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defined as a delusional condition in which a patient falsely believes someone, usually a close friend or relative, has been replaced by an imposter.)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