slept in two shifts, each of a few hours - a first sleep and a second sleep. Between these two sleeps was a period of remarkable alertness and productivity, reading or talking or tending the animals at two or three in the morning. Priests could pray, adulterers could meet at windows, slaves could whisper together.

Or that's what the author reckons. If that's true, you could argue that what we today call insomnia is normal, is something that used to pass unremarked. I have no idea if this is true or not, and it's of only theoretical interest to the person who wakes tired and red-eyed, but it's an oddly intriguing idea.

I like the idea of that interregnum, that time away from the heat and the light and the eyes of priests and neighbours, purposive and vigorous instead of lying in the dark and staring at the ceiling. I know there is some intimate connection between light and mood - I know that light can be used to treat some severe forms of depression - the most famous is Seasonal Affective Disorder, or SAD. I also know that several of our guests, when we lived in the hills away from the city, so dark you could see nine of the Pleiades, could not sleep in our house - it was too dark, too quiet.

I suppose another reason that my thoughts are inclining this was is that the "sleep medication" zolpidem (sold over here and in the UK as Stilnox, in the US as Ambien) may be reclassified over here as a schedule 8 drug - subject to the same legal restrictions as morphine and methadone. I don't know about this. Zolpidem certainly doesn't help sleep in the way it is used by most people I know, but the more I find out about sleep and mood and cognition, the more complicated it is and the more questions I have.

I have some of the answers in a book on my desk. I have downloaded all four hundred pages of the ICSD DCM, the International Classification of Sleep Disorders Diagnostic and Coding Manual. This is to sleep what the DSM IV is to madness - or rather, what it is to sanity. It classifies sleep disorders, first into dyssomnias, parasomnias, those with medical, mental and other causes, and finally "proposed" (sleep disorders that are on the waiting list), and then fuirther, into hundreds of separate sleep pathologies. As far as I can see, they are listed in order of intrinsic horribleness.

For example: the dyssomnias include relatively common entities like narcolepsy and obstructive sleep apnoea, and the common-sense (stimulant dependent sleep disorder - if you take a lot of speed you don't sleep). It also contains the more unusual: altitude insomnia and food allergy insomnia.

The parasomnias mention impaired sleep-related penile erections and the alarming but hopefully not fatal "sleep related sinus arrest" - you go to sleep and your heart stops - presumably it starts again.

Amongst the "medical and mental" group are (unsurprisingly) African trypanosomiasis (the original sleeping sickness), but also the disorders of sleep that occur as the architecture of the personality is eroded - the insomnias of the various dementias, the slow derangement of Parkinsons Disease. You read about these conditions with a deep sense of - I don't know what, a yearning to offer some comfort to these people, a wish you could just do something. In fatal familial insomnia the part of the brain that permits sleep is scarred and stutters and fails. The ability to sleep is lost, these people can no more sleep than you or I can clench an amputated hand. The time between the last moment of sleep and eventual death is measured in months.

Anyhow. On that happy note I have to start seeing patients, almost all of whom feel and believe that they cannot sleep, haven't not been tired for decades. This means that parrots (and it's a damn interesting parrot) and religion and Tycho Brahe will have to wait until the next post.

Speak soon. Thanks for listening,
John


*No.

Architecture

My brother worked in a steel shed. A lot of the time it was loading steel onto trailers for the trucks to take away. They used to get the lengths of steel in - all kinds of steel, long tube and pipe and plate, merchant bar, that kind of thing. He'd pick it up - he used to drive the nine tonne crane, there was a nine tonne crane and a four and a half tonne crane, pick it up off the semis trailers with the magnetic crane and stack it, and next day trucks'd come in from the coast or the shipyards or the mining towns and my brother'd load them up and that'd be that.

On the days when there was no trucks he'd weld - twelve hour days in the pit, steel-caps and thick overalls and cracked welder's mask, forty four degree days.

He is more like our father - technically, his father - than I am. Dad worked in the mines in Kalgoorlie - nickel, copper, silver and gold. It was shift-work, the kind of things where he'd be gone in the early morning, come home to sleep in the afternoons. Mines are warm, but Kalgoorlie was hot, long days under the West Australian sun. The first story I ever sold to anyone was about him and mum in the days before the divorce, each pale-skinned and speaking their heavily accented speech, him the soft tones of the Dubliner, her precise German, him working two or three jobs and her at home with the kids and in the meantime trying and failing to work things out.

Dad worked, and my brother works.

Today I sat in an air-conditioned office and listened to people. In ninety minutes I saw two people and spent some time on the phone. With the two patients I saw I mostly listened, made a few simple decisions, offered the bare minimum of advice. I finished up at four thirty and drove home.

But tonight I am exhausted.

Let me explain.

The first patient is Mr Thames. Mr Thames speaks in a precise estuary accent, and frequently hesitates in his speech, as if seeking exactly the right word with which to express himself. The combination of his manner of speech, his fine, almost thin features, and his presentation (he is close to fifty, the very last of that generation who dresses up to see the doctor) combine to suggest some kind of refinement, almost a gentility in his character. If I am not careful, I find myself drifting along with this impression, treating him in a subtly different way from my other clients, assuming that he lives a life in accordance with these accidents of speech and birth, that he deals with life in the way that the lower classes imagine the upper classes do.

However, if I listen to what he is saying, things fall apart. Mr Thames is one of my most unwell patients. He is barely staying afloat. The waves are rising and he is clinging to things that are slowly sinking beneath him.

There is the issue of the benzodiazepines, the "anxiety" tablets that he takes "to help with sleep". He hasn't slept in three nights now. Doctors refer to the "architecture" of sleep, and it is a surprisingly apt metaphor - Mr Thames takes ten temazepam a night. He takes handfuls of diazepam, some off-white pills he buys from someone he used to work with, packets of over the counter antihistamines, can't go a day without topping up. If normal sleep has architecture, his is derelicted, a ruin, no stone upon another stone.

And the tablets aren't working like they used to, so he's been buying.

The other day he got frightened. He was at some guy's house, out in the southern suburbs - bars on windows, no streetlights, no trees, no jobs, hot and flat, dead lawns and boarded up windows. He was sitting on the edge of the guy's couch, trying to buy some alprazolam, and in the room - "not even in the corner, but in plain view, as far from me as you are" - rats ran unceasingly across the floor. The man himself scratched and picked at his skin as he spoke to Mr Thames, mainly due to the amphetamine psychosis but also because of what he described as "these fucking lice".

A tall man with a beard emerged several times from the kitchen, holding a butcher's knife, to stare at Mr Thames, each time seeming increasingly irritated by his presence, but each time returning to the kitchen to cut up meat.

When he got home he was so frightened by the experience he took all the tablets, fifty tablets in half a day, managed to get half an hour's rest.

I tried to go through the options for Mr Thames. We are forbidden to prescribe alprazolam to people purely as a treatment for alprazolam addiction, although it is possible that something like that may help Mr Thames in the very short term, forestall what may well be his death.

Having said that, whatever amount I prescribed would be inadequate within a month. His consumption is not copious, by our standards, but it is occurring on the background of considerable psychopathology. He drove here today (!), parked his car in the public carpark, asked three or four of the staff if that was okay, if the car was in anyone's way, had he done something wrong, he was very sorry. Anxiety is crippling him.

But everything is overlaid upon everything else. His dependency is overlaid on his mental illness. Behind the mental illness you can see the childhood events that helped make him who he is, details of his childhood, behind that, further back, you can even guess at his genetic makeup. It is quite possible that his GABAa receptor structure is subtly abberant. It is relatively certain that when he was six his father would beat him with a wooden rod for opening his eyes during prayer, and that his mother continues to attribute his illness to demonic possession. Beyond doubt, stretching back behind his parents are his grandparents, their parents, fuckups and freaks back to the Bronze Age.

There's so much going on it seems almost impossible to work out where to start, but in reality the choices are fairly simple. He is not detainable under the mental health act. He has no interest in referral to a psychiatrist, because the good psychiatrists won't prescribe him alprazolam and the bad psychiatrists aren't getting anywhere near him. We are slowly working through -

- I was going to say there we are slowly working through the relationship between his anti-anxiety medications and his anxiety, his sleeplessness and his sleeping pills, but I don't know about that. "Work" in some way implies progress, building something, the construction of something where there was nothing before, and I doubt that this is the case. There is too much damage done, not enough to build with, the foundation too riddled with doubt.

I don't know. I have not been able to express this adequately. Part of the reason I have decided to do psychiatry is that it may give me the tools with which to articulate some of these ideas, ways that I can understand and therefore help.

Anyway. After Mr Thames leaves my room, teary, drenched in sweat, I sink back into my chair. I know it's not the same kind of tired as my brother gets, or my father got - I've had that bone-deep weakness a few times in my life, enough to make me realize I can't do it for a living. But even if it's a less honest kind of tired, it's a significant one. In the mornings some times I punch the punching bag until I cannot raise my hands to my head - this is the same kind of thing, but it's brain rather than biceps brachii. In the same way that exhausted hands can't make a fist, for half an hour after seeing Mr Thames my brain can't articulate a thought.

And that's without the screaming schizophrenic or the heroin-soaked teen mother or the very very bad man with the easy, affable manner.

Anyway. As I write this other people are working. Tonight is tenth wedding anniversary dinner night - I'd better go get ready.

Thanks for listening,
John

Resus.

Hail,
Long time no write, and thanks for the comments. It's not that I haven't been feeling "writey", or that stuff hasn't happened, it's just that a lot has been going on. And you prioritise things, order things in your head, and usually when I do that now blogging is ranked relatively low.

However, I did read that there was an average, almost a natural, lifespan for blogs of about two years. I don't know if that's true, but it seems likely. I don't think it will be true for this blog, but to be honest I don't know. If it is, by that measure Stranger's Fever would be palliative by now.

I started this blog initially to write. I want to write, I've always written, and one thing I have tried to hammer into my head is the idea that you get better at writing by writing, like you get better at boxing by boxing. There is only so far that watching great fighters or reading books by experts can tell you, in the end you get better at boxing by hitting the bag and then getting in the ring, hitting and being hit, being able to do what works. Writing is exactly the same, but with groin punches and biting allowed, no breaks between rounds and a higher rate of traumatic brain injury.

Anyway, I started Strangers Fever in the hope that I would write down some stuff I could use for my "real" writing, and to that extent I think it has succeeded very well. The frequent writing (I think there's over three hundred thousand words here) has made me a better writer. I've written stuff somewhere in here that I'm quite proud of as it stands, rather than just seeing it as raw materials or rough drafts, and a lot of it will be going into the novel, whenever that happens.

But blogging, particularly pseudonymous blogging is about a lot more than producing better writing. Most people who wirte aren't looking to write a novel, they are doing something else - self expression, that need to shout out into the emptiness, that almost psychotherapeutic process of revelation of your deepest psychic fears - initially to nobody at all, and then to strangers who are, like you, safely pseudonymous.

I don't believe life-long psychotherapy is usually that helpful, and for the same reason I don't believe long-term purely psychotherapeutic blogging is that useful. And there has been an element of that in Strangers Fever, that shrieking into the dark, that "urge to purge" that I don't have any more.

Part of the problem is the therapy or something like it worked. There are worries - Sarah's pain is number one, of course - but these are open worries, things we are handling, not secrets scrunched up inside, misery masquerading as madness, that kind of thing.

Despite everything that is going on, I am so damn happy now. Large scale, randomised, double blind trials have repeatedly shown that Sarah is the best wife in the galaxy. My sons are perfect. My job is going brilliantly - yesterday I saw a man on venlafaxine and methadone, suspected and looked for and diagnosed the dangerous interaction between the two, sent him off to his GP with a referral letter that managed to mention both cytochrome p4503A4 and the triumphant return to power at the Federal level of the Australian Labor Party.

I am reading good books and listening to good music, in February I start part time at the psych ward and the director, to whom I have spoken, has read my CV and is eager to discuss how I got to psychiatry from the study of Holocene pollen fossils.

I have had a story accepted for publication in the top SF/Fantasy/Horror magazine in the country, I am writing my non-"Stranger's Fever" novel at the steady rate of three hundred words a day, my cats are sleek and well-fed.

I am slowly losing weight* and twice a week I go to muay thai classes where I get my bottom spanked by teenaged boys (I should put that as a title for this blog entry - that'd get the numbers up). This may or may not be an improvement on this time last year in judo ("the gentle art") where I was getting thrown on my head by teenaged girls - the boys are good, they hit hard and are hard to hit and everything, but grappling that girl was like trying to pin a greased weasel, and in the end, judo beats most other martial arts.

Anyway, sadly, and possibly boringly, there just isn't that much emotional trauma driving me at the moment.

So - what this means is that I am still going to try to write. If I wasn't as shy** as I am, I'd be contacting some of you and asking if you would mind if we corresponded emailingly, but since that is guaranteed never ever ever going to happen, I would still like to keep up this weird kind of relationship. And I still see interesting patients, read fascinating things, have things I want to say and ask about and so on. But I don't want to say I'll be writing stuff regularly when I'm going to be doing other things instead. I'll still be writing, but I'm going to try and promise and achieve weekly rather than daily.

See, I really enjoyed writing that post. I do love this when I do it.

Let's try Tuesdays. Every Tuesdays I'll post something. See how that goes.

Anyhow. Thanks for listening, and more (seriously) soon.
BDC

*Sadly, if I exercise as hard as I can for as long as I can as often as I can and eat frequent meals that total as little as I can stand, I lose weight. As everyone knows, it's not knowing what to do, it's doing it - I should be on the treatmill now, for example. It's not that interesting.

It actually gets slightly more interesting if you look one level higher at the cognitive and behavioural stuff, the economics (in the sense of "the choices you make") of diet and exercise. Someone suggested that people concerned about body fat try the "Blackmail Diet": in this case, I would write a large cheque, with the proviso that unless I weigh (insert number here) by (insert date here) the money will be mailed off to and organisation I despise (insert the various conservative parties of Australia here. Or preferably here) - with the expressed wish that this gift be publically acknowledged in some form.

I know, as much as I know anything, that I would rather gnaw my own pancreas out and then grate it into a salad than give those bastards a red cent. Seriously, you'd see muscles anatomists didn't know human beings had.

** I am in no way an expert, and am open to other opiniuons, but my current medical opinion is that this is largely wank.

John