[Above photo: Named the “Nuclear Catastrophe Overcome Pagoda” on a gilded sign beneath it, this pagoda demonstrates the prescience of the 12th century Bagan kings.]
10 November 2019
This is a 4 day holiday weekend, Tazaungdaing, in celebration of the end of the rainy season and the end of Kathina, when the monks are offered alms and new robes. Of course, it has been raining hard for the past 4 days (or nights). I heard an amazingly loud, live pop musical number half an hour ago. From my deck I saw a truck with a long flatbed transformed into a sound stage with two female vocalists and an amplified band parked on Anawaratha Street, 300 feet from my building. It has now moved on, suggesting the next few days will not be restful!
My wish to train and supervise mental health workers through UNICEF is getting closer to fruition, I think. My consulting fees are being discussed. Although I have retirement income and don’t need money to live, I still want to get paid. It feels right to be reimbursed for taking the responsibility of doing serious work. I can use the money to develop pet projects, like the national conversation on bullying in schools which I want to facilitate. It sounds rather grandiose to say that, yet it is possible since I am the only (seasoned) child psychiatrist here and now have some connections.
I’ve begun to consider settling here. When I think of living in rural Maine, sitting alone in a lovely cabin overlooking 3 feet of snow and Penobscot Bay for months on end in the winters or trying, somehow, to buy myself back into the Bay Area, very expensive, smoky and congested, I wonder what would I do? In the Bay Area I’d have friends to see and Seneca to consult with. In Maine I’d have my daughter, the natural beauty, and no crowding. The friends I have in Maine are generally through Linda and I don’t want to infringe on those relationships, But I don’t see a vital role for myself in either place. No grandchildren planned. I do not want to start a practice again, and don’t think I should, given the painful effect on patients of a therapist who dies or gets dotty. In Maine I could write, volunteer in schools, and get active in local politics, which might be gratifying.
However, here I can help develop something sustainable and of significant public value. It’s as if all the good work my teachers and supervisors and colleagues in the past have done with me can come to a useful fruition in a substantial way. It is also an easy hop to breathtaking and interesting vacation spots.
The downside is being away from friends and family, living in a land not my own, and having, finally, to learn Burmese. I’ll see how it goes on this vacation—I leave 8 days from now!—and decide based on that. And, of course, it isn’t an irreversible course, though I’ve noticed I am not actually getting younger as I’d hoped with this mineral water and quinoa diet. I don’t have a partner with me here, as I don’t there, but perhaps that isn’t the end of the world. I have friends in a variety of places. My mother was widowed at 48yo and lived alone cheerfully and productively for another 30. She did watch a bit of TV and drink some Jim Beam in the evenings but that hurt no one and was her coping strategy. I’m sure she would have been happier if my father had not died suddenly at 55yo, as I would be if our marriage hadn’t soured or if Linda and I had managed better. As to a land of my own, sometimes I look at America and our politicians and their constituents and think, I don’t know them. This is not my land. Who are these minions of stunted, fearful, hate-filled, self-entitled, anti-thinking people? I realize that is a description of only a slice of his base, but seeing those behind him at his rallies smile and shout approval as he dribbles his lies into the microphone chills me: mass hypnosis, as always acting against their own best interests.
Jose and Kelly and, later, Irene, with whom I drank beer and played pool at Byblos last night, were very enthusiastic about my leanings. I can make a community here if I wish, despite my being virtually everyone’s senior. And it feels so good to pass on some of what I’ve learned. Glancing at Erik Erikson’s later Stages of Psychosocial Development, I’m not doing so well with Intimacy vs. Isolation, very well with Generativity vs. Stagnation, and increasingly well with Integrity vs. Despair. I could see myself quite despairing, living alone in a lovely cabin in the woods in Maine. I think I may find more like-minded friends and colleagues here in this large community of helpers, in fact. And as much as I love the beauty and solitude of Nature, and I always shall, I am drawn to the thrum of humanity, messy and craven as it often is. We foul our own nests in the most careless way. If we see that in an animal—poop in their bedrooms, say—we are disgusted and think they are very low creatures. But who messes their nest, Planet Earth, more completely and permanently than we do?
At the conclusion of teaching my second day of the Short Course in Child and Adolescent Psychiatry for Psychiatrists 3 days ago, two of my students took me aside to present a case to me that they had seen that afternoon in clinic. An 11yo girl from a very remote village in a very remote part of Rakhine State was hospitalized here for mutism. Three months ago she had a fever for 3 days. Her father is an alcoholic fisherman and he and her mother had a loud argument, after which the girl fell to the floor stiff, with her eyes rolled up in her head. There was no incontinence, no loss of consciousness, and no clonic movements. She has no prior history of seizures. After that she became totally mute, except for a single sentence a few weeks later when she asked her mother for a pan thi (apple). Complicating the picture is her maternal uncle who lives with the family and is very close to the girl. Of note is that she has heard her parents argue many times in the past and often tries to get them to stop. She is an only child.
My students did a good job evaluating her but were anxious, intolerant of their uncertainty. Had she been sexually abused? Physical exam by the pediatrician demonstrated nothing and she communicated slowly with a nod or a shake of her head, denying abuse, as did the mother who seemed protective of her. How to formulate a management plan without a clear diagnosis, my students wondered? More searching for a diagnosis, I’d think.
I saw her the next morning with the students and she was a cute, alert girl. She seemed confused at following directions at times but it was not easy to know if her confusion was possibly language-based, since Rakhine differs considerably from Myanmar. She repeatedly refused to draw—a tree-house-person, a family member, anything. But when I drew she began to copy what I did with precision. She wrote her name in exquisitely beautiful Myanmar script. I did a mini-neurological examination and found—-eureka! She couldn’t move her left eye past the mid-point. Her mother had never seen it before and the girl hadn’t complained of double vision.
I thought, if her mutism is the consequence of abuse or of another psychological origin, perhaps if she becomes familiar with me she’ll be more cooperative. So I saw her again yesterday in the hospital with a junior pediatrician interpreting. I learned little new. I left her an empty copy book and a pen so she could write or draw anything if she wanted to communicate with me.
I’ll see her again on Monday before I go to Mandalay for the second Short Course. I think she has a forme fruste (attenuated) autoimmune encephalitis affecting her speech production and her eye movement. You may recall we saw two young girls in clinic within two weeks of each other with anti-NMDA receptor encephalitis and psychosis following viral infections. One responded promptly to prednisolone orally, the other didn’t. The second had been mis-diagnosed with childhood schizophrenia 9 months before and treated simply with antipsychotics. Patients with this disorder tend to do poorly, even dying, if not treated early. The girl from Rakhine is getting a CT scan with contrast in 3 days to look for a structural cause of her ophthalmoplegia.
So unless I gather evidence pointing clearly to a psychological etiology, when I see her on Monday, I’ll suggest a lumbar puncture and evaluation of the CSF for specific antibodies. As before, I may have to pay the $60 or so for the test or it cannot/will not be done.
All this keeps my brain alive, lets me demonstrate to the students how to live thoughtfully with uncertainty, and allows me to learn more about an illness of which I’d never heard until 6 months ago.
Alternately, I could sit in my cabin and watch CNN, curse the president and his crowd, and sip Jim Beam, although I prefer a single-malt whiskey.
I’ll still spend summers on the Island with family and friends.
A Psychiatrist in Myanmar 