In Extremis—Part One

The first time I meet Annie she’s in the middle of a handstand push-up against the wall outside her room. Balanced on her palms, her back and legs straight up, she pushes off without a sound. A cropped tee falls to her bra line, exposing the bone marimba of her ribs. Her tangle of auburn hair spills to the floor and she has the translucent skin I associate with redheads; an appealing scatter of freckles dusts her nose. She looks more like a gangly teen than the twenty-five years I know her to be.

“Hey,” she calls as I pass by. She rises on thin sinewy arms without missing

a beat, and huffs audibly as she lowers herself.

“Hey yourself.” I bend down and smile at her upside-down face.

“Could you help me? I need to shave my legs but someone has to watch me.” She sniffs toward the clinical desk. “They’re all too busy.”

“I’ll see how my morning looks and get back to you in a few minutes. You must be Annie.” It’s difficult to imagine her near death, but when I bend down to greet her I note the black sutures that bite into the separated edges of flesh on her left wrist. Her self-inflicted wounds are almost healed, but I walk away with a sense of Annie’s troubled life.

“You heard of me?”

I’ve spent the last hour immersed in her past, familiarizing myself with her case. Of course, I don’t tell her that. I’ve been in this field a year, on 3 East, a thirty-bed locked psychiatric ward in a hospital in Portland, Oregon. It’s a long road from being a student to any sense of competency. Annie’s presence on the ward is daunting; a twinge of stage fright comes back over me when I greet her. She’s challenged far more seasoned professionals than I.

Her chart is seven inches thick—the clinical equivalent of hundreds of thousands of frequent flier miles—distilled from dozens of hospitalizations and years of outpatient treatment. It’s hard to believe the upside-down, in-person Annie has burned as many bridges as hospital-chart Annie.

Joanie, a newly minted MSW, watches the monitors at the clinical desk; they illuminate the dark corners and heavy magnetic doors on 3 East and hopefully prevent assaults and elopements. She’s working her way out of the deep hole of college-loan poverty. We’re a subset of a weekend team that includes six therapists, five nurses, and five psychiatrists who rotate call. We have each others backs in emergencies.

“Any reason I shouldn’t help Annie shower?”

“Yeah,” Joanie says. Alan’s leading process group. Annie declined his invitation to attend. When process group is in session, everything else stops.

In report we discussed our strategy for working with Annie, particularly the need for consistency. Joanie and I are needed on the floor until Alan’s free.

Several patients are still asleep. Others start their day's journey in a slow drift upward from the strange and frightening dreams that come of psychosis and antipsychotic medication.

I check my watch. Breakfast has come and gone while I’ve gotten caught up on Annie’s history. I work back-to-back sixteen-hour shifts Saturday and Sunday. It’s Saturday morning, the start of my workweek.

Patients are admitted to 3 East in the acute phase of their illness, for assessment, stabilization, and referral.

Annie was admitted on Wednesday on a psychiatric hold for patients who are a danger to themselves or others—with a diagnosis of borderline personality disorder. Because her illness has been well documented over its ten-year course, we know what to expect—up to a point. Her overly bright greeting, the strenuous exercise, her mood of the moment could swiftly devolve into something dark and irrational.

She’ll manipulate staff, split us into enemy camps, hate us then love us—go from zero to sixty—in the time it takes her heart to beat twice. Her landscape is one of emotional extremes. She’ll rage at those who are supposed to love her, who did love her once, until it got too hard. She’ll rage at their abandonment. She’ll rage equally at those who try to hang onto her. We can expect her to try anything to fill the emptiness that—like an organ not visible on a CT scan but with an anatomical location vaguely near the human heart—comes with her disorder.

Beyond genetics, we recognize people by their personality traits—the quirks and behaviors that distinguish us from each other. Personality disorders—patterns of inflexible and maladaptive behaviors – manifest in adolescence and young adulthood later, when they harden and set. A parent or husband or sister may recognize something’s wrong, then ignore their own discomfort, frustration and intuition. They'll say it’s just the way she is. A borderline personality disorder sometimes forms in response to triggers like abuse or abandonment, real or perceived—but not always. The origins of the disorder are a mystery at its core.

Young women with Annie’s diagnosis often act out in the form of suicidal gestures. These days, BPD comes with websites that cater to self-cutters and teach innovative means of self-destruction. Annie shares creative nihilism the way best friends share clothing and secrets.

When group ends, I find Annie. I turn up the hot water for her shower and bring her a cheap, pink, hospital-issue razor. She comes equipped with a heavy white Turkish towel and her cosmetics kit, stuffed with miniature, free-gift-with-purchase samples of expensive toiletries.

Delicate white scars road-map her flesh; intricate patterns crisscross her arms, legs, stomach, trails of superficial cuts that dead-end before reaching the generous blood supplies of her arteries and deep veins. I hand her the disposable razor.

“Not a pretty sight, is it?”

“You look like my grandmother’s lace curtains.”

She giggles. The bathroom fills with steam, and I can’t see her reflection in the mirror. I’m uneasy and move closer to watch her stroke the razor easily up her long legs.

“These razors are the pits. They never get it all.”

When she arrives for lunch, she’s meticulously made-up and neatly dressed in designer jeans and a bulky Aran-knit sweater, just a pretty young woman sitting down to lunch on a sunny afternoon. She drinks a glass of milk, wolfs down two portions of Salisbury steak and gravy, two portions of mashed potatoes with butter and sour cream—all served on paper plates with plastic utensils—and four styrofoam cups of ice cream for dessert.

When I walk past her room fifteen minutes later, I hear her throwing up in her bathroom.

“Are you okay?” I interrupt the unmistakable gagging noise she makes as she purges her lunch.

"Yeah,” she calls. “I’ll be out in a minute.”

A stuffed animal rests on her pink pillowcase. She’s taped photos to the wall above her bed. One photo in particular catches my eye. I lean in to study it. Annie stands at the center of a group of people jammed together in tree-dappled sunshine. They pose for the camera, smile and wave happily to an unseen audience. Annie looks healthy and plump.

When she emerges from the bathroom her lips are raw. She smells of toothpaste and has changed into a hospital gown. She slumps down on her bed and clutches a shabby teddy bear.

I look from her image to Annie in her bed.

“Who are these people?” I ask. “How old are you here?”

“Sixteen. My mother, my brother, my uncle, my cousin, and my best friend.”

I search for clues in the photo. Nine years. What the hell happened to her?

“Do I have to act out to get a shot? I just want to sleep now.”

“I’ll bring you something.”

I inject a mild sedative. Now is not the time to discuss coping mechanisms. She skips dinner and sleeps through the evening. Sometimes that’s the best you can do for someone.

When I leave the hospital that night through the sliding glass doors of the emergency room, I inhale deeply. There’s a disconnect between 3 East and the rest of the world. It’s an occupational hazard. Inside, I lose track of time. I’m reminded it’s Christmas when cards and an artificial flame-retardant tree decorated with soft ornaments appears on 3 East.

Now it’s the end of February, still dreary and cold, a clear night with a dazzling array of stars and a sliver of bright white moon. Plumes of vapor billow from my mouth. I point my car home. Garlands of Christmas lights still grace houses and trees in Portland. I can’t decide whether my neighbors are lazy or crazy or both; maybe they’re depressed by our long gray winters or eccentrics who love Christmas lights. Whatever their reason, that night I'm grateful.

Copyright: Evelyn Sharenov

To be continued.