12 May 2019
Above photo: Cute teenage girls enjoying a fruit smoothie and a selfie at City Mall St. John.
This has not been my favorite week here. The mid-term exam went smoothly, most of the students did well, and everyone learned something, myself included. Like the double meaning of grasp—I used it as “to understand” but one of the students understood it literally “to take ahold of”. I had a couple of questionable questions. Is putting a large, violent, intellectually disabled man with autism on 7 medications an example of “wishful thinking” or “polypharmacy”? Both. Admittedly, it was a pretty simple question, but I was making a point. Some of the students’ mistakes derived from losses in translation. Several of the students are caring for young children, so when the electricity went off the night before the exam they had to sit up most of the night and fan the little ones, who couldn’t sleep in the heat. Overall, however, they are beginning to understand Child and Adolescent Psychiatry.
We saw a 14yo girl who had a difficult birth, leaving her with Intellectual Disability. Four years ago she began to have complex partial seizures. A year ago she was switched from carbamazepine (an anticonvulsant), because it was no longer controlling her seizures, to topiramate. Shortly thereafter she began to have disruptive behaviors, auditory hallucinations, and paranoid delusions, although her seizures were controlled. She was then put on two antipsychotics at high dose, gained a lot of weight, and is somnolent. She doesn’t have language although she is bowel- and bladder-trained. Somewhere along the way a CT was done which demonstrated bilateral calcifications in her basal ganglia, her cerebral cortex, and her cerebellum. A presumptive diagnosis of Fahr Disease was made. Fahr Disease, epilepsy, and topiramate have each been associated with psychosis. And she is in the right demographic for the beginnings of schizophrenia. A perfect opportunity for us to use our critical thinking skills, which I have been drilling into the students. We’ll try to get her on a single antipsychotic and have the neurologists switch the topiramate to another anticonvulsant. I’d certainly never heard of Fahr Disease.
On the following day we saw another girl, a 6yo, who was developing normally with her motor, social, and language milestones up to 24 months. She then gradually lost speech and the use of her lower limbs and developed persistent stereotypical (not purposeful) movements of her upper extremities. She was a cutie and appeared to relate somewhat but clearly was very compromised. Her skull circumference was below normal, as is common with Rett Syndrome. Rett used to be considered a subtype of autism but 4 years ago its genetic origins were discovered. It was one of those rarities I read about in my Child Fellowship but then forgot, never having seen a case. This sort of thing happens in developing countries, where the most severely ill come to your office. In the US, they’d be seen at a child development center in a medical school. [On re-reading this, I realize we are in a child development center at a medical school and I’m the professor!] She’ll have a shortened life span, marked by disease progression and a massive burden on her parents. She’s getting kind care and is involved in physical therapy. We’ll monitor her every few months, helping the mother to manage her complications as they arise.
I took the students to lunch at Shan Yoe Yar, a lovely traditional restaurant, to celebrate seeing the exam in their rearview mirror. The Shan food was so good—-a soccer-ball sized meringue, browned on the outside, filled with a mix of seafoods and vegetables, yummy spicy shredded beef with intense garlic sauce, and two types of fish. One had a tamarind sauce and was heavenly. The waiter took lots of photos with our phones, as the students always love to do. Maybe the historic uncertainty of life here, with poverty, infectious diseases, natural disasters [Cyclone Nargis in 2008 killed 138,000 people!], and capricious military oppression, encourages making permanent records of good times.
Toward the end of journal club on Thursday, my nose began to run like a hose. I’ve had a sore throat, as well, for four days and feel yucky so I sit in my aerie and work, read, or watch the circus in Washington, DC. I have a huge smart tv with fast internet and cable service so I can immerse myself in electronic media all too easily. Especially the YouTube segments with Colbert, Trevor Noah, Seth Meyers, John Oliver and all the CNN talking heads. I was sneezing and dripping so much that I cancelled my language lesson, as well as supper with a friend. I feel passive and unproductive, having watched so much TV. Seeing all the maneuvering of the various factions in our capitol is like intense foreplay but with no actual delivery of the goods. I just don’t want us to look back and have taken a major misstep so that this destructive bigot gets elected for 4 more. The temptation is to react to his repeated provocations but then it, also, isn’t smart to let them simply wash over us. I trust Nancy to lead us—smart, tough, principled, and with years of experience. We cannot count on the ‘Pubs to defect, so long have they been in bed with him now, all damp from his near-constant golden showers, this man for whom incontinence is a fetish.
I vow today not to turn on the TV for 24 hours. One day at a time. Cold turkey is my way. A simple decision—-“No”.
I summoned Beethoven String Quartets this morning to lift me out of my pixel-induced sludge of mind. As soon as one began, I felt cleaner and more alert. Not narcotized, like some music can do. I have had the immense pleasure of hearing a lot of live classical chamber music in my life, especially when I lived in Boston and NY, but in Berkeley, Aspen, Marlboro, Tanglewood, and Bar Harbor, as well, and each time it feels like a small miracle.
Here’s the additional piece, after my cold and watching too much TV, that has me unsettled. I encountered three small young boys in my building when I came home Thursday from work. They were riding the elevator up and down. Two were dressed in monk’s robes. They got off the elevator and begged for money. When I refused, they begged for one of the mangos I was carrying.
I recognized one of the boys, who had harassed me a month ago on the street. I gave him a bit of money as one does to monks, but he wanted much more money and refused to leave an ATM enclosure where I was attempting to withdraw some kyat for the week. He followed me up the street, under my feet, demanding. I am certain that he has been physically abused, as he was fearlessly provoking me to do the same, which I resisted, of course. Children from awful home situations are often put into monasteries for care.
When I got onto the elevator on Thursday, one of the other boys held the call button so I couldn’t close the door. My blood was boiling but I restrained myself, using my foot to firmly pry him away from the button. Ten minutes later, putting away my groceries, my doorbell rang several times, clearly them. I didn’t answer. At 9 that night the doorbell rang again; it was a man with his wife and daughter, a tenant in the building, saying, “Keep the [main front] gate locked.”, referring to the boys who he had also encountered. He was visiting all the apartments in the building.
Talking with three young doctors about a project the next morning, one suggested that they were not monks. Street children will often get an old monks’ robe to legitimize their begging. Moreover, they said that burglars often use street children to case a target.
It isn’t a big deal, really. I am [relatively] rich, marked in a big city with a lot of poverty, and I’ve lived in high-crime cities in the US and Malawi. It’s just that the balloon of unreality with which I had surrounded myself suddenly popped and I must take notice. Also, that the repetition compulsion and the power of projective identification in a child is so powerful that I’d have to make a firm, conscious decision not to whack an 8yo hard, that he could arouse such strong feelings in me which run so counter to all I teach and believe, leaves me a little breathless. In touch with my humanness, I guess.
On Monday I’ll talk with the landlord to suggest: 1) a gate for my front door like all the other apartments lower in the building; 2) that he tell all the tenants, officially, that we are to keep the front gate locked.
A Psychiatrist in Myanmar 