My Most Fascinating Patient

I first met Linda, a 32-year old veterinarian, when she was rushed into the MICU with a dangerously elevated heart rate, weighing a mere fifty-nine pounds. When her thyroid blood tests came back off the charts, I thought her emaciation and fast heartbeat were due to severe hyperthyroidism. But it turned out, Linda had intentionally ingested animal thyroid hormone in her desperate effort to lose weight. In short, Linda suffered from the worst case of Anorexia nervosa I have ever seen. Skinnier than a concentration camp victim, she resisted all efforts to help her gain weight. Once Linda's pulse was stabilized, she refused to stay in the hospital, in part because she had no health insurance and in part because she was solely responsible for a kennel full of sick dogs and cats. Despite her profound emaciation, NONE of the reputable eating disorder clinics would take her without health insurance, even if she had been willing to go. To commit her against her will would have required two physicians to legally testify in court that she was mentally incompetent. The problem was, Linda was competent in every area of her life--except her weight. An gifted veterinarian, she managed her practice, finances, and personal affairs well. But talk about delusional! How could she weigh a mere fifty-nine pounds and still see herself as fat?

I probed that issue with Linda's mother and discovered the Anorexia started at age fourteen, when Linda began to develop curves. Her older brother uttered a snarky remark that triggered her onto a diet that never quit. I was fascinated to learn the ONLY time Linda's Anorexia went into remission was during the four years she attended an elite vet school. Linda became so obsessed with graduating at the top of her class, she transferred all her time and energy into studying instead of exercising and dieting. Unfortunately, as soon as she conquered that hurdle-- class Valedictorian-- she reverted back to her eating disorder with a vengeance and remained that way until the day I met her in the MICU.

Over the next year, I attempted outpatient management with psychiatric medications, but none of them worked (or more likely, she never took them.) Two psychiatrists consulted on her and had little to offer. In fact, both projected her prognosis was grim and she would die of her disease. Meanwhile, Linda aimed for a zero fat gram,  eight-hundred calorie-a-day diet and spent two hours every day power walking.

But I wasn't willing to give up on her. We tried counseling, twelve-step groups, sharing the gospel, and parental oversight of her eating, but nothing made a dent in her obsession to starve herself. One day, when she came into my office for her bi-monthly weighing, a large bag of coins fell out of her underwear and onto the floor. She'd wanted to deceive me into thinking she weighed more than she did.

After a full year of spinning my wheels with Linda, I jumped through the considerable legal hoops to get her declared mentally incompetent to make her own medical decisions. (I had the full approval of her family, who were obviously worried about her.) This granted me the authority to force her into an extended inpatient eating disorder program. Since she had FINALLY been approved for TennCare, (Tennessee's Medicaid program) finances were no longer an issue.

But two days before her admission, she developed a systemic fungal infection - Aspergillis - and had to be admitted to the MICU again. Because of her suppressed immune system, she was unable to conquer the infection and died at the tender age of thirty-three, thus fulfilling the dire predictions of her psychiatrists. I suspected she self-injected the fungus to delay or avoid admission into the eating disorder clinic--she was that petrified about gaining weight. And as a vet, she was smart enough to know how to inoculate herself  in a manner  I could never prove was self-induced.

Right or wrong, I had granted Linda ten days advanced warning about her admission so she'd have time to make appropriate arrangements for the animals under her care. Since she was a dedicated veterinarian, I felt I owed her (and the animals) that much. But I sometimes wonder-- if I had admitted her with NO notice whatsoever--and thus no time to self-inject the fungus-- would she still be alive? The psychiatrists predicted she'd just relapse once she was released from the eating disorder clinic, but I felt she deserved a chance to get aggressive help.

I look back on Linda's case with sadness--a brilliant woman who loved animals but was so bent on self-destruction, no one could help her. Her high intelligence offered no protection whatsoever and even two excellent psychiatrists couldn't prevent her untimely demise from a frustrating mental illness.