My Body Is a Book of Rules. Elissa Washuta
You might think that means I am white. You are wrong. I have a photo ID card that says OFFICIAL TRIBAL above my official Indian grin—you know it’s a legit tribal ID because the photographer didn’t tell me to wipe the smile off my face. I suffer from gallbladder disease, of which Indians are at particular risk. I look vaguely Indian when I wear maroon and grow my hair long. Why can’t the one-drop rule apply to me? I don’t have just a drop of Indian blood—half my skull is Indian, or my two hands, one neck made of the same doomed substance as Tumalth’s.
University Health Center
University of Maryland
College Park, MD 20742
July 24, 2007
Campus Psychiatrists
Hall Health Center
Mental Health Clinic
University of Washington
Seattle, WA 98195-4410
To Whom It May Concern:
The patient requested her medical records as proof of her diagnosis and treatment as she prepares to move from Maryland to Seattle. We agreed that some of the contents of her medical records, especially notes on her mental state recorded by myself and her therapists, may be troubling to the patient. Therefore, I agreed to write this letter, which she can carry with her wherever she travels. These recollections have been gathered from my records and memories following our final appointment. Please use the following information as you wish.
The patient was first seen at the University of Maryland Mental Health Clinic in August of 2006 for symptoms of severe depression and anxiety. After completing a mood inventory upon her first visit, the patient scored 36 on the Beck Depression Inventory, indicating severe depression. We prescribed Lexapro.
The patient had consulted with a campus counselor in the spring of 2006 to deal with issues stemming from a sexual assault in January of 2005 (“Acquaintance rape”). The patient maintained a relationship with the young man despite his abusiveness. The patient exhibited no symptoms suggestive of PTSD. The patient discontinued counseling sessions due to concerns that her counselor failed to take her problems seriously (his primary suggestion for avoiding late-night meltdowns was to create an hour-by-hour schedule for evening activities [which, I agreed, was a flawed suggestion]).
We assigned her to one of our clinic therapists who, despite her training, cried when the patient detailed her wrung-out existence. The patient felt that the therapist’s miniature Zen rock garden stationed next to the patient’s chair, complete with sand and a tiny rake with which to move it around, was insulting to her emotional intelligence. The patient excelled in her English classes and maintained a 4.0 GPA.
The patient visited my office almost weekly while we worked to stabilize her moods. The patient was a regular fixture at the clinic. She saw me for drug adjustments more often than most patients see talk therapists. Although the patient’s knowledge of psychopharmaceuticals could have caused concern that she may have been “medication-seeking,” I instead saw this as a remarkable desire to understand her own drug regimen and possible future treatments. The patient was med-compliant to a nearly unmatched degree, exhibiting a complete willingness to improve her mental state through drug treatment. I disclosed to the patient that she was my favorite patient. Upon hearing this, the patient nodded and reported that she was only ever sane in doctors’ offices.
The patient exhibited no developmental problems. The patient had no family history of psychiatric disorders. The patient grew up in a loving family. The patient had many friends on campus. The patient reported no prior history of alcohol or substance abuse, but, on occasion, she came to my office straight from class, stinking of booze. When I asked her about it, she replied that she had come from her creative writing workshop, and I had to admit that some of the greats were drunks.
The patient’s mood gradually improved over the weeks following the use of Lexapro; however, following a setback, we added Wellbutrin for mood, low motivation, and daytime sedation. In addition, we added PRN Ativan for episodic anxiety.
The patient described nightly treks across campus to sit in a tunnel. The patient also described walks toward dangerous neighborhoods, cut short by fatigue. The patient described Ativan as somewhat helpful in cutting these “meltdowns” short by inducing sleep. The patient said that sleep would not save her forever. To hug her would have been unprofessional.
The patient’s daytime sedation and low motivation began to interfere with her studies. As a result, we added Ritalin as needed in order to allow her to complete her senior year schoolwork. Although insufflation is always a concern when prescribing psychostimulants to mentally ill patients, I had to disregard any far-out notions about what abuses she might be doing to the linings of her nostrils in favor of keeping the sheen on her GPA.
The patient witnessed an episode of elevated mood and confidence. As a result, we made a decision to discontinue Lexapro and add Lamictal. After a difficult month-long titration period, during which the dosage was increased in weekly intervals of 25 mg, the patient improved and returned to baseline affect and function.
Every other week of the winter, the patient crossed campus in maroon plaid flannel pants with the hems worn and torn and stained with snow. The patient collected hooded sweatshirts and wore them under a puffy coat. I did not notice that the patient had lost 35 pounds and become underweight until she informed me.
We began to reduce Wellbutrin with the aim of discontinuing it, as we continued to be concerned about the likelihood of the patient having a bipolar spectrum disorder. Her original diagnosis of unipolar depression was based on her answers to questions asking that she catalog her moods at that moment. This method of scoring darkness has its limitations. For example, it asks that the college students we treat—most of whom are paying tens upon tens of thousands of dollars to take classes they report to be “fucking lame” in order to earn degrees that often prepare them for prestigious unpaid internships—sit in a waiting room and circle numbers on sheets fastened to a clipboard that correspond to statements like, “1.) I don’t feel I am being punished. // 2.) I feel I may be punished. // 3.) I expect to be punished. // 4.) I feel I am being punished.” We add up the numbers and decide whether we believe the students feel hopeless. We decided that the patient hated herself. We diagnosed her with “severe unipolar depression.” While that was true at that moment, in other moments, she thought she was a rapper so famous she didn’t need the ability to rap. The patient’s apparent hypomania, associated with the use of antidepressant monotherapy, as well as known mood instability in bipolar patients resulting from antidepressant monotherapy (meaning, putting a bipolar patient on antidepressants will send them into ultradian [multiple cycles per day] cycling), led us to discontinue.
The patient’s level of composure and charisma during office visits made it difficult to believe she was so fucked up.
After Lamictal was increased to 125 mg, the patient’s mood regained stability. However, the patient developed a fever of 103, followed by a rash on the torso, upper arms, and legs, indicating that the patient may have developed Stevens-Johnson Syndrome, a rare and potentially fatal reaction. The patient would have been in the less-than-one percent of all patients on Lamictal who develop SJS.
The patient visited my office, stating that there was an emergency. After I closed the door, the patient lifted her shirt to reveal a rash on her stomach. The patient twisted her spine to show a rash on her back. For the first time, she cried in my office. “I know I have to stop taking it,” the patient said, “or I’ll die, but I don’t want to stop taking it.” I said, “I’ve never seen this before. Of all the people, I wish it didn’t have to be you. Dammit, why did this have to happen to one of my favorite people?” When I said “people,” I must have meant “patients.” I had to send the patient downstairs for a benadryl injection that would knock her out until she would be kicked out of the clinic at closing time.
We were forced to discontinue Lamictal.
We added lithium. Once again