Chapter 1: Mother Nature's Son
On a warm day in early spring, two New York City cops and two EMS workers roll a gurney down the hallway, escorting a man to the entrance of Bellevues psychiatric emergency room, where I work. Lying on the stretcher underneath a white sheet, with a head of dirty blond hair beaded and dreadlocked, he is naked, sunburned, and screaming. I walk out to greet my new patient as the drivers hand me his paperwork to sign.
"Whatd you bring me?" I ask eagerly. I can see hes a live one. I love the live ones.
Over the shrieking, one of the EMS guys gives me "the bullet," the few pieces of relevant information when introducing a patient to a doctor: age, chief complaint, pertinent history. "This is Joshua Silver. Twenty-three. No significant medical history, no allergies, no meds. Also, he denies a psych history," he says archly, shooting me a look.
"And how'd he get to you guys? Who called 911?"
"NYPD called in an EDP." This is cop-talk for a psychiatric patient: emotionally disturbed person. "Hed taken off his clothes in Times Square and was parading around, barking like a dog. And growling," he adds.
This gets the patients attention, and he interrupts the driver to clarify, "It was my way of showing them that I was not an animal. I am not a dog!"
Barking and growling to prove he is not a dog? His logic is lost on me, but at least hes stopped yelling and started communicating.
"You can talk to me," I say, turning my full attention toward him.
"See, there were some guys from Nation of Islam preaching on the corner, and they told a woman who was arguing with them that she was just a dog - God spelled backwards - to which I took offense." He then explains to me, as he did to them, that all people are art." 'Thou art art, I told them. "Once you accept that all people, all objects, are art, you will live in heaven as I do."
"You know what, Joshua?" I ask, having decided it is time to move out of the triage area and into the locked area. "I think you and I should go talk about this inside." I want us to sit in an interview room so I can try to get some more history, and I dont feel like standing over him while he lies on a stretcher. I can already tell hes an admission and will need to be in the detainable area for patients awaiting beds upstairs.
I let EMS and NYPD know that they are free to leave, and I grab my new patient some hospital pajamas. I help him off the stretcher, wrapping his sheet around him, and walk him into the larger, locked part of the ER. As I escort him through the entrance, the door clicks definitively behind us, and I hope he doesnt notice that he is now locked in. Because he is naked, we can dispense with the contraband search, which is good. The search is often the point where people become uncooperative and agitated, ending up restrained and medicated.
Prior to entering the detainable area, a patient must remove his belt, shoelaces, rosary beads - anything that can be used to hang himself or choke a fellow patient. Inevitably, the patient will insist that he is not suicidal or dangerous, but it doesnt matter; these items are not allowed in the detainable area. Neither are cell phones, crack pipes, backpacks, knives, pens, wallets, and the list goes on. The patient has to give up just about everything along with his freedom.
Luckily, Joshua is oblivious. I show him to the bathroom where he puts on the pajamas quickly. I alternate between keeping an eye on him and setting up the interview room. There are several windowed rooms within the detainable area, each with a desk and two chairs. I put my chair closer to the door. As we settle into our talk, the first thing I notice is that although he is disheveled, he seems well-educated with an impressive vocabulary. He tells me he has written a twenty-eight-page manuscript, which he calls a prose-poem, based on his newly embraced credo that everything is art. He is hoping to reach millions of people by delivering his manifesto on the Howard Stern show on K-ROCK, a radio station in the city.
"I am a holy man," he tells me, explaining how his writing has elevated him to this level. "I feel like King Arthur in a tower of Babel." He is hyper-verbal, spewing non sequiturs. I try to keep up with him, playing follow the leader, as if we are hopping from rock to rock in a rushing stream, but he is pulling far ahead of me. Eventually, I have to tell him hes not making a lot of sense.
"Joshua, you need to slow down. I want to understand what youre saying, but its difficult for me. Im focusing on the illogical connections that youre making "
It sounds like "theological connections" to him, and his smile beams; hes pleased that Ive grasped his religious message. I dont bother to correct him.
Being preoccupied with religion is a classic manic symptom, and mania is the better-known half of manic depression, now called bipolar disorder. In a manic state, people have less desire for sleep; they will talk more, create more, do more. Commonly, bipolar patients get hyper-religious in their newfound frenzy and sometimes end up on a street corner and then a psych ER explaining that they are Jesus or the Messiah, or that theyve discovered a new religion. Theyve been touched by the Lord who spoke to them. Theyve had a vision, an epiphany, and they want to share it with the world. Their grandiosity can be charismatic and alluring. Religions and cults are formed around this kind of energy, and Im happy to warm myself by Joshuas fire during the interview.
In March and April, our ER becomes crowded with manic patients. For many bipolars, there is a seasonality to their symptoms. Just as more people get depressed in the winter months, increased exposure to bright sunlight can elevate moods. Also, the air is heady with religious themes during spring, when Easter and Passover coincide. The resurrection is reenacted in the budding trees and sprouting flowers, miraculously coming to life where once lay a blanket of snow. We get multiple Jesuses in the ER this time of year.
Joshuas pressured speech is another sign of his mania. It rambles hither and yon, like a butterfly dancing merrily among the flowers, setting down briefly on the themes of religion and art as if they were particularly colorful blossoms. I try to join him in his wordplay, to engage him gently in the hopes of learning more about him: where hes from, where his parents are, and whether hes stopped his medication, which is a good bet. Most of the manic patients who come through our doors have gone off their meds. The mood stabilizers have significant side effects, and people are often resentful about having to use them. Also, mania usually feels better than being medicated, at least for a while. Its a bit like surfing, knowing it has to end with the inevitable wipeout, but loving the balancing act required to keep it going.
Most of our patients battle with their need for medications. When they start to feel better, they abandon their treatment plan, thinking theyre cured. Even if they know theyll get sick again, they hate taking the pills so much that they stop anyway. Coming through our doors is a painful and humbling lesson in how to manage their illness.
"Joshua," I begin yet again.
"I fought the battle of Jericho."
"Ive heard that about you, yes." I smile. "Are you from Jericho?" I ask earnestly.
"No, I dont think so."
"Or maybe a town near there? You took a bus to New York City from where?" I ask. "Can you tell me where your parents live? Is there anyone who might be worried about you, who doesnt know where you are?"
A town near Jericho? What the hell am I thinking? Ill tell you: I am trying to meet him where he is, to work within his delusions and focus on whats important to him, and then gently lead him out to where I am, in reality. This is one definition of psychotic - broken with reality. He lives in a dream, but his hallucinations and delusions are as real to him as the movies we star in while we sleep.
Despite my coaxing, I cant get anything useful out of him. I want to find his parents because I need to talk to someone who knows him to learn whether hes been sick like this before. And I want to let them know that hes been found. Ive made dozens of phone calls to parents of the bipolar kids who end up on our doorstep. We get plenty of "first breaks" at Bellevue, the first episodes of psychosis that often herald the arrival of bipolar disorder or schizophrenia. They tend to occur in the late teens or early twenties. This is when the brain is pruning back and reorganizing connections made throughout adolescence, and also when everything is getting more challenging: starting college, joining the army, traveling. Sometimes, during these phone calls, I hear about how bright and promising their children were before they got sick. Other times, when its not the first break, but the latest in a long series of them, the parent on the phone is terse and angry, burned-out, tired of being woken up in the middle of the night to answer the same questions from yet another psychiatrist. In many ways, thats easier for me to deal with than the heartbreak of talking to the "new" parents, giving the first diagnosis, gingerly explaining the illness and its treatment, knowing as I do that they may be in for decades of calls from ER docs.
But tonight there is no phone conversation with the Silvers. Joshua wont even acknowledge that they exist, and I have nothing to go on but his manic ramblings. He tells me hes come to New York City with three dollars in his pocket and nowhere to stay. Knowing no one in the city, he made his way from the Port Authority bus terminal to the K-ROCK radio station at five a.m. in order to spread his message. When I first started my job at Bellevue, I heard the Port Authority referred to as The Port of Atrocities, because EMS brought us such sick people from there. That name stuck with me throughout my tenure at the hospital.
Joshua continues, chronicling the events of his day. After K-ROCK turned him away, he spent the rest of the morning sleeping in Central Park. Later in the afternoon, the police in the park told him to move on, and gave him a tip: Try hanging out around Forty-Second and Broadway. Wandering around Times Square, he happened upon some teens entertaining the tourists by playing drums on overturned white plastic buckets. He danced for them, and the tourists threw him money and took his picture.
"You know how theres cops there on horses? They let me pet the horses; they seemed cool about me touching the animals, and the tourists took my picture again!" He seems impressed that hed become a tourist attraction himself.
"Well, werent you naked by then?" I remind him.
He admits that he must have been by this point, but then begins to digress into a tirade against photographers, who, instead of living life and immersing themselves in their surroundings, only interact superficially by documenting the scene.
"You may have a point there," I offer. I think of my boyfriend the photographer whom I confronted with exactly this accusation not so long ago.
My patient perceives me as a friend and ally because I am aligning with him, chatting agreeably rather than asking the standard annoying psychiatrist questions. Theres no need for those as far as Im concerned - hes a definite admission. The only is whether I can get him to sign in voluntarily or will have to fill out the 9.39 paperwork for commitment.
The criterion for a 9.39 is danger to self or others, or an inability to care for self. If a patient doesnt fit this narrow definition, he needs to sign in voluntarily. A frustrating situation often develops in a family when a patient clearly needs psychiatric help but is unwilling to agree to a hospitalization. In Joshuas case, I can probably justify the danger-to-self scenario. He cant fend for himself while hes psychotic like this: Hes on the street with three dollars in his pocket - that is, when hes got his pants on - eating and drinking nearly nothing.
Could severe dehydration and low blood sugar be affecting his behavior? Is he high from LSD or PCP? My money is on mania, the "working diagnosis," but its my job to second-guess myself. If its drug-induced, hell come down in a day or so, but the mania wont de-escalate that rapidly. I can ask the nurses to obtain a urine sample to be tested for PCP - phencyclidine - a tranquilizer called Sernyl, once FDA-approved but now illegal. When people are high on PCP, they frequently disrobe and run amok. There is a saying among toxicologists that "naked running is PCP until proven otherwise." Since Joshua presented to the ER naked and disorganized, I figure I should at least send for the test.
If I could just talk to his parents, Id get a sense of his history - whether hes been depressed or manic before, and what meds work best for him. Of course, he wont offer me any telephone numbers for his family, only for K-ROCK, a number he knows by heart. He still wants Howard Stern to broadcast his manifesto.
I push forward on my chosen tack: schmooze-fest. I tell him I admire his theory that people are art. I share his appreciation for the perfection of all he surveys, of the complexities and magic in the world around us. Like being high on hallucinogens, mania can provide a sense of wonder and awe at the realization of how the universe works. Its easier to access the macro, to pull back and see the big picture. Often there is a feeling that "everything is connected," a realization in common with experiences on psychedelics and with mystical religious epiphanies. There are likely neurochemical similarities between the mystical, psychedelic, and manic states.
At Bellevue, I am repeatedly shown the big picture, taught that there is more than one way to look at just about everything. When I open my ears and mind to the "ravings of a madman," Im reminded to pay more attention, to Be Here Now. Everywhere we choose to see it, the world is full of splendor and wonderment. Ill never forget the manic teenage boy who tapped my shoulder in the detainable area, excited to explain to me that, "Were part of this huge experiment. All of us are under one microscope, being observed and studied. You know where the eyepiece of the microscope is?" he asked me, his pupils dilated with enlightenment. He pointed to the ceiling, "Its what you call the sun."