Although it’s common, the medical profession does a dehumanizing disservice to patients when it defines them by diagnosis, particularly anyone diagnosed with a mental illness.
Of course, the “Gall Bladder in Room 3” will probably be just fine, whereas the “Borderline in Room 7” is likely to be discharged with the same issues that brought her to the hospital in the first place. And it’s like a virus: patients often define themselves by their diagnoses as well. You’re more likely to hear "I’m a paranoid schizophrenic" than "I’m a college student and sometimes I hear voices" – the already fragile psyche stigmatized by itself.
From her records I learn that A. defiantly embraces her diagnosis. On a limited playing field, she takes pride in being the best at something where few seek a trophy. It has its own perverse logic. She derives her identity from being "a borderline" and sees herself as a teacher of other borderlines.
BPD effects approximately two percent of the general population; 10 percent of outpatient and 20 percent of inpatient clients meet the diagnostic criteria. Of those diagnosed with BPD, 75 percent are female and A. is one of them.
“I flunked DBT,” she brags during intake. DBT – Dialectical Behavior Therapy, an offshoot of cognitive behavioral therapy – is the most effective treatment for someone as non-committal as A. is to life’s infinitive, "to be." It teaches basic skills, skills needed to stay alive, like how and when to breathe, how to walk step by step past disaster.
A. arrives on 3 East following several suicidal gestures, a smorgasbord of passive and aggressive attempts at self-annihilation. The serendipitous arrival of a friend usually thwarts her plan. This last time she upped the ante. She swallowed barbiturates, then passed a razor across her left wrist. When she changed her mind, when no one came, she called 9-1-1 and left the phone line open as she spiraled down into unconsciousness.
It's my second weekend with A. She invites me into her room and collapses onto her bed. I pull up a chair. Her features are gaunt and distorted by crying. Her chart indicates she’s down six pounds from a week ago. There’s a cotton ball taped to the antecubital space of her left arm, from the morning’s blood draw. Purging destroys fluid and electrolyte balance. It can lead to seizures and cardiac arrest. A phlebotomist arrives daily to collect a tube of A.'s blood.
Her nightstand is a mess. Sticky remains of last night’s juice smear its surface. Used tissues dry into stiff white clots. An open composition notebook invites snooping.
“How was your week?” I ask her. She wants me to ask her.
“Just awful. If I can’t get out of here, I don’t know what I’ll do.”
Is that a threat? Certainly she can make the connection between her suicide attempt and her hospitalization. Does she really imagine we’ll open the doors and let her out?
“Sounds like you feel pretty hopeless,” I say. Although I really want to know about her week, I have stage fright; my voice sounds thin and practiced. A. spots my insecurity and pounces.
“Don’t talk to me like that,” she snaps, then starts to sob.
I had it coming. “Like what, A.?”
“Like a nurse or therapist, whatever.”
“I am a nurse. How do you want me to talk to you?”
“Like a friend.”
“I care about you; I want to know what’s going on; that’s why I asked.” How easily she walks over my carefully constructed boundaries. “I don’t think you’re ready for discharge, if that’s what you’re asking. What would you do if you got out of here tomorrow?”
She stops crying. “They’d find me dead with a needle in my arm.”
“Well, now, that’s kind of dramatic. And not likely to encourage me to advocate for your freedom.”
“I’m nothing if not dramatic.”
“OK, you got me. So short of finding you dead with a needle in your arm, what do you want to do? What happens after here?”
“I want a life. Like everyone else. I deserve it.”
“Of course you deserve it, but we work for the lives we want, and sometimes we don't get them. Swallowing pills and slashing your wrists doesn’t tell me that you want a life,” I point out. “It tells me you’re ambivalent.”
“Yeah, I get that.”
We sit quietly for a few minutes, then I stand to go.
“Evelyn…”
“Yes?”
“Do you have to be so neutral?”
“A., you know the limits of our relationship. Maybe a shower and some fresh clothes, clean up your mess. You might feel…”
“Go to hell.” There was something animal in her voice, growling, cold, and hungry.
I keep walking. Neutral? When I think of A. I feet weary and sad. I want to grab her by the shoulders and shake some sense into her; definitely not neutral.
I’m surprised when A. makes it to my transitions group in the afternoon. I designed it for patients nearing discharge. It covers basics – your first steps after you walk out of the hospital into the daylight, where you’re going and how you’ll get there, how you fill your prescriptions. And more complex issues, like staying out of the hospital, and access to housing and health care – how to keep from falling through the cracks of the bureaucracy. I teach our most vulnerable citizens how to negotiate a draconian system.
A. comes up to me at the end.
“I liked your group. I learned something from it.”
“Tell me.”
“That it has nothing to do with me.” She smiles and walks away.
The doctor sees her on rounds, speaks with her briefly, jots some notes, increases her Ativan, an anti-anxiety medication. Although his gaze holds you long after you admit you hate your mother, his approach is pleasantly straightforward. Many patients find this combination abrasive. He’s not A.’s psychiatrist, but he’s well versed on her case – everyone who works on 3 East is familiar with A.’s story.
We tweak her medications. Until new and better medications come along, that’s all we can do. A.’s been on anti-depressants, atypical antipsychotics, mood stabilizers, anti-anxiety medications, and sedatives. They relieve some of her symptoms and temporarily improve her quality of life. But there are no medications for the personality like there are for germs. One therapist, in complete frustration, suggests that A. needs a "personality transplant."
Later in the evening, Joanie calls me. Her voice carries from A.’s room down the long hall to the community room. She’s at A.’s side when I arrive. A. is tangled in a mess of sheets and hospital gown. Her eyes roll up in her head, her back arches and she thrashes uncontrollably, half off the bed. She’s unresponsive and white froth turns blood-tinged when she bites her lip. It looks like a classic grand mal seizure.
A. experiences these after particularly violent episodes of purging. Alan gets there just after me. We catch her before she hits her head and carefully lower her onto the floor.
It’s over in an eternity of moments, and then A. is still. Her blood pressure and pulse are normal; her breathing is unlabored, but she’s pale. I give her low-flow oxygen through nasal prongs for a few minutes and notify the physician. An hour later, she’s awake but sleepy.
“What happens when I have a seizure?” she asks. Do her lips turn blue? Does she froth at the mouth? Do her eyes roll back in her head? Do her arms and legs jerk?
I think about it.
“It’s pretty scary looking,” I answer.
I help her clean up and change into flannel pajamas. I think about neutrality and professional boundaries. Then I sit down with her and describe her seizure in detail.
She sits cross-legged on her bed. A tiny reading lamp clipped to her notebook cast a halo of warm light around her. When I leave for the night, she’s writing it all down.
Evelyn Sharenov
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