The Clock

Susannah Cahalan describes her lost month of madness only through bits and pieces of what she remembers, videos taken in the hospital, and synopses of events from her friends and family.

Cahalan is admitted to the epilepsy unit of the NYU Langone Medical Center on March 23. She is set up in a room that is monitored by cameras, in order to keep surveillance of seizures and epileptic episodes. Immediately after admittance, Cahalan begins to experience symptoms of Capgras Syndrome.

(Capgras Syndrome: defined as a delusional condition in which a patient falsely believes someone, usually a close friend or relative, has been replaced by an imposter.)

Cahalan's increased paranoia initiates the first of her escape attempts. After Cahalan's first neurological exam after her admittance to the hospital, Debra Russo, an attending neurologist in the epilepsy unit, concludes two possible diagnoses: "First presentation of bipolar, versus postictal psychosis" (81).

(Postictal psychosis (PIP): psychotic behavior following a cluster of seizures; can persist for as little as 12 hours or as long as three months.)

Following Dr. William Siegal, Dr. Sabrina Khan is the fourth doctor to join Cahalan's medical team. After assessing Cahalan, who tells Khan that she has multiple personality disorder, Khan concludes that  on a scale from 1 to 100 of Bipolar I mood symptoms, Cahalan is a 45 (which translates to "serious symptoms"). Khan suggests that Cahalan is assigned a body guard to prevent future escape attempts (85). Dr. Ian Arslan is the fifth doctor to join Cahalan's medical team, and he, too, concludes two possible diagnoses: postictal psychosis and schizoaffective disorder.

(Schizoaffective Disorder: a condition in which a person experiences a combination of schizophrenia symptoms- such as hallucinations or delusions- and mood disorder symptoms, such as mania or depression.)

After her third escape attempt, Cahalan is threatened to be moved from the hospital to "a place that won't have [the same] level of care" (91). Dr. Russo also changes the primary complaint in Cahalan's daily progress from "seizures" to "psychosis and possible seizures" to just "psychosis" since she had not had a seizure since she was admitted to the hospital (91). In addition, Dr. Russo adds a new line to her progress note:

Continue 1:1. Transfer to psych if psych team feels this is warranted. Psychosis management per psychiatry, appreciate input.

After being in the hospital only four days, doctors six, seven, eight, and nine join Cahalan's medical team: an infectious disease specialist, a rheumatologist, an autoimmune specialist, and an internist. Cahalan continues to deteriorate physically, but her psychosis does recede somewhat. Due to Cahalan's newfound ability to fully cooperate, the doctors decide to perform a spinal tap. 

At the beginning of her second week in the hospital, Cahalan begins to experience new symptoms:

"My mother had arrived midmorning to find that my slurring of words had worsened so considerably that it was as if my tongue was five sizes too big for my mouth. . . My tongue twisted when I spoke; I drooled and, when I was tired, let my tongue hang out of the side of my mouth like an overheated dog; I spoke in garbled sentences; I coughed when I drank liquids, which required that I drink water out of a cup that dispensed only a tablespoon of liquid at a time; I also stopped speaking in full sentences, moving from unintelligible ramblings to monosyllables and sometimes just grunts. . .I was also making constant chewing motions, not unlike the lip licking in Summit the week before. And now I was making weird grimaces too. My arms kept stiffening out in front of me, as if I was reaching for something that wasn't there" (106-107).

Cahalan's spinal tap shows elevated levels of white blood cells, which indicates possible infection or inflammation. Her blood test from the CDC, however, comes back negative for all of the following:

• Lyme disease, often caused by tick bites
• Toxoplasmosis, a parasitic disease usually carried by cats
• Cryptococcus, a type of fungus that can cause meningitis
• Tuberculosis, which affects the lungs
• Lymphoreticulosis, or "cat scratch fever"
• Sjogren's syndrome, which affects the glands that produce tears and saliva
• Multiple sclerosis, which harms the fatty layer of myelin that sheaths neurons
• Lupus, a connective tissue disease
• Scleroderma, a disease of the skin

After the negative test results, as well as the resignation of Dr. Siegal from Cahalan's case, Dr. Najjar joins Cahalan's team. Dr. Najjar does not believe the schizoaffective theory, and he suggests another spinal tap and the administration of an infusion of IV acyclovir, an antiviral drug. The virus panel comes back negative for herpes and HIV, but this indicates the possibility of an autoimmune response. Dr. Najjar has Cahalan administered with intravenous immunoglobulin infusions, which are serums of antibodies that attack invading pathogens. Dr. Najjar is also the first of Cahalan's doctors to suggest the presence of catatonia, which is caused by a misfiring of neurons in the brain and is characterized by absence, inability, and non-behaviors: muscle rigidity and fixedness of posture, immobility, refusal to eat or drink, mutism, impulsivity, rigidity, etc. Another spinal tap reveals an even higher white blood cell count, which indicates that a part of Cahalan's brain is definitely inflamed. A few days later, Dr. Najjar finally appears to give Cahalan a neurological assessment. After asking Cahalan to answer a series of questions and perform certain tasks, Dr. Najjar asks Cahalan to draw a clock. With much difficulty, Cahalan completes her drawing: 

Cahalan's drawing proves that the right hemisphere of her brain is impaired. The drawing answers many other questions; it "explains the paranoia, the seizures, and the hallucinations. It might even account for [her] imaginary bedbugs, since [her] 'bites' occurred on [her] left arm" (133). Dr. Najjar concludes that the inflammation of Cahalan's brain is the result of an autoimmune reaction caused by her own body. 

"Her brain is on fire...Her brain is under attack by her own body"(134).

Dr. Najjar insists that a brain biopsy is necessary to identify the true extent of the damage. The results of the brain biopsy confirm that her brain is inflamed. Cahalan is set on a rigorous regime of corticosteroids to help reduce the inflammation, but her condition seems to worsen. During this time, Dr. Najjar has blood samples from Cahalan sent to the lab of Dr. Josep Dalmau at the University of Pennsylvania. Four years earlier, Dr. Dalmau had discovered a rare autoimmune disease called anti-NMDA-receptor encephalitis. 

(Anti-NMDA-receptor encephalitis: an autoimmune disease in which antibodies are generated against NMDA receptors and go on to attack theses receptors where they are most highly concentrated- in the brain. NMDA receptors are vital to learning, memory, and behavior, and they are a main staple of brain chemistry (149). Receptor antibodies attack these NMDA receptors and inhibit them from sending and receiving important chemical signals.)

Cahalan's test results come back positive for anti-NMDA-receptor encephalitis, making her the 217th person ever diagnosed with the disease. Her doctors set her on an aggressive treatment of steroids, IVIG treatment, and plasmapheresis in order to reduce the inflammation and reduce and flush out the antibodies. On Saturday, April 18, after 28 days in the hospital, Cahalan is finally discharged.

Susannah Cahalan's Month of Madness:https://www.youtube.com/watch?v=Najj0aVLJwU

Crazy: Part II

After Susannah Cahalan's extreme epileptic episode, she regains her consciousness to find herself in a hospital emergency room. Despite the hesitations of her family, as well as manic mood swings she experiences in the ER, Cahalan is discharged from the hospital with the suggestion to visit a neurologist as soon as possible. After being notified by Stephen, Cahalan's boyfriend, about Cahalan's seizure and ER visit, Cahalan's mother and stepfather decide it best that she live with them so that they can take care of her. Cahalan eventually complies after much resistance.

Though while at her mother's house she avoids most calls, Cahalan does talk on the phone to a friend whose mother, a shrink, believes that Cahalan has bipolar disorder.

(Bipolar Disorder: noun; any of several psychological disorders of mood characterized usually by alternating episodes of depression and mania.)

The thought of possibly having bipolar disorder is actually comforting to Cahalan, who is relieved that she can finally put a name to what plagues her. Her mother and stepfather, however, are unconvinced and insist that Cahalan revisit neurologist Dr. Bailey. After a basic neurological exam and questions, Dr. Bailey concludes that he believes Cahalan is simply "partying too hard, not sleeping enough, and working too hard" (50). He writes her a prescription for Keppra and tells Cahalan's mother to make sure she doesn't drink. 

After the visit to Dr. Bailey, Cahalan visits psychiatrist Dr. Levin. When Dr. Levin asks Cahalan why she is there, Cahalan immediately asserts that she is bipolar. Dr. Levin's field notes from Cahalan's visit:

"Said she had bipolar disorder. Hard to conclude. . . Everything is very vivid. Started in last few days. Can't concentrate. Easily distracted. Total insomnia but not tired, not eating. Has grand ideas. No hallucinations. No paranoid delusions. Always impulsive." (52)

Dr. Levin concludes that she believes Cahalan is experiencing a "mixed episode".

(Mixed episode: noun; defined by symptoms of mania and depression that occur at the same time, or in rapid sequence.)

Dr. Levin writes Cahalan a prescription for Zyprexa, which is an antipsychotic used to treat mood and thought disorders. After the psychiatrist visit, Cahalan's mother calls Cahalan's younger brother to inform him that his sister had had a seizure. After some discussion, they both conclude that they do not believe Cahalan to be an alcoholic or bipolar.

Later that same night, Cahalan has what she believes to be an "epiphany" and decides that the Keppra prescribed to her by Dr. Bailey was the cause for her "insomnia, forgetfulness, anxiety, hostility, moodiness, numbness, loss of appetite," despite the fact that she had only been on the drug for 24 hours (54). She hears a voice that demands she get the Keppra out of her body, so she forces herself to throw it up. The next day, she writes the first of many random Word documents that serve as her temporary diary through this time period and illustrate her scattered and erratic thought process:

"Basically, I'm bipolar and that's what makes me ME. I just have to get control of my life. I LOVE working. I LOVE it. I have to break up with Stephen. I can read people really well but I'm too humbly. I let work take way too much out of my life." (55)

Cahalan has another seizure.

Cahalan's thoughts and behavior become increasingly erratic and paranoid while at her mother's house, and she decides to spend a night with her father. While waiting for a taxi with her father and stepmother, Cahalan panics and insists she doesn't want to go. They get her into a taxi where she screams that she is being kidnapped. After dinner at her father's house, Cahalan experiences a series of hysterics that end with Cahalan making her father cry. When she goes to check on her father, she believe that she hears her father, in another room, mercilessly beating and then killing his wife. 

The next morning, Cahalan's parents take her to the New York University Langone Medical Center where she is to be monitored for 24 hours in the epileptic unit. After getting coffee, Cahalan has another seizure. The last thing she remembers before losing consciousness is her mother yelling, "She's having a seizure!" and three doctors running toward her.  

In the next month, Cahalan explains that she only remembers bits and pieces, mostly hallucinatory, from her time in the hospital. This seizure marked the point where Cahalan says she was "gone." This seizure was the beginning of her lost month of madness. 

Crazy: Part I

In early 2009, Susannah Cahalan woke up with what she believed to be two bed bug bites on her arm. Worried about a possible bedbug infestation, Cahalan does what any normal person would do and calls an exterminator who searches her apartment and deems it bedbug free.

At the beginning of her book, Susannah Cahalan is a young and thriving journalist who works for the New York Post. The day of her bedbug scare, she finds herself in her routine Tuesday meeting with her boss and editor, Steve, without any new pitches for an upcoming news story. This incident somewhat sets Cahalan off, and she returns home that day to trash all of her beloved article clippings that she had saved. She recounts that "Though it felt necessary at the moment, this callous throwing away of years' worth of work was completely out of character for [her]" (Cahalan 8). At the time, what she didn't know was that bedbug scares can often be a sign of psychosis.

A few days later, while at her boyfriend Stephen's apartment, Cahalan experiences an overwhelming urge to read Stephen's emails and go through all of his belongings in order to find some sort of evidence that he is cheating on her. After this incidence, which she describes to be "wholly unlike [her]," she begins to feel what felt like pins and needles in her left hand and decides to visit a neurologist (11). Cahalan's exam and MRI results come back normal, but her doctor explains that she has an small amount of enlarged lymph nodes in her, which could possibly indicate mononucleosis.

Within the next few days, Cahalan receives word from her doctor that her blood results tested negative for mono, but she continues to experience mental highs and lows of extreme happiness and depression until she finally has what her coworkers believe to be a nervous breakdown. Her behavior becomes more erratic until one night, while with watching TV with Stephen, everything goes hazy.

"As Stephen later described that nightmarish scene, I had woken him up with a strange series of low moans, resonating among the sounds from the TV. At first he thought I was grinding my teeth, but when the grinding noises became a high-pitched squeak, like sandpaper rubbed against metal, and then turned into deep, Sling Blade-like grunts, he knew something was wrong. He thought maybe I was having trouble sleeping, but when he turned over to face me, I was sitting upright, my eyes wide open, dilated but unseeing.
'Hey what's wrong?'
No response.
When he suggested I try to relax, I turned to face him, staring past him like I was possessed. My arms suddenly whipped straight out in front of me, like a mummy, as my eyes rolled back and my body stiffened. I was gasping for air. My body continued to stiffen as I inhaled repeatedly, with no exhale. Blood and foam began to spurt out of my mouth trough clenched teeth. Terrified, Stephen stifled a panicked cry and for a second, he stared, frozen, at my shaking body. Finally he jumped into action-though he'd never seen a seizure before, he knew what to do. He laid me down, moving my head to the side so that I wouldn't choke, and raced for his phone to call 911" (40).

(Cahalan's seizure was what is known as a "tonic-clonic seizure. This is characterized by loss of consciousness or muscle rigidity and strange, involuntary dance-like movements. This seizure was merely the largest and most dramatic of a series of seizures she had been experiencing for a while before this incident occurred. She had also been experiencing what are known as "complex partial seizure" that occur as a result of overstimulation of the temporal lobes and include side effects that range from a "'Christmas morning" feeling of euphoria to sexual arousal to religious experiences" (42).)

Cahalan explains that this blackout "marked the line between sanity and insanity," and that it was "the start of the dark period of [her] illness" (41).