Diagnosis From The Guts


He was just 18. He had been followed by child psychiatry with a diagnosis of depression. He had long refused to take any pills.  As far as this poor, agricultural county was concerned, I was just seeing him so I could bill MediCal and fatten up the county coffers. The previous psychiatrists had simply noted he was depressed, was not suicidal, and refused any participation in his own treatment.

He was a young man of few words, with a common Hispanic name.  He sat there and twirled one of his lush curls. It became pretty obvious he wasn’t going to give me a complete history.  He said he would never take pills, not ever. To his credit, he did say I could talk to his mother, if I wanted to, but he had to be in the room and hear what she said. Someone brought her to me, from the waiting room.  She spoke only Spanish; fine with me. I learned my Spanish mostly from my patients, who in that time and place could rarely communicate well in either Spanish or English. His mother was charming, really grateful that I wanted to talk to her. She kept complimenting my clothes and elegance. I told her it was all thrift shop.  I doubt she believed me.

His father was a laborer.  He was always angry at the patient.  Mom said she was angry, too.  He would not do anything to help either her or dad around the house. He got through school, barely.  He had no friends.  She had another son, a bit older, who did better in school, helped around the house; had even just started junior college and was going to do something in business.

There was something wrong with this son. I told her I would do all I could to help.

I asked her what her son did in his room all day. He had a little television; just black and white.  He had a keyboard.  He liked to turn off the volume and create his own soundtracks. He had never taken any music lessons.  Yet mother said that the songs he improvised sounded really good to her.

The young man in the office nodded, said he really liked playing his music more than anything else.

By now I had the diagnosis.  According to the Diagnostic and Statistical Manual (Fifth and current edition) it was “Autistic Spectrum Disorder.” When my brother and father were living on this earth, it was known as Asperger’s syndrome.  Before that, people so afflicted were known as “idiot savants,” for as much as they were challenged by communication and social skills, they had a field in which they were outstanding, with seemingly superhuman abilities.

Although my husband (and in this case, a therapist who became a sort of “fan”) would say I could make a diagnosis like this because I am a great psychiatrist, the truth of the matter is that I recognized this diagnosis because the behavior of this young man was treacherously close to that of people in my immediate family who had been very dear to me. I probably made the diagnosis by “feelings” more than by reviewing a list of diagnostic criteria in my head.  I always do that, and simply did it later in this case. I suspected the diagnosis before mother joined us, from the way I felt when talking to the patient.  The frustration of wanting him to talk more in the initial interview was exactly the same as the feeling I used to get talking to my brother of blessed memory, when I wanted him to say more.

The idea is that more diagnoses are made by “guts” than by the most well-thought out criteria.  I was in the military, looking at a military residency, when I heard a high-up officer in psychiatry talk about how he used his ulcer to diagnose personality disorders. Personality disorders are poorly adapted ways of getting along in life that cause pain either to the person so diagnosed, or to others who are found to have them. Personality disorders were a frequent cause of separation from the military.  This military psychiatrist separated many personnel from the military with such diagnoses, which had often been suggested by these folks’ direct commanding officers.

But back to “visceral” diagnosis.  The truth of the matter is that a diagnosis, although admittedly crucial to the medical way of treatment, is all too rarely as objective or scientific as we would like to believe that it is.

It was around World War II that Dr. Balint started these groups.  The idea was to help the doctor to connect better with the patient–mainly through recognizing their own patterns and prejudices.  While I was in the military, I took part in such a group, as all military psychiatrists of my level were ordered to at the time.

I will admit it felt a bit uncomfortable at first, but I did learn about my own style and how I made decisions.

Although I have never heard of anyone who voluntarily took part in such a group, the Balint Society is alive and well on the internet.

Me, let’s just say that my family was pretty crazy.  I never knew how much until I grew up and moved out on my own.  So it is no real surprise that I have a friendly, informal style with patients, and tend to treat them like family. It was also in such a group that I learned I am a “receptacle personality.”  This means that I am a relatively hang-up free personality, so other people seem to project their feelings on me, sometimes for reasons that have little or nothing to do with me.  Sometimes they have very strong feelings about me.

The psychiatrist consultant told me that I came on like somebody in charge, like a big old mother.  Lucky for me, most people love their mothers. Those who did not like their mothers would not particularly like me.

Don’t worry; I think I found them, a while ago.  There might be more.

Since then, I lost a bunch of weight.  Strangely enough, I seem to look like other people’s sister or ex-girlfriend instead.

Meanwhile. A therapist took my autistic young patient to a store that sold keyboards. His noodling around seemed simple, to the therapist. But I explained to the therapist that even “idiot-savants” can use a little instruction.  This kid never had any.

Since he would not take pills (or blood tests) under any circumstances, I could not justify keeping him in my care.

I told the therapist to send both him and mom to the Regional Center, a system in California that takes care of autistic folks, among other things.

I offered Mom my email, something I do for everyone who wants to keep in touch with me. I was not surprised to learn it would not work.  She was not computer literate, and knew nothing of email.  She was not literate in either English or Spanish, understandable given the extreme misery she had grown up in.

She asked me my first name.  “Estelle” is “Estrella,” meaning “star” in Spanish.  She said she would look at the stars every night, and think of me, and pray for my well-being, because I was trying so hard to give her son a second chance.

I started to blush and fought tears, because that kind of feeling is what it is all about.


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