Every December, for 18 years, her card shows up. And here it is again this year, amidst my stack of professional mail. Surrounded by piles of reprints, files of manuscripts in various stages of preparation, and varied forms of professional correspondence yet to be answered, I pause a moment from the harried bustle of my office life to open it.
I had been a psychiatric resident for all of 6 weeks that morning when I first met her. She looked like a scared rabbit—frightened and trembling. She had become increasingly paranoid over the last 2 weeks, feeling that people were following her and making fun of her. As we walked to my office—I remember that first interview so clearly—she sat down, her eyes scanning the small room for signs of danger. "Mrs. E," I said, "My name is Dr. Kendler. I am going to be your doctor now. I am here to try to help." I tried to sound calm, but inside I too was frightened. I was pretty new at this and still struggling with the power and strangeness of delusional thinking—with the concept that this wasn’t just "make-believe."
She was a woman with agonizingly poor self-esteem. In both of her psychotic episodes, the first symptom was derogatory ideas of reference: that people could smell a bad odor coming from her "private parts," that they would stare at her and comment about her terrible smell. As she slipped farther into psychosis, she became convinced that people everywhere—on the street, at her place of work, in the grocery store—smelled her and knew that she had "abused" herself.
She was hospitalized for 6 weeks, during which time I saw her daily, watching as the psychosis slowly melted to reveal a fragile, anxious young woman. For the next 2 years, the rest of my psychiatric residency, we met regularly—weekly at first and then monthly. We talked some about her "sick thoughts," but as time went on, more and more our discussions focused on her "real-world" problems related to her self-esteem: her tensions at work and difficulties with a domineering husband. It wasn’t easy for her to learn to stick up for herself, but she did get a little better at that over time with my encouragement.
As for me, I was struggling with the idea that although psychosis might be an illness, it happened to people with the same cares, concerns, and anxieties as the rest of us. I started my psychiatric residency with the feeling that my psychotic patients were "them." Over time, they become more "us," as the strange and even bizarre melted into the commonplace tribulations of life.
Sitting in my office, I open the letter. "Dear Dr. Kendler," she writes,
My husband retired last year. I am doing better. What do you think of the new medicines for schizophrenia? I am still on haloperidol. It seems to work fine after all these years. My doctor thinks I should try them. What do you think? How is your research going? How are your children? Is your oldest ready for college?
I remember clearly one Saturday night years ago. My wife and I had just finished dinner. The phone rang. It was Mrs. E—we had agreed that she could call me at home if things got bad. She never abused the privilege. She was frightened. "Dr. K, my husband and I had a fight on Friday. I am really upset. The sick thoughts are coming back bad. I went shopping downtown today and on the bus and in the stores everybody was making nasty comments about me. I’m scared. I don’t want to go back into the hospital. These are sick thoughts, aren’t they? They weren’t really making fun of me were they?" "Yes, P," I said, using her first name, "You remember our talks about this. Those thoughts are not real. But they come back when you are upset. How did you sleep last night?" "Not well." "P, we have had a few upsets like this in the last few years and we have always gotten through it OK without your having to go back into the hospital. I think we can do that now, too. You need to take it easy for a few days. Call in sick at work on Monday and come in to see me. How about 3 o’clock? Increase your haloperidol tonight before you go to bed. I’ll be around tomorrow if you need me." I felt her on the edge of psychosis, trying to resist the pull of her delusional thinking, drawing on the trust we had established over all those meetings. She was much better on Monday.
When my children were little, and I had moved to another city after my residency, she used to send them small presents each year, along with her cards. Knowing I was Jewish, one year she sent them both little stars of David on a chain. Although my children had never met her, she entered into their lives in a small way: Daddy’s patient who sends us little presents for Hanukkah.
I finish her letter and grab for my Dictaphone.
It is good to hear from you as it is every year. I am doing well—a bit too busy perhaps. My eldest daughter went off to college this year. I miss her and it has taken a bit of getting used to. The question you ask about your medicines is hard to answer. For some patients, the new medicines are better than the older drugs like haloperidol, but not for everyone. You have been using haloperidol for many years and it seems to have worked pretty well for you. You and your doctor will need to discuss this and make a decision together.
We are working hard to understand the genetic basis of schizophrenia, but it has been hard-going so far. I wish you and your husband the very best for the coming year. With fond personal wishes…
Thinking about how our personal lives can sometimes become entwined with those for whom we care, and how enriching that process can be, I put the Dictaphone down and turn to confront the pile of mail and other unfinished business before me.
Address reprint requests to Dr. Kendler, Psychiatric Genetics Research Program, Virginia Institute for Psychiatric and Behavioral Genetics, Department of Psychiatry, 800 East Leigh St., P.O. Box 980126, Richmond, VA 23298-0126.